Does giving Nerpali women money to deliver their babies in hospital have something to do with the falling maternal death rates in the country? Martin Wroe and Malcolm Doney investigate.

It is nine in the morning at Baglung District Hospital and already pregnant women are queuing up for one of their regular check-ups. In the labour room, Mina Jishi, is in the final hours of her fourth pregnancy. She has travelled into the town from a remote hill village in the district of Sigana. A long and ardous journey, for some of the way she walked, and for some she was carried on a stretcher by family members. It took her five hours and, in the final days of pregnancy, it would have been easier to stay at home and rest. But it could also have been fatal.

“I know I will be safe here,” she says, as the senior staff nurse Debi Bhattarai takes her blood pressure. “I suppose I could have gone to one of the health posts which would have been less of a journey but I felt getting to Baglung and the hospital was going to be the best for me and my baby.”

Across the corridor, in a ward of four beds, three new mothers all back up Mina’s instinct. Within the last 24 hours they have given birth to healthy babies and are now safely recuperating under the watchful eye of the team of nurses. Sarasitu Bhatta, 26, gave birth to twin boys yesterday, after making the one-hour walk from her home in the hills outside the town. “It was a tough journey to get here,” she says. “But I knew my babies would be born safely here.

“If I had had these twins at home I really don’t think I would have survived,” she adds. “The doctor had already told me I would be taking a big risk but I wasn’t going to take any chances and I was right – when I was giving birth I had confidence in the team.”

The Nepal Safer Motherhood Project

DFID has been supporting maternal health programming in Nepal since 1997, when the Government of Nepal first launched its national Safe Motherhood Programme. The DFID Nepal Safer Motherhood Project (NSMP) ran from 1997 to 2003, followed by the current Support to Safe Motherhood Programme (SSMP). This is one of DFID’s largest maternal health programmes anywhere, with a budget of £20 million, of which half is financial aid managed by the Nepal government and half is for technical assistance. The SSMP financial aid accounted for 37% of Nepal’s national safe motherhood (including family planning) budget for the year 2007/08.

More and more women in Nepal, whatever the remoteness of their homes, are choosing to get professional medical advice during their pregnancy and then – when it comes time to give birth – to make the journey to hospital, however gruelling. It is a cultural sea-change which has gathered pace in the last decade and helps explain the dramatically declining rate of maternal mortality in the country.

Rising levels of female education and of maternal health awareness have been vital – as signalled by the poster on the wall of the ward (right) with its three-fold advice: Take help from a competent health worker for your delivery. Save the lives of the newborn and the mother. Take mothers to hospital for safe delivery.

But one other innovation is also playing a critical part – women are now being paid to have their babies in hospital. “That is such a big help for us Nepalese women,” says Mina. “Many of us are very poor and the money is very important.” Any mother who agrees to give birth accompanied by a trained birth attendant, is paid 1,000 rupees (after the baby is delivered) – money which can help her buy good food for her new child. One important factor is that the money is paid direct to her, not to her husband or some other relative. She gets to decide, and often a part of the money goes on transport – a vital requirement with precipitous hills and long distances.

“There is definitely a change since the money started being provided,” says Dr Sagar Rajbhandari, 46, Senior Medical Officer at the hospital. “Previously we had up to 50 deliveries a month, now I estimate we have up to 90. And of course if someone comes here for their baby’s delivery then there is a good chance they will survive.” For example, he says, at home, if the placenta is retained – the mother will die. Or, during a home delivery, if a newborn baby doesn’t cry, he will often not be resuscitated: “People don’t have the knowledge or the facilities, and that baby will die, but if he is born here, we can go to work and he will be fine.”

Nepal has seen an extraordinary fall in the numbers of women dying in childbirth. In 1996 the maternal mortality ratio (MMR) for the country was estimated at 539 deaths per 100,000 live births – the equivalent of a woman dying every two hours. Ten years later, in 2006, the same survey indicated a drop to 281 deaths per 100,000 live births. If these estimates are accurate, the country is on track to meet the target of the fifth Millennium Development Goal of 134 maternal deaths per 100,000 live births by 2015.

And while the surveys do not provide cast iron evidence (precise assessments remain difficult in countries like Nepal), a recent DFID-funded review confirmed strong support for a dramatic decline in maternal mortality, supporting a substantial decline of at least 20%, or a reduction of one in five deaths.

Many factors have contributed to this fall, including the increased use of doctors, nurses and auxiliary nurse midwives in attending deliveries – doubling to nearly 19% in the decade to 2006. Emergency obstetric care has improved considerably, while far more women now benefit from legal and safe abortion services. Beyond the health sector, there have been improvements in water and sanitation, transport and communication. But perhaps most significantly, female education levels have increased – in 1996, only 11% had primary education, 6% secondary and 3% School Leaving Certificate. In 2006, the equivalent figures had more or less doubled.

All of these factors help to explain why more women than ever now come to hospital to have their babies, confirms Baglung’s Dr Rajbhandari. “The consciousness of the people has changed, people now want quality of service and they know that they will get that if they come here.”

And as education and awareness among women rises, so they are able to challenge the patriarchal nature of Nepali society. Debi Bhattarai, says that in the past the husband would not always allow his wife to come to a hospital to give birth. But she cites a recent example when one woman insisted on bringing another woman to the hospital, who would have died but for the successful caesarean section they carried out. “Sometimes the husband is reluctant to spend the money on the woman going to hospital,” says Sister Bhattarai, “but increasingly the women are deciding to go anyway – they know it is important both for them and for their baby.”

The money can sometimes be a bone of contention within families “Now and again there is a big scene, when someone’s mother-in-law starts crying because she believes she should have the money!” says Dr Rajbhandari. But the staff abide by the rules, “The mother has to sign for it,” says Sister Bhattarai. “If you give it to some other relative, then it may not be spent on the baby or on getting home safely.” She adds “This money is incredibly important for the mother. Women from the villages have no money for food or transport but now that they know they will get this money, it encourages them to make the journey and come here to have their baby.”

Three hours after we first visited Mina Jishi, she is resting happily in the recovery ward, the proud mother of a little boy. “I’m very happy,” she beams, as proud as any other new mum. “And with the 1,000 rupees I receive when I am discharged I will get us both some good food.”