Urgent Action Needed to Address Reproductive Health Needs of Nepali Women

Contacts:
In Kathmandu: Rajib Upadhya (9771) 4226792/3
rupadhya@worldbank.org
In Washington: Erik Nora (202) 458 4735
enora@worldbank.org

Kathmandu March 5, 2009 – Nepal faces an uphill task in meeting its Millennium Development Goals (MDG) related to improving the reproductive health of its women, according to a new World Bank report launched today.  Among its suggestions, the report calls for integration of reproductive health services, decentralized and action oriented planning, targeting poor geographic areas and finding innovative ways of financing reproductive health.

The report, Sparing Lives: Better Reproductive Health for Poor Women in South Asia, analyses the current state of reproductive health in five countries in the region – Bangladesh, India, Nepal, Pakistan and Sri Lanka – and highlights the major risks faced by poor women.  The report calls for urgent action in reducing Nepal’s maternal mortality, scaling up skilled birth attendants, maternal and child nutrition, and increasing the use of contraceptives.

The report underlines the need for countries in the region to pay more attention to poor women’s reproductive health if MDGs related to maternal and child health is to be achieved.  It points out that an average South Asian woman faces a hundred times greater risk of dying during childbirth (1 in 43) than a woman in an industrialized country (1 in 4,000).

Today, Nepal’s Maternal Mortality Ratio (MMR) is two times higher than its MDG goal of a two-thirds reduction. Nepal’s target is to reduce MMR to 134 by 2015 from the current official estimate of 281 (per hundred thousand live births). The lifetime risk of dying during pregnancy for a woman in Nepal is 1 in 42. It lags far behind Sri Lanka (1 in 430); Bangladesh (1 in 59); and India (1 in 48) and is only slightly better than in Pakistan (1 in 31). Sri Lanka has the highest child immunization coverage (94 percent) in the region, followed by Nepal (83 percent), Pakistan (77 percent), Bangladesh (65 percent) and India (44 percent).

“This report highlights the enormous challenges that the region faces in addressing the reproductive health needs of poor women,” said Ms. Susan Goldmark, the World Bank Country Director for Nepal.  “At the same time, there are lessons in the report that countries can learn from each other. For Nepal, given the diversity and disparities between the rich and the poor, the challenges are even more significant. We stand ready to support Nepal in its commitment to overcoming the challenges of achieving better reproductive health outcomes for women,” she said.

The report acknowledges the positive strides Nepal has made in the area of fertility. Between 1995-96 and 2005-06, fertility declined from 4.6 to 3.1 births per woman. The greatest change occurred among the adolescent group of 15-19 year-olds, which is a positive trend.  Most urban areas have achieved replacement level fertility.

The challenges ahead: The widening gap between the rich and the poor

The report advocates the need to reduce disparities between the rich and the poor in accessing health services. For example in Nepal the number of poor women having access to antenatal care is 25 % that of the rich.

“Women’s low education and poverty are consistently associated with low use of reproductive health services,” said Meera Chatterjee, Senior Social Development Specialist at the World Bank and lead author of the report.  “If we want to break the cycle of poverty we cannot ignore reproductive health because poor reproductive health undermines the well-being and survival of individuals and represents significant losses to the community, resulting in transmission of poverty from one generation to the next,” she said.

Poor nutrition
Poor nutrition is another major challenge, according to the report. An estimated 50 million children in India suffer from under-nutrition today. In fact, two-fifths of all children under five in the region are malnourished. In Bangladesh, India and Nepal, 40-50 percent of all children are under-nourished.

The disparities between the rich and the poor are also very stark.  Compared to the richest quintile of urban women in Nepal, the poorest urban quintile is 4.8 times more likely to be under-nourished, and the poorest rural quintile, 5.6 times more likely.

Contraceptive use
To reduce fertility, the report calls for Nepal to accelerate availability and use of temporary methods. “In 2005-06, 48 percent of Nepali couples were using modern methods of contraception.  However, only one-fifth of them were using temporary methods.  While the availability of spacing contraceptives has increased in the past decade, the continued emphasis on terminal methods (i.e., sterilization) means that many couples do not contraceptive and continue to have more children than they really want, says the report.

The report makes the following recommendations to help improve reproductive health in the region:

• Single window for complete package of essential reproductive health services: Poor women often do not have the time, money, or the power to approach providers for health care, family planning, and childbirth. They, therefore, need to be provided a continuum of care through a ‘single window’.
• Antenatal care and skilled birth attendance need to be stepped up: Institutional delivery or the presence of a skilled birth attendant can make a critical difference to the survival of mothers and their babies. It is only in Sri Lanka that almost all births take place in institutions; in India and Pakistan it is less than 40 percent and in Nepal it is only 21 percent.
• Decentralized and action oriented planning is needed: The focus should be on action planning which involves poor women themselves, their institutions, local governments and health staff. This will increase relevance and accountability.
• Disseminating ‘know-how’: Good practices that have worked within the developed world and in the region need to be shared and is an important central function that must be stepped up. 
• Efficient financing: The report calls for innovative financing to the reproductive health sub-sector to ensure the inputs for additional and better services.  Increasing allocations to in-patient maternal and child health services over current low levels in most areas could substantially increase the use of needed health care by the poor.
• Innovative financing: Vouchers, reimbursement, insurance and social marketing are some feasible approaches that will reduce heavy out-of-pocket expenditures by the poor on reproductive health care. For example, Bangladesh has a good voucher system which is being used to increase the availability of services and improve equity, the report adds.

For more information about the World Bank’s in Nepal, please visit
http://www.worldbank.org/np