In 2001, 540 women were dying per 100,000 live births in Nepal. A recent Nepal Demographic Health Survey shows the number of deaths has dropped to 280. Health experts say this dramatic improvement is the result of a combination of government and private initiatives as well as policy changes, but warn that even the current rate of death is higher than it should be.

"Reduction of pre- and post-delivery haemorrhage and infection is the key to saving the lives of pregnant women," says Shyam Raj Upreti, chief of the Expanded Program on Immunisation in the Child Health Division. He adds that it is crucial to have doctors and health workers who are trained in delivery.

The biggest factor in reducing maternal mortality was the decision to legalise abortion in Nepal in 2002. From early 2004, the government began providing comprehensive care, training doctors and approving clinics all over the country where women could have an abortion safely.

"The number of deaths related to unsafe abortion was very high," says Indira Basnett of Ipas, an international organisation that works to empower women to exercise their sexual and reproductive rights. "When abortion was legalised, the number of women dying due to pregnancy-related causes dramatically decreased."

Today more than 177 approved government and private clinics in 71 districts provide abortion services to women. In 2004, more than 150,000 women underwent successful operations.

Basnett says more women also know about family planning today. The government's network of village health workers has raised awareness of maternal health and the care of pregnant women, and the growth of privately run health services specialising in obstetric care has also helped to reduce the mortality rate.

The government only provides emergency obstetric care in the zonal hospitals. Patients either have to walk for days to reach them, or must drive or fly to Kathmandu. It is often cheaper for family members to take the pregnant woman to a private clinic in the closest urban centre.

But public health experts warn that the apparent improvement in mortality rates may be misleading. They say that in areas like Dadeldhura, Bajura, Bajhang, Mugu and other districts in far western Nepal, there is unlikely to have been much improvement.

"We are talking about areas where there are no doctors, women deliver at home, and if they die their deaths are not registered, areas where women suffer from acute malnutrition, haemorrhaging, tetanus and other infections. Pregnancy-related deaths rates are still very high there," Aruna Upreti, a public health expert told Nepali Times.

Upreti of Child Health Division agrees: "When the maternal mortality rate was 540 per 100,000 live births, we had estimated more than 1,000 deaths per 100,000 live births in rural Nepal. That cannot have changed much."

Asok Sharma, a public health expert now working with Merlin Sri Lanka in strengthening local-level maternal and child health, says that the 12 years of conflict devastated the country's health systems. "In conflict areas, routine services were not provided, health workers were confined to headquarters, not a single doctor was available, and services were not upgraded. How could maternal mortality have gone down in these areas?" he asks.

Experts say the key to future improvements lies in building the capacity of health workers and midwives deployed at VDC level. There is also a need to register pregnancies and to provide specialised obstetric and neonatal care beyond just the zonal hospitals.

Nevertheless, reducing maternal mortality by nearly 50 percent is no small feat. Basnett is confident that lessons have been learnt and mortality rates can be reduced. "If the service is accessible, acceptable in terms of quality, and affordable, then we can save more women. Let this be the lesson to doctors, health workers, midwives, public health experts and government while devising future policies relating to maternal health."