Initiatives to Reduce MMR and MMR Related Issues • Integrated Reproductive Health Package in Nepal

1. Initiatives to Reduce MMR and MMR Related Issues • Integrated Reproductive Health Package in Nepal – Family Planning; – Safe Motherhood; – Child health (new born 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

2. Initiatives to Reduce MMR and MMR Related Issues (contd…) • National Reproductive Health Strategies in Nepal - Implement the “Integrated Reproductive Health Package” at hospital, PHC Center, Health Posts and Sub-Health Posts as well as through Primary Health Care Outreach, TBAs, FCHVs/Mothers Groups and other community and Family level activities based on standardized clinical protocols and operational guidelines; – Enhance functional integration of Reproductive Health activities carried out by different divisions; – Emphasize advocacy for the concept of Reproductive Health including the creation of an enabling environment for inter and intra-sectoral collaborations; – Review and develop IEC materials to support all levels of intervention including rumour countering message; – Review and update the existing training curricula of various health workers to include missing Reproductive Health components;

3. Initiatives to Reduce MMR and MMR Related Issues (contd…) – Ensure effective management systems by strengthening and revitalizing existing committees at various levels; – Develop a national RH research strategy which outlines research priorities and work plans based on information requirements of policy makers, planners, managers and service providers; – Construct/upgrade appropriate service delivery and training facilities at the National Regional, District and Health Post level; – Institutional strengthening through structured Planning, Monitoring/Supervision and Performance Review; – Develop an appropriate RH programme for adolescents; – Support for national experts/consultants; and – Promote inter-sectoral and multi-sectoral co-ordination.

4. Initiatives to Reduce MMR and MMR Related Issues (contd…) • Safe Motherhood Program started in 1997 • DOHS developed National Safe Motherhood Plan for 15 years i.e. 2002-2017 • The long-term goals of the 15 year plan mainly envisage: – establishment of BEOC and CEOC services in all 75 districts of the country – skilled attendance of all births • The Post Abortion Care (PAC) Program started in 1995 at the Maternity Hospital in Kathmandu through the Manual Vaccum Aspiration (MVA) method. PAC service sites have been expanded to 51 health facilities of 36 districts. However, many facilities are still practicing D & C for those cases, which could be managed by MVA.

5. Initiatives to Reduce MMR and MMR Related Issues (contd…) • Comprehensive Abortion Care (CAC) started in March 2002. National Safe Abortion Policy 2002 and the Procedural Guidelines were developed and distributed to 36 sites (23 Govt. and 13 Private) in 27 districts. • Abortion can be done on request up to 12 weeks of pregnancy for any reason, up to 18 weeks in cases of rape or incest and up to any gestation in case of risk to the woman’s life and mental and physical health or foetal detormity. • Birth Preparedness Package (BPP) is a tool designed to assist women, their families and communities to plan for normal pregnancies, deliveries and emergencies. The BPP is designed to be implemented through community mobilizers and health care providers, such as FCHVs, MCHWs, TTBAs who have received training on how to use BPP flip-chart to educate people about how to plan for birth. BPP has been implemented in 23 districts.

6. Initiatives to Reduce MMR and MMR Related Issues (contd…) • Midwifery Skills Training of 18 months for selected MCHWs. • Incentive package to encourage institution-based delivery and safe home-based delivery. • Implementation of Process Indicators for monitoring safe motherhood program. These Process Indicators are: – One CEOC facility for 100,000 people – Four BEOC facility for 100,000 people – Proportion of Birth at B/CEOC – Met need for EOC – C/S rate Met need for C/S – Care Fatality Rate (CFR)

7. Initiatives to Reduce MMR and MMR Related Issues (contd…) • The C/S rates in 13 districts was 0.5% (desirable rate is 5-15%) • The CFR was less than 1% in all 13 districts (desirable rate less than 1 for every 100 complications) • RHIYA (Reproductive Health Initiative for Youth in Asia) is a EU/UNFPA Regional Programme and aims to empower adolescents and youths (10-24) with life skills and appropriate information and education on sexual and reproductive health and rights issues. • This programme is being implemented in the rural areas of 18 districts through 7 local NGOs in close collaboration with concerned govt. agencies and organizations.

8. Issues and Challenges • The 4 delays: – Delay in convincing – Delay in deciding – Delay in reaching – Delay in receiving • The slogan “Plan the first, Delay the second and never the third”, is yet to be realized • Observation of 5 basic human rights for women: – women’s right to lives, – to liberty and security, – to the highest available standard of health, – to maternity protection, and – to non-discrimination.

9. Issues and Challenges (contd…) • Deployment and Retention of Trained Health Manpower in the remote and rural areas • Facility-based Delivery Vs Home-based Delivery • Disparities – Urban Vs Rural – Rich Vs Poor • Delegation of Authority to lower level of Health Workers • Quality of middle level manpower and Accreditation • Mobilization of Private Sectors • Conflict situation in the country – Deployment and Retention – Supervision – Access to the institution – Access of medicines and other logistics • Overall development (e.g. Education, Transport, Communication etc.)

10. Thank You