Brief Overview of Management of Safe Motherhood and Newborn Health Services in Nepal
1. Brief Overview of Management of Safe
motherhood and Newborn Health
Services in Nepal
Presented By :
Mohammad Aslam Shaiekh
Master of Public Health (MPH)
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2. Introduction
• The Safe Motherhood Program began in 1997 and
has made significant progress since formulation of
safe motherhood policy in 1998.
• Service coverage has grown along with the
development of policies, programmes and protocols.
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3. Introduction
• Important factors for maternal and newborn
morbidity and mortality in Nepal are:
– Delays in seeking care,
– Delay in reaching care and
– Delay in receiving care
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4. Safe Motherhood and Newborn Health
Program
Goal
• To reduce maternal and neonatal morbidity and
mortality and
• To improve maternal and neonatal health through
preventive and promotive activities and by
addressing avoidable factors that cause death during
pregnancy, childbirth and the postpartum period.
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5. SDG Target
• SDG 3: Good Health and well being
By 2030, reduce the global maternal mortality ratio to
less than 70 per 100 000 live births.
By 2030, end preventable deaths of newborns and
children under 5 years of age, with all countries aiming
to reduce neonatal mortality to at least as low as 12
per 1000 live births and under-5 mortality to at least as
low as 25 per 1000 live births.
• To achieve this target Nepal needs to reduce its MMR
by at least 7.5% annually.
• Current status: 239 maternal deaths per 100000 live
births (NDHS 2016)
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6. Major strategies
Promoting birth preparedness and complication
readiness including awareness raising and improving
preparedness for funds, transport and blood
supplies.
Expansion of 24 hours birthing facilities alongside
Aama Suraksha Programme promotes antenatal
check-ups and institutional delivery.
The expansion of 24-hour emergency obstetric care
services (basic and comprehensive) at selected public
health facilities in all districts.
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7. Contribution of Policies, Programs and
Guidelines
1. The policy on skilled birth attendants (2006)
highlights the importance of skilled birth
attendance (SBA) at all births and embodies the
government’s commitment to train and deploy
doctors, nurses and ANMs with the required skills
across the country.
2. Introduction of Aama programme to ensure free
service and encourage women for institutional
delivery has improved access to institutional
deliveries and emergency obstetric care services.
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8. • The Nepal Health Sector Strategy (NHSS) identifies
equity and quality of care gaps as areas of concern
for achieving the maternal health SDG target, and
gives guidance for improving quality of care,
equitable distribution of health services and
utilization and universal health coverage with better
financing mechanism to reduce financial hardship
and out of pocket expenditure for ill health.
• The endorsement of the revised National Blood
Transfusion Policy (2006) ensures the availability of
safe blood supplies for emergency cases.
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9. Major Activities
1. Birth Preparedness Package and community level maternal
and newborn health
2. Rural Ultrasound Programme
3. Reproductive health morbidity prevention and
management programme
a) Management of pelvic organ prolapse:
b) Cervical cancer screening and prevention training
c) Obstetric fistula management
4 Human resources
5 Expansion and quality improvement of service delivery sites
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10. Major activities
6. Emergency referral Fund
7. Safe Abortion Service
8. Obstetric first aid orientations
9. Nyano Jhola Programme
10. Aama and Newborn Programme
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11. Major activities in 2073/74
1. Birth Preparedness Package and community level
maternal and newborn health
• FHD continued to expand and maintain MNH
activities at community level including the Birth
Preparedness Package (jeevansuraksha flipchart and
card) and distributed the matrisurakshachakki
(misoprostol) to prevent postpartum haemorrhage
(PPH) in home deliveries.
• Three districts (Kaski, Parbat and Syangja) has
implemented this program from FY 2073/74.
• Total 48 districts
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12. Major activities in 2073/74
2. Rural Ultrasound Programme
• It aims for the timely identification of pregnant
women with risks of obstetric complication to refer
to comprehensive emergency obstetric and neonatal
care (CEONC) centres.
• Portable ultrasound is used.
• This programme is being implemented in the 12
remote districts ,Dhading, Darchula,
Sindhupalchowk, Solukhumbu, Bajura, Bajhang,
Achham, Dhankuta, Dolpa, Humla, Baitadi, and
Sindhuli.
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13. Major activities in 2073/74
3. Reproductive health morbidity prevention and
management programme
a. Management of pelvic organ prolapse:
• The government allocates funds to manage POP
including
free screening,
providing silicon ring pessaries,
Kegel’s exercise training and
free surgical services at designated hospitals.
• In 2073/74 more than 14,600 women were
screened for the reproductive morbidity, 13Aslam Aman
14. Major activities in 2073/74
• About 23 percent of women (3374 women) were
diagnosed of having POP.
• Among women who were screened 8.9 percent had
first degree POP, 6.6 percent second degree POP and
7.5 percent third degree POP.
• About 52 percent of these women with POP received
ring pessary treatment.
• More than 2,000 women received surgical
treatment.
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15. Major activities in 2073/74
b. Cervical cancer screening and prevention training
• Most common cancer of women in Nepal,
accounting for 21.4 % of all cancer among 34–64
year old women.
• The national guidelines on cervical cancer screening
and prevention (2010) call for screening at least 50 %
of women aged 30–60 yrs for reducing the mortality
due to cervical cancer by 10% with recommended
screening among this group every five yrs.
• As of 2073/74, cervical cancer screening has been
expanded to 64 districts. 15Aslam Aman
16. Major activities in 2073/74
c. Obstetric fistula management
• The government has allocated funds for the free
screening of obstetric fistula integrated with pelvic
organ prolapsed screening and free surgical services
at the BP Koirala Institute of Health Sciences (BPKIHS,
Dharan) and Model hospital, Kathmandu.
• In 2073/74, 120 women received free surgical
treatment for obstetric fistula.
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17. Major activities in 2073/74
4. Human resources
• In 2073/74, 582 SBA, 28 ASBA and 20 AA were
trained by NHTC and NAMS.
• By the end of 2073/74 a total of 9,000 SBAs and 168
ASBAs have been trained.
• FHD continued to monitor the deployment of
doctors (MDGP, OBGYN, ASBA) and AAs,and inform
DOHS and MOH as necessary for appropriate
transfer.
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18. Major activities in 2073/74
5. Expansion and quality improvement of service
delivery sites
• By the end of 2073/74 CEONC services were
established in 72 districts, only 60 districts were
functional throughout the year.
• During the fiscal year 8-12 districts provided
interrupted C-section services.
• A total of 1,811 birthing centres and 158 BEONC sites
were functioning by the end of 2073/74.
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19. Major activities in 2073/74
6. Emergency referral Fund
• A total of 4,000,000 Rupees was allocated to five
regions and fourteen women from nine districts
received support from this fund in 2073/74.
• Additional 4,400,000 Rupees was allocated to 46
districts to support transport fares women who could
not afford referral to high facility.
• The RHD/Provincial also have funds to airlift to
women from areas where motorised transport is not
available or when immediate transfers are needed.
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20. Major activities in 2073/74
7. Safe Abortion Service
• Comprehensive abortion care (manual vacuum
aspiration [MVA]) services are available in all 75
district hospitals and majority of PHCCs.
• Second trimester abortion services are available in
30 hospitals where CEONC services are also available.
• Medical abortion services have been expanded to 60
districts with the support of various partners.
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21. Major activities in 2073/74
8. Obstetric first aid orientations
• In 2070/71, FHD started orienting paramedics on first
aid to manage obstetric complications at health
facilities without birthing centres and to enable
paramedics to support SBAs and ANMs at times of
emergency.
• In 2073/74, 51 trainers were trained on this subject
in 17 districts.
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22. Major activities in 2073/74
9. Nyano Jhola Programme
• Launched in 2069/70 to protect newborns from
hypothermia and infections and to increase the use
of peripheral health facilities (birthing centres).
• Two sets of clothes (bhoto,daura, napkin and cap) for
newborns and mothers, and one set of wrapper, mat
for baby and gown for mother are provided for
women who give birth at birthing centres and district
hospitals.
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23. 10. Aama and Newborn Programme
The government has introduced demand-side
interventions to encourage women for institutional
delivery for women delivering their babies in health
institution
Transport incentives to institutional delivery
Incentives to 4 ANC
Free institutional delivery a payment to health facility
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31. Management Perspectives of Safe
Motherhood Program (POSDCORB)
1. Planning
2. Organizing
3. Staffing
4. Directing
5. Coordinating
6. Controlling
7. Recording and Reporting
8. Budgeting
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32. Planning
• Family Welfare Division (FWD) is the main body
for formulating plans and activities regarding safe
motherhood.
• Regional Health Directorate (RHD)/ Provincial
Government at provincial level and District Health
Office (DHO) at district level responsible for
planning, implementation, and supervision of SM
program.
• Operative part of planning in district level is
focused by nursing staffs (Public health nurse) of
various levels.
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33. Organizing
• Follows the pattern as per the organizational
structure of DoHS.
• Related Functions
– FHD/FWD continues support for expansion and
maintenance of various activities on safe
motherhood at community level.
– FHD/FWD continues to expand 24/7 service
delivery sites like birthing centers, BEONC and
CEONC sites at existing PHCC/HP and hospitals.
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34. Staffing
• A significant share of family health division’s budget
has been allocated for the recruitment of ANMs in
short term contract to ensure the 24 hour birthing
services at PHCC/HP levels.
• FHD as also provided fund at local level to recruit
human resource mix needed to provide surgical
management for obstetric complications at district
hospitals.
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35. Staffing
• FHD has been coordinating with National Health
Training Center (NHTC) and National Academy for
Medical Sciences (NAMS) for pre‐service and
in‐service training of health workers.
• NHTC provides training on SBA, ASBA, OT
management, Family Planning training including
Implants and IUCD, and antenatal USG.
• More than 7100 SBAs and 140 ASBAs have
already been trained since SBAtraining began.
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36. Staffing Pattern
• Central Level (FHD)
– Director (Senior executive)
• Regional Level (RHD)
– RH Directorate
– Nursing Officer (Focal Person)
• District Level (D/PHO)
– D/PH Officer
– Public Health Nurse (Focal Person)
• Below district level
– PHCC: Medical Officer and Staff Nurse
– HP: Health Assistant and Auxillary Nurse Midwive
– Health workers with SBA for 24 hours birthing center at HP level
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37. Directing
• However, the process of directing principally follows
the scalar chain and/or hierarchical pattern in SM
program as per the structure of DoHS.
• It may include but not limited to leadership,
motivation, authority delegation, issuing order and
communication from officer to focal person to
operative employees at below district level
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39. Coordinating
• Intra-sectoral coordination
Service from maternity care at hospitals and birthing
centre
MoH/DoHS, FHD, DHO/DPHO and peripheral HFs
• Inter-sectoral coordination
Deployment of staffs for birthing center at below
district level
Municipality/Rural Municipality
INGO’s and NGO’s(Save the Children, UMN,
RTI,NSI,ADRA, IPAS,etc)
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40. Recording
• HMIS form for recording the service provided by HFs at
district and below district level
• Major recording forms are under Family Health
Category No. 3
• 3.1 Face sheet Pills
• 3.2 : Depo service register
• 3.3 : IUCD/Implant service register
• 3.4 : Sterilization register
• 3.5 : Maternal and newborn health card
• 3.6 : Maternal and newborn service register
• 3.7 : Safe abortion service register
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41. Reporting
• Reporting mechanism follows the overall reporting pattern
established by DoHS/MoHP
• District Health Information System has been established
• All facilities follow the pattern through prescribed reporting
forms of HMIS
9.1: FCHV reporting collection form
9.2 : Community level health service monthly reporting form -
Immunization & PHC,ORC
9.3 : PHCC, HP reporting form
9.4 : Public hospital reporting form
9.5 : Non public health facility reporting form
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42. Budgeting
Budgeting process of SM program comes under the
overall budgeting process of health programs at
central level.
Health care financing
• The safe motherhood program has a demand side
financing approach where the mothers are provided
free delivery care at health facility with provision of
transport funds.
Program Budgeting
• Separate budgets for SM program allocated by MoH
and utilized by FHD, under various activities.
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44. Issues and
constrains
Recommendations Responsib
ilities
1.High
maternal
mortality rate
Review of programme implementation
and effectiveness
Plan for road map to reduce MMR
based on global and Nepal evidences
FWD,
DoHS,
MoH
2.Referral
mechanism
needs to be
established
Review/assessment of referral
strengthening at district level
Revise the Aama Programme to
facilitate an appropriate referral
mechanism and improve access to life-
saving services
FWD
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45. Issues Recommendations Respons
ibilities
3. No CEONC services
in some remote
districts: Rasuwa,
Manang and Mustang
Discussion with local government
on the advantages of have CEONC,
and challenges in maintaining
CEONC functionality in low
population areas
FWD
4. Federal structure
and governance of
health institutions;
limited understanding
of health service
delivery
Orientation of local and provincial
level government on their roles in
health services delivery and
governance
FWD/M
OH
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46. Issues Recommendations Respo
nsibilit
ies
5.Plateauing (State
with no change) of
4ANC use and timely
first ANC visits, and
very low PNC
coverage
Raise the quality of ANC
counseling services.
Develop a special package to
encourage timely first ANC visits.
Initiate PNC home visit in selected
councils
DHO,
DPHO,
FWD
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47. Issues Recommendations Responsibi
lities
6. Low use of
institutional
delivery and
C-section
services in
mountain
districts, and
province
number 2
and 6
Produce a strategy to reach
unreached sub-populations
Rapidly assess and expand
rural ultrasonography (USG)
Expand services in remote
and difficult locations and
ensure continuous availability
of services (birthing centres
and CEONC services
DHO,
DPHO,FWD
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48. Issues Recommendations Respon
sibilitie
s
7. Fluctuating
functionality
of CEONC
and birthing
centre
services
Monitoring service provision status
Availability of human resource
Promote the production of skilled service
providers
Ensure appropriate skill mix at CEONC sites by
deployment and appropriate transfer of skilled
human resources
MoH,
DoHS,
FWD,
NHTC
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49. Issues Recommendations Respon
sibilitie
s
7.(Contd
)
Continue allocation of fund for contracting out
short - term service providers
Provide locum doctors and anesthesia assistants in
strategically located referral hospitals for each
province
Introduce a special package to provide CEONC
services in mountain districts
Support local government for training of human
resources in necessary skills
MoH ,
DoHS,
FHD,
NHTC
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50. Issues Recommendations Responsi
bilities
8. Availability of
quality maternity
care services at
hospitals and birthing
centers
24/7 availability of
services
skills and
knowledge of staff
enabling
environment and
motivation
overcrowding at
referral hospitals.
Introduce construction
standards for birthing
centerss
Support birthing centers at
strategic locations
Provide additional
budgetary support for
overcrowded hospitals
Develop quality
improvement tools and
minimum service standards
MoH,
DoHS
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51. Bibilography
• Pathak LR, Kwast BE, Malla DS, PradhanAS, Rajlawat
R, Campbell BB. Process indicators for safe
motherhood programmes: their application and
implications as derived from hospital data in Nepal.
Tropical Medicine & International Health. 2000 Nov
1;5(12):882-90.
• Freedman LP, Graham WJ, Brazier E, Smith JM, Ensor
T, Fauveau V, Themmen E, Currie S, Agarwal K.
Practical lessons from global safe motherhood
initiatives: time for a new focus on implementation.
The Lancet. 2007 Oct 19;370(9595):1383-91.
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52. Bibilography
• Bhatta BN. Public Health Awareness Building in the
field of Safe Motherhood. Journal of Nepal Health
Research Council. 2008;6(2):69-73.
• KcA, Thapa K, Pradhan YV, Kc NP, Upreti SR, Adhikari
RK, Khadka N, Acharya B, Dhakwa JR, Aryal DR, Aryal
S. Developing community-based intervention
strategies and package to save newborns in Nepal.
Journal of Nepal Health Research Council. 2011 Dec
18.
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53. Bibilography
• www.ifrc.org,Saving lives, changing minds.”Maternal,
newborn and child health framework” International
Federation of Red Cross and Red Crescent Societies,
Geneva, 2013
• Annual Report department of Health Service
2073/74 ,Government of Nepal , Ministry of Health.
• http://www.policyproject.com/matrix/SafeMotherho
od.cfm
• http://sustainabledevelopment.un.org/
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