Practicum presentation on Safe Motherhood Program (SMP) and Maternal and Perinatal Death Surveillance and Response (MPDSR) Program in MNH Section of Family Welfare Division..

Practicum Presentation on
Safe Motherhood Program in
Maternal and Neonatal Health
Section, Family Welfare
Division
Mohammad Aslam Shaiekh
MPH-4rth Semester

Objectives of Practicum
• To observe, participate and engage in
various activities of MNH Section during
the practicum period.
• To critically appraise the present state and
mode of the Health promotion, education
and communication interventions of MNH
section.
• To prepare and carry out the prototype
mini project following the systematic step
of a project preparation and
implementation.

Objectives of Practicum
• To involve in the activities assigned by the
institutional supervisor
• Develop interpersonal skills and
competencies to work in group/team for
quality project management

Methodology
Visited different organizations and
contacted head of those organizations
With an interest to do practicum in the area
of MCH and went to meet Chief of MNH
section, FWD through phone and email
conversation
After discussion with the Chief, approval was
given to do a practicum in the MNH section
Approval was taken to do a practicum in the
MNH section for 3 weeks
Detail Plan of Action was developed and get
approved by the Chief of MNH Section

Methods
• Review of documents and reports
• Document review for renew and
approval of Safemotherhood
program and Guidelines etc.
Desk
Review
• Interaction with MNH section
staffs, and NHSSP staffs was
done to enhance further
understanding on programs and
activities and to understand the
management process.
Interaction
s

Methods
• Different units of MNH section and
NHSSP were visited and
observation was done to
understand the management
process and activities performed.
Observation
s
• Attended meetings related to
Monthly progress review and
FP2020.
• Participated in the Public Private
Partnership (PPP) workshop and
MPDSR Orientation
Participation
s

Activities Carried Out
Activities Approach
Read documents and reports
related to Safemotherhood
program and interaction with SMP
focal person to be familiarize with
SM program
Desk Review
Interaction
Exploring the MNH activities and
Organizational structure
Discussion
Interaction
Attended monthly progress review
meeting
Participation &
Observation
Attended workshop on Public
Private Partnership (PPP) for
Participation and
Observation

Activities Approach
Develop slides on MPDSR
and 3 years progress of
SMP activities
Discussion,
Documents review
and Consultation with
section chief
Discussion and orientation
about NHSSP support and
their activities
Interaction
NHSS-RF data compilation Data entry
Attended FP2020 meeting Participation and
Observation

Activities Approach
Operating STAT-Compiler for
NDHS data regarding SMP
indicators
Application of
STAT-Compiler
Conducted Mini-Action-Project
(MAP)
Gap analysis
Final Presentation and Vote of
Thanks for Supporting over the
practicum period
Presentation and
Discussion

MNH Section, Family Welfare
Division
• Family health is one of the priority programs of
Government of Nepal, Ministry of Health.
• FHD is responsible for improving overall quality of life of
the whole family by improving the health status of
mothers, neonates and children and by increasing
access and utilization of quality services.
• To achieve this important goal various programs like
FP, ASRH, SMP, and neonatal health care services
through health facilities, PHC/ORC and Female
Community Health Volunteers (FCHVs) are in
operation.

MNH Section, Family Welfare
Division
• Nepal has been able to partially achieve MDG 4
and 5 and there is much to do towards improving
reproductive health status of Nepalese population.
• To further improve MNH status of country, Nepal is
committed to sustain these achievements and
further improve maternal and neonatal health and
achieve target of Maternal Mortality Ratio to less
than 70/100000 live birth, Institutional Delivery to
90%, Contraceptive Prevalence Rate (CPR) to
75%, and Neonatal Mortality Rate to (1/1000 Live
Birth) which are set for Sustainable Development
Goal (SDG) by 2030.

Functions of MNH Section,
Family Welfare Division
• Support the MoHP to prepare national policy,
strategy, directories, criteria, protocols regarding
MNH.
• Assist in survey / research related to MNH.
• Provide technical assistance to the national and
regional policy by analyzing MNH conditions.
• Based on national policy, international guidance
and territorial needs, facilitate new programs
related to MNH.
• Coordinate and implement technological issues
with the state, local level and stakeholders.

Functions of MNH Section,
Family Welfare Division
• Coordinated and cooperative for implementing
national priority programs of Maternal and
Newborn.
• Necessary support to the regional and local level
to enhance the quality of services through the
expansion of emergency 24-hour service

Managerial Aspects of MNH
Section:
Planning
• First of all financial plan is developed by NPC in
coordination with Ministry of Finance (MoF).
• MoF provide budget ceiling to plan the programs
and activities to MoHP who later sends budget
ceiling to DoHS and to respective divisions.
• Based on the budget ceiling MNH section
develops programs and activities in consultation
with donor agencies and experts and finalize the
program and activities sitting together with
planning section of FWD.
• Those planned programs and activities are
submitted to MoHP where final selection of
programs and activities are made.

Planning
• Finalized plan from MoHP is submitted to NPC.
• After approval from NPC it submits plan to MoF
for selection of programs and activities and
allocation of budget.
• MoF submits back the final plan to NPC.
• Detail plan document is prepared by NPC and
put it forward to cabinet for its approval. The
plan is executed after Cabinet approval.

Staffing
• The people for the sanctioned permanent posts in
MNH section are recruited through Public Service
Commission and MoHP carries out training and
development, performance appraisals, promotions
and transfers of the personnel. Temporary staffs can
be recruited by Family Welfare Division.
• Altogether there are five staffs under MNH section
of FWD.
 Section Chief (9th level) - 01
 Community Health Nursing Officer-1 (7th level)
 Na.Su-1
 Computer Assistant -1
 Public Health Inspector-2 (7th level) – 01
 Office Assistant – 1

Directing
• The chief of MNH Section have full authority to
mobilize the human resources.
• Delegation of the authority with resources is
given by the chief to other staffs to carry out their
responsibilities.

Coordination
• There are two types of coordination that take
place in MNH section.
• One is vertical coordination, where the
coordination is done with Family Welfare
Division, DoHS and Ministry of Health in the
central level and with Provincial Health
Directorate and at Health sections of Palika in
local level for successful implementation of the
Safemotherhood programs at province and
local/peripheral level.
• Another is horizontal coordination with other
divisions and centers like LMD, NHTC, NHEIC,
NPHL, EDCD, and MD.

Coordination
• MNH section works in close coordination with
partner agencies like WHO, NHSSP, UNICEF,
UNFPA etc.
• Intra-sectoral coordination within health sector
and inter-sectoral coordination among other
sectors like water and sanitation, agriculture,
education, etc. is maintained by MNH section.
• Within the MNH section there is coordination
between different units (Finance, Admin….)

Reporting
• Data generated from SMP services are reported
through HMIS to HMIS section of Management
Division of DoHS.
• HMIS section collects and analyzes this
information and sends to MNH section of FWD
for review and feedback.
• MNH section also provides the information about
program achievement to the DG in every
monthly review meeting

Budgeting
• Budget planning is done at the time of
developing plan for programs and activities.
• The process of budget follow and disbursement
of budget is through the governmental process
at each level.
• At the end of the fiscal year internal auditing is
done by FCGO and external auditing is done by
Auditor General Office.

Monitoring and Evaluation
• Quarterly and yearly review meetings are done
from the center for the monitoring and evaluation
of Safe Motherhood Program (SMP).

Safe Motherhood Program (SMP):
Introduction
• The evidence suggests that three delays are
important factors for maternal and newborn
morbidity and mortality in Nepal (delays in
seeking care, reaching care and receiving care).
• Hence, The Safe Motherhood Programme,
initiated in 1997 has made significant progress
with formulation of safe motherhood policy in
1998.
• 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

Introduction
• Introduction of Aama programme to ensure free
service and encourage women for institutional
delivery has improved access to institutional
deliveries and emergency obstetric care
services.
• The endorsement of the revised National Blood
Transfusion Policy (2006) was another
significant step for ensuring the availability of
safe blood supplies for emergency cases

Goal
• 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.

Strategies
• Promoting birth preparedness and complication
readiness including awareness rising and
improving preparedness for funds, transport and
blood transfusion.
• Expansion of 24 hours birthing facilities
alongside Aama Suraksha Programme promotes
antenatal check-ups and institutional delivery.
• The expansion of 24-hour emergency obstetric
care services (basic and comprehensive) at
selected health facilities in all districts

Activities
Community level MNH interventions
• FWD continued to expand and maintain MNH
activities at community level including the Birth
Preparedness Package and distribution of matri-
surakshachakki (misoprostol) to prevent
postpartum hemorrhage (PPH) in home
deliveries.
• Through FCHV, public health system promotes:
 Birth preparedness and complication readiness
(preparedness for money, place for delivery,
transport and blood donors);

Activities
Community level MNH interventions
• Through FCHV, public health system promotes:
 Self-care (food, rest, no smoking and no
alcohol) in pregnancy and postpartum periods;
 Antenatal care (ANC), institutional delivery and
postnatal care (PNC) (iron, tetanus toxoid,
Albendazole ,Vitamin A);
 Essential newborn care; and
 Identification of and timely care seeking for
danger signs in the pregnancy, delivery,
postpartum and newborn period.

Activities
Rural Ultrasound Program
• Aims of this activities is to timely identification of
pregnant women with risks of obstetric
complication to refer to comprehensive
emergency obstetric and neonatal care
(CEONC) centers.
• Trained nurses (SBA) scan clients at rural
PHCCs and health posts using portable
ultrasound. Women with detected abnormalities
such as abnormal lies and presentation of the
foetus and placenta previa are referred to a
CEONC site for the needed services.
• This programme is being implemented in the 14
remote districts.

Activities
RH morbidity prevention & Management
• Management of pelvic organ prolapse and Obstetric
Fistula
• Cervical cancer screening and prevention training
Expansion and quality improvement of service
delivery sites:
• FWD continued to expand 24/7 service delivery sites
like birthing centers, BEONC and CEONC sites at
PHCCs, health posts and hospitals.
• The expansion of service sites is possible mostly
due to the provision of funds to contract short-term
staff locally.

Activities
Safe Abortion Services:
• FWD has defined the four key components of
comprehensive abortion care as:
 Pre and post counseling on safe abortion
methods and post-abortion contraceptive
methods;
 Termination of pregnancies as per the national
protocol;
 Diagnosis and treatment of existing reproductive
tract infections; and
 Provide contraceptive methods as per informed
choice and follow-up for post-abortion
complication management.

Activities
Emergency Referral Funds:
• In cases of difficult geographical terrain and
unavailable CEONC services, FWD allocated
emergency referral funds to Provincial
Directorate for air lifting of women in need of
immediate transfer to higher centers.
• A transport fare in districts is also allocated to
support women who could not afford referral to
high facility.
• 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

Activities
Human Resource Management:
• A significant share of FWD’s budget goes for recruiting
human resource (Staff nurses, ANMs)on short term
contracts to ensure 24 hour services on MNH at
PHCCs and health posts.
• FWD also provides funds to DHOs and DPHOs to
recruit the human resource mix needed to provide
surgical management for obstetric complications at
district hospitals (CEONC sites).
• FWD has been coordinating with NHTC and the NAMS
for the pre-service and in-service training of health
workers.
• NHTC provides training on SBA, ASBA, Anesthesia
assistant, operating theatre management, family
planning (including implants and IUCD), CAC and

Activities
Onsite Clinical Coaching and Mentoring:
• FWD started to implement on-site clinical
coaching /mentoring programme since
2073/2074 from 16 districts to enhance
knowledge and skill of SBA and non-SBA
nursing staffs providing delivery services at
BC/BEONC and CEONC service sites.
• Onsite clinical coaching and mentoring includes,
 Clinical coaching/mentoring for MNH service
providers (SBA and Non-SBA),
 Infection prevention and
 MNH readiness QI self-assessment.

Activities
MNH Readiness Hospital and BC/BEONC
Quality Improvement:
• Improvement in quality of service delivery
through self-assessment, infection prevention
demonstration and action plan implementation is
evidence based effective program
• The process of quality improvement is also
being implemented in birthing centers in
integration with onsite coaching/mentoring
process

Activities
PNC Home Visits (Micro Planning for PNC):
• Access to and utilization of PNC services is a
major challenge while the majority of maternal
deaths occur during post-natal period.
• Women who received PNC according to the
protocol is 16 %.
• In FY2074/75, FWD provided 30 local palikas
from 15 districts to strengthen PNC services by
mobilizing MNH service providers from health
facilities to provide PNC at women’s home

Activities
Maternal and Perinatal Death Surveillance &
Response (MPDSR) And Birth Defect
Surveillance (BDS):
• Identification, notification, quantification and
determination of causes and avoidability of all
maternal and perinatal deaths at community and
health facilities, as well as the use of this
information to respond with actions that will
prevent future deaths.
Obstetric first aid orientations

Activities
NYANO JHOLA Program:
• The Nyano-Jhola Programme was launched in
2070/71 to protect newborns from hypothermia
and infections and to increase the use of
peripheral health facilities (birthing centres).
• Two sets of clothes (bhoto,daura, napkin and
cap) for newborns and mothers, and one set of
wrapper, mat for baby and gown for mother are
provided for women who give birth at birthing
centers and district hospitals.
• The programme was interrupted due to financial
constraints, however MOH allocated extra
budget for due to popular demand.

Activities
AAMA and Free Newborn Program:
• The government has introduced demand-side
interventions to encourage women for
institutional delivery.
• The Maternity Incentive Scheme, 2005 provided
transport incentives to women to deliver in
health facilities.
• In 2006, user fees were removed from all types
of delivery care in 25 low HDI districts and
expanded to nationwide under the Aama
Programme in 2009.
• In 2012, the separate 4 ANC incentives
programme was merged with the Aama
Programme.

Activities
• In 2073/74, the Free Newborn Care Programme
(introduced inFY2072/73) was merged with the
Aama Programme which was again separated in FY
2074/75 as two different programmes with the
provisions listed below:
Aama programme provision
For women delivering their babies in health
institutions:
• Transport incentive for institutional delivery:
Cash payment to women immediately after
institutional delivery (NPR 3,000 in mountains, NPR
2,000 in hills and NPR 1000 in Tarai districts).
• Incentive for 4 ANC visits: A cash payment of NPR
800 to women on completion of four ANC visits at 4,
6, 8 and 9 months of pregnancy, institutional delivery
and postnatal care.

Activities
• Free institutional delivery services:
A payment to health facilities for providing free
delivery care.
 For a normal delivery health facilities with less
than 25 beds receive NPR 1,000 and health
facilities with 25 or more beds receive NPR
1,500.
 For complicated deliveries health facilities
receive NPR 3,000 and for C- sections (surgery)
NPR 7,000.

Activities
 Ten types of complications (antepartum hemorrhage
(APH) requiring blood transfusion, postpartum
hemorrhage (PPH) requiring blood transfusion or
manual removal of placenta (MRP) or exploration,
severe pre-eclampsia, eclampsia, MRP for retained
placenta, puerperal sepsis, instrumental delivery,
and management of abortion complications requiring
blood transfusion) and admission longer than 24
hours with IV antibiotics for sepsis are included as
complicated deliveries.
 Anti-D administration for RH negative is reimbursed
NPR 5,000.
 Laparotomies for perforation due to abortion,
elective or emergency C-sections, laparotomy for
ectopic pregnancies and ruptured uterus are
reimbursed NPR 7,000 to both public and private
facilities.

Activities
Aama programme provision
• Incentives Provision to health service
provider:
 For deliveries: A payment of NPR 300 to health
workers for attending all types of deliveries to be
arranged from health facility reimbursement
amounts.

Activities
Newborn Care programme provision
• For sick newborns: There are four different types
of package (Package 0, Package A, B, and Package
C) for sick newborns case management. Sick
newborn care management cost is reimbursed to
health facility. The cost of package of care include
0 Cost for Packages 0, and NPR 1000, NRP 2000
and NRP 5000 for package A, B and C
respectively. Health facilities can claim a maximum
of NPR 8,000 (packages A+B+C), depending on
medicines, diagnostic and treatment services
provided.
• Incentives to health service provider: A payment
of NPR 300 to health workers for providing all forms
of packaged services to be arranged from health
facility reimbursement amounts.

Mini Action Project (MAP):
Introduction
• As per one of the activity of the organization,
there was the orientation program on MPDSR to
the staffs of hospitals and PHCC. Thus in
consultation and recommendation with MNH
section chief and Community Nursing Officer
(CNO), they suggested me to make a draft for
the orientation slide to present in orientation
program as my MAP.
• So I developed the presentation draft on the
topic Maternal and Perinatal Death Surveillance
and Responses (MPDSR) with a mini-lecture
and conducted as my mini-project in the
orientation program with the support of CNO.

Objectives
• To describe the status of maternal and perinatal
mortality in Nepal,
• To describe the rationale, goal, objectives and
components of MPDSR.
• To provide rationale and process of MPDSR in
hospital
• To orient the HWs on Complete the Maternal Death
Review (MDR) and Perinatal death Review (PDR)
forms correctly.
• To make capable to HWs to Identify the Cause and
avoidable factors of the maternal and perinatal
deaths
• To develop the skills on Formulate, implement and

Detail of MAP Implementation
• Date: 24th October 2019
• Duration: 11:00 AM – 4:00 PM
• Venue/setting: NHTC Training Hall
• Staff from Health Section: Dr. Punya Gautam
(MNH Section Chief) and Mrs. Kumari Bhattarai
(Community Nursing Officer)
• Number of Participants:
• Target Group: Doctors form Hospital and PHCC

Contents of Orientation on
MPDSR
• Background and Rationale of MPDSR program
• Process of MPDSR in Hospitals
• Review on the tools of MDR and MPDSR
• Formulation, Implement and monitoring action
plan for appropriate response

Background of MPDSR
• Development of any country is reflected by the
status of health of mothers and children.
• Globally, about 3 Lakh women die every year
due to maternal cause in pregnancy, 99% of
such maternal deaths occur in less developed
countries.
• In Nepal, about 1700 women die every year due
to maternal causes. Nepal had target to reduce
Maternal Mortality Ratio (MMR) to 134 by 2015,
Nepal Health Sector Strategy (2015-2020) has
target to reduce MMR to 125 by 2020.
Sustainable Development Goals has targets to
reduce MMR to 70 per 100000 live births by
2030.

Background of MPDSR
• Prematurity, birth asphyxia and sepsis are the most
common causes of death followed by congenital
anomalies, pneumonia, diarrheal diseases among
the neonates.
• Considering the stagnant NMR, MPDSR has equal
focus to review still births and early neonatal deaths
in the hospitals as more than two thirds of the
neonates die within first week of life. It is possible to
achieve the targets if MPDSR is effectively
implemented.
• MPDSR is a strong proven system which can guide
and assist in preventing maternal deaths and reduce
MMR.

What is MPDSR
• Continuous identification, notification,
quantification and determination of causes and
avoidability of all maternal and perinatal deaths,
as well as the use of this information to respond
with actions that will prevent future deaths.

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.

MPDSR 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.

Components of MPDSR
Identify
cases
Collect
informatio
n
Analyze
results
Recommen
-dations
for actions
Evaluate
and refine

Key Principles of MPDSR
No woman
should die
giving birth
Every death
counts
Beyond the
numbers
Not used for
litigation
No blame
No name
No punitive
action
Black Box
Every death
has a lesson

Role of Attending Doctors/Nurse
for MPDSR Process

Feedbacks from Orientation
• Increase in case notification with identification of
hidden cases
• Increased responsibility and accountability on
maternal death at community level
• Need of multi-sectoral approach required to
implement actions

Challenges to MPDSR
Implementation
• Under reporting of suspected maternal deaths
• Blame culture at some places that inhibits health
professionals and others from participating fully in
the MPDSR process
• Incomplete or inadequate legal frameworks
• Inadequate staff numbers, resources and budget
• Problems of geography and infrastructure that
inhibit the timely operation of MDSR.
• Review and reporting of perinatal deaths in
hospitals
• Cause of death assignment at hospitals
• Delay/Incomplete notification, screening, review,
response & use of web-based MPDSR system

Tools for MPDSR
a. Notification form
b. Screening form (Hospital Based)
c. Community verbal autopsy form
d. Community cause of death assignment
form

Limitations of Internship
a. The duration of the internship was a limitation for me
in terms of mastering the organizational functioning,
3 weeks is too short to adapt to a new organization
and to start deliver to your maximum capacity.
b. The Practicum between the Dashain and Tihar
festival is not appropriate for students because there
is limited activities in that period so the internee
cannot get the opportunity to learn more and more.
c. The first week spend to be familiarized and to get to
know the organization and activities; when I settled in
I realized that I was at the verge of concluding the
internship. Even though the objectives were
accomplished, some were done through desktop
than being actively involved.

Learning from Internship
• Got opportunity to excel the programmatic
knowledge and information and have also
enhanced skills to work in a team.
• Team work and communication is the most
important weapon to make necessary
achievements and progress in the project work.
• Difference between theoretical knowledge and
practical skills. It seems a tough job to put
theoretical knowledge practically in the field.
• To prove myself I must become opportunistic, be
ready to undertake complex tasks and be ready
to work on deadlines.

Recommendations
Recommendations for MNH Section
• MNH section should Scale up of PNC home
visits program
• The MPDSR need to strengthen to all hospitals
including public and private both.
• Regular mentoring and onsite coaching should
increase at all birthing centers for qualitative
services
• Emphasize on collaboration with development
partners and multi stakeholders to harmonize
safe motherhood services.

Recommendations for SAHS, PU
• There should be an MoU between the
organization and University for Practicum
• The duration of practicum, 3 weeks is too short
to adapt to a new organization and to deliver the
learning objectives.
• The practicum between the Dashain and Tihar is
not appropriate from learning perspectives so it
would be better to shift after Dashain and Tihar.
• Frequent visits from faculty members to boost
relationships with the organization
• Provision of allowances to supervisors of
respective organization.

Practicum presentation on Safe Motherhood Program (SMP) and Maternal and Perinatal Death Surveillance and Response (MPDSR) Program in MNH Section of Family Welfare Division..

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Practicum presentation on Safe Motherhood Program (SMP) and Maternal and Perinatal Death Surveillance and Response (MPDSR) Program in MNH Section of Family Welfare Division..