The safe motherhood programme is one of the priority programme of Nepal. The goal of the National Safe Motherhood Program is to reduce maternal and neonatal morbidity and mortality and to improve the maternal and neonatal health through preventive and promotive activities as well as by addressing avoidable factors that cause death during pregnancy, childbirth and postpartum period. This presentation incorporates historical context, introduction, major achievements, actors, what Went Well, what didn’t go well, limitations, challenges, way forward of Safe Motherhood Program in Nepal.

1. Safe Motherhood Program in
Nepal: Challenges,
Opportunities and Way
Forward
Submitted By:
Kusumsheela Bhatta (403)
Madhurjee Dhakal (404)
Shrijana Shrestha (410)
MPH
Patan Academy of Health Sciences
Feb 14 , 2022 1

2. 2
Table of
Contents
2
• Historical Context
• Introduction
• Major Achievements
• Actors
• What Went Well
• What didn’t go well
• Limitations
• Challenges
• Way Forward

3. 01
Historical Context

4. 1976-
1985
1982
1987
1989
• The United Nations Decade for Women
• Helped focus attention on women's rights
and health
• Decade culminated in formulation of the
'Forward Looking Strategies' which called
for a reduction in maternal mortality by the
year 2000.
• WHO and the International
Federation of Gynaecologists and
Obstetricians(FIGO) Task Force
established
• Motive to draw attention to safe
motherhood at both global and
regional levels
• Safe motherhood conference in
Nairobi
• Global awareness of issue of maternal
mortality
• Commitment to strive for reducing
the mortality and morbidity related
to pregnancy and childbirth.
• World summit for
children, New York
• Included reduction in
maternal mortality as one
of the goals to be
monitored along with
increases in antenatal care
attendance.
Global context
Source: (WHO, 2003)

5. 1990
1994
1995
1996
• The women's Global Network for reproductive
rights and the latin American and Caribbean
• Women's Health Network issued a call to Action
on 28 May, 1990, declared International Day of
Action for Women's Health.
• Campaign focused particular attention on unsafe
abortion and on the poor quality of care meted
out to women by formal health care system.
The SMI Inter Agency Group
embarked upon a 2 year effort to
bring maternal health to a wider
audience and to a higher level of
decision-makers.
• ICPD conference Cairo
• Reinforced the above commitment
• Call to reduce maternal mortality and morbidity by
at least 50 percent
• Safe motherhood recognized as key component of
reproductive health
• Enabling environment, enhancing gender equality ,
equity and empowerment of women
• Gave priority in promoting reproductive health
including family planning and sexual health and
reproductive rights.
• UN Fourth World conference on Women in
Beijing
• Advocated integrated approach
• Includes health services, family planning
and women empowerment
• Social Summit in Copenhagen
Global context
Source: (WHO, 2003)

6. 1997
1998
• World Health Day 1998
• Devoted to safe motherhood
• Slogan 'Pregnancy is special: let's make it safe'
• Executive heads of major international
agencies came together with different
politicians to issue a Call to Action for safe
motherhood
• International technical consultation
in Colombo, Sri Lanka.
• Consultation brought together
different stakeholders
• Discussion helped to forge greater
consensus on interventions needed to
reduce maternal mortality
Global context
Source: (WHO, 2003)

7. Early
1960’s
1975
1988
1997
1998
• Integrated approach to community health and
family planning programmes
• Led the way for safer motherhood
• First long-term health plan (1975-1990)
• Contributed to scale up 1968 family planning and
maternal and child health project to all 75 districts.
Safe Motherhood Policy
• FCHV programme started
• Roles has gradually expanded
beyond FP to maternal and
child health information
services nationwide
• Safe motherhood programe
commenced under SLTP(1997-2017)
• Emphasized strengthening of
infrastructure for the reproductive
health service delivery
National context
Source: Nepal’s Safe Motherhood and
Newborn Health (SMNH) Road Map 2030

8. Safe motherhood policy,1998
● Policy emphasized on strengthening maternity care including family planning
services at all levels of health care
● Strengthening technical capacity of maternal health care providers at all levels
● Strengthening referral services for emergency obstetric care
● Policy objective - To reduce mortality and morbidity among women during
pregnancy, childbirth and the postnatal period through the adoption of combination
of health and health related measures.
11/12/2022 8

9. Safe motherhood policy,1998
● Strategies
 Promoting inter-sectoral collaboration in order to attain the aims of safe motherhood
 Strengthening and expanding basic maternity care services, including family
planning at all institutional levels
 Raising the status of women so that maternal morbidity and mortality will be
reduced
 Promoting research on safe motherhood
11/12/2022 9

10. 2000
2002
2004
• The National Adolescent Health and Development Strategy
developed
• Recently revised with aim to improve health and SES of
adolescent
• Implementation of abortion
services at public facilities
• Abortion legalized
• National Safe Motherhood Plan
(2002-2017)
National context
Source: Nepal’s Safe Motherhood and
Newborn Health (SMNH) Road Map 2030

11. Safe motherhood plan, 2002-2017
● Strategy: to increase access to services at hospital and PHCC through establishment
of basic and comprehensive essential obstetric care and skill attendance
● Advocating for community mobilization for transport arrangement and empowering
community, families and women to access care
● Overall Mission Statement : To facilitate creation of an enabling environment where a
woman's right to safe pregnancy, delivery and post-partum care is achieved.
● Overall Goal : Maternal and neonatal health status improved
● Purpose : Sustained increase in utilization of quality maternal health services
11/12/2022 11

12. 2005
2006
2009
2012
2014
2015
• The Safe Delivery Incentive Programme (SDIP) was
introduced
• Motive to promote delivery by SBA at health institutions
• The policy on SBAs endorsed
• It identified the importance of skilled
birth attendance at every birth
• The constitution of Nepal
• Established people's health as
fundamental right, guaranteeing every
woman the rights to safe motherhood
and reproductive health
• Aama programme
• Free delivery care at public
and some private facilities.
Ama programme further modified to
include incentives for attending 4 ANC
visit and institutuional delivery
• National Health Policy 2014
• Takes into account the aspirations of the people and
guarantees their reproductive health rights
National context
Source: Nepal’s Safe Motherhood and
Newborn Health (SMNH) Road Map 2030

13. Skill Birth Attendant Policy(SBA Policy)
● Introduced in 2006 .
● This policy is supplementary to the Nepal Safe Motherhood Policy,
1998.
Objective
● To reduce maternal and neonatal morbidity and mortality by
ensuring availability, access and utilization of skilled care at every
birth.
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14. Skill Birth Attendant Policy(SBA Policy) Contd.
The SBA Policy 2006 had three strategies:
1) as a short-term measure, train SBAs through in-service training,
2) as a medium-term measure, revise the pre-service curriculum and
include SBA core skills in courses for ANMs, SNs and doctors, and
3) in the long term, develop professional midwives.
11/12/2022 14

15. 2015-
2020
2018
2019
• The National Family Planning Costed
Implementation Plan
• Aims to enable women and couples to attain
their desired family size and have healthy
birth spacing.
Nepal Safe Motherhood And
Newborn Health Road Map
2030
National Health Policy, 2019
• The Safe Motherhood and
Reproductive Health Act, 2018(2075)
• Guarantees the reproductive rights of
every woman and makes specific
provision for maternity care,
maternity leave, newborn care, FP,
abortion and treatment of
reproductive morbidities
National context
Source: Nepal’s Safe Motherhood and
Newborn Health (SMNH) Road Map 2030

16. National Health Policy,2019
● In policy , it is mentioned that " In accordance with the concept of health across the
lifecycle, health services around safe motherhood, child health…and reproductive
health…shall be developed.
● Strategy :
- Safe motherhood & reproductive health services shall be made of good quality,
affordable & accessible
- For Social determinants affecting women's health, special programmes shall be
implemented.
- In order to strengthen safer motherhood & reproductive health, SBA shall be
arranged in all wards
- Abortion services shall be made qualitative & effective as per the law.
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17. 02
Safe Motherhood Program
Introduction

18. 3 delays behind maternal mortality and
mobility
11/12/2022 18
1. Delay in seeking
care,
2. Delay in reaching
care, and
3. Delay in receiving
care

19. 19
To reduce maternal and
neonatal morbidity
and mortality.
● 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.
Goal

20. 20
Promoting inter-sectoral coordination and
collaboration at all levels with a focus on
poor and excluded groups.
Strengthening and expanding delivery by
SBA and providing BEONC, CEONC
services at all levels
01
Strengthening community-based awareness on
birth preparedness and complication
readiness through FCHVs and increasing
access to information
Strategies
02
03

21. Supporting activities that
raise the status of women in
society
21
Promoting research on safe
motherhood to contribute to
improved planning and
more cost-effective interventions.
Strategies
04
05

22. 02
Safe Motherhood Program
Components

23. Community level maternal and newborn health
interventions
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Birth preparedness and complication
readiness (preparedness for money,
place for delivery, transport and
blood donors)
Self-care (food, rest,
no smoking and no
alcohol)
ANC, institutional delivery and PNC
(iron, tetanus toxoid, Albendazole,
Vitamin A)
Distribution of Matri SurakshaChakki
(misoprostol) to prevent postpartum
haemorrhage (PPH) in home deliveries
Essential newborn care
Identification of and timely care seeking for
danger signs
01
02
03
04
05
06

24. Rural Ultrasound Programme
● For the timely identification of
pregnant women with risks of
obstetric complication to refer to
CEONC centers.
● Trained nurses (SBA) scan clients at
rural PHCCs and health posts using
portable ultrasound.
● Implemented in the remote districts
11/12/2022 24

25. Expansion and quality improvement of service
delivery sites
● A significant share of FWD’s budget
 for recruiting human resource
(Staff nurses, ANMs) on short term
contracts to ensure 24 hour services
on MNH at PHCCs and health posts.
11/12/2022 25

26. Onsite clinical coaching and mentoring
● Most effective means to improve knowledge,
skills and practices of health service providers
(WHO)
● Evidence based effective program
11/12/2022 26

27. Onsite clinical coaching and mentoring
11/12/2022 27
Dolakha and Ramechhap
Districts after 2072
earthquake
Outcome
Improvement in knowledge, skills, and
practices of MNH service providers
• On-site clinical coaching /mentoring
programme since 073/2074 from 16
districts
Source: Annual Report 2076/77

28. MNH readiness Hospital and BC/BEONC Quality
Improvement
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Improvement in quality-of-service
delivery through self-assessment,
infection prevention demonstration and
action plan implementation
Taplejung hospital
2070/71
Hetauda hospital
Evidence based effective program
Source: Annual Report 2076/77

29. PNC home visit (micro planning
for PNC)
To strengthen PNC services by mobilizing MNH service
providers from health facilities to provide PNC at women’s
home
11/12/2022 29
From 2074/75
15
Districts
30
Municipals
From 2076/77
40
Districts
229
Municipals
Source: Annual Report 2076/77

30. Emergency referral funds
● In cases of difficult geographical terrain and unavailable CEONC services
● FWD allocated emergency referral funds to six provinces (1, Bagmati, Gandaki
province, 5, Karnali and Sudurpaschim Province) for air lifting of women in need of
immediate transfer to higher centres.
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7,500,000
Rupees
Six Provinces to support women in need
12,000,000
Rupees
For the hospitals in the districts
through 7 provinces to support transport
fares women who could not afford referral
to high facility (nearby CEONC facilities).
Source: Annual Report 2076/77

31. Safe abortion services
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Pre and post counselling on safe abortion
methods and post-abortion contraceptive
methods
01

32. Safe abortion services
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Termination of pregnancies as per the national protocol
02

33. Safe abortion services
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Diagnosis and treatment of existing reproductive
tract infections
03

34. Safe abortion services
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Provide contraceptive methods as per
informed choice and follow-up for post-
abortion complication management
04

35. Obstetric first aid orientations
● In 2070/71, FHD started orienting paramedics on
first aid
● To manage obstetric complications at health facilities
without birthing centres
● To enable paramedics to support SBAs and ANMs at
times of emergency
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Source: Annual Report 2076/77

36. Aama Surakshya and Free New Born
Program
Transport incentives to women to
deliver in health facilities
2005
2006
2009
2012
User fees were removed from all types
of delivery care in 25 low HDI districts
Expanded to nationwide under the
Aama Programme
Separate 4 ANC incentives programme
was merged with the Aama Programme
Source: Annual Report 2076/77

37. Aama Surakshya and Free New Born
Program
Free Newborn
Care Programme (introduced
inFY2072/73) was merged with the Aama
Programme
2016/17
2017/18 Again separated as two different
programmes
Source: Annual Report 2076/77

38. Aama Surakshya and Free New Born Program
Transport incentive for
institutional delivery
Incentive for 4 ANC
visits
Free institutional
delivery services
A payment of NPR 300
to health workers
A payment of NPR 300
to health workers
Four different types of package
(Package 0, Package A, B, and
Package C)
Source: Annual Report 2076/77

39. Incentives provision
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Transport incentive for institutional delivery: A cash payment is
made to women immediately following institutional delivery: NPR.
3000 in mountain, NPR. 2,000 in hill and NPR. 1000 in Terai districts.
Incentive for 4 ANC visits: A cash payment of NRs. 800 is made to
women on completion of four ANC visits at the 4, 6, 8 and 9 months of
pregnancy institutional delivery and post-natal care.

40. Antenatal care
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Fourth month
Sixth month
Eighth month
Ninth month

41. Antenatal care
11/12/2022 41
A minimum of four antenatal
check-ups at regular intervals
Blood pressure, weight and
foetal heart rate
monitoring
IEC and BCC on pregnancy, childbirth
and early new born care and family
planning
Information on danger signs and
timely referral to appropriate health
facilities
Early detection and management of
complications during pregnancy.
Provision of tetanus toxoid and diphtheria
(Td) immunization, iron folic acid tablets
and
deworming tablets to all pregnant women,
and malaria prophylaxis where necessary.

42. Delivery care
11/12/2022 42
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
Registration of births and
maternal and neonatal deaths

43. Emergency obstetric care
43
● Management of pregnancy
complications by assisted
vaginal delivery (vacuum or
forceps)
● Manual removal of placentas
● Removal of retained products
of abortion (manual vacuum
aspiration)
● Administration of parental
drugs
● Resuscitation of newborns
and referrals
Basic emergency obstetric and
newborn care (BEONC)
-Surgery (caesarean section)
-Anaesthesia
-Blood transfusions
Comprehensive
emergency obstetric
care (CEONC)
11/12/2022

44. Post natal care
11/12/2022 44
24 hours
Third day
Seventh day

45. Post natal care
11/12/2022 45
Three Post-natal check ups
Promotion of exclusive
breastfeeding
Personal hygiene and nutrition
education, and postnatal vitamin A
and iron supplementation
for mothers
Immunization of newborns
Postnatal family planning counselling
and services
Identification and management of
complications of mothers and newborns
and referrals to appropriate health
facilities

46. Implementation of Maternal and Perinatal
Death Surveillance and Response (MPDSR)
11/12/2022 46
Identification Notification
Quantification
Determination of causes
and to avoid all maternal
and perinatal deaths
Use of this
information to
respond with
actions to prevent
future deaths
Designed to measure and track all maternal deaths
in real time
Objective : To understand the underlying
factors contributing to mortality and to
provide guidance for how to respond to
and prevent future deaths
From FY 2073/74
Continous Process
Source: Annual Report 2076/77

47. 03
Actors

48. Actors
● Local NGOs
 NGOs contribution towards improving the access, quality and coverage of safe
motherhood services in a number of ways
 The MOH’s 1998 Safe Motherhood Policy states as one of its five policy directives
that the MOH will expand and improve maternity care services at all institutional
levels by “encouraging the active participation of NGOs at the community level.”
 Non-governmental organization- Kidasha, Nepal technical assistance group, Nick
Simon’s Institute, Sunaulo Pariwar Nepal etc.
11/12/2022 48

49. Actors
● Government/ Public Sector
 Promoting inter-sectoral coordination and collaboration at Federal, Provincial,
districts and Local levels to ensure commitment
 Sets national reproductive health policies and develops IEC strategies and clinical
guidelines
 Example: Ministry of Social Development at provincial level, Chairpersons of Health
Management Committees of local health facilities, District health officers health
coordinators
11/12/2022 49

50. Actors
● Private Sector/Professional Organizations
 Technical support
 Advocacy, lobbying, social responsibility, accountability
 Example- MCH Products, Pvt. Ltd., the manufacturers of the Clean Home Delivery Kit,
offer the the use of their excellent educational materials and a simple, low-cost
product to promote that helps to save the lives of mothers and newborns.
11/12/2022 50

51. Actors
● International Agencies, Donors and INGOs
 Important role in capacity building and providing technical assistance.
 Multilateral organization- UNFPA, WHO, WHO Nepal
 Bilateral organization- GIZ, USAID
 International non-government organizations- IPAS, John Snow Research and
Training Institute, Plan International Nepal, Population Services International (PSI),
United Mission to Nepal (UMN), World Vision International Nepal (WVIN)
11/12/2022 51

52. Actors
● Other Actors
 Health Workers Including FCHV’s
 Media
 Maternal Health Experts
 Local Elected Leaders
 Community People
11/12/2022 52

53. 04
Major Achievements

54. MDG and SDG Targets
● MDG Achievements and Unfinished Agenda
11/12/2022 54
Goal Situation in
2000
MDG
Targets
(2015)
MDG
Achievemen
ts (2015)
SDG Targets
(2016-2030)
Goal 5: Improve Maternal Health
Maternal mortality ratio (per
100,000 live births)
415 213 258 Reduce to 70
Proportion of births attended by
skilled birth attendants
11 60 55.6 Increase to 90%
Contraceptive prevalence rate
(modern methods) %
35.4 70 49.6 Increase to 58%

55. SDG Targets
● In order to achieve SDG
target, Nepal needs to
decrease its MMR by at
least 5% (12 maternal
deaths) per year while
addressing several
inequities in maternal
health access, utilization
and quality.
11/12/2022 55
(Source: NDHS.1996, 2006,2016)

56. Major Achievements
11/12/2022 56
NDHS 1996
539 per 1,00,000
live birth
NDHS 2006
281 per 1,00,000
live birth
Maternal
Mortality
Ratio
(Source: NDHS.1996,2006)

57. Major Achievements
11/12/2022 57

58. Major Achievements
11/12/2022 58
(Source: DOHS, 2076/77)

59. Major Achievements Contd.
11/12/2022 59
(Source: DOHS, 2076/77)

60. Major Achievements
11/12/2022 60

61. Major Achievements Contd.
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● Total number of females receiving treatment for Emergency Obstetric Complications
in the FY 2075/76 was 45903, while in the FY 2076/77 was found to be 46239
(Source: DOHS, 2076/77)

62. Major Achievements Contd.
11/12/2022 62
(Source: DOHS, 2076/77)

63. Major Achievements Contd.
11/12/2022 63
(Source: DOHS, 2076/77)

64. 05
What Went Well

65. What went well
● Adequate policies, plans, and strategies for maternal health in Nepal
● The cash incentives and free delivery services had attracted women
to institutional delivery.
● Initiation of in-kind support or gift of salt, soap, or oil for those
coming for antenatal check-up and delivery.
11/12/2022 65

66. What went well Contd.
● Increased institutional delivery coverage through establishment of
BEOCs and BCs in and Comprehensive Emergency Obstetric and
Newborn Care (CEmONC) sites
● Reduction in maternal mortality after legalizing abortion and
providing safe abortion services
● Maternity waiting homes in some places have been well utilized.
Such homes are very relevant in the hilly geography of Nepal,
helping to address the second delay.
11/12/2022 66

67. 06
What didn't go well

68. What didn’t go well
11/12/2022 68
NDHS 2006
281 per 1,00,000
live birth
NDHS 2016
239 per 1,00,000
live birth
Maternal
Mortality
Rate
(Source: NDHS.2006,2016)

69. What didn’t go well
11/12/2022 69

70. What didn’t go well
11/12/2022 70
(Source: NDHS, 2016)

71. Equity Gap
● Clear disparities according to
geography
● Lowest percentage of institutional
delivery than the national average
was observed in Karnali province
(38%) and Province 2 (43%)
11/12/2022 71
Source: NDHS, 2016

72. Equity Gap
● Clear disparities according to socio-
economic status
● Institutional delivery was less than
national average in the poorest (36
percent) and poorer (48%) quintiles
11/12/2022 72
Source: NDHS, 2016

73. Equity Gap
● Clear disparities according to
educational status
● Women who had no formal
education more likely to choose
home delivery (63%)
11/12/2022 73
Source: NDHS, 2016

74. 07
Limitations

75. Limitations
11/12/2022 75
● Referral guidelines for delivery services are not clear in various
contexts and are not effective.
● Fluctuating functionality of CEONC and birthing center services
● Plateauing of 4 ANC use and timely first ANC visits, and very low
PNC coverage

76. Limitations
11/12/2022 76
● Low use of institutional delivery and C-section services in mountain
districts, and province number 2 and 6
● No CEONC services in some remote districts: Rasuwa, Manang and
Mustang
● The inadequate use of some birthing centers and increasing the
number of birthing centers

77. Limitations
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● Inadequate and unskilled human resources
● Poor infrastructure and maintenance
● Lower utilization of services by poorer families
● Overcrowding at referral hospitals

78. Limitations
11/12/2022 78
● Federal structure and governance of health institutions; limited
understanding of health service delivery
● Inadequate monitoring and supervision of the services.

79. 08
Challenges

80. Challenges
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● High Maternal Mortality Rate
● Implementation Maternal and Perinatal Death Surveillance and
Response (MPDSR) has become a challenge to the GoN
● Safe abortion implementation in Nepal including gaps in access,
equity, and quality; effective and ongoing sector-wide monitoring
and evaluation of safe abortion services and their providers

81. Challenges
11/12/2022 81
● Limited capacity, resources, and absence of mandates to carry out
social accountability roles in Nepal.
● Provision of quality services and equitable access to marginalized,
poor and disable women.

82. 09
Way Forward

83. Way Forward
● The strategic location of hospitals and maternity waiting homes
● SBA training to midwifery and nurses
● Birth preparedness activities, including awareness-raising involving
family members and mobilize female community health volunteers
and local leaders.
● Enhancing local capacity and coordination between federal,
provincial, and local bodies is equally important.
11/12/2022 83

84. Way Forward Contd.
● Incentives supplemented by in-kind support such as soap, salt, egg,
chicken or oil to create more demand for antenatal and delivery
services.
● Expand services in remote and difficult locations
● Effective and continuous sector-wide monitoring and supervision
● Strengthen existing programs with a special focus on marginalized
and vulnerable communities
11/12/2022 84

85. Way Forward Contd.
● Review of program implementation and effectiveness
● Plan for road map to reduce MMR based on global and Nepal
evidences
● Revise Aama Program and Safe Motherhood Policy
● Deployment and appropriate transfer of skilled human resources
11/12/2022 85

86. Way Forward Contd.
● 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
11/12/2022 86

87. Way Forward Contd.
● Provide additional budgetary support for overcrowded hospitals
and ensure continuous availability of services (birthing centres and
CEONC services).
● Rapidly assess and expand rural ultrasonography (USG)
● Raise the quality of ANC counselling services, focusing on
continuum of care
● Develop a special package to encourage timely ANC visits
11/12/2022 87

88. Way Forward Contd.
● Strengthen referral services and ensure the availability of a
transport system/ambulances for taking care of women with
obstetric complications and newborns that need special care
● Social accountability needed to be strengthened by means of social
audits, role models, and empowering health facility operation and
management committees.
● Orientation of local and provincial level government on their roles
in health services delivery and governance
11/12/2022 88

89. References
● Karkee R, Tumbahanghe KM, Morgan A, Maharjan N, Budhathoki B,
Manandhar DS. Policies and actions to reduce maternal mortality in
Nepal: perspectives of key informants. Sexual and Reproductive
Health Matters. 2022 Jan 10;29(2):1907026.
● Department of Health Services. Annual Report, 2076/77.
● Ministry of Health and Popuation. Nepal Safe Motherhood and
Newborn Health Road Map 2030, September 2019
11/12/2022 89

90. Thank You
90