National Safe Motherhood Program in Nepal is initiated in 1997 with the aims to reduce maternal and neonatal mortality and morbidities by addressing avoidable factors that are caused by the complications of pregnancy and childbirth. Global evidence shows that all pregnancies are at risk. Moreover, complications during pregnancy, delivery and the postnatal period are difficult to predict. Evidence has suggested that three delays are of critical importance to the outcomes of an obstetric emergency in Nepal’s context:
(i) delay in seeking care, (ii) delay in reaching care, and (iii) delay in receiving care.
To reduce the risks associated with pregnancy and childbirth and address factors associated with mortality and
morbidity three major strategies have been adopted in Nepal:
- Promoting birth preparedness and complication readiness including awareness raising and improving the availability of funds, transport and blood supplies.
- Encouraging for institutional delivery.
- Expansion of 24-hour emergency obstetric care services (basic and comprehensive) at selected public health facilities in every district.
National Safe Motherhood Program has made significant progress since its initiation. Service coverage has grown along with the development of policies and protocols. For example, role of service providers such as skilled birth attendants (SBA) has expanded. The policy on skilled birth attendants endorsed in 2006 by MoHP specifically identifies the importance of skilled birth attendance at every birth and exemplify the Government’s commitment to training and deploying doctors and nurses/ANMs with the required skills across the country. Similarly, endorsement of revised National Blood Transfusion Policy 2006 is also a significant step towards ensuring the availability of safe blood supplies in the event of an emergency.
In order to ensure focused and coordinated efforts among the various stakeholders involved in safe motherhood and neonatal health programming, the National Safe Motherhood Plan (2002-2017) has been revised with wide participation of government and non-government, national and international partners. The revised Safe Motherhood and Neonatal Health Long Term Plan (SMNHLTP 2006-2017) includes recent developments not adequately covered in the original plan. These include: recognition of the importance of addressing neonatal health as an integral part of safe motherhood programming; the policy for skilled birth attendants; health sector reform initiatives; legalization of abortion and the integration of safe abortion services under the safe motherhood umbrella; addressing the increasing problem of mother to child transmission of HIV/AIDS; and recognition of the importance of equity and access efforts to ensure that most needy women can access the services they need. The SMNHLTP identifies the following goal, purposes and outputs.
The objective of SMP is to reduce mortality and morbidity among women and new borne, during pregnancy, child birth and the post natal period through the adoption of a combination of health and non-health measures.
1. Birth Preparedness Package and MNH Activities at Community Level
Expansion and maintenance of MNH activities at community level which includes
- revised Birth Preparedness Package (Jeevan Suraksha Flip Chart and Jeevan Suraksha Card) and Matri Suraksha Chakki (Misoprostol)
- distribution for prevention of postpartum haemorrhage (PPH) at home delivery focusing continuum of care from pregnancy, through birth and the post-partum period, including the newborn.
Community level activities promote strengthening birth preparedness and complication readiness (preparedness of money, SBA/health facilities, transport and blood donors), promotion of key ANC/PNC services (Iron, TT, Albendazole), self-care in pregnancy and post-partum period (food, rest, no smoking and no drinking alcohol), identification and prompt care seeking for danger signs in pregnancy, delivery and post-partum period and education and distribution of Matri Suraksha Chakki for prevention of PPH at home delivery.
2. Rural Ultra Sound Program
Timely identify the complication during pregnancy and provide appropriate referral to the health facility for complication management. For this, a trained nurse uses a portable ultrasound machine for scan purpose during pregnancy. In last FY 2068/69, the program has been piloted in two districts Mugu and Dhading. This year these two districts have formally initiated the program.
3. Uterine Prolapse
Many factors are directly and indirectly cause Uterine Prolapse (UP). It is related to every aspects of mandate of Reproductive health (RH) and Rights, gender equity, and empowerment of women. Addressing this problem has the potential to serve as an entry point for improving women’s Reproductive Health and Reproductive Rights. While UP is not an MDG indicator, it is indirectly related to goal of NHSP-2.
Uterine prolapsed is the priority one program of Government of Nepal. In the last 5 years separate fund has been allocated for uterine prolapse. Uterine prolapse treatment and surgery operational guideline 2065 was developed and has been revised twice first in 2066 and second in 2068. A focal person has been identified for the program in the FHD.
4. Human Resource
A total of 1,200 ANMs and 60 staff nurses have been recruited on local contract to support 24-hour delivery services in PHCCs and HPs. Additionally, money has been allocated to strengthen and expand CEOC services in twenty seven districts with emphasis on (local) recruitment of MDGP/Gynecologists. This has resulted in increased number of CS in these districts. Six doctors who have been trained by National Academy of Medical Sciences (NAMS) in Gynecology and Obstetrics (one-year Diploma course) have currently been providing the service.
Family Health Division has been coordinating with NHTC to provide SBA training to doctors and staff nurses. Since in-service SBA training was initiated in 2007, a total of 5247 SBAs have been trained. 79 doctors have also been trained in advanced SBA training including caesarean section.
5. Emergency Referral Fund
It is estimated that 15 percent of the pregnant women develop complication during pregnancy and 5 to 15 percent of them need CS for delivery (WHO, 2009). In difficult geographical terrain and inadequate BEOC/CEOC services, it is very important to have referral services to the pregnant women. To address this issue, FHD has lunched emergency referral fund program to facilitate referral services in fourteen districts namely Bhojpur, Khotang, Sunsari, Rasuwa, Manang, Mustang, Dolpa, Humla, Jajarkot, Mugu, Rolpa, Rukum, Bajhang, and Darchula.
A total of two hundred thousand rupees has been allocated as seed money for each district to be used by a locally formed committee as per the guidelines. The main objective of this program is to provide the referral services to women from poor, dalit, janjati, geographically disadvantage; socially and economically disadvantage communities who need emergency caesarean section (C/S) or complication management during pregnancy.
6. Safe Abortion Services
Comprehensive Abortion Care (CAC)A encompasses comprehensive approach integrated between three services, family planning, safe abortion and post abortion care. Ensuring the availability of CAC refers, termination of unwanted pregnancies through safe technique with effective pain management, post procedure family planning information and service to ensure women are able to plan when to have children and avoid further unwanted pregnancies.
Only trained doctors or health workers can provide safe abortion services at the government accredited health facilities, with the consent of women and based on the criterion spelled in the safe abortion service guideline. The increasing trend in abortion utilization shows that more and more women are seeking safe abortion services. In FY 2069/70 alone a total of 195 service providers have been trained on safe abortion services. 84,011 women received safe abortion service from 574 listed
In situation such as high turnover of doctors, training nurse providers, especially auxiliary nurse midwife, in safe abortion service has been seen as an effective way to ensure uninterrupted service delivery. Nepal is also implementing medical abortion (MA) in some districts mainly with the support from IPAS and currently there are 179 MA listed sites. The existing FCHV network has been utilized to communicate information on safe abortion as in the case of other RH problems. They provide appropriate referral based on the RH needs assessment (using urine pregnancy tests for early detection of pregnancy) for services such as ANC, FP and CAC. Additionally, Medical personnel networks such as pharmacist associations and nursing college teachers ‘groups have also been used to reach women in their communities as well as current and future service providers.
7. Aama Program
The revised Aama guideline has been implemented since the start of FY 2069/70. The Aama guideline specifies the services to be funded, the tariffs for reimbursement and the system for claiming and reporting on free deliveries each month. After revision, Aama program has four components:
- the Safe Delivery Incentive Program (SDIP), a cash incentive scheme, which was initiated in July 2005,
- free institutional delivery care, which was launched in mid-January 2009,
- incentive to health worker for home delivery and
- incentive to women for 4ANC visits.
The Aama program provisions are:
- Incentives to women on institutional delivery: A cash payment is made to women immediately following institutional delivery: NRs. 1,500 in mountain, NRs. 1,000 in hill and NRs. 500 in Terai region.
- Free institutional delivery services: A payment to the health facility for the provision of free delivery care. For a normal delivery health facilities with less than 25 beds receive NRs. 1,000; health facilities with 25 or more beds receive NRs. 1,500.
- For complicated deliveries health facilities receive NRs. 3,000; for C-Sections NRs. 7,000. Ten complications i.e. APH requiring blood transfusion, PPH requiring blood transfusion or MRP or exploration, Severe, pre-eclampsia, Eclampsia, Retained placenta with MRP, Puerperal Sepsis, Instrumental delivery, Multiple delivery, RH Negative and post abortion management cases that include blood transfusion for haemorrhage, and admission longer than 24 hours with IV antibiotics for sepsis are included as complicated deliveries while laparotomy for perforation due to abortion has also been added to the criteria for surgery along with C/S, laparotomy for ectopic pregnancy and ruptured uterus.
- Incentive to women for 4ANC visits: A cash payment of NRs. 400 is made to women on completion of four ANC visits at the 4, 6, 8 and 9 months of pregnancy following institutional delivery.
- Incentives to health workers for home deliveries: A cash payment of NRs. 100 is made to health worker for home deliveries. Copies of birth registration or death certificate need to be produced to claim incentive for home deliveries.