Safe Motherhood in Nepal

SSMP/Options and partners have successfully used the technique of Appreciative Inquiry (AI) for strengthening health facility management in programme districts, helping to improve maternal health services and increase their utilisation. More recently this has been scaled up under government funding in 50 health facilities in 28 districts through a contract with a private company, Genesis Management. The main aim was to encourage local facilities to start 24-hour delivery services and to improve the quality of emergency obstetric care in hospitals. Genesis Management conducted AI participatory planning workshops in district hospitals and trained teams of district facilitators to roll this out to the local level health facilities, with back-up support.

The National Health Training Centre worked with Support to the Safe Motherhood Programme (SSMP/ Options) to pilot an intensive post training follow up programme for skilled birth attendants (SBA). A total of 119 SBAs, mainly nurses and auxiliary nurse midwives (ANM) were visited at 38 health facilities by trainers from five training sites. The trainers interviewed SBAs and their supervisors and observed the SBAs’ performance, providing on site coaching as required. Key findings were that most SBAs were using their new life-saving skills and were confident and competent in providing delivery and emergency obstetric care services. The trainers also learned about the professional realities of rural nurses and ANMs, which will enable them to better train and support SBAs in the future. Key recommendations were to: follow up all SBAs within three to six months of training; provide orientation for SBA supervisors to ensure on site support; ensure SBAs have the required equipment for services; improve clinical practice opportunities during training. These and other recommendations will be used to improve the SBA training and support system.

This report presents an overview of a policy process carried out during the months of August and September 2005 to reach consensus on a draft National Maternal and Neonatal Package of Services (MNH Package). The process was facilitated by two consultants, Dr. Madhu Devkota, a local paediatrician and public health professor with extensive experience in safe motherhood and Pamela Putney, a nurse-midwife, maternal/child health specialist with experience in policy and health sector reform. The consultants were contracted and supported by Options through the Nepal Support to Safe Motherhood Project (SSMP), funded by DFID. The purpose of the assignment was to support DoHS (FHD) and MoH (Human Resource and Financial Management Division) to develop a rational, evidence-based and contextually appropriate package of essential services to address the basic health needs of mothers, newborns and children of Nepal.

The recently completed Maternal Mortality and Morbidity Study, carried out in eight districts of Nepal, as a follow on to a similar study in 1997, provides new insights into the effects of community and facility related factors on maternal outcomes. The main study findings were disseminated at a meeting of stakeholders in November 2009. An encouraging finding was the maternal mortality ratio for the eight study districts of 229 per 100,000 live births, a figure that is consistent with the 2006 Demographic and Health Survey national result of 281, a dramatic drop from the 1997 figure of 539. The results of verbal autopsies and interviews carried out in communities and health facilities show that many of the women who died as a result of pregnancy and delivery complications went to a facility too late, when their condition was already critical; or went to an inappropriate facility first, thus wasting time before accessing the level of care they needed; and/or experienced delays or poor service at the facility due to lack of appropriately skilled staff, equipment or supplies. The mountain districts surveyed do not have comprehensive emergency care services, meaning that women in these districts have to travel further for care, and the facilities are generally less well equipped and staffed than those in the Tarai. An important finding was that maternal/ pregnancy related causes were no longer the leading cause of death for women of reproductive age, but now ranked third, reflecting improvements in management of pregnancy complications over the last decade. In particular the contribution of postpartum haemorrhage to maternal deaths has been reduced (from 41% to 24%), although it remains the leading cause. The contributions of eclampsia and abortion have increased. A shocking finding was that suicide was the leading single cause of death (16%), where it was only ranked third in 1997.

A study carried out under the DfID Health Sector Reform Support Programme (HSR-SP) by Riitta-Liisa Kolehmainen-Aitken and Ishwar Shrestha (RTI International, 2009, Human Resource Strategy Options for Safe Delivery. Research Triangle Park, NC, USA reviewed staffing in a selection of district hospitals, Primary Health Care Centres (PHCC) and health posts in 15 districts of Nepal. Findings highlighted critical shortages, such as lack of staff nurses in PHCCs and health posts; unfilled posts and incomplete safe delivery teams in district hospitals; and lack of Auxiliary Nurse Midwives (ANM) in health posts.