5.2 Proportion of births attended by skilled health personnel:

a.    2001: 11.9^[13]

b.    2006: 18.7^[14]

c.    2007:

A skilled attendant, according to WHO, refers to “an accredited health professional-such as a midwife, doctor or nurse- who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period, and in the identification, management and referral of complications in women and newborns.” Traditional Birth attendants (TBA) either trained or untrained are excluded from the category of skilled health workers.

Skilled attendants at birth in 2006 in Nepal were reported to be 18.7^[15].

Critical indicators to comprehensively monitor skilled health attendance would include not just skilled birth attendants but also access to basic and comprehensive emergency obstetric care services and post-partum care

The quality of care provided by skilled attendants at birth is crucial. Particularly when complications occur, skilled personnel need access to essential drugs, supplies, equipment and emergency obstetric care. They should receive training on required competencies. And they need supervision that helps ensure high standards of care, which is vitally important^[16].

Global and country studies on skilled attendants showed that the overall effectiveness of skilled attendants depends on their access to a functioning health system with basic and comprehensive level of obstetric care, including surgery and blood transfusions  in case of complications. The key to maternal death reduction is universal access to emergency obstetric care which is a major challenge in most of the Asian countries.

It is therefore critical to not just look at skilled attendants at birth, but also look at a) access to emergency obstetric care services and b) postpartum care so as to reduce maternal deaths meaningfully.

5.2.1 Access to emergency obstetric care

An assessment study carried out to evaluate the Nepal Safer Motherhood Project1997-2004, showed that challenges to improving the emergency obstetric care lay in the sustained functioning of the health system, in major shortages of skilled professionals, and in the availability of blood, and administration of anaesthesia.^[17] Of the 157 facilities surveyed in Nepal between 1999-2000, 18% had five EmOC facilities per 500,000 population, including both private and public facilities.

5.2.2 Post partum care

A large proportion of maternal deaths occur during the 24 hours after delivery and hence postnatal care constitutes a critical safe pregnancy intervention. The first two days following delivery are critical for monitoring complications arising from the delivery.

The single most common cause of maternal mortality is obstetric haemorrhage, generally occurring postpartum and accounting for 25—33% of all maternal deaths. The rate of death due to post partum haemorrhage (PPH) varies widely in the developing world. PPH-related mortality rates based on hospital studies are estimated to be 25—30% in India, and 43% in Indonesia. However, women who come to a hospital for care do not represent the general population of women. Because haemorrhage is more apt to occur and more difficult to treat in the community, studies have suggested higher rates of PPH-related mortality in these areas, but there is comparatively little data available outside of a hospital setting.^[18]

According to the 2006 Nepal Demographic Health Survey, in the five years preceding the survey, one-third (33 %) of women received postnatal care for their last birth. One in five women received postnatal care within four hours of delivery, more than one in four (27 %) received care within the first 24 hours, and four percent of women were seen 1-2 days following delivery.

5.3 Adolescent birth rate (per 1000 women):

a.    2001: 84.0^[19]

b.    2004: 106.3^[20]

c.    2007:

The adolescent birth rate measures the annual number of births to women 15 to 19 years of age per 1,000 women in that age group. It represents the risk of childbearing among adolescent women 15 to 19 years of age. It is also referred to as the age-specific fertility rate for women aged 15-19^[21].

According to the Nepal Dempographic Health Survey (2006), “Nineteen percent of women age 15-19 have already had a birth or are pregnant with their first child. The percentage of women who have begun childbearing increases rapidly with age, from 1 percent among women age 15 to 41 percent among women age 19. Although the proportion is lower in urban areas than in rural areas, the difference is not very large. Adolescent childbearing is lowest in the hills (17 percent) and highest in the mountains (20 percent). Teenage pregnancy has declined markedly in the terai zone from 31 percent in 1996 and 26 percent in 2001 to the current level of 19 percent. Not surprisingly, early childbearing is inversely related to educational level. For example, teenagers with no education are three times as likely to have begun childbearing as those with some secondary education. There is a marked difference between the percentage of teens with SLC or higher level of education who have started childbearing and teens at all other levels of education. The percentage of teenagers who have begun childbearing is highest (22 percent) in the middle wealth quintile and lowest among teens in the wealthiest households (14 percent). Nationally, the proportion of teenage pregnancies has declined from 24 percent in 1996 and 21 percent in 2001 to 19 percent in 2006.”

Adolescent  fertility and pregnancies are a major health concern because adolescent girls  and their children are at high risk of reproductive morbidity and mortality. Early childbearing  also impedes the overall development of teenage girls and their access to education and labour force participation.

Critical indicators to comprehensively monitor adolescent birth rate would look at the median age at marriage, the legal age at marriage and access to sex and sexuality education

5.3.1 Median age at marriage

The median  age for marriage for women aged (25-49) in Nepal is 17.2 years. According to the Nepal Demographic health Survey (2006), “The proportion of women married by age 15 has declined from 25 percent among women age 45-49 to 6 percent among women age 15-19. There has been a noticeable increase in the median age at marriage among women age 20-49 over the last ten years from 16.4 years in 1996 to 17.2 years in 2006. However, this change was marked between 1996 and 2001, with little difference between 2001 (17.0 years) and 2006.”

5.3.2 Legal age of marriage 

The legal age of marriage in Nepal is 20 for women and 20 for men. Individuals aged 18 -20 also need parental consent.

5.3.3 Sex and sexuality education

Sex education is defined as the basic education about reproductive processes, puberty and sexual behaviour. Sex education may include other information, for example about contraception, protection from sexually transmitted infections and parenthood.^[22] Sexuality education is defined as education about all matters relating to sexuality and its expression. Sexuality education covers the same topics as sex education but also includes issues such as relationships, attitudes towards sexuality, sexual roles, gender relations and the social pressures to be sexually active, and it provides information about SRH services. It may also include training in communication and decision-making skills.^[23]

In Nepal, the National Adolescent Health and Development Strategy (2000) considers adolescents a key target group for information and services. Nevertheless, the extent to which sex education is being provided in schools has received little attention. At higher secondary level, students are supposed to be taught basic sex education using a chapter in a textbook called Health, Population and Environment. Little is known about how or how well this material is covered. A study in 2002 found that adolescents in these schools did not appear to be getting the information they needed. Most of the teachers did not want to deal with sensitive topics and feared censure by their colleagues and society. Some lacked the skills to give such instruction. Many students also felt uncomfortable with the topics. The challenge is to strengthen sex education, make it more appropriate for the students and ensure that teachers are more comfortable and able to give instruction on the topic.^[24]

5.3.4 Access to reproductive health services for adolescents within the public health system

Data is not readily available

5.4 Contraceptive prevalence rate (Current contraceptive use among married women 15-49 yrs old any method%:

3 Contraceptive prevalence rate (Current contraceptive use among married women 15-49 yrs old any method%:

a.    2000: 37.3^[25]

b.    2006: 48.0^[26]

c.    2007:

In Nepal, the CPR increased from 37.3 in 2000 to 48.0 in 2006.

Critical indicators to comprehensively monitor contraceptive prevalence rate would include looking at range of methods available including access to modern methods and provision of informed choice.

5.4.1 Range of contraceptive methods available.

Beyond the numbers for CPR it is essential to look at access to a range of contraceptive services.

In Nepal, in the 2006 DHS, female sterilization accounted for 37.91% of all contraceptive methods; male sterilization accounted for 13.1% of all methods. Permanent methods formed more than half of all contraceptive methods. A preponderence of one method often demonstrates provider bias/ service provision bias or policy bias with regards to contraception and population.

5.4.2 Provision of informed choice service provision.

Informed choice of family planning methods is an important rights indicator. However it has not been commonly regarded as an important aspect of the service provided with the contraception method. Informed choice includes: information on the full range of methods including traditional and male methods; information on side-effects of all methods and the appropriate course of action; and information on the efficacy of each of the methods.^[27]

Information on side-effects and appropriate courses or action was given to few users. In Nepal “56% of current users were informed about side effects and problems of methods used, [and] 51% of the users were informed about what to do if they experienced side effects.” ^[28]

Information on the permanent effects of sterilisation which was given to 81% of women undergoing sterilisation in Nepal. ^[29]  

5.5 Unmet Need for contraception:

a.    2001: 27.8^[30]

b.    2006: 24.6^[31]

c.    2007:

Unmet need reduced from 27.8 in 2001 to 24.6 in 2006.

In Nepal, unmet need for spacing constitutes around 9% and unmet need for limiting is around 15%.^[32]

Women with lower education or are uneducated, who are poor, who live in remote areas and rural areas face the greatest challenge in controlling their own fertility. Socio-economic inequities are closely inter-linked with higher rates of unintended births and it is important to ensure access to contraception to all groups of women.^[33]

The accepted definition of “[u]nmet need for contraception is the percentage of fertile, married women of reproductive age who do not want to become pregnant and are not using contraception.”^[34] The concept of unmet need is an important one because it assesses the ‘need’ for contraception based on whether and when a woman wants a child or another one rather than focusing on government limits on family size. The limitation, currently, is that the DHS calculates unmet need based on a sample of married, heterosexual women and not single, unmarried women and this does not accurately capture the extent of unmet need in a country. Another limitation is that it assumes all users as having their need ‘met’ including women with infertility and secondary infertility. But many women may be using a contraceptive method not of their choice due to provider bias or government policy as earlier discussed and this constitutes an ‘unmet need’ too. It is also important to keep in mind that contraception is primarily focused on pregnancy prevention. There is also an urgent unmet need for disease/infection prevention which is not being considered.^[35]

Critical indicators to comprehensively monitor unmet need would take into account differences between total and wanted fertility rates and reasons for non-use of contraception.

5.5.1 Total and Wanted Fertility Rates

      Wanted fertility rates compared to TFR

a.    Total Fertility Rate (2005): 3.1^[36]

b.    Wanted Fertility Rate (2005): 2.0^[37]

c.    % difference: 55%^[38]

It is important to look at Wanted Fertility Rates and Total Fertility Rates to also establish unmet need.

In the DHS 2006, the TFR was 3.1 and the WFR was actually 2.0; this means women were having 55% more children than they actually wanted and this constitutes an unmet need.^[39]

5.5.2 Reasons for non-use of contraception

One of the most common reasons given by married women with an unmet need for not using contraception is associated with the supply of methods and services and within this category, concerns about the side effects, health consequences and inconvenience of methods were the most prominent reasons. The prevalence of these concerns is particularly high in South Asia.^[40]

Apart from the fertility-related reasons, method-related reasons and health concerns, a major reason for non-use of contraception in Nepal is ‘fatalism’ (1.2%) i.e. fertility is still seen as something ‘fate’ deals out rather than a matter of exercising choice. In addition, opposition to use (both own and spousal) constitutes 11.9% and religious prohibition constitutes 6.6% all of which are not being considered in discussing unmet need.^[41]

5.6 Antenatal care coverage

a.    At least one visit (%):

Ø  2003: 27.0^[42]

Ø  2006: 43.7^[43]

Ø  After 2005:

b.    At least four visits(%):

Ø  2001: 14.3^[44]

Ø  2006: 29.4^[45]

Ø  2007: