Maheshwori Devi Bishwokarma, 19, is pregnant with her second child. Despite being three days past due, Maheshwori continues to herd goats, scratching out a living in the Himalayan foothills of Nepal. Her husband, who lives and works in neighboring India, comes home once a year.

Till a decade ago, a large number of young mothers like Maheshwori used to die due to pregnancy complications. Nepal's maternal mortality was much higher among nations in Asia. For many women, pregnancy then meant death. However, the situation has changed now.

In less than two decades, Nepal has managed to halve the number of women dying during childbirth, a case of 'globally remarkable' progress, according to a leading global development think tank.

Researchers at the Overseas Development Institute have released a report that found a virtuous cycle of political commitment, financial resources and household changes has helped overcome significant challenges posed by Nepal’s unique terrain. The number of deaths per 100,000 live births in Nepal dropped from 539 in 1996 to 229 in 2008 making it one of the very few countries on track to meet Millennium Development Goal 5 on maternal health before 2015.

Approximately 350,000 women die globally each year as a result of pregnancy and childbirth, and maternal mortality remains the main contributor to excess female mortality in reproductive years. Millennium Development Goal 5, which includes a target of reducing the maternal mortality ratio by 75% between 1990 and 2015, is considered one of the most off-track MDGs.

"The decline seen in maternal mortality in Nepal is striking. The reduction in maternal deaths represents a substantial improvement over a short period in a country that contains some of the most challenging terrains in the world for the delivery of essential health services. Much of the progress was achieved in the midst of a protracted insurgency and during a period when, for the majority, household incomes did not increase substantially," said the report published by the Overseas Development Institute (ODI) in London, a leading global development think tank

The authors emphasize the role of high-level political commitment to maternal health, spurred on by a vocal advocacy community. This led to greatly increased government expenditure and international aid dedicated to health, enabling widespread improvements in access to medical services, particularly in the more remote rural areas of the country. This in turn contributed to a higher percentage of births attended by skilled health personnel and access to essential medicines, such as antibiotics, which can help effectively treat infections that could otherwise prove fatal. Today, over 50% of expectant mothers seek the recommended four antenatal visits, a fivefold increase in the course of 15 years.

Perhaps even more significant have been profound changes at the household level, which have contributed to greater numbers of women seeking support during pregnancy and labour.  Access to education has improved substantially: the percentage of women with at least some secondary or higher education has increased by 48% in the past five years, while women are now more likely to be in paid work or run their own business than they were a decade ago. Poverty (according to the national poverty line) has dropped from 68% of the population to 25% in 15 years. And longstanding efforts to facilitate family planning have led to a massive reduction in the fertility rate: Nepali women went from having six children in the early 1980s to an average of 2.6 in the most recent 2011 household survey.

Jonathan Glennie, Research Associate at the Overseas Development Institute (ODI) in London said: “This is an astonishing example of social progress. What’s most remarkable is that the reduction in maternal mortality has been achieved in such a short space of time. There’s no doubt other countries could learn a lot from the Nepalese experience. The combination of political commitment and financial resources, along with on-going changes at the household level, means that thousands of lives are now being saved.”

While significant challenges remain - including addressing inequalities, increasing community mobilization to improve accountability and maintaining the political and financial commitment to safer motherhood - Nepal’s story of progress can provide important lessons for other countries struggling to address high levels of maternal mortality, especially within a context of difficult terrain, conflict and high poverty rates.