UNFPA has ranked Nepal  as the worst affected region in South Asia as it has a maternal mortality ratio that is higher than other Asian countries with similar levels of development. According to the latest Nepal Demographic and Health Survey Report, 2006, it has a maternal mortality ratio of 281 per 100,000 live births that translates into an estimated six mothers dying everyday.
Emergency obstetric care
These statistics reveal that many women in Nepal die as a result of pregnancy and childbirth. Most of the maternal deaths (70 per cent) in Nepal are due to obstetric emergencies. These emergencies arise due to such complications as haemorrhage, infection, hypertensive disorders, obstructed labour and the consequences of unsafe abortion. These five leading causes of complications account for as much as half of all maternal deaths in our country.
Access to and use of emergency obstetric care are, therefore, very important for the management of complications arising during pregnancy, delivery and the post-partum period. These care services should be made available because some 15 per cent of pregnant women are estimated to develop serious pregnancy-related complications. The saddest situation, however, occurs when women somehow manage to reach a healthcare facility with pregnancy-related life threatening conditions, but the latter is not able to provide these services.
Nepal’s maternal health services are provided at various levels in the health care system. Local health posts and sub-health posts provide the first level of obstetric care, viz., stabilising the patients with obstetric first aid, making an appropriate referral and arranging for transport. Primary health care centres are expected to provide basic emergency obstetric care for the prevention and treatment of haemorrhage, puerperal sepses, eclampsia, infection and in the management of prolonged labour. Hospital settings, on the other hand, are expected to provide comprehensive essential obstetric care that includes all the above services plus caesarean section, anaesthesia and blood transfusion.
Although hospitals should be the first-line referral centre for emergencies, most district hospitals and medical centres are ill equipped to handle emergency cases referred to by the primary health care centres, health posts and sub-health posts. Utilisation of emergency obstetric care services in Nepal is extremely low at only 5 per cent, reflecting a huge unmet need. Obviously, most maternal deaths could be averted with timely medical treatment of those expectant mothers who are in desperate need of these emergency obstetric care services.
Unfortunately, obstetric emergency care facilities are not available even in half of the district hospitals /medical colleges of Nepal. Even in those medical institutions where these services are available, there is an acute shortage of manpower defined in this context as both health and non-health personnel that support the operation of the facility and that are responsible for the patients’ care. Most of the hospital staff want to work in Kathmandu and other big cities of Nepal because they tend to be isolated, undervalued in the remote districts. This adversely affects both clinical and inter-personal care provided by them.
Delays in salary payment, excessive work loads and insensitive management are some other issues that negatively impact the working atmosphere. The working environment is also spoiled by such work risks as physical violence, verbal abuse by patients and their relatives and transmissible infections. These factors deter both health professionals and non-medical professionals from working in the remote rural areas.
The hospitals of Nepal also struggle to provide even the most basic of emergency obstetric care since most of them lack a maternity unit, an operating theatre, equipment, running water, electricity and power backup system and residential facility to provide round the clock services. These hospitals are also deficient in drugs and supplies, making the cost of medication the patients’ responsibility.
Under the circumstances, no woman wants to go to a healthcare facility only to die there for want of adequate or appropriate care. Furthermore, it is not just the technical aspects of health care that women consider important for them. Nepalese women perceive that the care they receive is of poor quality if and when they are not treated with respect, dignity and equity. This is reflected in the providers’ interaction and attentiveness towards them and in the cleanliness of the facility. Women regard cleanliness as a sign of respect for the client as it relieves them from fears of infection.
Pregnant women’s choice of health workers and health care institutions are also greatly influenced by the condescending attitudes and behaviours of the health care providers. Nepalese women often seek care from traditional birth attendants because they behave nicely towards them. They also do not charge much for their services. On the contrary, most doctors and obstetric nurses do not behave as nicely even though they should be understanding of women who come to seek their help for delivery. In most cases, women have to undergo unnecessary humiliating procedures in these facilities, in addition to them paying higher costs for the services.
Although emotional support during childbirth is a respected norm in Nepalese culture and the hospital staff are supposed to be supportive during labour, delivery and immediate post-partum period, it is not strictly adhered to in the hospitals here. On top of that, companions are not allowed to stay with expectant mothers, especially during the second and third stages of labour. This causes stress, increases anxiety and fear, adversely affecting the progression of labour and pregnancy outcomes.
Emergency obstetric care is also not something that can be postponed. Even if it is at 2 in the morning, an obstetric emergency, by definition, is not something for which the mother can be told to come back the next day. For instance, if the woman needs a caesarean but does not get it, then it is very simple: she will die. Thus, 24-hour availability of emergency obstetric care is indispensable.
While emergency obstetric care is needed at all levels of the health care system, this necessarily does not guarantee quality emergency obstetric care services. Women and their families need to be satisfied with the care they receive or else they will not make use of these professional services. When women perceive the quality of care at a facility to be unacceptable or if others have told them it is so, they think twice before seeking medical care even during complications.
Quality emergency obstetric care, thus, plays a vital role in the prevention of maternal mortality, and lack of access to these or lesser use of these services contributes to rising maternal mortality.
Accountability
Health care institutions should provide high quality maternity services. Even when the care provided is deemed to be of high quality by all recognised standards of good practice, women may consider it still sub-optimal if it does not meet their needs and expectations. A harmonious relationship between the health care providers and the community of users is crucial in developing a sense of accountability on both sides so that an appropriate course of action can be taken for women’s health and emergency obstetric care.