Critical Appraisal on Post Natal Care (PNC) Services in Nepal

1. Critical Appraisal of Policies Programs
Guidelines and Implementation Strategy
of Postnatal Care
Mohammad Aslam Shaiekh
MPH-3rd Batch
School of Health & Allied Sciences
Pokhara University (P.U)
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2. Postnatal care
• Postnatal care (PNC) is the care given to the
mother and her newborn baby immediately
after the birth and for the first six weeks of
life(42days)
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3. The Aims of Postpartum Care:
• Support mother and family
• Prevention, early diagnosis and treatment of
• complications
• Referral
• Counselling
• Support of breastfeeding
• Educate on nutrition, and supplementation
• Counselling contraception and the resumption of
sexual activity
• Immunization of infant
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4. Importance
• To increase the awareness of warning signal
and appropriate intervention at all level.
• About 2/3 of the maternal deaths occur
during the postnatal period
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6. Complications during Postpartum
period(Maternal)
• Postpartum haemorrhage
• Pre(eclampsia)
• Pueperal genital infection
• Thromboembolic disease
• Psychological Problem
• Postpartum depression
• HIV/Aids
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7. WHO highlights
• Provide postnatal care in first 24 hours for every birth:
 Delay facility discharge for at least 24 hours.
 Visit women and babies with home births within the first 24 hours.
• Provide every mother and baby a total of four postnatal visits on:
 First day (24 hours)
 Day 3 (48–72 hours)
 Between days 7–14
 Six weeks
• Offer home visits by midwives, other skilled providers or well-
trained and supervised community health workers (CHWs).
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8. WHO highlights
• Use chlorhexidine after home deliveries in
high newborn mortality settings.
• Re-emphasize and support elements of quality
postnatal care for mother and newborn,
including identification of issues and referrals.
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9. Twelve recommendations of WHO
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 Timing of discharge from a health facility
 Number and timing of post natal care
 Home visits for Postnatal care
 Assessment of the baby
 Exclusive breasfeeding
 Cord care
 Other post natal care for the newborn
 Assessment of the mother
 Counselling
 Iron and folic acid supplementation
 Prophylactic antibiotics
 Psychological support
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11. Postnatal care services in context of
Nepal
• Three postnatal check-ups, the first within 24 hours of
delivery, the second on the third day and the third on
the seventh day after delivery.
• The identification and management of complications of
mothers and newborns and referrals to appropriate
health facilities.
• The promotion of exclusive breastfeeding.
• Personal hygiene and nutrition education, and
postnatal vitamin A and iron supplementation for
mothers.
• The immunization of newborns.
• Postnatal family planning counseling and services.
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12. Source: NDHS 2016)
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13. Key findings of NDHS 2016
• Eighty-one percent of women who delivered in a
health facility received a postnatal check within 2 days
after the delivery
• Sixty-four percent of urban women received a
postnatal checkup within 2 days after delivery, as
compared with 48% of rural women.
• Only 39% of women residing in Province 6 received
postnatal care, compared with 68% of women in
Province 4.
• Women in the highest wealth quintile were more than
twice as likely (81%) to receive postnatal care within 2
days of delivery as women in the lowest quintile (37%).
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14. Key findings NDHS 2016
• More than half (53%) of women who gave birth in
the 2 years before the survey received their first
postnatal care from a doctor, nurse, or auxiliary
nurse midwife.
• Place of First Postnatal Check Among women who
gave birth in the 2 years preceding the survey,
39% reported that their first postnatal check was
provided in a government-sector facility and 10%
reported receiving care from the private sector
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16. Policies
• Second Long Term Health Plan (1997 – 2017)
• Safe Motherhood Policy (1998)
• National Safe Motherhood Program (2002–2017)
• National Safe Abortion Policy (2003)
• Maternal Incentive Scheme (2005)
• Safe Motherhood and Neonatal Health Long Term Plan (2006–2017)
• National Policy on Skilled Birth Attendants (2006)
• National Free Delivery Policy (2009)
• Nepal Health Sector Programme Implementation Plan II (2010 –
2015)
• Nepal Health Sector Support Strategy (2015-2020)
• Safe Motherhood Information Education Communication (IEC)
strategy (2003-2008)
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17. Safe Motherhood Policy (1998
• To increase the accessibility, availability and utilization
of maternal health care facilities;
• To strengthen the technical capability of maternal care,
particularly at the district level and with specific
emphasis on appropriate referral of high-risk cases;
• To increase the availability and use of contraceptives
for child spacing and family planning purposes;
• To raise public awareness about the importance or the
health care of women and in particular , maternal
health care and safe motherhood; and
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18. Second long term health plan:
• MMR will be reduced to 250 per 100000
• CPR will be increased 58.2%
• Percentage of newborns weighing less than
2500 will be reduced to 12 %
• Skilled birth attendant increased to 95%
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19. SBA Policy 2006
Objectives
• To ensure that sufficient SBAs are trained and
deployed
• To strengthen referral services
• To strengthen SBA training institutions
• To strengthen supervision and support system
• To develop regulating, accrediting and re-
licensing systems.(15)
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20. Nepal safe motherhood long term plan
2002-2017
• Purpose: Sustained increase in utilization of
quality maternal health services
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21. Nepal safe motherhood and New born
health long term plan 2006-2017
(Revised)
• Specific emphasis on neonatal health,
recognition of the importance of skilled birth
attendance in reducing maternal and neonatal
mortalities, health sector reform initiatives,
legalisation of abortion, recognition of the
significant levels of mother to child
transmission of HIV/AIDS and equity issues in
safe motherhood services.
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22. NHSSP (2010-2015)
• Emphasized in community-based services; FCHVs, mother’s group etc
• Expanded in service SBA training
• Improved the coverage of CEOC and BEOC services
• Expansion of medical abortion services
• Piloted community based administration of misoprostol
• Expansion of blood donation service
Target
• to reduce MMR 134 per 100000 live birth and
• to increase births attended by SBA to 60% by 2015;
• to train maternal health care provider to fulfill the demand (5000 by 2012
and 7000 by 2015);
• to expand BEmOC/CEmOC facilities;
• to upgrade sub health post to health post with 24 hours normal delivery
facility throughout the week.(19)
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23. National Health Policy, 1991
• To reduce MMR to 400 from 850 per 10000
live birth by 2000
• Policy stated maternal and child health
services are priority program of government.
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24. National Safe Motherhood & Newborn
Health Long Term Plan 2006-2017
• Reduction in the MMR from 539 to 134 per
100,000 by 2017
• Increase in % of deliveries by SBA to 60% by
2017
• Increase % of deliveries taking place in health
facility to 40% by 2017.
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National Health Policy 2014
• The policy put emphasis on producing skilled
HR for safe motherhood and provision of a
doctor and a nurse in every VDC & a midwife
in every ward.
Nepal Health Sector Strategy 2015 - 2020
• G1: Reduction in MMR below 125 per 10000
live birth by 2020.
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26. Programs
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27. Safe motherhood and Newborn Care
1. Birth Preparedness Package and community level maternal and
newborn health:
• Distribution of Matrisurakshya chhaki to prevent post partum
haemorrhage
• birth preparedness and complication readiness (preparedness of
money, health facilities for the delivery, transport and blood
donors);
• self-care (food, rest, no smoking and alcohol) in pregnancy and
postpartum periods;
• antenatal care (ANC), institutional delivery and postnatal care (PNC)
(iron, tetanus toxoid, albendazole);
• essential newborn care; and
• identification of and timely care seeking for danger signs in the
pregnancy, delivery, postpartum and newborn periods.
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28. Contd….
1. Trained Human resources: SBA trained human
resources
2. Expansion and quality improvement of service
delivery sites : BEONC and CEONC services
3. Nyano Jhola Programme
4. Aama and Newborn Programme: Incentives to
health workers for home delivery, decreased to
Rs 200 to discourage home delivery
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29. Family Planning services
• A special focus is on increasing access in rural
and remote places and to poor, Dalit and
other marginalized people with high unmet
needs and to postpartum and post-abortion
women, the wives of labour migrants and
adolescents.
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30. Challenges
• Inadequate information on PNC care
• Inadequate trained human resources
• Limited health infrastructure
• Economic status of women
• Transportation
• Cultural and geographical factors
• Perceived low importance of care in the postpartum
period
• Poor coordination of family planning services, ANC
providers, maternity wards, and postnatal care
providers also contributed to the high unmet need for
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31. Recommendations
• PNC related health education and awareness
campaigns
• Recruitment of trained staff and training should be
given to existing staff
• Women empowerment
• Involvement of men in maternal care
• Coordination among institution
• Emphasizing on family support
• Home visits by trained staff
• Focusing on Postnatal care during formulation of
policies
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32. References
• DoHS. Annual Report: Department of Health
Services 2073/74 (2015/2016). Kathmandu,
Nepal Department ofHealth Services, Ministry of
Health, Government of Nepal; 2017.
• NDHS. Maternal and Newborn Health Care; P
151- 193: 2016.
• http://www.searo.who.int/entity/health_situatio
n_trends/data/chi/postnatal-care-for-mothers-
and-babies/en/
• WHO. (2013). WHO South east Asia.
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33. • Harvard School public health. (2014).
Postnatal care in Nepal. Retrieved from
Maternal health task force.
• WHO. (2013). WHO recommendations on
Postnatal Care and newborn.
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