Safe Motherhood and Newborn Program

Safe Motherhood and Newborn Program

1. Safe Motherhood and Newborn Health ( Source : DOHS annual report FY 2075/76) Master of Public Health(MPH) Bachelor of public health(BPH ) Binam Raj Shrestha

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

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

4. I mportant factors for maternal and newborn morbidity and mortality in Nepal are:- delays in seeking care , delays in reaching care delays in receiving care

5. The goal :- T o reduce maternal and neonatal morbidity and mortality and To Improve maternal and neonatal health through preventive and promotive activities and by addressing avoidable factors that cause death during pregnancy, childbirth and the postpartum period .

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

7. Program , policy and guidelines The policy on skilled birth attendants (2006) highlights the importance of skilled birth attendance (SBA) at all births and embodies the government’s commitment to train and deploy doctors, nurses and ANMs with the required skills across the country . Introduction of Aama programme to ensure free service and encourage women for institutional delivery has improved access to institutional deliveries and emergency obstetric care services.

8. The endorsement of the revised National Blood Transfusion Policy (2006) was another significant step for ensuring the availability of safe blood supplies for emergency cases. The Nepal Health Sector Strategy (NHSS) identifies equity and quality of care gaps as areas of concern for achieving the maternal health sustainable development goal (SDG) target, and gives guidance for improving quality of care, equitable distribution of health services and utilisation and universal health coverage with better financing mechanism to reduce financial hardship and out of pocket expenditure for ill health .

9. By 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live births By 2030, end preventable deaths of newborns and children under 5 years of age, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1,000 live births and under-5 mortality to at least as low as 25 per 1,000 live births The maternal mortality ratio (MMR) for Nepal is 239 deaths per 100,000 live births for the seven-year period before the survey (NDHS 2016)

10. Major activities

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

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

13. Community level maternal and newborn health interventions Family Welfare Division (FWD) continued to expand and maintain MNH activities at community level including the Birth Preparedness Package ( jeevansuraksha flipchart and card) and distribution of matrisurakshachakki (misoprostol) to prevent postpartum haemorrhage (PPH) in home deliveries. Through FCHV , public health system promotes: • birth preparedness and complication readiness (preparedness for money, place for delivery, transport and blood donors );

14. self-care (food, rest, no smoking and no alcohol) in pregnancy and postpartum periods ; antenatal care (ANC), institutional delivery and postnatal care (PNC) (iron, tetanus toxoid, Albendazole ,Vitamin A); • essential newborn care; and • identification of and timely care seeking for danger signs in the pregnancy, delivery, postpartum and newborn periods.

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

16. Rural Ultrasound Programme The Rural Ultrasound Programme aims for the timely identification of pregnant women with risks of obstetric complication to refer to comprehensive emergency obstetric and neonatal care ( CEONC) centres . Trained nurses (SBA) scan clients at rural PHCCs and health posts using portable ultrasound. Women with detected abnormalities such as abnormal lies and presentation of the foetus and placenta previaare referred to a CEONC site for the needed services. This programme is being implemented in the 14 remote districts. In FY 2075/76, a total of 15 SBA were trained on rural ultra sound by NHTC and FWD .

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

18. Human resources A significant share of FWD’s budget goes for recruiting human resource (Staff nurses , ANMs)on short term contracts to ensure 24 hour services on MNH at PHCCs and health posts . NHTC provides training on SBA, ASBA, Anaesthesia assistant, operating theatre management, family planning (including implants and IUCD), CAC and antenatal ultrasonography.

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

20. Onsite clinical coaching and mentoring FWD had started to implement on-site clinical coaching /mentoring programme since 2073/2074 from 16 districts to enhance knowledge and skill of SBA and non-SBA nursing staffs providing delivery services at BC/BEONC and CEONC service sites . This programme has been scaled up in 15 districts in FY 2074/2075 . This guideline has included mainly three parts; Clinical coaching/mentoring for MNH service providers (SBA and non_SBA ), Infection prevention and MNH readiness QI self-assessment.

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

22. PNC home visit(microplanning for PNC ) In FY2074/75FWD provided 30 local palikas from 15 districts to strengthen PNC services by mobilizing MNH service providers from health facilities to provide PNC at women’s home.

23. Emergency referral funds To address this issue FWD allocated emergency referral funds to Regional Directorate for air lifting of women in need of immediate transfer to higher centres . The main objective of this programme is to support emergency referral transport to women from poor, Dalit, Janajati , geographically disadvantaged, and socially and economically disadvantaged communities who need emergency caesarean sections or complication management during pregnancy or child birth.

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

25. FWD has defined the four key components of comprehensive abortion care as : pre and post counselling on safe abortion methods and post-abortion contraceptive methods; termination of pregnancies as per the national protocol; diagnosis and treatment of existing reproductive tract infections; and provide contraceptive methods as per informed choice and follow-up for post-abortion complication management.

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

27. Obstetric first aid orientations In 2070/71 , FHD started orienting paramedics on first aid to manage obstetric complications at health facilities without birthing centres and to enable paramedics to support SBAs and ANMs at times of emergency .

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

29. Aama and Free Newborn Programme The government has introduced demand-side interventions to encourage women for institutional delivery . The Maternity Incentive Scheme , 2005 provided transport incentives to women to deliver in health facilities. In 2006 , user fees were removed from all types of delivery care in 25 low HDI districts and expanded to nation wide under the Aama Programme in 2009 .

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

31. Aama programme provision a. For women delivering their babies in health institutions : Transport incentive for institutional delivery: Cash payment to women immediately after institutional delivery (NPR 3,000 in mountains, NPR 2,000 in hills and NPR 1000 in Tarai districts). Incentive for 4 ANC visits: A cash payment of NPR 800 to women on completion of four ANC visits at 4, 6, 8 and 9 months of pregnancy, institutional delivery and postnatal care.

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

33. Ten types of complications (antepartum haemorrhage (APH) requiring blood transfusion, postpartum haemorrhage (PPH) requiring blood transfusion or manual removal of placenta (MRP) or exploration, severe pre-eclampsia, eclampsia, MRP for retained placenta, puerperal sepsis, instrumental delivery, and management of abortion complications requiring blood transfusion) and admission longer than 24 hours with IV antibiotics for sepsis are included as complicated deliveries.

34. Anti-D administration for RH negative is reimbursed NPR 5,000. Laparotomies for perforation due to abortion, elective or emergency C-sections, laparotomy for ectopic pregnancies and ruptured uterus are reimbursed NPR 7,000 to both public and private facilities.

35. b. Incentives to health service provider: For deliveries : A payment of NPR 300 to health workers for attending all types of deliveries to be arranged from health facility reimbursement amounts .

36. Newborn Care Programme Provision a. For sick newborns: There are four different types of package (Package 0, Package A, B, and Package C) for sick newborns case management. Sick newborn care management cost is reimbursed to health facility . The cost of package of care include 0 Cost for Packages 0, and NPR 1000, NRP 2000 and NRP 5000 for package A, B and C respectively. Health facilities can claim a maximum of NPR 8,000 (packages A+B+C), depending on medicines, diagnostic and treatment services provided.

37. b. Incentives to health service provider: A payment of NPR 300 to health workers for providing all forms of packaged services to be arranged from health facility reimbursement amounts .

38. Achievements

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

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

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

42. Delivery care Delivery care services include: 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; and the registration of births and maternal and neonatal deaths.

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

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

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

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

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

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

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

50. Implementation of Maternal and Perinatal Death Surveillance and Response (MPDSR ) This is a continuous identification, notification , quantification and determination of causes and avoidability of all maternal and perinatal deaths , as well as the use of this information to respond with actions that will prevent future deaths . GoN prioritized and implemented MPDSR in FY 2073/74 MPDSR with further strengthening and expansion. MPDSR was scaled up in 21 districts out of which 7 districts in this fiscal year ( Bhangang , Dailekh , Palpa , Myagdi , Taplegung and Rautahati , and 99 hospitals( both public and private) in FY2074/75 . Government of Nepal ( GoN ) developed MPDSR guidelines 2015.

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

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

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

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

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

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

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

58. Thank you