Safe motherhood program of Nepal

1. Safe motherhood:International
perspective and national
strategies,policies and components.
Kabita Yadav
Mph -2018
2/18/2024
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2. Contents
 Introduction
 International perspectives
 Safe Motherhood in Nepal
 Component
 Policies & program
 Strategies
 Activities
 Achievements
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3. Introduction
 Safe motherhood encompasses a series of initiatives,
practices, protocols and service delivery guidelines
designed to ensure that women receive high-quality
gynecological, family planning, prenatal, delivery and
postpartum care, in order to achieve optimal health for
the mother, fetus and infant during pregnancy,
childbirth and postpartum.
 The Safe Motherhood Initiative was launched by the
World Health Organization (WHO) and other
international agencies in 1987.
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4. International perspective
 In 1930 the League of the National Health Section
noted concerns about maternal mortality.
 The first international conference on safe motherhood
was held in 1987,Nairobi. It led to the formation of an
Inter-Agency Group (IAG) for Safe Motherhood. To
reduce Maternal mortality and morbidity by 50%
in 1 decade.
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5.  The ICPD(1994) and Beijing commitments also
reinforced the position that maternal deaths and
disability are violations of women’s human rights, and
are strongly tied to women’s status in society and
economic dependency. At a fundamental level, women
have a right to health services that promote their health
and survival during pregnancy and childbirth.
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6. Global scenario of maternal health
 Every day, approximately 830 women die from
preventable causes related to pregnancy and childbirth.
 99% of all maternal deaths occur in developing
countries.
 Maternal mortality is higher in women living in rural
areas and among poorer communities.
 Young adolescents face a higher risk of complications
and death as a result of pregnancy than other women.
 Skilled care before, during and after childbirth can save
the lives of women and newborn babies.
 Between 1990 and 2015, maternal mortality worldwide
dropped by about 44%.
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7. fig: Maternal mortality fell by almost half between 1990 and
2015
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7 data.unicef.org

8. Safe Motherhood in Nepal
 The goal of the National Safe Motherhood Programme:
 to reduce maternal and neonatal morbidity and mortality.
 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.
 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).
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9.  Addressing maternal health means reinsuring that all
women receive care they need to be safe and healthy
throughout pregnancy and childbirth and even after
that.
 Millennium Development Goals 5: reduce Maternal
mortality by 75 percent and universal access to
reproductive health.
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10. SDG 3: Good Health and well being
 By 2030, reduce the global maternal mortality ratio to
less than 70 per 100 thousand 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.
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11.  SLTHP(1997-2017) recognized neonatal health as an
integral part of safe motherhood programs.
 It has also included the importance of policy in
Skilled Birth Attendants
 Legalization of abortion
 Transmission of HIV from mother to child .
 Importance of Equity
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12. Components of Safe motherhood
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 Safe Pregnancy
 Safe Childbirth
 Postpartum Care upto 6 weeks
 Neonatal Care

13. Pillars of Safe Motherhood
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14. Family Planning
 FP is an important component of safe motherhood
 It is necessary to ensure that individuals and couples have
adequate information and services regarding FP
 FP is also necessary to plan the timing, number of children,
spacing between pregnancies, delay pregnancy, etc.
Antenatal care
 ANC checkup is necessary to detect complications early
and treat them as soon as possible
 It is also essential to provide pregnant women with vitamin
supplements, iron tablets and vaccinations so that they can
have a healthy and strong pregnancy.
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15. Obstetric Care
 Obstetric care ensures that all the deliveries are done
by the skill birth attendants or the medical
professionals.
 Birth attendants should have the knowledge, skills, and
equipment to perform a clean and safe delivery.
 Moreover, emergency care for high-risk pregnancies
and complications are made available to all women
who need it.
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16. Postnatal Care (PNC)
 It is necessary to ensure that postpartum care is
provided to the mother and baby
 It includes counselling mothers about child handling,
exclusive breast feeding, etc.
 Moreover, PNC also comprises of providing awareness
regarding the FP, and managing the danger signs and
symptoms seen in both mother and child.
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17. Post abortion Care
 It is necessary to prevent complications of abortion
 It also helps to identify/detect if there are any
complications of abortion
 Useful to refer other reproductive health problems
when necessary
 Also provides counselling and awareness about
different family planning methods
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18. STD/HIV/AIDS Control
 HIV screening is done to prevent, and manage HIV
and AIDS transmission to the baby
 To assess risk for future infection
 To provide voluntary counseling and testing
 To expand services to address mother to child
transmission.
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 Community –based PMTCT(CB-PMTCT) program
has been expanded in all district of Nepal where HIV
screening and counselling is done among every ANC
visitors at the district.
 ARV medicine are made available at every district of
Nepal . However , life long ARV service is only
provided through 68 ART sites and 25 ART dispensing
centre ( ADC) throughout the country.

20. Program and Policies
 National Safe Motherhood Programme,
 Skilled Birth Attendants Policy, 2006
 National Blood Transfusion Policy, 2006
 National Abortion law, 2002
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21. Strategies for Management
 Promoting Inter-sectoral coordination at different
levels of health system with a focus on poor and
excluded groups.
 Strengthening and expanding delivery by SBAs and
providing emergency obstetric care at appropriate
levels of the health care system .
 Strengthening other human resources
 Encourage community based awareness activities that
raise the status of women in community.
 Establish functional referral system
 Promote research on safe motherhood.
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22. Current Activities of Safe
Motherhood in Nepal
 Birth Preparedness and community level maternal
and newborn health
 Rural Ultrasound programme
 Reproductive health morbidity prevention and
management programme
– Management of pelvic organ prolapse
– Cervical cancer screening and prevention training
– Obstetric Fistula management
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23. Cont…..
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 Human Resources
 Expansion and quality improvement of service
delivery sites
 Emergency referral funds motherhood services
 Obstetric first aid orientation
 Nyano Jhola Programme
 Aama and Newborn programme( maternity
Incentive Scheme, user fees removal, Free
newborn care)

24. The public health system promotes:
 Birth preparedness and complication readiness (preparedness of
money, health facilities for the delivery, transport and blood
donors)
 Antenatal care (ANC) and postnatal care (PNC) (Iron, Tetanus-
Diptheria, Albendazole);
 Self-care (food, rest, no smoking and alcohol) in pregnancy and
postpartum periods;
 Essential newborn care; and the identification of and prompt
care seeking for danger signs in the pregnancy, delivery,
postpartum and newborn periods.
Birth Preparedness Package and community level
maternal and newborn health
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25.  In 2066/67, the government approved PPH education and the
distribution of the matri suraksha chakki through FCHVs to
prevent PPH in home deliveries.
 For home deliveries, three misoprostol tablets (600 mcg) are
handed over to pregnant women to take immediately after
delivery and before the placenta is expelled.
 Forty-five districts were implementing the programme in
2072/73 and FHD implemented in three new district(kaski,
Parbat, & syanga districts) in 2073/74
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26.  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. Women with detected abnormalities such as abnormal
lies and presentation of the fetus are referred to a facility with
the needed services.
 This programme is being implemented in the 12 remote
districts of Mugu, Dhading,Darchula, Sindhupalchowk,
Solukhumbu, Bajura, Bajhang, Achham, Dhankuta, Humla,
Baitadi ,Sindhuli.
Rural Ultrasound Programme
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27. a. Management of pelvic organ prolapse:
• Pelvic organ prolapse (POP) is a common reproductive health
morbidity in Nepal and contributes to many disability adjusted
life years (DALYs) and social consequences.
• Multiparity, maternal malnutrition, too frequent pregnancies
and heavy work after delivery are the main risk factors. Each
year the government allocates funds to manage POP including
free screening, providing silicon ring pessaries, Kegell
exercise training and free surgical services at designated
hospitals.
• In 2073/74 more than 14,600 women were screened for the
condition of which 8.9 % had first degree POP, 6.6 % had
second degree POP and 7.5 % third degree POP.
prevention and management
programme
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28. b. Cervical cancer screening and prevention training:
 Cervical cancer is the 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 years and for reducing the mortality due to cervical
cancer by 10 % with recommended screening among this group
every five years.
 Cervical cancer screening is done by visual inspection of the
cervix by trained nurses or doctors. If any signs of a pre-
cancerous lesion are seen, women are referred for cryotherapy
to cure the lesion.
 As of 2073/74, cervical cancer screening has been expanded to
64 districts. 2/18/2024
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29. c. Obstetric fistula management:
• The government has allocated funds for the free screening of
obstetric fistula, integrated with pelvic organ prolapsed
screening and surgical services at the BP Koirala Institute of
Health Sciences (BPKIHS, Dharan) and Model hospital,
Kathmandu.
• In 2073/74, 120 women received free surgical treatment for
obstetric fistula.
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30.  A significant share of FHD’s budget goes for recruiting ANMs
on short term contracts to ensure 24 hour birthing services at
PHCCs and health posts.
 FHD also provides funds to DHOs and DPHOs to recruit the
human resource mix needed to provide surgical management
for obstetric complications at district hospitals.
 FHD 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..
Human resources
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31.  FHD continued to expand 24/7 service delivery sites like
birthing centres, 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.
 By the end of 2073/74 CEONC services were present in 72
districts, although only 60 districts were functional through out
the year.
 A total of 1,811 birthing centres and 158 BEONC sites were
functioning by the end of 2073/74.
Expansion and quality improvement of service
delivery sites
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32.  FHD has defined the four key components of comprehensive
abortion care as:
a. Pre and post counselling on safe abortion methods and
post-abortion contraceptive methods;
b. Termination of pregnancies as per the national protocol;
c. Diagnosis and treatment of existing reproductive tract
infections; and
d. Provide contraceptive methods as per informed choice
and follow-up for post-abortion complication management.
Safe abortion services
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33.  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.
Obstetric first aid orientations
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34.  The Nyano Jhola Programme was 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.
Nyano Jhola Programme
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35.  The government has introduced demand-side interventions to
improve the quality of maternal care and encourage
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 under the
Aama Programme.
 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.
Aama and Newborn Programme
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36. For women delivering their babies in health institutions:
 Transport incentive for institutional delivery: Cash payment to
women immediately after institutional delivery (NPR 3000 in
mountains, NPR 2,000 in hills and NPR 1000 in Terai
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.
Provisions of the Aama and Newborn Programme
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37.  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, indicated
or emergency C-sections, laparotomy for ectopic pregnancies
and ruptured uteruses are reimbursed NPR 7,000.
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38. b. For newborns:
 A payment to health facilities for providing free sick newborn
care. Facilities are reimbursed for set packages of care: Packages
0, A, B and C costing nothing, NPR 1,000, NPR 2,000 and NPR
5,000 respectively.
 Health facilities can claim a maximum of NPR 8,000 (packages
A+B+C), depending on medicines and diagnostic
and treatment services provided.
c. Incentives to health workers (to be arranged from health
facility reimbursement amounts):
 For deliveries: A payment of NPR 300 to health workers for
attending all types of deliveries.
 For sick newborn care: A payment of NPR 300 to health
workers for providing all forms of packaged services.
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39. Sunaula Hazar Din: Golden Thousand Days
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 Sunaula Hazar Din is being implemented by
Government of Nepal.
 The Project is designed primarily to address the risk
factors for chronic malnutrition although Nepal has
high levels of both chronic malnutrition (stunting and
micro-nutrient deficiencies) as well as acute
malnutrition (wasting) aligning with the main focus of
the Government of Nepal's Multi-Sectoral Nutrition
Plan.

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 Golden first 1,000 days,” refers to the period between
conception and 24 months of age, when children are
most vulnerable to malnutrition.
 The Project Development Objective level indicators
will track improvements in:
a) family planning practices of girls and young women
aged 15-25 years;
b) practices of pregnant women regarding iron and folic
acid supplementation; c) breastfeeding practices of
mothers with children 0-6 months of age;

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d) child feeding practices of households with children 6
to 24 months of age;
e) attitude of community members towards the
importance of keeping girls school until age 20;
f) attitude of community members towards the
importance of reducing indoor air pollution and
g) attitudes of pregnant women towards their dietary
needs.

42.  Measuring progress in maternal health programs and
projects has remained a challenge over the past decade.
Initially, measuring progress in Safe Motherhood was
assumed to mean measuring change in maternal mortality
levels. This has proved impractical in most cases.
 Since neither the maternal mortality ratio (MMR) nor the
severity of the maternal morbidity level are practical
measures of impact for Safe Motherhood projects or
programs.
Safe motherhood Indicators
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43.  The present recommendation of WHO, UNICEF and
others, is to rely on process indicators to measure
change in project outcomes
 Process indicators
A. Access/Use of Services Indicators
1. Met Need for Essential Obstetric Care
2. Unmet Obstetric Need
3. Cesarean Section Rate
4. Who delivers the woman, and where does birth take
place
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44. B. Quality of care indicators
1. Case Fatality Rate (and numbers of maternal deaths)
2. Referral Rates
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45. Achievements
Fig: Fourth ANC visit (as per protocol) as a percentage of first ANC visit(as
per protocol)
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46. Fig: Trend of institutional deliveries as percentage of expected live
births (2071/72 – 2073/74)
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47. Fig: Trend of three PNC (as per protocol) as percentage
of live births
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48. fig: Maternal health care indicators in seven Provinces of Nepal
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52. References
 https://www.who.int/docstore/world-health-
day/en/documents1998/whd98.pdf
 https://www.slideshare.net/PolyBegum/safe-
motherhood-2018
 https://www.who.int/news-room/fact-
sheets/detail/maternal-mortality
 Annual Report ,DOHS 2073/74.
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THANK YOU