The document provides an overview of Nepal's Safe Motherhood and Newborn Health Program, including its goals, strategies, activities and management. Some key points: - The program aims to reduce maternal and neonatal morbidity and mortality through preventative activities and addressing factors that cause death during pregnancy, childbirth and postpartum. - Major strategies include promoting birth preparedness, the Aama program to promote antenatal checkups and institutional delivery, and expanding emergency obstetric services. - Key activities include distribution of birth preparedness packages, rural ultrasound programs, expansion of birthing centers and emergency obstetric care sites, and training of skilled birth attendants. - The program is managed through planning

1. Brief overview of management of Safe
motherhood and newborn health program
&
SWOT analysis of Safe motherhood and
newborn health program
Presented By: Sirjana Tiwari
MPH 2nd semester (PHSM)

2. Introduction
• National Safe Motherhood Program was started in 1997 in
Nepal
• Service coverage has grown along with the development of
policies, programs and protocols.
• The policy on skilled birth attendants endorsed in 2006 by MoH
specifically highlights the importance of skilled birth attendance
at every birth
• National Blood Transfusion Policy 2006 was 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 the National
Safe Motherhood Plan (2006‐2017) has been revised, with wide
participation of partners.
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3. Safe Motherhood Program
• Goal:
− To reduce maternal and neonatal morbidity and mortality
− 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.
• Evidences suggest that three delays are important factors behind
the maternal and new born morbidity and mortality outcome in
Nepal’s context:
1. Delay in seeking care,
2. Delay in reaching care, and
3. Delay in receiving care.
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4. • To reduce the risks during pregnancy and childbirth and
address factors associated with mortality and morbidity three
major strategies have been adopted in Nepal:
1. Promoting birth preparedness and complication readiness
including awareness raising and improving the
availability of funds, transport and blood supplies.
2. Aama Suraksha Program to promote antenatal checkups
and institutional delivery
3. Expansion of 24‐hour emergency obstetric care services
(basic and comprehensive) at selected public health
facilities in every district.
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5. Activities
1. Birth Preparedness Package and MNH Activities
at Community Level
• Distribution of jeevan suraksha flipchart and card)
and the matri suraksha chakki (misoprostol) to
prevent postpartum haemorrhage (PPH) in home
deliveries.
• Forty-two districts were implementing the
programme in 2072/73 and FHD has budgeted to
scale the programme up to three more districts in
2073/74.
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6. 2. Rural Ultra Sound Program
• timely identification of pregnant women with risks of
obstetric complication to refer to comprehensive
emergency obstetric and neonatal care (CEONC)
centres.
• This programme is being implemented in the 11
remote districts of Mugu, Dhading,
• Darchula, Sindhupalchowk, Solukhumbu, Bajura
Bajhang, Achham, Dhankuta, Humla, and Baitadi.
• Eighteen SBAs received three weeks training on
antenatal ultrasonography in 2072/73.
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7. 3. Reproductive Health Morbidity
Prevention and management Program
3.a. Management of Pelvic Organ Prolapse
• To manage POP including free screening, providing
silicon ring pessaries, Kegell exercise training and
free surgical services at designated hospitals
• 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.
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8. 3.b. Cervical cancer screening and
prevention training
• As of 2072/73, cervical cancer screening has been
expanded to 45 districts.
• In the reporting year nurses from 68 government
health facilities in Kaski and from 40 facilities in
Chitwan were trained on visual inspection with acetic
acid under the human papilloma virus (HPV)
demonstration project in coordination with CHD with
support from WHO.
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9. 3. c. Obstetric Fistula management
• In 2072/73 obstetric fistula management was being
integrated with pelvic organ prolapsed screening and
surgical services at the BP Koirala Institute of Health
Sciences (BPKIHS, Dharan) and Patan Academy of
Health Sciences, Lalitpur.
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10. 4. Human Resource
• NHTC & NAMS have been trained 8,500 SBAs
and 140 ASBAs, since SBA training began.
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11. 5. Expansion and quality improvement of
services delivery sites
• A total of 1,751 birthing centers and 159
BEONC sites were functioning by the end of
2072/73
• In 2072/73 FHD began upgrading 58 birthing
center to comprehensive centers of excellence
(CCEs) in12 districts with support from UNICEF
and NHSSP.
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12. 6. Emergency Referral Fund
• A total of NPR 200,000 rupees emergency
referral fund has been allocated as seed
money for 30 district in 2072/73.
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13. 7. Safe Abortion Services
• second trimester abortion services are
available in 24 hospitals
• 538 health facilities were listed as MVA service
sites.
• Medical abortion services have been
expanded to 42 districts
• Safe abortion programme ensure the
availability of five modern contraceptive
methods at all safe abortion sites from
2071/72.
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14. 8. Obstetric First Aid orientation
• In 2072/73 FHD trained paramedics in 16
district on first aid to manage obstetric
complications at health Facilities at the time
of emergency.
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15. 9. Nyano Jhola Program
• The Nyano Jhola Programme was
implemented in all 75 districts in 2072/73.
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16. 10. Aama Program
a. For women delivering their babies in health
institution
• Transport incentives to institutional delivery
• Incentives to 4 ANC
• Free institutional delivery a payment to health
facility
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17. 10. Aama Program
b. For Newborn
Free sick newborn care package to health
institution
A=1000, B=2000, C=5000
A+B+C=8000
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18. 10. Aama Program
c. Incentives to health workers
• For deliveries (any time) = 300
• For sick newborn care= 300(for any package)
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19. Management Perspectives of SafeMotherhood
Program in Nepal (POSDCOORB)
• Planning
• Organizing
• Staffing
• Directing
• Coordinating
• Controlling
• Recording and Reporting
• Budgeting
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20. Planning
• Family Health Division (FHD) is the main body for
formulating plans and activities regarding safe
motherhood.
• Regional Health Directorate (RHD) at regional level
and District Health Officer (DHO) at district level
responsible for planning, implementation, and
supervision of SM program
• Operative part of planning in regional level and district
level is focused by nursing staffs (Public health nurse)
of various levels.
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21. Organizing
• Follows the pattern as per the organizational structure of DoHS.
• Related Strategies
– Developing the infrastructure for delivery and emergency
obstetric care.
– Standardizing basic maternity care and emergency obstetric
care at appropriate levels of the healthcare system;
• Related Functions
– FHD continues support for expansion and maintenance of
various activities on safe motherhood at community level.
– FHD continues to expand 24/7 service delivery sites like
birthing centers, BEONC and CEONC sites at existing
PHCC/HP and hospitals.
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22. Staffing
• Related strategies
– Strengthening human resource management; DGO, ASBA,
SBA, Anesthesia Assistant training and deployment
• Related functions
– A significant share of family health division’s budget has been
allocated for the recruitment of ANMs in short term contract
to ensure the 24 hour birthing services at PHCC/HP levels.
– FHD has also provided fund at local level to recruit human
resource mix needed to provide surgical management for
obstetric complications at district hospitals.
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23. – FHD has been coordinating with National Health
Training Center (NHTC) and National Academy for
Medical Sciences (NAMS) for pre‐service and
in‐service training of health workers.
– NHTC provides training on SBA, ASBA, OT
management, Family Planning training including
Implants and IUCD, and antenatal USG.
– More than 7100 SBAs and 140 ASBAs have already
been trained since SBA training began.
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24. • Central Level (FHD)
– Director (Senior executive)
• Regional Level (RHD)
– RH Directorate
– Nursing Officer (Focal Person)
• District Level (D/PHO)
– D/PH Officer
– Public Health Nurse (Focal Person)
• Below district level
• PHCC: Medical Officer and Staff Nurse
• HP: Health Assistant and Auxillary Nurse Midwive
• Health workers with SBA for 24 hours birthing center at HP
level
Staffing Pattern
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25. Directing
• Most difficult part of management to explain about
because the nature, extent and process of directing
differ as per the manager’s style of managing.
• However, the process of directing principally follows
the scalar chain and/or hierarchical pattern in SM
program as per the structure of DoHS.
• It may include but not limited to leadership,
motivation, authority delegation, issuing order and
communication from officer to focal person to
operative employees at below district level.
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26. Coordinating
• Inter‐sectoral coordination and collaboration at
central, regional, districts and community levels
• Intra-sectoral coordination
– Service from maternity care at hospitals and
birthing centre
– MoH/DoHS, FHD, DHO/DPHO and peripheral
HFs
• Inter-sectoral coordination
– Deployment of staffs for birthing center at below
district level
– DHO with DDC and/or HP with VDCs
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27. Recording
• HMIS form for recording the service provided by HFs
at district and below district level
• Major recording forms are under Family Health
Category No. 3
3.1 : Face sheet Pills
3.2 : Depo service register
3.3 : IUCD/Implant service register
3.4 : Sterilization register
3.5 : Maternal and newborn health card
3.6 : Maternal and newborn service register
3.7 : Safe abortion service register
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28. Reporting
• Reporting mechanism follows the overall reporting
pattern established by DoHS/MoHP
• All facilities follow the pattern through prescribed
reporting forms of HMIS
9.1: FCHV reporting collection form
9.2 : Community level health service monthly
reporting form - Immunization & PHC,ORC
9.3 : PHCC, HP reporting form
9.4 : Public hospital reporting form
9.5 : Non public health facility reporting form
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29. HMIS 9.1FCHV reporting
collection form
HMIS 9.2 Community level health
service monthly reporting form -
Immunization & PHC,ORC
HMIS 9.3 PHCC, HP and SHP reporting form
HMIS 9.4 Public hospital reporting form
HMIS 9.5 Non public health
facility reporting form
DP/HO RHD
DoHS
MIS Section

30. Budgeting
• Budgeting process of SM program comes under the
overall budgeting process of health programs at
central level.
Health care financing
• The safe motherhood program has a demand side
financing approach where the mothers are provided
free delivery care at health facility with provision of
transport funds.
Program Budgeting
• Separate budgets for SM program allocated by MoH
and utilized by FHD, DHS under various activities.
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31. 31
ACHIEVEMENTS
ANALYSIS of
Safe
motherhood
Programme

32. Receipt of free and transport incentive
as of expected live births
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33. Regional and national trends of four ANC
visits( as per protocol) among expected
pregnancies
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34. Four ANC visit (as per protocol as a
percentage of first ANC visit (as per
protocol)
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35. Deliveries attended by SBAs as percentage
expected live births (2070/72–2072/73)
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36. Institutional deliveries as percentage of
expected live births
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37. Status of birthing center, BEONC and
CEONC expansion
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38. Summary of budget allocated for Aama program,
4ANC and newborn care (2071/72 and 2072/73)
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39. Three PNC Visits as per protocol, 2071/72
and 2072/73
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40. Trends of proportion of caesarean sections
among total expected live birth
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41. Met need for EOC based on Aama
programme reporting
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42. Trend of post abortion contraceptive use
(%)
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43. SWOT analysis of safe motherhood program
Strength
•Emergency referral fund
•Aama program
•Cervical cancer screening and prevention training
•Obstetrics fistula management
•HR production with SBA training
•Expansion of birthing center, BEONC & CEONC
services
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44. Strength
• Promotion of birth preparedness package
• Rural ultra sound program
• 24 hour service delivery
• Regular conduction of PHC/ORC
• Continuous supply of Family planning services
• Upgraded rural health facility
• Behavioral change strategy for newborn health
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45. Strength
• Different supportive program
Nutrition program
Immunization program
CBIMNCI program
Disease control program
Family planning program
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46. Weakness
• Vacant sanctioned post
• Dependent on donor fund
• Poor CS services at mountain region
• Inadequate refreshment training
• poor infrastructure and inadequate supply of
commodities, medical equipment(delivery kits) and drug
supply( iron folic tablet, cotrim, CHX)
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47. Weakness
• Poor retention of human resources
• Poor referral mechanism
• Poor recording and reporting mechanism
• Poor monitoring and supervision from central level
• Lack of space and equipments for quality maternity
services at health
• Fluctuating functionality of EONC and birthing
centre services
• lack of 24 hours power back up supply in Hospital
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48. Opportunities
• Support of EDP( budget, SBA training)
• SDG
• Health service camp by private organization
(Permanent family planning services, uterine
prolapse)
• Continuous services (CS, Abortion )from private
health institution.
• Regular conduction of health mothers groups
discussion (ANC,PNC, Exclusive breastfeeding)
• Maternal death audit
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49. Threats
• Poor transportation and communication services for
referral
• Stagnant neonatal mortality rate
• MMR
• Increasing number of unintendent pregnancy
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50. Threats
• Sex selective abortion
• Poverty: intergeneration cycle of Malnutrition
• Existence of different taboos: food,
• Unmet need of family planning
• high out-of-pocket expenditure
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51. Reference
• Pathak LR, Kwast BE, Malla DS, Pradhan AS, Rajlawat R, Campbell BB. Process indicators
for safe motherhood programmes: their application and implications as derived from hospital
data in Nepal. Tropical Medicine & International Health. 2000 Nov 1;5(12):882-90.
• Bhatta BN. Public Health Awareness Building in the field of Safe Motherhood. Journal of
Nepal Health Research Council. 2008;6(2):69-73.
• Freedman LP, Graham WJ, Brazier E, Smith JM, Ensor T, Fauveau V, Themmen E, Currie S,
Agarwal K. Practical lessons from global safe motherhood initiatives: time for a new focus on
implementation. The Lancet. 2007 Oct 19;370(9595):1383-91.
• Chaudhary SK. Scaling up safe motherhood program at Dang district: Impact of
programmatic intervention. Nepal Journal of Obstetrics and Gynaecology. 2014 Jul
29;3(2):21-5.
• Kc A, Thapa K, Pradhan YV, Kc NP, Upreti SR, Adhikari RK, Khadka N, Acharya B, Dhakwa
JR, Aryal DR, Aryal S. Developing community-based intervention strategies and package to
save newborns in Nepal. Journal of Nepal Health Research Council. 2011 Dec 18.
• www.ifrc.org,Saving lives, changing minds.”Maternal, newborn and child health framework”
International Federation of Red Cross and Red Crescent Societies, Geneva, 2013
• Annual Report department of Health Service 2072/73 ,Government of Nepal , Ministry of
Health.
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