Safe Motherhood and Newborn Program

2. Outline
• Introduction
• Goal ,
• Major strategies ,
• Major activities
• Achievement
• Issues, constraints and recommendations

3. Introduction:-
• The Safe Motherhood Programme, intiated in 1997 has made significant
progress with formulation of safe motherhood policy in 1998.

4. • Important factors for maternal and newborn morbidity and mortality
in Nepal are:-
1. delays in seeking care,
2. delays in reaching care
3. delays in receiving care

5. The goal :-
• To reduce maternal and neonatal morbidity and mortality and
• 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.

6. Major strategies:-
• Promoting birth preparedness and complication readiness including
awareness raising 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.

7. Program , policy and guidelines
• 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.

8. • 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.
• The Nepal Health Sector Strategy (NHSS) identifies equity and quality of care
gaps as areas of concern for achieving the maternal health sustainable
development goal (SDG) target, and gives guidance for improving quality of care,
equitable distribution of health services and utilisation and universal health
coverage with better financing mechanism to reduce financial hardship and out of
pocket expenditure for ill health.

9. • By 2030, reduce the global maternal mortality ratio to less than 70 per 100,000
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
1,000 live births and under-5 mortality to at least as low as 25 per 1,000 live
births
• The maternal mortality ratio (MMR) for Nepal is 239 deaths per 100,000 live
births for the seven-year period before the survey(NDHS 2016)

10. Major activities

11. Major activities
• Community level maternal and newborn health interventions
• Rural Ultrasound Programme
• Reproductive health morbidity prevention and management programme
a) Management of pelvic organ prolapse
b) and Obstetric Fistula:
c) Cervical cancer screening and prevention training:

12. • Human resources
• Expansion and quality improvement of service delivery sites
• Emergency referral funds
• NyanoJhola Programme
• Aama and Free Newborn Programme
• Obstetric first aid orientations

13. 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);

14. • 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 periods.

15. • In 2066/67, the government approved PPH education and the distribution
of the matrisurakshachakki (MSC) tablets through FCHVs to prevent PPH
in home deliveries.
• For home deliveries, three misoprostol tablets (600 mcg) are handed over
to pregnant women by FCHV at 8th month of pregnancy through proper
counselling to take immediately after delivery and before the placenta is
expelled.

16. Rural Ultrasound Programme
• 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 previaare referred to a CEONC site for the needed services.
• This programme is being implemented in the 14 remote districts. In FY 2075/76, a total of
15 SBA were trained on rural ultra sound by NHTC and FWD.

17. Reproductive health morbidity prevention
and management programme
a. Management of pelvic organ prolapse and Obstetric Fistula: Pelvic
organ prolapse (POP) is common reproductive health morbidity in Nepal
and contributes to disability adjusted life years (DALYs) and social
consequences. Multiparity, maternal malnutrition, too frequent
pregnancies and heavy work after delivery are the main risk factors
b. Cervical cancer screening and prevention training:

18. 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.
• NHTC provides training on SBA, ASBA, Anaesthesia assistant,
operating theatre management, family planning (including implants
and IUCD), CAC and antenatal ultrasonography.

19. Expansion and quality improvement of service
delivery sites
• FWD continued to expand 24/7 service delivery sites like birthing centres,
BEONC and CEONC sites at PHCCs, health posts and hospitals
• Study in 2013 (FHD 2013) shows that the overcrowding of normal delivery
services at referral hospitals has contributed to poor quality of care. To
expand and improve the quality of maternity services, FWD has been
allocating budget to overcrowded hospitals since 2069/70.

20. Onsite clinical coaching and mentoring
• 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.
• This programme has been scaled up in 15 districts in FY 2074/2075.
• 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.

21. MNH readiness Hospital and BC/BEONC
Quality Improvement
• The process of quality improvement is also being implemented in
birthing centers in integration with onsite coaching/mentoring
process.

22. PNC home visit(microplanning for PNC)
• 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.

23. Emergency referral funds
• To address this issue FWD allocated emergency referral funds to Regional
Directorate for air lifting of women in need of immediate transfer to higher
centres.
• 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.

24. Safe abortion services
• Global and national evidence shows that many women face unwanted pregnancy
including due to limited access to family planning information and services.
• Such women who cannot access safe abortion services in a timely way are at a
high risk of developing complications due to unsafe abortions, or in the worst
case, suicide due to social pressure.
• In Nepal abortion rate among WRA is 42 per 1000 women of reproductive age
women (15-49) , highest in central region (59) and lowest in far western region
(21) .

25. • FWD has defined the four key components of comprehensive abortion care as:
• pre and post counselling 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.

26. • Comprehensive abortion care (manual vacuum aspiration [MVA]) services are
available in all 77 district hospitals and majority of PHCCs. Additionally, second
trimester abortion services are available in 30 hospitals where CEONC services
are also available.
• Medical abortion (MA) services are being expanded in health posts through the
additional training of SBAs.
• Medical abortion services have been expanded to 60 districts with the support of
various partners.

27. Obstetric first aid orientations
• 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.

28. 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.

29. 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 nation wide under the Aama Programme in 2009.

30. • In 2012, the separate 4 ANC incentives programme was merged with the Aama
Programme.
• In 2073/74, the Free Newborn Care Programme (introduced in FY2072/73) was
merged with the Aama Programme which was again separated in FY 2074/75 as
two different programmes.

31. Aama programme provision
a. 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.

32. • 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.

33. • 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.

34. • 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.

35. b. Incentives 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.

36. Newborn Care Programme Provision
a. 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.

37. b. 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.

38. Achievements

39. Antenatal care
• WHO recommends a minimum of four antenatal check-ups at regular intervals to all pregnant
women (at the fourth, sixth, eighth and ninth months of pregnancy).
• During these visits women should receive the following services and general health check-ups:
1. Blood pressure, weight and foetal heart rate monitoring.
2. IEC and BCC on pregnancy, childbirth and early newborn care and family planning.
3. Information on danger signs during pregnancy, childbirth and in the postpartum period, and
timely referral to appropriate health facilities.

40. 4. Early detection and management of complications during pregnancy
5. Provision of tetanus toxoid and diphtheria (TD) immunization ,iron
folic acid tablets and deworming tablets to all pregnant women, and
malaria prophylaxis where necessary

41. • The percentage of women who had at least one ANC check-up in FY 2075/76 is
110% at the national level. With 127% highest in Karnali province and 90%
lowest in sudhurpaschim province
• The proportion of pregnant women women attending at least 4 ANC visits as per
the protocol was 56 percent in FY 2075/76 at the national level.
• More than 8 in 10 women (84%) age 15-49 receive antenatal care (ANC) from a
skilled provider (doctor, nurse, and auxiliary nurse midwife).(NDHS 2016)

42. Delivery care
Delivery care services include:
1. skilled birth attendance at home and facility-based deliveries;
2. early detection of complicated cases and management or referral
(after providing obstetric first aid) to an appropriate health facility
where 24 hours emergency obstetric services are available; and
3. the registration of births and maternal and neonatal deaths.

43. • Although women are encouraged to deliver at a facility, home
deliveries using clean delivery kits with provision of misoprostol to
prevent post-partum haemorrhage and early identification danger
signs and complications, are important components of delivery care in
settings where institutional delivery services are not available or not
used by the women.

44. Delivery attended by Skilled Birth Attendants (SBAs):
• At the national level, percentage of births attended by SBAs was 60 percent in FY 2075/76
• Province five achieved the highest's with 73 percent deliveries attended by SBA.
• The gandaki province has the lowest percent of delivery attendant SBA at 47 percent
Institutional delivery:
• Institutional deliveries as percentage of expected live births have increased to 63 percent
in 2075/76

45. Postnatal care
Postnatal care services include the following:
1. Three postnatal check-ups, the first in 24 hours of delivery, the second on
the third day and the third on the seventh day after delivery.
2. The identification and management of complications of mothers and
newborns and referrals to appropriate health facilities.
3. The promotion of exclusive breastfeeding.

46. 4. Personal hygiene and nutrition education, and postnatal vitamin A and
iron supplementation for mothers.
5. The immunization of newborns.
6. Postnatal family planning counselling and services.
The proportion of mothers attending three PNC visits as per the protocol was
16 percent in 2075/76.

47. Newborn care
Newborn care includes:
• delivery by a skilled birth attendant at home and facility births with
immediate newborn care (warmth, cleanliness, immediate breast
feeding, cord care, eye care and immunization) for all newborns and
the resuscitation of newborns with asphyxia;

48. • health education and behaviour change communication for mothers on
early newborn care at home;
• The identification of neonatal danger signs and timely referral to an
appropriate health facility; and
• community based newborn care

49. Safe abortions
• More than 100,000 women have received safe abortion services from
certified service sites since the service began in Nepal in 2060/61.
• Total SAS users were 90,677 (12.6%) in 2075/76.
• The proportion of adolescent (<20 years) among SAS user declined
for medical abortion (9%)
• And slightly increased (13%) for surgical abortion in this fiscal year.

50. Implementation of Maternal and Perinatal
Death Surveillance and Response (MPDSR)
• This is a 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.
• GoN prioritized and implemented MPDSR in FY 2073/74 MPDSR with further strengthening and
expansion.
• MPDSR was scaled up in 21 districts out of which 7 districts in this fiscal year (Bhangang,
Dailekh, Palpa , Myagdi , Taplegung and Rautahati , and 99 hospitals( both public and private) in
FY2074/75.
• Government of Nepal (GoN) developed MPDSR guidelines 2015.

51. • Community-based MPDSR: Community based MPDSR program was
implementing in 21 districts 99 hospitals.
• In community-based MPDSR program community, maternal deaths and perinatal
deaths are reviewed and responses planned.
• Hospital-based MPDSR: Currently 99 hospitals are implementing MPDSR
program. In hospitals, each maternal death is reviewed individually and perinatal
deaths are reviewed in a monthly basis.
• Formation of MPDSR Committees at different levels

52. One stop Crisis Management Centre (OCMC)
• One stop crisis management Orientation program was successfully
completed in five different district hospital i.e. Chautara Hospita,
Sindhupalchowk, Dhulikhel Hospital, Kavrepalanchowk, Sandhikharka
Hospital, Argakhachi, Taulihawa Hospital, Kapilbastu and Prithivichandra
Hospital, Nawalpara.
• The objective of the program was to enhance service provider’s knowledge
and skill regarding case management.

53. Issues, constraints and recommendations
Issues and constraints Recommendations Responsibilities
High maternal mortality
rate
1. Review of programme implementation an
effectiveness
2. Plan for road map to reduce MMR based on
global and Nepal evidences
FWD, DoHS,
MoH
Referral mechanism
needs to be established
1. Revise the Aama Programme to facilitate an
appropriate referral mechanism and improve
access to life-saving services.
2. Develop Referral Guideline.
FWD
Fluctuating functionality
of CEONC and birthing
centre services
1. Focusing on functionality and quality of existing
CEONC sites, rather than establishing new sites.
2. Monitoring service provision status and
availability of human resource
3. Promote the production of skilled service
providers (AAs, MDGPs, MD obgyn) and ensure
appropriate skill mix at CEONC sites by
deployment and appropriate transfer of skilled
human resources
MoH , DoHS,
FHD, NHTC

54. Issues and constraints Recommendations Responsibilities
Continue allocation of fund for contracting out short –
term service providers
• Provide locum doctors and anaesthesia assistants in
strategically located referral hospitals for each province
• Introduce a special package to provide CEONC services
in mountain districts
• Support local government for training of human
resources in necessary skills
Availability of quality
maternity care services at
hospitals and birthing centres:
• 24/7 availability of services
• skills and knowledge of staff
• enabling environment and
motivation
• overcrowding at referral
hospitals.
1. Introduce quality improvement process for all
maternity care services including QIP self assessment
and on-site clinical coaching
2. Introduce monitoring process indicator for quality
maternity care in health facilities
3. Adequate budgets allocated for equipment in birthing
centres and CEONC sites
4. Regular MNH skills update programmes for nurses
focusing on continuum of care
5. Introduce construction standards for birthing centres
6. Support birthing centres at strategic locations only
7. Provide additional budgetary support for overcrowded
hospitals

55. Issues and constraints Recommendations Responsibilities
Plateauing of 4ANC use and timely
first ANC visits, and very low PNC
coverage
1. Raise the quality of ANC counselling services,
focusing on continuum of care
2. Develop a special package to encourage timely
first ANC visits.
3. Initiate PNC home visit in selected councils
DHOs, DPHOs,
FHD
Low use of institutional delivery and
C-section services in mountain
districts, and province number 2
and 6
1. Produce a strategy to reach unreached sub
populations
2. Rapidly assess and expand rural ultrasonography
(USG)
3. Expand services in remote and difficult locations
and ensure continuous availability of services
(birthing centres and CEONC services)
FHD, DHOs,
DPHOs
No CEONC services in some remote
districts: Rasuwa, Manang and
Mustang
1. Discussion with local government on the
advantages of have CEONC, and challenges in
maintaining CEONC functionality in low
population areas
FHD
The high public demand for free
delivery services at BPKIHS
1. Implement the Aama Programme at BPKIHS MoH, BPKIHS,
FHD, RHDs

56. Issues and constraints Recommendations Responsibilities
The inadequate use of some birthing
centres and increasing the number
of birthing centres, and increasing
use of referral hospitals
1. The strategic upgrading of health facilities into
birthing centres
2. Upgrade strategically located birthing centres to
provide comprehensive quality primary health
care services and aim for ‘home delivery free’
VDCs
3. Run innovative programmes to encourage
delivery at birthing centres
FHD, DHOs
DPHOs
High demand for free surgery for
uterine prolapse cases
1. Increase the budget and target for regional health
2. Hospitals provides regular services of POP
surgery .
FWD
Federal structure and governance of
health institutions; limited
understanding of health service
delivery
1. Orientation of local and provincial level
government on their roles in health services
delivery and governance
FWD/MOHP

57. Bibliography
1. https://dohs.gov.np/wp-content/uploads/2020/11/DoHS-Annual-
Report-FY-075-76-.pdf
2. https://nepal.unfpa.org/sites/default/files/pubpdf/NDHS%202016%2
0key%20findings.pdf

58. Thank you