Nepal’s Safe Motherhood and Newborn Health (SMNH) Road Map 2030 aims to ensure a healthy life for, and the well-being of, all mothers and newborns. The Road Map is aligned with the Sustainable Development Goals (SDGs) to reduce the current Maternal Mortality Ratio (MMR) from 239 to 70 deaths per 100,000 live births (or at least two-thirds from the 2010 baseline) by 2030. It also aims to reduce the Newborn Mortality Rate (NMR) from the current 21 to less than 12 deaths per 1,000 live births, and the stillbirth rate from the current 18 to below 12.5 deaths per 1,000 live births by 2030.

The Road Map also provides the framework to realise Nepal’s commitments in the Safe Motherhood and Reproductive Health Act 2018.

The Road Map builds upon the review findings of Nepal’s SMNH Programme under the Nepal Health Sector Strategy (NHSS, 2015–2020) and other national and international experiences and recommendations. The NHSS has an overall focus on Universal Health Coverage (UHC), with four strategic areas of direction: equitable access, high-quality health services, health systems reform and a multisectoral approach.

The Road Map is a national document with key recommendations for Maternal and Newborn Health (MNH) for the first five years of implementation. Based on the national-level recommendations presented in the Road Map it is expected that Provincial and Local Governments will develop context-specific five-year activity-level plans. The Road Map will be reviewed after five years and, if necessary, recommendations and targets will be adjusted.

Key Maternal and Newborn Health Issues

• There is little change in the leading causes of maternal deaths over time
• Causes of newborn mortality have also not changed
• Women’s awareness about maternal health issues remains limited
• Short birth-intervals persist
• Rate of pregnancies is high and contraceptive use is low among teenagers
• Fertility rates reduced and FP increased, but low contraceptive prevalence continues among some groups
• Overall ANC coverage has increased, but quality has been relatively weak
• Institutional deliveries and skilled birth attendance increased
• Awareness about legality of abortions and compliance with service standards is low
• PNC is crucial for preventing maternal and newborn deaths, but current coverage levels are low
• Access to health services has improved but quality of care is still poor
• Patient satisfaction and respectful and high-quality care are low across facilities

Vision, Mission, Goal
The Road Map contributes to deliver Nepal’s 2030 vision: ‘Nepal as an enterprise-friendly middle-income country, peopled by a vibrant and youthful middle class living in a healthy environment, with absolute poverty in the low single digits and decreasing.’
But more directly, the Road Map will help deliver the vision and mission of the National Health Policy 2014.
Vision: All Nepali citizens have the physical, mental, social and spiritual health to lead productive and high-quality lives.
Mission: Ensure citizens’ fundamental rights to stay healthy by optimally utilising the available resources and fostering strategic cooperation between health service providers, service users and other stakeholders.
Goal: Ensuring healthy lives and promoting wellbeing for all mothers and newborns.

Major recommendations

• 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. For example, in the mountain and hills, the focus should be on strengthening access to services, whereas in the more accessible Terai regions, the focus should be on improving utilisation of available services by removing sociocultural barriers.
• A 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, focussing on promoting the physiological process of birth and minimising complications. In this context, it is recommended that the government focuses on providing four high-quality ANC visits and encourages a further four ANC contacts with a health worker, improves delivery services and closely monitors CS rates by using Robson’s criteria.
• 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. The existing BEONC sites should be made fully functional and selected existing BCs should be upgraded to BEONC sites. While this is being done, a few BCs that are most accessible to communities but far from BEONC/CEONC sites should be made functional 24 hours a day (strategic BC), with strong referral facilities, including ambulances, means of communication and linkages with pre-identified fully functional CEONC sites.
• It is recommended that the capacity of the local and provincial governments is enhanced for planning and monitoring. Using the Geographic Information System (GIS) the Provincial and Local Governments complete a profile of their population, health HR, infrastructure and caseload for each existing health facility and develop a joint five-year plan. This plan outlines which HPs or health facilities will become strategically located BCs or BEONC sites and formalises clear referral pathways from these strategically located BCs to pre-identified CEONC sites.
• Since the majority of maternal and newborn deaths occur in the postnatal period when mothers are mostly unsupervised by skilled healthcare providers, it is important that 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. This will mean that health facilities where deliveries are conducted are further strengthened to accommodate the needs of postnatal mothers, newborns and their families.
• Capacity for prevention and management of PPH should be increased through the promotion and strengthening of the PPH Bundle, including temperature regulation of oxytocin storage (provision of refrigerator with electric/solar power back-up), making ergometrine, tranexaminic acid and prostacycline available, improving blood transfusion services, and enhancing surgical skills of doctors. The oral misoprostol programme must be scaled up and made available where SBAs are unlikely to be available at home births.
• 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. To start with, the HR necessary for PNC can be made available by relocating existing ANMs after analysing their workload, providing resources to facility-based ANMs to also cover postnatal home visits if feasible, or by hiring extra ANMs/SNs on contract. Such health personnel should be given orientation on community approaches and guidance on their function at postnatal mothers’ homes and in the community. In the longer term a cadre of Community Nurses should be developed, who not only take care of reproductive and maternal health but of other health services and the sanitation and nutrition information needs of the community.
• To improve the quality of midwifery care, it is recommended that the Federal government finalise the draft National Nursing and Midwifery Strategy and Action Plan (2020 – 30) and both Federal and Provincial governments ensure the production of midwives (Proficiency Certificate Level (PCL) and Bachelor-level) as projected by the Nursing and Midwifery Strategic Plan (—2020-30). While production is going on, the GoN should prioritise deployment and transition plans for relevant health personnel, including revising the SBA Policy 2006.
• High-caseload CEONC service sites with more than 300 deliveries per month should have on-site birthing units led by midwives or by SBA-trained nurses. A protocol should be developed by a technical team of senior midwives and obstetricians.
• Care of newborns should be strengthened using feedback from studies that review the effectiveness of implementation of NeNAP.
• To make maternal and perinatal death reviews more effective, health care providers’ concerns, including confidentiality, must be addressed to ensure more accurate and complete reporting. Including analysis of near misses in the review mechanism could boost the morale of health workers. The review system should be scaled up across the country and used to monitor the conditions that contributed to deaths and whether improvements have been made in health system response to critical cases. One aspect of the Accountability Mechanism will be for the Health Facility Management Committee (HFOMC) to follow up if, how and what preventive actions have been taken after Maternal and Perinatal Death Surveillance and Response (MPDSR), and make necessary provisions to support the implementation of the recommendations.
• The Road Map further recommends that Peoples’ Representatives have the tools and use them to advocate to the government for greater investment in MNH. The leaders should be encouraged to use the tools to develop sound plans for their constituencies as well as to advocate to stakeholders about the economic benefits of investing in the health system, especially for MNH and other social and environmental determinants of health.
• Recommendations are made to foster collaboration between the public and private sector and improve utilisation of innovative approaches in service delivery, eHealth and mHealth to ensure an effective and efficient health system that takes into account the voices of the people and enhances accountability at all levels.

STRATEGIC APPROACHES

The strategic approaches build on NHSS 2015–2020, and include the following:

• Health systems reform: high priority will be given to strengthening current programmes and introducing new elements where necessary, keeping in view the structural reforms due to federalisation.
• Multisectoral approach: this approach recognises the importance of social determinants and other sectors that will contribute to the reduction of maternal and newborn deaths, such as education, economic and social upliftment, including for gender, agriculture and nutrition, roads and transport, water, sanitation and hygiene, legal and administrative etc. will continue to receive priority engagement and support.
• Partnerships: private sector, non-governmental organisation, academic and research institutions, professional bodies and civil society will continue to have important roles for MNH in the Road Map
• Innovations: innovative technology, such as distance learning, electronic and mobile phone applications for patient follow-up and education, and data generation, management and utilisation will be increasingly strengthened and used.
• Capacity building: while the technical capacity of health staff will continue to be enhanced, an additional focus will be held on the planning, implementation and monitoring of programmes in the federal context, where roles and responsibilities are being defined for all levels of the government. In addition, the Road Map will also engage with and build the capacity of peoples’ representatives and civil society to demand greater investment in MNH.

• The Right to Safe Motherhood and Reproductive Health Regulation, 2020
• International Safe Abortion Day- “Self-Managed Abortion”
• COVID-19 and Maternal Health: Tips for Pregnant Women need to do during Lockdown
• Interim Guidance for RMNCH services in COVID 19 Pandemic
• Shining a spotlight on maternal and neonatal sepsis: World Sepsis Day 2017

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