This document discusses natal (delivery) care in Nepal, outlining its objectives, services, policies, and challenges. It defines natal care and outlines its key components. It describes Nepal's plans and policies to increase skilled birth attendance and institutional deliveries, including the Safe Motherhood Policy (1998) and National Free Delivery Policy (2009). The document discusses increasing c-section rates in Nepal and highlights issues like shortages of trained health professionals that pose challenges to improving natal care.

1. Public Health Concern
of Natal Care
Presented by:
Jagat Upadhyay
Muskan Pudasainee

2. Outline of Presentation
• Introduction to Natal Care
• Objectives and Services
• Plans and Policies regarding Natal care
• Global/National Trends
• Issues and Challenges
• Conclusion and Recommendation

3. Natal/Intra-natal/Delivery
Care
• Natal care includes labor, delivery care
and essential newborn care
• Natal care is started from true labor pain
to one or two hour after delivery
• Can also be called From true labor to
removal of placenta.
• Normal birth is defined as spontaneous
in onset, low risk at start of labor and
remaining so throughout labor and
delivery

4. Natal/Intra-natal/Delivery Care
Delivery care services include:
• Skilled birth attendant and facility-based deliveries;
• Early detection of complicated cases and management
or referral (after providing obstetric first aid) to an
appropriate health facility where 24 hours emergency
obstetric services are available,
• The registration of births, maternal and neonatal deaths.
• Nepal is committed to achieving 70 percent of all
deliveries by SBAs and at institutions by 2020
(2076/77) to achieve the SDG target 90% in 2030.

5. Natal/Intra-natal/Delivery Care
Childbirth is a normal physiological process, but
complications may arise septicemia may arise result from
unskilled and septic manipulations and tetanus neonatrum
from the use of unsterilized instruments. This emphasis on
cleanliness. It Entails:
• Clean Hands and Fingernails
• Clean surface for delivery
• Clean cutting and care of the cord

6. OBJECTIVES OF NATAL CARE
• To maintain the health and well-being of pregnant women and
their off-springs during the intranatal period
• To keep the women in labour under close observation and
avoid interference with the natural process of delivery unless
there is a valid reason to do so.
• To encourage and support women in labour and extend
personal attention to them
• To ensure a safe delivery; outcome in the form of healthy
mother's healthy babies

7. Services
• Safe and clean delivery procedure including six cleans
of delivery (Historical Fact)
– Clean surface for delivery
– Clean perineum of pregnant women
– Clean hands of attendants
– Clean tie (of the cord)
– Clean cut (of the cord)
– Clean cord stump (no any application in cord stump)
• Management of obstetric complications
• Referral of obstetric emergencies like prolonged and
obstructed labor, non-cephalic presentation, hand, leg
prolapsed, etc.

8. Complications that could arise
during delivery
• Premature/preterm labor
• Prolonged labor/obstructed labor
• Maternal distress
• Fetal distress
• Breech delivery
• Cord prolapsed
• Hand prolapsed
• Shoulder dystocia
• Postpartum hemorrhage
• Inversion of uterus

9. Birthing Center/BEONC/CEONC
• Birthing centre includes woman examination, preconception
counselling, prenatal care, childbirth education, breastfeeding classes,
postpartum care and support and post-baby birth control.
• Basic emergency obstetric and new-born care (BEONC) covers the
management of pregnancy complications by assisted vaginal delivery
(vacuum or forceps), the manual removal of placentas, the removal of
retained products of abortion (manual vacuum aspiration), and the
administration of parental drugs (for postpartum haemorrhage, infection
and pre-eclampsia and eclampsia) and the resuscitation of newborns
and referrals.
• Comprehensive emergency obstetric and new-born care (CEONC)
includes CS, blood transfusion and neonatal resuscitation in addition to
the seven basic signal functions (administration of parenteral
antibiotics, uterotonic drugs, and/or parenteral anticonvulsants as
needed; manual removal of the placenta; removal of retained products;
assisted vaginal delivery; basic neonatal resuscitation).

10. Why concern for delivery service?
• Labor and birth always have natural and good outcome
unless pathogens are introduced into the uterine cavity.
However, many underlying factors contribute to maternal
death during pregnancy.
• The underlying causes include:
• Prolong labor, when the membranes are ruptured,
predisposes both mother and infant to sepsis.
• Obstruct labor can cause ruptured uterus and death from
hemorrhage.

11. Contd..
 Eclampsia, is the stage where the woman can develop
convulsions, rapidly loses consciousness and dies from brain
hemorrhage or failure of the heart, kidney or liver.
 Retained products can cause puerperal sepsis.
 Retained products and puerperal sepsis, in turn, lead to
secondary postpartum hemorrhage.
 Most obstetrical complications can lead not only to death but
also to serious problems for those who survive (for example,
asphyxia and low birth weight among infants, prolapse and
fistula among mothers).

12. SDG
Goal 3 Ensure healthy live and promote well-being
for all at ages
• Targets – 13,
• Indicators - 28
• 3.1 By 2030, reduce the global maternal
mortality ratio to less than 70 per lakh live birth
• 3.2 By 2030,end preventable deaths of new-
borns and children under 5 years of age, with all
countries aiming to reduce neonatal mortality to
at least as low as 12 per 1,000 live births and
under 5 mortality to at least as low as 25 per
1,000 live births
• 3.7 By 2030, ensure universal access to sexual
and reproductive health-care services, including
for family planning, information and education,
and the integration of reproductive health into
national strategies and programmes

13. Plans and Policies Regarding Natal
Care in Nepal
• 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)

14. Plans and Policies Regarding Natal
Care in Nepal
• Nepal Health Sector Programme
Implementation Plan II (2010-2015)
• Nepal’s Every Newborn Action Plan (2016)
• Nepal Health Sector Support Strategy (2015-
2020)
• Nyano Jhola Programme
• Aama and Newborn Programme
• Emergency Referral Fund

15. Safe Motherhood Policy 1998
• Focuses on increasing the availability, accessibility, and
utilization of maternal health services and strengthening technical
capacity of service provider at all level.
• Safe motherhood program is one of the priority program of
ministry of health
• The Safe Motherhood Programme started in 1997 and with
formulation of safe motherhood policy in 1998.
• The policy on skilled birth attendants (2006) highlights the
importance of 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.
• The Nepal Health Sector Strategy (NHSS) identifies equity and
quality of care gaps as areas of concern for achieving the
maternal health sustainable development goal (SDG) target,

16. National Safe Motherhood Plan
(2002-2017)
• Focused on strengthening the technical capacity of
maternal health care providers through effective training.
• Specific trainings to ensure that all the health care
providers have knowledge/skills of skilled birth
attendants.

17. National Free Delivery Policy (2009)
• Launched safe motherhood program
throughout the country.

18. Nyano Jhola Programme
• The Nyano Jhola Programme was
launched in 2069/70 to protect newborn
baby from hypothermia and infections.
• The Nyano Jhola Programme was
implemented in all 75 districts in 2072/73.
The government had introduced Nyano
Jhola programme aimed at reducing the
number of infant deaths due to cold and
infection across the country.
• Set of clothes are provided (Two sets of
bhoto, daura, napkin, cap and one set of
wrapper, mat for baby and gown for
mother)

19. Aama and Newborn Program
• Incentive scheme introduced (Travel, Delivery incentives)
• The government has introduced demand-side interventions to
encourage women for institutional delivery. The Maternity
Incentive Scheme, 2005 provided transport incentives to women
to deliver in health facilities. In 2006, expanded to nationwide
under the Aama Programme in 2009. In 2012, the separate 4ANC
incentives programme was merged with the Aama Programme.
• In 2073/74, the Free Newborn Care Programme (introduced in
FY 2072/73) was merged with the Aama Programme with the
provisions
• Several Programs merged and formed separate Aama and
Newborn Program (4ANC Visits, Free Newborne care program)

20. National Health Policy, 2076
• In accordance with the concept of health across the lifecycle,
health services around safe motherhood, child health,
adolescence and reproductive health, adult and senior citizen
shall be developed and expanded
• Safe motherhood and reproductive health service shall be
made of good quality, affordable and accessible

21. Fifteenth Five Year Plan (2019/20-2023-24)
National goal,
targets and
indicators
Unit
Status in
FY 2018/19
Target for FY
2023/24
Target for FY
2043/44
Maternal mortality
rate (per 100000
live birth
Number 239 99 20
Mortality rate of
children under five
years (per 1000 live
birth)
Number 39 24 8
Long Term vision 2043/44 Fifteenth Five Year Plan (2019/20-2023-24)

22. Comparison of Neonatal Mortality (Data as of 2016)
1
3
4 4
5
7
20
21
25
40
46
Japan UK USA Malasia China Thailand Bangladesh Nepal India Afghanisthan Pakistan
Lowest
in the
world
Source: UNICEF (Every Child Alive)

23. Neonatal Deaths (NDHS, 2016)
<1 hour
17%
1-23 hours
40%
24-167
hours
22%
7-27 days
21%
Percent distribution of neonatal deaths within 0-27
days of birth

24. C-Section rate: Increasing trends
0.8 0.2 0.3 0.2
2 2
9.0
2.4
4.2
7
9
28
0.0
5.0
10.0
15.0
20.0
25.0
30.0
Nepal Lowest Q Second Q Middle Q Fourth Q Highest Q
2001 2006 2011 2016
Source: NDHS
CS rate increasing in Nepal
CS rate at Population level: 10% (WHO 2015)

28. Met Need for Emergency Obstetric Care

29. Gandaki Province (Data in %)

30. Gandaki Province

31. Gandaki Province (Data in %)

32. Gandaki Province

33. Issues and challenges
• Lack of resources and shortage of
trained health professional.
• 80% of mothers in Madhesh
Pradesh(P2) said they felt that it was
not necessary to deliver in a health
facility
• In Sudurpaschim Pradesh (P7), 38%
of mothers said the birth took place
before reaching the facility
• Services from government isn’t
uniform across all districts and
referral mechanism is not seen.

34. Issues and
challenges
• Low use of institutional delivery and
C-section services in mountain
districts, and Madesh Pradesh and
Karnali Pradesh
• Increased C-section in Urban Areas
• No CEONC services in some remote
districts: Rasuwa, Manang and
Mustang
• Not enough trained health
professionals

35. Conclusion
• Natal Care lasts for a very short period of time but
has a major public health importance.
• Skilled delivery care at birth in Nepal is still very
poor.
• 17% of neonatal deaths have occurred within first
hour of life.
• More than half of neonatal deaths have occurred
within the first day of life (57%).
• CS rate increasing in urban areas.
• Safe motherhood-related indicators are low in
Gandaki province.

36. Recommendations
• Introduce a special package to provide CEONC
services in mountain districts
• Discussion with local government on the advantages of
having CEONC, and challenges in maintaining
CEONC functionality in low-population areas.
• Support local government for training of human
resources in necessary skills.
• Awareness of delivery care plays a vital role in
perceiving the need for skilled delivery care.

37. Recommendations
• An intervention consisting of awareness programmes
promoting delivery care should be implemented
targeting women, family, mothers-in-law,
• More skilled health workers should be made available
in equitable manner.
• Upgrade strategically located birthing centers to
provide comprehensive quality primary health care
services and aim for home delivery free areas
• Run innovative programme to encourage delivery at
birthing centers.

38. Recommendation
• Strengthen national policies related to safe
motherhood.
• Increase utilization of FCHVs.
• Strengthen Routine Data Quality Assessment
System (RDQA)

39. References
• DOHS Annual Report 2074/75, 2075/76, 2076/77
• NDHS 2016
• Safe Motherhood Policy (1998)
• The National Safe Motherhood Plan 2002-17
• The National Safe Motherhood Training Strategy, 2002
• National Safe Motherhood Program
• National Free Delivery Policy (2009)
• Safe Delivery Incentives Programme (2005)
• YADAV DK, SHUKLA GS, SHRESTHA N. CHILD HEALTH POLICY,
PROGRAM AND GAPS IN NEPAL
• Ministry of Health (Nepal), New ERA, and, ICF. Nepal Demographic and Health
Survey 2016. Kathmandu, Nepal: Ministry of Health, Nepal; 2017
• DoHS. Annual Report: Department of Health Services 2075/76 (2018/2019).
Kathmandu, Nepal Department of Health Services, Ministry of Health, Government
of Nepal; 2020.

40. Thank You!