Maternal Health in Nepal _Saroj Rimal.pptx

Presented By:
Saroj Rimal (BPH,MPH)
2023.05.22
Maternal Health in Nepal

Contents
Contents
⮚ Background
⮚ Status and Trends of Maternal Health
Indicators
⮚ Obstetric Transition
⮚ Evolution of Maternal Health Policies in Nepal
⮚ Maternal Health Policies and Strategies of
Nepal
⮚ Current Maternal Health Program in Nepal
⮚ Issues and Challenges
⮚ Recommendation
⮚ Conclusion
⮚ References
2

Maternal health refers to the health of women
during pregnancy, childbirth and the postnatal
period.
Although important progress has been made in the
last two decades, about 287,000 women died
during and following pregnancy and childbirth in
2020 globally. This number is unacceptably high.
Most maternal deaths are preventable with timely
management by a skilled health professional
working in a supportive environment.
(Source: World Health Organization. Maternal health [Internet]. Who.int. World Health Organization; 2019. Available from: https://www.who.int/health-topics/maternal-
health#tab=tab_1) 4

(Source: National Population and Housing Census 2021: Nepal Maternal Mortality Study 2021)
5

National Situation and Trends
6

7

Maternal Mortality Decline, 1996–2022, with Projected Targets to 2030
151
9

Maternal mortality ratio (modeled estimate, per 100,000 live births) - Nepal
553
521
520
470
447
415
386
361
342
323
305
285
266
248
231
236
200
186
(Source: Worldbank, 2017)
10

11

12

13

DELIVERY CARE (Status and Trends)
14

(Source: National Joint Annual Review 2078/79 (2021/22))
15

(Source: NDHS 1996-2022)
Trends in Institutional Deliveries and Home Deliveries, 1996-2022
16

Trend of Deliveries by Caesarean Section, 1996-2019
(Source: NDHS 1996-2016; MICS 2014, 2019)
17

Trend of Antenatal Care, 2001-2022
18

Status of Antenatal Care, MICS 2019
(Source: MICS 2019)
19

Trend of Postnatal Care Check during first 2 days after birth, 2001-
2022
(Source: NDHS 2001-2022; MICS 2014, 2019)
20

Trend of Abortion, 2001-2016
According to NDHS
2016, only 48% of
women know a safe
place for abortion!!!
21

Trend of Teenage/Adolescent Pregnancy, 1996-2022
22

OBSTETRIC TRANSITION
Stages Features
Stage I MMR >1,000 maternal deaths/100,000 live births
Stage II MMR 999–300 maternal deaths/100,000 live births
Stage III MMR 299–50 maternal deaths/100,000 live births
Stage IV (MMR <50 maternal deaths/100,000 live births
Nepal is at Stage III of the obstetric transition, which is characterised by better
availability of care, but still with high maternal mortality due to direct causes
(Source: NEPAL SAFE MOTHERHOOD AND NEWBORN HEALTH ROAD MAP 2030)
23

24
Policies, strategies
and guidelines: a
snapshot

National Health Policy
National Health Policy
identified safe
motherhood as priority
program
Primary health
care outreach
clinics
introduced
Safe Motherhood
Plan of Action
(1994-97)
National Maternity
Care Guidelines
defines care to be
provided at different
levels of health
facility
National Safe
Motherhood Plan
(2002-2017)
Abortion
legalised
Safe
abortion
services
introduced
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
Second long
term health plan
Skilled Birth Attendants Policy
introduces task-shifting with
MBBS doctors trained to perform
caesarean sections and
nurses and health assistants
trained as anaesthesia assistants
Maternity Incentive
Scheme
introduces financial
incentive to pregnant
women to cover transport
costs of travelling to a
health facility
Safe Delivery Incentive
Programme added incentives
for health workers to provide
care for institutional and home
deliveries, and free institutional
delivery care in 25 low
performing districts
Aama Programme
includes ANC4 and
transport incentives,
health worker
incentives (not for home
births), free delivery
care
Local recruitment
CEONC teams,
staff nurses and
ANMs
Remote Areas
Guidelines for
Safer
Motherhood
Scale-up of
misoprostol
distribution through
FCHVs
Revised National
Blood Transfusion
Policy
referral funds to
district hospitals
where CEONC
services are not
available
Birth preparedness
package distributed
through FCHVs
Calcium during
ANC piloted
MDG
Goal 5:
Improve
Maternal
Health
SDG
Source:Safe Motherhood and Neonatal Health
(SMNH) Roadmap 2030
25
5/15/2023

26
(Source: Strategy for Skilled Health Personnel and SBA (2020-2025))
5/15/2023

27
Maternal Health
Policies and
Strategies of Nepal

Safe Motherhood Policy-1998
Policy Objective
To reduce mortality and morbidity among
women during pregnancy, childbirth and
the postnatal period through the adoption
of a combination of health and health
related measures.
28

Strategies
1. Promoting intersectoral collaboration in order to attain the aims of safe
motherhood
2. Strengthening and expanding basic maternity care services, including family
planning, at all institutional levels
3. Raising the status of women so that maternal morbidity and mortality will be
reduced
4. Promoting research on safe motherhood
Source: Safe Motherhood Policy-1998
29

Maternity care at various level of Health Care Delivery System
1. Maternity care at family level
2. Maternity care at community level
3. Maternity care at health post level
4. Maternity care at PHC centers
5. Maternity care at District/ Zonal/ Center level
Referral System
30
Source: Safe Motherhood Policy-1998

National Safe Motherhood Plan
(2002-2017)
National Safe Motherhood Plan was developed with a
long term vision to scale up the coverage of
maternal and newborn health care at all levels of
health care delivery system
31

Contd…
❏ Globally, awareness of the issue of maternal mortality began in 1987 at the Safe
Motherhood Conference in Nairobi; Commitment to strive for reducing the
mortality and morbidity related to pregnancy and childbirth was obtained.
❏ This commitment was reinforced in the ICPD conference held in Cairo in 1994: to
reduce maternal mortality and morbidity by at least 50 percent by the turn of the
century, Safe Motherhood (SM) was recognized as one of the key components of
reproductive health.
Source: National Safe Motherhood Plan (2002-2017)
32

Rationale for the 15-year Plan
❏ The past strategies of carrying out the Family Planning / Maternal and Child
Health in an integrated manner, promoting attendance of birth through the TBA
and promoting ANC visits were not adequate in addressing the issues of reducing
maternal deaths.
❏ Experience also showed that avoidance of the three delays was imperative to
achieve the goal of reduction of maternal mortality.
❏ Maternal Mortality and Morbidity Study (MMMS) in 1996- maternal deaths to be 71
% by direct causes (post partum haemorrhage, obstructed labour, eclampsia,
puerperal sepsis and abortion) and 29% by indirect causes.
33

Contd..
❏ 90% of the deliveries occurring at home, most of the deaths occur in the
community (79%) and only 21% in the health institution.
❏ Antenatal coverage is low and since most deliveries occur outside a health
institution and only 10 % of the deliveries are attended by a trained personnel
(most being attended by friends and relatives) most deaths take place during the
postpartum period (62%)
❏ Needs Assessment done in 2000 (UNICEF) showed an overwhelming unmet
need for basic essential obstetric care services.
34

Plan Format
❏ In the context of the situation highlighted above the Ministry of Health’s current strategy is to
increase access to services through establishment of basic and comprehensive essential
obstetric care and skilled attendance through trained Maternal and Child Health Workers (MCHW)
at the community level.
❏ In order to overcome delay in reaching care the government advocated for community
mobilization for transport arrangement and is also trying to empower community, families and
women both economically and socially to access care.
❏ IEC is an important aspect of the Safe Motherhood program to recognize the danger signs and
facilitate to take appropriate decision to seek care on time when problem arises.
❏ Ensuring quality of basic and comprehensive essential obstetric care services avoids the third
delay.
35

National safe motherhood and newborn health long
term plan 2006-2017
Goal: Improved maternal and neonatal health and
survival, especially of the poor and excluded.
The key indicators for this NSMNH-LTP goal are:
1. A reduction in the maternal mortality ratio from 539
per 100,000 live births to 134 per 100,000 by 2017.
2. A reduction in the neonatal mortality ratio from 39
per 1,000 to 15 per 1,000 by 2017.
36

1. Equity and access
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
37
Increased healthy practices, and utilisation of quality maternal and neonatal
health services, especially by the poor and excluded, delivered by a well-
managed health sector.
Outputs: Eight outputs are specified in the plan, each with individual indicators.

National Reproductive
Health Strategy 1998
Includes safe motherhood in the
integrated RH care package
38

National Reproductive Health Strategy 1998
❏ National reproductive health strategy seeks to strengthen the existing Safe
motherhood, Family Planning, HIV/ AIDS, STD, Child Survival and Nutrition
programmes with a holistic life cycle approach.
❏ This calls for strengthening inter-divisional linkages within the DoHS and other
sectors e.g. education, women and development and legal justice system.
❏ National Reproductive Health Strategy fits within the context of 1991 health policy
as well as the 1997-2017 second long term plan.
Source: National Reproductive Health Strategy 1998
39

Integrated Reproductive Health Package
The integrated RH
package will be delivered
through existing Primary
Health Care system.
● Family Planning
● Safe Motherhood
● Child health (newborn care)
● Prevention and management of complications of
abortion
● RTI/ STD/ HIV/ AIDS
● Prevention and management of subfertility
● Adolescent reproductive health and
● Problems of elderly women i.e. uterine, cervical and
breast cancer treatment at the tertiary level or in the
private sector Source: National Reproductive Health Strategy 1998
40

National Safe abortion policy 2003
❖ Eleventh amendment in civil act on 2058 BC. Verified on 11th Aashoj 2059.
❖ Before the 11th amendment was passed. The MULUKI AIN had the provision of punishing
women for abortion. The provision was jail punishment of 1year, 3 years or 5 years for
committing abortion with pregnancy of 12 weeks, 25 weeks and beyond 25 weeks
respectively
(National safe abortion policy,final draft, August 7, 2003)
41

42
(National safe abortion policy,final draft, August 7, 2003)

Basis for the development of Safe Abortion Policy:
In response to advocacy efforts that emphasized the high rates of maternal morbidity
and mortality attributed to unsafe abortion
Studies published between 1982 to 2002 showed that at least one-fifth of women in
prison had been convicted for illegal abortion
Even in the urban areas many abortion service providers were untrained and as high
as 50% of all maternal deaths in the study hospitals were due to abortion-related
complications
Source: Abortion care in Nepal, 15 years after legalization, Abortion law in Nepal: The Road to Reform
43

National policy on SBA 2006
During the time of policy formation only 13% of the
delivery were attended by health worker and not
all of these workers were qualified as skilled birth
attendant.
As a signatory to the MDG, Nepal had to reach
the target of 60 % of delivery attended by SBA by
2015.
Need of policy that guide to achieve MDG target
considering challenges related to HRD, socio-
economic and cultural barriers, high unmet need
for obstetric care, and weak referral back-up.
Source: National policy on SBA
44

National policy on SBA 2006
MMR 539/100000
NMR 39/1000
largely due to the lack of skilled attendance at birth, as well as poor referral systems and lack of
access to life-saving emergency obstetric care when complications occur.
This will require 24 hours a day and 7 days a week, “women-friendly” services that are culturally
sensitive and affordable to all families, especially those in poor and underserved areas. However,
high financial cost has been identified as a major barrier to women accessing skilled birth
attendance and health facilities for emergency obstetric care in Nepal.
January 2005 the Government of Nepal introduced the maternity cost sharing scheme
45
Source: National policy on SBA

Skilled Birth Attendant
“An accredited health professional-such as a midwife, doctor or nurse-who has
been educated and trained to proficiency in the skills needed to manage normal
(uncomplicated) pregnancies, childbirth and the postnatal period and in the
identification, management and referral of complications in women and
newborns.”
Elements of SBA policy
Strength maternity care
Strength the technical capacity
Human resource management
46

Skill requirements for SBA
❖ Twenty seven basic skills which are core for SBA
❖ Six additional skills for advanced SBA.
1. Perform Forceps delivery
2. Perform Cesareans sections
3. Perform Laparotomy
4. Perform Hysterectomy
5. Provide anaesthesia-local, spinal and general
6. Provide blood transfusion.
47

Strategies of SBA Policy
1. Human resources development
a. Short term( in services measures)
i. Staff nurse / ANM
ii. Doctors
b. Medium term
c. long term ( pre service measures)
48

2. Strengthening SBA Training Sites
3. Deployment and Retention of SBAs
4. Service Provision
5. Enabling Environment
6. Role of Professional organisations/association
7. Role of non-government sector and private sector
8. Institutional Arrangements
49
Strategies of SBA Policy

The Right to Safe Motherhood and Reproductive Health Act, 2075
(2018)
An Act Made to Provide for the Right to Safe Motherhood
and Reproductive Health.
It aims to ensure women's access to safe and legal
abortion, family planning services, and reproductive health
care.
The act also recognizes the right of every person to make
decisions regarding their reproductive health without any
discrimination.
Areas covered:
Right to Reproductive Health
Safe Motherhood and Newborn Baby
Safe Abortion
Right to obtain morbidity care
Provide disability friendly service
(Source: Right to safe motherhood and reproductive health Act -2018)
5/15/2023 50

Safe Motherhood and Newborn Baby
● Right to get obstetric service
● To provide obstetric care
● Emergency obstetric and newborn care
● Health care of newborn baby
● To maintain record of the births of infants
● Right to obtain family planning service
● Not to get family planning performed forcefully
● Right to obstetric leave
5/15/2023 51

Safe Abortion:
● To perform safe
abortion:
● Not to get abortion
conducted forcefully
● Not to commit abortion
upon identifying sex
● Safe abortion service
● To maintain
confidentiality
5/15/2023 52

Part-3- Fundamental Rights and Duties
35. Right relating to health:
(1) Right to free basic health services from the State, and no one shall be deprived
of emergency health services.
(2) Right to get information about his or her medical treatment.
(3) Every citizen shall have equal access to health services.
(4) the right of access to clean drinking water and sanitation.
Article 38: Right of Women:
○ Every woman shall have equal right to lineage without any gender
discrimination
○ Every woman shall have the right relating to safe motherhood and
reproductive health
○ There shall not be any physical, mental, sexual or psychological
or any other kind of violence against women, or any kind of
oppression based on religious, social and cultural tradition, and other
practices. Such an act shall be punishable by law and the victim shall
have the right to be compensation as provided for in law
Constitution of Nepal:(2015)
(Source: Constitution of Nepal -2015)
5/15/2023 53

○ It is expedient to make necessary legal provisions for implementing the
right to get free basic health service and emergency health service
guaranteed by the Constitution of Nepal.
● Chapter 2: Rights, Duties of Service Recipients and Responsibilities of
Health Institutions
○ 3: Access to and certainty of health service:
■ 4: Every citizen shall have the right to obtain free basic health
services under the following headings, as prescribed:
● (a) Vaccination service
● (b) Motherhood, infant and pediatric health service such as
integrated infant and pediatric disease management, nutrition
service, pregnancy, labor and childbirth service, family planning,
abortion and reproductive health
The Public Health Service Act, 2075 (2018)
(Source: Constitution of Public health service act -2018)
5/15/2023 54
The Public Health Service Act, 2075 (2018)

National Health Policy 2019
●Vision
■ Healthy, alert and conscious citizens oriented to happy life
Mission
■ To ensure fundamental health rights of citizens through
optimum and effective use of resources, collaboration and
participations
Goal
○ To develop and expand a health system for all citizens in
the federal structure based on social justice and good
governance and ensure access to and utilization of quality
health services
(Source: National Health Policy -2019)
5/15/2023 55

National Health Policy 2019
●Objectives
∙ To create opportunities for all citizens to use their constitutional rights to health.
∙ To develop, expand and improve all types of health systems as per the federal
structure.
∙ To improve the quality of health services delivered by health institutions of all levels
and to ensure easy access to those services.
∙ To strengthen social health protection system by integrating the most marginalised
sections.
∙ To promote multi-sectoral partnership and collaboration between governmental,
non-governmental and private sectors and to promote community involvement.
∙ To transform the health sector from profit-orientation to service-orientation.
5/15/2023 56

Policy 6.20
● 6.20 In accordance with the concept of health across the lifecycle,
health services around safe motherhood, child health,
adolescence and reproductive health, adult and senior citizen
shall be developed and expanded.
■ 6.20.1. Safe motherhood and reproductive health services
shall be made of good quality,affordable and accessible.
■ 6.20.2. Health services targeted to vulnerable age groups
such as maternal-infant health, child health, adolescent health,
adult health and geriatric health shall be strengthened and
professional midwifery and nursing services shall be
expanded.
5/15/2023 57

Policy 6.20
● 6.20.3. In view of social determinants that affect women's health,
special programs shall be implemented in coordination with concerned
stakeholders.
● 6.20.4. In order to strengthen safer motherhood and reproductive
health, skilled birth attendants shall be arranged in all wards.
● 6.20.5. Abortion services shall be made qualitative and effective as
per the law.
● 6.20.6. Health services related with infertility shall be gradually
extended to the state levels.
5/15/2023 58

Second long-term Health Plan(1997-2017)
Goal
The health status of the Nepalese population will be improved through the healthcare
system, which provides equitable access to quality health care for all people.
Targets on maternal health
★ Maternal Mortality Ratio will be reduced to 250 per hundred thousand births from its
present level of 475
★ Contraceptive Prevalence Rate will be increased to 58.2 percent from its present level
of 30.1
★ Percentage of deliveries attended by trained personnel will be increased to 95% from
its present level of 31.5
Source: MoHP G. Second Long Term Health Plan 1997-2017. Kathmandu: Ministry of Health and Population, Government of Nepal. 1997
59

Policy statement on safe abortion
❖ Comprehensive abortion care services (CAC)
❖ Human resources development
❖ Right of women
❖ Role of non government and private sector
❖ Advocacy, IEC and social mobilization
❖ Coordination , monitoring , planning, supervision and follow up
❖ Research
❖ Institutional arrangements
60

National communication strategy for Maternal
Neonatal and Child health 2011-2016
GOAL AND OBJECTIVE
The goal of the safe motherhood and newborn health (SMNH)
programme is improved maternal and neonatal health and survival,
especially of the poor and excluded
COMMUNICATION GOAL
The goal of the SMN communication is to contribute to increasing
access to and utilization of improved maternal and newborn health
information and quality services.
61

Communication Objectives:
❖ Increase positive attitude and behaviour of health workers and FCHVs that
pregnancy, delivery and postnatal are special times for fast action to save the
lives of mothers and newborns.
❖ Increase mobilization of community resources to support birth preparedness,
EOC and maternal and newborn care and referral services.
❖ Increase ability of community to identify facilities forinstitutional delivery and EOC
and skilled birth attendants.
❖ Improve interpersonal communication skills of service providers and FCHVs.
❖ Improve home based nutrition for pregnantwomen and adolescent.
62

❖ Increase knowledge and desired behaviour of community to recognize and
act on maternal and newborn danger signs. .
❖ Increase support for creation of an enabling environment for women’s rights, to
improve women’s status, birth preparedness discrimination caused by
gender and caste/ethnicity, regional identity, income status
and location and reduced ‘laaj’ among women.
❖ Increase knowledge about prevention of unwanted pregnancy and safe abortion
services.
63
Communication Objectives:

National Blood Transfusion Policy-2014
● Vision:
○ Every individual could get safe and enough blood product when needed.
● Mission:
○ To develop blood transfusion service as per the international level by using
maximum available resources and coordination between regulating
authority, service providers, donors, receivers and concerned stakeholders.
● Goal:
○ To provide safe and quality blood and blood products for all the citizen of
Nepal whenever needed in easy and convenient way.
● Objective:
○ To prepare organizational financial and legal aspects for blood collection
from Voluntary Non-Remunerated blood donation and distribute to needy ones.
(Source: National Blood Transfusion Policy-2014)
5/15/2023 64

National Blood Transfusion Policy
(Strategies:)
● Follow the GLP( Good Laboratory Practice) during the testing
, GMP(Good Manufacturing practice) for processing and
GCP(Good clinical Practice) for use blood products to
prevent the TTI (Transfusion Transmissible illness)
● To promote safe and appropriate use of blood and blood
products in clinical practice
● To develop good management systems
● To develop the national information system
● To help and co-operate with national and international
stakeholders.
(Source: National Blood Transfusion Policy-2014)
5/15/2023 65

National Population Policy 2014
● Vision:
○ Every individual has increased opportunity to improve Quality Of Life.
● Mission:
○ Enhancing people's lives by addressing population issues, development of
population, guaranteeing people's reproductive well-being and
reproductive rights as crucial human rights and promoting equity and
incorporation in all sustainable development strategies
● Goal:
○ Integrating the population issues with development in order to improve the
quality of life of the people , assuring the reproductive rights and maintaining
the gender equity and social inclusion.
○ To set the targets for sustainable Development Goals for next 20 years after
implementation of the policy for 2090 BS(2034). (Source: National Population Policy 2014)
5/15/2023 66

Strategy 2:
Develop reproductive health services including sexual health,
family planning and safe abortion as a rightful program.
○ Increase the accessibility of safe sexual and reproductive health by developing
as basic rights
○ Provide information on family planning devices and its utilization.
○ Fulfill the unmet demand of family planning
○ Ensure safe abortion and post abortion services and free of cost for women of
poor and disadvantages group
○ ANC checkup for the improvement in health of mother and child.
○ Special programs for the protection of disadvantages group such as Raute,
Kusunda, Chepang, Rajbanshi, Chamr, Musahar, Baadi, Raaji, etc.
○ Encourage the marriage only after the age of 20 and birthing procedure only after
being capable in terms of psychological, social and economical.
(Source: National Population Policy 2014)
5/15/2023 67

2. Develop reproductive health services…(Cont...)
● Conduction of and appropriate birth spacing program related to
IEC(information Education and Communication) and BCC aiming
to increase age at marriage .
● Addressing the problem of fertility and subfertility as per the demand
of people.
● Ensure the accessibility of reproductive health and sex education in
a comfortable environment for men, women and third gender, and
adolescents and youths.
● Advocacy and discussion program to prevent adolescents from drug
abuse and sexual abuse
● Expansion of maternal health centered health services to reduce
maternal mortality.
(Source: National Population Policy 2014)
5/15/2023 68

National HRH(Human Resource for Health) Strategy:
● Based on the Global Strategy on
Human Resources for Health:
Workforce 2030
● Guiding principles:
○ Trend of Morbidity and Mortality Rate
○ Prioritize Basic Health Services
○ Universal access to quality healthcare
○ Distribution of health manpower
according to population density and
workload.
○ Skill Blending Concept
(Source: National HRH strategy- 2078 BS)
5/15/2023 69

National HRH(Human Resource for Health) Strategy:
● Vision:
○ Availability and equitable distribution of skilled and quality health personnel.
● Mission:
○ Making maximum use of available resources, in collaboration between
stakeholders of production and deployment of skilled health manpower with skills
mixed in accordance with population, geography and federal structure.
● Goal:
○ Establishment, operation of educational for production of health manpower.
○ To guide the central , province and local levels according to the federal system to
manage quality health manpower.
○ To develop and expand health services according to the country's health needs, to
protect people's health, to prevent and treat diseases, to achieve the goals of
sustainable development in accordance with Universal Health Coverage.
5/15/2023 70

Strategies Action:
● Production and development of health
manpower
● Distribution and management of health
manpower
● Managerial leadership and governance of
the health workforce
● Health Workforce Information System
● Coordinate in Brain gain and , contribute to
Nepal program champion
5/15/2023 71

National Guideline on Antenatal to Postnatal Continuum of Care-2076
Goal of Guideline:
Ensure healthy outcome for the mother and her newborn, as well
as a positive experience with the health system and therefore help
to reduce maternal and neonatal mortality.
Guiding Principle:
● Antenatal Care
● Quality of Care
● Women and Newborn centered care and Informed Decision
making
● Use of standard precautions for Infection Prevention and
Control
Source: National Guideline on Antenatal to Postnatal Continuum of Care-2076
5/15/2023 72

ANC Model for NEPAL
Existing Government of Nepal
ANC model
2016 WHO ANC model ANC model proposed by the Government of
Nepal
Four focused ANC visits Eight ANC contacts Eight ANC contacts
Visit 1: up to 16 weeks Contact 1: up to 12 weeks Contact 1:up to 12 weeks
Visit 2: 24 weeks Contact 2: 20 weeks Contact 2: up to 16 weeks
Visit 3: 32 weeks Contact 3: 26 weeks Contact 3: 20-24 weeks
Visit 4: 36 weeks Contact 4: 30 weeks Contact 4: 28 weeks
Contact 5: 34 weeks Contact 5: 32 weeks
Contact 6: 36 weeks Contact 6 : 34 weeks
Contact 7: 38 weeks Contact 7: 36weeks
Contact 8:40weeks Contact 8: 38-40 weeks
5/15/2023 73

Recommended postnatal contacts based on roadmap 2030 and WHO
recommendations:
PNC check
(for mother &
newborn)
Facility Delivery Home Birth
At 24 hours At facility and integrated into discharge
protocol
Home contact by community nurse
/Midwives as soon as possible but
within 48 hours of birth
3rd day Home contact by Community
Nurse/Midwives
Home contact by Community
Nurse/Midwives
7 – 14 days Home contact by Community Nurse
/Midwives
Home contact by Community
Nurse/Midwives
6 weeks Health facility contact, EPI clinics Health facility contact; EPI clinics
5/15/2023 74

Continuum of care
Federal
Government
Tertiary, Academic
and Super Specialty
Provincial
Government
Secondary Hospitals
Local Government
Primary Hospital, Health
Posts,CHC,ORC,BHCC,
UHC
Appropriate Referral
Counter Referral
Follow-up
Continuum of Care across the woman’s
lifecycle
Women
Centere
d Care
Pre-
Conceptio
n
Pregnan
cy
ANC
Labour
&
Delivery
PNC
Family
Planning ,
Immunizati
on and
nutrition
5/15/2023 75

Strategy for Skilled Health Personnel and SBA (2020-2025)
Vision
● To ensure the fundamental rights of the mother
and baby to live healthy lives, and to achieve
equitable health outcomes.
Goal
● To reduce maternal and newborn morbidity and
mortality through quality health services,
provided by SHP/SBAs working in an enabling
environment.
Source: Strategy for Skilled Health Personnel and SBA (2020-2025)
5/15/2023 76

Strategic
Approaches
• Ensure availability of quality MNH care at service
delivery points including referral services
• Train SHP/SBAs and strengthen post-training support
• Strengthen supervision and monitoring
• Build capacity in leadership, management,
accountability, and governance
• Collaborate for enabling environment
• Institutional Arrangements
National Health Policy (2019) recommends one skilled birth attendant per ward (6.20.4)
The operational guidelines for the Basic Health Service Package recommends birthing centers only at health post that have a catchment
population of 7,000 or above.
The Safe Motherhood and Newborn Health Roadmap 2030, recommends that all women give birth at an existing basic emergency obstetric
and newborn care (BEONC) site or a comprehensive emergency obstetric and newborn care (CEONC) site that is within 2 hours walking
distance, and recommends strategic birthing center for women who are not able to access the CEONC/BEONC easily.
Source: Strategy for Skilled Health Personnel and SBA (2020-2025)
5/15/2023 77

Nepal Safe Motherhood and Newborn Health Roadmap-2019 (2020-2030)
● The Road Map is a national document with key recommendations for
MNH for the first five years.
● It is expected that Provincial and Local Governments will develop
context-specific five-year activity-level plans that are based on the
recommendations of the Road Map.
● The Road Map will be reviewed after five years and, if necessary,
based on results, the recommendations and targets will be adjusted.
● The Road Map’s results framework is consistent with the targets and
indicators of the NHSS, SDGs and the NeNAP.
● An evaluation will take place in 2030, at the end of the Road Map
period, to assess progress and achievements.
Source: Nepal Safe Motherhood and Newborn Health Roadmap-2019 (2020-2030)
5/15/2023 78

● Nepal’s Safe Motherhood and Newborn Health (SMNH) Road Map 2030 is developed
with a focus on ending preventable maternal and newborn deaths, by building on the
successes of the SMNH Programme and addressing the remaining challenges,
especially around strengthening community health system platforms and improving
institutional quality of care in an equitable manner.
● Preventing maternal deaths is inextricably linked to preventing stillbirths and newborn
deaths and the Road Map will build upon activities that are already outlined in NeNAP
(2016–2035).
● The implementation period for the Road Map will be just over 10 years
Source: Nepal Safe Motherhood and Newborn Health Roadmap-2019 (2020-
2030)
5/15/2023 79

2030)
5/15/2023 80

Outcomes and Outputs
• Output 1.1 Reproductive, maternal and newborn health
services are available, and health facilities that comply with
the standards are located in strategically accessible areas,
with functional referral linkages
• Output 1.2 Readiness of health facilities (public and
private) to provide services is ensured
• Output 1.3 An enabling environment is ensured for health
staff to provide high-quality services
Outcome 1:
The availability of
high-quality maternal
and newborn health
services increased,
leaving no one behind
5/15/2023 81

• Output 2.1 Mothers and families have appropriate and accurate
information and knowledge to seek care in a timely manner
• Output 2.2 Health managers have adequate capacity and address
users’ needs
• Output 2.3 More effective and equitable outreach services are
ensured
• Output 2.4 Parliamentarians and locally elected leaders are
empowered to demand adequate investment in maternal and
newborn health
Outcome 2:
The demand for
and utilization of
equitable
maternal and
newborn health
services
increased Source: Nepal Safe Motherhood and Newborn Health Roadmap-2019 (2020-
2030)
82

• Output 3.1 Adequate financing is ensured for maternal and
newborn health services
• Output 3.2 Effective and sustainable partnerships are
ensured for maternal and newborn health services
• Output 3.3 Accountability for maternal and newborn health
services is enhanced at all levels
Outcome 3:
The governance of
maternal and
newborn health
services is
improved, and
accountability is
ensured
2030)
83

• Output 4.1 Monitoring of maternal and newborn health
is improved
• Output 4.2 Evaluation of maternal and newborn health
and health services is planned during the programme
design and is effectively carried out
Outcome 4:
Monitoring and
evaluation of
maternal and
newborn health
improved
2030)
84

• Output 5.1 Preparedness of maternal and newborn
health services to address emergencies is
improved
• Output 5.2 Response to maternal and newborn
health care in emergencies is strengthened
Outcome 5:
Emergency
preparedness
and response for
maternal and
newborn health
strengthened
2030)
85

National Strategy on Nurses and Midwifery 2022
Vision
● Universal Access to quality nursing and midwifery services.
Mission
● Promotion of quality health services and professionalism through
mobilization of quality nursing and midwifery human resources.
Goal
● To fulfill the important role for improving health of every citizen
and strengthening, dignifying, managing & maintaining quality of
nursing and midwifery services thorough federal level inclusive
and equity based health service system.
Source: National Strategy on Nurses and Midwifery
2022
5/15/2023 86

Guiding Principle:
Ensuring quality
nursing and
midwifery
education
Increasing
access of quality
and equity based
health services
Health service
delivery with
honesty &
professionalism
Expansion of
specialized
nursing
education and
services
Partnership
between public
and private
sector
Cooperation and
coordination
according to
country’s
restructured
basis
Source: National Strategy on Nurses and Midwifery
2022
5/15/2023 87

The Cairo Conference,1994
● The International Conference on Population and Development (ICPD)- convened under
the auspices of the United Nations, took place in Cairo, Egypt, September 5-13, 1994.
● It brought together representatives from over 179 governments and 11,000 non-
governmental organizations participants.
● The conference adopted a 20-year Program of Action, which focused on individuals'
needs and rights, rather than on achieving demographic targets.
● Broadened concept of family planning to include reproductive & sexual health.
Source: UNICEF Factsheet, SRHR in
Nepal
5/15/2023 88

1994
ICPD
1999
ICPD +5:
Governme
nt reaffirm
support
2000
Millenni
um
Summit
Declarat
ion
2009
ICPD
+15
201
9
ICP
D
+25
2004
ICPD
+10
2005
World
Summi
t
ICPD Commitment timeline
Nepal
5/15/2023 89

ICPD Goals
Raise the quality of
life and the well-
being
Promote human
development
Recognizing
population and
development
policies link
Achieve poverty
eradication
Sustained
economic growth
in the context of
sustainable
development
The guarantee of
all human rights,
including
reproductive
right
Nepal
5/15/2023 90

Recommitment to the ICPD Programme of Action at the Nairobi Summit on
ICPD 25, 2019
Achieve the three zeros:
a. Zero unmet need for family planning
b. Zero preventable maternal death
c. Zero gender based violence and harmful practices, including child marriage
Ensure young people can exercise their SRHR by expanding adolescent-friendly services and comprehensive
sexuality education (CSE)
Ensure that the basic humanitarian needs of affected populations, including sexual and reproductive health care
and gender-based violence prevention and response services, are addressed in humanitarian contexts
Put in place financing policies, instruments and structures to ensure the full implementation of the ICPD
Programme of Action and the 2030 Agenda and Sustainable Development Goals (SDGs)
Source: UNICEF Factsheet, SRHR in Nepal
5/15/2023 91

What’s changed in Nepal since the Cairo Conference
The maternal mortality ratio has come down from 539 (1996) to 151 (2022)
The births attended by skilled health personnel has gone up from 10% (1996) to 80% (2022)
The total fertility rate has decreased from 4.6 (1996) to 2.1 (2022)
The adolescent fertility rate has decreased from 127 (1996) to 71 (2022)
The modern contraceptive prevalence rate has gone up from 26.0% (1996) to 43.0% (2022)
Unmet need for family planning has slightly dropped from 24.6% (2006) to 21% (2022)
Source: 25 Years of the ICPD- Accelerating the Promise,
5/15/2023 92

Unfinished Business
● In Nepal, 151 mothers die for every 100,000 births. Many more suffer from injuries and
chronic disability incurred during childbirth. This is long way from the global target set
in 1994 to reduce maternal deaths to fewer than 75 per 100,000 live births, and the
Agenda 2030 target of 70.
● About 1.5 million currently married women in Nepal who would like to control their own
fertility still do not have access to modern contraceptives. Without this access, they
lack the power to make decisions about their own bodies, including whether or when
to become pregnant. The lack of this power—which influences so many other facets of
life: education, income, safety—leaves women and girls unable to shape their own
futures.
● Still 22 per cent of women in Nepal age 15-49 have experienced physical violence
since age 15 and 7 per cent have ever experienced sexual violence.
Source: 25 Years of the ICPD- Accelerating the Promise, UNICEF
5/15/2023 93

Beijing Conference
The United Nations has organized four world conferences on women. These took place in Mexico
City (1) in 1975, Copenhagen (2) in 1980, Nairobi (3) in 1985 and Beijing (4) in 1995.
The United nation’s fourth world conference on Women held in Beijing, China September 4-15, 1995.
Largest and most influential of all the World Conference on Women
Prepared a Platform for Action that aimed at achieving greater equality and opportunity for women.
The official name of the Conference was "The Fourth World Conference on Women: Action for
Equality, Development and Peace“
The Conference was participated by 189 Governments/countries.
Source: Beijing Declaration, IOM
Lecture
5/15/2023 94

Beijing Conference: Critical Areas of Concern
Source:
https://archive.unescwa.org/our-work/beijing-declaration-and-platform-action
5/15/2023 95

Nepal’s Commitment to the Beijing POA
Nepal’s
Commitment
To revitalize women as an integral group and redesign
mainstreaming programmes with life cycle perspective
To reform laws discriminatory to women
To incorporate women’s needs and concerns in poverty
reduction programmes
To broaden the coverage of PHC facilities and
strengthening MCH services
To achieve universal literacy and increase women access
to education
To encourage and assist NGO work with CBO for advocacy,
institution building and the delivery of services to women
Source:
Beijing
Declaration,
IOM
Lecture
5/15/2023 96

After Beijing Declaration
The
Ministry
of
Women
and
Social
Welfare
was
formed.
The
National
Work
Plan for
Gender
Equity
and
Women’
s
Empowe
rment
(1997)
was
formulat
ed.
Govern
ment
has
gender
focal
point in
all
governm
ent
agencies
.
Rights of
inheritan
ce to
propert
y
between
son and
daughte
r
In 2002
Nepal’s
parliame
nt
passed
a liberal
abortion
law
Human
Rights
Commis
sion Act
of 1996
establish
ed a
National
Human
Rights
Commis
sion –
woman’s
right to
protectio
n,
develop
ment,
participa
tion and
survival
Ninth
Plan(199
7-2002)
have
included
a
Women
and
Gender
Equality
Policy
National
Policy
on
Family
Planning
, 1997
National
Reprodu
ctive
Health
Strategy,
1998
Safe
Motherh
ood
Policy,1
998
MDGs-
Goal 3
and 5
National
Adolesc
ent
Health
and
Develop
ment
Strategy,
2000
Source: Beijing Declaration, IOM
5/15/2023 97

Millennium Development Goals (2000-2015)
Nepal’s achievement of the MDG targets, 1990–2015
Source: Nepal and MDG; Final Report 2000-2015, NPC, 2016
5/15/2023 98

Sustainable Development Goals (SDG)
Source: SDG Status and Roadmap-2016-2030, NPC
5/15/2023 99

Source: SDG Status and Roadmap-2016-2030, NPC
100

Impacts of COVID-19 on Maternal Health
Source: 25 Years of the ICPD- Accelerating the Promise, UNICEF 101

FCHV Program
Goal
To Improve the health of local community peoples by promoting public
health. This includes imparting knowledge and skills for empowering
women, increasing awareness on health related issues and involving local
institutions in promoting health care.
Source: Annual Report Department of Health Services 2077/78 (2020/21)
102

❏ GoN initiated the FCHV Programme in 2045/46 (1988/1989) In 27 districts and
expanded it to all 77 districts thereafter.
❏ The major role of FCHVs is to advocate healthy behaviour among mothers and
community people to promote safe motherhood, child health, for family planning
and other community-based health issues and service delivery.
❏ FCHVs’ role had been highly acknowledged by the GoN in achieving milestones of
Millenium Development Goal 4 and 5 and expected the same in the era of
Sustainable Development Goal by 2030 through contextual modification.
103

PHC-ORC Program
Objective : To bring health services closer to the communities.
PHC-ORC was initiated in 1994 (2051 BS)
Aim of these clinics is to improve access to basic health services including family
planning, child health and safe motherhood. These clinics are service extension sites of
PHCs and HPs.
Based on local needs, these clinics are conducted every month at fixed locations, dates and
times. They are conducted within half an hour's walking distance for their catchment
populations. ANMs/AHWs provide the basic primary health care services
104

Services to be provided by PHC-ORCs on maternal health
Safe motherhood
- ANC, PNC
- Iron supplement distribution
- Referral if danger signs identified
Family planning:
● DMPA (Depo-Provera) pills and condoms
● Monitoring of continuous use
● Education and counselling on family planning methods and emergency contraception
● Counselling and referral for IUCDs, implants and VSC services
● Tracing defaulters
Health education and counselling
105

106
Current Maternal
Health Programs
and Activities of
Nepal

National Safe
Motherhood
Programme
107

National Safe Motherhood Programme(I)
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
To reduce maternal and
neonatal morbidity and
mortality
Goal
108
Source: DOHS Annual Report FY 2077/78

Evidence suggests that three delays are important factors for maternal and
newborn morbidity and mortality in Nepal:
3 Delay Behind Maternal Morbidity and Mortality(II)
1. Delays in
seeking care
2. Delays in
reaching care
3. Delays in
receiving care
109

Strategies(III)
Promoting inter-sectoral coordination and collaboration at all levels with a focus on poor and
excluded groups.
Strengthening and expanding delivery by SBA and providing BEONC,CEONC services at all
levels.
Strengthening community-based awareness on the birth preparedness and complication
readiness through FCHVs and increasing access to information
Supporting activities that raise the status of women in society.
Promoting research on safe motherhood to contribute to improved planning and more cost
effectiveness interventions.
110

Components and
Activities of Safe
Motherhood
Programme
111

1. Community level maternal and newborn health interventions
Birth preparedness and complication
readiness(preparedness for money,
place for delivery, transport and blood
donors)
ANC, institutional delivery and PNC
(IFA,TD, Albendazole,Vitamin-A)
Identification of and timely care
seeking for danger signs in the
pregnancy, delivery, postpartum and
newborn periods
Self-care (food,rest,no smoking and no
alcohol)
Distribution of Matri-Suraksha Chakki
(misoprostol) to prevent PPH in home
deliveries
Essential newborn care
112

2. SMNH Programme during COVID 19 Pandemic situation
Management of PPH
Prevention
Orientation
programme
❑ Provided PPH orientation to service providers in 22 hospitals of Lumbini and
Karnali.
❑ 312 doctors/nurses received virtual orientation on PPH (estimation of blood
loss, prevention of PPH and management and treatment of PPH (Uterotonic
drugs, management of trauma, retained placenta/tissue, Condom Balloon
Tamponade, Bimanual uterine compression, and Peripartum Hysterectomy)
RMNCAH Interim
Guideline
Orientation
Programme
❑ FWD led development of RMNCAH interim guideline and orientation to health
workers to ensure continuation of SMNH and RH services during the national
crisis situation.
❑ More than 14,500 Health workers working at the community level including
hospitals received virtual and face to face orientation about interim guideline
with support of various partners (NHSSP, OHW, UNFPA, SSBH, UNICEF, Care,
Ipas, Su-aahara).
Virtual SBA clinical
mentors’ refresher
❑ FWD adopted a virtual methodology to continue delivering the capacity building
initiatives and a total of 182 SBA clinical Mentors from all 7 provinces were
involved and received Virtual SBA clinical mentors’ refresher.
113

▪ Expected to contribute in reducing maternal
and neonatal deaths by identifying early
complications during pregnancy,delivery and
postpartum period.
▪ Trained SBA scan clients at rural PHCCs
and HPs using portable ultrasound.
▪ Detected abnormalities such as abnormal
lies and presentation of the foetus and
placenta previa are referred to a CEONC site
▪ Programme implemented in the remote
districts
3. Rural Ultrasound Programme(I)
1.Ultrasound Training to Staff Nurses working in rural health facilities of Lumbini Province [Internet]. FAIRMED. 2021 [cited 2023 May 10]. Available from: https://www.fairmed.org.np/news/ultrasound-
training-to-staff-nurses-working-in-rural-health-facilities-of-lumbini-province
2. Annual Report of DOHS 2077/2078
Aims for timely identification of pregnant women with risks of obstetric
complication to refer to CEONC
114

▪ 21 days Rural Ultrasound Training to Nurses
and midwives of rural HF and equipped with a
digital, semi portable ultrasound for scanning.
▪ FWD allocated programme implementation
budget in 248 local levels of 30 remote districts
in 2077/78.
▪ The total programme implementation districts
are 11 in Province 1, Myagdi and Baglung in
Gandaki, East Rukum in Lumbini, 9 districts in
Karnali and 7 districts in Sudurpaschim
Province.
3. Rural Ultrasound Programme(II)
115
1.Ultrasound Training to Staff Nurses working in rural health facilities of Lumbini Province [Internet]. FAIRMED. 2021 [cited 2023 May 10]. Available from: https://www.fairmed.org.np/news/ultrasound-
training-to-staff-nurses-working-in-rural-health-facilities-of-lumbini-province

▪ FWDs goes for continuous budget allocation and
recruiting human resources (Doctors, staff nurses,
ANMs) on short term contracts to ensure 24 hours
services on MNH at PHCCs and HPs
▪ 714 Palikas received budget for recruiting ANM
staffs, and 38 hospitals received budget for
recruiting Staff Nurses.
▪ Provide CEONC funds to 40 hospital/CEONC sites
to recruit the human resource mix needed to
provide surgical management for obstetric
complications at district hospitals (CEONC sites)
and 7 overcrowding hospitals for recruiting
Gynaecologist, Paediatrician, Anaesthesiologist
and Anesthesia Assistant.
4. Human Resources
116

4. Human Resources
▪ Coordinating with NHTC and NAMS for pre-service and in-service training of health workers.
▪ NHTC provides training on SBA, ASBA, Anaesthesia assistant, operating theatre
management, FP (including implants and IUCD), CAC and antenatal ultrasonography.
▪ Total 1208 SBA and 44 ASBA were trained by NHTC and PHTC in the Provinces and till end
of 2077/78 -11596-SBA ,278-ASBA trained
▪ The proper placement of trained staff such as ASBAs and anaesthesia assistants (AAs) has
been a continuous challenge.
▪ FWD continues to monitor the deployment of doctors (MDGP, OBGYN, ASBA) and AAs, and
inform DOHS and MOHP as necessary for appropriate transfer which improved functionality of
CEONC services.
117

● Expansion of 24/7 service delivery sites like birthing centers, BEONC and CEONC
sites at PHCCs, HPs 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 2077/78 CEONC services were established in 72 districts among
which 71 districts were functional throughout the year except 1 district
(Ramechhap).
● During the fiscal year, 7 (Taplejung, Solukhumbu, Gorkha, Tanahu, Dailekh,
Jajarkot, and Rukum) districts provided interrupted C-section services.
● Expansion of delivery services continues through the initiation of local government.
● Total 2236 health posts and 188 PHCC were reported to have provided (at least
one) delivery service in 2077/78.
5. Expansion and quality improvement of service delivery sites
118

6. MNH readiness Hospital and BC/BEONC Quality Improvement(I)
Improvement in quality-of-service delivery
through self-assessment, infection prevention
demonstration and action plan implementation
Evidence based effective program found in
piloting districts in 2070/2071.
Objective
119

● Expanded MNH readiness hospital quality improvement process (HQIP) gradually from
FY 2072/73
● Till 2077/78 HQIP/QIP programme expanded in 67 hospitals and PHCC with CEONC
services in 63 districts
● Since FY 2076/77, HQIP process was integrated with the onsite coaching and
mentoring process at hospitals
● The process of quality improvement is also being implemented in birthing centres in
integration with SBA onsite clinical coaching/mentoring process
● Till FY 2077/078, total QI reported BC/BEONC sites were 824
6. MNH readiness Hospital and BC/BEONC Quality Improvement(II)
120

• 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.
Objective
7. Emergency Referral Funds(I)
121
5/15/2023

●Family Welfare Division allocated emergency referral
funds to 53 hospitals of 52 districts in FY 2077/78 from
across the 7 provinces.
●A total of Rs. 6,700,000 was allocated to 53 hospitals to
support women when referral needed.
●Additional about Rs. 60,000 in each palika was allocated
for the BC and BEONC service sites to support transport
fares women who could not afford referral to high facility
(nearby CEONC facilities).
7. Emergency Referral Funds(II)
122
5/15/2023

8. Presidential Women Uplifting Programme(I)
A PROGRESSIVE JOURNEY TO GENDER EQUALITY AND WOMEN’S EMPOWERMENT ACHIEVEMENTS OF NEPAL Government of Nepal Ministry of Women, Children and Senior
Citizen Singhadurbar, Kathmandu [Internet]. [cited 2023 May 10]. Available from: https://mowcsc.gov.np/downloadfiles/0Cz7iCOxqikIdQNpREjhO2pbqXiIaQlz4BhM5scc-1625557539.pdf
⮚ The President Women Upliftment Program (PWUP) was launched in 8 March 2017 as a flagship
program to meaningfully transform the life of disadvantaged, poor and marginalized women
implemented by Ministry of Women, Children and Senior Citizens.
⮚ The program has various components under three clusters of activities.
I
-Focuses on livelihood improvement, employment generation and entrepreneurship
Cluster-I
II -Focuses on social awareness
Cluster-II
III -Focuses on activities such as heli-rescue of pregnant and lactating women,
grants for rehabilitation for children with disabilities , adolescent girls and women.
Cluster-III
123

▪ Helicopter lifting is one of major activities
of President Women’s Upliftment
Programme
▪ Heli-lifting of women at high risk pregnancy
and during delivery is becoming popular
initiative due to immediate life saving
impact.
▪ Program covers 34 districts, which stand
low in comparable HDI
▪ Being a 24/7 services, it is widely
acknowledged as a responsible step of
State towards its citizen.
8. Presidential Women Uplifting-Airlifting Programme(II)
Source: A PROGRESSIVE JOURNEY TO GENDER EQUALITY AND WOMEN’S EMPOWERMENT ACHIEVEMENTS OF NEPAL Government of Nepal Ministry of Women, Children and Senior
Citizen Singhadurbar, Kathmandu [Internet]. [cited 2023 May 10]. Available from: https://mowcsc.gov.np/downloadfiles/0Cz7iCOxqikIdQNpREjhO2pbqXiIaQlz4BhM5scc-1625557539.pdf 124

▪ Free air rescue of pregnant women in remote
areas has saved several lifes.
▪ If the health facility in the village cannot
provide specific services then the mother can
be taken to CEONC sites immediately under
the coordination of Ministry of
Women,Children and Senior Citizens.
8. Presidential Women Uplifting-Airlifting Programme(III)
▪ This initiative has saved the lives of 110 women and their infants from December
2018 to June 30, 2020
▪ In 2075/76, 26 pregnant women were airlifted, 87 in the fiscal year 2076/77, 103 lives
of pregnant women were saved in the fiscal year 2077/78 and 88 lives of pregnant
women at risk are saved in the current fiscal year so far.
125

Aama Surakshya Program
2005- Maternity
Incentive
Scheme
Transport
Incentive
2006- Safe Delivery
Incentive Programme
(SDIP)
User Fees removed from
all types of delivery care
in 25 low HDI Districts
2009- Aama
Program
Expanded
Nationwide
2012- Addition
of 4 ANC
incentive in the
Aama Program

Components of the Program
Antenatal
Care
(ANC)
Delivery
Care
Emergency
Obstetric
Care
Postnatal
Care
(PNC)

Antenatal Care
Blood pressure, weight and
fetal heart rate monitoring
IEC and BCC on pregnancy,
childbirth, and early newborn
care and family planning
Information on danger signs
and timely referral to
appropriate health facilities
Provision of Tetanus toxoid
and Diphtheria (TD)
immunization, iron folic acid
tablets and deworming tablets
to all pregnant women, and
malaria prophylaxis where
necessary
Early detection and
management of complications
during pregnancy
8 antenatal checkups

Incentive Scheme
Source: Review of Aama Surakshya Programme in Nepal, NHSSP-III, 2020.

Delivery Care
• Skilled birth attendance at home and facility-based deliveries
• 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
• Registration of births and maternal and neonatal deaths.

Emergency obstetric care
Basic emergency obstetric and newborn care
(BEONC)
• Management of pregnancy complications by assisted vaginal delivery
(vacuum or forceps)
• Manual removal of placentas
• Manual vacuum aspiration
• Administration of parental drugs
• Resuscitation of newborns and referrals
Comprehensive emergency obstetric and newborn
care (CEONC)
• Surgery (caesarean section)
• Anaesthesia
• Blood transfusions
• BEONC functions

Postnatal Care
Three
postnatal
check-ups
1st
In 24 hours
of delivery
2nd
On the third
day
3rd
On the
seventh day
after delivery

Components-PNC
• The identification and management of complications of mothers
and newborns and referrals to appropriate health facilities.
• The promotion of exclusive breastfeeding.
• Personal hygiene and nutrition education, and postnatal vitamin A
and iron supplementation for mothers.
• The immunization of newborns.
• Postnatal family planning counselling and services.

PNC Home Visit Program (Rationale)

FY
2075/
76
FY
2076/
77
FY
2077/
78
FY
2074/
75
Program
Initiation
Allocating annual
budget to 30
Municipals from 15
districts
Expansion Expansion
396 Municipals
from 50
districts
Expansion
Source: DOHS Annual Report FY 2076/77 and FY 2077/78
PNC Home Visit Program
229 Municipals
from 40
districts

• To strengthen PNC services by
mobilizing MNH service
providers from health facilities to
provide PNC at women’s home.
Objective

• Women who received PNC according to the protocol is 25 percent
in 2077/78 (HMIS).
• Amongst the 29 districts (where majority of the local levels were
able to implement the program) the PNC as per protocol is 35% of
expected live births in 2077/78 which is a 75-point percent
increase from FY 2076/77 in the same districts (20%)

Safe Abortion Services
Pre and post counseling on safe abortion methods as
well as contraceptive methods
Termination of pregnancy as per national protocol
Diagnosis and treatment of existing Reproductive Tract
Infections
Provide contraceptive methods as per informed choice
and follow up for post abortion complication
management
Source: https://mohp.gov.np/program/safe-abortion-services-(nsas)/en

Onsite Clinical Coaching and Mentoring
To enhance knowledge and skill of SBA and
non-SBA nursing staffs providing delivery
services at BC/BEONC and CEONC service
sites based on coaching/mentoring guideline
and tool.

Onsite Coaching and Mentoring
Proved to be
effective
through a
study done in
Dolakha and
Ramechhap.
FWD
implemented
since
2073/2074
from 16
districts
In FY
2074/2075
total 320
Municipalities
from 31
districts
In FY
2075/2076,
total 359
Municipalities
of 38 districts
In FY
2076/2077
528
Municipalities
of 51 districts
In FY 2077/78,
626
Municipalities
of 63 districts

Onsite Coaching and Mentoring
• Till the end of FY 2077/2078 total 260 SBA clinical mentors were
trained from 72 districts
• A set of models are used for model-based practice during clinical
coaching.
• FWD and supporting partners provided these models (Skill Lab
Material) to SBA clinical mentors to all districts.
• By end of FY 2077/78, total 4906 MNH service providers received
on-site clinical mentoring from SBA

Role of SBA Clinical Mentors
They are the key skill persons who:
Visit each BC/BEONC sites and conduct
onsite coaching/mentoring
Conduct MNH readiness quality
improvement self-assessment process to
enhance capacity of delivery service
providers, HF staffs and HFOMC
members to make MNH service
readiness

Maternal and Perinatal Death Surveillance
and Response (MPDSR)
Goal
• To eliminate preventable maternal and perinatal mortality by obtaining and using
information on each maternal and perinatal death to guide public health actions and
monitor their impact.
Objectives
• To provide information that effectively guides immediate as well as long-term actions to
reduce maternal mortality at health facilities and community and perinatal mortality at
health facilities.
• To count every maternal and perinatal death, permitting an assessment of the true
magnitude of maternal and perinatal mortality and the impact of actions to reduce it.
Source: MPDSR Guideline, MoHP, DoHS.

The MPDSR Process

Maternal and Perinatal Death Surveillance
and Response (MPDSR)
HO
Data Management and Analysis

MPDSR
• As of FY 2077/78, MPDSR is being implemented in 15 Districts
and 95 Hospitals, whereas training is ongoing in 17 Districts.
• A total of 95 hospitals are implementing facility based MPDSR, with
the maximum number of hospitals in Bagmati province.
• A total of 21 districts are implementing community MPDSR, of
which 15 districts have full implementation while in seven districts
implementation is partial.

Multilateral Organizations
1. UNFPA
1. Sexual and Reproductive Health Program: Policy Advocacy & Capacity
Building on SRHR, Capacity Building of Health Workers on ASRH, and
Strengthening Adolescent Friendly Health Services; Emergency preparedness
and response including RH sub-cluster coordination and support.
2. Family Planning: FP/RH commodities support; Strengthening SCM including
eLMIS; Service delivery and capacity building support to improve method mix and
accessibility to services, Systems strengthening (Family Planning Sustainability
Roadmap, FP2030 partnership), and evidence generation.
3. Maternal Health: Support implementation of Safe Motherhood Roadmap,
Midwifery regulations, faculty strengthening, education standardization, support
national program on RH morbidities, Support Maternal Mortality Study, and policy
advocacy.
148
Source: https://nepal.unfpa.org/en

2. UNICEF
1. Maternal and newborn health -Mahottari
2. Child Health including immunization -Kanchanpur
3. Adolescent Health and HIV services -Mahottari
149
Source: https://un.org.np/agency/united-nations-children-fund-unicef

3. WHO Nepal
1. 1. Vaccine preventable disease surveillance and technical support to strengthen
immunization coverage.
2. 3. Support in development of National Policies, Strategies and Guidelines for
Communicable and Non-Communicable Diseases and strengthening Disease
Control & Elimination interventions.
3. 4.Support to strengthen health systems capacities – policy, regulations,
strategies, plans, guidelines, protocols on environmental health, SRHR, RMNACH
health information, digital health and health system improvement including support
to provincial government
150
Source: https://www.who.int/nepal

4. United Nations World Food Programme (WFP)
1. Maternal and Child Health and Nutrition (MCHN) Program; with the objective to improve the
nutritional status of the children 6 to 23 month of children and PLW. (10 districts (Kalikot, Jumla,
Mugu, Humla, Dolpa Saptari, Siraha, Jhapa, Morang, and Sunsari)
2. Fill the Nutrient Gap (FNG): Conduct a situational analysis of the barriers to consuming a
nutritious diet and provide evidence for ongoing and planned programming for making the
implementation of nutrition and food security policy more effective.
151
Source: https://www.wfp.org/countries/nepal

Bilateral Organizations
1.USAID
152
Major programs:
- Maternal Newborn and Child
Health
- Family Planning & Reproductive
Health
- HIV/AIDS and STI
Projects:
Suaahara II
SSBH
Redbook and
MDHD
SafaaPani
Source: https://www.usaid.gov/global-health

2. KfW-German Financial Cooperation
153
Major Programs
- Sector Support/Pool Fund
- Support to Social Marketing-
Nepal CRS
- Recovery I and II
- Improvement of Maternity and
Childcare in Remote Areas
- COVID budget support
Geographical Coverage
-National Level
-Gorkha,Ramechhap, Jiri, Sankhu,
Bhimeshwor,Jhaukhel & Melbisauna
-Province 7
-National Level
Source: https://www.kfw.de/About-KfW/F%C3%B6rderauftrag-und-Geschichte/Geschichte-der-KfW/KfW-Themen/Finanzielle-Zusammenarbeit/

INGOs
1. Helen Keller International
154
-Nutrition,Maternal,Neonatal, Child HEalth, Family
planning,adolescence health, WASH, GESI,good
governance (Tanahu)
- Gov. collaboration on BMS( Breast milk Substitution) Act
amendment and monitoring (Center level)
-Expanding neonatal and Ophthalmic Care to Prevent and
Treat ROP in Nepal (Banke, surrounding districts and
Solukhumbu)
-Feasibility of Drying Fruits and Vegetables using Chimney
Dryer and acceptability of fruits and veg among women and
children (Taplejung) Source: https://hki.org.np/

2. ADRA Nepal
155
Major Programs
- Family Planning & Adolescent Sexual and Reproductive
Health, eLMIS and End Child Marriage (Ilam)
- Women’s Health & System Strengthening project
related uterine prolapse(Okhaldhunga)
- Improvement inMaternal & child health program
(Taplejung)
- COVID-19 Response and Recovery (14 hospitals,8
districts)
Source: https://adranepal.org/

3. CARE Nepal
Major Program Areas
1. Reproductive, Maternal, Neonatal, Child and Adolescent Health (RMNCAH): Capacity
building
of health workers, construction of birthing center, equipment support to birthing center, community
mobilization and awareness(Sindhuli, Kavre, sindhupalchok, Nuwakot, Rasuwa and Jajarkot)
2. COVID-19 response and recovery; PPE support to hub hospital and birthing centers, RCCE,
WASH and technical support to local government to develop and implement health emergency
response plan (Nabalparasi west, Rupandehi, Kapilvastu, Banke, Bardia, Kailali and Kanchanpur)
3. COVID-19 vaccination program: equipment supports for cold chain, training to health workers,
transportation of vaccine, community mobilization and awareness raising activities.(Nabalparasi west,
Rupandehi, Kapilvastu, Banke, Bardia, Kailali and Kanchanpur)
156
Source: https://carenepal.org/

4. One Heart Worldwide
1) Maternal and neonatal health- Mahottari
2) COVID prevention support (PPE, medicines for case
management, Oxygen cylinders and Oxygen concentrators)
157
Source: https://oneheartworldwide.org/

5. Population Services International Nepal
1. Women’s Health Project (WHP)
- Improve knowledge and access to Long Acting Reversible Contraception (LARC) and
Safe abortion Services through private and public sector: Training on Implant, IUCD
and MA to Providers onsite quality assurance, distribution of FP
commodities,medical equipment, recording and reporting using HMIS,
communication and counselling through community level mobilizer and mass
media (Province: 1, 2, 3, 4, 5 & 7), Kathmandu
2. Adolescent Youth Project (AYP)
· Increase knowledge and use of family planning products and services among
adolescents and youth (15-24) from private sector adolescent youth from service sites
(Province: 5, 7), Dhankuta
158
Source: https://www.psi.org/country/nepal/

6. Save the Children
1. Healthy Transition for Nepali Youth – Focus on Behavior Change and system strengthening for Adolescent
Reproductive Health (Surkhet, Kalikot, Dailekh, Jajarkot)
1. Sponsorship – Adolescent friendly services, Menstrual Health program, School Health and Nutrition
Program, Maternal Health system strengthening.(Saptari, Sarlahi, Mahottari)
1. Early Start – Nutrition program for children under 3 yrs (Dailekh)
1. Small Sick Newborn assessment and assessment on intrapartum nutrition practices (Federal level
assessment)
2. Programs for responding against TB, Malaria and HIV in Nepal.
159
Source: https://www.savethechildren.net/

7. FHI 360 Nepal
USAID- and PEPFAR-supported EpiC Nepal
- HIV and sexually transmitted infection (STI) prevention education, referral and follow- up
through online and offline platforms
- Demand generation and provision of HIV pre-exposure prophylaxis (PrEP)
- Condom and lubricant promotion and distribution
- HIV testing and counseling (HTC) services (index testing, online-to- offline (virtual), HIV self-
testing, community-led testing, enhanced peer outreach approach, recency testing)
- Community-based ART service and more HIV related activities
160
Source: https://www.fhi360.org/

8. Nick Simons Foundation International (NSFI)
Major program focus:
1) Training – SBA
2) Support in infrastructure-CEONC site
3) Technical Support
4) Research & Advocacy
161
Source: https://www.nicksimonsfoundation.org/

NGOs
GharGhar Ma Swastha (GGMS) Project - Expansion of Sangini Franchise Network 49 districts (Hills
and Mountain)
Sales and distribution of Family Planning, Maternal Child Health and Sexually Transmission
Infection Commodities in all 77 districts
Menstrual Hygiene Management (MHM) Project, Social Marketing and Behavior Change
Communication activity for Sanitary Napkin “Freedom” Dadeldhura, Doti, Bajhang and Baitadi
MOMENTUM Private Healthcare Delivery (MPHD) - Project for establishment of Adolescent
Friendly Service Center to provide quality FP services to adolescent and emerging/young adults
162
1. Nepal CRS Company (Contraceptive Retail Sales )
Source: https://www.crs.org.np/

2. Medic Mobile
1. Design, configuration and implementation of an open- source mHealth toolkit for community-based
maternal and child health care coordination. SMS based use cases that are currently deployed in
partnership with municipalities and NGO partners include
a) Antenatal care
b) Postnatal care
c) MPDSR (Maternal and perinatal death surveillance and response) (in districts where
Community based MPDSR has been implemented)
2. Supporting the Nursing and Social Security Division in the design, configuration and implementation
of Community Health Toolkit (open source) in Bhaktapur and Bardibas Municipalities.
163
Source: https://medic.org/stories/tag/nepal/

Other NGOs
164
Safe Abortion
Family Planning
Adolescent Reproductive Health
Integrated SRH services
Comprehensive Sexuality Education
Comprehensive abortion Care
Minimum Initial Service Package (MISP)
Basic Essential Primary Health care.
Maternal and Child Health
Community awareness program
Traditional healers Training
Source: https://www.fpan.org/
Source: https://phasenepal.org/
Source: https://www.mariestopes.org.np/

165
Issues, Challenges
&
Recommendations

● Service delivery:
○ Limited access to quality maternal health services, particularly in remote and
marginalized areas.
○ Insufficient availability of skilled health personnel, including midwives and obstetricians.
○ Lack of comprehensive emergency obstetric care facilities in many regions.
● Health workforce:
○ Inadequate numbers of skilled health workers, leading to a shortage of skilled
birth attendants.
○ Geographic maldistribution of health personnel, with a concentration in urban
areas.
○ Insufficient training and capacity building opportunities for healthcare providers
(Source: Annual report 2077/78,DOHS,Nepal Safe Motherhood and Neonatal Health Roadmap 2019)
166
Issues and Challenges

● Health information systems:
○ Incomplete and inaccurate data collection and reporting systems for maternal health
indicators.
○ Inadequate monitoring and evaluation of maternal health programs and interventions.
○ Limited use of data for evidence-based decision-making and resource allocation.
● Access to essential medicines and technologies:
○ Inconsistent availability of essential medicines and supplies, including contraceptives and
safe delivery kits.
○ Limited infrastructure for proper storage and distribution of medicines and medical
equipment.
○ High out-of-pocket expenses for maternal health services, deterring access for
economically disadvantaged women.
167

● Financing:
○ Insufficient government investment in maternal health programs and
infrastructure.
○ Limited financial protection mechanisms, leading to high out-of-pocket
expenditures.
○ Challenges in efficient allocation and utilization of available resources for
maternal health.
● Leadership and governance:
○ Weak policy implementation and enforcement related to maternal health.
○ Inadequate coordination among different stakeholders involved in maternal
health programs.
○ Limited community participation and engagement in decision-making processes
168

Recommendations
Major
Recommenda
tions
Ongoing Safe Motherhood and Reproductive Health Programmes should be
strengthened, with a focus on improving quality and equity and a particular focus on the specific needs of
the community.
It is recommended that the capacity of the local and provincial governments is enhanced
All women should be encouraged to give birth in a BEONC/CEONC site; such sites
should be easily accessed and within two hours’ walking distance of the woman’s home.
Life-cycle approach is to be encouraged, with a focus on reducing early marriage, on adolescent
reproductive health, and on continuum of care through pre-pregnancy, pregnancy, labour, delivery
and PNC for both mothers and newborns, focusing on promoting the physiological process of birth
and minimizing complications.
5/15/2023 169

Major
Recommend
ations
Arrangements should be made for postnatal home visits for women who have given birth at home and
for continued supervision of all postnatal mothers and newborns.
Mothers and newborns are encouraged to stay in health facilities for at least 24 hours after an institutional childbirth
and be monitored closely for complications.
To make maternal and perinatal death reviews more effective, health care providers’ concerns,
including confidentiality, must be addressed to ensure more accurate
Advocacy and Investment in MNH by People’s Representatives
170

1.Maternal Health refers to the health of women during pregnancy,childbirth and the post natal
period.
2.Although important progress has been made in the last two decades,about 2,87,000 women
died during and following pregnancy and childbirth in 2020 globally.
3.Most maternal deaths are preventable with timely management by a skilled health
professional working in a supportive environment.
4.Maternal mortality is in declining trend from 539 per 1 lakh live birth in 1996 NHFS to
239/1lakh live births in 2016 NDHS and 151/1 lakh live births in 2020,with target of 70/1 lakh
according for SDG 2030.
(Source: World Health Organization. Maternal health [Internet]. Who.int. World Health Organization; 2019. Available from: https://www.who.int/health-
topics/maternal-health#tab=tab_1)
172
Conclusion

5.Regarding place of Maternal deaths,57% maternal deaths occurs in health facilities,followed by
26% in home and 17% on the way to or between facilities according to NMMS 2021.
6.According to NMMS 2021 68% of Maternal deaths are caused due to direct causes and 32% of
Maternal deaths are caused by indirect causes.
7.According to NDHS 2022,79% of Deliveries occur in health facility which is in increasing trend
and home Deliveries are at decreasing trend that is 41% in NDHS 2016 from 92% home
Deliveries in 1996.
8.According to NDHS 2022 trend of PNC visit during first 2 days after birth is in increasing trend
that is 70 % coverage in 2022.
173
Conclusion

9.According to NDHS 2022,trend of teenage Adolescent pregnancy is in decreasing trend that is 14%
in 2022,from 17% in 2011 NDHS.
10. While progress has been made, challenges such as geographical disparities, socio-cultural norms,
and limited access to healthcare facilities in remote areas still persist.
11.To overcome these challenges, sustained efforts and continued investment in maternal health
policies and programs are crucial.
12.It is essential to focus on capacity building, infrastructure development, and community
engagement to ensure that all women, regardless of their location or background, can access the
necessary maternal healthcare services.
174
Conclusion

1. World Health Organization. Maternal health [Internet]. Who.int. World Health Organization; 2019. Available from:
https://www.who.int/health-topics/maternal-health#tab=tab_1)
2. MoHP, NSO. National Population and Housing Census 2021: Nepal Maternal Mortality Study 2021. Kathmandu:
Ministry of Health and Population; National Statistics Office;2022
3. Maternal mortality ratio (modeled estimate, per 100,000 live births) - Nepal | Data [Internet]. Worldbank.org. 2017.
Available from:
https://data.worldbank.org/indicator/SH.STA.MMRT?end=2017&locations=NP&start=2000&view=chart
4. National Joint Annual Review 2078/79 (2021/22) [Internet]. MoHP. [cited 2023 May 11]. Available from:
https://www.mohp.gov.np/uploads/articles/Health%20Sector%20Progress_MoHP.pdf
5. Ministry of Health and Population, Nepal; New ERA; and ICF. 2022. Nepal Demographic and Health Survey 2022:
Key Indicators Report. Kathmandu, Nepal: Ministry of Health and Population, Nepal.
6. Ministry of Health, Nepal; New ERA; and ICF. 2017. Nepal Demographic and Health Survey 2016. Kathmandu,
Nepal: Ministry of Health, Nepal
7. Ministry of Health and Population (MOHP) [Nepal], New ERA, and ICF International Inc. 2012. Nepal Demographic
and Health Survey 2011. Kathmandu, Nepal: Ministry of Health and Population, New ERA, and ICF International,
Calverton, Maryland
8. Ministry of Health and Population (MOHP) [Nepal], New ERA, and Macro International Inc. 2007. Nepal
Demographic and Health Survey 2006. Kathmandu, Nepal: Ministry of Health and Population, New ERA, and
Macro International Inc
9. Pradhan, Ajit, Ram Hari Aryal, Gokarna Regmi, Bharat Ban, and Pavalavalli Govindasamy. 1997. Nepal Family
Health Survey 1996. Kathmandu, Nepal and Calverton, Maryland: Ministry of Health [Nepal], New ERA, and Macro
International Inc
10. Central Bureau of Statistics (CBS),2020. Nepal Multiple Indicator Cluster Survey 2019,Survey Findings Report.
Kathmandu, Nepal: Central Bureau of Statistics and UNICEF Nepal
11. Central Bureau of Statistics, 2015. Nepal Multiple Indicator Cluster Survey 2014, Final Report. Kathmandu, Nepal:
Central Bureau of Statistics and UNICEF Nepal
12. Motherhood NS. Newborn Health Road Map 2030. Family Welfare Division Ministry of Health and Population
Government of Nepal. 2019.
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178

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