Safemotherhood review and program

1. Chairman
Mr.Rajendra ruchal
Lecturer, UCMS
Dept Of Community
Medicine
Presented by
Subash adhikari
1st Batch BPH
UCMS

2. Safe motherhood and newborn
care

3. Safemotherhood
• Safemotherhood means creating the
circumstances within which the women is
enabled to choose whether she will become
pregnant, and if she does,ensuring she receives
care for preventing and treatment of
complications ,has access to emergency
obstetric care if she needs it,and care after
birth,so that she can avoid death and disability
from complications of pregnancy and child
birth.

4. Pillars of SM

5. Global Safe Motherhood Agenda
• The global campaign to reduce maternal mortality was launched in
February, 1987, when three UN agencies—UNFPA, the World Bank,
and WHO—sponsored the international Safe Motherhood Conference
in Nairobi, Kenya.
• Nepal, as a co-signatory in 1994 to the Plan of action of the
International Conference on Population and Development (ICPD), has
committed itself to improving Reproductive Health Status throughout
the kingdom.
• In order to implement this approach in a cost-effective manner the
Second Long Term Plan (1997-2017) was formulated.

7. Introduction:National Safemotherhood program
• It is the priority one program of Ministry of Health and Population.
• It comprises of significant portion of the national health budget in
public sector.
• The program was first started in 1997.
• 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.

8. • 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.
• The coordinated implementation of strategies and plans envisioned in
NHSP-2 and the National SafeMotherhood Plan (2006–2017) have
resulted in impressive progress on service expansion and the
increasing use of maternal and newborn health (MNH) and
reproductive health care services.

9. • 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.
• The 2015 earthquakes damaged many health facilities and disrupted
MNH and reproductive health services and the ability of communities to
access health services.
• FHD, with support from its partners, has made concerted efforts to
restore services and improve the quality of health services in line with
the government’s aim to ‘build back better’.

10. Strategies to reduce risks during pregnancy
and childbirth
1. Promoting birth preparedness & complication readiness including
awarness raising and improving the availability of funds, transport
& blood supplies.
2. Aama surakshya program to promote antenatal check up &
institutional delivery.
3. Expansion of 24 hour emergency obstetric care services (basic &
comprehensive) at selected public health facilities in every district.

11. Main strategies of the Safe Motherhood
Programme
1. Promoting inter-sectoral coordination and collaboration at central,
regional, districts and community levels to ensure commitment and
action for promoting safe motherhood with a focus on poor and
excluded groups.
2. Supporting activities that raise the status of women in society.
3. Promoting research on safe motherhood to contribute to improved
planning, higher quality services and more cost-effective
interventions.

12. 4. Strengthening and expanding delivery by skilled birth attendants and
providing basic and comprehensiveobstetric care services at all levels.
Interventions include:
i. Developing the infrastructure for delivery and emergency obstetric
care;
ii. Standardizing basic maternity care and emergency obstetric care at
appropriate levels of the health care system;
iii. Strengthening human resource management — diploma in gynaecology
(DGO), advanced skilled birth attendant (ASBA), SBA, anaesthesia assistant
training and deployment;

13. iv. Establishing a functional referral system with airlifting for emergency
referrals from remote areas, the provision of stretchers in VDC wards
and emergency referral funds in remote districts;
v. Strengthening community-based awareness on birth preparedness
and complication readiness through FCHVs and increasing access to
maternal health information and services.

14. Major activities under safe motherhood program in Nepal

15. Major activities under safe motherhood
program in Nepal
1. Birth preparedness package and MNH activities at community level
• To prevent PPH in home deliveries
• 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 (600mcg) are handed over
to pregnant women to take immediately after delivery and before the
placenta is expelled.
• Forty-two districts were implementing the programme in 2072/73 and
FHD has budgeted to scale the programme up to three more districts in
2073/74.

16. • Also 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 toxoid,
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.

17. 2.Rural ultrasound program
• 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.
• Woman with detected abnormalities such as abnormal lies and
presentation of the foetus are referred to a facility with the needed
services.
• This programme is being implemented in the 11 remote districts of
Mugu, Dhading, Darchula, Sindhupalchowk, Solukhumbu, Bajura
Bajhang, Achham, Dhankuta, Humla, and Baitadi.
• Eighteen SBAs received three weeks training on antenatal
ultrasonography in 2072/73.

19. 3.Reproductive health morbidity prevention and management
programme
I. Management of pelvic organ prolapse
• Pelvic organ prolapse (POP) is a common reproductive health morbidity
in Nepal and contributes DALYs.
• 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 2072/73 more than 14,800 women were screened for the condition of
which 8.8 percent had first degree POP, 7 percent second degree POP
and 8.9 percent third degree POP.
• More than 1,100 women received surgical treatment and 2,019 women
were instructed to manage the condition using ring pessaries.

20. ii.Cervical cancers screening and prevention training
• Cervical cancer is the most common cancer of women in Nepal,
accounting for 21.4 percent of all cancer among 34–64 year old women.
• Cervical cancer screening is done by visual inspection of the cervix by
trained nurses or doctors.
• This approach is cost effective as the early detection of lesions and early
management by cryotherapy will usually prevent progression to cervical
cancer, and the cost of scaling up this activity is relatively low.
• The FHD plans to scale up this approach to all 75 districts.
• As of 2072/73, cervical cancer screening has been expanded to 45
districts.

21. • In the reporting year nurses from 68 government health facilities in
Kaski and from 40 facilities in Chitwan were trained on visual
inspection withn acetic acid under the human papilloma virus (HPV)
demonstration project in coordination with CHD with support from
WHO.
iii.Obstetric fistula management
• Affects many women from poorer communities and significantly
impairs their quality of life due to the social stigma attached to this
condition and their physical suffering.
• The government has allocated funds for the free screening of obstetric
fistula, which in 2072/73 was being integrated with pelvic organ
prolapsed screening and surgical services at the BP Koirala Institute of
Health Sciences (BPKIHS, Dharan) and Patan Academy of Health
Sciences, Lalitpur.

22. 4.Human resources
• FHD’s budget goes for recruiting ANMs on short term contracts to ensure
24 hour birthing services at PHCCs and health posts.
• It also provides funds to DHOs and DPHOs to recruit the human resource
mix needed to provide surgical management for obstetric complications at
district hospitals.
• 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.

23. …….
• NHTC provides training on SBA, ASBA, operating theatre management,
family planning (including implants and IUCD), and antenatal
ultrasonography.
• More than 8,500 SBAs and 140 ASBAs have been trained since SBA
training began.
• In 2072/73, one diploma in gynaecology (DGO) graduated from NAMS
and wasdeployed at a CEONC centre. The proper placement of trained
staff such as SBAs and anaesthesiologist assistants (AAs) has been a
continuous challenge.
• FHD continued to monitor the deployment of MNH service providers
especially staff nurses and ANMs at birthing centre and BEONC level and
doctors (MCGP, obgyn medical doctors, advanced skilled birth attendants
[ASBAs]) and AAs at the hospital level.

24. 5.Expansion and quality improvement of service delivery sites
• FHD continued to expand 24/7 service delivery sites like birthing
centres, BEONC and CEONC sites at PHCCs, health posts and hospitals.
• By the end of 2072/73 CEONC services were present in 69 districts,
although only 61 districts were providing such services on a regular
basis. A total of 1,751 birthing centres and 159 BEONC sites were
functioning by the end of 2072/73.
• In line with strategies of the Nepal Health Sector Strategy (2015–
2020), in 2072/73 FHD began strengthening strategically located
birthing centres towards upgrading them to comprehensive centres of
excellence (CCEs) in12 districts with support from UNICEF and NHSSP.

25. ………..
• A total of 58 birthing centres were selected to be upgraded to CCEs.
• Anecdotal evidence suggests 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, FHD has
been allocating budget to 10 overcrowded hospitals since 2069/70.
• At the same time 11 overcrowded zonal and regional hospitals are
receiving funds for recruiting gynaecologists, anaesthesiologists and
anaesthetic assistants.
• FHD has also allocated budgets for recruiting staff nurses and ANMs
in hospitals and birthing centres to cope with the overcrowding of
maternity wards and is developing long-term strategies to overcome
this problem.

26. 6.Emergency referral funds
• It is estimated that 15 percent of pregnant women will develop
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 morbidity.
• Difficult geographical terrain and unavailable CEONC services are
major culprit.
• To address this issue FHD allocated emergency referral funds to
facilitate referral services in 16 districts in 2071/72.
• Fourteen more districts were allocated funds for emergency referral
in 2072/73. A total of NPR 200,000 rupees has been allocated as seed
money for each district to be managed by local committees as per the
operational guidelines.

27. ……….
• 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.
• The regional health directorates also have funds to airlift needy
women from areas where motorized transport is not available or
when immediate transfers are needed.
• Based on recommendations, free referrals for obstetric complications
from birthing centres and BEONC centres to CEONC centres are being
implemented in Ramechhap and Dolakha districts.

28. 7.Safe abortion services
• FHD has defined the four key components of comprehensive abortion
care as:
1•pre and post counselling on safe abortion methods and post-
abortion contraceptive methods;
2• termination of pregnancies as per the national protocol;
3• diagnosis and treatment of existing reproductive tract infections;
and
4• provide contraceptive methods as per informed choice and follow-
up for post-abortion complication management.

29. ……..
• Comprehensive abortion care (manual vacuum aspiration [MVA] and
medical abortion [MA]) services are available in all 75 district
hospitals and over 50 percent of PHCCs.
• Additionally, second trimester abortion services are available in 24
hospitals where CEONC services are also available and medical
abortion services are being expanded in health posts through the
additional training of SBAs.
• Medical abortion services have been expanded to 42 districts with
the support of various partners
• Beginning in 2070/71, the safe abortion programme was prioritised
to ensure the availability of five modern contraceptive methods at all
safe abortion sites.
• Up to the end of 2072/73, 1,020 ANMs and 466 health facilities were
listed for providing MA services and 1,414 doctors and 526 nurses as
MVA service providers and 538 health facilities were listed as MVA
service sites.

30. 8.Obstetric first aid orientation
• 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 2072/73, trainers were trained on this subject in 16 districts.

31. 9.Nyano jhola programme
• It 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.
• The programme was implemented in all 75 districts in 2072/73.

32. 10.Aama newborn programme
• 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 2009, 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) is being merged with the Aama Programme with the
provisions listed below.

33. Provisions of the Aama and Newborn Programme
A. For women delivering their babies in health
institutions
• Transport incentive for institutional delivery;
immediately after institutional delivery (NPR 1,500 in
mountains, NPR 1,000 in hills and NPR 500 in Tarai
districts).
• Incentive for 4 ANC visits: NPR 400 to women on
completion of four ANC visits at 4, 6, 8 and 9 months of
pregnancy, institutional delivery and postnatal care.

34. • Free institutional delivery services: For a normal delivery
• Health facilities with less than 25 beds receive NPR 1,000
• Health facilities with 25 or more beds receive NPR 1,500.
• For complicated deliveries
• For complicated deliveries health facilities receive NPR 3,000
and
• For C-sections (surgery) NPR 7,000.

35. • Note
• 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

37. • For newborns
• 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

38. • 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.

39. • At the end of 2072/73, 69 health facilities were providing CEONC
services (a further 8 CEONC centres were non-functional), 159
health facilities were functioning BEONC centres and 1,751
facilities had functioning birthing centres.
• All these facilities, plus 61 non-state health facilities, currently
implement the Aama Programme.
• There has been a large increase in the number of facilities
providing delivery services and of institutional deliveries since the
launch of the Aama Programme.

41. • In 2071/72, 54 percent of Aama Programme related expenditure
(transport and health facility reimbursement) and 25 percent of 4ANC
related expenditure was captured in MoH’s Transaction Accounting
and Budget Control System (TABUCS).
• This increased to 73 percent for Aama Programmerelated expenditure
and 76 percent for 4ANC expenditure in 2072/73 (note that the
increase in expenditure for 4ANC is due to reduced budget
allocation).
• Similarly, 15 percent of free newborn care expenditure was captured
in the TABCUS in 2072/73

43. Achievement
• Antenatal

44. • The proportion of pregnant women attending at least
4 ANC visits among expected pregnancies as per the
protocol has not increased significantly in the last two
years at the national level .
• only increased in EDR in 2072/73 compared to the
previous year.

46. • The national average of first ANC visits as a percentage of expected
pregnancies increased from 86 percent in 2070/71 to 96 percent in
2071/72 and 97 percent in 2072/73.
• These results show the need to focus on the quality of the ANC
consultation process as it is expected that satisfied and well informed
pregnant women will be more likely to complete the recommended
four visits.
• The percentage of pregnant women who received their first ANC visit
on time and who went on to complete all four visits on time increased
in 2072/73 indicating improved quality of ANC.

48. • In 2072/73 only four districts (Sunsari, Lalitpur, Kaski and
Baglung) had 4ANC coverage of above 80 percent in line with
the protocol.
• Eight districts achieved 60-80 percent coverage, 53 districts
30–60 percent coverage, while 10 districts had coverage of
less than 30 percent.

49. Delivery care

50. • Nepal is committed to achieving 70 percent of all deliveries
by SBAs and at institutions by 2020 (2076/77) to achieve
the SDG target.
• However, in 2072/73, nationally and in EDR, CDR and WDR,
the proportion of deliveries attended by SBAs declined
(Figure 3.2.5).

52. • Institutional deliveries as a percentage of expected live births
increased from 50 to 55 percent over the last three years, although
there was a slight decline in the last fiscal year (Figure 3.2.6).
• Institutional deliveries declined in all regions in 2072/73 from the
previous year.
• The negative impacts of the earthquakes and fuel crisis explain the
underperformance in many districts.

53. • The proportion of institutional deliveries taking place at birthing
centres (in health posts) declined from 29 percent of all institutional
deliveries in 2071/72 to 27 percent in 2072/73.
• This is a concern considering the increasing number of birthing
centres (BCs) at health posts — from 1,621 in the previous year to
1,755 in the current year (Table 3.2.2).
• Among all 2072/73 institutional deliveries, 33 percent were carried
out in district level hospitals and PHCCs, 24.4 percent in referral
hospitals and 13.3 percent in teaching hospitals.

55. • POSTNATAL CARE

56. • The percentage of mothers who received their first postnatal care at a
health facility within 24 hours of delivery among expected live births
increased to 52 percent in 2072/73 from 48 percent the previous year
(Figure 3.2.8).
• As stated above, institutional deliveries accounted for 55 percent of
all deliveries in 2072/73, but PNC within 24 hours stood at only 52
percent, a three percentage points gap.
• This could,however, be due to a lack of proper recording and
reporting. There was an increase in the receipt of the first PNC on
time in all regions in 2072/73.

58. • The revised HMIS introduced the monitoring of three PNC visits
according to a protocol in 2071/72.
• The proportion of mothers attending three PNC visits as per the
protocol declined in 2072/73 in all regions except EDR (Figure 3.2.9).
• Cultural and geographical factors affecting the movement of
postnatal mothers could be reasons for the low coverage while the
perceived low importance of care in the postpartum period could
also be significant.

59. • Newborn care

61. • Safe abortion care
• A total of 908,904 women have received safe abortion services from
certified service sites since the service began in Nepal in 2060/61.
• In 2072/73, 89,214 women received safe abortion services, among
whom 53 percent received medical abortions and sixteen percent of
safe abortion service users were adolescents (<20 years).
• Compared to fiscal year 2071/72, the proportion of women who had
a safe abortion and then used contraceptives increased from 60
percent in 2071/72 to 69 percent in 2072/73 (Figure 3.2.10).

63. Program indicator

64. CHALLENGES IN SAFEMOTHERHOOD

65. Issues and constraints Recommendations Responsibilities
Referral mechanism needs
to
be established
• Pilot the
recommendations of the
referral guidelines
and implement
accordingly
• Revise the Aama
Programme to facilitate an
appropriate referral
mechanism and improve
access to
life-saving services
FHD

66. Fluctuating
functionality
of
CEONC and
birthing
centre
services
• Explore a multi-year system for contracting nursing
staff
• Allocate adequate budget for CEONC sites and birthing
centres and continue need-based temporary hiring
• Provide locum doctors and anaesthesia assistants in
hospitals
• Promote the production of skilled service providers
(AAs, MDGPs, MD obgyn) and ensure appropriate skill
mix at CEONC sites
• Introduce a special package to provide CEONC services
in mountain districts
• Appoint only SBA trained ANMs at birthing centres
MoH ,
DoHS,
FHD

67. 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.
• Introduce quality improvement process for all
maternity care services including process and on-
site
coaching
• Adequate budgets allocated for equipment in
birthing
centres and CEONC sites
• Regular MNH skills update programmes for
nurses
• Introduce monitoring process indicator for
quality
maternity care in health facilities
• Introduce construction standards for birthing
centres
MoH,
DoHS
FHD
(quality of
care)
FHD

68. ………………………
………………………
……..
• Support birthing centres at
strategic locations
• Provide additional budgetary
support for overcrowded
hospitals
• Introduce birthing centres led by
SBAs in all larger
maternity units
• Develop quality improvement
tools and minimum
service standards
• Provide on-site coaching and
mentoring for MNH
health workers
FHD, DHOs,
DPHOs
FHD, DoHS

69. Plateauing of
4ANC use and
timely first ANC
visits
• Raise the quality of ANC counselling
services.
• Develop a special package to
encourage timely first
ANC visits.
DHOs,
DPHOs,
FHD
Low use of
institutional
delivery and C-
section
services in
mountain districts
• Produce a strategy to reach
unreached subpopulations
• Rapidly assess and expand rural
ultrasonography
(USG)
• Expand services in remote and
difficult locations
(birthing centres and CEONC services)
FHD,
DHOs,
DPHOs

70. The inadequate
use of
some birthing
centres and
increasing the
number of
birthing centres,
and
• The strategic upgrading of health facilities into
birthing
centres
• Upgrade strategically located birthing centres to
provide comprehensive quality primary health care
services and aim for ‘home delivery free’ VDCs
• Run innovative programmes to encourage delivery
at
birthing centres
FHD,
DHOs
DPHOs
High demand for
free surgery
for uterine
prolapse cases
• Increase the budget and target for regional health
directorates and hospitals in uterine prolapse (UP)
surgery
FHD

71. The high public demand
for free delivery services
at
BPKIHS
• Implement the Aama
Programme at BPKIHS
MoH, BPKIHS,
FHD, RHDs
No CEONC in Rasuwa
and Sindhupalchok and
no functional CEONC in
Rautahat and Sarlahi
Develop infrastructure for
CEONC in these four
districts to provide CEONC
services
FHD, MD, MoH

72. THANK YOU