Increased utilisation and quality: a focus on inequality and a learning health system approach-explaining Nepal's success in reducing maternal and newborn mortality 2000-2020.

Introduction: Maternal mortality in Nepal dropped from 553 to 186 per 100 000 live births during 2000-2017 (66% decline). Neonatal mortality dropped from 40 to 21 per 1000 live births during 2000-2018 (48% decline). Stillbirths dropped from 28 to 18 per 1000 births during 2000-2019 (34% decline). Nepal outperformed other countries in these mortality improvements when adjusted for economic growth, making Nepal a 'success'. Our study describes mechanisms which contributed to these achievements.

Methods: A mixed-method case study was used to identify drivers of mortality decline. Methods used included a literature review, key-informant interviews, focus-group discussions, secondary analysis of datasets, and validation workshops.

Results: Despite geographical challenges and periods of political instability, Nepal massively increased the percentage of women delivering in health facilities with skilled birth attendance between 2000 and 2019. Although challenges remain, there was also evidence in improved quality and equity-of-access to antenatal care and childbirth services. The study found policymaking and implementation processes were adaptive, evidence-informed, made use of data and research, and involved participants inside and outside government. There was a consistent focus on reducing inequalities.

Conclusion: Policies and programmes Nepal implemented between 2000 and 2020 to improve maternal and newborn health outcomes were not unique. In this paper, we argue that Nepal was able to move rapidly from stage 2 to stage 3 in the mortality transition framework not because of what they did, but how they did it. Despite its achievements, Nepal still faces many challenges in ensuring equal access to quality-care for all women and newborns.