Practicum presentation on Safe Motherhood Program (SMP) and Maternal and Perinatal Death Surveillance and Response (MPDSR) Program in MNH Section of Family Welfare Division

Practicum Presentation on
Safe Motherhood Program in
Maternal and Neonatal Health
Section, Family Welfare
Division
Mohammad Aslam Shaiekh
MPH-4rth Semester

Objectives of Practicum
• To observe, participate and engage in various
activities of MNH Section during the
practicum period.
• To critically appraise the present state and
mode of the HPEC interventions of MNH
section.
• To conduct Mini Action Project (MAP) on a
identified gaps/issue.
• Develop interpersonal skills and
competencies to work in group/team for
quality project management

Methodology
Visited different organizations and
contacted head of those organizations
With an interest to do practicum in the area
of MCH and went to meet Chief of MNH
section, FWD through phone and email
conversation
After discussion with the Chief, approval was
given to do a practicum in the MNH section
Approval was taken to do a practicum in the
MNH section for 3 weeks
Detail Plan of Action was developed and get
approved by the Chief of MNH Section

Methods
• Review of documents and reports
• Document review for renew and
approval of Safemotherhood
program and Guidelines etc.
Desk
Review
• Interaction with MNH section
staffs, and NHSSP staffs was
done to enhance further
understanding on programs and
activities and to understand the
management process.
Interaction
s

Methods
• Different units of MNH section and
NHSSP were visited and
observation was done to
understand the management
process and activities performed.
Observation
s
• Attended meetings related to
Monthly progress review and
FP2020.
• Participated in the Public Private
Partnership (PPP) workshop and
MPDSR Orientation
Participation
s

Activities Carried Out
Activities Approach
Read documents and reports
related to Safemotherhood
program and interaction with SMP
focal person to be familiarize with
SM program
Desk Review
Interaction
Exploring the MNH activities and
Organizational structure
Discussion
Interaction
Attended monthly progress review
meeting
Participation &
Observation
Attended workshop on Public
Private Partnership (PPP) for
Participation and
Observation

Activities Approach
Develop slides on MPDSR
and 3 years progress of
SMP activities
Discussion,
Documents review
and Consultation with
section chief
Discussion and orientation
about NHSSP support and
their activities
Interaction
NHSS-RF data compilation Data entry
Attended FP2020 meeting Participation and
Observation

Activities Approach
Operating STAT-Compiler for
NDHS data regarding SMP
indicators
Application of
STAT-Compiler
Conducted Mini-Action-Project
(MAP)
Gap analysis
Final Presentation and Vote of
Thanks for Supporting over the
practicum period
Presentation and
Discussion

MNH Section, Family Welfare
Division
• Family health is one of the priority programs of
Government of Nepal, Ministry of Health.
• FHD is responsible for improving overall quality of life of
the whole family by improving the health status of
mothers, neonates and children and by increasing
access and utilization of quality services.
• To achieve this important goal various programs like
FP, ASRH, SMP, and neonatal health care services
through health facilities, PHC/ORC and Female
Community Health Volunteers (FCHVs) are in
operation.

MNH Section, Family Welfare
Division
• Nepal has been able to partially achieve
MDG 4 and 5 and there is much to do
towards improving reproductive health status
of Nepalese population.
• To further improve MNH status of country,
Nepal is committed to sustain these
achievements and further improve maternal
and neonatal health and achieve target of
MMR to less than 70/100000 live birth,
Institutional Delivery to 90%, CPR to 75%,
and NMR to (1/1000 Live Birth) which are set
for SDG by 2030.

Functions of MNH Section,
Family Welfare Division
• Support the MoHP to prepare national policy,
strategy, directories, criteria, protocols regarding
MNH.
• Provide technical assistance to the national and
regional policy by analyzing MNH conditions.
• Based on national policy, international guidance
and territorial needs, facilitate new programs
related to MNH.
• Coordinate and implement technological issues
with the state, local level and stakeholders.
• Necessary support to the regional and local level
to enhance the quality of services through the
expansion of emergency 24-hour service

Staffing
• The people for the sanctioned permanent posts in
MNH section are recruited through Public Service
Commission and MoHP carries out training and
development, performance appraisals, promotions
and transfers of the personnel. Temporary staffs can
be recruited by Family Welfare Division.
• Altogether there are five staffs under MNH section
of FWD.
 Section Chief (9th level) - 01
 Community Health Nursing Officer-1 (7th level)
 Na.Su-1
 Computer Assistant -1
 Public Health Inspector-2 (7th level) – 01
 Office Assistant – 1

Safe Motherhood Program (SMP):
Introduction
• The evidence suggests that three delays are
important factors for maternal and newborn
morbidity and mortality in Nepal (delays in
seeking care, reaching care and receiving care).
• Hence, The SMP initiated in 1997 has made
significant progress with formulation of safe
motherhood policy in 1998.
• The policy on SBA (2006) highlights the
importance of SBA at all births and embodies the
government’s commitment to train and deploy
doctors, nurses and ANMs with the required
skills across the country.

Introduction
• Introduction of Aama programme to ensure free
service and encourage women for institutional
delivery has improved access to institutional
deliveries and emergency obstetric care
services.
• The endorsement of the revised National Blood
Transfusion Policy (2006) was another
significant step for ensuring the availability of
safe blood supplies for emergency cases

Goal
• The goal of the National Safe Motherhood
Programme is 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.

Strategies
• Promoting birth preparedness and complication
readiness including awareness rising and
improving preparedness for funds, transport and
blood transfusion.
• Expansion of 24 hours birthing facilities.
• Aama Suraksha Programme promotes antenatal
check-ups and institutional delivery.
• The expansion of 24-hour emergency obstetric
care services (basic and comprehensive) at
selected health facilities in all districts

Activities
Community level MNH interventions
• Through FCHV, public health system promotes:
 Birth preparedness and complication readiness
(preparedness for money, place for delivery,
transport and blood donors);
 distribution of matri-surakshachakki (misoprostol) to
prevent postpartum hemorrhage (PPH) in home
deliveries.
 Antenatal care (ANC), institutional delivery and
postnatal care (PNC) (iron, tetanus toxoid,
Albendazole ,Vitamin A);
 Identification of and timely care seeking for danger
signs in the pregnancy, delivery, postpartum and
newborn period.
 Self-care (food, rest, no smoking and no alcohol) in
pregnancy and postpartum periods;

Activities
Rural Ultrasound Program
• Timely identification of pregnant women with
risks of obstetric complication to refer to
comprehensive emergency obstetric and
neonatal care (CEONC) centers. (Implemented
14 remotes districts)
RH morbidity prevention & Management
• Management of pelvic organ prolapse and
Obstetric Fistula
• Cervical cancer screening and prevention
training

Activities
Expansion and quality improvement of service
delivery sites:
 FWD continued to expand 24/7 service delivery sites
like birthing centers, BEONC and CEONC sites at
PHCCs, health posts and hospitals.
Safe Abortion Services
 Pre and post counseling on safe abortion methods
and post-abortion contraceptive methods;
 Termination of pregnancies as per the national
protocol;
 Provide contraceptive methods as per informed
choice and follow-up for post-abortion complication
management.

Activities
Emergency Referral Funds:
• In cases of difficult geographical terrain and
unavailable CEONC services, FWD allocated
emergency referral funds to Provincial Directorate
for air lifting of women in need of immediate transfer
to higher centers.
Human Resource Management:
• A significant share of FWD’s budget goes for
recruiting human resource (Staff nurses, ANMs)on
short term contracts to ensure 24 hour services on
MNH at PHCCs and health posts.
• NHTC provides training on SBA, ASBA, Anesthesia
assistant, operating theatre management, family
planning (including implants and IUCD), CAC and
antenatal ultrasonography.

Activities
Onsite Clinical Coaching and Mentoring for
QI:
 Clinical coaching/mentoring for MNH service
providers (SBA and Non-SBA),
 Infection prevention and
 MNH readiness QI self-assessment.
PNC Home Visits (Micro Planning for PNC):
• In FY2074/75, FWD provided 30 local palikas
from 15 districts to strengthen PNC services by
mobilizing MNH service providers from health
facilities to provide PNC at women’s home.

Activities
Maternal and Perinatal Death Surveillance &
Response (MPDSR) And Birth Defect
Surveillance (BDS):
• Identification, notification, quantification and
determination of causes and avoidability of all
maternal and perinatal deaths at community and
health facilities, as well as the use of this information
to respond with actions that will prevent future
deaths.
NYANO JHOLA Program:
• Launched in 2070/71 to protect newborns from
hypothermia and infections and to increase the use
of peripheral health facilities (birthing centers).
• Two sets of clothes (bhoto,daura, napkin and cap)
for newborns and mothers, and one set of wrapper,
mat for baby and gown for mother.

Activities
Aama programme provision
For women delivering their babies in health
institutions:
• Transport incentive for institutional delivery:
Cash payment to women immediately after
institutional delivery (NPR 3,000 in mountains, NPR
2,000 in hills and NPR 1000 in Terai districts).
• Incentive for 4 ANC visits: A cash payment of NPR
800 to women on completion of four ANC visits at 4,
6, 8 and 9 months of pregnancy and Institutional
delivery.
Incentives Provision to health service provider:
 For deliveries: A payment of NPR 300 to health
workers for attending all types of deliveries to be
arranged from health facility reimbursement

Activities
• Free institutional delivery services:
A payment to health facilities for providing free
delivery care.
 For a normal delivery health facilities with less
than 25 beds receive NPR 1,000 and health
facilities with 25 or more beds receive NPR
1,500.
 For complicated deliveries health facilities
receive NPR 3,000 and for C- sections (surgery)
NPR 7,000.

Activities
Newborn Care programme provision
• For sick newborns: There are four different types
of package (Package 0, Package A, B, and Package
C) for sick newborns case management. The cost
of package of care include 0 Cost for Packages 0,
and NPR 1000, NRP 2000 and NRP 5000 for
package A, B and C respectively. Health facilities
can claim a maximum of NPR 8,000 (packages
A+B+C), depending on medicines, diagnostic and
treatment services provided.
• Incentives to health service provider: A payment
of NPR 300 to health workers for providing all forms
of packaged services to be arranged from health
facility reimbursement amounts.

Mini Action Project (MAP):
Introduction
• As per one of the activity of the organization,
there was the orientation program on MPDSR to
the staffs of hospitals and PHCC. Thus in
consultation and recommendation with MNH
section chief and Community Nursing Officer
(CNO), they suggested me to make a draft for
the orientation slide to present in orientation
program as my MAP.
• So I developed the presentation draft on the
topic Maternal and Perinatal Death Surveillance
and Responses (MPDSR) with a mini-lecture
and conducted as my mini-project in the
orientation program with the support of CNO.

Objectives
• To describe the status of maternal and perinatal
mortality in Nepal,
• To describe the goal, objectives, components
and process of MPDSR.
• To orient the HWs on Complete the Maternal
Death Review (MDR) and Perinatal death
Review (PDR) forms correctly.
• To make capable to HWs to Identify the Cause
and avoidable factors of the maternal and
perinatal deaths
• To develop the skills on Formulate, implement
and monitor action plan for appropriate
response.

Detail of MAP Implementation
• Date: 24th October 2019
• Duration: 11:00 AM – 4:00 PM
• Venue/setting: NHTC Training Hall
• Staff from Health Section: Dr. Punya Gautam
(MNH Section Chief) and Mrs. Kumari Bhattarai
(Community Nursing Officer)
• Number of Participants:
• Target Group: Doctors form Hospital and PHCC

Background of MPDSR
• Development of any country is reflected by the
status of health of mothers and children.
• Globally, about 3 Lakh women die every year
due to maternal cause in pregnancy, 99% of
such maternal deaths occur in less developed
countries.
• In Nepal, about 1700 women die every year due
to maternal causes. Nepal Health Sector
Strategy (2015-2020) has target to reduce MMR
to 125 by 2020.
• SDG has targets to reduce MMR to 70 per
100000 live births by 2030.

Background of MPDSR
• Prematurity, birth asphyxia and sepsis are the
most common causes of death followed by
congenital anomalies, pneumonia, diarrheal
diseases among the neonates.
• MDR started from maternity hospital Kathmandu
in 1990 and MPDR from 1996 to 6 hospitals later
in 2016 community based MPDSR started from
6 districts.
• MPDSR National guideline adopted in 2015.
• MPDSR is a strong proven system which can
guide and assist in preventing maternal deaths
and reduce MMR.

What is MPDSR
• Continuous identification, notification,
quantification and determination of causes and
avoidability of all maternal and perinatal deaths,
as well as the use of this information to respond
with actions that will prevent future deaths.

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.

MPDSR 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.

Components of MPDSR
Identify
cases
Collect
informatio
n
Analyze
results
Recommen
-dations
for actions
Evaluate
and refine

Key Principles of MPDSR
No woman
should die
giving birth
Every death
counts
Beyond the
numbers
Not used for
litigation
No blame
No name
No punitive
action
Black Box
Every death
has a lesson

Role of Attending Doctors/Nurse
for MPDSR Process

Feedbacks from Orientation
• Increase in case notification with identification of
hidden cases
• Increased responsibility and accountability on
maternal death at community level
• Need of multi-sectoral approach required to
implement actions

Challenges to MPDSR
Implementation
• Under reporting of suspected maternal deaths
• Blame culture at some places that inhibits health
professionals and others from participating fully in
the MPDSR process
• Incomplete or inadequate legal frameworks
• Inadequate staff numbers, resources and budget
• Problems of geography and infrastructure that
inhibit the timely operation of MDSR.
• Review and reporting of perinatal deaths in
hospitals
• Cause of death assignment at hospitals
• Delay/Incomplete notification, screening, review,
response & use of web-based MPDSR system

Tools for MPDSR
a. Notification form
b. Screening form (Hospital Based)
c. Community verbal autopsy form
d. Community cause of death assignment
form

Limitations of Internship
a. The duration of the internship was a limitation for me
in terms of mastering the organizational functioning,
3 weeks is too short to adapt to a new organization
and to start deliver to your maximum capacity.
b. The Practicum between the Dashain and Tihar
festival is not appropriate for students because there
is limited activities in that period so the internee
cannot get the opportunity to learn more and more.
c. The first week spend to be familiarized and to get to
know the organization and activities; when I settled in
I realized that I was at the verge of concluding the
internship. Even though the objectives were
accomplished, some were done through desktop
than being actively involved.

Learning from Internship
• Got opportunity to excel the programmatic
knowledge and information and have also
enhanced skills to work in a team.
• Team work and communication is the most
important weapon to make necessary
achievements and progress in the project work.
• Difference between theoretical knowledge and
practical skills. It seems a tough job to put
theoretical knowledge practically in the field.
• To prove myself I must become opportunistic, be
ready to undertake complex tasks and be ready
to work on deadlines.

Recommendations
Recommendations for MNH Section
• MNH section should Scale up of PNC home
visits program
• The interrupted NAYANOJHOLA Progaram,
should starts by allocating extra budget
• The MPDSR need to strengthen to all hospitals
including public and private both.
• Regular mentoring and onsite coaching should
increase at all birthing centers for qualitative
services
• Emphasize on collaboration with development
partners and multi stakeholders to harmonize

Recommendations for SAHS, PU
• There should be an MoU between the
organization and University for Practicum
• The duration of practicum, 3 weeks is too short
to adapt to a new organization and to deliver the
learning objectives.
• The practicum between the Dashain and Tihar is
not appropriate from learning perspectives so it
would be better to shift after Dashain and Tihar.
• Frequent visits from faculty members to boost
relationships with the organization
• Provision of allowances to supervisors of
respective organization.

Practicum presentation on Safe Motherhood Program (SMP) and Maternal and Perinatal Death Surveillance and Response (MPDSR) Program in MNH Section of Family Welfare Division

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Practicum presentation on Safe Motherhood Program (SMP) and Maternal and Perinatal Death Surveillance and Response (MPDSR) Program in MNH Section of Family Welfare Division