​This Development Progress case study explores the lessons that can be drawn from a remarkable story of progress, revealing that despite a 10-year insurgency, persistent political upheaval, and some of the world's most challenging terrain for the delivery of healthcare, Nepal has reduced its maternal mortality ratio by almost 50% - meaning it is one of the few countries on track to achieve MDG 5.

• Nepal achieved a striking reduction in maternal mortality during the 1990s and early 2000s. According to data from Nepal Demographic and Health Surveys (NDHSs), the country’s maternal mortality ratio (MMR) fell by 47% between 1996 and 2006. More recent survey data support this downward trend. Despite difficult terrain, conflict and political upheaval, it is one of the few countries likely to meet Millennium Development Goal 5 on maternal health.
  
• A consistent policy focus and sustained financial commitment by the government and donors throughout the past two decades, including substantial increases in funding for maternal health since the early 1990s, has allowed for widespread improvements in access to medical services, particularly in remote areas.
  
• MMR improvements have further been facilitated by behavioural and economic changes at the household level, driven by increased empowerment and education of women and greater awareness of how to mitigate pregnancy-related risks.
  
• Together with a sustained rise in incomes, these factors have combined to create what appears to be a virtuous cycle, with national policy and implementation reinforcing changes occurring at the household level. Nepal’s experience can provide important lessons for other countries struggling to address high levels of maternal mortality and morbidity, especially within a context of difficult terrain and high poverty rates.
  
• Despite these improvements, numerous systemic challenges remain. These include addressing inequalities, increasing community mobilisation to improve accountability, building more effectively on inter-sectoral synergies and, most importantly, maintaining political and financial commitment to safer motherhood.

 

Jakob Engel, Jonathan Glennie, Shiva Raj Adhikari, Sanju Wagle Bhattarai, Devi Prasad Prasai, Fiona Samuels