Why is Nepal an Exemplar?

Exemplar countries for neonatal and maternal mortality are defined as those that have demonstrated exceptional progress at reducing neonatal and maternal mortality—beyond what could be attributable to their socioeconomic progress alone. Figure 2 shows the association between growth in the gross national income (GNI) per capita and declines in neonatal and maternal mortality across low- and middle-income countries with populations of at least 2 million that have not yet reached the Sustainable Development Goals (SDGs) targets for these indicators. A fitted linear regression line is overlaid, indicating the expected relationship between GNI per capita change and mortality change. Countries falling below the fitted line are those that have experienced faster declines in mortality than what would be expected based on their GNI per capita increases alone.

Nepal made impressive progress in improving maternal and newborn health outcomes over the past two decades, contributing to its status as an Exemplar country. According to estimates from the United Nations (UN) Maternal Mortality Estimation Inter-agency Group (MMEIG), maternal mortality declined from 504 to 174 per 100,000 live births between 2000 and 2020.¹ Neonatal mortality decreased from 39 to 16 per 1,000 live births between 2000 and 2021, according to estimates from the UN Inter-agency Group for Child Mortality Estimation.² The maternal mortality ratio (MMR) declined at an average annual reduction rate (AARR) of 5.2%, and the neonatal mortality rate (NMR) declined by an AARR of 4.1%. Nepal achieved maternal mortality reductions at a pace comparable to other South Asian countries and outperformed the South Asian region overall in the pace of its neonatal mortality declines. Overall, Nepal generally outperformed other low- and middle-income countries after adjusting for economic growth, measured by GNI per capita.

Maternal mortality

Nepal achieved impressive reductions in maternal mortality over recent decades, although specific trend lines vary slightly by source. Figure 3 shows maternal mortality estimates from both the Institute for Health Metrics and Evaluation (IHME) and United Nations Maternal Mortality Estimation Inter-agency Group (UN MMEIG). We predominantly used the UN MMEIG estimates, which include a slightly more current time trend, in analyses throughout this narrative, but we leveraged IHME estimates to explore maternal causes of death.^1,3

According to UN MMEIG estimates, from 2000 to 2020, maternal mortality in Nepal decreased from 504 to 174 maternal deaths per 100,000 live births, which represents a 66% decrease.¹ The MMR in Nepal declined at an AARR of 5.2% over this period, comparable to the regional South Asia AARR of 5.4%.¹ An AARR near the regional average suggests strong progress, considering that the other NMR and MMR Exemplar countries in the region, India and Bangladesh, strongly influence regional trends in South Asia.

If Nepal continues its current pace of 5.2% AARR, it will meet the national SDG threshold of 116 maternal deaths per 100,000 live births in 2028, before the SDG deadline of 2030.⁴ More detailed forecasts are available in the Benchmarking Progress in Nepal section.

Determining cause-specific maternal mortality faces a variety of reporting challenges, given that maternal mortality itself is a relatively rare occurrence. This section explores several complementary sources of cause-specific maternal deaths, each with its own strengths and limitations. According to IHME estimates from the 2021 Global Burden of Disease, indirect maternal deaths, hemorrhage, and hypertensive disorders were the most common causes of maternal death in Nepal in 2021, respectively accounting for 66.7, 52.7, and 20.7 maternal deaths per 100,000 live births, as shown in Figure 4.³ Indirect maternal deaths result from previous existing diseases or diseases developed during pregnancy, and are not due to direct obstetric causes; examples include deaths due to cardiac and hepatic diseases worsened by pregnancy. From 1990 to 2021, deaths due to abortion or miscarriages, and maternal sepsis and infections saw the most notable declines, respectively declining 90% and 84% over this time period.³ Other leading causes of death, such as hemorrhage and hypertensive disorders, have contributed a relatively constant proportion of deaths over time, respectively accounting for 36% and 12% of maternal deaths in 1990 and 28% and 11% in 2021. Indirect maternal deaths increased from 22% of maternal deaths in 1990 to 35% in 2021, suggesting that Nepal will need to strategically target efforts toward addressing underlying maternal comorbidities that may exacerbate pregnancy- and birth-related mortality risk.

Additional evidence on causes of maternal death can be gathered from the Nepal Maternal Mortality Study (NMMS), a retrospective analysis of maternal mortality from the 12 months preceding the 2021 National Population and Housing Census conducted by the Ministry of Health and Population and the National Statistics Office.⁵ The inaugural report provides federal- and provincial-level MMR estimates for the first time in Nepal. Over time, improved data from this census will be more broadly available to enable time-series comparisons. Nonetheless, the top three maternal causes of death identified by the NMMS—indirect maternal deaths, hemorrhage, and hypertensive disorders—align with the top three causes per the IHME estimates. Additionally, these top three causes of death account for 70% and 75% of maternal deaths according to NMMS and IHME, respectively, suggesting broad alignment between the sources.

The 2021 NMMS found that direct causes of maternal deaths (combined) made up 68% of deaths, whereas indirect causes made up 32% of deaths.⁵ Respectively, 32%, 26%, 12%, and 7% of deaths were due to non-obstetric complications (indirect causes), obstetric hemorrhage, hypertensive disorders, and pregnancy-related infections. The NMMS found that 61% of deaths occurred postpartum, and only 6% of deaths occurred during delivery and 33% during pregnancy.⁵ The place of death was split between health facilities, where 57% of deaths took place; home, where 26% of deaths occurred; and on the way to or between facilities, where 17% of deaths occurred—highlighting the importance of strong transport and referral networks.⁵

Overall, the 2021 NMMS reported a national MMR of 151 maternal deaths per 100,000 live births.⁵ The MMR varies slightly by ecological zone, with 133 deaths per 100,000 live births in the mountains, 159 deaths per 100,000 live births in the hills, and 147 deaths per 100,000 live births in the terai, or low-lying flatlands. Province-specific MMRs are shown in Figure 5, with Lumbini, in the terai and hill ecological zones, having the highest MMR and Bagmati, in the hill and mountain zones and where national city of Kathmandu is located, having the lowest MMR.⁵

Neonatal mortality

Nepal has also seen rapid declines in neonatal mortality over recent decades.² According to estimates from the UN Inter-agency Group for Child Mortality Estimation shown in Figure 6, neonatal mortality decreased from 58 to 16 neonatal deaths per 1,000 live births from 1990 to 2021, which represents a 72% reduction.²

After a period of stagnation in the 1950s and 1960s, when the NMR remained above 90 neonatal deaths per 1,000 live births, improvements to the NMR began in the 1970s: Nepal’s AARR for the NMR from 1970 to 2000 was 2.6%. The NMR in Nepal decreased more rapidly after 1990. Over the time period from 2000 to 2021, Nepal’s AARR for the NMR was 4.1% compared with 3.3% regionally for South Asia.²

If Nepal continues at an AARR of 4.1%, the country will successfully reach the SDGs threshold of 12 neonatal deaths per 1,000 live births by 2029, ahead of the 2030 target. That pace would result in an NMR of 10.8 neonatal deaths per 1,000 live births in 2030, a remarkable achievement considering the high NMR in Nepal decades prior.

According to the World Health Organization Maternal and Child Epidemiology Estimation Group, in 2017, the leading causes of neonatal death in Nepal were prematurity, birth asphyxia and trauma, and sepsis and other infections, respectively contributing to 6.9, 4.7, and 3.3 neonatal deaths per 1,000 live births.⁶ Though these three categories remained the most common causes of neonatal death between 2000 and 2017, the rate of these causes decreased by 32%, 59%, and 48%, respectively, from 2000 to 2017, as shown in Figure 7.⁶

There were also substantial reductions in the rates of other neonatal causes of death, including acute respiratory infections, other perinatal or nutritional conditions, meningitis or encephalitis, injuries, tetanus, and diarrheal diseases. Congenital anomalies stood out as a cause that saw relatively little progress, only decreasing by 13% over the study period.

The NMR improved across subnational areas, residences, and wealth quintiles, as shown data from DHS surveys in Figure 8. The gap between development regions narrowed between 1996 and 2016, and all development regions saw notable reductions over this span. The Central and Eastern development regions saw the largest declines in the NMR over this period at approximately 57%, whereas the Far-Western development region saw the smallest decline of 39%.⁷

In 2016, the Nepal Demographic and Health Survey began surveying at the new provincial level. From 2016 to 2022, the equity gap between provinces decreased from a difference of 26 to 19 neonatal deaths per 1,000 live births. Substantial declines in NMR were visible in both of the provinces with the highest and lowest NMR, Sudurpashchim and Gandaki, respectively. As of 2022, the NMR was below the SDG target in Gandaki, but other provinces, such as Madhesh and Sudurpashchim, had NMR levels more than double the SDG target, each at 27 deaths per 1,000 live births.

Between 1996 and 2022, the gap between the NMR in urban and rural areas decreased from 22 to 6 neonatal deaths per 1,000 live births. Greater declines were observed in rural areas, suggesting that policies targeting rural populations are succeeding in improving NMR outcomes. Though the NMR in urban areas has decreased, these areas were also highly affected by the earthquake in 2015, especially Kathmandu. In terms of equity gaps between wealth quintiles, declines in the NMR were similar among all quintiles, with the gap remaining at 18 neonatal deaths per 1,000 live births between 1996 and 2022. The overall decline demonstrates strong progress, though future efforts may need to focus more on closing the wealth gap.

Stillbirths

The stillbirth rate in Nepal decreased from 30 to 16 per 1,000 total births from 2000 to 2021, which represents a 48% decrease (see Figure 9).⁸ This rate in 2021 is similar to the regional value for South Asia, which was 17 stillbirths per 1,000 total births in 2021.⁸ Progress in reducing stillbirth in Nepal can be seen in its AARR of 3.1% , nearly the same rate of progress seen regionally in South Asia, with an AARR of 3.0% from 2000 to 2021.

Stillbirth rates also declined greatly across subnational areas, residences, and wealth quintiles, as shown in Figure 10. Between 1996 and 2016, the Western, Mid-Western, and Far-Western development regions brought stillbirth rates down by 52%, 56%, and 50%, respectively. However, the Eastern and Central development regions decreased stillbirth rates to a lesser extent, by 31% and 32%, respectively. Recent Demographic and Health Surveys that incorporate the new provinces indicated that in 2022, Koshi, Sudurpashchim, and Bagmati had the lowest stillbirth rates and Lumbini had the highest stillbirth rate. The gap between stillbirth rates in urban and rural areas widened: in 1996, urban areas had slightly higher stillbirth rates than rural areas, whereas the opposite was true in 2022, since urban areas had rapidly improved. Stillbirth rates decreased for all wealth quintiles, and the gap between the poorest and wealthiest quintiles decreased from 13 to 9 stillbirths per 1,000 live births. These reductions suggest that Nepal’s health system has been able to better reach women in a variety of geographies, residences, and wealth classes to prevent stillbirths.