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Suicide, not child-birth complications, is the #1 cause of death among Nepali women of reproductive age, a year-long study says.
– Reported, January 16, 2012
The study by the Family Health Division (FHD) of the Department of Health Services with funding support from UK Department for International Development (DFID) and USAID was carried in carried out in 8 districtsBaglung, Jumla, Kailali; Okhaldhunga, Rupandehi, Rasuwa, Sunsari and Surkhet with a total population of 3,298,319, comprising 12 percent of Nepal’s population. The total population of women between 15-49 years was 86,000.
The study, carried out between 13 April 2008 to 13 April 2009, tracked changes in maternal mortality in the country since 1998, when the last such survey was conducted.
According to the report entitled Maternal Mortality and Morbidity Study, 2008-09: Summary of Preliminary Findings, suicide was far in the lead, accounting for 16 percent of deaths, with the second leading cause, accident, accounting for 9 percent Haemorrhage and eclampsia were the only maternal causes featuring, at 2.5 percent and 2.3 percent respectively, ranked eleventh and twelfth. This suggests that, despite improvements over the last decade, at least in management of post-partum haemorrhage, these complications still need focused attention.
The finding that suicide has emerged as the leading cause of death in Women of Reproductive Age (WRA) has shocked researchers and policy makers although some women activists have commented that the findings are not surprising, given that cases of suicide mostly remain underreported in Nepali society. In the 1998 study, suicide had ranked as the third single cause of death.
Theres also a heartening aspect in the findings. Maternal mortality rate in Nepal has improved substantially since 1998, from 539 per 100,000 live births to 229 per 100,000. A substantial reduction in the MMR, to 281 deaths per 100,000 live births was also indicated by the 2006 Nepal Demographic and Health Survey.
The report says that the shocking finding that suicide was reported as the leading cause of WRA deaths (16%), a steep increase from 1998, when it was ranked third (10%), highlights the urgent need to address this issue, which has received little attention since its significance was first noted in 1998. Research is needed to improve understanding of the circumstances and contributory factors of these tragic events, to guide interventions. Analysis of verbal autopsy data indicates mental health problems, relationships, marriage and family issues are key factors. It is also noteworthy that 21% of the suicides were young women, aged 18 years and under, indicating that youth is a factor to be investigated.
The report notes that there have been significant improvements over the past 10 years in access to routine and life saving care and prevention of maternal deaths. The findings also align with the NDHS 2006 MMR estimate, which indicates Nepal is on track to meet the fifth millennium development goal. This is a major achievement in a resource-poor setting that has suffered from political instability over much of this period. However, the stories of the hundreds of women who died during this study period are evidence of many issues that remain to be tackled.
Key findings
The overall Maternal Mortality Ratio (MMR) for the eight study districts is 229 per 100,000 live births, ranging from 153 to 301 by district. This is consistent with the 2006 Nepal Demographic and Health survey (NDHS) estimate of 281 per 100,000 live births.
MMR variations: The MMR was lowest amongst women in their twenties, with increased risk for those aged under 20 and between 30-34. The figure for those aged over 35 was considerably higher (962 per 100,000 live births). There were also differences between ethnic groups, with higher rates among Muslims, Terai /Madhesi and Dalits.
Maternal causes accounted for 93% of pregnancy related deaths, giving an overall pregnancy related mortality ratio of 247 per 100,000 live births and making this a good proxy indicator for maternal mortality.
Maternal causes accounted for 11% of all
The percentage contributions of eclampsia, abortion related complications, gastroenteritis and anaemia to maternal causes have increased, while those from obstructed labour and puerperal sepsis have more than halved since 1998. Heart disease did not even feature in 1998, but now accounts for 7%.
Place: There was an increase in the proportion of pregnancy related deaths occurring in a health facility, to 41%; with 40% occurring at home; and 14% in transit. In 1998 just 21% of deaths occurred in facilities and 67% at home.
Timing: All non-maternal pregnancy related deaths occurred during the antepartum period. Many were unwanted pregnancies, suggesting the pregnancy status of the women may have placed them at greater risk. Of the maternal deaths, 39% occurred during the intrapartum period and up to 48 hours afterwards and 61% in the antepartum and deaths of women of reproductive age, in postpartum periods suggest that third place by ICD-X chapter; down from 21% in 1998, when it was the leading cause by ICD-X chapter.
There has been a dramatic increase in the contribution of suicide (16%) to deaths of women of reproductive age, compared with 10% in 1998. This makes it the leading single cause of death, whereas in 1998 it was third.
Direct causes accounted for 69% of all maternal deaths and 31% were due to indirect causes. The proportion of direct deaths is considerably higher when only hospital deaths are considered (89% direct; 11% indirect).
The percentage contribution of haemorrhage (24%) to maternal causes has been dramatically reduced, down from 41% in 1998. However, it remains the leading cause of maternal death, and the decline reflects a reduction in postpartum (from 37% to 19%), rather than antepartum interventions should focus more on this period.
Over 80% of women who died from maternal causes were emergency admissions and in a critical state on admission: 18% died within four hours of arrival, 39% within the first twelve hours and 53% within the first 24 hours.
Supply side factors contributing to poor maternal outcomes included continued use of practices which are not evidence based, lack of appropriate staff; lack of essential drugs; weak referral systems and lack of blood.
Community factors contributing to poor maternal outcomes included delays in recognising the problem and deciding to seek care; long distances to a health facility; lack of finance and/or transport or time taken to make arrangements; seeking care from the informal sector; not being able to or not wanting to seek care alone or needing permission to seek care.
Credits: Nepal Monitor
More information: http://www.nepalmonitor.com/2010/01/suicide_1_cause_of_d.html
– WF Team