Maternal Health in Nepal _Saroj Rimal.pptx

1. Presented By: Saroj Rimal (BPH,MPH) 2023.05.22 Maternal Health in Nepal

2. Contents Contents ⮚ Background ⮚ Status and Trends of Maternal Health Indicators ⮚ Obstetric Transition ⮚ Evolution of Maternal Health Policies in Nepal ⮚ Maternal Health Policies and Strategies of Nepal ⮚ Current Maternal Health Program in Nepal ⮚ Issues and Challenges ⮚ Recommendation ⮚ Conclusion ⮚ References 2

3. Background 3

4. Maternal health refers to the health of women during pregnancy, childbirth and the postnatal period. Although important progress has been made in the last two decades, about 287,000 women died during and following pregnancy and childbirth in 2020 globally. This number is unacceptably high. Most maternal deaths are preventable with timely management by a skilled health professional working in a supportive environment. (Source: World Health Organization. Maternal health [Internet]. Who.int. World Health Organization; 2019. Available from: https://www.who.int/health-topics/maternal- health#tab=tab_1) 4

5. (Source: National Population and Housing Census 2021: Nepal Maternal Mortality Study 2021) 5

6. National Situation and Trends 6

9. Maternal Mortality Decline, 1996–2022, with Projected Targets to 2030 151 (Source: National Population and Housing Census 2021: Nepal Maternal Mortality Study 2021) 9

10. Maternal mortality ratio (modeled estimate, per 100,000 live births) - Nepal 553 521 520 470 447 415 386 361 342 323 305 285 266 248 231 236 200 186 (Source: Worldbank, 2017) 10

14. DELIVERY CARE (Status and Trends) 14

15. (Source: National Joint Annual Review 2078/79 (2021/22)) 15

16. (Source: NDHS 1996-2022) Trends in Institutional Deliveries and Home Deliveries, 1996-2022 16

17. Trend of Deliveries by Caesarean Section, 1996-2019 (Source: NDHS 1996-2016; MICS 2014, 2019) 17

18. Trend of Antenatal Care, 2001-2022 (Source: NDHS 2001-2022) 18

19. Status of Antenatal Care, MICS 2019 (Source: MICS 2019) 19

20. Trend of Postnatal Care Check during first 2 days after birth, 2001- 2022 (Source: NDHS 2001-2022; MICS 2014, 2019) 20

21. Trend of Abortion, 2001-2016 According to NDHS 2016, only 48% of women know a safe place for abortion!!! (Source: NDHS 2001-2016) 21

22. Trend of Teenage/Adolescent Pregnancy, 1996-2022 (Source: NDHS 1996-2022) 22

23. OBSTETRIC TRANSITION Stages Features Stage I MMR >1,000 maternal deaths/100,000 live births Stage II MMR 999–300 maternal deaths/100,000 live births Stage III MMR 299–50 maternal deaths/100,000 live births Stage IV (MMR <50 maternal deaths/100,000 live births Nepal is at Stage III of the obstetric transition, which is characterised by better availability of care, but still with high maternal mortality due to direct causes (Source: NEPAL SAFE MOTHERHOOD AND NEWBORN HEALTH ROAD MAP 2030) 23

24. 24 Policies, strategies and guidelines: a snapshot

25. National Health Policy National Health Policy identified safe motherhood as priority program Primary health care outreach clinics introduced Safe Motherhood Plan of Action (1994-97) National Maternity Care Guidelines defines care to be provided at different levels of health facility National Safe Motherhood Plan (2002-2017) Abortion legalised Safe abortion services introduced 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Second long term health plan Skilled Birth Attendants Policy introduces task-shifting with MBBS doctors trained to perform caesarean sections and nurses and health assistants trained as anaesthesia assistants Maternity Incentive Scheme introduces financial incentive to pregnant women to cover transport costs of travelling to a health facility Safe Delivery Incentive Programme added incentives for health workers to provide care for institutional and home deliveries, and free institutional delivery care in 25 low performing districts Aama Programme includes ANC4 and transport incentives, health worker incentives (not for home births), free delivery care Local recruitment CEONC teams, staff nurses and ANMs Remote Areas Guidelines for Safer Motherhood Scale-up of misoprostol distribution through FCHVs Revised National Blood Transfusion Policy referral funds to district hospitals where CEONC services are not available Birth preparedness package distributed through FCHVs Calcium during ANC piloted MDG Goal 5: Improve Maternal Health SDG Source:Safe Motherhood and Neonatal Health (SMNH) Roadmap 2030 25 5/15/2023

26. 26 (Source: Strategy for Skilled Health Personnel and SBA (2020-2025)) 5/15/2023

27. 27 Maternal Health Policies and Strategies of Nepal

28. Safe Motherhood Policy-1998 Policy Objective To reduce mortality and morbidity among women during pregnancy, childbirth and the postnatal period through the adoption of a combination of health and health related measures. 28

29. Strategies 1. Promoting intersectoral collaboration in order to attain the aims of safe motherhood 2. Strengthening and expanding basic maternity care services, including family planning, at all institutional levels 3. Raising the status of women so that maternal morbidity and mortality will be reduced 4. Promoting research on safe motherhood Source: Safe Motherhood Policy-1998 29

30. Maternity care at various level of Health Care Delivery System 1. Maternity care at family level 2. Maternity care at community level 3. Maternity care at health post level 4. Maternity care at PHC centers 5. Maternity care at District/ Zonal/ Center level Referral System 30 Source: Safe Motherhood Policy-1998

31. National Safe Motherhood Plan (2002-2017) National Safe Motherhood Plan was developed with a long term vision to scale up the coverage of maternal and newborn health care at all levels of health care delivery system 31

32. Contd… ❏ Globally, awareness of the issue of maternal mortality began in 1987 at the Safe Motherhood Conference in Nairobi; Commitment to strive for reducing the mortality and morbidity related to pregnancy and childbirth was obtained. ❏ This commitment was reinforced in the ICPD conference held in Cairo in 1994: to reduce maternal mortality and morbidity by at least 50 percent by the turn of the century, Safe Motherhood (SM) was recognized as one of the key components of reproductive health. Source: National Safe Motherhood Plan (2002-2017) 32

33. Rationale for the 15-year Plan ❏ The past strategies of carrying out the Family Planning / Maternal and Child Health in an integrated manner, promoting attendance of birth through the TBA and promoting ANC visits were not adequate in addressing the issues of reducing maternal deaths. ❏ Experience also showed that avoidance of the three delays was imperative to achieve the goal of reduction of maternal mortality. ❏ Maternal Mortality and Morbidity Study (MMMS) in 1996- maternal deaths to be 71 % by direct causes (post partum haemorrhage, obstructed labour, eclampsia, puerperal sepsis and abortion) and 29% by indirect causes. 33 Source: National Safe Motherhood Plan (2002-2017)

34. Contd.. ❏ 90% of the deliveries occurring at home, most of the deaths occur in the community (79%) and only 21% in the health institution. ❏ Antenatal coverage is low and since most deliveries occur outside a health institution and only 10 % of the deliveries are attended by a trained personnel (most being attended by friends and relatives) most deaths take place during the postpartum period (62%) ❏ Needs Assessment done in 2000 (UNICEF) showed an overwhelming unmet need for basic essential obstetric care services. 34 Source: National Safe Motherhood Plan (2002-2017)

35. Plan Format ❏ In the context of the situation highlighted above the Ministry of Health’s current strategy is to increase access to services through establishment of basic and comprehensive essential obstetric care and skilled attendance through trained Maternal and Child Health Workers (MCHW) at the community level. ❏ In order to overcome delay in reaching care the government advocated for community mobilization for transport arrangement and is also trying to empower community, families and women both economically and socially to access care. ❏ IEC is an important aspect of the Safe Motherhood program to recognize the danger signs and facilitate to take appropriate decision to seek care on time when problem arises. ❏ Ensuring quality of basic and comprehensive essential obstetric care services avoids the third delay. 35 Source: National Safe Motherhood Plan (2002-2017)

36. National safe motherhood and newborn health long term plan 2006-2017 Goal: Improved maternal and neonatal health and survival, especially of the poor and excluded. 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. 36

37. 1. Equity and access 2. Services 3. Public private partnership 4. Decentralisation 5. Human resource development: Skilled birth attendant strategy 6. Information management 7. Physical assets and procurement 8. Finance 37 Increased healthy practices, and utilisation of quality maternal and neonatal health services, especially by the poor and excluded, delivered by a well- managed health sector. Outputs: Eight outputs are specified in the plan, each with individual indicators.

38. National Reproductive Health Strategy 1998 Includes safe motherhood in the integrated RH care package 38

39. National Reproductive Health Strategy 1998 ❏ National reproductive health strategy seeks to strengthen the existing Safe motherhood, Family Planning, HIV/ AIDS, STD, Child Survival and Nutrition programmes with a holistic life cycle approach. ❏ This calls for strengthening inter-divisional linkages within the DoHS and other sectors e.g. education, women and development and legal justice system. ❏ National Reproductive Health Strategy fits within the context of 1991 health policy as well as the 1997-2017 second long term plan. Source: National Reproductive Health Strategy 1998 39

40. Integrated Reproductive Health Package The integrated RH package will be delivered through existing Primary Health Care system. ● Family Planning ● Safe Motherhood ● Child health (newborn care) ● Prevention and management of complications of abortion ● RTI/ STD/ HIV/ AIDS ● Prevention and management of subfertility ● Adolescent reproductive health and ● Problems of elderly women i.e. uterine, cervical and breast cancer treatment at the tertiary level or in the private sector Source: National Reproductive Health Strategy 1998 40

41. National Safe abortion policy 2003 ❖ Eleventh amendment in civil act on 2058 BC. Verified on 11th Aashoj 2059. ❖ Before the 11th amendment was passed. The MULUKI AIN had the provision of punishing women for abortion. The provision was jail punishment of 1year, 3 years or 5 years for committing abortion with pregnancy of 12 weeks, 25 weeks and beyond 25 weeks respectively (National safe abortion policy,final draft, August 7, 2003) 41

42. 42 (National safe abortion policy,final draft, August 7, 2003)

43. Basis for the development of Safe Abortion Policy: In response to advocacy efforts that emphasized the high rates of maternal morbidity and mortality attributed to unsafe abortion Studies published between 1982 to 2002 showed that at least one-fifth of women in prison had been convicted for illegal abortion Even in the urban areas many abortion service providers were untrained and as high as 50% of all maternal deaths in the study hospitals were due to abortion-related complications Source: Abortion care in Nepal, 15 years after legalization, Abortion law in Nepal: The Road to Reform 43

44. National policy on SBA 2006 During the time of policy formation only 13% of the delivery were attended by health worker and not all of these workers were qualified as skilled birth attendant. As a signatory to the MDG, Nepal had to reach the target of 60 % of delivery attended by SBA by 2015. Need of policy that guide to achieve MDG target considering challenges related to HRD, socio- economic and cultural barriers, high unmet need for obstetric care, and weak referral back-up. Source: National policy on SBA 44

45. National policy on SBA 2006 MMR 539/100000 NMR 39/1000 largely due to the lack of skilled attendance at birth, as well as poor referral systems and lack of access to life-saving emergency obstetric care when complications occur. This will require 24 hours a day and 7 days a week, “women-friendly” services that are culturally sensitive and affordable to all families, especially those in poor and underserved areas. However, high financial cost has been identified as a major barrier to women accessing skilled birth attendance and health facilities for emergency obstetric care in Nepal. January 2005 the Government of Nepal introduced the maternity cost sharing scheme 45 Source: National policy on SBA

46. 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 newborns.” Elements of SBA policy Strength maternity care Strength the technical capacity Human resource management 46

47. Skill requirements for SBA ❖ Twenty seven basic skills which are core for SBA ❖ Six additional skills for advanced SBA. 1. Perform Forceps delivery 2. Perform Cesareans sections 3. Perform Laparotomy 4. Perform Hysterectomy 5. Provide anaesthesia-local, spinal and general 6. Provide blood transfusion. 47

48. Strategies of SBA Policy 1. Human resources development a. Short term( in services measures) i. Staff nurse / ANM ii. Doctors b. Medium term c. long term ( pre service measures) 48

49. 2. Strengthening SBA Training Sites 3. Deployment and Retention of SBAs 4. Service Provision 5. Enabling Environment 6. Role of Professional organisations/association 7. Role of non-government sector and private sector 8. Institutional Arrangements 49 Strategies of SBA Policy

50. The Right to Safe Motherhood and Reproductive Health Act, 2075 (2018) An Act Made to Provide for the Right to Safe Motherhood and Reproductive Health. It aims to ensure women's access to safe and legal abortion, family planning services, and reproductive health care. The act also recognizes the right of every person to make decisions regarding their reproductive health without any discrimination. Areas covered: Right to Reproductive Health Safe Motherhood and Newborn Baby Safe Abortion Right to obtain morbidity care Provide disability friendly service (Source: Right to safe motherhood and reproductive health Act -2018) 5/15/2023 50

51. Safe Motherhood and Newborn Baby ● Right to get obstetric service ● To provide obstetric care ● Emergency obstetric and newborn care ● Health care of newborn baby ● To maintain record of the births of infants ● Right to obtain family planning service ● Not to get family planning performed forcefully ● Right to obstetric leave (Source: Right to safe motherhood and reproductive health Act -2018) 5/15/2023 51

52. Safe Abortion: ● To perform safe abortion: ● Not to get abortion conducted forcefully ● Not to commit abortion upon identifying sex ● Safe abortion service ● To maintain confidentiality (Source: Right to safe motherhood and reproductive health Act -2018) 5/15/2023 52

53. Part-3- Fundamental Rights and Duties 35. Right relating to health: (1) Right to free basic health services from the State, and no one shall be deprived of emergency health services. (2) Right to get information about his or her medical treatment. (3) Every citizen shall have equal access to health services. (4) the right of access to clean drinking water and sanitation. Article 38: Right of Women: ○ Every woman shall have equal right to lineage without any gender discrimination ○ Every woman shall have the right relating to safe motherhood and reproductive health ○ There shall not be any physical, mental, sexual or psychological or any other kind of violence against women, or any kind of oppression based on religious, social and cultural tradition, and other practices. Such an act shall be punishable by law and the victim shall have the right to be compensation as provided for in law Constitution of Nepal:(2015) (Source: Constitution of Nepal -2015) 5/15/2023 53

54. ○ It is expedient to make necessary legal provisions for implementing the right to get free basic health service and emergency health service guaranteed by the Constitution of Nepal. ● Chapter 2: Rights, Duties of Service Recipients and Responsibilities of Health Institutions ○ 3: Access to and certainty of health service: ■ 4: Every citizen shall have the right to obtain free basic health services under the following headings, as prescribed: ● (a) Vaccination service ● (b) Motherhood, infant and pediatric health service such as integrated infant and pediatric disease management, nutrition service, pregnancy, labor and childbirth service, family planning, abortion and reproductive health The Public Health Service Act, 2075 (2018) (Source: Constitution of Public health service act -2018) 5/15/2023 54 The Public Health Service Act, 2075 (2018)

55. National Health Policy 2019 ●Vision ■ Healthy, alert and conscious citizens oriented to happy life Mission ■ To ensure fundamental health rights of citizens through optimum and effective use of resources, collaboration and participations Goal ○ To develop and expand a health system for all citizens in the federal structure based on social justice and good governance and ensure access to and utilization of quality health services (Source: National Health Policy -2019) 5/15/2023 55

56. National Health Policy 2019 ●Objectives ∙ To create opportunities for all citizens to use their constitutional rights to health. ∙ To develop, expand and improve all types of health systems as per the federal structure. ∙ To improve the quality of health services delivered by health institutions of all levels and to ensure easy access to those services. ∙ To strengthen social health protection system by integrating the most marginalised sections. ∙ To promote multi-sectoral partnership and collaboration between governmental, non-governmental and private sectors and to promote community involvement. ∙ To transform the health sector from profit-orientation to service-orientation. (Source: National Health Policy -2019) 5/15/2023 56

57. Policy 6.20 ● 6.20 In accordance with the concept of health across the lifecycle, health services around safe motherhood, child health, adolescence and reproductive health, adult and senior citizen shall be developed and expanded. ■ 6.20.1. Safe motherhood and reproductive health services shall be made of good quality,affordable and accessible. ■ 6.20.2. Health services targeted to vulnerable age groups such as maternal-infant health, child health, adolescent health, adult health and geriatric health shall be strengthened and professional midwifery and nursing services shall be expanded. (Source: National Health Policy -2019) 5/15/2023 57

58. Policy 6.20 ● 6.20.3. In view of social determinants that affect women's health, special programs shall be implemented in coordination with concerned stakeholders. ● 6.20.4. In order to strengthen safer motherhood and reproductive health, skilled birth attendants shall be arranged in all wards. ● 6.20.5. Abortion services shall be made qualitative and effective as per the law. ● 6.20.6. Health services related with infertility shall be gradually extended to the state levels. (Source: National Health Policy -2019) 5/15/2023 58

59. Second long-term Health Plan(1997-2017) Goal The health status of the Nepalese population will be improved through the healthcare system, which provides equitable access to quality health care for all people. Targets on maternal health ★ Maternal Mortality Ratio will be reduced to 250 per hundred thousand births from its present level of 475 ★ Contraceptive Prevalence Rate will be increased to 58.2 percent from its present level of 30.1 ★ Percentage of deliveries attended by trained personnel will be increased to 95% from its present level of 31.5 Source: MoHP G. Second Long Term Health Plan 1997-2017. Kathmandu: Ministry of Health and Population, Government of Nepal. 1997 59

60. Policy statement on safe abortion ❖ Comprehensive abortion care services (CAC) ❖ Human resources development ❖ Right of women ❖ Role of non government and private sector ❖ Advocacy, IEC and social mobilization ❖ Coordination , monitoring , planning, supervision and follow up ❖ Research ❖ Institutional arrangements 60

61. National communication strategy for Maternal Neonatal and Child health 2011-2016 GOAL AND OBJECTIVE The goal of the safe motherhood and newborn health (SMNH) programme is improved maternal and neonatal health and survival, especially of the poor and excluded COMMUNICATION GOAL The goal of the SMN communication is to contribute to increasing access to and utilization of improved maternal and newborn health information and quality services. 61

62. Communication Objectives: ❖ Increase positive attitude and behaviour of health workers and FCHVs that pregnancy, delivery and postnatal are special times for fast action to save the lives of mothers and newborns. ❖ Increase mobilization of community resources to support birth preparedness, EOC and maternal and newborn care and referral services. ❖ Increase ability of community to identify facilities forinstitutional delivery and EOC and skilled birth attendants. ❖ Improve interpersonal communication skills of service providers and FCHVs. ❖ Improve home based nutrition for pregnantwomen and adolescent. 62

63. ❖ Increase knowledge and desired behaviour of community to recognize and act on maternal and newborn danger signs. . ❖ Increase support for creation of an enabling environment for women’s rights, to improve women’s status, birth preparedness discrimination caused by gender and caste/ethnicity, regional identity, income status and location and reduced ‘laaj’ among women. ❖ Increase knowledge about prevention of unwanted pregnancy and safe abortion services. 63 Communication Objectives:

64. National Blood Transfusion Policy-2014 ● Vision: ○ Every individual could get safe and enough blood product when needed. ● Mission: ○ To develop blood transfusion service as per the international level by using maximum available resources and coordination between regulating authority, service providers, donors, receivers and concerned stakeholders. ● Goal: ○ To provide safe and quality blood and blood products for all the citizen of Nepal whenever needed in easy and convenient way. ● Objective: ○ To prepare organizational financial and legal aspects for blood collection from Voluntary Non-Remunerated blood donation and distribute to needy ones. (Source: National Blood Transfusion Policy-2014) 5/15/2023 64

65. National Blood Transfusion Policy (Strategies:) ● Follow the GLP( Good Laboratory Practice) during the testing , GMP(Good Manufacturing practice) for processing and GCP(Good clinical Practice) for use blood products to prevent the TTI (Transfusion Transmissible illness) ● To promote safe and appropriate use of blood and blood products in clinical practice ● To develop good management systems ● To develop the national information system ● To help and co-operate with national and international stakeholders. (Source: National Blood Transfusion Policy-2014) 5/15/2023 65

66. National Population Policy 2014 ● Vision: ○ Every individual has increased opportunity to improve Quality Of Life. ● Mission: ○ Enhancing people's lives by addressing population issues, development of population, guaranteeing people's reproductive well-being and reproductive rights as crucial human rights and promoting equity and incorporation in all sustainable development strategies ● Goal: ○ Integrating the population issues with development in order to improve the quality of life of the people , assuring the reproductive rights and maintaining the gender equity and social inclusion. ○ To set the targets for sustainable Development Goals for next 20 years after implementation of the policy for 2090 BS(2034). (Source: National Population Policy 2014) 5/15/2023 66

67. Strategy 2: Develop reproductive health services including sexual health, family planning and safe abortion as a rightful program. ○ Increase the accessibility of safe sexual and reproductive health by developing as basic rights ○ Provide information on family planning devices and its utilization. ○ Fulfill the unmet demand of family planning ○ Ensure safe abortion and post abortion services and free of cost for women of poor and disadvantages group ○ ANC checkup for the improvement in health of mother and child. ○ Special programs for the protection of disadvantages group such as Raute, Kusunda, Chepang, Rajbanshi, Chamr, Musahar, Baadi, Raaji, etc. ○ Encourage the marriage only after the age of 20 and birthing procedure only after being capable in terms of psychological, social and economical. (Source: National Population Policy 2014) 5/15/2023 67

68. 2. Develop reproductive health services…(Cont...) ● Conduction of and appropriate birth spacing program related to IEC(information Education and Communication) and BCC aiming to increase age at marriage . ● Addressing the problem of fertility and subfertility as per the demand of people. ● Ensure the accessibility of reproductive health and sex education in a comfortable environment for men, women and third gender, and adolescents and youths. ● Advocacy and discussion program to prevent adolescents from drug abuse and sexual abuse ● Expansion of maternal health centered health services to reduce maternal mortality. (Source: National Population Policy 2014) 5/15/2023 68

69. National HRH(Human Resource for Health) Strategy: ● Based on the Global Strategy on Human Resources for Health: Workforce 2030 ● Guiding principles: ○ Trend of Morbidity and Mortality Rate ○ Prioritize Basic Health Services ○ Universal access to quality healthcare ○ Distribution of health manpower according to population density and workload. ○ Skill Blending Concept (Source: National HRH strategy- 2078 BS) 5/15/2023 69

70. National HRH(Human Resource for Health) Strategy: ● Vision: ○ Availability and equitable distribution of skilled and quality health personnel. ● Mission: ○ Making maximum use of available resources, in collaboration between stakeholders of production and deployment of skilled health manpower with skills mixed in accordance with population, geography and federal structure. ● Goal: ○ Establishment, operation of educational for production of health manpower. ○ To guide the central , province and local levels according to the federal system to manage quality health manpower. ○ To develop and expand health services according to the country's health needs, to protect people's health, to prevent and treat diseases, to achieve the goals of sustainable development in accordance with Universal Health Coverage. (Source: National HRH strategy- 2078 BS) 5/15/2023 70

71. Strategies Action: ● Production and development of health manpower ● Distribution and management of health manpower ● Managerial leadership and governance of the health workforce ● Health Workforce Information System ● Coordinate in Brain gain and , contribute to Nepal program champion (Source: National HRH strategy- 2078 BS) 5/15/2023 71

72. National Guideline on Antenatal to Postnatal Continuum of Care-2076 Goal of Guideline: Ensure healthy outcome for the mother and her newborn, as well as a positive experience with the health system and therefore help to reduce maternal and neonatal mortality. Guiding Principle: ● Antenatal Care ● Quality of Care ● Women and Newborn centered care and Informed Decision making ● Use of standard precautions for Infection Prevention and Control Source: National Guideline on Antenatal to Postnatal Continuum of Care-2076 5/15/2023 72

73. ANC Model for NEPAL Existing Government of Nepal ANC model 2016 WHO ANC model ANC model proposed by the Government of Nepal Four focused ANC visits Eight ANC contacts Eight ANC contacts Visit 1: up to 16 weeks Contact 1: up to 12 weeks Contact 1:up to 12 weeks Visit 2: 24 weeks Contact 2: 20 weeks Contact 2: up to 16 weeks Visit 3: 32 weeks Contact 3: 26 weeks Contact 3: 20-24 weeks Visit 4: 36 weeks Contact 4: 30 weeks Contact 4: 28 weeks Contact 5: 34 weeks Contact 5: 32 weeks Contact 6: 36 weeks Contact 6 : 34 weeks Contact 7: 38 weeks Contact 7: 36weeks Contact 8:40weeks Contact 8: 38-40 weeks Source: National Guideline on Antenatal to Postnatal Continuum of Care-2076 5/15/2023 73

74. Recommended postnatal contacts based on roadmap 2030 and WHO recommendations: PNC check (for mother & newborn) Facility Delivery Home Birth At 24 hours At facility and integrated into discharge protocol Home contact by community nurse /Midwives as soon as possible but within 48 hours of birth 3rd day Home contact by Community Nurse/Midwives Home contact by Community Nurse/Midwives 7 – 14 days Home contact by Community Nurse /Midwives Home contact by Community Nurse/Midwives 6 weeks Health facility contact, EPI clinics Health facility contact; EPI clinics Source: National Guideline on Antenatal to Postnatal Continuum of Care-2076 5/15/2023 74

75. Continuum of care Federal Government Tertiary, Academic and Super Specialty Provincial Government Secondary Hospitals Local Government Primary Hospital, Health Posts,CHC,ORC,BHCC, UHC Appropriate Referral Counter Referral Follow-up Continuum of Care across the woman’s lifecycle Women Centere d Care Pre- Conceptio n Pregnan cy ANC Labour & Delivery PNC Family Planning , Immunizati on and nutrition Source: National Guideline on Antenatal to Postnatal Continuum of Care-2076 5/15/2023 75

76. Strategy for Skilled Health Personnel and SBA (2020-2025) Vision ● To ensure the fundamental rights of the mother and baby to live healthy lives, and to achieve equitable health outcomes. Goal ● To reduce maternal and newborn morbidity and mortality through quality health services, provided by SHP/SBAs working in an enabling environment. Source: Strategy for Skilled Health Personnel and SBA (2020-2025) 5/15/2023 76

77. Strategic Approaches • Ensure availability of quality MNH care at service delivery points including referral services • Train SHP/SBAs and strengthen post-training support • Strengthen supervision and monitoring • Build capacity in leadership, management, accountability, and governance • Collaborate for enabling environment • Institutional Arrangements National Health Policy (2019) recommends one skilled birth attendant per ward (6.20.4) The operational guidelines for the Basic Health Service Package recommends birthing centers only at health post that have a catchment population of 7,000 or above. The Safe Motherhood and Newborn Health Roadmap 2030, recommends that all women give birth at an existing basic emergency obstetric and newborn care (BEONC) site or a comprehensive emergency obstetric and newborn care (CEONC) site that is within 2 hours walking distance, and recommends strategic birthing center for women who are not able to access the CEONC/BEONC easily. Source: Strategy for Skilled Health Personnel and SBA (2020-2025) 5/15/2023 77

78. Nepal Safe Motherhood and Newborn Health Roadmap-2019 (2020-2030) ● The Road Map is a national document with key recommendations for MNH for the first five years. ● It is expected that Provincial and Local Governments will develop context-specific five-year activity-level plans that are based on the recommendations of the Road Map. ● The Road Map will be reviewed after five years and, if necessary, based on results, the recommendations and targets will be adjusted. ● The Road Map’s results framework is consistent with the targets and indicators of the NHSS, SDGs and the NeNAP. ● An evaluation will take place in 2030, at the end of the Road Map period, to assess progress and achievements. Source: Nepal Safe Motherhood and Newborn Health Roadmap-2019 (2020-2030) 5/15/2023 78

79. ● Nepal’s Safe Motherhood and Newborn Health (SMNH) Road Map 2030 is developed with a focus on ending preventable maternal and newborn deaths, by building on the successes of the SMNH Programme and addressing the remaining challenges, especially around strengthening community health system platforms and improving institutional quality of care in an equitable manner. ● Preventing maternal deaths is inextricably linked to preventing stillbirths and newborn deaths and the Road Map will build upon activities that are already outlined in NeNAP (2016–2035). ● The implementation period for the Road Map will be just over 10 years Source: Nepal Safe Motherhood and Newborn Health Roadmap-2019 (2020- 2030) 5/15/2023 79

80. Source: Nepal Safe Motherhood and Newborn Health Roadmap-2019 (2020- 2030) 5/15/2023 80

81. Outcomes and Outputs • Output 1.1 Reproductive, maternal and newborn health services are available, and health facilities that comply with the standards are located in strategically accessible areas, with functional referral linkages • Output 1.2 Readiness of health facilities (public and private) to provide services is ensured • Output 1.3 An enabling environment is ensured for health staff to provide high-quality services Outcome 1: The availability of high-quality maternal and newborn health services increased, leaving no one behind Source: Nepal Safe Motherhood and Newborn Health Roadmap-2019 (2020-2030) 5/15/2023 81

82. • Output 2.1 Mothers and families have appropriate and accurate information and knowledge to seek care in a timely manner • Output 2.2 Health managers have adequate capacity and address users’ needs • Output 2.3 More effective and equitable outreach services are ensured • Output 2.4 Parliamentarians and locally elected leaders are empowered to demand adequate investment in maternal and newborn health Outcome 2: The demand for and utilization of equitable maternal and newborn health services increased Source: Nepal Safe Motherhood and Newborn Health Roadmap-2019 (2020- 2030) 82

83. • Output 3.1 Adequate financing is ensured for maternal and newborn health services • Output 3.2 Effective and sustainable partnerships are ensured for maternal and newborn health services • Output 3.3 Accountability for maternal and newborn health services is enhanced at all levels Outcome 3: The governance of maternal and newborn health services is improved, and accountability is ensured Source: Nepal Safe Motherhood and Newborn Health Roadmap-2019 (2020- 2030) 83

84. • Output 4.1 Monitoring of maternal and newborn health is improved • Output 4.2 Evaluation of maternal and newborn health and health services is planned during the programme design and is effectively carried out Outcome 4: Monitoring and evaluation of maternal and newborn health improved Source: Nepal Safe Motherhood and Newborn Health Roadmap-2019 (2020- 2030) 84

85. • Output 5.1 Preparedness of maternal and newborn health services to address emergencies is improved • Output 5.2 Response to maternal and newborn health care in emergencies is strengthened Outcome 5: Emergency preparedness and response for maternal and newborn health strengthened Source: Nepal Safe Motherhood and Newborn Health Roadmap-2019 (2020- 2030) 85

86. National Strategy on Nurses and Midwifery 2022 Vision ● Universal Access to quality nursing and midwifery services. Mission ● Promotion of quality health services and professionalism through mobilization of quality nursing and midwifery human resources. Goal ● To fulfill the important role for improving health of every citizen and strengthening, dignifying, managing & maintaining quality of nursing and midwifery services thorough federal level inclusive and equity based health service system. Source: National Strategy on Nurses and Midwifery 2022 5/15/2023 86

87. Guiding Principle: Ensuring quality nursing and midwifery education Increasing access of quality and equity based health services Health service delivery with honesty & professionalism Expansion of specialized nursing education and services Partnership between public and private sector Cooperation and coordination according to country’s restructured basis Source: National Strategy on Nurses and Midwifery 2022 5/15/2023 87

88. The Cairo Conference,1994 ● The International Conference on Population and Development (ICPD)- convened under the auspices of the United Nations, took place in Cairo, Egypt, September 5-13, 1994. ● It brought together representatives from over 179 governments and 11,000 non- governmental organizations participants. ● The conference adopted a 20-year Program of Action, which focused on individuals' needs and rights, rather than on achieving demographic targets. ● Broadened concept of family planning to include reproductive & sexual health. Source: UNICEF Factsheet, SRHR in Nepal 5/15/2023 88

89. 1994 ICPD 1999 ICPD +5: Governme nt reaffirm support 2000 Millenni um Summit Declarat ion 2009 ICPD +15 201 9 ICP D +25 2004 ICPD +10 2005 World Summi t ICPD Commitment timeline Source: UNICEF Factsheet, SRHR in Nepal 5/15/2023 89

90. ICPD Goals Raise the quality of life and the well- being Promote human development Recognizing population and development policies link Achieve poverty eradication Sustained economic growth in the context of sustainable development The guarantee of all human rights, including reproductive right Source: UNICEF Factsheet, SRHR in Nepal 5/15/2023 90

91. Recommitment to the ICPD Programme of Action at the Nairobi Summit on ICPD 25, 2019 Achieve the three zeros: a. Zero unmet need for family planning b. Zero preventable maternal death c. Zero gender based violence and harmful practices, including child marriage Ensure young people can exercise their SRHR by expanding adolescent-friendly services and comprehensive sexuality education (CSE) Ensure that the basic humanitarian needs of affected populations, including sexual and reproductive health care and gender-based violence prevention and response services, are addressed in humanitarian contexts Put in place financing policies, instruments and structures to ensure the full implementation of the ICPD Programme of Action and the 2030 Agenda and Sustainable Development Goals (SDGs) Source: UNICEF Factsheet, SRHR in Nepal 5/15/2023 91

92. What’s changed in Nepal since the Cairo Conference The maternal mortality ratio has come down from 539 (1996) to 151 (2022) The births attended by skilled health personnel has gone up from 10% (1996) to 80% (2022) The total fertility rate has decreased from 4.6 (1996) to 2.1 (2022) The adolescent fertility rate has decreased from 127 (1996) to 71 (2022) The modern contraceptive prevalence rate has gone up from 26.0% (1996) to 43.0% (2022) Unmet need for family planning has slightly dropped from 24.6% (2006) to 21% (2022) Source: 25 Years of the ICPD- Accelerating the Promise, 5/15/2023 92

93. Unfinished Business ● In Nepal, 151 mothers die for every 100,000 births. Many more suffer from injuries and chronic disability incurred during childbirth. This is long way from the global target set in 1994 to reduce maternal deaths to fewer than 75 per 100,000 live births, and the Agenda 2030 target of 70. ● About 1.5 million currently married women in Nepal who would like to control their own fertility still do not have access to modern contraceptives. Without this access, they lack the power to make decisions about their own bodies, including whether or when to become pregnant. The lack of this power—which influences so many other facets of life: education, income, safety—leaves women and girls unable to shape their own futures. ● Still 22 per cent of women in Nepal age 15-49 have experienced physical violence since age 15 and 7 per cent have ever experienced sexual violence. Source: 25 Years of the ICPD- Accelerating the Promise, UNICEF 5/15/2023 93

94. Beijing Conference The United Nations has organized four world conferences on women. These took place in Mexico City (1) in 1975, Copenhagen (2) in 1980, Nairobi (3) in 1985 and Beijing (4) in 1995. The United nation’s fourth world conference on Women held in Beijing, China September 4-15, 1995. Largest and most influential of all the World Conference on Women Prepared a Platform for Action that aimed at achieving greater equality and opportunity for women. The official name of the Conference was "The Fourth World Conference on Women: Action for Equality, Development and Peace“ The Conference was participated by 189 Governments/countries. Source: Beijing Declaration, IOM Lecture 5/15/2023 94

95. Beijing Conference: Critical Areas of Concern Source: https://archive.unescwa.org/our-work/beijing-declaration-and-platform-action 5/15/2023 95

96. Nepal’s Commitment to the Beijing POA Nepal’s Commitment To revitalize women as an integral group and redesign mainstreaming programmes with life cycle perspective To reform laws discriminatory to women To incorporate women’s needs and concerns in poverty reduction programmes To broaden the coverage of PHC facilities and strengthening MCH services To achieve universal literacy and increase women access to education To encourage and assist NGO work with CBO for advocacy, institution building and the delivery of services to women Source: Beijing Declaration, IOM Lecture 5/15/2023 96

97. After Beijing Declaration The Ministry of Women and Social Welfare was formed. The National Work Plan for Gender Equity and Women’ s Empowe rment (1997) was formulat ed. Govern ment has gender focal point in all governm ent agencies . Rights of inheritan ce to propert y between son and daughte r In 2002 Nepal’s parliame nt passed a liberal abortion law Human Rights Commis sion Act of 1996 establish ed a National Human Rights Commis sion – woman’s right to protectio n, develop ment, participa tion and survival Ninth Plan(199 7-2002) have included a Women and Gender Equality Policy National Policy on Family Planning , 1997 National Reprodu ctive Health Strategy, 1998 Safe Motherh ood Policy,1 998 MDGs- Goal 3 and 5 National Adolesc ent Health and Develop ment Strategy, 2000 Source: Beijing Declaration, IOM 5/15/2023 97

98. Millennium Development Goals (2000-2015) Nepal’s achievement of the MDG targets, 1990–2015 Source: Nepal and MDG; Final Report 2000-2015, NPC, 2016 5/15/2023 98

99. Sustainable Development Goals (SDG) Source: SDG Status and Roadmap-2016-2030, NPC 5/15/2023 99

100. Source: SDG Status and Roadmap-2016-2030, NPC 100

101. Impacts of COVID-19 on Maternal Health Source: 25 Years of the ICPD- Accelerating the Promise, UNICEF 101

102. FCHV Program Goal To Improve the health of local community peoples by promoting public health. This includes imparting knowledge and skills for empowering women, increasing awareness on health related issues and involving local institutions in promoting health care. Source: Annual Report Department of Health Services 2077/78 (2020/21) 102

103. ❏ GoN initiated the FCHV Programme in 2045/46 (1988/1989) In 27 districts and expanded it to all 77 districts thereafter. ❏ The major role of FCHVs is to advocate healthy behaviour among mothers and community people to promote safe motherhood, child health, for family planning and other community-based health issues and service delivery. ❏ FCHVs’ role had been highly acknowledged by the GoN in achieving milestones of Millenium Development Goal 4 and 5 and expected the same in the era of Sustainable Development Goal by 2030 through contextual modification. Source: Annual Report Department of Health Services 2077/78 (2020/21) 103

104. PHC-ORC Program Objective : To bring health services closer to the communities. PHC-ORC was initiated in 1994 (2051 BS) Aim of these clinics is to improve access to basic health services including family planning, child health and safe motherhood. These clinics are service extension sites of PHCs and HPs. Based on local needs, these clinics are conducted every month at fixed locations, dates and times. They are conducted within half an hour's walking distance for their catchment populations. ANMs/AHWs provide the basic primary health care services Source: Annual Report Department of Health Services 2077/78 (2020/21) 104

105. Services to be provided by PHC-ORCs on maternal health Safe motherhood - ANC, PNC - Iron supplement distribution - Referral if danger signs identified Family planning: ● DMPA (Depo-Provera) pills and condoms ● Monitoring of continuous use ● Education and counselling on family planning methods and emergency contraception ● Counselling and referral for IUCDs, implants and VSC services ● Tracing defaulters Health education and counselling Source: Annual Report Department of Health Services 2077/78 (2020/21) 105

106. 106 Current Maternal Health Programs and Activities of Nepal

107. National Safe Motherhood Programme 107

108. National Safe Motherhood Programme(I) To reduce maternal and neonatal morbidity and mortality and 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 To reduce maternal and neonatal morbidity and mortality Goal 108 Source: DOHS Annual Report FY 2077/78

109. Evidence suggests that three delays are important factors for maternal and newborn morbidity and mortality in Nepal: 3 Delay Behind Maternal Morbidity and Mortality(II) 1. Delays in seeking care 2. Delays in reaching care 3. Delays in receiving care 109 Source: DOHS Annual Report FY 2077/78

110. Strategies(III) 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. Strengthening community-based awareness on the birth preparedness and complication readiness through FCHVs and increasing access to information Supporting activities that raise the status of women in society. Promoting research on safe motherhood to contribute to improved planning and more cost effectiveness interventions. 110 Source: DOHS Annual Report FY 2077/78

111. Components and Activities of Safe Motherhood Programme 111

112. 1. Community level maternal and newborn health interventions Birth preparedness and complication readiness(preparedness for money, place for delivery, transport and blood donors) ANC, institutional delivery and PNC (IFA,TD, Albendazole,Vitamin-A) Identification of and timely care seeking for danger signs in the pregnancy, delivery, postpartum and newborn periods Self-care (food,rest,no smoking and no alcohol) Distribution of Matri-Suraksha Chakki (misoprostol) to prevent PPH in home deliveries Essential newborn care 112 Source: DOHS Annual Report FY 2077/78

113. 2. SMNH Programme during COVID 19 Pandemic situation Management of PPH Prevention Orientation programme ❑ Provided PPH orientation to service providers in 22 hospitals of Lumbini and Karnali. ❑ 312 doctors/nurses received virtual orientation on PPH (estimation of blood loss, prevention of PPH and management and treatment of PPH (Uterotonic drugs, management of trauma, retained placenta/tissue, Condom Balloon Tamponade, Bimanual uterine compression, and Peripartum Hysterectomy) RMNCAH Interim Guideline Orientation Programme ❑ FWD led development of RMNCAH interim guideline and orientation to health workers to ensure 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 guideline with support of various partners (NHSSP, OHW, UNFPA, SSBH, UNICEF, Care, Ipas, Su-aahara). Virtual SBA clinical mentors’ refresher ❑ 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. 113 Source: DOHS Annual Report FY 2077/78

114. ▪ Expected to contribute in reducing maternal and neonatal deaths by identifying early complications during pregnancy,delivery and postpartum period. ▪ Trained SBA scan clients at rural PHCCs and HPs using portable ultrasound. ▪ Detected abnormalities such as abnormal lies and presentation of the foetus and placenta previa are referred to a CEONC site ▪ Programme implemented in the remote districts 3. Rural Ultrasound Programme(I) 1.Ultrasound Training to Staff Nurses working in rural health facilities of Lumbini Province [Internet]. FAIRMED. 2021 [cited 2023 May 10]. Available from: https://www.fairmed.org.np/news/ultrasound- training-to-staff-nurses-working-in-rural-health-facilities-of-lumbini-province 2. Annual Report of DOHS 2077/2078 Aims for timely identification of pregnant women with risks of obstetric complication to refer to CEONC 114

115. ▪ 21 days Rural Ultrasound Training to Nurses and midwives of rural HF and equipped with a digital, semi portable ultrasound for scanning. ▪ FWD allocated programme implementation budget in 248 local levels of 30 remote districts in 2077/78. ▪ The total programme implementation districts are 11 in Province 1, Myagdi and Baglung in Gandaki, East Rukum in Lumbini, 9 districts in Karnali and 7 districts in Sudurpaschim Province. 3. Rural Ultrasound Programme(II) 115 1.Ultrasound Training to Staff Nurses working in rural health facilities of Lumbini Province [Internet]. FAIRMED. 2021 [cited 2023 May 10]. Available from: https://www.fairmed.org.np/news/ultrasound- training-to-staff-nurses-working-in-rural-health-facilities-of-lumbini-province

116. ▪ FWDs goes for continuous budget allocation and recruiting human resources (Doctors, staff nurses, ANMs) on short term contracts to ensure 24 hours services on MNH at PHCCs and HPs ▪ 714 Palikas received budget for recruiting ANM staffs, and 38 hospitals received budget for recruiting Staff Nurses. ▪ Provide CEONC funds to 40 hospital/CEONC sites to recruit the human resource mix needed to provide surgical management for obstetric complications at district hospitals (CEONC sites) and 7 overcrowding hospitals for recruiting Gynaecologist, Paediatrician, Anaesthesiologist and Anesthesia Assistant. 4. Human Resources 116 Source: DOHS Annual Report FY 2077/78

117. 4. Human Resources ▪ Coordinating with NHTC and NAMS for pre-service and in-service training of health workers. ▪ NHTC provides training on SBA, ASBA, Anaesthesia assistant, operating theatre management, FP (including implants and IUCD), CAC and antenatal ultrasonography. ▪ Total 1208 SBA and 44 ASBA were trained by NHTC and PHTC in the Provinces and till end of 2077/78 -11596-SBA ,278-ASBA trained ▪ The proper placement of trained staff such as ASBAs and anaesthesia assistants (AAs) has been a continuous challenge. ▪ FWD continues to monitor the deployment of doctors (MDGP, OBGYN, ASBA) and AAs, and inform DOHS and MOHP as necessary for appropriate transfer which improved functionality of CEONC services. 117 Source: DOHS Annual Report FY 2077/78

118. ● Expansion of 24/7 service delivery sites like birthing centers, BEONC and CEONC sites at PHCCs, HPs 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 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 2236 health posts and 188 PHCC were reported to have provided (at least one) delivery service in 2077/78. 5. Expansion and quality improvement of service delivery sites 118 Source: DOHS Annual Report FY 2077/78

119. 6. MNH readiness Hospital and BC/BEONC Quality Improvement(I) Improvement in quality-of-service delivery through self-assessment, infection prevention demonstration and action plan implementation Evidence based effective program found in piloting districts in 2070/2071. Objective 119 Source: DOHS Annual Report FY 2077/78

120. ● Expanded MNH readiness hospital quality improvement process (HQIP) gradually from FY 2072/73 ● Till 2077/78 HQIP/QIP programme expanded in 67 hospitals and PHCC with CEONC services in 63 districts ● Since FY 2076/77, HQIP process was integrated with the onsite coaching and mentoring process at hospitals ● The process of quality improvement is also being implemented in birthing centres in integration with SBA onsite clinical coaching/mentoring process ● Till FY 2077/078, total QI reported BC/BEONC sites were 824 6. MNH readiness Hospital and BC/BEONC Quality Improvement(II) 120 Source: DOHS Annual Report FY 2077/78

121. • To support emergency referral transport to women from poor, Dalit, Janajati, geographically disadvantaged, and socially and economically disadvantaged communities who need emergency caesarean sections or complication management during pregnancy or child birth. Objective 7. Emergency Referral Funds(I) 121 Source: DOHS Annual Report FY 2077/78 5/15/2023

122. ●Family Welfare Division allocated emergency referral funds to 53 hospitals of 52 districts in FY 2077/78 from across the 7 provinces. ●A total of Rs. 6,700,000 was allocated to 53 hospitals to support women when referral needed. ●Additional about Rs. 60,000 in each palika was allocated for the BC and BEONC service sites to support transport fares women who could not afford referral to high facility (nearby CEONC facilities). 7. Emergency Referral Funds(II) 122 Source: DOHS Annual Report FY 2077/78 5/15/2023

123. 8. Presidential Women Uplifting Programme(I) A PROGRESSIVE JOURNEY TO GENDER EQUALITY AND WOMEN’S EMPOWERMENT ACHIEVEMENTS OF NEPAL Government of Nepal Ministry of Women, Children and Senior Citizen Singhadurbar, Kathmandu [Internet]. [cited 2023 May 10]. Available from: https://mowcsc.gov.np/downloadfiles/0Cz7iCOxqikIdQNpREjhO2pbqXiIaQlz4BhM5scc-1625557539.pdf ⮚ The President Women Upliftment Program (PWUP) was launched in 8 March 2017 as a flagship program to meaningfully transform the life of disadvantaged, poor and marginalized women implemented by Ministry of Women, Children and Senior Citizens. ⮚ The program has various components under three clusters of activities. I -Focuses on livelihood improvement, employment generation and entrepreneurship Cluster-I II -Focuses on social awareness Cluster-II III -Focuses on activities such as heli-rescue of pregnant and lactating women, grants for rehabilitation for children with disabilities , adolescent girls and women. Cluster-III 123

124. ▪ Helicopter lifting is one of major activities of President Women’s Upliftment Programme ▪ Heli-lifting of women at high risk pregnancy and during delivery is becoming popular initiative due to immediate life saving impact. ▪ Program covers 34 districts, which stand low in comparable HDI ▪ Being a 24/7 services, it is widely acknowledged as a responsible step of State towards its citizen. 8. Presidential Women Uplifting-Airlifting Programme(II) Source: A PROGRESSIVE JOURNEY TO GENDER EQUALITY AND WOMEN’S EMPOWERMENT ACHIEVEMENTS OF NEPAL Government of Nepal Ministry of Women, Children and Senior Citizen Singhadurbar, Kathmandu [Internet]. [cited 2023 May 10]. Available from: https://mowcsc.gov.np/downloadfiles/0Cz7iCOxqikIdQNpREjhO2pbqXiIaQlz4BhM5scc-1625557539.pdf 124

125. ▪ Free air rescue of pregnant women in remote areas has saved several lifes. ▪ If the health facility in the village cannot provide specific services then the mother can be taken to CEONC sites immediately under the coordination of Ministry of Women,Children and Senior Citizens. 8. Presidential Women Uplifting-Airlifting Programme(III) ▪ This initiative has saved the lives of 110 women and their infants from December 2018 to June 30, 2020 ▪ In 2075/76, 26 pregnant women were airlifted, 87 in the fiscal year 2076/77, 103 lives of pregnant women were saved in the fiscal year 2077/78 and 88 lives of pregnant women at risk are saved in the current fiscal year so far. 125

126. Aama Surakshya Program 2005- Maternity Incentive Scheme Transport Incentive 2006- Safe Delivery Incentive Programme (SDIP) User Fees removed from all types of delivery care in 25 low HDI Districts 2009- Aama Program Expanded Nationwide 2012- Addition of 4 ANC incentive in the Aama Program Source: DOHS Annual Report FY 2077/78

127. Components of the Program Antenatal Care (ANC) Delivery Care Emergency Obstetric Care Postnatal Care (PNC) Source: DOHS Annual Report FY 2077/78

128. Antenatal Care Blood pressure, weight and fetal heart rate monitoring IEC and BCC on pregnancy, childbirth, and early newborn care and family planning Information on danger signs and timely referral to appropriate health facilities Provision of Tetanus toxoid and Diphtheria (TD) immunization, iron folic acid tablets and deworming tablets to all pregnant women, and malaria prophylaxis where necessary Early detection and management of complications during pregnancy 8 antenatal checkups

129. Incentive Scheme Source: Review of Aama Surakshya Programme in Nepal, NHSSP-III, 2020.

130. Delivery Care • 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. Source: DOHS Annual Report FY 2077/78

131. Emergency obstetric care Basic emergency obstetric and newborn care (BEONC) • Management of pregnancy complications by assisted vaginal delivery (vacuum or forceps) • Manual removal of placentas • Manual vacuum aspiration • Administration of parental drugs • Resuscitation of newborns and referrals Comprehensive emergency obstetric and newborn care (CEONC) • Surgery (caesarean section) • Anaesthesia • Blood transfusions • BEONC functions Source: DOHS Annual Report FY 2077/78

132. Postnatal Care Three postnatal check-ups 1st In 24 hours of delivery 2nd On the third day 3rd On the seventh day after delivery Source: DOHS Annual Report FY 2077/78

133. Components-PNC • The identification and management of complications of mothers and newborns and referrals to appropriate health facilities. • The promotion of exclusive breastfeeding. • Personal hygiene and nutrition education, and postnatal vitamin A and iron supplementation for mothers. • The immunization of newborns. • Postnatal family planning counselling and services. Source: DOHS Annual Report FY 2077/78

134. PNC Home Visit Program (Rationale) Source: DOHS Annual Report FY 2077/78

135. FY 2075/ 76 FY 2076/ 77 FY 2077/ 78 FY 2074/ 75 Program Initiation Allocating annual budget to 30 Municipals from 15 districts Expansion Expansion 396 Municipals from 50 districts Expansion Source: DOHS Annual Report FY 2076/77 and FY 2077/78 PNC Home Visit Program 229 Municipals from 40 districts

136. PNC Home Visit Program • To strengthen PNC services by mobilizing MNH service providers from health facilities to provide PNC at women’s home. Objective Source: DOHS Annual Report FY 2077/78

137. PNC Home Visit Program • Women who received PNC according to the protocol is 25 percent in 2077/78 (HMIS). • Amongst the 29 districts (where majority of the local levels were able to implement the program) the PNC as per protocol is 35% of expected live births in 2077/78 which is a 75-point percent increase from FY 2076/77 in the same districts (20%) Source: DOHS Annual Report FY 2077/78

138. Safe Abortion Services Pre and post counseling on safe abortion methods as well as contraceptive methods Termination of pregnancy as per national protocol Diagnosis and treatment of existing Reproductive Tract Infections Provide contraceptive methods as per informed choice and follow up for post abortion complication management Source: https://mohp.gov.np/program/safe-abortion-services-(nsas)/en

139. Onsite Clinical Coaching and Mentoring To enhance knowledge and skill of SBA and non-SBA nursing staffs providing delivery services at BC/BEONC and CEONC service sites based on coaching/mentoring guideline and tool. Source: DOHS Annual Report FY 2077/78

140. Onsite Coaching and Mentoring Proved to be effective through a study done in Dolakha and Ramechhap. FWD implemented since 2073/2074 from 16 districts In FY 2074/2075 total 320 Municipalities from 31 districts In FY 2075/2076, total 359 Municipalities of 38 districts In FY 2076/2077 528 Municipalities of 51 districts In FY 2077/78, 626 Municipalities of 63 districts Source: DOHS Annual Report FY 2077/78

141. Onsite Coaching and Mentoring • Till the end of FY 2077/2078 total 260 SBA clinical mentors were trained from 72 districts • A set of models are used for model-based practice during clinical coaching. • FWD and supporting partners provided these models (Skill Lab Material) to SBA clinical mentors to all districts. • By end of FY 2077/78, total 4906 MNH service providers received on-site clinical mentoring from SBA Source: DOHS Annual Report FY 2077/78

142. Role of SBA Clinical Mentors They are the key skill persons who: Visit each BC/BEONC sites and conduct onsite coaching/mentoring Conduct MNH readiness quality improvement self-assessment process to enhance capacity of delivery service providers, HF staffs and HFOMC members to make MNH service readiness Source: DOHS Annual Report FY 2077/78

143. Maternal and Perinatal Death Surveillance and Response (MPDSR) Goal • To eliminate preventable maternal and perinatal mortality by obtaining and using information on each maternal and perinatal death to guide public health actions and monitor their impact. Objectives • To provide information that effectively guides immediate as well as long-term actions to reduce maternal mortality at health facilities and community and perinatal mortality at health facilities. • To count every maternal and perinatal death, permitting an assessment of the true magnitude of maternal and perinatal mortality and the impact of actions to reduce it. Source: MPDSR Guideline, MoHP, DoHS.

144. The MPDSR Process Source: MPDSR Guideline, MoHP, DoHS.

145. Maternal and Perinatal Death Surveillance and Response (MPDSR) HO Data Management and Analysis Source: MPDSR Guideline, MoHP, DoHS.

146. MPDSR • As of FY 2077/78, MPDSR is being implemented in 15 Districts and 95 Hospitals, whereas training is ongoing in 17 Districts. • A total of 95 hospitals are implementing facility based MPDSR, with the maximum number of hospitals in Bagmati province. • A total of 21 districts are implementing community MPDSR, of which 15 districts have full implementation while in seven districts implementation is partial. Source: DOHS Annual Report FY 2077/78

147. 147 Supporting Organizations

148. Multilateral Organizations 1. UNFPA 1. Sexual and Reproductive Health Program: Policy Advocacy & Capacity Building on SRHR, Capacity Building of Health Workers on ASRH, and Strengthening Adolescent Friendly Health Services; Emergency preparedness and response including RH sub-cluster coordination and support. 2. Family Planning: FP/RH commodities support; Strengthening SCM including eLMIS; Service delivery and capacity building support to improve method mix and accessibility to services, Systems strengthening (Family Planning Sustainability Roadmap, FP2030 partnership), and evidence generation. 3. Maternal Health: Support implementation of Safe Motherhood Roadmap, Midwifery regulations, faculty strengthening, education standardization, support national program on RH morbidities, Support Maternal Mortality Study, and policy advocacy. 148 Source: https://nepal.unfpa.org/en

149. 2. UNICEF 1. Maternal and newborn health -Mahottari 2. Child Health including immunization -Kanchanpur 3. Adolescent Health and HIV services -Mahottari 149 Source: https://un.org.np/agency/united-nations-children-fund-unicef

150. 3. WHO Nepal 1. 1. Vaccine preventable disease surveillance and technical support to strengthen immunization coverage. 2. 3. Support in development of National Policies, Strategies and Guidelines for Communicable and Non-Communicable Diseases and strengthening Disease Control & Elimination interventions. 3. 4.Support to strengthen health systems capacities – policy, regulations, strategies, plans, guidelines, protocols on environmental health, SRHR, RMNACH health information, digital health and health system improvement including support to provincial government 150 Source: https://www.who.int/nepal

151. 4. United Nations World Food Programme (WFP) 1. Maternal and Child Health and Nutrition (MCHN) Program; with the objective to improve the nutritional status of the children 6 to 23 month of children and PLW. (10 districts (Kalikot, Jumla, Mugu, Humla, Dolpa Saptari, Siraha, Jhapa, Morang, and Sunsari) 2. Fill the Nutrient Gap (FNG): Conduct a situational analysis of the barriers to consuming a nutritious diet and provide evidence for ongoing and planned programming for making the implementation of nutrition and food security policy more effective. 151 Source: https://www.wfp.org/countries/nepal

152. Bilateral Organizations 1.USAID 152 Major programs: - Maternal Newborn and Child Health - Family Planning & Reproductive Health - HIV/AIDS and STI Projects: Suaahara II SSBH Redbook and MDHD SafaaPani Source: https://www.usaid.gov/global-health

153. 2. KfW-German Financial Cooperation 153 Major Programs - Sector Support/Pool Fund - Support to Social Marketing- Nepal CRS - Recovery I and II - Improvement of Maternity and Childcare in Remote Areas - COVID budget support Geographical Coverage -National Level -Gorkha,Ramechhap, Jiri, Sankhu, Bhimeshwor,Jhaukhel & Melbisauna -Province 7 -National Level Source: https://www.kfw.de/About-KfW/F%C3%B6rderauftrag-und-Geschichte/Geschichte-der-KfW/KfW-Themen/Finanzielle-Zusammenarbeit/

154. INGOs 1. Helen Keller International 154 -Nutrition,Maternal,Neonatal, Child HEalth, Family planning,adolescence health, WASH, GESI,good governance (Tanahu) - Gov. collaboration on BMS( Breast milk Substitution) Act amendment and monitoring (Center level) -Expanding neonatal and Ophthalmic Care to Prevent and Treat ROP in Nepal (Banke, surrounding districts and Solukhumbu) -Feasibility of Drying Fruits and Vegetables using Chimney Dryer and acceptability of fruits and veg among women and children (Taplejung) Source: https://hki.org.np/

155. 2. ADRA Nepal 155 Major Programs - Family Planning & Adolescent Sexual and Reproductive Health, eLMIS and End Child Marriage (Ilam) - Women’s Health & System Strengthening project related uterine prolapse(Okhaldhunga) - Improvement inMaternal & child health program (Taplejung) - COVID-19 Response and Recovery (14 hospitals,8 districts) Source: https://adranepal.org/

156. 3. CARE Nepal Major Program Areas 1. Reproductive, Maternal, Neonatal, Child and Adolescent Health (RMNCAH): Capacity building of health workers, construction of birthing center, equipment support to birthing center, community mobilization and awareness(Sindhuli, Kavre, sindhupalchok, Nuwakot, Rasuwa and Jajarkot) 2. COVID-19 response and recovery; PPE support to hub hospital and birthing centers, RCCE, WASH and technical support to local government to develop and implement health emergency response plan (Nabalparasi west, Rupandehi, Kapilvastu, Banke, Bardia, Kailali and Kanchanpur) 3. COVID-19 vaccination program: equipment supports for cold chain, training to health workers, transportation of vaccine, community mobilization and awareness raising activities.(Nabalparasi west, Rupandehi, Kapilvastu, Banke, Bardia, Kailali and Kanchanpur) 156 Source: https://carenepal.org/

157. 4. One Heart Worldwide 1) Maternal and neonatal health- Mahottari 2) COVID prevention support (PPE, medicines for case management, Oxygen cylinders and Oxygen concentrators) 157 Source: https://oneheartworldwide.org/

158. 5. Population Services International Nepal 1. Women’s Health Project (WHP) - Improve knowledge and access to Long Acting Reversible Contraception (LARC) and Safe abortion Services through private and public sector: Training on Implant, IUCD and MA to Providers onsite quality assurance, distribution of FP commodities,medical equipment, recording and reporting using HMIS, communication and counselling through community level mobilizer and mass media (Province: 1, 2, 3, 4, 5 & 7), Kathmandu 2. Adolescent Youth Project (AYP) · Increase knowledge and use of family planning products and services among adolescents and youth (15-24) from private sector adolescent youth from service sites (Province: 5, 7), Dhankuta 158 Source: https://www.psi.org/country/nepal/

159. 6. Save the Children 1. Healthy Transition for Nepali Youth – Focus on Behavior Change and system strengthening for Adolescent Reproductive Health (Surkhet, Kalikot, Dailekh, Jajarkot) 1. Sponsorship – Adolescent friendly services, Menstrual Health program, School Health and Nutrition Program, Maternal Health system strengthening.(Saptari, Sarlahi, Mahottari) 1. Early Start – Nutrition program for children under 3 yrs (Dailekh) 1. Small Sick Newborn assessment and assessment on intrapartum nutrition practices (Federal level assessment) 2. Programs for responding against TB, Malaria and HIV in Nepal. 159 Source: https://www.savethechildren.net/

160. 7. FHI 360 Nepal USAID- and PEPFAR-supported EpiC Nepal - HIV and sexually transmitted infection (STI) prevention education, referral and follow- up through online and offline platforms - Demand generation and provision of HIV pre-exposure prophylaxis (PrEP) - Condom and lubricant promotion and distribution - HIV testing and counseling (HTC) services (index testing, online-to- offline (virtual), HIV self- testing, community-led testing, enhanced peer outreach approach, recency testing) - Community-based ART service and more HIV related activities 160 Source: https://www.fhi360.org/

161. 8. Nick Simons Foundation International (NSFI) Major program focus: 1) Training – SBA 2) Support in infrastructure-CEONC site 3) Technical Support 4) Research & Advocacy 161 Source: https://www.nicksimonsfoundation.org/

162. NGOs GharGhar Ma Swastha (GGMS) Project - Expansion of Sangini Franchise Network 49 districts (Hills and Mountain) Sales and distribution of Family Planning, Maternal Child Health and Sexually Transmission Infection Commodities in all 77 districts Menstrual Hygiene Management (MHM) Project, Social Marketing and Behavior Change Communication activity for Sanitary Napkin “Freedom” Dadeldhura, Doti, Bajhang and Baitadi MOMENTUM Private Healthcare Delivery (MPHD) - Project for establishment of Adolescent Friendly Service Center to provide quality FP services to adolescent and emerging/young adults 162 1. Nepal CRS Company (Contraceptive Retail Sales ) Source: https://www.crs.org.np/

163. 2. Medic Mobile 1. Design, configuration and implementation of an open- source mHealth toolkit for community-based maternal and child health care coordination. SMS based use cases that are currently deployed in partnership with municipalities and NGO partners include a) Antenatal care b) Postnatal care c) MPDSR (Maternal and perinatal death surveillance and response) (in districts where Community based MPDSR has been implemented) 2. Supporting the Nursing and Social Security Division in the design, configuration and implementation of Community Health Toolkit (open source) in Bhaktapur and Bardibas Municipalities. 163 Source: https://medic.org/stories/tag/nepal/

164. Other NGOs 164 Safe Abortion Family Planning Adolescent Reproductive Health Integrated SRH services Comprehensive Sexuality Education Comprehensive abortion Care Minimum Initial Service Package (MISP) Basic Essential Primary Health care. Maternal and Child Health Community awareness program Traditional healers Training Source: https://www.fpan.org/ Source: https://phasenepal.org/ Source: https://www.mariestopes.org.np/

165. 165 Issues, Challenges & Recommendations

166. ● Service delivery: ○ Limited access to quality maternal health services, particularly in remote and marginalized areas. ○ Insufficient availability of skilled health personnel, including midwives and obstetricians. ○ Lack of comprehensive emergency obstetric care facilities in many regions. ● Health workforce: ○ Inadequate numbers of skilled health workers, leading to a shortage of skilled birth attendants. ○ Geographic maldistribution of health personnel, with a concentration in urban areas. ○ Insufficient training and capacity building opportunities for healthcare providers (Source: Annual report 2077/78,DOHS,Nepal Safe Motherhood and Neonatal Health Roadmap 2019) 166 Issues and Challenges

167. ● Health information systems: ○ Incomplete and inaccurate data collection and reporting systems for maternal health indicators. ○ Inadequate monitoring and evaluation of maternal health programs and interventions. ○ Limited use of data for evidence-based decision-making and resource allocation. ● Access to essential medicines and technologies: ○ Inconsistent availability of essential medicines and supplies, including contraceptives and safe delivery kits. ○ Limited infrastructure for proper storage and distribution of medicines and medical equipment. ○ High out-of-pocket expenses for maternal health services, deterring access for economically disadvantaged women. (Source: Annual report 2077/78,DOHS,Nepal Safe Motherhood and Neonatal Health Roadmap 2019) 167 Issues and Challenges

168. ● Financing: ○ Insufficient government investment in maternal health programs and infrastructure. ○ Limited financial protection mechanisms, leading to high out-of-pocket expenditures. ○ Challenges in efficient allocation and utilization of available resources for maternal health. ● Leadership and governance: ○ Weak policy implementation and enforcement related to maternal health. ○ Inadequate coordination among different stakeholders involved in maternal health programs. ○ Limited community participation and engagement in decision-making processes (Source: Annual report 2077/78,DOHS,Nepal Safe Motherhood and Neonatal Health Roadmap 2019) 168 Issues and Challenges

169. Recommendations Major Recommenda tions Ongoing Safe Motherhood and Reproductive Health Programmes should be strengthened, with a focus on improving quality and equity and a particular focus on the specific needs of the community. It is recommended that the capacity of the local and provincial governments is enhanced All women should be encouraged to give birth in a BEONC/CEONC site; such sites should be easily accessed and within two hours’ walking distance of the woman’s home. Life-cycle approach is to be encouraged, with a focus on reducing early marriage, on adolescent reproductive health, and on continuum of care through pre-pregnancy, pregnancy, labour, delivery and PNC for both mothers and newborns, focusing on promoting the physiological process of birth and minimizing complications. Source: Nepal Safe Motherhood and Newborn Health Roadmap-2019 (2020-2030) 5/15/2023 169

170. Major Recommend ations Arrangements should be made for postnatal home visits for women who have given birth at home and for continued supervision of all postnatal mothers and newborns. Mothers and newborns are encouraged to stay in health facilities for at least 24 hours after an institutional childbirth and be monitored closely for complications. To make maternal and perinatal death reviews more effective, health care providers’ concerns, including confidentiality, must be addressed to ensure more accurate Advocacy and Investment in MNH by People’s Representatives Source: Nepal Safe Motherhood and Newborn Health Roadmap-2019 (2020-2030) 170

171. 171 Conclusion

172. 1.Maternal Health refers to the health of women during pregnancy,childbirth and the post natal period. 2.Although important progress has been made in the last two decades,about 2,87,000 women died during and following pregnancy and childbirth in 2020 globally. 3.Most maternal deaths are preventable with timely management by a skilled health professional working in a supportive environment. 4.Maternal mortality is in declining trend from 539 per 1 lakh live birth in 1996 NHFS to 239/1lakh live births in 2016 NDHS and 151/1 lakh live births in 2020,with target of 70/1 lakh according for SDG 2030. (Source: World Health Organization. Maternal health [Internet]. Who.int. World Health Organization; 2019. Available from: https://www.who.int/health- topics/maternal-health#tab=tab_1) 172 Conclusion

173. 5.Regarding place of Maternal deaths,57% maternal deaths occurs in health facilities,followed by 26% in home and 17% on the way to or between facilities according to NMMS 2021. 6.According to NMMS 2021 68% of Maternal deaths are caused due to direct causes and 32% of Maternal deaths are caused by indirect causes. 7.According to NDHS 2022,79% of Deliveries occur in health facility which is in increasing trend and home Deliveries are at decreasing trend that is 41% in NDHS 2016 from 92% home Deliveries in 1996. 8.According to NDHS 2022 trend of PNC visit during first 2 days after birth is in increasing trend that is 70 % coverage in 2022. (Source: National Population and Housing Census 2021: Nepal Maternal Mortality Study 2021) 173 Conclusion

174. 9.According to NDHS 2022,trend of teenage Adolescent pregnancy is in decreasing trend that is 14% in 2022,from 17% in 2011 NDHS. 10. While progress has been made, challenges such as geographical disparities, socio-cultural norms, and limited access to healthcare facilities in remote areas still persist. 11.To overcome these challenges, sustained efforts and continued investment in maternal health policies and programs are crucial. 12.It is essential to focus on capacity building, infrastructure development, and community engagement to ensure that all women, regardless of their location or background, can access the necessary maternal healthcare services. (Source: National Population and Housing Census 2021: Nepal Maternal Mortality Study 2021) 174 Conclusion

175. 1. World Health Organization. Maternal health [Internet]. Who.int. World Health Organization; 2019. Available from: https://www.who.int/health-topics/maternal-health#tab=tab_1) 2. MoHP, NSO. National Population and Housing Census 2021: Nepal Maternal Mortality Study 2021. Kathmandu: Ministry of Health and Population; National Statistics Office;2022 3. Maternal mortality ratio (modeled estimate, per 100,000 live births) - Nepal | Data [Internet]. Worldbank.org. 2017. Available from: https://data.worldbank.org/indicator/SH.STA.MMRT?end=2017&locations=NP&start=2000&view=chart 4. National Joint Annual Review 2078/79 (2021/22) [Internet]. MoHP. [cited 2023 May 11]. Available from: https://www.mohp.gov.np/uploads/articles/Health%20Sector%20Progress_MoHP.pdf 5. Ministry of Health and Population, Nepal; New ERA; and ICF. 2022. Nepal Demographic and Health Survey 2022: Key Indicators Report. Kathmandu, Nepal: Ministry of Health and Population, Nepal. 6. Ministry of Health, Nepal; New ERA; and ICF. 2017. Nepal Demographic and Health Survey 2016. Kathmandu, Nepal: Ministry of Health, Nepal 7. Ministry of Health and Population (MOHP) [Nepal], New ERA, and ICF International Inc. 2012. Nepal Demographic and Health Survey 2011. Kathmandu, Nepal: Ministry of Health and Population, New ERA, and ICF International, Calverton, Maryland 8. Ministry of Health and Population (MOHP) [Nepal], New ERA, and Macro International Inc. 2007. Nepal Demographic and Health Survey 2006. Kathmandu, Nepal: Ministry of Health and Population, New ERA, and Macro International Inc 9. Pradhan, Ajit, Ram Hari Aryal, Gokarna Regmi, Bharat Ban, and Pavalavalli Govindasamy. 1997. Nepal Family Health Survey 1996. Kathmandu, Nepal and Calverton, Maryland: Ministry of Health [Nepal], New ERA, and Macro International Inc 10. Central Bureau of Statistics (CBS),2020. Nepal Multiple Indicator Cluster Survey 2019,Survey Findings Report. Kathmandu, Nepal: Central Bureau of Statistics and UNICEF Nepal 11. Central Bureau of Statistics, 2015. Nepal Multiple Indicator Cluster Survey 2014, Final Report. Kathmandu, Nepal: Central Bureau of Statistics and UNICEF Nepal 12. Motherhood NS. Newborn Health Road Map 2030. Family Welfare Division Ministry of Health and Population Government of Nepal. 2019. 175 Bibliography

176. 13. Annual Report Department of Health Services 2077/78 (2020/21) Government of Nepal Ministry of Health and Population Department of Health Services Kathmandu [Internet]. Available from: https://dohs.gov.np/wp-content/uploads/2022/07/DoHS-Annual-Report-FY-2077-78- date-5-July-2022-2022_FINAL.pdf 14. Ministry of Health and Population (MoHP). (2019). Annual Report 2018/19. Government of Nepal. 15. Paudel, Y. R., Jha, T., Mehata, S., Paudel, D., & Dariang, M. (2018). Assessing the role of female community health volunteers (FCHVs) in delivering maternal health services in rural Nepal: A qualitative study. PloS one, 13(11), e0205530. 16. Source: MoHP G. Second Long Term Health Plan 1997-2017. Kathmandu: Ministry of Health and Population, Government of Nepal. 1997. 17. MPDSR Guideline, MOHP, DOHS. 18. Review of Aama Surakshya Programme in Nepal, NHSSP-III, 2020. 19. Safe Abortion Service, MOHP [Internet]. Available from: https://mohp.gov.np/program/safe-abortion-services-(nsas)/en 20. in. Ultrasound Training to Staff Nurses working in rural health facilities of Lumbini Province [Internet]. FAIRMED. 2021 [cited 2023 May 10]. Available from: https://www.fairmed.org.np/news/ultrasound-training-to-staff-nurses-working-in-rural-health-facilities-of-lumbini-province 21. A PROGRESSIVE JOURNEY TO GENDER EQUALITY AND WOMEN’S EMPOWERMENT ACHIEVEMENTS OF NEPAL Government of Nepal Ministry of Women, Children and Senior Citizen Singhadurbar, Kathmandu [Internet]. [cited 2023 May 10]. Available from: https://mowcsc.gov.np/downloadfiles/0Cz7iCOxqikIdQNpREjhO2pbqXiIaQlz4BhM5scc-1625557539.pdf 176 Bibliography

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178. Bibliography 31. https://nepal.unfpa.org/en 32. https://un.org.np/agency/united-nations-children-fund-unicef 33. https://www.wfp.org/countries/nepal 34. https://www.who.int/nepal 35. https://www.usaid.gov/global-health 36. https://www.kfw.de/About-KfW/F%C3%B6rderauftrag-und-Geschichte/Geschichte-der-KfW/KfW-Themen/Finanzielle- Zusammenarbeit/ 37. https://hki.org.np/ 38. https://adranepal.org/ 39. https://carenepal.org/ 40. https://oneheartworldwide.org/ 41. https://www.psi.org/country/nepal/ 42. https://www.fhi360.org/ 43. https://www.nicksimonsfoundation.org/ 44. https://www.crs.org.np/ 45. https://medic.org/stories/tag/nepal/ 46. https://www.mariestopes.org.np/ 47. https://www.fpan.org/ 48. https://phasenepal.org/ 178

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