Safemotherhood

SAFE MOTHERHOOD AND NEWBORN HEALTH

By Sarina Basu Shrestha

BACKGROUND The goal of the National Safe Mother

Programme is to reduce maternal and neonatal mortalities by addressing factors related to various moridities,death and disability caused by complications of pregnancy and childbirth .

Experience shows that 3 key delays are of critical importance to the outcome of an obstetric emergency:

I. Delay in seeking careII. Delay in reaching careIII. Delay in receiving care

To address these delays 3 major strategies been adopted in Nepal:

1. Promoting birth prepadeness and complication readiness including awareness raising and improving the availability of funds ,transport and blood supplies .

2. Encouraging for instituitional delivery.3. Expansion of 24-hr emergency obstetrics

care services (basic and comprehensive )at selected public health facilities in every district.

Safe Motherhood Programme ,since its intiation in 1997,has made signinficant progress in terms of the development of the policies and protocols as well as expand in the role of service providers such staff nurses and ANMs in life saving skills.

Policy of on Skilled Birth Attendants edorsed in 2006 by MoPH specifically identifies the importance of skilled birth attendance at every birth and government’s commitment to training and deploying doctors and nurses /ANMs with the required skills across the country.

Endorsement of revised National Blood Transfusion Policy 2006 ensured th availability of safe blood supplies in event of emergency.

The National Safe Motherhood Plan(2002-2017) was revised .

The revised SafeMotherhood and Neonatal Health Long Term Plan (SMNHLTP 2006-2017) include:

1. Recognition of the importance of addressing neonatal health as an integral part of safe motherhood programming.

2. Legalisation of abortion and the integration of the safe abortion services under the safe motherhood umbrella

3. Recognition of the importance of equity and acess efforts to ensure that most needy women can acess the services they need.

GOALS OF SMNHLTP

Improved maternal and neonatal health and survival ,especially of the poor and excluded .

The key ingredient for the goal are:1) A reduction in the maternal mortality ratio

from the current 281 per 100,000 live births to 134 per 100,000 by 2017

2) A reduction in the neonatal mortality ratio from the current 33 per 1,000 to 15 per 1,000 by 2017.

PURPOSE OF SMNHLTP Increased healthy practices and utilisation of the

quality maternal and neonatal health services especially by the poor and excluded ,delivered by a well managed health sector .

Key indicators for this include :1. Increase in the percentage of deliveries

assisted by an SBA to 60% by 2017.2. The percentage of deliveries taking place in a

health facility increased to 40%by 2017.3. Increase in met need for emergency obstetric

care of 3%per year

Indicators of the service provision include :1. Percentage of health post providing 24 hr

delivery service 15% by 2009,30% by 2012 and 70% by 2017

2. Percentage of PHCC providing BEOC service including CAC service 40% by 2009, 60% by 2012, 80% by 2017

3. No of district providing CEOC service 37 by 2009,47 by 2012 and 60 by 2017

4. CAC service available in all district hospitals by 2009

OUTPUT Eight output are specified in the plan ,each

with individual indicators.1. Equity2. Services3. Public private partnership4. Decentralisation5. Human resource development ;Skilled birth

attendant strategy6. Information management 7. Physical assets and procurement8. Finance

INDICATORS

1.Knowledge of danger signs: No. of men and WRAs knowing danger signs 100 Total no. of men and women of reproductive age(WRA)

2.Knowledge of B/EOC sites No of men and WRAs knowing where services are

available 100 total no of men and WRAs3.Behaviour change No of women practicing safe ANC,PNC, EOC,PAC,CAC 100 Total no of delivered women

4.Birth preparedness No of men and WRAs practicing same 100Total no of men and WRAs

5.Sustainable emergency funds and transport schemes

No of sustainable funds and transport schemes 100

total no target communities

6.ANC service coverageNo of ANC first visits 100 Expected no of pregnancies

7.Percentage of 4 ANC visit No of 4 time ANC visit 100 No of 1st ANC visit

8.Percentage of delivery by SBAtotal no of deliveries by SBA 100 Total no of expected live births

9.Percentage of delivery by other than SBA

Total no of deliveries by other than SBA 100Total no of expected deliveries

10.Pregnancy complicationsTotal no of pregnancy complications 100Total no of expected pregnancies

11.Proportion of births in B/C EOC facilityTotal no of birth in B/C EOC facility in district

100Total no live birth in that district

12.Postnatal service coverageTotal no of 1st postnatal visits 100Total no of expected pregnancies

13.C/S Rate (as proportion of expected births population):

Total C-sections performed in a districtTotal no. of expected births in that

district

14.Maternal mortality ratio:Total maternal deaths 100,000Total live births

CONTD..

15.Maternal deaths: Annual no. of maternal deaths

16.Case fatality rate(all maternal complications):

Deaths from specific maternal complications at a facilityComplicated obstetric cases in the facility

17.No of facilities providing basic EOC per 50,000 population(excluding blood and C-section):

No of facilities providing basic EOC services 500,000

Total population

18.No. of facilities providing comprehensive EOC per 500,000 population (including blood and C-section):

No. of facilities providing comprehensive EOC services

500,000 Total population

19.Iron distribution coverage (pregnant women and postnatal mother):

No. of pregnant women who received 225 iron tablets 100

Total no. of expected pregnancies

20.Immunisation coverage for TT2 vaccine among pregnant women:

No. of pregnant women immunized with TT2 100

Total no. of expected pregnancies

STRATEGIES Safe mother goals and objectives are to be

achieved through the implementation of the following strategies;

1. Promoting inter –sectorial collaboration by ensuring advocacy for and commitments to reproducing health , including safe motherhood ,at the central,regional ,district and community levels focusing poor and excluded groups.

Ensuring the commitment to SMNH initiative at all levels by promoting collaboration between sectors like health, education, and social welfare ,legal and local development

Mobilizing national authorities , District Health Management Committee(DHMC) ,community leaders and community members to play active roles in creating sustainable environment for promoting safe motherhood.

2. Strengthening and expanding delivery by skilled birth attendant , 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.

Standardising basic maternity care and emergency obstetric care at the appropriate levels of the healthcare system;

Strengthening human resource management Establishing functional referral system and

advocating for emergency transport systems and funds from communities to district hospitals for obstetrics emergencies and high –risk pregnancies.

Strengthening community –based awareness on birth preparedness and complication readiness through FCHVs ,increasing acess of all relevant maternal health information and service.

3.Supporting activities that raise the status of women in society

4.Promoting research on safe motherhood to contribute to improved planning , higher quality services, and more cost-effective interventions.

AAMA SURAKCHHYA PROGRAMME

AAMA SURAKCHHYA PROGRAMME

1) Introduction

Aama programme has 3 components: Free institutional delivery care The Safe Delivery Incentive

Programme(SDIP) Incentive to women who completed 4

ANC visits and delivered their babies at health institutions.

Since 2005 GoN has been providing direct cash handouts to women who delivered in state and listed non-state facilities, providing free institutional delivery care for every woman at all facilities capable of providing these services.

Through its 2nd revision effective from July 2009, the Aama programme now provides:

1. Incentive to women: a cash payment after delivery at a facility:NRs.1,500($20)in mountain areas, NRs.1,000($13) in hill areas and NRs.500($7) in the terai.

2. Free delivery services

A payment to health facility for the provision of free care:Normal delivery at health facility with 25 and more beds NRs.1500 and health facility with less than 25 beds NRs.1000;complication NRs.3000;C-section NRs.7000.

covers:cost of all required drugs,supplies,instruments and a small incentive to health workers NRs.300 . This provision doesn’t require individual claims from health workers;however,institution requires submitting the claim.

Incentives to health workers for home delivery has been reduced to NRs.200 from NRs.300 to discourage the home based delivery.

A women gets NRs.400 if she completes 4 ANC visits, institutional delivery and 1st PNC. But she cant get the incentive if she delivers her baby at home.

Aama program is being implemented by 41 NGOs and private hospitals.

PROGRESS UPDATE OF SERVICE PROVISION

CEOC services are now functional in 33 districts and BEOC services at 105 sites(47 hospitals and 58 PHCCs). Thus, the service outlets increased for C-section and complication management.

24 hour delivery service is available at 148 PHCCs, 406 health posts and 137 SHPs.

The no.of birthing centres is in rise and many communities have now established new birthing centres and started providing normal delivery care services.

Over 20 private(NGO,community managed,teaching hospital and for profit)hospitals are currently implementing the Aama programme.

Before the introduction of SDIP, the coverage of deliveries assisted by SBAs and health workers used to increase marginally(1%) but after commencement of SDIP it has increased considerably by 2-3% annually and after the introduction of free delivery care, it jumped to 42% in case of deliveries attended by health workers and 29.4% in case of SBA assisted deliveries.

IMPLEMENTATION PROGRESS

Programme implementation has improved significantly since the launch of the original Maternity Incentive Scheme(MIS) in 2005/2006 during which fewer than one third (29.6%) of women delivering in an institution actually received the cash incentive.

By 2008/2009 this figure had risen to 89% and almost all women received the incentive in 2009/10.

By contrast, reflecting the lesser priority now being given to payments to health workers, the no.of trained health workers receiving incentive for home delivery has fallen over the years.

FUND EXPENDITURE

Total budget allocation and expenditure in NRs.Million

Fiscal Year Allocation Expenditure Percent

2062/63(2005/06)

139.85 59.27 42.38

2063/64(2006/07)

159.2 111.58 70.09

2064/65(2007/08)

194.5 143.7 73.88

2065/66(2008/09)

444.6 336.7 75.73

2066/67(2009/10)

574.3 463.5 80.7

MAJOR ACTIVITIES

Evaluation of Aama programme The impact evaluation was carried out in

2010 to determine who benefited by free delivery and incentive scheme.

80% of facility births were free of charge in the 3 low HDI districts where the incidence of poverty is at higher level.

This figure is 58% in case of high HDI districts.

Over the past 5 yrs, there has been a substantial increase in the proportion of women giving birth in a health facility.

In the high HDI districts, the rate of institutional delivery care has increased 21 points from 33% to 54% in the 5 yr period.

In the low HDI districts, the rate has increased 15 points from 6% to 21% over the same period.

Women’s awareness of the cash incentive during pregnancy has risen from 14% in July 2005 to 64% in Feb 2010.

RAPID ASSESSSMENTS 3 rapid assessments of the SDIP have been carried

out to date; 2 in April and October 2008 and third one in July 2009. These assessments reviewed effectiveness of the implementation including cross verification of payments.

The findings of these assessments have been used to strengthen implementation guidelines and process.

Learning from the 3 rapid assessments the FHD has contracted out the 4th rapid assessments.

It began the work on 1st Nov 2009 and covered 6 districts:

1. Mustang2. Taplejung3. Achham4. Nuwakot5. Bardiya6. Rautahat

SOCIAL AUDITING

A social audit was conducted at 21 facilities of 7 districts under the Aama Programme in 2009/010. They were consolidated and made available to the general public and auditors.

This has contributed to checking the misuse of funds, developing the sense of ownership among the stakeholders, reducing the hassles in distributing the incentives..

ADDITIONAL SAFEGUARDS MEASURES

Based on the findings of the third rapid assessment, FHD prepared a framework of additional safeguards.

Comprehensive Plan for Aama Programme Monitoring

FHD has implemented comprehensive monitoring activities from 2009/10. This includes household survey, monitoring of Aama programme fund reimbursement in selected health facilities, independent rapid assessment and review of the auditor general’s final audit reports.

Information campaign During this reporting period the National

Health Education Information Communication Centre(NHEICC) has implemented the Aama communications strategy. Posters flex boards and leaflets were designed, printed and delivered to all districts.

however., delivery to facilities has not met requirements.

National , regional and local radio stations aired messages about the Aama programme.

IMPLEMENTATION ISSUES

Clarity on free care components and financial status of hospital

Some of the issues identified during field visits were:

1. Confusion on the types of managed complications

2. Uncertain use of unit cost given for the free delivery

FHD had sent an instructional letter to all implementing facilities mentioning the priority of the Aama programme, permissible use of unit cost including provider’s incentives, clarity on managed complications.

Addressing the false reportingWhile the programme is seen to be meeting its

primary objectives, the risk of fraudulent claims for both institutional and home deliveries may remain high. This was recognized in the 3rd rapid assessment which recommended the effective implementation of public auditing. In order to respond to this issue, FHD had endorsed “Aama Programme Additional Safeguard measures” in 2009/10.

Low awareness among prenant womenThe 3rd RA included anecdotal information from

field visits suggesting that one of the major barriers to accessing free care and incentives is the low level of awareness on the Aama programme.

FHD core team members are working closely with NHEICC, Nepal health journalist forum, FM radio networks for the proper dissemination of Aama programme messages.

REPRODUCIVE HEALTH PROGRAM COORDINATION MECHANISM

Under the MOHP, different level RH committee has been established from policy level to district with the objective to promote GO/NGO collaboration and partnership, to ensure compliance of GO policy, strategy and guidelines and to avoid duplication and overlapping in program planning and implementation.

Many of these sub-committees are functional. They are meeting regularly as per plan. These sub-committees are providing valuable inputs in program planning, budgeting and on policy formulating.

RH Streeing Committee(Policy Body That Meets Once Per Year)

RH Coordination Committee(Coordination Body That Meets 3 Times Per Year)

Sub-Committee District RHCC

SMN FP TCIC

Research

CHFCH

VADH

DISTRICT REPRODUCTIVE HEALTH COORDINATION COMMITTEE(DRHCC)

Has been formulated in all 75 districts. This forum is basically responsible to conduct

meeting, facilitating NGO/INGO support administration and logistics for meeting, conduct orientation, review activities quaterly, develop future action plan.

ANALYSIS OF ACHIEVEMENTS BY MAJOR ACTIVITIES

ACTIVITIES CARRIED OUT IN FISCAL YEAR 2 066/2067

2.1.1Antenatal care: Antenatal services include: At least four antenatal checkups(first at

four month, second at six month, third at eight month and fourth a nine month)

Monitor blood pressure, eight and fetal heart rate

2.1. 2. delivery care:Delivery care includes: Provision of skilled birth attendants at

deliveries(either home based or facility based), early detection of complicated cases and management of referral after providing obstetric first aid by health worker to appropriate health facility where 24 hour emergency obstetric services are available

Provision of obstetric first aid at home/ health post/ sub health post if complication occur, using emergency obstetric care kit

Identification and management of complications during delivery and referral to appropriate health facility as and when needed

Encourage registration of birth and registration of neonatal deaths.

Provide information, education, and communication(IEC)and behavior change communication(BCC) for danger signs and care during pregnancy, delivery and postnatal and immediate newborn care for both mother and newborn and timely referral to the appropriate health facilities.

Birth preparedness and complication readiness(BPCR) for both normal and obstetric emergencies.

Detection and management of complications Provision of tetanus toxoid and immunization iron

tablets deworm to all pregnant women and malaria prophylaxis where necessary.

2.1.3. Postnatal care: Postnatal services include: 3 postnatal visits(first within 24 hours of

delivery, second visit on the third day and third visit on seventh day after delivery.

Identification and management of mother’s and newborn in complication of postnatal period and referral to appropriate health facility as and when needed.

Promotion of exclusive breast feeding Personal hygiene and nutritional education ,

postnatal vit. A and iron supplement for mother

Immunization of newborn Postnatal family planning counseling and

services

2.1.4. Newborn care: Health education and behavior change

communication on essential newborn care practices , which includes cord care, prevention and management of hypothermia through kangaroo mother care, initiation of immediate breastfeeding within one hour of childbirth

Identification of danger signs and timely referral

To the appropriat health facility

2.1.5. Emergency obstetric care and birthing centers

BEOC covers management of pregnancy complication by assisted vaginal deliveries( vaccum or forceps), manual removal of placenta, removal of retained products of abortion(manual vaccum aspiration), and administration of parenteral drugs(for postpartum hemorrhage, pre eclampsia /eclampsia), resuscitation of newborn and referral.

Comprehensive emergency obstetric care (CEOC) includes surgery(caeserean section) an aesthesia and blood transfusion along with BEOC. Safe blood transfusion is an is an essential part of CEOC , and to support this the national blood transfusion policy was revised in 2006 and blood transfusion guideline developed.

The safe motherhood and neonatal health(SMNH) long term plan identifies the need for phased strengthening and expansion of quality SMNH services at all levels, especially the number and quality of B/CEOC sites and birthing centers

Since the majority of women still give birth at home, the aim is to ensure the normal delivery care and referral services are available at community level through home visit, outreach clinics and health posts/ sub health posts with 24 hours birthing centers able to manage normal deliveries.

The target is that by 2017, CEOC services will be available in 60n districts and 80% of PHCCs will provide BCOC services. There is significant increase in availability of CEOC, BEOC and birthing sites as in table given below:

Fiscal year

CEOC BEOC hospital

BEOCPHCC

BEOCtotal

24 hr. delivery at PHCC

24 hr. delivery at HP

24 hr. delivery at SHP

Birthing center

2007/08

51 in 33 districts

31 37 68 168(78%)

219 35 422

2008/09

76 in 35 districts

45 45(22%) 90 169(79%)

301(45%)

64(2%) 532

2009/10

94 in 45 districts

47 58 105 148(71%)

406(60%)

137(4%) 695

2012 target

47 districts

- 60% of PHCC

- - 30% of HP

- -

A total of 586 ANMs and 4o staff nurses have been recruited on local contract to support 24 hour delivery services in PHCs and HPs.

2.1.6. SAFE ABORTION SERVICES

Training service, delivery and monitoring From July 2009 to june2010, 88,938 women

received safe abortion service from 331 listed sites in 75 districts.

Upon the approval of the scale up strategy, medical abortion was integrated in CAC training and 180 providers were trained in both MA and MVA scaling up MA in 75 districts.

As a pilot, MA was integrated in 2 batches of SBA training out of which 10 were from government sites.

They receive intensive follow up and support.

Implementation for performance monitoring system for clinical trainees and active service delivery sites continued. A total of 88 sites received follow up during this fiscal year. 100% of trainees trained from June 2009-10 were followed up within 3;4 weeks post training and 180 providers at ;9 months.

POLICY AND ADVOCACY

Ipas/ Nepal joined hand with MWCSW(ministry of women, children and social welfare) and women development department and organized a high level advocacy workshop with the objective to sensitize high level policy makers on the abortion related issues , as well as to their existing network in reaching women including the young women

Safe abortion services has been included in EHCS(essential health care service)

PROBLEMS/RECOMMENDATIONS AND SOLUTIONS

problems Recommendations/ actions

Women in rural and remote areas are underserved or completely deprived of the service forcing them to choose unsafe abortion.

Expand medical abortion upto the health post level.

A study revealed that 13% of the clients denied safe abortion service as they were above 12 weeks gestation.

Orient female community health volunteers in early detection of pregnancy as they are key referral link between the community and health service.

The high proportion of client accepting short term contraception indicates that there s either lack of providers trained in long term methods or shortage of the commodity at the site.

Access providers and sites and facilitate for training and listening.

Untrained/ unlisted providers providing abortion services from unlisted sites.

Need to strengthen the capacity of CAC listed sites in managing post cac complications.

Reported two cases of maternal deaths from the CAC listed sites.

WORK PLAN FOR FISCAL YEAR 2067/68

1. Training Integrated(MVA+MA) training to 100

doctors and 100 nurses Refreshers training for 40 providers On the job training for 30 MD students Second trimester training for 80

obsgyn/ MDGP CAC integrated first trimester training

for 40 private doctors MA only training to 120 SBAs

2. Community engagement mobilization Train 1200 FCHVs from 4 districts review1200FCHVs (old and new) from

10 districts Subcontract local NGO to begin

implementation of newly developed youth intervention.

3. Monitoring and mentoring Onsite monitoring of 150 CAC trained

providers Post training follow up to 100%

providers Orient 10 PHNs on supportive

supervision guidelines on MA Orient 25 nurses(CAC) providers from

37 PHCs on clinical mentoring onsite support to 10 non functioning or problematic sites

4. Research and studies Implementation research on “the

provision of MA by ANMs trained as SBAs in peripheral level of health institutions”

Study on assessing “the impact of counseling on method selection and contraceptives uptakes”.

: 2.1.7 INFRASTRUCTURES DEVELOPMENT AND EQUIPMENT

Type of services

completed Under construction

Planned for 2010/2011

Total

CEOC sites 89 54 25 168

BEOC sites 20 6 4 30

CAC sites 17 4 4 25

HP’s with birthing center

93 51 62 206

PHCC’s with BEOC

24 49 20 93

SHP upgrade to HP with birthing unit

0 123 13 136

2.1.8 BIRTH PREPAREDNESS PACKAGE AND MATERNAL AND NEONATAL HEALTH ACTIVITIES AT COMMUNITY LEVEL

By the end of 2065/66,birth preparedness package(BPP)has been rolled out in all 75 districts.

Family health division(FHD)revised the package(BPP flip chart and jeevan surakshya card)focusing on continuum of care from pregnancy,through birth and the post-partum period,including newborn.

Family health division(FHD) with technical assistance from partners such as USAID funded Nepal Family Health Program(NFHP 2),United Mission to Nepal(UMN),UNICEF,SDC funded Rural Health Development Project(RHDP) and Care Nepal has been implementing maternal and neonatal activities at the community level.

MNH activities at community level focuses on strengthening birth preparedness,identification and prompt care seeking for danger sings in pregnancy,delivery and post-partum period and education and distribution of Misoprostol(Matri Surakshya Chakki)for post partum hhemorrhage(PPH) at home birth.

In the fiscal year 2066/67 PPH education and Matri Surakshya Chakki distribution by FCHVs has been approved for national level expansion in integration with birth preparedness package.

At the national level,Master training of trainers were organised in 4 batches.

Misoprostol implementation guidelines were developed for expansion of Matri Surakshya Chakki distribution by Female Community Health Volunteers.

In the fiscal year 2066/67,revised BPP was implemented to 41 districts(25 by GON and 16 by partners).

In 2066/67,revised BPP is planned to expand in 30 districts (25 by GON and 5 by partners)and maintainance of BPP in existing districts.

Education and distribution of Matri Surakshya Chakki(MSC) by FCHVs for prevention of PPH at homebirth will be maintained in existing districts and expansion in a few districts.

Pilot study on use of Chlorhexidine for prevention of umbilical cord infection is on-going in 4 districts(Banke,Jumla,Bajhang and Parsa).

intervention Completed in 2065/66

Plan for 2066/67

Revised BPP With GON funding (25 districts)Dhankuta,Ilam,Khotang,Morang,Sankhwasabha,Siraha,Sunsari,Solukhumbu,Taplejung,Bara,Kavrepalanchowk,Nuwakot,Parsa,Rasuwa,Sarlahi,Baglung,Lamjung,Myagdi,Nawalparasi,Palpa,Parbat,Dolpa,Jajarkot,Surkhet and Baitadi.With support from partners(15 districts)Jhapa,Okhaldhunga,Dolakha,Sindhuli,Banke,Kanchanpur,Jumla,Mugu,Bajhang,Salyan,Rolpa,Rukum,Kailali,Bajura and Darchula.

With GON funding(25 districts)Bhojpur,Panchthar,Saptari,Terhathum,Udaypur,Chitwan,Lalitpur,Makwanpur,Ramechap,Rautahat,Sindhupalchowk,Aarghakhachi,Gulmi,Kapilbastu,Kaski,Manang,Mustang,Rupandehi,Syanjha,Tanahu,Bardia,Dang,Humla,Pyuthan,and Achham,Dadeldhura and Doti.With support from partners –Ramechap,Dhading,Gorkha,Rolpa,Dailekh and Salyan.

PPH education and distribution of M atri Suraksha Chakki for prevention of PPH at homebirth

Sindhuli(distribution from ANC clinics),Banke,Mugu,Jumla,Kalikot,Bajhang,Darchula,Bajura, and Doti(distribution from ANC clinics)

Shifting distribution of Matri Suraksha Chakki by FCHVs for prevention of PPH at homebirth in Sindhuli and Doti.Maintainance of PPH education and MSC distribution in 6 districts(okhaldhunga,ramechap,dailekh,rolpa,salyan and kalikot)

2.1.10 Human Resources Development (HRD)

With support from RTI and SSMP/Options, a study on human resources available for safe delivery was conducted in 15 districts, which formed the basis for developing a national Human Resource Strategy for Safe Delivery Service. One of the study recommendations was to recruit additional staff under local contracts to ensure sufficient staff for 24-hour delivery and C/BEOC services.

. In response, FHD provided additional budget to districts and 318 ANMs and 14 staff nurses were recruited. However, only two out of a planned six districts were able to recruit MDGPs (Nuwkot and Gulmi). In two districts (Dailekh and Sankhuwasabha) the hospitals contracted medical colleges to provide CEOC services. Stakeholders have continued to advocate for production of more gynaecologists and MDGPs for CEOC services and NAM institute has agreed to initiate a one-year diploma course in gynaecology and obstetrics.

Family Health Division coordinated with NHTC to provide safe motherhood related training for various cadres of health worker, with a particular focus on SBA training, as shown in the Table 3b.3 below. The Learning Resource Package for SBA training was reviewed and updated and a combined .Supplementary Reference Manual for SBAs produced. A five-year SBA operational training plan was finalised, based on the National SBA Policy (2006).

Since in-service SBA training was initiated in 2007, a total of 1,134 SBAs have been trained (including MDGPs, Ob/ Gyn, medical officers, nurses and ANMs, some from the private sector and pre-service education faculties). The majority were from district hospitals and PHCCs. At least one SBA has been trained from all 75 districts.

Activities Planned numbers

Achieved numbers

% achievement

SBA Training 750 559 75

Anaesthetic Assistant Training

12 14 117

Operation Theatre Techniques andManagement for Surgery

20 19 95

Advanced SBA with Surgical Skills

4 2 50

Clinical Training Skills

16 14 88

A further six SBA training sites have been developed, including needs assessment, training of trainers, and providing teaching learning materials and models. In total 15 training sites are now conducting SBA training with support from SSMP/Options, NHTC conducted a pilot SBA post-training follow up programme, using 24 SBA trainers to follow up 119 SBA service providers.

. On-site coaching was provided where needs and it was found that most of the SBAs are using the core skills from their training. nursing).

Furthermore,a national Pre-Service SBA Education Strategy has been developed, to ensure that in future all medical and nursing graduates will be SBAs and not require further in-service training. This is in process for approval from the Ministry of Education, and SBA skills are already included in updated curriculum institutions under the IoM (MBBS, BSc Nursing, and certificate level)

2.1.11 Equity and Access(samata Ra Pahunch Karyakaram)

In partnership with Action Aid Nepal, SSMP/Options has continued implementing a targeted Equity and Access Programme (EAP) in eight districts (Morang, Chitwan, Nawalparasi, Rupandehi, Parbat, Myagdi, Dailekh and Dadeldhura), working through 26 local NGO partners to empower communities, particularly poor and excluded, to utilise SMNH services. Mass media activities have also continued in two additional districts, Baglung and Surkhet.

Based on needs assessment (with baseline KAP survey), 184 VDCs and 7 municipalities were selected for rights based social mobilisation activities, as these are majority poor and socially excluded people. Approximately 90,000 women participate in more than 3,500 local groups, linked through women networks at VDC level to create demand for SMNH services.

Key activities were:• Group meetings and networking to

empowering women to raise their voices for improved services and access . Encouraging marginalised and excluded women to hold decision making positions in the groups and other bodies, such as HFMC, users groups, Behaviour Change Communication (BCC) initiatives such as street drama, development and distribution of localised posters and pamphlets, radio and quiz competitions

• Technical support to NHEICC for design and dissemination of SMNH messages through radio

drama serial and weekly radio magazine through six FM and radio stations.

• Follow up and orientation for VDC members, local political/social leaders, school teachers,

FCHVs and traditional healers to generate an enabling environment for poor and social excluded

people to access SMNH services

Strengthening peripheral HFMCs by facilitating interaction meetings between service providers, management committees and communities to ensure more responsive service delivery.

Advocacy activities for media people, transport workers, district level stakeholders including Reproductive Health Coordination Committee members about SMNH

Second round of voice collection (service users and providers) on perceptions about services and access to inform policy and programme reforms.

An end-line KAP survey was carried out to assess the achievements of the EAP, which ended in July 2009. Results indicated improved SMNH knowledge and substantially increased SMNH service utilisation, demonstrating the success of the targeted approach to empowering poor and excluded people. Specific achievements are:

• Over 3,500 community groups mobilised with emergency funds, over 80% of which were utilised by poor and excluded groups.

• Around 52% of the groups have their own local emergency transport and all groups have access to the emergency transport. Again 80% of the users are poor and excluded.

• Around 73% of key positions are held by socially excluded women (chairperson, secretary,treasurer).

• All District RHCCs in EAP districts functional, with five having a RH strategic plan.

• Institutional deliveries increased by 30% in 2008/2009 (FY 064/65), compared with 2006/2007 (FY062/63). Dalits doubled their institutional delivery rate, to 26%, and relatively advantaged Janajatis almost doubled their institutional delivery rate, to 65%.

• Around 25% of people practising at least two out of four (money, transport, blood and SBA) methods of birth preparedness and complication readiness in EAP districts.

• Knowledge of at least three danger signs among poor and excluded increased (by 43% during pregnancy, 54% during labour and 48% up to 42 days after delivery).

Increased knowledge about neonatal danger signs and management of complications, at least four

out of eight listed elements in each case, up from 9% to 35% and from 22% to 52% respectively.

• Increased knowledge about legal provision of safe abortion, by 58%.

Correct identification of health facility for the management of complications during pregnancy, labour and postpartum period (99%).

Increased knowledge of the Safe Delivery Incentive Programme, by 90% from 27%.

EAP contributed to improved service utilisation in 13 selected facilities that received appreciative.

Scaling up Equity and Access activities through FA

FHD has committed to implementing equity and access activities in additional districts using SSMP

Financial Aid (FA). Activities have been expanded into two new districts, Gorkha and Kanchanpur, through district (public) health offices directly contracting a local NGO in each district. Initial results are promising in terms of increased service utilization. FHD has also agreed to further scaling up of EA activities in eight districts in 2009/10 using SSMP FA.

MATERNAL AND NEONATAL HEALTH UPDATE

FHD ,with support from various partners,conducted MNH update in 7 districts(namely Dailekh,Rolpa,Surkhet ,Bara,Sindhuli,Kailali, and Doti)

MNH update is essentially a 3-days update of health workers(namely doctors,staff nurses,ANMs and MCHWs)working in health facilities that provides 24-hour delivery services(hospital,PHC,HP and SHP)based on the standard SBA training package.

During the update,service providers are trained on the use of partographs,active management of the 3rd stage of labor(AMTSL)for prevention of PPH including conduction of normal labor,management of PPH,use of MgSO4 for severe pre/eclampsia and neonatal resuscitation.

This intervention is conducted with an aim of improving the knowledge and skills of health workers providing delivery services in remote health facilities,on identification,management and/or referral of women and newborns with complications,till the time they receive the formal SBA training which is the goldstandard.

Since the start of this program in 2009,more than 252 providers from 7 hospitals and more than 122 health facilities have received this update.This is a ‘whole-site update’for all providers in the health facility at the same time,thus ensuring uniform services delivery as well as creating an enabling environment at work.This intervention will be continued in these districts in addition to its expansion to at least 5 more districts in the coming year.