Around half of the births in Nepal take place with no trained birth attendant present. Maternity waiting homes, where mothers with high-risk pregnancies can stay during the final period before their due date, can make it practically possible for more of them to give birth in hospital. The measure is particularly beneficial for young, primiparous women.
Is it medically prudent to give birth at home? This topic was recently debated in the Journal of the Norwegian Medical Association (1). In this article I wish to provide some perspectives from a rural district in Nepal. Viewed from here, the issue looks quite different.
Mother and child mortality is on a downward trend in most low- and middle-income countries. In Nepal, both maternal mortality and infant mortality have also been reduced. In 2015, they stood at 258 per 100 000 births and 21.9 per 1 000 live births, respectively (2). These levels are still high, so further efforts in these areas must be prioritised. Almost half of all births in Nepal still take place with no trained birth attendant present (3), and two-thirds of maternal deaths occur outside of health institutions (4). It is therefore essential to work towards enabling more births to take place in health institutions under the supervision of qualified personnel.
Nepal is among the world's least developed countries. Total health spending per inhabitant in 2014 amounted to USD 137, while the corresponding figure for Norway was USD 6 347 (5). With so little money available, it is even more important to find cost-effective health measures.
The small Okhaldhunga Community Hospital in Eastern Nepal (6) is situated in rural surroundings with scattered settlements (Fig. 1). I have worked here for the last 14 years. The hospital now sees well over one thousand births per year, but we still see disastrous effects resulting from pregnant women failing to obtain qualified assistance in time. Much of the problem has been that they have relied on a home birth. Heavy postpartum haemorrhage alone causes 25–30 % of maternal deaths here in Nepal (7), about the same as in most poor countries in Asia and Africa (8). In a population of more than 250 000 people in Okhaldhunga District, this alone represents a number of deaths annually. Obstructed labour due to mechanical anomalies or an undiagnosed abnormal fetal position is also common. For those who fail to reach the hospital in time, this may lead to ischaemic injury with lifelong sequelae in the child or fetal death, possibly also uterine rupture and risk to the mother's life. This brings us to the heart of the matter: In a part of the world where maternal mortality is high and transport is slow and costly, how can we ensure that women in labour reach the hospital in time?
In the last ten years the number of hospital births has increased from 211 to 1 126 (Fig. 2). There are several reasons for this. Firstly, the district gained a permanent road connection to the outside world around eight years ago, and the number of roads increased and improved. Secondly, until five years ago women in labour had to pay for maternity care at the hospital themselves. There is also reason to believe that the increase is partly attributable to the offer to stay at a maternity waiting home close to the hospital in the final days or weeks before the due date. We have recently reviewed the experiences gathered from this home. Since maternal healthcare work is a high priority for Norwegian development assistance for health, these experiences may also be relevant to other places.