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Brief Overview of Management of Safe
motherhood and Newborn Health
Services in Nepal
Presented By :
Mohammad Aslam Shaiekh
Master of Public Health (MPH)
1Aslam Aman
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.
2Aslam Aman
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
3Aslam Aman
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.
4Aslam Aman
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)
5Aslam Aman
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.
6Aslam Aman
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.
7Aslam Aman
• 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.
8Aslam Aman
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
Aslam Aman 9
Major activities
6. Emergency referral Fund
7. Safe Abortion Service
8. Obstetric first aid orientations
9. Nyano Jhola Programme
10. Aama and Newborn Programme
Aslam Aman 10
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
11Aslam Aman
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.
12Aslam Aman
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
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.
14Aslam Aman
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
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.
16Aslam Aman
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.
17Aslam Aman
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.
18Aslam Aman
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.
19Aslam Aman
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.
20Aslam Aman
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.
21Aslam Aman
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.
22Aslam Aman
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
23Aslam Aman
Situation of Safe motherhood
program status in Nepal
Aslam Aman 24
Aslam Aman 25
Aslam Aman 26
Aslam Aman 27
Aslam Aman 28
29Aslam Aman
Aslam Aman 30
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
31Aslam Aman
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.
32Aslam Aman
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.
33Aslam Aman
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.
34Aslam Aman
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.
35Aslam Aman
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
36Aslam Aman
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
37Aslam Aman
Directing
38Aslam Aman
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)
39Aslam Aman
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
40Aslam Aman
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
41Aslam Aman
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.
42Aslam Aman
Issues and Recommendations
43Aslam Aman
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
44Aslam Aman
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
45Aslam Aman
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
46Aslam Aman
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
47Aslam Aman
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
48Aslam Aman
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
49Aslam Aman
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
50Aslam Aman
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.
51Aslam Aman
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.
52Aslam Aman
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/
53Aslam Aman
54Aslam Aman

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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) 1Aslam Aman
  • 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. 2Aslam Aman
  • 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 3Aslam Aman
  • 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. 4Aslam Aman
  • 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) 5Aslam Aman
  • 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. 6Aslam Aman
  • 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. 7Aslam Aman
  • 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. 8Aslam Aman
  • 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 Aslam Aman 9
  • 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 Aslam Aman 10
  • 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 11Aslam Aman
  • 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. 12Aslam Aman
  • 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. 14Aslam Aman
  • 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. 16Aslam Aman
  • 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. 17Aslam Aman
  • 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. 18Aslam Aman
  • 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. 19Aslam Aman
  • 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. 20Aslam Aman
  • 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. 21Aslam Aman
  • 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. 22Aslam Aman
  • 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 23Aslam Aman
  • 24. Situation of Safe motherhood program status in Nepal Aslam Aman 24
  • 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 31Aslam Aman
  • 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. 32Aslam Aman
  • 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. 33Aslam Aman
  • 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. 34Aslam Aman
  • 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. 35Aslam Aman
  • 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 36Aslam Aman
  • 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 37Aslam Aman
  • 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) 39Aslam Aman
  • 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 40Aslam Aman
  • 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 41Aslam Aman
  • 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. 42Aslam Aman
  • 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 44Aslam Aman
  • 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 45Aslam Aman
  • 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 46Aslam Aman
  • 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 47Aslam Aman
  • 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 48Aslam Aman
  • 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 49Aslam Aman
  • 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 50Aslam Aman
  • 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. 51Aslam Aman
  • 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. 52Aslam Aman
  • 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/ 53Aslam Aman