Safe motherhood:

The safe motherhood initiative was launched at an international conference held in Nairobi, Kenya in 1987. Its aim was to draw attention to the dimension and consequences of poor maternal health in developing countries and to mobilize action to address the high rate of death and disability caused by complication of pregnancy and childbirth. The goal set by initiative, later adopted at several united Nations conferences, was to reduce maternal mortality and morbidity by one half by the year 1 2000AD.

Definition: Safe motherhood means creating the circumstances within which a woman is able to choose whether she becomes pregnant and if she does , ensuring that she receives care for prevention and treatment of pregnancy complications, that she has access to skill birth attendance, and if she needs it to emergency obstetric care and care after birth to prevent death or disability from complications of pregnancy, and childbirth.
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Safe Motherhood Programme of Nepal: The goal of the National Safe Motherhood Programme is to reduce maternal & neonatal mortalities by addressing factors related to various morbidities, death& disability caused by complications of pregnancy& childbirth. Global evidence shows that all pregnancies are at risk,& complications during pregnancy, delivery& the postnatal period are difficult to predict. Experience also shows that three key delays are of critical importance to the outcomes of an obstetric emergency. Delay in seeking care Delay in reaching care Delay in receiving care. 3

Contd..
To reduce the risks associated with pregnancy & childbirth & address these delays, three major strategies have been adopted in Nepal: Promoting birth preparedness & complication readiness including awareness raising & improving the availability of funds ,transport & blood supplies.
Encouraging for institutional delivery.

Expansion of 24-hour emergency obstetric care services (basic& comprehensive) at selected public health facilities in every district.
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Since its initiation in 1997,the Safe Motherhood Programme has made significant progress in terms of the development of policies & protocols as well as expands in the role of service providers such as staff nurses& ANMs in life saving skills. The FHD of the DHS developed the national safe motherhood plan (2002-2017), which lays out various levels of outputs and activities. The long term goal of 15 year plan includes establishment of BEOC,CEOC services in all 75 districts, SBA at all births and increased access to emergency fund and appropriate transport services. The revised National Safe Motherhood and Newborn health Long Term Plan 2006-2017 has been developed to be line with second long term health plan , Nepal Health Sector Programme Implementation Plan and mellenium development Goals (MDG). 5

The revision takes into account recent developments such as the increased specific emphasis on neonatal health, recognition of importance of SBA, legislation of abortion etc. The Policy on Skilled Birth Attendants endorsed in 2006 by MoHP specifically identifies the importance of skill birth attendance at every birth. Similarly, endorsement of revised National Blood Transfusion Policy 2006 is also a significant step towards ensuring the availability of safe blood supplies in the event of an 6 emergency.

National Safe Motherhood and Newborn health Long Term Plan 2006-2017: Goal: improve maternal and neonatal health and survival, especially of the poor and excluded. The key indicators for the goal are: A reduction in the maternal mortality ratio from current 281 per 1000 live birth to 134 per 100000 by 2017 A reduction in the neonatal mortality ratio from the current 33 per 1000 to 15 per 1000 by 2017

Purpose: increased healthy practices and utilization of quality maternal and neonatal health services, especially by poor and excluded, delivery by a well managed health sectors. Key indicators for this include: Increase in 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 Increased in met need for emergency obstetric care of 3% per year Increased in met need for cesarean section of 4% per year

Indicators for service provision include: The percentage of health post providing 24 hours delivery service 15% by 2009, 30% by 2012 and 80% by 2017. The percentage of PHCc providing BEOC service including CAC service 40% by 2009, 60% by 2012 and 80% by 2017. Number of districts providing CEOC service including 37 by 2009, 47 by 2012 and 60 by 2017. CAC service available in all district hospitals by 2009.

Output: Eight outputs are specified in the plan, each with individual indicators. Equity and access Services Public private partnership Decentralization Human resource development :skilled birth attendant strategy. Information management Physical access and procurement Finance 10

Safe motherhood policy: National health policy identified reduction of maternal and neonatal mortality as national objective. Safe motherhood program is a major component of primary health care. Program focus is on improvement of maternity service including FP at all levels of health care delivery system. Aims to improve the women by bringing about attitudinal, behavioral and societal changes.

Policy objectives: General: Adopt a combination of health and health related measures to reduce maternal and neonatal mortality Specific: To increase accessibility, availability and utilization of maternal health care. To strengthen technical capacity at all levels. To strengthen referral services for maternity care. To increase availability and use of contraceptives. To raise public awareness on maternal health and safe motherhood. To improve the legal and socioeconomic status of woman.

Strategies Safe Motherhood goals and objectives are to be achieved through the implementation of the following strategies: Promoting inter-sectoral collaboration by ensuring advocacy for and commitments to reproductive health, including safe mother hood, at the central, regional, district and community levels: - Ensuring the commitment to SMNH initiate at all levels by promoting collaboration between sectors like health, education and social welfare, legal and local development. (Strengthening RHSC, RHCC District RHCC and SMNSC)

 Mobilizing national authorities, District Health Management Committee (DHMC), community leaders and community members to play active roles in creating suitable environment for promoting safe motherhood. Strengthening and expanding delivery by skilled health worker, basic and comprehensive obstetric care services (including family planning) at all levels. Interventions include the following: Developing the infrastructure for delivery and emergency obstetric care. Standardizing basic maternity care and emergency obstetric care at appropriate levels of the healthcare system. Strengthening Human Resource Management.

 Establishing functional referral system and advocating emergency transport systems and funds from communities to district hospitals for obstetric emergencies and high-risk pregnancies. Strengthening community-based awareness on birth preparedness and complication readiness through FCHVs and MCHWs and Increasing access of all relevant maternal health information and service. Supporting activities that raise the status of women in society. Promoting research on safe motherhood to contribute to improved planning higher quality services and more costeffective interventions.

Element (Component) of Safe Motherhood 1. 2. 3. 4. 5. 6. Family planning Antenatal care Clean and Safe delivery Essential obstetric care Postpartum care Post abortion care

National Policy on Skilled Birth Attendants

Definition of Skilled Birth Attendant An accredited health professional such as a midwife, doctor or nurse who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the postnatal period and in the identification, management and referral of complications in women and newborns. National Policy on SBA The proportion of birth assisted by skilled Birth Attendants is a Millennium Development Indicator and a key indicator for assessing progress towards maternal mortality reduction. As a signatory of Millennium Declaration, GoN is committed to achieving the Millennium Development Goals (MDG).

The two indicators proposed by the MDG framework for monitoring progress towards MDG 5 are: A reduction of MMR by three quarters between 1990 and 2015; and An increase in the proportion of birth attended by skilled attendant. The international targets for the proportion of birth attended by a skilled attendant call for 80% of all births by 2005, 85% by 2010 and 90% by 2015. However, WHO suggests that in countries where the MMR is very high, the goal should be at least 40% of all births assisted by skilled birth attendants by 2005, 50% by 2010 and 60% by 2015.

Objectives of SBA Policy

General Objective To reduce maternal and neonatal morbidity and mortality by ensuring availability, access and utilization of skilled care at every birth. Specific Objective To ensure that sufficient numbers of SBAs are trained and deployed at primary health care levels with necessary support system. To strengthen referral services for safe motherhood and newborn care, particularly at the first referral level (district hospitals). To strengthen the pre-service and in-service SBA training institutions to ensure that all graduates will have the necessary skills.

 To strengthen supervision and support system to ensure that all SBAs are able to provide quality maternal and newborn health care according to the national standard and protocol. To develop regulating, accrediting and re-licensing systems for ensuring that all SBAs have the abilities and skills to practice in accordance with the core competencies.

Strategies
To ensure skilled care at every birth, rapid expansion of accredited SBA training sites and capacity enhancement of trainers in order to ensure quality training is imperative. Deployment of SBAs at primary health care levels to promote their availability for all families and ensuring SBAs are supported and recognized by the communities are crucial issues to be addressed. Hence, with a long term vision. MoHP identifies the following strategies: 1. Human Resource Development a) Short Term (in service) measures- SBA, Advanced SBA, diploma in midwifery b) Medium term (pre service) measures- revision of curriculum (ANM,PCL, MBBS, MDGP) c) Long term (pre-service) measures-Professional Midwife

2. 3. 4. 5.

Strengthening SBA Training Sites Deployment and Retention of SBAs Service Provision Enabling Environment - Professional Accreditation, Licensure and legal Issues 6. Role of Professional organizations/association 7. Role of non-government sector and private sector 8. Institutional Arrangements.

Concept of Essential Obstetric Care, Basic Emergency Obstetric Care and Comprehensive Obstetric Care Essential Obstetric Care Essential obstetric care is the term used to describe the element of obstetric care needed for the management of both normal and complicated pregnancy, delivery and postpartum period. Essential obstetric cadre includes normal care, basic emergency obstetric care and comprehensive emergency obstetric care. Essential obstetric care refers to the minimum package of services that should be made available to all pregnant women, i.e. Prenatal care, safe delivery, postnatal care, identification of complications and referral to emergency services and emergency obstetric care.

Primary Essential Obstetric care (Obstetrical first aid) Administration of parenteral antibiottics Administration of parenteral oxytocic drugs Administration of parenteral anticonvusants. Basic Essential Obstetric care Administration of injectable antibiotics Administration of injectable oxytocic drugs Administration of parenteral anticonvusants. Manual removal of placenta Evacuation of product of conception (MVA) Assisted deliveries by vacuum of forceps.

Comprehensive essential obstetric care Administration of injectable antibiotics Administration of injectable oxytocic drugs Administration of parenteral anticonvusants. Manual removal of placenta Evacuation of product of conception (MVA) Assisted deliveries by vacuum of forceps. Blood transfusion Surgical obstetrical intervention including cesarean section

Emergency Obstetric Care Emergency obstetric care (EmOC) is the term to be used to describe the element of obstetric care needed for management of complications arising during pregnancy, delivery and the postpartum period. EmOC service should be available during life threatening conditions during pregnancy, delivery or after delivery. It is commonly agreed that approximately 15% of all pregnant woman will develop serious pregnancy related complications.

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