1.

4 Maternal and neonatal

health status
 Maternal health status in Nepal

Globally ,585,000 women died from the

complication of pregnancy and labour.(WHO1996)
more than 99% of deaths occurred in developing
countries and MMR is at 100 times higher in Nepal
than in other developed countries. the MMR of
Nepal is 539/100,000 (1996) and
281/100,000( 2006) and 170 deaths/100,000 live
births (2010)
 continue

44% of mother received ANC from SBA.

In additional 28% received ANC from train
health worker such as HA,ANM and MCHW
or VHW.
>2% of women received ANC from a TBA or
FCHW.
1 in 4 birth received no ANC at all
 continue

There has been a significant improvement over the

past ten year in the proportion of mothers who
receive ANC from SBA, increasing from 24%in
1996,to 28%in 2001 and 44%in 2006,

About 3 in 10 women make 4 or more ANC visits

during their entire pregnancy.

The %of women who made 4 or more ANC visit

during their pregnancy tripled during the past 10
years.
 continue

The median duration of pregnancy for the 1st

antenatal visit is 4.6 months, indicating that
Nepalese women start ANC care at relatively late
stage of their pregnancy.

Among mother who received ANC more than

half(57%)reported that they were informed about
pregnancy complication during ANC visit.
 continue
79.5% took iron tablets &20%took intestinal parasite
drugs while pregnant with their last birth.(2011)

About 34% of pregnant women who sought ANC wt.

and had their BP taken.

About 3 in 10 women gave urine and Blood sample

for testing.

Less than two third of pregnancy women received

two or more TT injection during their last pregnancy.
 continue

The % of received at least 2 TT injection for their last

birth has increasing by 40% over the past five years.

The birth taking place in a health facility has double

in the past 5 years.

Less than one -fifth of births take place with the

assistance of SBA.health assistance or health worker
assist in the delivery of 4% of birth,FCHWs assist
2% of births and TBAs assist in 19%of birth.
 continue

7% of births were delivered without any type of

assistance at all.

One third of women received PNC.

1 in 5 women received care with in the first 24

hours and 4 %of women were seek with in 1-2 days of
delivery for PNC .
 continue

19% of mothers received PNC from an SBA.

1 in 5 mothers had a pelvic examination during their

postnatal check up.

The delivery by SBA has increased from 21% in

2065/66 to 32% in 2066/67 and 36% in 2067/68.

35% of the mother delivered in health facilities in

2o11
 Neonatal health status in Nepal.

18 % of no institutional births involved the use of

instrumental from a clean home delivery.

There is significant increasing over the past 10 years

in the use of instrumental from a clean home
delivery kit .

The clean home delivery kit is used most in the far

western terai sub region (39%)and least in the far
western hill sub region (4%)
 continue

The use of these kit is more common among highly

educated women .

In addition to the use of instrumental from a safe

delivery kit ,a new or boiled blade is used in 61% of
birth.

A hasiya is used in 12% of birth and a used blade in

5%of birth.
 continue

About a quarter of the babes had some material (oil ,

ointment)placed on their stump ,a practice that
could lead to infection.

The practice of keeping the newborn worm is not

common in Nepal.

The general practice is to look for clothes after the

baby is born and in most cases, families do not have
worm clothes ready at the time of delivery.
 continue
The newborn is kept naked or covered by a thin piece of
cloth until the placenta is delivered or the umbilical
cord is cut.

The 9 in 10 babies were given a bath within 24 hours of

delivery

4% of babes received PNC from an SBA.

neonatal mortality rate is 33/1ooo in 2011

IMR of Nepal is 46/1000 live birth. This should be

reduced to 38/1000 by the year 2068-2o71
 The Safe Motherhood Initiative

In 1987 the World Bank, in collaboration with WHO

and UNFPA, sponsored a conference on safe
motherhood in Nairobi, Kenya to help raise global
awareness about the impact of maternal mortality and
morbidity.
The conference launched the Safe Motherhood
Initiative (SMI), which issued an international call to
action to reduce maternal mortality and morbidity by
one half by the year 2000 AD. It also led to the
formation of an Inter Agency Group (IAG) for Safe
Motherhood, which has since been joined by UNICEF,
UNDP, IPPF, and the Population Council.
 Safe motherhood program in Nepal

 The main trust of national safe motherhood

programmed is to reduce maternal and neonatal
mortality by addressing the high rate of death and
disability caused by the complication of pregnancy
and childbirth.
 This is because global experience shows that all
pregnancies are at risk and complications during
pregnancy, delivery and postnatal , maternal
deaths are difficult to predict.
 continue
Experience also shows that the avoidance of the 3
delays was imperative (necessary) to achieve the goal
of reducing maternal mortality .
these delays included ,
 delays in seeking care

Delay in reaching care

Delay in receiving care

 continue

Recognizing that every pregnancy is at risk.

The following three majors strategies
have been adopted.
Providing round and clock emergency
obstetrics care
Ensuring the presence of skilled birth
attendants at delivery.
Promoting birth preparedness and
complication readiness by preparing for BT
and money.
 Goal

Improve maternal and neonatal health and

survival
A reduction in the maternal mortality ratio
from 281 per 1000 live birth to 134 per 1000 by
2017
A reduction in the neonatal mortality ratio
from the 33/1000 to 15/1000 by 2017
 Purpose

Increase health practice and utilization of quality

maternal and neonatal heath service
Increase in percentage of deliveries assisted by on
SBA 36% by 2o11 to 60% by 2017
The % of deliveries taking place in a health facility
increased35%by 2o11 to 40% by 2017
Increase in met need for emergency obstetrics care
of 3% per year
Increase in met in need for C/S of 4%per year
 2.1. Essential Services for Safe Motherhood

Safe motherhood can be achieved by providing high

quality maternal health services to all women. These
services for safe motherhood should be readily
available through a network of linked community
health care providers, clinics and hospitals.
These services could be provided at different levels
including home and health institutions
Essential Services include:
1. Community education on safe motherhood
2. Prenatal care and counseling, including the promotion
of maternal nutrition
3. Skilled assistance during childbirth
4. Care for obstetric complications, including emergencies
5. Postpartum care
6. Post-abortion care and, where abortion is not against
the law, safe services for the termination of pregnancy
7. Family planning counseling, information and services
8. Reproductive health education and services for
adolescents
 Concept of essential obstetric care

It is the term used to describe the element of

obstetric care needed for the management of
both normal and complicated pregnancy
delivery and postpartum period. It includes
Primary essential obstetric care
Basic essential obstetric care
Comprehensive essential obstetric care.
 Primary essential obstetric care

Administration of parental antibiotic

Administration of parental oxytocic drugs

Administration of parental anticonvulsion

 Basic essential obstetric care.

Primary essential obstetric all care other are

Manual removal of placenta.

Evacuation of product of conception(MVA)

Assisted deliveries by vacuum or forceps

Comprehensive essential obstetric care

All care provide as primary essential obstetric

care and basic essential obstetric care and
other are

Blood transfusion

Surgical obstetrical intervention including C/S

 Emergency obstetric care

EmOC is the term to be used to describe the element of

obstetric care needed for complication arising during
pregnancy, delivery and postpartum period. It is
commonly agreed that approximately 15%of all pregnant
women will develop serious complication.
there are five major causes of direct maternal
death such as
 Hemorrhage
Sepsis
Obstructive labour
Hypertensive disorder
Unsafe abortion.
Definition of Skilled Birth Attendant

“An accredited health professional-such as a

midwife, doctor or nurse-who has been
educated and trained to proficiency in the
skills needed to manage normal
(uncomplicated) pregnancies, childbirth and
the postnatal period and in the
identification, management and referral of
complications in women and newborn”
 SBA Policy Statement

The main thrust of MoHP towards reducing maternal

and neonatal mortality in Nepal is through the Safe
Motherhood Programme,including Newborn Care, by
improving maternal and neonatal health services at all
levels of the health care delivery system and ensuring
skilled care at every birth.

MoHP=ministry of health and population

 General Objective

To reduce maternal and neonatal morbidity

and mortality by ensuring availability, access
and utilization of skilled care at every birth.
 Specific Objectives

 To ensure that sufficient numbers of SBAs are

trained and deployed (utilized) at primary health
care levels with necessary support system.

To strengthen referral services for safe motherhood

and newborn care, particularly at the first referral
level (district hospitals).

To strengthen the pre-service and in-service SBA

training institutions to ensure that all graduates will
have the necessary skills.
 continue
To strengthen supervision and support
system to ensure that all SBAs are able to
provide quality maternal and newborn
health care according to the national
standard and protocol.

To develop regulating and re-licensing

systems for ensuring that all SBAs have the
abilities and skills to practice in accordance
with the core Competencies.
 Elements of SBA Policy

Safe Motherhood was identified as a priority

programmed for the government in the
National Health Policy of 1991; which was
followed in 1994 by the formulation of a
national Safe Motherhood Policy that placed
emphasis on:
 continue

Strengthening maternity care ,including

family planning services at all levels of
health service delivery including the
community.
Strengthening the technical capacity of
maternal health care providers at all levels of
the health care system through training.
 continue

Deploying and providing appropriate

support and personnel for each level of
maternity services was an identified
objective. The importance of appropriate
human resource as an essential component
for ensuring quality maternal health
services.
 Rationale of introducing SBA policy

1) A reduction of MMR by three-quarters

between 1990 and 2015;
2) An increase in the proportion of births
attended by skilled attendant.
The international targets for the proportion of
births attended by a skilled attendant call for
80% of all births by 2005, 85% by 2010 and
90% by 2015.
 continue

However, WHO suggests that in countries

where the MMR is very high, the goal should
be at least 40% of all births assisted by skilled
birth attendants by 2005, 50% by 2010 and
60% by 2015.

In Nepal, currently only 13 percent of women

are attended by a health worker during
delivery, and it is important to note that not
all of these health workers qualify as SBAs.
 Strategies

MoHP identifies the following strategies:

1 Human Resource Development
A continuum of properly functioning maternal and
neonatal health services based on the availability of
SBAs having all necessary skills and abilities at the
PHC level, will take time. Therefore, a part from
having a medium and long-term strategy, a short-
term strategy is also required.
 continue

a) Short-Term (in-service) Measures

The short term course such as midwifery refresher,

BEOC training and one year post basic diploma
course in midwifery.
 continue

b) Medium-Term (Pre-service) Measures

The current ANM course will be reviewed, and will

be restructured as a two-year course in order to
ensure that all ANMs attending the course develop
competency

The midwifery section of the current staff nurse

(PCL) and B.Sc. Nursing course will be revised and
adjusted to include core elements of SBA skills.
 continue
The MDGP course will be updated for SBA skills and
advanced SBA skills

The Obstetrics and Gynaecology section of the

current MBBS course will be reviewed and adjusted
to include core elements of the SBA skills.
 continue
c) Long-Term (Pre-service) Measures

MoHP is in the process of initiating a new cadre

(group of trained personnel) of Professional
Midwife(PM) as a crucial human resource for safe
motherhood, providing service and leadership in
midwifery for the country.
2 Strengthening SBA Training Sites

All existing training sites (pre-service and in-service)

will undergo the process of accreditation. Rapid
expansion of the number of new accredited training
sites will be a priority to ensure production of
competent SBAs for in order to achieve the national
target of 60% deliveries conducted by SBAs.
 3 Deployment and Retention of SBAs

As a part of decentralization SBAs will be addressed

locally to ensure round the clock provision of delivery
services.

Job descriptions of doctors, staff nurses, midwives

and ANMs will be updated according to the core
competencies identified for SBAs

Priority for posting of ANM with SBA skills will go to

remote districts.
 4 service provision

Quality services as a continuum of integrated care at

primary health care and referral levels will be
ensured in conformity with the evidence based
National Standard and Protocol. This will cause
provision of essential maternal and newborn health
care at primary health care level by SBAs, and when
complications occur, at referral levels (BEOC and
CEOC sites).
 5 Enabling Environment

Maternal and neonatal health outcomes will only be

improved if the SBA is supported by: strong referral
back-up by a district health team, including
supportive supervision; effective partnerships with
other health workers such as the HA, AHW, MCHW,
VHW, health volunteers (FCHV), other non-formal
care givers like TBAs, and the community.
6 Role of Professional organizations /association

Professional organizations/associations, in
collaboration with MoHP, will develop a system of
quality assurance, performance review and capacity
building support for SBAs.
 7 Role of non-government sector and
private sector
NGOs, the private sector and communities will be
encouraged to establish maternity hospitals and
community based ''birthing centres'‘ by mobilizing
their own resources. These facilities could be used as
midwife led training sites.
 8 Institutional arrangements.

The HR division of MoHP will take the lead role for

human resource management, and particularly the
SBAs. The National Health Training Centre (NHTC)
will take lead role for SBA human resource
development. The roles and responsibilities of the
education ministry and Council for Technical
Education and Vocational Training (CTEVT) will be
re-enforced in strengthening standards of training
institutions and the SBA course.
 Core competencies of SBA

Communicate effectively to provide holistic “women

center” care.
Take history, performs physical examination and
specific screening test as required.
Educate and assist women and family about the
importance of making birth plan.
Identify complication in mother and newborns
perform 1st line management and make effective
referral.
 continue
Perform PV examination and interpret the findings

Identify the onset of labour.

Monitor maternal and fetal well being during labour

and provide supportive care.

Record maternal and fetal well being on a

partograph and identify maternal and fetal distress
and take appropriate action including referral
 continue
Identify the delayed progress of labour and take
appropriate action including referral.

Manage normal vaginal delivery and third stage of

labour.

Assess the newborn at birth and give immediate

care.

Identify the life threatening condition in new born &

take essential life saving measure.
 continue
Identify hemorrhage and HTN in labour and provide
1st line management including referral.

Provide postnatal care to women and newborn ,and

also provide post abortion care.

Assess women and newborn for early and exclusive

breastfeeding and successful breastfeeding.
 continue

Supervise non skilled and semi skilled attendants

including TBAs MCHWs & paramedics to ensure that
they provide care during pregnancy, childbirth and
postpartum is of good quality.

Provide advice ,counseling and service in postpartum

family planning .

Educate women and family to prevent STDs

including HIV.
 continue
Collect and report relevant data, collaborate in data
analysis and case audits.

Use vacuum extraction in vaginal delivery.

Perform MVA for the management of incomplete

abortion.

Repair vaginal tears

Perform manual removal of placenta.

 REPRODUCTIVE HEALTH

The concept of reproductive health was introduced

at the international conference on population and
development (ICPD) at Cairo in 1994 later on it was
also accepted by WHO.
WHO’S definition of RH, adopted in the program of
action of the international conference on population
and development (ICPD) and endorsed, support by
the UN general assembly and by the Beijing
declaration is as follows ;
 1.4 REPRODUCTIVE HEALTH

• Reproductive health (RH) is define as a state of

complete physical, mental and social well being and
not merely the absence of disease and infirmity in all
matters related to the reproductive system and to its
function and processes.
• Reproductive health therefore implies that people are
able to have a satisfying and safe sex life and that
they have the capability to reproduce and the
freedom to decide if, when, and how often to do so.
• The right of men and women to be informed of and
have access to safe, effective, affordable and
acceptable method of family planning of their
choices as well as other methods of their choice of
regulation of fertility ,which are not against the law
and the right to access to appropriate health care
services that will enable women to go safely through
pregnancy and childbirth .
 Components of Reproductive Health

1. Safe motherhood : education, and service for

healthy pregnancy, safe delivery and postnatal care
including breast feeding.
2. Family Planning: Family planning counseling,
information, education, communication and
services (emphasizing the prevention of unwanted
pregnancy).
3. Child health: Care of new born
4. Prevention and management of complications of
abortion
5. RTI/STI/HIV/AIDS: Treatment of reproductive tract
infections, including sexually transmitted infections;
Information and counseling on human sexuality,
responsible parenthood and sexual and reproductive
health
6. Prevention and management of sub fertility
7. Adolescent reproductive health
8.Problems of elderly women : uterine prolapse,
cervical , breast cancers and cancer of the reproductive
system and care of the elderly.
9. Gender based violence : sex selection , forced
prostitution , rape of girl children and others.
NATIONAL REPRODUCTIVE HEALTH STRATEGY

Implement the Integrated Reproductive Health

Package at all levels based on standardized clinical
protocols and operational guidelines.
Enhance functional integration of RH activities
carried out by different divisions.
Emphasize advocacy for the concept of RH including
the creation of an enabling environment for inter
and intra-sectorial collaboration.
 Review and develop IEC materials
 Cont..

 Review and update the existing training curricula of

various health workers.
Ensure effective management system by
strengthening and revitalizing existing committees at
various levels.
Develop national RH research strategies which
outlines research priorities and work plans based on
information requirements of policy makers,
planners, managers, and service providers
 CONTD.

Construct /upgrade appropriate service delivery and

training facilities at the National, regional, District and
health post level.
Institutional strengthening through structural
planning, monitoring/ Supervision and performance
evaluation review.
Develop an appropriate RH programme for adolescents
Support for national experts/consultants
Promote inter-sectoral and multi-sectoral co-
ordination. 
 INTEGRETED HEALTH PACKAGE

Based on the essential element of Comprehensive Reproductive

health Care, an integrated health care package has been adopted for
Nepal. The integrated Reproductive health care package will include;
 Family planning
 Safe motherhood
 Child health (new born care)
 Prevention and, management of complications of abortion
 RTI/STD/HIV/AIDS
 Prevention and management of sub fertility
 Adolescent reproductive health
 Problem of elderly women, i.e. uterine prolapse, cervical and breast
cancers treatment at tertiary and private sectors. 
 Major problems related to RH

1 Maternal morbidities:
a.Immediate complications: Sepsis, hypertensive
disorders, hemorrhage etc.
b.Long term complications: Vesicovaginal or
rectovaginal fistula, uterine prolapse, Pelvic
inflammatory diseases, urinary or faecal 
 Contd.

c. Indirect obstetric morbidity: Resulted from diseases

like anaemia, TB, aggravated by the physiological
effects of pregnancy.
d. Psychological obstetric morbidity: Postpartum
psychosis or depression and other mental health
problems
 Continued.

2. Gynecological morbidity: Condition, disease or

dysfunction of reproductive system that is not related to
pregnancy, abortion or childbirth, but may be related to
sexual behavior.
a. Reproductive tract infection
i) STIs: Viral, bacterial, chlamydial infections,
gonorrhoea, trichomoniasis, syphilis, chancroid,
genital herpes, genital warts and HIV.
ii) Endogenous infections: overgrowth of organisms
normally present in the vagina e.g. bacterial vaginosis
and candidiasis.
 Contd.

iii) Iatrogenic infections:

a. introduction of microorganism into the reproductive
tract through a medical procedure.
b. Endocrine or hormonal disorder: Metrorrhagia,
amenorrhea, menorrhagia, dysmenorrhoea,
oligomenorrhoeac. Infertility: WHO estimates 8-12%
of couples are infertile. causes: endocrinal disorder,
STI, puerperal sepsis, post abortion sepsis,
congenital 
 Contd.

d. Uterine prolapse
 Causes:
 Multiparity,
 Excess intra abdominal pressure
 Tissue atrophy
 Chronic health problem: constipation, pulmonary
disease etc.
 Family history
 Hard physical labour, lifting heavy weights
 Poor nutrition
 Contd

e. Gynaecological cancers:
 Cervical cancer
 Breast cancer
 Endometrial cancer
 Ovarian cancer
 Vaginal caner
 Vulva cancer
 Rarely fallopian tubes
f. Sexual dysfunctiong. Menopausal problems
 FAMILY / DICSISION MAKERS LEVEL

1.Family planning
 Need identification
 Knowledge of shops and institutions where contraceptives are
available.
 2.Safe Motherhood
 Identification of pregnant woman and recognition of danger signs
 Provide nutritious diet, supplements and adequate rest to
pregnant women.
 Encourage utilization of antenatal care services.
 Identify SBA for care during delivery.
 Birth preparedness and complication readiness including
arrangement of emergency funds and transport.
 Encourage utilization of postnatal care.
 Encourage registration of maternal death
 continued

3.New born care

 Proper care of newborn baby
 Identification of danger signs and complications related to newborn and
seek care from appropriate health institution.
 Complete immunization as the schedule of EPI programme.
 Registration of neonatal birth and death event.
 4. Prevention and management of abortion complication
 Recognition of sign and symptoms of abortion complications.
 Know where to seek help.
 5. RTI/STI/HIV/AIDS
 Promotion of condom.
 Recognize RTI/STD symptoms and seek care.
 Treatment of both partners in the case of infection.
 continued

6. Infertility
 Identification of Infertility
 Seek care and treatment of infertility by both partners.
 7. Adolescent health Family life education programme; eg, discussion
between parents and children about
delay marriage,
 delay pregnancy,
 nutritious diet especially to daughter
 education to daughters etc.
8. Elderly RH problem
 Identification of RH problem of reproductive organs.
 Identification of different health institutions for their treatment
and management.