Practicum presentation on Safe Motherhood Program (SMP) and Maternal and Perinatal Death Surveillance and Response (MPDSR) Program in MNH Section of Family Welfare Division

1. Internship/Practicum Project Report
On
Safe Motherhood Program in Maternal and Neonatal Health
Section under the Family Welfare Division
Prepared by-
Mohammad Aslam Shaiekh
Roll No: 18700003
E-mail: amanjawed27@gmail.com
skaslam4aman1@gmail.com
Submitted To
Master of Public Health Program
School of Health and Allied Sciences
Faculty of Health Sciences
Pokhara University
2019

2. i
Internship/Practicum Project Report
On
Safemotherhood Program in MNH Section under Family Welfare Division
Mohammad Aslam Shaiekh
PU Regd. No: 2018-4-70-0003
amanjawe27@gmail.com
Organization of Maternal and Neonatal Health (MNH) Section
Practicum Placement: Family Welfare Division (FWD)
Department of Health Services (DoHS)
Teku, Kathmandu
Contact: Dr. Punya Paudel
Section Chief
9851107356
punya.dr@gmail.com
Faculty Advisor: Dr. Arun Kumar Koirala
Professor
School of Health and Allies Sciences
Pokhara University
9849264178
arunkoirala@gmail.com
Master of Public Health Program
School of Health and Allied Sciences
Faculty of Health Sciences
Pokhara University
November, 2019

3. ii
Approval
Mr. Mohammad Aslam Shaiekh has prepared the project report entitled “Practicum report on
Safemotherhood Program in Maternal and Neonatal Health (MNH) Section under the Family
Welfare Division (FWD)”. The project report has been prepared and presented for the partial
fulfillment of the requirement for the degree of Master of Public Health (MPH) and forwarded for
final evaluation.
……………………………….
Prof. Dr Arun Kumar Koirala
Professor, Public Health
SHAS, Pokhara University
Date: …………………….
Master of Public Health (MPH) Program, School of Health and Allied Sciences, Faculty of
Health Sciences, Pokhara University, Pokhara Metropolitan-30, Kaski, Nepal.
This report/proposal has been reviewed and accepted
Accepted
Accepted with condition
Not accepted
External Examiners
1. Name: _____________________ Signature: _____________ Date: _________
2. Name: _____________________ Signature: ______________ Date: __________
__________________ ____________________
ChiranjiviAdhikari Dr. DamaruParsad Paneru
Program Coordinator, MPH Director
School of Health & Allied Sciences School of Health & Allied Sciences
School Seal

4. iii
Acknowledgement
It is indeed great pleasure to extend my sincere appreciation to all individuals and
institutions for their help and support to make this practicum really fruitful and success.
Firstly I would like to express my sincere gratitude to my supervisors Professor Dr. Arun
Kumar Koirala for their continuous support and guidance during the practicum period. I
would like to put my heartfelt thanks to the Faculty of Health Sciences especially
Associate Professor Dr. Damaru Prasad Paneru (Director, School of Health and Allied
Sciences), Assistant Professor Mr. Chiranjivi Adhikari (MPH Program Coordinator,
SHAS), Associate Professor Dr. Tulsi Ram Bhandari and Dr. Dipendra Kumar Yadav
and every one of the faculty members for providing the opportunity and great support.
I am very grateful to Maternal and Neonatal Health (MNH) Section of Family Welfare
Division (FWD) for providing opportunity to conduct this practicum. I would like to
express my gratitude to Mrs. Dr. Punya Paudel, Chief of MNH section of Child Health
Division who have indebted me with his kind support, valuable suggestions and guidance
during the stay in this section. Special thanks to Safemotherhood Program Supervisor
(Community Nursing Officer), Mrs Kumari Bhattarai for their kind guidance/mentoring,
support and co-operation throughout the period.
I would like to extend my cordial thanks to Mrs. Mahalaxmi Prajapati and Nepal Health
Sector Support Program (NHSSP) team for providing me the opportunity to involve in
various activities of their NHSSP and special thanks to Mr. Binod Joshi, Monitoring and
Evaluation Officer, FP2020 for their invaluable support and cooperation.
Last but not the least I would like to express my thanks to my family, all my colleagues
and all other people who helped me directly or indirectly to complete this practicum.
Mohammad Aslam Shaiekh
November, 2019

5. iv
Table of Contents
Approval ...........................................................................................................................................ii
Acknowledgement...........................................................................................................................iii
List of Table ......................................................................................................................................v
List of Figure .....................................................................................................................................v
Abbreviations ..................................................................................................................................vi
Executive Summary........................................................................................................................vii
Chapter I: Introduction.................................................................................................................... 1
1.1 Background............................................................................................................................ 1
1.2 Objectives.............................................................................................................................. 1
Chapter II: Methodology ................................................................................................................. 2
2.1 Methodology:........................................................................................................................ 2
2.2 Activities carried out during practicum Period and Approached applied:............................ 3
Chapter III: Information (Qualitative and Quantitative) ................................................................. 4
3.1 Background of MNH Section ................................................................................................. 4
3.2 Managerial Aspects of MNH Section..................................................................................... 5
3.2. Result of Desk Review and Interview ................................................................................... 7
Unit IV Mini Action Project............................................................................................................ 14
4.1 Introduction:........................................................................................................................ 14
4.2 Objectives:........................................................................................................................... 14
4.3 Details of Intervention Project: ........................................................................................... 14
4.4 Contents of Mini Lecture:.................................................................................................... 14
Unit IV: Conclusion and Recommendations.................................................................................. 22
5.1 Conclusion: .......................................................................................................................... 22
5.2 Limitations of the internship ............................................................................................... 22
5.3 Lesson Learned:................................................................................................................... 22
5.4 Recommendations............................................................................................................... 23
Annexes:........................................................................................................................................ 25
Annex 1: Photos:........................................................................................................................ 25
Annex 2: Letter from College.................................................................................................... 26

6. v
Annex 3: Action Plan ................................................................................................................ 27
Annex 4: Attendance-Sheet....................................................................................................... 28
Annex 5: Practicum Completion Letter..................................................................................... 29
List of Table
Table 1: Activities and Approaches ................................................................................................ 3
Table 2: Major Achievement in FY 2075/76 (Till September)..................................................... 13
List of Figure
Figure 1: Organogram ..................................................................................................................... 6

7. vi
Abbreviations
ANM Auxiliary Nursing Midwives
CPR Contraceptives Prevalence Rate
DG General Director
DoHS Department of Health Services
FCHV Female Community Health Volunteers
FCHV Female community Health Voluntree
FP Family Planning
FWD Family Welfare Division
MoHP Ministry of Health and Population
FY Fiscal Year
HMIS Health Management Information System
LMD Logistic Management Division
MAP Mini Action Project
MDG Millennium Development Goals
MNH Maternal and Neonatal Health
MoF Ministry of Finance
MPDSR Maternal and Perinatal Death Surveillance and Response
NDHS Nepal demography and Health Survey
NHSSP Nepal Health Sector Support Program
NPC National Planning Commission
PHCC Primary Health Care center
PHC-ORC Primary Health Care Out Reach Clinic
PPP Public Private Partnership
SDG Sustainable Development Goal
SMP Safemotherhood Program
WHO World Health Organization

8. vii
Executive Summary
This report is a practical experience of practicum which was designed for the partial
fulfillment of Master degree in Public Health. Practicum was conducted Maternal and
Neonatal Health (MNH) section of Family Welfare Division (FWD) for the period of
three weeks starting from 10th
October to 5th
November 2019 and placement was done as
an Intern with the various tasks assigned.
The purpose of Practicum/internship was to observe, participate and engage in various
activities, to critically appraise the present state and mode of the Health promotion,
education and communication status of MNH Section of FWD and to prepare and carry
out the prototype mini project following the systematic step of a project preparation and
implementation.
Learning objectives of the practicum were to learn about Safemotherhood program and
activities, understanding managerial aspect of MNH section and enhancing managerial
skills through involvement in different activities. The practicum was started with an
approval of the detail plan of action to be accomplished from Chief of MNH section.
Desk review, discussion, record review, interaction, observation and participation
methods and approaches were used to carry out the various activities for the fulfillment of
the learning objectives.
The major activities conducted during the internship were participation in monthly
review of progress meeting, participation in FP 2020 meeting, document review
regarding the renew and approval for SM program, detail orientation about NHSSP
activities, preparation of draft for MPDSR, progress review from annual report, data
compilation, learning on use of application of STAT-Compiler for NDHS data etc
The MNH section basically provides support to MoHP to prepare national policy,
strategies, directories, protocol regarding the maternal and newborn health, provide
technical support and assistance to the federal and provincial policy by analyzing
maternal and newborn health status, facilitate new program at provincial and local levels,
coordinate and cooperate for the MNH activities implementation and enhance the quality
of services through the expansion of emergency 24 hour services.
Practicum provided a good opportunity to learn and develop skills and utilize
competencies through the involvement in the different aspects of Safemotherhood
program and MPDSR activities. Practicum helped to learn public health management
process and program and activities carried out Safemotherhood. Moreover, it helped to
enhance interpersonal communication skills, writing skills and managerial skills.
With the achievement in learning objectives in short period of time, the practicum was
successfully completed.

9. 1
Chapter I: Introduction
1.1 Background
Internship is the position of a student or trainee who works in an organization, in order to
gain work experience or satisfy requirements for a qualification. This internship is
designed as one of the course of MPH to help us develop skills on and attitudes towards
identifying various problems and issues prevalent in the field of HPEC and critically
analyzing them. In addition, we will develop the skills of carrying out specific health
project/campaign utilizing our knowledge on carrying out HPEC project on selected
public health problems and issues systematically. The course is primarily interactive and
practical in nature. Survey of GO, INGOs, NGOs implementing integrated health
promotion, education and communication programs in the community is the main
objective of this internship.
1.2 Objectives
 To observe, participate and engage in various activities of MNH Section during
the practicum period.
 To critically appraise the present state and mode of the Health promotion,
education and communication interventions of MNH section.
 To prepare and carry out the prototype mini project following the systematic step
of a project preparation and implementation.
 To involve in the activities assigned by the institutional supervisor
 Develop interpersonal skills and competencies to work in group/team for quality
project management

10. 2
Chapter II: Methodology
2.1 Methodology:
At first it was very difficult to identify the organization. Visited different organizations
and contacted head of those organizations and found that many organizations didn’t have
provision for short period of time i.e. about 3 weeks practicum. With an interest to do
practicum in the area of MCH and went to meet Chief of MNH section in Family Welfare
Division through phone and email conversation. After discussion with the Chief,
approval was given to do a practicum in the MNH section. Integration of interest of
student and organization lead to development of a learning contract and signed from the
both sides. Placement was done in the organization as an intern for the period of three
weeks started from 10th
October 2019 to 5th
November 2019.
After the placement in the organization, a detail plan of action was developed and
approved by the Chief of MNH section. Based on approved detail plan of action, different
methods like discussion, records and documents review, observation, interaction, and
participation etc. were adopted for conducting various activities in order to achieve
practicum objectives.
(i) Desk Review:
Review of documents and reports like Annual report, Documents review for renew
and approval of Safemotherhood program and Guidelines etc. was done for
understanding the program and activities on SMP and organizational policy and
strategy.
(ii) Interaction:
Interview with Chief of MNH section and other SMP supervisors was done to
enhance further understanding on programs and activities and to understan the
management process.
(iii) Observation:
Different units of MNH section and NHSSP were visited and observation was done
to understand the management process and activities performed. Attended meetings
related to Monthly progress review and FP2020.
(iv) Participation:
Participated in the Public Private Partnership (PPP) workshop and MPDSR Orientation

11. 3
2.2 Activities carried out during practicum Period and Approached applied:
Table 1: Activities and Approaches
S.N. Activities Methods/Approaches
1 Read documents and reports related to Aama
Surakshya (Safemotherhood) program and
interviewed with Section Chief to be familiarize
with SM program
Desk review, Interview
2 Exploring the MNH activities and Organizational
structure
Discussion
2 Attended progress review meeting, visited to
different units, worked together with supervisors
to understand managerial process in
Immunization section
Participation, Interaction,
Interview, Observation
3. Attended workshop on Public Private Partnership
(PPP)
Participation and
Observation
4 Develop slides on MPDSR and 3 years progress
of SMP activities
Discussion, Documents
review and Consultation
with section chief
5. Discussion and orientation about NHSSP support
and their activities
Interaction
6. NHSS-RF data compilation Data entry
7 Attended FP2020 meeting Participation and
Observation
8. Operating STAT-Compiler for NDHS data
regarding SMP indicators
Application of STAT-
Compiler
9 Conducted Mini-Action-Project (MAP) Gap analysis
10 Final Presentation and Vote of Thanks for
Supporting over the practicum period
Presentation and
Discussion

12. 4
Chapter III: Information (Qualitative and Quantitative)
3.1 Background of MNH Section
Family health is one of the priority programs of Government of Nepal, Ministry of
Health, DoHS. As per constitution of Nepal and related policies and strategic direction,
Family Health Division (FHD) is responsible for improving overall quality of life of the
whole family by improving the health status of mothers, neonates and children and by
increasing access and utilization of quality family planning and safe motherhood services
closer to rural households in full participation and involvement of community in public
health activities. To achieve this important goal various programs like family planning,
adolescent sexual and reproductive health, safe motherhood and neonatal health,
reproductive health care services through Primary Health Care out Reach Clinic
(PHC/ORC) and Female Community Health Volunteers (FCHVs), planning, monitoring
and reproductive health research are in operation.
Nepal has been able to partially achieve Millennium Development Goal (MDG) 4 and 5
and there is much to do towards improving reproductive health status of Nepalese
population. To further improve maternal and newborn health status of country, Nepal is
committed to sustain these achievements and further improve maternal and neonatal
health and achieve target of Maternal Mortality Ratio to less than 70/100000 live birth,
Institutional Delivery to 90%, Contraceptive Prevalence Rate (CPR) to 75%, and
Neonatal Mortality Rate to (1/1000 Live Birth) which are set for Sustainable
Development Goal (SDG) by 2030.
Hence, to improve the maternal and newborn health status of country, MNH section of
family welfare division works:
 To support the Ministry of Health and Population to prepare national policy,
strategy, directories, criteria, protocols regarding Maternal and Newborn health.
 To assist in survey / research related to Maternal and Newborn Health.
 To provide technical assistance to the national and regional policy by analyzing
maternal and newborn health conditions.
 Based on national policy, international guidance and territorial needs, to facilitate
new programs related to maternal and newborn health
 To coordinate and implement technological issues with the state, local level and
stakeholders.
 Coordinated and cooperative for implementing national priority programs of
Maternal and Newborn.
 Necessary support to the regional and local level to enhance the quality of
services through the expansion of emergency 24-hour service.

13. 5
3.2 Managerial Aspects of MNH Section
A. Planning:
Planning is an important part of management which predetermines the future. The
planning process carried out for the development of SMP is shortly described as: First of
all financial plan is developed by National Planning Commission (NPC) in coordination
with Ministry of Finance (MoF). MoF provide budget ceiling to plan the programs and
activities to Ministry of Health (MoH) who later sends budget ceiling to DoHS and to
respective divisions. Based on the budget ceiling MNH section develops programs and
activities in consultation with donor agencies and experts and finalize the program and
activities sitting together with planning section of FWD. Those planned programs and
activities are submitted to MoHP where final selection of programs and activities are
made. Finalized plan from MoHP is submitted to NPC. After approval from NPC it
submits plan to MoF for selection of programs and activities and allocation of budget.
MoF submits back the final plan to NPC. Detail plan document is prepared by NPC and
put it forward to cabinet for its approval. The plan is executed after Cabinet approval.
B. Staffing:
The people for the sanctioned permanent posts in MNH section are recruited through
Public Service Commission and Ministry of Health carries out training and development,
performance appraisals, promotions and transfers of the personnel. Temporary staffs can
be recruited by Family Welfare Division.
Altogether there are five staffs under MNH section of FWD.
 Section Chief (9th level) - 01
 Community Health Nursing Officer-1 (7th level)
 Na.Su-1
 Computer Assistant -1
 Public Health Inspector-2 (7th level) – 01
 Office Assistant – 1

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C. Organizing:
The organizational structure of Immunization section is as below:
D. Directing:
The chief of Immunization Section have full authority to mobilize the human resources.
Delegation of the authority with resources is given by the chief to other staffs to carry out
their responsibilities.
E. Coordination:
There are two types of coordination that take place in MNH section. One is vertical
coordination, where the coordination is done with Family Welfare Division, DoHS and
Ministry of Health in the central level and with Provincial Health Directorate and at
Health sections of Palika in local level for successful implementation of the
Safemotherhood programs at province and local/peripheral level. Another is horizontal
coordination with other divisions and centers like LMD, NHTC, NHEIC, NPHL, EDCD,
and MD.MNH section works in close coordination with partner agencies like WHO,
NHSSP, UNICEF, UNFPA. Intra-sectoral coordination within health sector and inter-
sectoral coordination among other sectors like water and sanitation, agriculture,
Family Welfare Division
(FWD)
Child Health
and
Immunization
Section
Maternal &
Newborn Health
Section
(Section Chief-1)
Family
Planning and
Reproductive
Health Section
Nutrition
Section
Community Health Nursing Officer-1 Na. Su.-1
Public Health Inspector-2 Office Supporter-1
Computer Assistant.-1
Figure 1: Organogram

15. 7
education, etc. is maintained by MNH section. Within the MNH section there is
coordination between different units.
F. Reporting:
Data generated from SMP services are reported through HMIS to HMIS section of
Management Division of DoHS. HMIS collects and analyzes this information and sends
to MNH section of FWD for review and feedback. MNH section also provides the
information about program achievement to the DG in every monthly review meeting.
G. Budgeting:
Budget planning is done at the time of developing plan for programs and activities. The
process of budget follow and disbursement of budget is through the governmental process
at each level. At the end of the fiscal year internal auditing is done by FCGO and external
auditing is done by Auditor General Office.
H. Monitoring and Evaluation:
Quarterly and yearly review meetings are done from the centre for the monitoring and
evaluation of SM program.
3.2. Result of Desk Review and Interview
Through the review of reports and other policy and strategy documents and interview
with Community Health Nursing Officer and Chief of MNH Section came to know about
the program and activities of MNH carried out in Nepal which has been described below
.
Safe Motherhood Program
Introduction:
The evidence suggests that three delays are important factors for maternal and newborn
morbidity and mortality in Nepal (delays in seeking care, reaching care and receiving
care). Hence, The Safe Motherhood Programme, initiated in 1997 has made significant
progress with formulation of safe motherhood policy in 1998. Service coverage has
grown along with the development of policies, programmes and protocols. 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. 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. The
endorsement of the revised National Blood Transfusion Policy (2006) was another
significant step for ensuring the availability of safe blood supplies for emergency cases.

16. 8
Goal:
The goal of the National Safe Motherhood Programme is to reduce maternal and
neonatal morbidity and mortality and 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.
Strategies:
The following major/main strategies have been adopted to reduce risks during pregnancy
and childbirth and address factors associated with mortality and morbidity:
 Promoting birth preparedness and complication readiness including awareness
rising and improving preparedness for funds, transport and blood transfusion.
 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 health facilities in all districts
The supporting strategies of Safemotherhood program are:
 Promoting inter-sectoral coordination and collaboration at Federal, Provincial,
districts and Local levels to ensure commitment and action for promoting safe
motherhood with a focus on poor and excluded groups.
 Strengthening and expanding delivery by skilled birth attendants and providing
basic and comprehensive obstetric care services at all levels. Interventions
include:
 Developing the infrastructure for delivery and emergency obstetric care; o
standardizing basic maternity care and emergency obstetric care at
appropriate levels of the health care system;
 Strengthening human resource management —training and deployment of
advanced skilled birth attendant (ASBA), SBA, anesthesia assistant and
contracting short-term human resources for expansion of services sites;
 Establishing a functional referral system with airlifting for emergency
referrals from remote areas, the provision of stretchers in Palika wards and
emergency referral funds in all remote districts;
 Strengthening community-based awareness on birth preparedness and
complication readiness through FCHVs and increasing access to maternal health
information and services.
 Supporting activities that raise the status of women in society.
 Promoting research on safe motherhood to contribute to improved planning,
higher quality services and more cost-effective interventions.

17. 9
Major Activities:
a. Community level maternal and newborn health interventions
Family Welfare Division (FWD) continued to expand and maintain MNH
activities at community level including the Birth Preparedness Package
(jeevansuraksha flipchart and card) and distribution of matrisurakshachakki
(misoprostol) to prevent postpartum haemorrhage (PPH) in home deliveries.
Through FCHV, public health system promotes:
 Birth preparedness and complication readiness (preparedness for money,
place for delivery, transport and blood donors);
 Self-care (food, rest, no smoking and no alcohol) in pregnancy and
postpartum periods;
 Antenatal care (ANC), institutional delivery and postnatal care (PNC)
(iron, tetanus toxoid, Albendazole ,Vitamin A);
 Essential newborn care; and
 Identification of and timely care seeking for danger signs in the
pregnancy, delivery, postpartum and newborn period.
b. Rural Ultrasound Program:
The Rural Ultrasound Programme aims for the timely identification of pregnant
women with risks of obstetric complication to refer to comprehensive emergency
obstetric and neonatal care (CEONC) centres. Trained nurses (SBA) scan clients
at rural PHCCs and health posts using portable ultrasound. Women with detected
abnormalities such as abnormal lies and presentation of the foetus and placenta
previa are referred to a CEONC site for the needed services. This programme is
being implemented in the 14 remote districts.
c. Reproductive health morbidity prevention and management programme
 Management of pelvic organ prolapse and Obstetric Fistula
 Cervical cancer screening and prevention training
d. Human Resources:
A significant share of FWD’s budget goes for recruiting human resource (Staff
nurses, ANMs)on short term contracts to ensure 24 hour services on MNH at
PHCCs and health posts. FWD also provides funds to DHOs and DPHOs to
recruit the human resource mix needed to provide surgical management for
obstetric complications at district hospitals CEONC sites). FWD has been
coordinating with the National Health Training Centre (NHTC) and the National
Academy for Medical Sciences (NAMS) for the pre-service and in-service
training of health workers. NHTC provides training on SBA, ASBA, Anesthesia

18. 10
assistant, operating theatre management, family planning (including implants and
IUCD), CAC and antenatal ultrasonography.
e. Expansion and quality improvement of service delivery sites:
FWD continued to expand 24/7 service delivery sites like birthing centers,
BEONC and CEONC sites at PHCCs, health posts and hospitals. The expansion
of service sites is possible mostly due to the provision of funds to contract short-
term staff locally.
f. Onsite clinical coaching and mentoring
Quality service at the service delivery point is one of the focused themes of NHSS
and its implementation plan 2016-2021. On-site coaching and clinical skill
enhancement of service providers is considered the most effective means to
improve knowledge, skills and practices of health service providers (WHO). FWD
had started to implement on-site clinical coaching /mentoring programme since
2073/2074 from 16 districts to enhance knowledge and skill of SBA and non-SBA
nursing staffs providing delivery services at BC/BEONC and CEONC service
sites. Onsite clinical coaching and mentoring programme based on
coaching/mentoring guideline and tool. This guideline has included mainly three
parts; Clinical coaching/mentoring for MNH service providers (SBA and
non_SBA), Infection prevention and MNH readiness QI self-assessment.
g. MNH readiness Hospital and BC/BEONC Quality Improvement
Improvement in quality of service delivery through self-assessment, infection
prevention demonstration and action plan implementation is evidence based
effective program The process of quality improvement is also being implemented
in birthing centers in integration with onsite coaching/mentoring process.
h. PNC home visit (micro planning for PNC)
Access to and utilization of post-natal care services is a major challenge while the
majority of maternal deaths occur during post-natal period. As reported above in
PNC section women who received PNC according to the protocol is 16 percent. In
FY2074/75FWD provided 30 local palikas from 15 districts to strengthen PNC
services by mobilizing MNH service providers from health facilities to provide
PNC at women’s home.
i. Emergency referral funds
It is estimated that 15 percent of pregnant women will develop serious
complications during their pregnancies and deliveries, and 5 to 10 percent of them
will need caesarean section deliveries (WHO, 2015) to avoid deaths or long-term

19. 11
morbidity. In cases of difficult geographical terrain and unavailable CEONC
services, it is crucial that these women are referred to appropriate centres. To
address this issue FWD allocated emergency referral funds to Provincial
Directorate for air lifting of women in need of immediate transfer to higher
centres. A transport fare in districts is also allocated to support women who could
not afford referral to high facility. The main objective of this programme is to
support emergency referral transport to women from poor, Dalit, Janajati,
geographically disadvantaged, and socially and economically disadvantaged
communities who need emergency caesarean sections or complication
management during pregnancy or child birth.
j. Safe abortion services
FWD has defined the four key components of comprehensive abortion care as:
 Pre and post counseling on safe abortion methods and post-abortion
contraceptive methods;
 Termination of pregnancies as per the national protocol;
 Diagnosis and treatment of existing reproductive tract infections; and
 Provide contraceptive methods as per informed choice and follow-up for
post-abortion complication management.
k. Maternal and Perinatal Death Surveillance and Response (MPDSR)
l. Obstetric first aid orientations
m. Nyano Jhola Programme
The Nyano Jhola Programme was launched in 2070/71 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. The
programme was interrupted due to financial constraints, however MOH allocated
extra budget for due to popular demand.
n. Aama and Free Newborn Programme
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, user fees
were removed from all types of delivery care in 25 low HDI districts and
expanded to nationwide under the Aama Programme in 2009. In 2012, the
separate 4 ANC incentives programme was merged with the Aama Programme. In

20. 12
2073/74, the Free Newborn Care Programme (introduced inFY2072/73) was
merged with the Aama Programme which was again separated in FY 2074/75 as
two different programmes with the provisions listed below:
Provisions of the Aama Programme and Newborn Programme:
Aama programme provision
For women delivering their babies in health institutions:
 Transport incentive for institutional delivery: Cash payment to women
immediately after institutional delivery (NPR 3,000 in mountains, NPR 2,000 in
hills and NPR 1000 in Tarai districts).
 Incentive for 4 ANC visits: A cash payment of NPR 800 to women on completion
of four ANC visits at 4, 6, 8 and 9 months of pregnancy, institutional delivery and
postnatal care.
 Free institutional delivery services: A payment to health facilities for providing
free delivery care. For a normal delivery health facilities with less than 25 beds
receive NPR 1,000 and health facilities with 25 or more beds receive NPR 1,500.
For complicated deliveries health facilities receive NPR 3,000 and for C- sections
(surgery) NPR 7,000. Ten types of complications (antepartum haemorrhage
(APH) requiring blood transfusion, postpartum haemorrhage (PPH) requiring
blood transfusion or manual removal of placenta (MRP) or exploration, severe
pre-eclampsia, eclampsia, MRP for retained placenta, puerperal sepsis,
instrumental delivery, and management of abortion complications requiring blood
transfusion) and admission longer than 24 hours with IV antibiotics for sepsis are
included as complicated deliveries. Anti-D administration for RH negative is
reimbursed NPR 5,000. Laparotomies for perforation due to abortion, elective or
emergency C-sections, laparotomy for ectopic pregnancies and ruptured uterus are
reimbursed NPR 7,000 to both public and private facilities.
Incentives Provision to health service provider:
 For deliveries: A payment of NPR 300 to health workers for attending all types of
deliveries to be arranged from health facility reimbursement amounts.
Newborn Care Programme Provision:

21. 13
 For sick newborns: There are four different types of package (Package 0,
Package A, B, and Package C) for sick newborns case management. Sick
newborn care management cost is reimbursed to health facility. The cost of
package of care include 0 Cost for Packages 0, and NPR 1000, NRP 2000 and
NRP 5000 for package A, B and C respectively. Health facilities can claim a
maximum of NPR 8,000 (packages A+B+C), depending on medicines, diagnostic
and treatment services provided.
 Incentives to health service provider: A payment of NPR 300 to health workers
for providing all forms of packaged services to be arranged from health facility
reimbursement amounts.
Table 2: Major Achievement in FY 2075/76 (Till September)
Indicators Achievements
% of Pregnant Women who had at least one ANC Check-up 61.2%
% of pregnant women who had 4 ANC checkups as per protocol
(4th, 6th, 8th and 9th month)
56.5%
% of Institutional Delivery 61.2%
% of births attended by a Skilled Birth Attendant (SBA) 57.6
% of postpartum women who received a PNC check-up within 24
hours of delivery
60.2%
% of women who had 3 PNC check-ups as per protocol (1st within
24 hours, 2nd within 72 hours and 3rd within 7 days of delivery)
16%
No. of Delivery Conducted by SBA at Facility 22545
% of women received 180 day supply of iron folic acid during
pregnancy
50.6%
Guiding Documents of SMP:
 MNH guideline 2073
 Safemotherhood policy 1998
 Policy on SBA 2006.
 National Blood transfusion policy 2006

22. 14
Unit IV Mini Action Project
4.1 Introduction:
As per one of the activity of the organization, there was the orientation program on
MPDSR to the staffs of hospitals and PHCC. Thus in consultation and recommendation
with MNH section chief and Community Nursing Officer (CNO), they suggested me to
make a draft for the orientation slide to present in orientation program as my MAP. So I
developed the presentation draft on the topic Maternal and Perinatal Death Surveillance
and Responses (MPDSR) with a mini-lecture and conducted as my mini-project in the
orientation program.
4.2 Objectives:
The objective of mini-project is
 To describe the status of maternal and perinatal mortality in Nepal,
 To describe the rationale, goal, objectives and components of MPDSR and
 To provide rationale and process of MPDSR in hospital
 To orient the HWs on Complete the Maternal Death Review (MDR) and Perinatal
death Review (PDR) forms correctly
 To make capable to HWs to Identify the Cause and avoidable factors of the
maternal and perinatal deaths
 To develop the skills on Formulate, implement and monitor action plan for
appropriate response.
4.3 Details of Intervention Project:
Date: 24th
October 2019
Duration: 11:00 AM – 4:00 PM
Venue/setting: NHTC Training Hall
Staff from Health Section: Dr. Punya Gautam (MNH Section Chief) and
Mrs. Kumari Bhattarai (Community Nursing Officer)
Target Group: Doctors form Hospital and PHCC
4.4 Contents of Mini Lecture:
a. Background and Rationale of MPDSR Program
b. Process of MPDSR in Hospitals
c. Review on the tools of MDR and MPDSR
d. Formulation, Implement and monitor action plan for appropriate
response
a. Background and Rationale of MPDSR

23. 15
Development of any country is reflected by the status of health of mothers and
children. Globally, about 3 Lakh women die every year due to maternal cause in
pregnancy, 99% of such maternal deaths occur in less developed countries. In
Nepal, about 1700 women die every year due to maternal causes. Nepal had target
to reduce Maternal Mortality Ratio (MMR) to 134 by 2015, Nepal Health Sector
Strategy (2015-2020) has target to reduce MMR to 125 by 2020. Sustainable
Development Goals has targets to reduce MMR to 70 per 100000 live births by
2030.
Prematurity, birth asphyxia and sepsis are the most common causes of death
followed by congenital anomalies, pneumonia, diarrheal diseases among the
neonates.
Considering the stagnant NMR, MPDSR has equal focus to review still births and
early neonatal deaths in the hospitals as more than two thirds of the neonates die
within first week of life. It is possible to achieve the targets if MPDSR is
effectively implemented. MPDSR is a strong proven system which can guide and
assist in preventing maternal deaths and reduce MMR.
Implementing MPDSR also strengthens other processes in the health system.
Identifying deaths can enhance vital registration, reporting maternal deaths in
community and health facility helps in tracking of maternal mortality, reviewing
the maternal and perinatal deaths can assist in reviewing the quality of care at
different level and implementing the response improves the quality of care.
It complements the system of national systems for civil registration and vital
statistics (CRVS) and health management information systems (HMIS). The
system will generate reliable data on the rate and causes of maternal mortality –
and so act as a cornerstone for a national CRVS system.
It has been estimated that reported maternal mortality underestimates the true
magnitude by up to 30% worldwide and by 70% in some countries. An effective
MDSR system will produce more accurate and complete estimates of maternal
mortality, providing robust and consistent data for a country’s CRVS system.
What is MPDSR?
Continuous identification, notification, quantification and determination of causes and
avoidability of all maternal and perinatal deaths, as well as the use of this information to
respond with actions that will prevent future deaths
MPDSR Goal:

24. 16
To eliminate preventable maternal and perinatal mortality by obtaining and using
information on each maternal and perinatal death to guide public health actions and
monitor their impact
MPDSR Objectives:
 To provide information that effectively guides immediate as well as long-term
actions to reduce maternal mortality at health facilities and community and
perinatal mortality at health facilities.
 To count every maternal and perinatal death, permitting an assessment of the true
magnitude of maternal and perinatal mortality and the impact of actions to reduce
it.
Components of MPDSR:
Identify
cases
Collect
informati
on
Analyze
results
Recomme
n-dations
for
actions
Evaluate
and refine

25. 17
Key Principles of MPDSR:
Nepal MPDSR Process:
No woman
should die
giving birth
Every death
counts
Beyond the
numbers
Not used for
litigation
No blame
No name
No punitive
action
Black Box
Every death has
a lesson

26. 18
Role of Attending Doctor and/or Nurse
Action plans implemented at Hospitals (Example from Some District Hospitals)
 Availability of Hepatitis E test kit in laboratory
 Oxygen and suction pipeline at ER
 Back-up laryngoscope at ER
 Conduct outreach ANC clinic from hospital
 Hypertensive patients to be delivered at referral sites
 Use of disposable ET Tubes
 Microbiological culture samples from ET tubes and ambo bags to rule out source
of infection
 Revise history taking form
 Simultaneously prepare for hysterectomy while using balloon tamponade so that
hysterectomy could be done immediately
 Conduct cardio-pulmonary resuscitation training for clinical staff
 Feedback on timely communication to the referring site
 Establish blood bank/blood cross match facility
 Revise ANC cards to include all important information
 Develop and display flex on danger signs in ANC clinics
 Involve staff from other departments also in case of emergency for support
Feedbacks from Orientation:
 Increase in case notification with identification of hidden cases
 Increased responsibility and accountability on maternal death at community level

27. 19
 Need of multi-sectoral approach required to implement actions
Challenges to MPDSR Implementation:
 Under reporting of suspected maternal deaths
 Blame culture at some places that inhibits health professionals and others from
participating fully in the MPDSR process
 Incomplete or inadequate legal frameworks
 Inadequate staff numbers, resources and budget
 Problems of geography and infrastructure that inhibit the timely operation of
MDSR.
 Review and reporting of perinatal deaths in hospitals
 Cause of death assignment at hospitals
 Delay/Incomplete notification, screening, VA, review, response & use of web-
based MPDSR system
Tools of MPDSR
a. Tool 1: Notification form

28. 20
b. Tools 2: Screening Form
c. Tool 3: Community verbal autopsy form
,
,
.
. . ( )
.
.
.
.
MPDSR Tool 3

29. 21
d. Tool 4: Community cause of death assignment form

30. 22
Unit IV: Conclusion and Recommendations
5.1 Conclusion:
Working as an intern in MNH section of FWD for three weeks practicum period under
the supervision of Chief of MNH section, performed all the assigned tasks, worked
together with staffs in a team. Got opportunity to excel the programmatic knowledge and
information and have also enhanced skills to work in a team. All those activities provided
a good opportunity to meet the learning objectives and successfully completed the
practicum for partial fulfillment of Master degree in Public Health.
5.2 Limitations of the internship
The duration of the internship was a limitation for me in terms of mastering the
organizational functioning, 3 weeks is too short to adapt to a new organization and to
start deliver to your maximum capacity. The Practicum between the Dashain and Tihar
festival is not appropriate for students because there is limited activities in that period so
the internee cannot get the opportunity to learn more and more. Adding on to that, the
first weeks of the month the main aim was to get to know the organization better which
comprised more of learning and adjusting; when I settled in I realized that I was at the
verge of concluding the internship. Even though the objectives were accomplished, some
were done through desktop research than being actively involved. Learning to work for
an organization that works for the community or to work in a team is a long process that
requires one to know the community very well and its needs to which 12 weeks seems
too little to grasp the concepts.
5.3 Lesson Learned:
 Team work and communication is the most important weapon to make necessary
achievements and progress in the project work.
 Difference between theoretical knowledge and practical skills. It seems a tough
job to put theoretical knowledge practically in the field.
 To prove myself I must become opportunistic, be ready to undertake complex
tasks and be ready to work on deadlines.

31. 23
5.4 Recommendations
Recommendations for MNH Section
 MNH section should Scale up of PNC home visits program
 The MPDSR need to strengthen to all hospitals including public and private both.
 Regular mentoring and onsite coaching should increase at all birthing centers for
qualitative services
 Emphasize on collaboration with development partners and multi stakeholders to
harmonize interventions within the area.
Recommendations for School of Health and Allied Sciences (SHAS)
 There should be an MoU between the organization and University for Practicum
 The duration of practicum, 3 weeks is too short to adapt to a new organization and
to deliver the learning objectives.
 The practicum between the Dashain and Tihar is not appropriate from learning
perspectives so it would be better to shift after Dashain and Tihar.
 Frequent visits from faculty members to boost relationships with the organization
 Provision of allowances to supervisors of respective organization.

32. 24
References:
1 Annual report, 2073/74, DoHS
2. MNH Strategy plan 2073.

33. 25
Annexes:
Annex 1: Photos:

34. 26
Annex 2: Letter from College

35. 27
Annex 3: Action Plan

36. 28
Annex 4: Attendance-Sheet

37. 29
Annex 5: Practicum Completion Letter