Early marriage, short birth intervals, poor maternal nutrition and lack of healthcare facilities due to the ongoing insurgency, have combined to send Nepal's maternal mortality rate soaring, with one Nepalese woman dying every hour during childbirth. According to the "State of the World Population, 2003 Report," published recently by the United Nations Population Fund (UNFPA), Nepal's maternal mortality rate has doubled in the past seven years and stands at 905 per 100,000. After Afghanistan, which has a mortality rate of 1,276 per 100,000, Nepal has the second highest mortality rate in South Asia. It was 539 per 100,000 in 1996 in Nepal. "Nepal is passing through a critical time in terms of its adolescent population. Thanks to inadequate health facilities and early marriage, the mortality rate in Nepal has increased alarmingly," points out the acting resident representative of UNFPA (Nepal), Dr Hernando Agudelo. "The present trend indicates there is a need to encourage adolescents, particularly girls, in reproductive health programs. And more investment in this sector is required," urges Agudelo. Insurgency proved a major killer. In the past eight years of insurgency, Nepal's limited health infrastructure has suffered the rage of destruction. Health centers are non-functional in the absence of trained medical staff. "With the upsurge in violence, many health centers, including rural health posts and health units were destroyed, resulting in a scarcity of medical facilities for pregnant women," says the president of Aama Milan Kendra, Roshan Karki. The Kendra is a nongovernmental organization (NGO) with a nationwide network, and has been working in the area of safe motherhood and adolescent health. "Because of the growing threat, NGOs like ours, too, have had to close offices in some areas," says Karki. Even during periods of normalcy, only a small percentage of the population in rural Nepal has access to health facilities. Assistance during delivery from a doctor, trained nurse or midwife is relatively low in Nepal. According to the Nepal Demographic and Health Survey (NDHS) 2001, conducted by the Health Ministry's family health division, just over one in ten births is attended by a trained doctor or paramedic. Nearly one in four are attended by only relatives or friends. Nine percent of births are not attended by anyone at all. For all their village wisdom, untrained midwifery can be disastrous for the mother. The maternal mortality and morbidity study shows the majority of maternal deaths are caused by postnatal complications. Take Manmaya Magar, 17, of Rukum district, 300 miles west of the capital, who died recently because of delivery complications. According to a newspaper report, she was declared dead due to excessive bleeding by the time she was brought to the local health post in the district headquarters. Similarly, 16-year-old Jamuna Rai of Basantapur, 400 miles east of Kathmandu, died on the way to the regional hospital because of postnatal complications. "Many girls are married at an age when they don't even know the functions of different organs of their bodies and many pregnant girls are totally unaware of reproductive health," says the director of UNFPA's regional office, Dr Wasim Zaman. "In South Asia as a whole, adolescent girls often face discrimination, neglect and possibly exploitation and marry before reaching their reproductive age," adds Zaman. According to the UNFPA report, females aged between 15 and 19 are twice as likely to die during childbirth. Just about 13 percent of women receive assistance from a doctor, nurse or midwife during delivery, and 87 percent of women give birth at home under the supervision of traditional birth attendants or family members. In many remote areas, none of the pregnant women have ever been in contact with health workers. Poor maternal nutrition and health, short birth intervals, and the lack of accessibility of obstetrical (emergency) services contribute to Nepal's high levels of maternal and neonatal mortality and morbidity. The situation is worsened by the practice of early marriage. Among the 2.5 million girls aged between 15 and 19, half are already married and nearly a quarter are mothers or pregnant with their first child. The UNFPA report states that 60 percent of girls marry before they turn 18 in Nepal. "The young rural girls, who are usually unprepared for pregnancy and motherhood, and are under-nourished and under-fed, have a higher chance of dying as a result of their pregnancy," says Karki. "Our studies have shown that unsafe delivery, postnatal complications, early marriage and unsafe abortion are responsible for higher maternal mortality rate," says a public health expert at the Ministry of Health, Tek Bahadur Dangi. Despite its legalization, post-abortion complications are still a major problem in Nepal, with 20-27 percent of maternal deaths in hospitals caused by such complications. Studies conducted in 1998 showed that five percent of maternal deaths in villages are caused by unsafe abortion. The Ministry of Health has recently extended its post abortion care program to 19 hospitals. These efforts are yet to yield results since most women die before reaching hospital. Records for 2002 maintained by the National Maternity Hospital in the capital Kathmandu, show that nearly ten percent of the 18,000 patients admitted to hospital were abortion-related cases. According to a government survey, three in four women dying of delivery complications were illiterate. Educated women had better access to a doctor or medical worker. Which is why the UNFPA report stresses the need to invest in girls' education. The report shows that 76 percent of females above 15 years are illiterate, against 43 percent of the male population group. "Maternal morbidity and mortality are closely related to literacy. Educating adolescents will dramatically change the status," maintains Karki. "This is a failure of our policies and programs. We are perfect in formulating programs, but their implementation has always been weak," says Minister of Health Kamal Thapa. "The time has come to take drastic steps to reduce the maternal mortality rate," he declares. Promises a demographer with the National Planning Commission, an apex policy making body, Dr Ramhari Aryal, "We will introduce more effective programs to reach out to pregnant women." [Source: One World Asia]