Benchmarking progress in Nepal

In assessing neonatal and maternal mortality progress in Nepal, it is valuable to contextualize this progress in comparison with peer countries and international targets. Although lessons from Exemplar countries like Nepal are designed to provide insights for peer countries, Exemplar countries themselves can still benefit from cross-country comparisons. Positioning progress on an international scale is important to understand trajectories of mortality reduction, potential future challenges, and progress toward global targets.

The maternal and peri-neonatal mortality transition framework

Multi-country comparison

Nepal’s reductions in neonatal and maternal mortality make the nation stand out clearly as an Exemplar country. Nepal is on track to reach its national Sustainable Development Goal (SDG) target of 116 maternal deaths per 100,000 live births as well as the neonatal mortality rate SDG of 12 neonatal deaths per 1,000 live births ahead of 2030.

Nepal’s maternal mortality ratio in 2020 was 174.4 maternal deaths per 100,000 live births, and its neonatal mortality rate in 2021 was 16.2 neonatal deaths per 1,000 live births.^1,2 Although Nepal serves as an Exemplar country in our study, findings from other Exemplar countries could still prove valuable in helping the country accelerate and/or sustain progress toward the SDG targets.

Learnings from a multicountry analysis using an integrated maternal, neonatal, and stillbirth mortality transition framework could prove useful as Nepal looks to further reduce neonatal and maternal mortality. In this framework, mortality levels are categorized into five phases, with phase I indicating higher mortality levels and phase V indicating lower mortality levels (for example, see Figure 31 below). The transition framework is a tool that can be used to benchmark country progress and chart a path to progress—with distinct drivers generally most prominent in certain phases of the transition framework.

Stepwise trajectory to progress

From 2000 to 2020, Nepal progressed from phase II to phase III on the transition framework. Now in phase III, Nepal looks to continue its trajectory into phase IV as it closes in on SDG targets.

Through the multicountry analysis, we identified key factors associated with advances along this transition, as outlined in Figure 32 below. Advancements beyond phase I were often linked to increased contraceptive use and fertility declines. Further progress through phases II and III often occurred as coverage of antenatal care (ANC), institutional delivery, skilled birth attendance, and postnatal care (PNC) improved, in part due to an expansion of physical infrastructure and human resources for health. This often led to a transition in causes of death in phase III, as preventable deaths, often by way of infectious disease, shrank and indirect causes contributed to a growing share of deaths. Finally, transitions to phase IV and V frequently reflected a prioritization of health equity, as vulnerable communities gained access to interventions previously more accessible to wealthier, more urban, or highly educated communities.

Nepal is currently situated in phase III. Programs and policies described in this narrative have driven the country’s progressions, such as safe motherhood policies and programs that incentivized usage of health care services and removed user fees, and the female community health volunteer program to bridge gaps between health facilities and communities. Nepal expanded the health facility network, especially in rural and mountainous regions, and implemented the National Policy on Skilled Birth Attendants to improve the number and skills of health professionals. The Nepal Safe Motherhood and Newborn Health Road Map 2030 continues to build on strong progress from the past two decades with programs to improve access, coverage, and quality of services.³

According to the transition framework, to advance beyond phase III and into phases IV and V, the next challenge for Nepal is to narrow existing equity gaps. As such, the following sections of this report will highlight trends in health care equity.

Progressing toward the Sustainable Development Goals

As highlighted in this report, Nepal has made exemplary progress in reducing neonatal and maternal mortality in the past two decades and is positioned to reach the SDG targets, assuming the country maintains the rate of progress it has experienced over the last two decades. To attain the national SDG target of 116 maternal deaths per 100,000 live births, Nepal will need to achieve an average annual reduction rate (AARR) of 3.96%, which is below the 5.17% observed from 2000 to 2020 and the 6.71% observed from the 10 years from 2010 to 2020.¹ Nepal is also on track to meet the SDG target of 12 neonatal deaths per 1,000 live births by 2030. The country would need a 3.26% AARR to meet this goal, lower than the 4.13% AARR observed from 2000 to 2021 and the 4.35% AARR observed since 2010.² See Figure 33 below for an illustration of Nepal’s trajectory.

Equity trends for key reproductive, maternal, newborn, and child health indicators in Nepal

In the last 20 years, key indicators such as modern contraceptive coverage, ANC coverage, institutional delivery rates, rates of C-section, and PNC coverage have generally become more equitable across several dimensions. In particular, several indicators have near equal coverage across residence groups, such as family planning (FP) demand satisfied using modern methods, ANC coverage, and neonatal PNC and maternal PNC coverage. This suggests that Nepal’s efforts to target rural areas have been successful.

Nepal has been reducing health disparities through the policies and programs described above, which have driven progress to its current state at phase III in the transition framework. However, equity gaps persist along income gradients, especially in C-section rates and institutional deliveries. As countries progress through the integrated maternal, neonatal, and stillbirth mortality transition framework, reducing equity gaps tends to be a key factor for success as countries advance to phase IV, which is a critical next phase for Nepal’s continued progression.

Family planning

FP has been at the core of Nepal’s maternal health strategy since 1959. FP services are an area in which access across wealth quintiles is more equitable than other indicators.⁴ For example, in 1996, the gap between the wealthiest and poorest quintiles in FP demand satisfied using modern methods was 33.5% in favor of the wealthiest quintile.⁵ By 2022, the gap had been eliminated, with slightly higher demand satisfied among the poorest quintile as compared with the wealthiest quintile (see Figure 34 below).⁵ Though the reduction of equity gaps is encouraging, this gap suggests that progress among the wealthiest communities has stalled.

Equity gaps also persist among other indicators of FP services, such as unmet need, where 24.7% of need was unmet among married women in the poorest quintile compared with 16.9% of married women in the wealthiest quintile.⁵ Such variation in metrics related to FP coverage and usage indicates that inequalities still exist in FP services between wealth groups.

In 1996, the gap in FP demand satisfied between urban and rural populations was 22.8%.⁵ By 2022, this gap had been mostly eliminated, with rural populations seeing 6.8% higher coverage than urban populations (see Figure 34 below).⁵ Slowing uptake in the urban groups suggests this part of the population is opting for other, traditional contraceptive options or not using FP at all. Similar variation is also visible across ecological zones. In 2022, demand satisfied using modern methods among currently married women was 61.2% in mountain, 50.3% in hill, and 57.2% in terai ecological zones.⁵ The phenomenon of plateauing demand satisfied in urban areas and hill ecological zones, especially from 2016 to 2022, may be influenced by post-earthquake effects as Nepal continues to rebuild health services.⁵ Geographically, the gap between provinces in demand satisfied by modern FP methods was 14.2% in 2022, with Gandaki having the lowest coverage at 44.2% and Karnali having the highest coverage at 58.4% (see Figure 34 below).⁵

One important factor affecting contraceptive use is cyclical patterns of male migration. As of 2021, approximately 2.1 million Nepalis worked abroad. Nepal’s percentage of gross domestic product from remittances grew from 1.0% in 1996 to 22.8% of gross domestic product in 2022.^6,7 Over a third of married women had husbands working abroad in 2016; women with migrant husbands often have lower contraceptive usage, pausing usage while their partner is away.⁸ Data from Nepal’s Central Bureau of Statistics suggest that in 2012, 56% of families in Nepal received remittances, which on average made up 31% of their household income.^9,10 Increased cyclical male migration to work abroad could be contributing to stagnation in the uptake of FP products in wealthier quintiles and urban populations.

Nepal has seen FP indicators increase in equity but plateau in some populations over the past decade. Though the majority of health facilities offer at least one contraceptive method and nearly all offer FP services, frequent stockouts still occur, especially in rural areas, and only one in five facilities that offer FP services provide long-acting reversible contraceptives.^3,4,10 In the past five years, exposure to information about FP among both women and men has also decreased.³ Nepal will need to develop new strategies to promote FP across residences and wealth quintiles to close the gaps and increase overall access to FP products and services.

Antenatal care

In 1996, the coverage gap between the wealthiest and poorest quintiles for women attending at least four antenatal care visits (ANC4+) was 28.7%.⁵ All wealth quintiles have since seen large increases in coverage, and this gap decreased to 18.1% by 2022, as shown in Figure 35 below.⁵ One likely driver of the increases in coverage is an incentive introduced in 2009 for women who had ANC4+, delivered in a facility, and completed one PNC visit. The drop in ANC4+ coverage for the wealthiest quintile from 90.3% in 2011 to 85.3% in 2016 may be a result of ongoing service disruption from the earthquake. The rise to 92.6% in 2022 for this group suggests that Nepal’s health systems have strengthened once again, especially in terms of strong primary health care services.

The urban–rural gap in ANC4+ coverage decreased from 28.2% in 1996, with urban areas having higher coverage than rural areas, to 2.9% in 2022, with rural areas having higher coverage than urban areas (see Figure 35 below).⁵ This rapid progress in rural groups’ access to ANC suggests the FCHVs and targeted incentives have been impactful. However, similar to FP, the data also suggest recent stagnation for urban groups from 2011 to 2022, when urban ANC4+ coverage increased slightly from 73.7% to 79.5%.⁵ As described in the What Did Nepal Do? section, this may be a result of large urban areas such as Kathmandu being affected by the earthquake. Given the magnitude of the disaster, Nepal’s ability to maintain and even make these improvements in coverage speaks to the resilience of communities and health systems.

Between provinces, coverage in 2022 varied substantially, with the province of Madhesh having the lowest ANC4+ coverage at 68.4% and the province of Sudurpashchim having the highest ANC4+ coverage at 90.0% (see Figure 35 below).⁵ Though Madhesh is in the terai ecological zone, the province is one of the most resource-limited and densely populated provinces of Nepal, with 630 people per square kilometer compared with Nepal’s average of 203 people per square kilometer. Madhesh had 21% of Nepal’s population in 2019; however, they had the lowest per capita health budget allocation of all provinces that year. Madhesh had an allocation of 2,751 Nepali rupees (NPR) compared with an average allocation of NPR 3,086 for Nepal as a whole, which may have contributed to lower levels of access to health care services.^11,12 Similar trends were also reflected in the ecological zone breakdowns of ANC4+ coverage in 2022, with 90.5% coverage in the mountain zone, 86.5% coverage in the hill zone, and 76.0% coverage in the terai zone.⁵

In 2022, 94.3% of women reported receiving ANC from a skilled provider compared with 24.8% in 1996.⁵ Even though these improvements have been made for many groups, the provider of ANC still varies by wealth quintile. Among women in the wealthiest quintile, 89.1% reported receiving ANC from doctors in 2022, whereas only 9.0% reported receiving ANC from nurses/midwives.⁵ In contrast, 26.7% of women in the lowest wealth quintile reported receiving ANC from a doctor in 2022, while 63.8% reported receiving ANC from a nurse/midwife.⁵

Several markers of service provision can offer a degree of insight into the quality of care provided at ANC. The ANC quality index combines indicators from Demographic and Health Surveys about the number and timing of ANC visits, as well as other components of ANC reported by women, such as seeing a skilled provider in at least one ANC visit, blood pressure measurement, blood sample collection, urine sample collection, and provision of at least one shot of tetanus toxoid vaccination. In this index, ANC quality ranges on a scale of 1 to 10. Gaps in the ANC quality index between wealth quintiles have narrowed over recent decades: in 2001, the poorest quintile had a score of 1.7, whereas the wealthiest quintile had a score of 5.7. By 2019, these values had respectively improved to 7.0 and 8.6, suggesting overall progress and accelerated quality improvements in the poorest quintile.¹³ These figures indicate substantial progress in certain markers of ANC quality for the poorest quintile in roughly two decades, an achievement for Nepal’s health system and a testament to its strength through periods of change.

Institutional delivery

Institutional delivery rates have grown substantially for all groups, from single digit percentages for most quintiles in 1996 to 65.8% for the poorest quintile and 97.6% for the wealthiest quintile in 2022.⁵ However, the gap between the wealthiest and poorest groups widened slightly from 1996, when the gap was 29.2%, to 31.8% in 2022, as shown in Figure 36 below.⁵ Despite deliveries being free in public facilities, delivery services are still often associated with treatment costs above and beyond what is covered, resulting in large out-of-pocket costs: this factor likely contributes to lower coverage among the poorer quintiles.³

The urban–rural gap in institutional delivery has decreased greatly, from 39.0% to 4.4% between 1996 and 2022, indicative of intentional expansions of programming and higher-level health facilities in rural areas, as well as overall incentives for facility-based delivery (see Figure 36 below).⁵ However, it appears that progress has plateaued in the last decade in urban areas, from 79.2% coverage in 2011 down to 73.5% in 2016 and back up to 80.9% in 2022.⁵ A dip in urban area institutional delivery coverage in 2016 was likely because of the 2015 earthquake’s effects destroying and damaging health facilities; a return to 2011 levels by 2022 suggests that Nepal has been able to successfully rebuild the physical infrastructure associated with its health care system and encourage women to deliver in facilities.

Geographically, women in the mountainous ecological zones are less likely to deliver in a facility.¹⁴ In 2022, institutional delivery was at 75.3% in the mountain zone, 81.6% in the hill zone, and 78.6% in the terai zone.⁵ Karnali, a province with mountainous and hill zone districts, had the second-lowest institutional delivery by province at 79.1% in 2022.⁵ However, ecological zone is not the only driving factor in institutional delivery, as the province of Madhesh had the lowest institutional delivery rate by province at 66.8% in 2022, yet it is made up of terai zone districts.⁵ Institutional delivery rates were highest in Bagmati in 2022 at 88.3%.⁵ Bagmati has the capital city, more wealthy households, and a dense distribution of both private and public health care facilities that support institutional delivery. See Figure 36 below for all provinces’ institutional delivery rates.

C-section

Although Nepal’s rising C-section rate at the national level suggests increased access to comprehensive health care services, it is crucial to note that the gap in C-section rates between the wealthiest and poorest wealth quintiles multiplied nearly 10-fold from 1996 to 2022, increasing from 3.5% to 32.4% (see Figure 40 below).⁵ In 1996, all quintiles had C-section rates below 4%, whereas in 2022, the wealthiest quintile had a C-section rate of 38.4% and the poorest quintile had a C-section rate of 6.0%.⁵ According to the 2022 Demographic and Health Survey, private-sector institutions had a C-section rate of 51.4%, compared with 15.1% in public facilities.⁵ Women in the wealthiest quintile in 2022 delivered in a private facility 31.4% of the time, compared with 6.9% of women in the poorest quintile, meaning more wealthy women received C-sections during delivery.⁵

Substantial differences also existed by province in 2022, with Karnali’s C-section rate at 5.8%, compared with Bagmati’s nearly sixfold rate at 34.6%, as shown in Figure 41 below.⁵ Sudurpashchim had the second-lowest C-section rate by province at 7.8%.⁵ Both Karnali and Sudurpashchim have mountainous and hilly zone terrain, relatively long travel times to health facilities, and lower availability of health care practitioners—all likely contributing to lower C-section rates.³ In the mountain ecological zone more broadly, accessibility of secondary facilities is lower when farther from district centers and often requires upward of 90 minutes of travel time by motorized transport.¹⁵ Accessibility of tertiary facilities is extremely low in the mountain zone districts in the northern parts of Sudurpashchim, Karnali, Gandaki, and Koshi.¹⁵

By urban or rural residence, the gap in C-section rates increased from 3.8% in 1996 to 9.5% in 2022, a narrower disparity than the one that exists across wealth quintiles (see Figure 40 below).⁵ Urban residents have a C-section rate of 21.5%, higher than the 10.0% threshold rate that the World Health Organization indicates, above which higher C-section rates likely confer a minimal overall effect on reducing maternal mortality.¹⁶

Postnatal care

Wealth equity for maternal PNC is improving, as shown in Figure 38 below. The gap between the poorest and wealthiest quintiles decreased from 31.6% in 1996 to 16.5% in 2022.⁵ The gap between urban and rural groups for this indicator has also decreased, from 13.3% in 2006 to 2.9% in 2022.⁵ The reduction of equity gaps for maternal PNC both by wealth quintile and residence is a positive sign overall and suggests that policies targeting the rural and the poor have been successful. However, progress for maternal PNC has stagnated at approximately 60% coverage. 5 Maternal PNC coverage in urban areas dipped from 55.7% in 2011 to 49.1% in 2016 but returned to 54.4% by 2022.⁵ In context of the earthquake’s impact, especially in Kathmandu, improving maternal PNC provision overall and maintaining coverage levels in the following years for wealthier quintiles and urban groups are accomplishments. Moving forward, Nepal will need to continue to improve coverage for all groups to ensure all mothers receive care shortly after delivery.

Compared with 2011, a greater proportion of neonates received PNC within 1 hour of birth in all wealth quintiles except for the wealthiest quintile in 2022 (see Figure 39).⁵ However, the indicator peaked for all quintiles in 2016, ranging from 19.5% for the poorest quintile to 25.6% for the second-wealthiest quintile. It regressed in 2022, ranging from 13.7% for the poorest quintile to 18.3% for the wealthiest quintile.⁵ The gap between richest and poorest quintiles for neonatal PNC within 1 hour of birth decreased from 2006 to 2022, from 15.9% to 4.6%.⁵ It is notable that Nepal was able to make gains in the years immediately following the earthquake and improve equity between wealth quintiles.

Urban and rural coverage of neonatal PNC within 1 hour after birth demonstrated slight decreases from 2011 to 2022, from 17.9% in 2011 to 16.7% in 2022 for urban areas and from 20.4% in 2011 to 17.9% for rural areas.⁵ However, neonatal PNC in 1 to 3 hours after birth over the same time period increased more than this slight decrease (as shown in the What Did Nepal Do? section), suggesting that neonates are still receiving this essential care, albeit at a later time. Another positive sign is that the gap between urban and rural coverage of neonatal PNC within 1 hour after birth was small at 1.2% in 2022, suggesting equivalent access to this service between these groups.⁵

Geographically, Lumbini had both the highest coverage of maternal PNC within 4 hours at 61.9%, and neonatal PNC within 1 hour at 24.8% coverage in 2022.⁵ Sudurpashchim had the second-highest coverage by province for maternal PNC and the third-highest for neonatal PNC this same year. In 2022, Karnali had the lowest coverage for the maternal indicator at 43.4%, and Bagmati had the lowest for the neonatal indicator at 9.9%.⁵ See Figure 38 and 39 below for the coverage rates in all provinces.