Pre-eclampsia/Eclampsia Situation in Nepal and the Need

for Protein Test in Urine during Pregnancy

1.  Background

Pre-eclampsia refers to a condition that occurs only in pregnancy, usually towards later part or third trimester. In this condition, blood pressure is abnormally high and, protein is found in their urine. Pre-eclampsia is often referred to toxemia of pregnancy. The exact cause of pre-eclampsia and eclampsia (PE/E) is unknown but generally seen in primipara and in either too young or too old pregnant women. The pre-eclampsia when progresses, it will result in complications of the lungs, kidney and liver, or can progress to a more serious and life-threatening condition of eclampsia. Eclampsia can occur before, during or after childbirth.

PE/E contributes between 8–25% of maternal mortality worldwide[1]. In Nepal, PE/E is the second leading direct cause of maternal mortality at the community level after PPH. It is the number one direct cause of maternal death in health facilities which accounts for 30% of maternal deaths. The Nepal Maternal Mortality and Morbidity Study 2008/2009 revealed that 21% maternal death was due to eclampsia, which was increased from 14% in 1998. The same study found that the rate for eclampsia in EOC facilities in the eight districts was 6 per 1000 births. The incidence ranged from none in Baglung district, 0.8 in Kailali to 27 in Rasuwa district[2].

PE/E is preventable and treatable. There are three levels of intervention for prevention and management of PE/E. Primary prevention of PE/E can be done through calcium supplementation during pregnancy. Calcium can be easily distributed to women in their homes and communities much like iron by trained health workers—even by FCHVs. In Nepal, female community health volunteers (FCHVs) can be trained to educate women and distribute calcium. Secondary prevention includes the detection of pre-eclampsia at its early stages, often before there are any symptoms. For this, regular screening of urine protein and blood pressure measurement is essential. Currently regular screening of blood pressure has been carried out in most of the health facilities of Nepal but regular urine protein test is performed in selected health facilities only. Still over 25% of pregnant women receive no antenatal care (ANC), and among those who do, routine screening is often not carried out[3].

Screening of pre-eclampsia has been mentioned as one of the main component of the antenatal care in all national standards and guidelines developed in Nepal. The method of screening PE/E has been mentioned in the clinical protocols developed by FHD for each cadre of health workers. All health workers have been oriented with these protocols. In addition to this, more than thousands of nurses have completed Skilled Birth Attendant (SBA) training on which they were provided in depth knowledge and skills in diagnosis and management of PE/E. But there were limited data found in implementation of these skills.

2.  Estimated numbers of Pregnant Women in a year

The total estimated population, married women of reproductive age and expected pregnancy according to each district is given below in table 1:

Table 1. Estimated number of PW by district

SN / District / Est pop / MWRA (15-49) / Exp preg /
1 / Bhojpur / 228983 / 44825 / 6243
2 / Dhankuta / 192889 / 39231 / 5597
3 / Ilam / 334376 / 68119 / 9897
4 / Jhapa / 801041 / 173446 / 26325
5 / Khotang / 264129 / 49777 / 6969
6 / Morang / 1000114 / 210045 / 30237
7 / Okhaldhunga / 181009 / 34260 / 4738
8 / Panchthar / 234926 / 45235 / 6438
9 / Sankhuwasabha / 183832 / 35906 / 5063
10 / Saptari / 673056 / 131482 / 17,731
11 / Siraha / 677957 / 129386 / 17,586
12 / Solukhumbu / 123960 / 23978 / 3324
13 / Sunsari / 756321 / 153748 / 22,173
14 / Taplejung / 155540 / 29829 / 4289
15 / Teharthum / 229959 / 25860 / 3695
16 / Udaypur / 344588 / 65582 / 9389
17 / Bara / 675072 / 126025 / 17,594
18 / Bhaktapur / 270107 / 59240 / 9052
19 / Chitwan / 568495 / 119133 / 17610
20 / Dhading / 398915 / 76788 / 10,969
21 / Dhanusha / 793609 / 148397 / 19.918
22 / Dolkha / 238628 / 46343 / 6383
23 / Kathmandu / 1363512 / 305539 / 33,648
24 / Kavre / 451595 / 88891 / 12,803
25 / Lalitpur / 405469 / 90727 / 13,638
26 / Mahottari / 657220 / 121504 / 16,083
27 / Makawanpur / 465293 / 88803 / 12,857
28 / Nuwakot / 336873 / 63998 / 9088
29 / Parsa / 599199 / 113360 / 15,627
30 / Ramechhap / 245534 / 45777 / 6211
31 / Rasuwa / 52687 / 9620 / 1368
32 / Rautahat / 654723 / 121077 / 16,858
33 / Sarlahi / 759631 / 140332 / 19,322
34 / Sindhuli / 331736 / 61864 / 8935
35 / Sindhupalchowk / 356831 / 67194 / 9603
36 / Arghakhanchi / 242159 / 48182 / 6738
37 / Baglung / 312830 / 64073 / 9,200
38 / Gorkha / 334022 / 67479 / 9136
39 / Gulmi / 331828 / 68274 / 9521
40 / Kapilvastu / 576769 / 107536 / 15,085
41 / Kaski / 455559 / 97112 / 14,001
42 / Lamjung / 205882 / 41958 / 5,707
43 / Manang / 12412 / 2569 / 350
44 / Mustang / 17005 / 3201 / 440
45 / Myagdi / 132594 / 26714 / 3,753
46 / Nawalparasi / 672760 / 134251 / 19,383
47 / Palpa / 311021 / 62298 / 8,773
48 / Parbat / 181277 / 36824 / 5,189
49 / Rupandehi / 857291 / 167468 / 24,060
50 / Syangja / 362929 / 73856 / 10,314
51 / Tanahu / 368194 / 75301 / 10,557
52 / Banke / 466702 / 90725 / 13,215
53 / Bardiya / 460026 / 90453 / 13,600
54 / Dailekh / 264616 / 50384 / 7349
55 / Dang / 554482 / 111307 / 16,488
56 / Dolpa / 34564 / 6828 / 935
57 / Humla / 47489 / 8691 / 2119
58 / Jajarkot / 157874 / 31440 / 4470
59 / Jumla / 104542 / 19990 / 2847
60 / Kalikot / 123724 / 24203 / 3519
61 / Mugu / 51696 / 9403 / 1312
62 / Pyuthan / 250148 / 48655 / 6836
63 / Rolpa / 245082 / 47052 / 6734
64 / Rukum / 221859 / 44081 / 6401
65 / Salyan / 249442 / 47044 / 6880
66 / Surkhet / 344237 / 68896 / 10,403
67 / Achham / 269504 / 51142 / 7210
68 / Baitadi / 273219 / 52261 / 7574
69 / Bajhang / 196026 / 37073 / 5254
70 / Bajura / 127176 / 23840 / 3301
71 / Dadeldhura / 148217 / 28129 / 4136
72 / Darchula / 143148 / 27702 / 3983
73 / Doti / 244907 / 46238 / 6626
74 / Kailali / 761652 / 147320 / 22,010
75 / Kanchanpur / 465912 / 90242 / 13,459

Source: Annual Report 2008/09

3.  Estimated numbers of pregnant women requiring ANC

It is a reproductive health right that all pregnant women (PW) should have access to required ANC for betterment of their and their baby’s health. But in Nepal, not all pregnant women had got that opportunity. Table 2 illustrates the current situation and gap:

Table 2. Estimated number of PW requiring ANC

Estimated pregnancy / ANC required / ANC 1st visit / ANC 4th visit / Remarks
770684 / 100% PW should have access to ANC services / Only 67% PW went for ANC 1st visit / Only 38% PW went for ANC 4th visit / Gap- 33% in 1st visit
62% in ANC 4th visit
(AR 2008/09)
100% PW should have access to ANC services / 74% / 30% / Gap- 26% in 1st visit
70% in 4th visit
(NDHS 2006)

4.  How many women use ANC?

Antenatal care aims to prevent maternal and perinatal mortality and morbidity. In Nepal, at least four antenatal visits are recommended during pregnancy. However, this service has been underutilized. Different studies and surveys showed the following result:

A Mid-term Survey done by NFHP II and New ERA on February 2010 showed some improvement in the practice of antenatal care including the practice of seeking care from skilled health workers. The frequency of antenatal care was found to be increased—1st ANC visit was 87% and 4th visit was 47%, both increased than the 2006 NDHS survey[4].

In Nepal, 67% PW completed ANC first visit and among them only 38% PW completed the required (four) ANC visits[5]. According to latest unpublished data from government HMIS division, it was increased to 79% and 46% respectively. Table 3 showed the percentage of ANC 1st visit and 4th visit by district.

NDHS survey 2006 showed that the proportion of women reporting at least one antenatal care contact between 1996 and 2006 has increased considerably, especially in rural areas where it has increased by more than 50 percent[6]. The report showed 74% of PW attended ANC 1st visit while ANC 4th visit was only 30%. While In 2001, ANC first visit was 49% and ANC 4th visit was only 14%.

Mother and Infant Research Activities (MIRA) at Makwanpur conducted a retrospective study to monitor the quality of antenatal care among 13368 women who delivered their babies either at home or at health institution. This study found that 66% of those women had taken ANC services and 34% had not. Among those who received ANC services, 100% had gone for ANC 1st visit while only 47% completed the four or more ANC visits.

Table 3. ANC 1st and 4th visit according to district

SN / District / ANC 1st visit % / ANC 4th visit% / Remarks /
1 / Bhojpur / 58 / 26
2 / Dhankuta / 62 / 35
3 / Ilam / 55 / 34
4 / Jhapa / 116 / 48
5 / Khotang / 97 / 49
6 / Morang / 72 / 39
7 / Okhaldhunga / 85 / 42
8 / Panchthar / 62 / 38
9 / Sankhuwasabha / 75 / 31
10 / Saptari / 107 / 76
11 / Siraha / 107 / 76
12 / Solukhumbu / 95 / 62
13 / Sunsari / 80 / 46
14 / Taplejung / 70 / 39
15 / Teharthum / 59 / 33
16 / Udaypur / 68 / 38
17 / Bara / 85 / 50
18 / Bhaktapur / 34 / 17
19 / Chitwan / 81 / 36
20 / Dhading / 80 / 45
21 / Dhanusha / 94 / 54
22 / Dolkha / 69 / 35
23 / Kathmandu / 103 / 115
24 / Kavre / 73 / 38
25 / Lalitpur / 68 / 40
26 / Mahottari / 122 / 91
27 / Makawanpur / 62 / 28
28 / Nuwakot / 57 / 29
29 / Parsa / 84 / 31
30 / Ramechhap / 60 / 34
31 / Rasuwa / 12 / 8
32 / Rautahat / 99 / 56
33 / Sarlahi / 105 / 45
34 / Sindhuli / 68 / 26
35 / Sindhupalchowk / 54 / 27
36 / Arghakhanchi / 56 / 34
37 / Baglung / 78 / 40
38 / Gorkha / 56 / 26
39 / Gulmi / 69 / 52
40 / Kapilvastu / 99 / 71
41 / Kaski / 82 / 61
42 / Lamjung / 83 / 50
43 / Manang / 24 / 7
44 / Mustang / 49 / 22
45 / Myagdi / 92 / 59
46 / Nawalparasi / 76 / 44
47 / Palpa / 111 / 45
48 / Parbat / 61 / 44
49 / Rupandehi / 86 / 43
50 / Syangja / 62 / 42
51 / Tanahu / 62 / 32
52 / Banke / 92 / 39
53 / Bardiya / 81 / 50
54 / Dailekh / 102 / 62
55 / Dang / 78 / 37
56 / Dolpa / 90 / 36
57 / Humla / 144 / 69
58 / Jajarkot / 113 / 51
59 / Jumla / 177 / 54
60 / Kalikot / 116 / 24
61 / Mugu / 151 / 43
62 / Pyuthan / 99 / 53
63 / Rolpa / 85 / 38
64 / Rukum / 85 / 32
65 / Salyan / 87 / 33
66 / Surkhet / 108 / 66
67 / Achham / 125 / 76
68 / Baitadi / 93 / 35
69 / Bajhang / 111 / 39
70 / Bajura / 117 / 32
71 / Dadeldhura / 140 / 99
72 / Darchula / 86 / 58
73 / Doti / 108 / 44
74 / Kailali / 64 / 33
75 / Kanchanpur / 66 / 32

Source: HMIS unpublished data

The coverage of first antenatal visit was highest in Jhapa, Sarlahi, Palpa, Jumla and Dadeldhura districts, all exceeded 100%. Similarly, the coverage of fourth antenatal visit was also highest in Saptari, Kathmandu, Kapilvastu, Humla and Dadeldhura districts.

Similarly, the coverage of first antenatal visit was lowest in Ilam, Rasuwa, Manang, Dang and Kailali district. Similarly, the coverage of fourth antenatal visit was lowest in Bhojpur, Bhaktapur, Manang, Kalikot and Bajura district (table 4).

Table 4. Highest and Lowest ANC 1st and 4th visit Coverage according to Region

Region / Highest coverage districts / Lowest coverage districts
1st visit / 4th visit / 1st visit / 4th visit
Eastern / Jhapa 115% / Saptari 76% / Ilam 55% / Bhojpur 26%
Central / Sarlahi 105% / Kathmandu 115% / Rasuawa 12% / Bhaktapur 17%
Western / Palpa 111% / Kapilvastu 71% / Manang 24% / Manang 7%
Midwestern / Jumla 176% / Humla 68% / Dang 78% / Kalikot 24%
Farwestern / Dadeldhura 140% / Dadeldhura 99% / Kailali 64% / Bajura 31%

4.1  . How many women use ANC by Ethnicity and Wealth Quintile?

There are limited data available on ANC users by ethnicity and wealth quintile. An End line Survey on KAP on Safe Motherhood and Neonatal Health by SSMP in 2009 reflects that utilization of antenatal services was much higher among Terai, literate and relatively advantaged Janajati women compared to the women of other categories. Utilization of antenatal services has also increased significantly across all social groups except for the Muslim and religious minorities. The rate of increase in utilization of antenatal services was much higher among relatively disadvantaged Janajatis and other socially excluded groups from baseline to endline survey. Table 5 shows the results in detail:

Table 5. Recently delivered women receiving ANC at least 4 times

Social group / Baseline / Endline / % points change
Brahmin/Chhetri and equivalent / 54 / 63 / 9
Rel. Adv. Janajati / 56 / 74 / 18
Rel. Disadv. Janajati / 48 / 61 / 13
Dalit / 39 / 53 / 14
Other socially excluded groups / 38 / 63 / 25
Muslim / 42 / 42 / 0
Total / 45 / 60 / 15

Both household and service utilization data indicate an increase in service utilization across all social groups, but the gain is appreciably high among Dalit and disadvantaged Janajatis.

Table 6 showed that the women with highest and fourth quintile are much more likely to have taken iron tablets, measured their weight, blood pressure and given their blood and urine samples during their pregnancy than their counterparts. However, there is very little variation in intake of deworming tablet by wealth quintile among various groups of women.