What did Nepal do?

Nepal has prioritized maternal, reproductive, and newborn health over the past few decades even while passing through periods of political transition. Nepal has improved key indicators of health system coverage for maternal and neonatal health by expanding health infrastructure and human resources and developing targeted programming with incentives. Along the continuum—from contraceptive access, antenatal care (ANC), and institutional delivery to postnatal care (PNC)—interventions are increasing in quality and reach for more Nepali women and children.

Improvements in reproductive, maternal, newborn, and child health indicators

Contraception access

Nepal’s government-supported family planning (FP) programs have been active since 1968, when the head of state endorsed the United Nations Declaration on Population, which stated that FP was a basic human right and an important factor in development planning.¹ Before the turn of the century, static clinics, hospitals, and mobile outreach camps (sibir) were key channels to reach women.² The mobile outreach camps were an important modality for access to contraceptives, especially in rural areas; in 1998, mobile outreach camps accounted for 40% of female tubal ligation procedures.² Nonreversible methods of contraception were strongly emphasized before the 1980s; knowledge and use of reversible methods of contraception were low.¹

In addition to government facilities and expanded programming, female community health volunteers (FCHV) have also promoted FP in the community since the inception of the FCHV program in 1988. Nepal’s emphasis on FP through this program and others contributed to a more educated population on this topic: awareness of at least one modern contraceptive method among currently married women of reproductive age increased from 21% to 93% among married women of reproductive age from 1976 to 1991.³ The FCHV program is discussed in more detail in the How did Nepal implement? section.

From 1996 to 2022, modern contraceptive prevalence among married women increased from 26.0% to 42.7%, as shown in Figure 11.⁴ Over this same time period, the demand for FP satisfied by modern methods increased from 42.8% to 54.7%, peaking in 2006 at 60.9%.⁴ Female sterilization and injections remained the most common forms of contraceptives between 2001 and 2022, with 13.4% and 9.3% of married women in 2022 using these methods. Female sterilization rates have gradually decreased since 2006, when 18% of married women reported using the method. Pills and condoms were each used by about 5% of married women as of 2022.

Intrauterine devices (IUDs) and implants were hard to access in the past. In 1992, only 10% of health facilities provided these services, but this rate has been growing quickly.² As of the 2021 Nepal Health Facility Survey, 95% and 97% of surveyed facilities respectively had IUDs and implants available.⁵ IUD and implant usage has increased 2.3 times and 9.2 times, respectively, since 2001, with 1.3% and 6.1% of married women using these methods in 2022.⁴ Despite notable progress in recent decades, advancements in recent years have stalled. Though maintaining modern contraceptive prevalence at 42.7% in both 2016 and 2022 speaks to the resilience of Nepal’s health system in the face of the 2015 earthquake, prolonged stagnation may present a challenge for Nepal’s future reductions in maternal and neonatal mortality.

As contraceptive use has increased over the last three decades, women in Nepal have had fewer children. The total fertility rate in Nepal declined from 4.1 live births per woman in 2001 to 2.1 in 2021 according to DHS data.⁴ As shown in Figure 12, declines in age-specific fertility rates were observed for all age groups, with particularly strong decreases for women ages 20 to 24 and 25 to 29. Women who were first married by age 15 decreased from 14.4% in 1996 to 2.8% by 2022, which reflects the decrease in births from younger women.⁴

Antenatal care coverage

Women in Nepal are receiving ANC earlier and more often, as shown in Figure 13. The percentage of women receiving at least one ANC visit from a skilled provider nearly doubled from 49% in 2001 to 97% in 2022.⁴ One policy that likely contributed to increased ANC coverage was the incentive introduced in 2009 for women for completing four ANC visits, delivering in a facility, and attending one PNC visit. After implementation of this policy, the percentage of women completing at least four ANC visits from skilled providers rose from 56.4% in 2011 to 86.3% in 2022.⁴ Incentives are discussed in more detail in the How Did Nepal Implement? section.

Especially in the 1990s and early 2000s, female community health workers (FCHVs) also helped refer women to ANC visits. A national survey in 2014 found that 95% of FCHVs had referred pregnant women for an ANC visit in the year prior to the survey.⁶ ANC often began earlier as well, with 73% of women in 2022 receiving their first ANC visit during their first three months of pregnancy, compared with only 16% in 2001.⁴

Antenatal care quality

In addition to ANC coverage increasing, markers that may reflect the quality of these visits have improved. During at least one of their ANC visits in 2022, 94.6% of women reported having their blood pressure taken, 94.6% of women reported being weighed, 89.9% of women reported providing a urine sample, and 86.1% of women reported providing a blood sample.⁴ All of these key indicators have increased substantially since 2001, as seen in Figure 14, suggesting that women are receiving more standardized components of high-quality ANC.⁴

ANC visits are also increasingly provided by different skilled health cadres, contributing to increases in overall quality of care.⁴ In 2022, 55.1% of women reported receiving ANC from doctors and 39.3% reported receiving care from nurse/midwives. These figures reflect an increase from 2001, when 16.6% of women reported receiving care from doctors and 11.2% of women reported receiving care from nurse/midwives.⁴

Institutional delivery

Nepal has made substantial progress in transitioning deliveries from homes to medical facilities, as shown in Figure 15 below. The rate of home births rapidly declined in the previous two decades: in 2001, 87.6% of births occurred at home in Nepal, compared with 18.7% by 2022.⁴ The most rapid growth during this period was among births at public facilities, which only accounted for 7.3% of all births in 2001 but constituted 61.6% of all births in 2022.⁴ Public facilities also accounted for the majority of facility births in 2022, making up 77.7% of all births in a facility. Private facilities accounted for only 17.7% of births in 2022, indicating the strength of Nepal’s health system, which has allowed for stronger uptake of free and high-quality services provided through the public sector.

Various policies in this time period promoted increased access to delivery services, starting with the Maternity Incentive Scheme in 2005 that provided a financial incentive that offset transport costs for women delivering in hospitals. In 2006, additional delivery-related incentives were provided to health workers and hospitals, and free delivery was piloted in 25 districts. Across the country, user fees were then eliminated for all types of delivery, including C-sections, in 2009. Between 2006 and 2022, delivery in public and private facilities rose from 19.9% to 79.3%—an increase in coverage of nearly 60%.

Several interviewees mentioned the rapid rise in institutional delivery, such as a retired government official who said:

Skilled birth attendants

Nepal’s health workforce has grown significantly over the past two decades, thanks to the significant growth in the number of training institutes and qualified trainers. The draft of HRH strategy produced in 2012, and the National HRH Strategy 2021-2030 outline the challenges in estimating the required number of HRH, then producing, recruiting, motivating and retaining HRH. Despite challenges, notable progress has been made in overall HRH management. In 2004, Nepal had 2.07 doctors and 4.55 nurse/midwives per 10,000 population. In 2021, these figures multiplied by fourfold for doctors and nearly eightfold for nurse/midwives, to 8.67 doctors per 10,000 population and 34.89 nurse/midwives per 10,000 population (See Figure 16). However, this density of HRH varies across ecological zones and provinces, with lower density in many rural and mountainous areas. Data limitations in HRH management tools, such as registered provider lists, may lead to health workforce data to not be comprehensive of all provider types across geographies.

Specific to maternal and newborn health, Nepal’s 2006 National Policy on Skilled Birth Attendants (SBA) has had a positive impact on improving access to and quality of MNH services through better availability of SBA. This policy introduced short-, medium-, and long-term strategies for improving the skills and number of health care workers, which are described in more detail in the National Policy on Skilled Birth Attendants subsection within the How did Nepal Implement? section.

In line with increases in institutional delivery, the percentage of births attended by a skilled provider (e.g., doctor, nurse, midwife) grew from 14.4% in 2001 to 80.1% in 2022.⁴ The short-term actions in the National Policy on Skilled Birth Attendants⁷ helped introduce additional training for these skilled birth attendant staff, shift tasks to nurses in areas with shortages of health personnel, and train more doctors in C-section surgeries. In 2022, the percentages of women who reported skilled birth attendance from doctors and nurse/midwives were nearly equal.⁴ This evidence similarly suggests that births by traditional birth attendants have declined over time, from 23% of births in 2001 to 6.3% of births in 2022, in line with Nepal’s discontinuation of training this type of health worker in 1997.⁴ See Figure 17 above for further detail.

Caesarean section

Nepal’s C-section rate has increased over time, from 0.9% in 2001 to 18.2% in 2022—a 20-fold increase in two decades (see Figure 18 below).⁴ As mentioned earlier in the Institutional Delivery section, several key policies in this time period increased access to delivery services, which in turn also can translate to increased C-section rates. User fees were eliminated for all types of delivery, including C-sections, in 2009. C-section rates in Nepal tripled from 2011 to 2022. Additionally, Nepal launched initiatives to upskill health workers starting in 2006 as part of the National Policy on Skilled Birth Attendants,⁷ such as providing additional advanced training in C-sections for doctors, especially for those who work in rural areas.

An analysis of 2016 Demographic and Health Survey (DHS) data found that C-section rates increased for higher-income women, older mothers over 30 years old, and women with a high body mass index, high birthweight babies, and four or more ANC visits.⁸ C-sections were also more common in private institutions: another analysis of DHS data suggests C-section rates in private facilities increased threefold from 8.9% in 1996 to 26.3% in 2016.⁹ The 2022 DHS also found that 51.4% of private facility births were delivered by C-section, compared with 15.1% of deliveries by C-section in public-sector health facilities. Additional literature suggests that some large private hospitals near Kathmandu have C-section rates of 40% to 50%.^4,10

While C-sections are a lifesaving intervention for mothers and newborns in case of obstetric complications, particularly high C-section rates among the demographics discussed above indicate that a substantial portion are likely not medically necessary. The World Health Organization has previously indicated that C-section rates that exceed 10% are not necessarily associated with a reduction in a country’s maternal mortality ratio.¹¹ When considering the coverage and potential overuse of C-section as an intervention, it is crucial to assess this procedure by its use across demographic dimensions; this is explored in the Benchmarking Progress in Nepal section.

Maternal, postnatal, and neonatal care

Coverage of PNC for mothers within 4 hours of birth increased from 14.9% in 2006 to 53.4% in 2022.⁴ The proportion of mothers who received no PNC decreased from 77.4% in 2006 to 27.7% in 2022.⁴ See Figure 19 below for more detail. During this same time frame, the proportion of mothers who reported receiving PNC from doctors, nurses, or midwives increased from 18.2% to 67.3%.⁴

More neonates in Nepal are receiving care, and this care is increasingly occurring earlier in their lives, as shown in Figure 19 below. In 2022, 64.2% of neonates received care within their first day of life, compared with 27.8% in 2011.⁴ The percentage of neonates not receiving PNC care decreased over this period from 68.0% to 27.5%.⁴ Mothers reported that key early life functions performed within two days of birth—such as cord examination, temperature measurement, counseling on danger signs, counseling on breastfeeding, observation of exclusive breastfeeding practices, and weighing—increased on average 10 percentage points between 2016 and 2022.⁴ Mothers reported that cord examination and temperature measurement both increased the most from 2016 to 2022, from 43.9% to 54.6% and from 42.8% to 52.9% of neonates, respectively.⁴

Though coverage has improved overall, PNC is accessed less frequently than ANC and institutional delivery. Continuity of care can be poor: an analysis of 2016 DHS data found that mothers and newborns can be discharged early from health facilities due to multiple facility and human resource constraints, and there is no system of follow-up at home during the postnatal period.^12,13 The Nepal Safe Motherhood and Newborn Health Road Map 2030 recommends home-based PNC to ameliorate these gaps.¹² Another reason PNC visits are less frequent is that only one PNC visit was required as a final step to receive the incentive for attending four ANC visits in the Safe Motherhood Program, part of Nepal’s overall plan to improve maternal and neonatal mortality.¹⁴ A separate PNC incentive has not been developed. The Safe Motherhood Program and other incentives are discussed in the How Did Nepal Implement? section.

Connecting reproductive, maternal, newborn, and child health indicators to mortality reductions

Fertility decline as a major driver of neonatal and maternal mortality declines

Nepal has seen large decreases in fertility over the past three decades, with the total fertility rate declining from 4.1 births per woman in 2001 to 2.1 in 2021 according to DHS data. Lower fertility rates translate to fewer high-risk pregnancies, longer birth intervals, and reduced birthrates among adolescents.

Our analysis, using Jain’s decomposition method, isolates the impact of fertility declines on maternal and neonatal mortality, leveraging UN estimates of fertility and mortality. Fertility decline alone in Nepal was found to explain 44% of maternal mortality reduction and 47% of neonatal mortality reduction.¹⁵ These mortality reductions due to only fertility decline correspond to 840 fewer maternal deaths in 2017 and 9,695 fewer neonatal deaths in 2019 than would have been expected if fertility levels had stayed constant since 2000. This decomposition approach attributes other improvements to “safe motherhood” initiatives, a term used to collectively refer to improving quality and coverage of interventions, such as ANC, institutional delivery, skilled birth attendance, and emergency care services.

Together, fertility decline and safe motherhood initiatives led to 4,572 maternal lives saved in 2017 and 31,380 neonatal lives saved in 2019 compared to what would have been expected if fertility rate and care coverage levels had remained constant since 2000. This result, illustrated in Figure 20, highlights the impact of fertility decline as a key driver of neonatal and maternal mortality decline, in tandem with other health care indicators commonly associated with neonatal and maternal mortality decreases.

Lives saved by intervention analysis

An analysis using the Lives Saved Tool was conducted, incorporating 15 maternal interventions and 14 neonatal interventions that were found to save lives as these interventions’ coverage improved from 2000 to 2022. The Lives Saved Tool uses estimates of intervention coverage, effectiveness of interventions, and estimates of NMR and MMR to model the contribution of each intervention to mortality reductions.¹⁶ However, at the time of this analysis, the only survey on facility readiness available to be input to the LiST analysis was the 2015 Service Provision Assessment (SPA) survey. While this analysis provides insight into the magnitude of intervention impact, exact numbers of lives saved should therefore be interpreted with caution.

The analysis estimated a total of 11,820 additional maternal lives saved from 2000 to 2022 due to increased intervention coverage. Most of the additional maternal lives saved were attributed to interventions during childbirth, which accounted for 92.3% of additional lives saved. Within this category, the largest contributors to maternal lives saved were cesarean delivery, uterotonics, magnesium sulfate, and assisted vaginal delivery. Uterotonics are used in the prevention and treatment of postpartum hemorrhage; magnesium sulfate is used to prevent complications from pre-eclampsia and eclampsia as well as temporarily slow preterm labor. Respectively, increased coverage of these four interventions explained 2864, 2332, 1508, and 1018 maternal lives saved cumulatively between 2000 and 2022. Cesarean section alone explained 24.2% of additional maternal lives saved over this period.

The analysis estimated a total of 103,955 additional neonatal lives saved from 2000 to 2022. The intervention that contributed the most to additional neonatal lives saved was case management of neonatal sepsis/pneumonia. Improved coverage of this single intervention accounted for 23,502 additional neonatal lives saved between 2000 and 2022, representing 22.6% of the total number of additional neonatal lives saved during this time due to increased intervention coverage. Outside of this category, most of the neonatal lives saved were attributed to interventions during childbirth, which accounted for 71.2% of additional neonatal lives saved. The largest contributors to neonatal lives saved during childbirth were cesarean delivery, neonatal resuscitation, assisted vaginal delivery, and thermal protection. Respectively, increased coverage of these four interventions accounted for 17,869, 14,897, 11,893, and 9,601 additional neonatal lives saved cumulatively between 2000 and 2022.

For both maternal and neonatal lives saved, gradual increases between 2005 and 2009 may be linked with the expansion of the Safe Motherhood program, removal of user fees in some districts with lower socioeconomic status, and its incentives to women, health facilities, and healthcare workers. Rapid increases in lives saved are also visible after 2009, when user fees for delivery care were removed for women in all districts of Nepal. These programs helped encourage institutional delivery and access to lifesaving interventions. More details can be found below in the How did Nepal Implement? section.

Hierarchical neonatal mortality decomposition

The rapid reduction in neonatal and maternal mortality seen in Nepal is driven by interconnected distal, intermediate, and proximate factors. Distal factors reflect upstream social, political, and economic influences. Intermediate factors include programs and services that influence people’s ability to access high-quality health care as well as household and individual contextual factors that influence health-seeking behavior. Proximate factors include variables immediately relevant to individuals seeking health care, playing more direct roles in influencing health outcomes.

Using these distinct categorizations, a multivariable hierarchical decomposition analysis was conducted for the period 2001 to 2022. Through this analysis, we aimed to produce findings that could yield more granular insights than the fertility-based Jain’s decomposition analysis presented earlier while still reflecting the influence of broader variables that cannot be captured in an intervention-based lives saved analysis. This analysis was conducted only for the reduction of neonatal mortality—not maternal mortality—due to the relative rarity of maternal mortality as compared with neonatal mortality, resulting in scarce individual-level maternal mortality data. Overall, the factors considered in this hierarchical decomposition model were found to account for 92% of neonatal mortality decline.

In this analysis, the proximal driver of skilled birth attendance was identified as a key contributor to neonatal mortality reduction in Nepal. Skilled birth attendance coverage rose substantially from 14.4% in 2001 to 80.1% in 2022.⁴ Our analysis found that 46% of neonatal mortality decline can be attributed to this increased SBA coverage. An important note is that skilled birth attendance coverage is highly collinear with institutional delivery coverage, so this component captures the effects of both factors. Additionally, this result does not speak to the effect of varying SBA quality, including differences in education, standards of practice, or enabling environments in which SBAs work. Key policies and programs, which are described in the How Did Nepal Implement? section, influenced the availability of skilled birth attendants and health facilities while encouraging women to deliver in institutions, such as the 2006 National Policy on Skilled Birth Attendants,⁷ health facility expansion, and the range of incentives in the Safe Motherhood Program.

Several intermediate factors were also influential in the neonatal mortality decline in Nepal: increasing rates of maternal education, percentage of households headed by women, and C-section rates. The rate of maternal education, defined as women who completed at least some secondary education, increased from 13.2% of women in 2001 to 42.5% of women in 2022. This model suggests that 9% percent of neonatal mortality reduction could be attributed to increases in maternal secondary education. This analysis also suggests that women who have secondary education have a 12% lower risk of neonatal mortality for their child.

Increased women’s empowerment also impacts other drivers: the percentage of households headed by women rose 20% between 2001 and 2022. Even accounting for other intermediate factors, including education and wealth quintile, this increase was found to contribute to 9% of neonatal mortality reduction. One potential driver of women as heads of households in this 21-year period is the rapid rise in Nepali migrant workers. Remittances accounted for about 23% of gross domestic product in 2021, and over a third of married women had husbands working abroad in 2016.^17,18 One analysis suggests that women with migrant husbands were more likely to have full autonomy of decision-making.¹⁸ Migrant husbands’ impacts on women’s decision-making patterns in the home, as well as FP usage, are discussed further in the Benchmarking Progress in Nepal section.¹⁸

Increases in C-section rates at the community level were also found to contribute to 12% of neonatal mortality reduction in Nepal. C-section rates are included in the model at the primary sampling unit level to mitigate endogeneity bias that occurs when higher-risk births are more likely to occur in facilities.

Another intermediate factor that impacts neonatal mortality reduction is household crowding, defined as more than six members in a household. In this analysis, household crowding was found to be protective of neonatal mortality: neonates born into crowded households were 12% less likely to experience neonatal mortality. The percentage of households in Nepal with six or more residents decreased 19% between 2001 and 2022, likely due to increased urbanization, increase in migrant workers abroad, and decreased fertility, among other factors. These and other contextual shifts are discussed in the Context section. Though fewer crowded households may represent a positive sign in terms of development, in the case of Nepal we hypothesize that households with more members comprised a bigger support network for mothers and newborns.

Changes in characteristics of pregnant women in Nepal have also contributed toward shifts in risk profiles. This analysis considers births of high parity, births with short spacing, and births by younger or older women as high risk. From 2001 to 2022, births that had one or multiple of these high-risk characteristics decreased 11% and 12%, respectively. The expansion of FP services, decreases in adolescent marriage, and broader women’s empowerment are all factors that may have contributed to these reductions. Despite the decrease in these high-risk categories over time, these findings suggest that the broader shift in maternal risk profiles has not driven the country’s neonatal mortality reduction, as reflected by the negative contribution to mortality decline in Figure 23.

This analysis also found that 8% percent of neonatal mortality reduction is attributable to increases in body mass index. Fewer women are underweight, and more women have a higher body mass index, reflecting progress in women’s nutrition, especially during the maternal period.

Two distal factors emerged through this analysis as key drivers of progress: increased urbanization and increases in modern contraceptive prevalence. Increased urbanization was found to account for 10% of neonatal mortality decline between 2001 and 2022. Living in an urban area increases access to health care services, including shorter travel times to facilities, especially those that offer more comprehensive care and services such as C-section delivery.¹⁹ Additionally, contraception usage at the community level was found to contribute to 11% of reduction in neonatal mortality. As explored in the Benchmarking Progress in Nepal section, equity gaps in access to FP decreased greatly between 2001 and 2022, with access similar across residence and wealth quintiles.