Safemotherhood

SAFE MOTHERHOOD AND NEWBORN
HEALTH

By Sarina Basu Shrestha

BACKGROUND
 The goal of the National Safe Mother Programme
is to reduce maternal and neonatal mortalities by
addressing factors related to various
moridities,death and disability caused by
complications of pregnancy and childbirth .
 Experience shows that 3 key delays are of critical
importance to the outcome of an obstetric
emergency:
I. Delay in seeking care
II. Delay in reaching care
III. Delay in receiving care

 To address these delays 3 major strategies been
adopted in Nepal:
1. Promoting birth prepadeness and complication
readiness including awareness raising and
improving the availability of funds ,transport and
blood supplies .
2. Encouraging for instituitional delivery.
3. Expansion of 24-hr emergency obstetrics care
services (basic and comprehensive )at selected
public health facilities in every district.

 Safe Motherhood Programme ,since its intiation in
1997,has made signinficant progress in terms of the
development of the policies and protocols as well
as expand in the role of service providers such
staff nurses and ANMs in life saving skills.
 Policy of on Skilled Birth Attendants edorsed in
2006 by MoPH specifically identifies the importance
of skilled birth attendance at every birth and
government‟s commitment to training and deploying
doctors and nurses /ANMs with the required skills
across the country.

 Endorsement of revised National Blood Transfusion
Policy 2006 ensured th availability of safe blood
supplies in event of emergency.

 The National Safe Motherhood Plan(2002-2017)
was revised .

 The revised SafeMotherhood and Neonatal Health
Long Term Plan (SMNHLTP 2006-2017) include:
1. Recognition of the importance of addressing
neonatal health as an integral part of safe
motherhood programming.
2. Legalisation of abortion and the integration of the
safe abortion services under the safe motherhood
umbrella
3. Recognition of the importance of equity and acess
efforts to ensure that most needy women can
acess the services they need.

GOALS OF SMNHLTP
 Improved maternal and neonatal health and
survival ,especially of the poor and excluded .
 The key ingredient for the goal are:

1) A reduction in the maternal mortality ratio from the
current 281 per 100,000 live births to 134 per
100,000 by 2017
2) A reduction in the neonatal mortality ratio from the
current 33 per 1,000 to 15 per 1,000 by 2017.

PURPOSE OF SMNHLTP
 Increased healthy practices and utilisation of the quality
maternal and neonatal health services especially by the
poor and excluded ,delivered by a well managed health
sector .

Key indicators for this include :
1. Increase in the percentage of deliveries assisted by an
SBA to 60% by 2017.
2. The percentage of deliveries taking place in a health
facility increased to 40%by 2017.
3. Increase in met need for emergency obstetric care of
3%per year

 Indicators of the service provision include :
1. Percentage of health post providing 24 hr delivery
service 15% by 2009,30% by 2012 and 70% by
2017
2. Percentage of PHCC providing BEOC service
including CAC service 40% by 2009, 60% by
2012, 80% by 2017
3. No of district providing CEOC service 37 by
2009,47 by 2012 and 60 by 2017
4. CAC service available in all district hospitals by
2009

OUTPUT
 Eight output are specified in the plan ,each with
individual indicators.
1. Equity
2. Services
3. Public private partnership
4. Decentralisation
5. Human resource development ;Skilled birth
attendant strategy
6. Information management
7. Physical assets and procurement
8. Finance

INDICATORS

1.Knowledge of danger signs:
No. of men and WRAs knowing danger signs 100
Total no. of men and women of reproductive age(WRA)

2.Knowledge of B/EOC sites
No of men and WRAs knowing where services are
available 100
total no of men and WRAs
3.Behaviour change
No of women practicing safe ANC,PNC,
EOC,PAC,CAC 100
Total no of delivered women

4.Birth preparedness
No of men and WRAs practicing same 100
Total no of men and WRAs

5.Sustainable emergency funds and transport schemes
No of sustainable funds and transport schemes 100
total no target communities

6.ANC service coverage
No of ANC first visits 100
Expected no of pregnancies

7.Percentage of 4 ANC visit
No of 4 time ANC visit 100
No of 1st ANC visit

8.Percentage of delivery by SBA
total no of deliveries by SBA 100
Total no of expected live births

9.Percentage of delivery by other than SBA

Total no of deliveries by other than SBA 100
Total no of expected deliveries

10.Pregnancy complications
Total no of pregnancy complications 100
Total no of expected pregnancies

11.Proportion of births in B/C EOC facility
Total no of birth in B/C EOC facility in district 100
Total no live birth in that district

12.Postnatal service coverage
Total no of 1st postnatal visits 100
Total no of expected pregnancies

13.C/S Rate (as proportion of expected births
population):
Total C-sections performed in a district
Total no. of expected births in that district

14.Maternal mortality ratio:
Total maternal deaths 100,000
Total live births

CONTD..
15.Maternal deaths: Annual no. of maternal
deaths

16.Case fatality rate(all maternal complications):
Deaths from specific maternal complications at a facility
Complicated obstetric cases in the facility

17.No of facilities providing basic EOC per 50,000
population(excluding blood and C-section):
No of facilities providing basic EOC services 500,000
Total population

18.No. of facilities providing comprehensive EOC
per 500,000 population (including blood and C-
section):
No. of facilities providing comprehensive
EOC services 500,000
Total population

19.Iron distribution coverage (pregnant women and postnatal
mother):
No. of pregnant women who received 225 iron tablets 100
Total no. of expected pregnancies

20.Immunisation coverage for TT2 vaccine among
pregnant women:
No. of pregnant women immunized with TT2 100
Total no. of expected pregnancies

STRATEGIES
 Safe mother goals and objectives are to be
achieved through the implementation of the
following strategies;
1. Promoting inter –sectorial collaboration by
ensuring advocacy for and commitments to
reproducing health , including safe motherhood ,at
the central,regional ,district and community levels
focusing poor and excluded groups.
 Ensuring the commitment to SMNH initiative at all
levels by promoting collaboration between sectors
like health, education, and social welfare ,legal
and local development

 Mobilizing national authorities , District Health
Management Committee(DHMC) ,community
leaders and community members to play active
roles in creating sustainable environment for
promoting safe motherhood.

2. Strengthening and expanding delivery by skilled
birth attendant , basic and comprehensive
obstetric care services (including family planning)
at all levels. Interventions include the following :
 Developing the infrastructure for delivery and
emergency obstetric care.

 Standardising basic maternity care and emergency
obstetric care at the appropriate levels of the
healthcare system;
 Strengthening human resource management
 Establishing functional referral system and
advocating for emergency transport systems and
funds from communities to district hospitals for
obstetrics emergencies and high –risk pregnancies.
 Strengthening community –based awareness on
birth preparedness and complication readiness
through FCHVs ,increasing acess of all relevant
maternal health information and service.

3.Supporting activities that raise the status of women
in society
4.Promoting research on safe motherhood to
contribute to improved planning , higher quality
services, and more cost-effective interventions.

AAMA SURAKCHHYA PROGRAMME
1) Introduction
Aama programme has 3 components:
 Free institutional delivery care

 The Safe Delivery Incentive
Programme(SDIP)
 Incentive to women who completed 4 ANC
visits and delivered their babies at health
institutions.

 Since 2005 GoN has been providing direct cash
handouts to women who delivered in state and
listed non-state facilities, providing free institutional
delivery care for every woman at all facilities
capable of providing these services.
 Through its 2nd revision effective from July
2009, the Aama programme now provides:
1. Incentive to women: a cash payment after delivery
at a facility:NRs.1,500($20)in mountain
areas, NRs.1,000($13) in hill areas and
NRs.500($7) in the terai.
2. Free delivery services

 A payment to health facility for the provision of free
care:Normal delivery at health facility with 25 and
more beds NRs.1500 and health facility with less
than 25 beds NRs.1000;complication NRs.3000;C-
section NRs.7000.
 covers:

cost of all required drugs,supplies,instruments and
a small incentive to health workers NRs.300 . This
provision doesn‟t require individual claims from
health workers;however,institution requires
submitting the claim.

 Incentives to health workers for home delivery has
been reduced to NRs.200 from NRs.300 to
discourage the home based delivery.
 A women gets NRs.400 if she completes 4 ANC
visits, institutional delivery and 1st PNC. But she
cant get the incentive if she delivers her baby at
home.
 Aama program is being implemented by 41 NGOs
and private hospitals.

PROGRESS UPDATE OF SERVICE PROVISION
 CEOC services are now functional in 33 districts and
BEOC services at 105 sites(47 hospitals and 58
PHCCs). Thus, the service outlets increased for C-
section and complication management.
 24 hour delivery service is available at 148 PHCCs, 406
health posts and 137 SHPs.
 The no.of birthing centres is in rise and many
communities have now established new birthing centres
and started providing normal delivery care services.
 Over 20 private(NGO,community managed,teaching
hospital and for profit)hospitals are currently
implementing the Aama programme.

 Before the introduction of SDIP, the coverage of
deliveries assisted by SBAs and health workers
used to increase marginally(1%) but after
commencement of SDIP it has increased
considerably by 2-3% annually and after the
introduction of free delivery care, it jumped to 42%
in case of deliveries attended by health workers
and 29.4% in case of SBA assisted deliveries.

IMPLEMENTATION PROGRESS
 Programme implementation has improved
significantly since the launch of the original
Maternity Incentive Scheme(MIS) in 2005/2006
during which fewer than one third (29.6%) of
women delivering in an institution actually received
the cash incentive.
 By 2008/2009 this figure had risen to 89% and
almost all women received the incentive in 2009/10.
 By contrast, reflecting the lesser priority now being
given to payments to health workers, the no.of
trained health workers receiving incentive for home
delivery has fallen over the years.

FUND EXPENDITURE
Total budget allocation and expenditure in NRs.Million

Fiscal Year Allocation Expenditure Percent
2062/63(2005/06) 139.85 59.27 42.38

2063/64(2006/07) 159.2 111.58 70.09

2064/65(2007/08) 194.5 143.7 73.88

2065/66(2008/09) 444.6 336.7 75.73

2066/67(2009/10) 574.3 463.5 80.7

MAJOR ACTIVITIES
 Evaluation of Aama programme
 The impact evaluation was carried out in 2010 to
determine who benefited by free delivery and
incentive scheme.
 80% of facility births were free of charge in the 3
low HDI districts where the incidence of poverty is
at higher level.
 This figure is 58% in case of high HDI districts.

 Over the past 5 yrs, there has been a substantial
increase in the proportion of women giving birth in a
health facility.

 In the high HDI districts, the rate of institutional delivery
care has increased 21 points from 33% to 54% in the 5
yr period.
 In the low HDI districts, the rate has increased 15 points
from 6% to 21% over the same period.
 Women‟s awareness of the cash incentive during
pregnancy has risen from 14% in July 2005 to 64% in
Feb 2010.
 RAPID ASSESSSMENTS
 3 rapid assessments of the SDIP have been carried out
to date; 2 in April and October 2008 and third one in July
2009. These assessments reviewed effectiveness of the
implementation including cross verification of payments.

 The findings of these assessments have been used to
strengthen implementation guidelines and process.
 Learning from the 3 rapid assessments the FHD has contracted
out the 4th rapid assessments.
 It began the work on 1st Nov 2009 and covered 6 districts:
1. Mustang
2. Taplejung
3. Achham
4. Nuwakot
5. Bardiya
6. Rautahat

SOCIAL AUDITING
 A social audit was conducted at 21 facilities of 7
districts under the Aama Programme in 2009/010.
They were consolidated and made available to the
general public and auditors.
 This has contributed to checking the misuse of
funds, developing the sense of ownership among
the stakeholders, reducing the hassles in
distributing the incentives..

ADDITIONAL SAFEGUARDS MEASURES
 Based on the findings of the third rapid
assessment, FHD prepared a framework of
additional safeguards.
 Comprehensive Plan for Aama Programme
Monitoring
 FHD has implemented comprehensive monitoring
activities from 2009/10. This includes household
survey, monitoring of Aama programme fund
reimbursement in selected health
facilities, independent rapid assessment and review
of the auditor general‟s final audit reports.

 Information campaign
 During this reporting period the National Health
Education Information Communication
Centre(NHEICC) has implemented the Aama
communications strategy. Posters flex boards and
leaflets were designed, printed and delivered to all
districts.
 however., delivery to facilities has not met
requirements.
 National , regional and local radio stations aired
messages about the Aama programme.

IMPLEMENTATION ISSUES
 Clarity on free care components and financial
status of hospital
Some of the issues identified during field visits were:
1. Confusion on the types of managed complications
2. Uncertain use of unit cost given for the free
delivery
 FHD had sent an instructional letter to all
implementing facilities mentioning the priority of
the Aama programme, permissible use of unit cost
including provider‟s incentives, clarity on managed
complications.

Addressing the false reporting
While the programme is seen to be meeting its
primary objectives, the risk of fraudulent claims for
both institutional and home deliveries may remain
high. This was recognized in the 3rd rapid
assessment which recommended the effective
implementation of public auditing. In order to
respond to this issue, FHD had endorsed “Aama
Programme Additional Safeguard measures” in
2009/10.

 Low awareness among prenant women
The 3rd RA included anecdotal information from field
visits suggesting that one of the major barriers to
accessing free care and incentives is the low level
of awareness on the Aama programme.
FHD core team members are working closely with
NHEICC, Nepal health journalist forum, FM radio
networks for the proper dissemination of Aama
programme messages.

REPRODUCIVE HEALTH PROGRAM
COORDINATION MECHANISM
 Under the MOHP, different level RH committee has
been established from policy level to district with
the objective to promote GO/NGO collaboration and
partnership, to ensure compliance of GO
policy, strategy and guidelines and to avoid
duplication and overlapping in program planning
and implementation.
 Many of these sub-committees are functional. They
are meeting regularly as per plan. These sub-
committees are providing valuable inputs in
program planning, budgeting and on policy
formulating.

RH Streeing Committee
(Policy Body That Meets Once Per Year)

RH Coordination Committee
(Coordination Body That Meets 3 Times Per Year)

Sub-Committee District RHCC

SM AD Researc FCH
N FP TCIC CH
H h V

DISTRICT REPRODUCTIVE HEALTH
COORDINATION COMMITTEE(DRHCC)
 Has been formulated in all 75 districts.
 This forum is basically responsible to conduct
meeting, facilitating NGO/INGO support
administration and logistics for meeting, conduct
orientation, review activities quaterly, develop future
action plan.

ANALYSIS OF
ACHIEVEMENTS BY
MAJOR ACTIVITIES

ACTIVITIES CARRIED OUT IN FISCAL YEAR 2
066/2067

2.1.1Antenatal care:
Antenatal services include:
 At least four antenatal checkups(first at four
month, second at six month, third at eight month
and fourth a nine month)
 Monitor blood pressure, eight and fetal heart rate

2.1. 2. delivery care:
Delivery care includes:
 Provision of skilled birth attendants at
deliveries(either home based or facility based),
early detection of complicated cases and
management of referral after providing obstetric
first aid by health worker to appropriate health
facility where 24 hour emergency obstetric services
are available
 Provision of obstetric first aid at home/ health post/
sub health post if complication occur, using
emergency obstetric care kit

 Identification and management of complications
during delivery and referral to appropriate health
facility as and when needed
 Encourage registration of birth and registration of
neonatal deaths.

 Provide information, education, and
communication(IEC)and behavior change
communication(BCC) for danger signs and care during
pregnancy, delivery and postnatal and immediate
newborn care for both mother and newborn and timely
referral to the appropriate health facilities.
 Birth preparedness and complication readiness(BPCR)
for both normal and obstetric emergencies.
 Detection and management of complications
 Provision of tetanus toxoid and immunization iron tablets
deworm to all pregnant women and malaria prophylaxis
where necessary.

2.1.3. Postnatal care:
Postnatal services include:
 3 postnatal visits(first within 24 hours of
delivery, second visit on the third day and third visit
on seventh day after delivery.
 Identification and management of mother‟s and
newborn in complication of postnatal period and
referral to appropriate health facility as and when
needed.
 Promotion of exclusive breast feeding
 Personal hygiene and nutritional education
, postnatal vit. A and iron supplement for mother

 Immunization of newborn
 Postnatal family planning counseling and services

2.1.4. Newborn care:
 Health education and behavior change
communication on essential newborn care practices
, which includes cord care, prevention and
management of hypothermia through kangaroo
mother care, initiation of immediate breastfeeding
within one hour of childbirth
 Identification of danger signs and timely referral

 To the appropriat health facility

2.1.5. Emergency obstetric
care and birthing
centers
BEOC covers management of pregnancy
complication by assisted vaginal deliveries(
vaccum or forceps), manual removal of
placenta, removal of retained products of
abortion(manual vaccum aspiration), and
administration of parenteral drugs(for postpartum
hemorrhage, pre eclampsia
/eclampsia), resuscitation of newborn and referral.

Comprehensive emergency obstetric care (CEOC)
includes surgery(caeserean section) an aesthesia
and blood transfusion along with BEOC. Safe blood
transfusion is an is an essential part of CEOC , and
to support this the national blood transfusion policy
was revised in 2006 and blood transfusion guideline
developed.

The safe motherhood and neonatal health(SMNH)
long term plan identifies the need for phased
strengthening and expansion of quality SMNH
services at all levels, especially the number and
quality of B/CEOC sites and birthing centers
Since the majority of women still give birth at
home, the aim is to ensure the normal delivery care
and referral services are available at community
level through home visit, outreach clinics and health
posts/ sub health posts with 24 hours birthing
centers able to manage normal deliveries.

The target is that by 2017, CEOC services will be
available in 60n districts and 80% of PHCCs will
provide BCOC services. There is significant
increase in availability of CEOC, BEOC and birthing
sites as in table given below:

Fiscal CEOC BEOC BEOC BEOC 24 hr. 24 hr. 24 hr. Birthing
year hospital PHCC total delivery delivery delivery center
at PHCC at HP at SHP

2007/ 51 in 31 37 68 168(78% 219 35 422
08 33 )
distric
ts
2008/ 76 in 45 45(22%) 90 169(79% 301(45 64(2%) 532
09 35 ) %)
distric
ts
2009/ 94 in 47 58 105 148(71% 406(60 137(4%) 695
10 45 ) %)
distric
ts
2012 47 - 60% of - - 30% of - -
target distric PHCC HP

A total of 586 ANMs and 4o staff nurses have
been recruited on local contract to support
24 hour delivery services in PHCs and HPs.

2.1.6. SAFE ABORTION SERVICES
Training service, delivery and monitoring
 From July 2009 to june2010, 88,938 women
received safe abortion service from 331 listed
sites in 75 districts.
 Upon the approval of the scale up
strategy, medical abortion was integrated in
CAC training and 180 providers were trained in
both MA and MVA scaling up MA in 75 districts.
 As a pilot, MA was integrated in 2 batches of
SBA training out of which 10 were from
government sites.
They receive intensive follow up and support.

 Implementation for performance monitoring system
for clinical trainees and active service delivery sites
continued. A total of 88 sites received follow up
during this fiscal year. 100% of trainees trained
from June 2009-10 were followed up within 3;4
weeks post training and 180 providers at ;9 months.

POLICY AND ADVOCACY
 Ipas/ Nepal joined hand with
MWCSW(ministry of women, children and
social welfare) and women development
department and organized a high level
advocacy workshop with the objective to
sensitize high level policy makers on the
abortion related issues , as well as to their
existing network in reaching women
including the young women
 Safe abortion services has been included in
EHCS(essential health care service)

PROBLEMS/RECOMMENDATIONS AND
SOLUTIONS
problems Recommendations/ actions
Women in rural and remote areas Expand medical abortion upto the
are underserved or completely health post level.
deprived of the service forcing
them to choose unsafe abortion.
A study revealed that 13% of the Orient female community health
clients denied safe abortion volunteers in early detection of
service as they were above 12 pregnancy as they are key referral
weeks gestation. link between the community and
health service.
The high proportion of client Access providers and sites and
accepting short term contraception facilitate for training and listening.
indicates that there s either lack of
providers trained in long term
methods or shortage of the
commodity at the site.
Untrained/ unlisted providers Need to strengthen the capacity of

WORK PLAN FOR FISCAL YEAR 2067/68
1. Training
 Integrated(MVA+MA) training to 100
doctors and 100 nurses
 Refreshers training for 40 providers
 On the job training for 30 MD students
 Second trimester training for 80 obsgyn/
MDGP
 CAC integrated first trimester training for
40 private doctors
 MA only training to 120 SBAs

2. Community engagement mobilization
 Train 1200 FCHVs from 4 districts
 review1200FCHVs (old and new) from 10
districts
 Subcontract local NGO to begin
implementation of newly developed youth
intervention.

3. Monitoring and mentoring
 Onsite monitoring of 150 CAC trained
providers
 Post training follow up to 100% providers

 Orient 10 PHNs on supportive supervision
guidelines on MA
 Orient 25 nurses(CAC) providers from 37
PHCs on clinical mentoring onsite support to
10 non functioning or problematic sites

4. Research and studies
 Implementation research on “the provision
of MA by ANMs trained as SBAs in
peripheral level of health institutions”
 Study on assessing “the impact of
counseling on method selection and
contraceptives uptakes”.

DEVELOPMENT AND EQUIPMENT

Type of completed Under Planned for Total
services constructio 2010/2011
n
CEOC sites 89 54 25 168
BEOC sites 20 6 4 30
CAC sites 17 4 4 25
HP‟s with 93 51 62 206
birthing
center
PHCC‟s with 24 49 20 93
BEOC
SHP 0 123 13 136
upgrade to
HP with
birthing unit

2.1.8 BIRTH PREPAREDNESS PACKAGE AND
MATERNAL AND NEONATAL HEALTH ACTIVITIES AT
COMMUNITY LEVEL

 By the end of 2065/66,birth preparedness
package(BPP)has been rolled out in all 75 districts.

 Family health division(FHD)revised the
package(BPP flip chart and jeevan surakshya
card)focusing on continuum of care from
pregnancy,through birth and the post-partum
period,including newborn.

 Family health division(FHD) with technical
assistance from partners such as USAID funded
Nepal Family Health Program(NFHP 2),United
Mission to Nepal(UMN),UNICEF,SDC funded Rural
Health Development Project(RHDP) and Care
Nepal has been implementing maternal and
neonatal activities at the community level.

 MNH activities at community level focuses on
strengthening birth preparedness,identification and
prompt care seeking for danger sings in
pregnancy,delivery and post-partum period and
education and distribution of Misoprostol(Matri
Surakshya Chakki)for post partum
hhemorrhage(PPH) at home birth.

 In the fiscal year 2066/67 PPH education and Matri
Surakshya Chakki distribution by FCHVs has been
approved for national level expansion in integration
with birth preparedness package.

 At the national level,Master training of trainers were
organised in 4 batches.
 Misoprostol implementation guidelines were
developed for expansion of Matri Surakshya Chakki
distribution by Female Community Health
Volunteers.

 In the fiscal year 2066/67,revised BPP was
implemented to 41 districts(25 by GON and 16 by
partners).
 In 2066/67,revised BPP is planned to expand in 30
districts (25 by GON and 5 by partners)and
maintainance of BPP in existing districts.

 Education and distribution of Matri Surakshya
Chakki(MSC) by FCHVs for prevention of PPH at
homebirth will be maintained in existing districts
and expansion in a few districts.
 Pilot study on use of Chlorhexidine for prevention of
umbilical cord infection is on-going in 4
districts(Banke,Jumla,Bajhang and Parsa).

intervention Completed in Plan for 2066/67
2065/66
Revised BPP With GON funding With GON funding(25
(25 districts) districts)
Dhankuta,Ilam,Khotan Bhojpur,Panchthar,Sa
g,Morang,Sankhwasa ptari,Terhathum,Udayp
bha,Siraha,Sunsari,So ur,Chitwan,Lalitpur,Ma
lukhumbu,Taplejung,B kwanpur,Ramechap,R
ara,Kavrepalanchowk, autahat,Sindhupalcho
Nuwakot,Parsa,Rasuw wk,Aarghakhachi,Gul
a,Sarlahi,Baglung,Lam mi,Kapilbastu,Kaski,M
jung,Myagdi,Nawalpar anang,Mustang,Rupan
asi,Palpa,Parbat,Dolp dehi,Syanjha,Tanahu,
a,Jajarkot,Surkhet and Bardia,Dang,Humla,P
Baitadi. yuthan,and
With support from Achham,Dadeldhura
partners(15 districts) and Doti.
Jhapa,Okhaldhunga,D With support from

PPH education and Sindhuli(distribution Shifting distribution
distribution of M atri from ANC of Matri Suraksha
Suraksha Chakki for clinics),Banke,Mugu, Chakki by FCHVs for
prevention of PPH at Jumla,Kalikot,Bajhan prevention of PPH at
homebirth g,Darchula,Bajura, homebirth in
and Doti(distribution Sindhuli and Doti.
from ANC clinics) Maintainance of PPH
education and MSC
distribution in 6
districts(okhaldhung
a,ramechap,dailekh,r
olpa,salyan and
kalikot)

2.1.10 Human Resources Development (HRD)
With support from RTI and SSMP/Options, a study on
human resources available for safe delivery was
conducted in 15 districts, which formed the basis for
developing a national Human Resource Strategy for
Safe Delivery Service. One of the study
recommendations was to recruit additional staff
under local contracts to ensure sufficient staff for
24-hour delivery and C/BEOC services.

. In response, FHD provided additional budget to
districts and 318 ANMs and 14 staff nurses were
recruited. However, only two out of a planned six
districts were able to recruit MDGPs (Nuwkot and
Gulmi). In two districts (Dailekh and
Sankhuwasabha) the hospitals contracted medical
colleges to provide CEOC services. Stakeholders
have continued to advocate for production of more
gynaecologists and MDGPs for CEOC services and
NAM institute has agreed to initiate a one-year
diploma course in gynaecology and obstetrics.

 Family Health Division coordinated with NHTC to
provide safe motherhood related training for various
cadres of health worker, with a particular focus on
SBA training, as shown in the Table 3b.3 below. The
Learning Resource Package for SBA training was
reviewed and updated and a combined
.Supplementary Reference Manual for SBAs
produced. A five-year SBA operational training plan
was finalised, based on the National SBA Policy
(2006).

 Since in-service SBA training was initiated in
2007, a total of 1,134 SBAs have been trained
(including MDGPs, Ob/ Gyn, medical
officers, nurses and ANMs, some from the private
sector and pre-service education faculties). The
majority were from district hospitals and PHCCs. At
least one SBA has been trained from all 75 districts.

Activities Planned Achieved % achievement
numbers numbers
SBA Training 750 559 75
Anaesthetic 12 14 117
Assistant
Training
Operation 20 19 95
Theatre
Techniques and
Management for
Surgery
Advanced SBA 4 2 50
with Surgical
Skills
Clinical Training 16 14 88
Skills

 A further six SBA training sites have been
developed, including needs assessment, training of
trainers, and providing teaching learning materials
and models. In total 15 training sites are now
conducting SBA training with support from
SSMP/Options, NHTC conducted a pilot SBA post-
training follow up programme, using 24 SBA
trainers to follow up 119 SBA service providers.

 . On-site coaching was provided where needs and it
was found that most of the SBAs are using the core
skills from their training. nursing).

Furthermore,a national Pre-Service SBA Education
Strategy has been developed, to ensure that in
future all medical and nursing graduates will be
SBAs and not require further in-service training.
This is in process for approval from the Ministry of
Education, and SBA skills are already included in
updated curriculum institutions under the IoM
(MBBS, BSc Nursing, and certificate level)

 2.1.11 Equity and Access(samata Ra Pahunch
Karyakaram)
 In partnership with Action Aid Nepal, SSMP/Options
has continued implementing a targeted Equity and
Access Programme (EAP) in eight districts
(Morang, Chitwan, Nawalparasi, Rupandehi,
Parbat, Myagdi, Dailekh and Dadeldhura), working
through 26 local NGO partners to empower
communities, particularly poor and excluded, to
utilise SMNH services. Mass media activities have
also continued in two additional districts, Baglung
and Surkhet.

 Based on needs assessment (with baseline KAP
survey), 184 VDCs and 7 municipalities were
selected for rights based social mobilisation
activities, as these are majority poor and socially
excluded people. Approximately 90,000 women
participate in more than 3,500 local groups, linked
through women networks at VDC level to create
demand for SMNH services.

 Key activities were:
• Group meetings and networking to empowering
women to raise their voices for improved services
and access . Encouraging marginalised and
excluded women to hold decision making positions
in the groups and other bodies, such as HFMC,
users groups, Behaviour Change Communication
(BCC) initiatives such as street drama,
development and distribution of localised posters
and pamphlets, radio and quiz competitions

 • Technical support to NHEICC for design and
dissemination of SMNH messages through radio
 drama serial and weekly radio magazine through
six FM and radio stations.
 • Follow up and orientation for VDC members, local
political/social leaders, school teachers,
 FCHVs and traditional healers to generate an
enabling environment for poor and social excluded
 people to access SMNH services

Strengthening peripheral HFMCs by facilitating
interaction meetings between service
providers, management committees and
communities to ensure more responsive service
delivery.
 Advocacy activities for media people, transport
workers, district level stakeholders including
Reproductive Health Coordination Committee
members about SMNH

Second round of voice collection (service users and
providers) on perceptions about services and
access to inform policy and programme reforms.

 An end-line KAP survey was carried out to assess
the achievements of the EAP, which ended in July
2009. Results indicated improved SMNH
knowledge and substantially increased SMNH
service utilisation, demonstrating the success of the
targeted approach to empowering poor and
excluded people. Specific achievements are:

• Over 3,500 community groups mobilised with
emergency funds, over 80% of which were utilised
by poor and excluded groups.
• Around 52% of the groups have their own local
emergency transport and all groups have access to
the emergency transport. Again 80% of the users
are poor and excluded.

• Around 73% of key positions are held by socially
excluded women (chairperson, secretary,treasurer).
• All District RHCCs in EAP districts functional, with
five having a RH strategic plan.
• Institutional deliveries increased by 30% in
2008/2009 (FY 064/65), compared with 2006/2007
(FY062/63). Dalits doubled their institutional
delivery rate, to 26%, and relatively advantaged
Janajatis almost doubled their institutional delivery
rate, to 65%.

• Around 25% of people practising at least two out of
four (money, transport, blood and SBA) methods of
birth preparedness and complication readiness in
EAP districts.
• Knowledge of at least three danger signs among
poor and excluded increased (by 43% during
pregnancy, 54% during labour and 48% up to 42
days after delivery).

 Increased knowledge about neonatal danger signs
and management of complications, at least four
 out of eight listed elements in each case, up from
9% to 35% and from 22% to 52% respectively.
• Increased knowledge about legal provision of safe
abortion, by 58%.

 Correct identification of health facility for the
management of complications during
pregnancy, labour and postpartum period (99%).
 Increased knowledge of the Safe Delivery
Incentive Programme, by 90% from 27%.

 EAP contributed to improved service utilisation in
13 selected facilities that received appreciative.

 Scaling up Equity and Access activities through
FA
 FHD has committed to implementing equity and
access activities in additional districts using SSMP
 Financial Aid (FA). Activities have been expanded
into two new districts, Gorkha and Kanchanpur,
through district (public) health offices directly
contracting a local NGO in each district. Initial
results are promising in terms of increased service
utilization. FHD has also agreed to further scaling
up of EA activities in eight districts in 2009/10 using
SSMP FA.

MATERNAL AND NEONATAL HEALTH UPDATE
 FHD ,with support from various partners,conducted
MNH update in 7 districts(namely
Dailekh,Rolpa,Surkhet ,Bara,Sindhuli,Kailali, and
Doti)

MNH update is essentially a 3-days update of health
workers(namely doctors,staff nurses,ANMs and
MCHWs)working in health facilities that provides
24-hour delivery services(hospital,PHC,HP and
SHP)based on the standard SBA training package.

 During the update,service providers are trained on
the use of partographs,active management of the
3rd stage of labor(AMTSL)for prevention of PPH
including conduction of normal labor,management
of PPH,use of MgSO4 for severe pre/eclampsia
and neonatal resuscitation.

This intervention is conducted with an aim of
improving the knowledge and skills of health
workers providing delivery services in remote health
facilities,on identification,management and/or
referral of women and newborns with
complications,till the time they receive the formal
SBA training which is the goldstandard.

Since the start of this program in 2009,more than 252
providers from 7 hospitals and more than 122
health facilities have received this update.This is a
„whole-site update‟for all providers in the health
facility at the same time,thus ensuring uniform
services delivery as well as creating an enabling
environment at work.This intervention will be
continued in these districts in addition to its
expansion to at least 5 more districts in the coming
year.

Safemotherhood

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