By
Sushant Luitel
3/23/2023
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National Safe Motherhood Plan 2002-2017 (Revised Safe
Motherhood and Neonatal Health Long-Term Plan 2006-2017

Introduction
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• The overarching goal of development efforts in Nepal is to reduce poverty, as
highlighted in the Tenth Plan (Poverty Reduction Strategy Paper) 2002- 2007, and
health sector development efforts are treated as an integral part of this strategy.
• The Ministry of Health and Population (MoHP, formerly Ministry of Health) developed
the Second Long Term Health Plan (1997- 2017) as a sectoral perspective plan and the
National Safe Motherhood Long Term Plan (NSMLTP) (2002-2017) was based on this
document as a sub sector plan, in line with the Nepal Health Sector Programme
Implementation Plan (NHSP-IP) 2004-2009.

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 Within the health sector, safe motherhood has been a national priority program for the
last decade and is highlighted in all major health-related policies and plans.
 The Tenth Plan, the Second Long Term Health Plan, and the NSMLTP (2002-2017) all
highlight the need to reduce the high levels of mortality among women, infants, and
children.
 The Millennium Development Goals (MDG) specify a two-thirds reduction in the under-
five mortality rate and a 75 percent reduction in the maternal mortality ratio by the year
2015.
 The NHSP-IP draws on the Millennium Development Goals to improve the Nepalese
population's health status by utilizing essential health care services (EHCS), specifying
maternal and infant mortality, and reducing child mortality among other essential health
care indicators.
 Since safe motherhood and newborn health are not purely health issues, they warrant a
multi-sectoral approach, and the role of other sectors is particularly important in
enhancing access and promoting equity.
 This is acknowledged in the NSMLTP and outputs are related to programs in education,
information and communication, transport, and local development, as appropriate.

Rationale for Revision of the National Safe
Motherhood Long Term Plan
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 In recent years many safe motherhood stakeholders, both government and non-
government, at district, regional, and national forums, have noted gaps in the
original NSMLTP and advocated for its revision and updating.
 In order to retain its effectiveness as a guide to programming, the plan needs to
be treated as a rolling document, and revised regularly, in line with the changing
context of new developments.
 A number of specific issues have been identified that highlight the urgent need
for revision as follows:

MDGs and Neonatal health:
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 The NSMLTP (2002-2017) was developed before the Millennium Development Goal Country Report was prepared,
and so was unable to fully take into account the recommendations it contained.
 The infant mortality rate in Nepal is declining but only slowly - child mortality declined by 34 percent between 1996
and 2001, but during the same period infant mortality declined by only 18 percent.
 Since two-thirds of infant deaths occur in the neonatal period, a significant reduction in infant mortality rates depends
on a decrease in the neonatal mortality rate.
 While it is understood that safe motherhood interventions do contribute to a reduction of perinatal and neonatal
mortality, in order to achieve the substantial infant and child mortality reductions encompassed by the MDGs,
additional specific newborn health interventions need to be integrated with safe motherhood programming.
 The National Neonatal Health Strategy and National Neonatal Health Long Term Plan formulated in 2004 and 2005
respectively to address neonatal health issues had also not been incorporated into the previous plan.

Skilled birth attendance:
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 The original NSMLTP (2002-2017) placed little emphasis on the importance of
skilled birth attendance in the drive to reduce maternal and neonatal mortalities.
 Global standards for what constitutes skilled birth attendance and how a skilled
birth attendant (SBA) is defined have also changed significantly in the last few
years.
 The National SBA Policy has been only recently formulated and endorsed, and
key points from this need to be incorporated into the current plan.

Health sector reform
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 The NSMLTP (2002-2017) pre-dated the recent work on health sector
reform and strategy development, and the outputs of the Nepal Health
Sector Strategy and Nepal Health Sector Programme Implementation Plan
(2004- 2009) need to be included.

Abortion:
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 The legalization of abortion under specified conditions in 2002 has resulted in an
intensive program to establish comprehensive abortion care (CAC) services in
public hospitals from 2004 and a commitment to integrating CAC into safe
motherhood programming.
 This important step acknowledges the significant effect of complications due to
unsafe abortions on the high maternal mortality ratio in Nepal and was not
included in the original NSMLTP (2002-2017).

Mother-to-child transmission of HIV
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 It is an increasing problem.
 As HIV infection rates grow, this is likely to become a major issue in the near
future for service provision As it is a recently acknowledged phenomenon,
prevention activities are not mentioned in the original NSMLTP.
 Prevention of mother-to-child transmission (PMTCT) needs to be incorporated
into the current plan.

Equity issues
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 In access and utilization of safe motherhood and neonatal health (SMNH)
services are not mentioned in the original NSMLTP and are of critical
importance if the neediest members of society are to be targeted and the MDGs
achieved.

Goal:
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 Improved maternal and neonatal health and survival, especially of the poor and
excluded.
Key Indicators
 The key indicators for this NSMNH-LTP goal are:
1. A reduction in the maternal mortality ratio from 539 per 100,000 live births to 134 per
100,000 by 2017
2. A reduction in the neonatal mortality ratio from 39 per 1,000 to 15 per 1,000 by 2017.

Purpose:
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 Increased healthy practices, and utilization of quality maternal and
neonatal health services, especially by the poor and excluded, delivered by
a well-managed health sector.
Key indicators for this include:
 Increase in the percentage of deliveries assisted by an SBA to 60% by 2017
 The percentage of deliveries taking place in a health facility increased to 40% by 2017
 Increase in met need for emergency obstetric care of 3% per year
 Increase in met need for a cesarean section of 4% per year.

Eight outputs are specified in the plan, each with
individual indicators.
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1. Equity and access
2. Services
3. Public-private partnership
4. Decentralization
5. Human resource development: Skilled birth attendant strategy
6. Information management
7. Physical assets and procurement
8. Finance

1. Equity and Access
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 The purpose is to ensure that individuals, groups, and networks are socially
empowered to practice desired Safe Motherhood and neonatal Health (SMNH)
behaviors, leading to increased equity of and access to health services.
 The key activity areas are in advocacy, social mobilization, and behavior change
communication.

2. Services
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 The purpose is to enhance the equitable provision of quality SMNH services.
 These include focused antenatal care, delivery and newborn care by the skilled
birth attendants, postnatal care, emergency obstetric care, comprehensive
abortion care, and referral services.
 Activity areas include strengthening and expansion of SMNH services,
improvement in quality of services, reaching socially excluded groups, creating
an enabling environment for services, and developing appropriate linkages.

3. Public-Private Partnership
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 The purpose is to increase participation of the private sector, NGOs,
community-based organizations, and professional/academic
institutions in SMNH-related public services to ensure consumers
have equitable access to affordable services.

4. Decentralization
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 The purpose is to enhance local government and partner capacity to
plan and oversee SMNH services in line with the Local Self
Governance Act (LSGA).

5. Human Resource Development: Skilled Birth
Attendant Strategy
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 The purpose is to develop and implement a strategy and plan for
human resource development in safe motherhood and neonatal
health, particularly skilled birth attendant training.

6. Information Management
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 The purpose is to develop a comprehensive sector-wide SMNH
information base and to incorporate and utilize this within the Health
Information System to support policy, planning, monitoring,
evaluation, and advocacy at national and local levels.
 Key activity areas include information management, data collection,
and quality, access to information, and monitoring.

7. Physical Assets and Procurement
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 The purpose is to ensure adequate physical resources for SMNH
services along with year-round availability of SMNH-related drugs
and supplies.
 Key activity areas include construction and maintenance, planning
and quality assurance, and distribution of drugs and commodities.

8. Finance
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 The purpose is to ensure improved sustainable financing systems for
SMNH services.
 Key activity areas include mobilization of resources, alternative
financing systems, and formation of safety nets for the socially
excluded.

Rights-based approach
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 Human rights standards relevant to maternal health include, but are not
limited to:
 The right to life and survival
 The right to the highest attainable standard of health
 The right to decide freely the number and spacing of one’s children
 The Convention for the Elimination of Discrimination against Women
(CEDAW).

Risks and assumptions
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1. Continuing political commitment to safe motherhood and neonatal care as a high priority in both policy and
programming, including allocation of resources
2. Effective and timely execution of the Nepal Health Sector Programme Implementation Plan
3. Social, political, and economic stability, enabling activities to be carried out as planned and resources accessed as
needed
4. Resolution of the conflict and/or development of effective strategies for working safely and effectively in conflict-
affected areas, such as using locally acceptable community workers as bridging people and using rights-based
messages and approaches
5. Elected leaders in place in the functional district and village development committees, able to facilitate devolved
decision-making, local ownership, and accountability
6. Commitment to local-level capacity building and support, combined with decentralization, to ensure quality
services.

Major activities in fiscal year 2077/78
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I. SMNH Roadmap 2030 provincial planning
 In line with the spirit of federalism and to promote the development of
context-specific plans with need-based prioritization, Family Welfare
Division had planned for provincial orientation on the SMNH roadmap in
all 7 provinces and the development of province-specific action plans for
implementation.
 In FY 2077/78, FWD completed the orientation in Province 1, Bagmati
province, Gandaki, and Karnali province. All oriented provinces have
developed their own action plan for their implementation in the process.

ii. Community level maternal and newborn health
interventions
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 Family Welfare Division (FWD) has continued to expand and maintain
MNH activities at the community level.
 A pictorial card (revised BPP card) is now attached to the MNH card of
HMIS for ensuring the availability and use of BPP messages by all
pregnant women during their antenatal visit.
 FWD has provided approved MNH cards to provinces for printing in FY
2077/78 who were interested to print (provinces 1 and 5).

Cont…
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 In 2066/67, the government approved PPH education and the distribution
of the Matri Suraksha Chakki (MSC) tablet through FCHVs to prevent
PPH during home deliveries.
 For home deliveries, three Misoprostol tablets (600 mcg) are handed over
to pregnant women by FCHV at the 8th month of pregnancy and are
advised to be taken orally immediately after the delivery of the baby and
before the expulsion of the placenta.
 Fifty districts were implementing the program till FY 2075/76. Further
eight districts, Gorkha, Dolakha, Solukhumbu, Parsa, Panchthar, Gulmi,
Lamjung, and Mustang, started implementing the program in the fiscal
year 2076/77.

Cont…
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 By the end of FY 2077/78, a total of 58 districts continue
implementation of the program. NDHS (2016) shows that only 13
percent of women who gave childbirth without skilled assistance
took MSC tablets.
 This calls for strengthening the existing program, as women who
delivered at home are likely to be at higher risk.
 As the program is not yet implemented nationwide, monitoring is
not yet integrated into HMIS.

iii. SMNH Programme during COVID 19 Pandemic
situation
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1. Management of the PPH Prevention Orientation program
 During the COVID-19 Pandemic situation, FWD focused on maternal
death follow-up monitoring and found the major cause of maternal deaths
was Postpartum Haemorrhage (PPH).
 FWD planned and provided immediate response for implementation with
the support of partners.

Cont…
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 As a result of the Partners’ meeting, FWD provided PPH orientation to
service providers in 22 hospitals in Lumbini Province and Karnali
Province Total of 312 participants doctors and nurses received virtual
orientation on PPH (estimation of blood loss, prevention of PPH
(AMTSL) and management and treatment of PPH (Uterotonic drugs,
management of trauma, retained placenta/tissue, Condom Balloon
Tamponade, Bimanual uterine compression, and Peripartum
Hysterectomy).

2. RMNCAH Interim Guideline Orientation
Programme
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 As a response to the COVID-19 Pandemic situation, FWD led the
development of RMNCAH interim guideline development and orientation
to health workers to ensure the continuation of SMNH and RH services
during the national crisis situation.
 More than 14,500 Health workers working at the community level
including hospitals received virtual and face-to-face orientation about
interim guidelines with the support of various partners (NHSSP, OHW,
UNFPA, SSBH, UNICEF, Care, Ipas, Su-aahara).

3. Virtual SBA clinical mentors’ refresher
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 Due to the inability to deliver in-person capacity building, FWD adopted a
virtual methodology to continue delivering the capacity building
initiatives, and a total of 182 SBA clinical Mentors from all 7 provinces
were involved and received Virtual SBA clinical mentors’ refresher.

iv. Rural Ultrasound Programme
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 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) centers.
 Trained nurses (SBA) scan clients at rural PHCCs and health posts using portable
ultrasound. Women with detected abnormalities such as abnormal lies and
presentation of the fetus and placenta previa are referred to a CEONC site for the
needed services.
 This program is being implemented in remote districts. In FY 2077/78, FWD
allocated a program implementation budget in 248 local levels of 30 remote
districts.
 The total program implementation districts are 11 except the Terai districts (Jhapa,
Morang, and Sunsari) in Province 1, 2 districts (Myagdi and Baglung) in Gandaki,
East Rukum in Lumbini, 9 districts except for Surkhet in Karnali and 7 districts
except for Kailali and Kanchanpur in Sudurpaschim Province.

v. Expansion and quality improvement of service
delivery sites
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 FWD continued to expand 24/7 service delivery sites like birthing centers,
BEONC, and CEONC sites at PHCCs, health posts, and hospitals. The
expansion of service sites is possible mostly due to the provision of funds to
contract short-term staff locally.
 By the end of 2077/78 CEONC services were established in 72 districts among
which 71 districts were functional throughout the year except for 1 district
(Ramechhap). During the fiscal year, 7 (Taplejung, Solukhumbu, Gorkha,
Tanahu, Dailekh, Jajarkot, and Rukum) districts provided interrupted C-section
services.
 Expansion of delivery services continues through the initiation of local
government. Total of 2236 health posts and 188 PHCCs were reported to have
provided (at least one) delivery service in 2077/78

vi. Onsite clinical coaching and mentoring
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 Nepal has taken the lead in improving quality services at the point of service
delivery as a focus theme mentioned in the NHSS and its implementation plan for
2016-2021.
 WHO has also given emphasis and mentioned that the on-site coaching and
clinical skill enhancement of service providers is considered one of the most
effective means to improve the knowledge, skills, and practices of health service
providers.
 Onsite clinical coaching and mentoring process is an evidence-based effective
program as per outcome (improvement in knowledge, skills, and practices of
MNH service providers) found in Dolakha and Ramechhap during the transition
and recovery plan implemented after the 2072 earthquake in 2072/2073 supported
by NHSSP and 7 districts’ onsite coaching and mentoring process supported by
GIZ.

Cont…
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 FWD had started to implement an on-site clinical coaching /mentoring
program in 2073/2074 from 16 districts and in FY 2074/2075 total of 320
Municipalities from 31 districts to enhance knowledge and skill of SBA
and non-SBA nursing staff providing delivery services at BC/BEONC and
CEONC service sites. This program has been scaled up gradually.
 In FY 2075/2076, a total of 359 Municipalities of 38 districts, and in FY
2076/2077 528 Municipalities of 51 districts and in FY 2077/78, 626
Municipalities of 63 districts implemented onsite clinical coaching and
mentoring program based on coaching/mentoring guideline and tool.

vii. 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 is an
evidence-based effective program as per outcome found in piloting
districts, Taplejung and Hetauda hospital in FY 2070/2071.
 FWD expanded MNH readiness hospital quality improvement process
(HQIP) gradually from FY 2072/73.
 Till the end of FY 2077/78 the HQIP/QIP program expanded in 67
hospitals and PHCC with CEONC services in 63 districts.

Cont…
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 The cumulative number of CEONC sites with HQIP service expansion is 7
in 2072/73, 12 in 2073/74, 35 in 2074/075, 52in 2075/076, and 57 in
2076/077, and 67 hospitals in 2077/78. Since FY 2076/77, the HQIP
process was integrated with the onsite coaching and mentoring process at
hospitals.
 The process of quality improvement is also being implemented in birthing
centers in integration with SBA onsite clinical coaching/mentoring
process. Till FY 2077/078, the total QI reported BC/BEONC sites were
824 (44 in FY 2073/74, 122 in FY 2074/75 and 267 in FY 2075/76, 139 in
2076/77, 252 in 2077/78.

viii. Emergency referral funds
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 It is estimated that 15 percent of pregnant women will develop serious
complications during their pregnancies and deliveries, and 5 to 10 percent
of them will need cesarean section deliveries (WHO, 2015) to avoid
deaths or long-term morbidity.
 In cases of difficult geographical terrain and unavailable CEONC services,
it is crucial that these women are referred to appropriate centers.
 To address this issue FWD allocated emergency referral funds to 53
hospitals of 52 districts in FY 2077/78 from across the 7 provinces.
 A total of 6,700,000 Rupees was allocated to 53 hospitals to support
women when referrals were needed.

Cont…
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 Additional about 60,000 Rupees in each Palika were allocated for the BC
and BEONC service sites s to support transport fares for women who
could not afford referral to the high facilities (nearby CEONC facilities).
 The main objective of this program is to support emergency referral
transport to women from poor, Dalit, Janajati, geographically
disadvantaged, and socially and economically disadvantaged communities
who need emergency cesarean sections or complication management
during pregnancy or childbirth.
 The airlifting support for immediate transfer to the higher centers is no
longer implemented by the FWD as the emergency Airlifting program is
now implemented by the Presidential Women Uplifting Programme in the
Ministry of Women, Children, and Senior Citizens

ix. Vitamin K1 to newborn babies
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 In FY 2077/78, after the decision of the Ministry of Health and Population
to introduce Vit K1 injection to newborn babies for preventing Vitamin K
Deficiency Bleeding (VKDB), for the first time Family Welfare Division
allocated a budget to purchase injection of Vitamin K1 for distributing in
all BC/BEONC and CEONC sites.
 Injection Vitamin K1 needs to be given to newborn IM after breastfeeding
within 1 hour of delivery.

x. Aama Surakshya Program and Free Newborn
Programme
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 The government has introduced demand-side interventions to encourage
women to institutional delivery.
 The Maternity Incentive Scheme, 2005 provided transport incentives to
women to deliver in health facilities.
 In 2006, user fees were removed from all types of delivery care in 25 low
HDI districts and expanded nationwide under the Aama Programme in
2009.
 In 2012, the separate 4 ANC incentives program was merged with the
Aama Programme.

References
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 setting-1.pmd (dohs.gov.np)
 Annual Report FY 2077/78 (2020/21) – Department of Health Services
(dohs.gov.np)
 National Safe Motherhood Plan (2002-2017) (dohs.gov.np)

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Thank You