Safe Motherhood and Newborn Health in Nepal

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. 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).
The following strategies have been adopted to reduce risks during pregnancy and childbirth and address factors associated with mortality and morbidity:

• Promoting birth preparedness and complication readiness including awareness raising and improving availability of funds, transport and blood supplies.
• The Safe Motherhood Programme (Aama Suraksha Programme) promotes antenatal checkups and institutional delivery.
• The expansion of 24-hour emergency obstetric care services (basic and comprehensive) at selected public health facilities in all districts.

The Safe Motherhood Programme has made significant progress since it began in 1997. Service coverage has grown along with the development of policies, programmes and protocols. The policy on skilled birth attendants (2006) highlights the importance of skilled birth attendance (SBA) at all births and embodies the government’s commitment to train and deploy doctors, nurses and ANMs with the required skills across the country. The 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 coordinated implementation of strategies and plans envisioned in NHSP-2 and the National Safe Motherhood Plan (2006–2017) have resulted in impressive progress on service expansion and the increasing use of maternal and newborn health (MNH) and reproductive health care services. 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.
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The 2015 earthquakes damaged many health facilities and disrupted MNH and reproductive health services and the ability of communities to access health services. FHD, with support from its partners, has made concerted efforts to restore services and improve the quality of health services in line with the government’s aim to ‘build back better’.

Main strategies of the Safe Motherhood Programme

1. Promoting inter-sectoral coordination and collaboration at central, regional, districts and community levels to ensure commitment and action for promoting safe motherhood with a focus on poor and excluded groups.

2. Strengthening and expanding delivery by skilled birth attendants and providing basic and comprehensive obstetric care services at all levels. Interventions include:

• developing the infrastructure for delivery and emergency obstetric care;
• standardizing basic maternity care and emergency obstetric care at appropriate levels of the health care system;
• strengthening human resource management — diploma in gynaecology (DGO), advanced skilled birth attendant (ASBA), SBA, anaesthesia assistant training and deployment;
• establishing a functional referral system with airlifting for emergency referrals from remote areas, the provision of stretchers in VDC wards and emergency referral funds in remote districts; and
• strengthening community-based awareness on birth preparedness and complication readiness through FCHVs and increasing access to maternal health information and services.

3. Supporting activities that raise the status of women in society.

4. Promoting research on safe motherhood to contribute to improved planning, higher quality services and more cost-effective interventions.

Activities

Birth Preparedness Package and community level maternal and newborn health

FHD continued to expand and maintain MNH activities at community level including the Birth Preparedness Package (jeevan suraksha flipchart and card) and distributed the matri suraksha chakki (misoprostol) to prevent postpartum haemorrhage (PPH) in home deliveries.

The public health system promotes:

• birth preparedness and complication readiness (preparedness of money, health facilities for the
• delivery, transport and blood donors);
• antenatal care (ANC) and postnatal care (PNC) (iron, tetanus toxoid, albendazole);
• self-care (food, rest, no smoking and alcohol) in pregnancy and postpartum periods;
• essential newborn care; and
• the identification of and prompt care seeking for danger signs in the pregnancy, delivery, postpartum and newborn periods.

In 2066/67, the government approved PPH education and the distribution of the matri suraksha chakki through FCHVs to prevent PPH in home deliveries. For home deliveries, three misoprostol tablets (600 mcg) are handed over to pregnant women to take immediately after delivery and before the placenta is expelled. Forty-two districts were implementing the programme in 2072/73.

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. Women with detected abnormalities such as abnormal lies and presentation of the foetus are referred to a facility with the needed services. This programme is being implemented in the 11 remote districts of Mugu, Dhading, Darchula, Sindhupalchowk, Solukhumbu, Bajura Bajhang, Achham, Dhankuta, Humla, and Baitadi.

Reproductive health morbidity prevention and management programme

1. Management of pelvic organ prolapse: Pelvic organ prolapse (POP) is a common reproductive health morbidity in Nepal and contributes to many disability adjusted life years (DALYs) and social consequences. Multiparity, maternal malnutrition, too frequent pregnancies and heavy work after delivery are the main risk factors. Each year the government allocates funds to manage POP including free screening, providing silicon ring pessaries, Kegell exercise training and free surgical services at designated hospitals. In 2072/73 more than 14,800 women were screened for the condition of which 8.8 percent had first degree POP, 7 percent second degree POP and 8.9 percent third degree POP. More than 1,100 women received surgical treatment and 2,019 women were instructed to manage the condition using ring pessaries.
2. Cervical cancer screening and prevention training: Cervical cancer is the most common cancer of women in Nepal, accounting for 21.4 percent of all cancer among 34–64 year old women. The national guidelines on cervical cancer screening and prevention (2010) call for screening at least 50 percent of women aged 30–60 years and for reducing the mortality due to cervical cancer by 10 percent with recommended screening among this group every five years. Cervical cancer screening is done by visual inspection of the cervix by trained nurses or doctors. If any signs of a pre-cancerous lesion are seen, women are referred for cryotherapy to cure the lesion. This approach is costeffective as the early detection of lesions and early management by cryotherapy will usually prevent progression to cervical cancer, and the cost of scaling up this activity is relatively low.
3. Obstetric fistula management: Obstetric fistula affects many women from poorer communities and significantly impairs their quality of life due to the social stigma attached to this condition and their physical suffering.

Expansion and quality improvement of service delivery sites: FHD continued to expand 24/7 service delivery sites like birthing centres, BEONC and CEONC sites at PHCCs, health posts and hospitals.

Emergency referral funds

The main objective of this programme is to support emergency referral transport to women from poor, Dalit, Janajati, geographically disadvantaged, and socially and economically disadvantaged communities who need emergency caesarean sections or complication management during pregnancy or child birth. The regional health directorates also have funds to airlift needy women from areas where motorised transport is not available or when immediate transfers are needed. Based on recommendations, free referrals for obstetric complications from birthing centres and BEONC centres to CEONC centres are being implemented in Ramechhap and Dolakha districts.

Safe abortion services

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.

Nyano Jhola Programme

The Nyano Jhola Programme was launched in 2069/70 to protect newborns from hypothermia and infections and to increase the use of peripheral health facilities (birthing centres). Two sets of clothes (bhoto, daura, napkin and cap) for newborns and mothers, and one set of wrapper, mat for baby and gown for mother are provided for women who give birth at birthing centres and district hospitals. The programme was implemented in all 75 districts in 2072/73.

Aama and Newborn Programme

The government has introduced demand-side interventions to improve the quality of maternal care and encourage institutional delivery. The Maternity Incentive Scheme, 2005 provided transport incentives to women to deliver in health facilities. In 2009, user fees were removed from all types of delivery care under the Aama Programme. In 2012, the separate 4ANC incentives programme was merged with the Aama Programme. In 2073/74, the Free Newborn Care Programme (introduced in FY 2072/73) is being merged with the Aama Programme with the provisions listed in HERE