2.

RURAL ULTRA SOUND PROGRAM

● The main focus of this program is to timely identify the complications during
pregnancy and provide appropriate referral to the health facility for their
management.
● A trained nurse uses a portable ultrasound machine for scan purpose during
pregnancy.
● In FY 2068/69, the program had been piloted in two districts Mugu and Dhading
and have formally initiated in the following fiscal year.
3. UTERINE PROLAPSE
● Uterine prolapse is one of the priority program of Government of Nepal.
● In the last few years, separate fund has been allocated for uterine prolapse.
● Uterine prolapse treatment and surgery operational guideline 2065 was
developed and has been revised twice first in 2066 and second in 2068.
● The major focus for this activity includes the identification of the females with
prolapsed uterus through screening camps/programs, categorizing the degree of
prolapse and then treating with ring pessary as well as surgical interventions.
4. HUMAN RESOURCES DEVELOPMENT
● Human resources of various levels, right from ANM’s , to doctors and
Gynecologist have been recruited in order to support 24-hour delivery services
in PHCCs and HPs and district hospitals.
● Likewise, National Health Training Center (NHTC) has been providing the¬ SBA
training as well as advanced SBA training to the appropriate staffs and thus is
developing their skills to attend and handle every possible cases of pregnancy.
5. EMERGENCY REFERRAL FUND
● It is estimated that 15 percent of the pregnant women develop complication
during pregnancy and 5 to 15 percent of them need CS for delivery (WHO,2009).
● In different geographical terrain and inadequate BEOC/CEOC services, it is very
important to have referral services to the pregnant women.
● To address this issue Family Health Division (FHD) has launched emergency¬
referral fund program to facilitate referral services.
● A total of two hundred thousand rupees has been allocated as send money for
each district to be used by a locally formed committee as per the guideline.
6. SAFE ABORTION SERVICE
● Preventing unwanted pregnancies through quality family planning services is a
first step towards addressing women’s reproductive health needs and increasing
access to safe abortion services has been considered as an opportunity to
prevent unwanted pregnancies.

18
 ● For this, trained doctors/health workers are provide safe abortion services at
the Government accredited health facilities, with the consent of women and
based on the criterion spelled in the safe abortion service guideline.
● The increasing trend in abortion utilization shows that more and more women
are seeking abortion services.
● In situation such as high turnover of doctors, training nurse providers, especially
auxiliary nurse midwife, in safe abortion service has been seen as an effective
way to ensure uninterrupted service delivery.
6. AAMA PROGRAM
● The revised Aama guideline has been implemented since the start of FY 2069/70
● The Aama guideline specifies the services to be funded, the tariffs for
reimbursement and the system for claiming and reporting on free deliveries each
month
After revision, Aama program has four components:
1) The Safe delivery incentive program (SDIP), a cash incentive scheme, which was
initiated in July 2005,
2) Free institutional delivery care, which was launched in mid-January 2009
3) Incentive to health worker for home delivery
4) Incentive to women for 4 ANC visits
❖ AAMA PROGRAM PROVISION
- Incentives to women on institutional delivery:
NRs 1,500 in Mountain
NRs 1,000 in Hill
NRs 500 in Terai
- Free Institutional delivery services:
A payment to the health facility for the provision of free delivery care. For a
normal delivery, health facilities will less than 25 beds receives : NRs 1000, health
facilities with 25 or more beds receive NRs 1,500.
- For complicated deliveries
Health facilities receive NRs 3,000
C-section NRs 7,000
Laparotomy for perforation due to abortion, indicated or emergency CS, laparotomy for
ectopic pregnancy and ruptured uterus is reimbursed NPR. 7000. Ten complications i.e.
APH requiring blood transfusion, PPH requiring blood transfusion or MRP or exploration,
severe pre-eclampsia, eclampsia, MRP for retained placenta, puerperal sepsis, instrumental
delivery, and management of abortion complications requiring blood transfusion and
admission longer than 24 hours with IV antibiotics for sepsis are included as complicated
deliveries. Anti-D administration for RH negative is reimbursed NPR.5000.

19
 ❖ Incentive to women for 4 ANC visits
A cash payment of NRs. 800 is made to women on completion of 4 ANC visits
❖ Incentive to health workers for home deliveries
A cash payment of NRs. 100 is made to health worker for home deliveries
❖ Incentives to health workers for deliveries:
- A cash payment of NPR. 300 are made to health worker attending all forms of
deliveries: normal, complicated and caesarian section. This is to be arranged form
the health facility reimbursement.
❖ Free sick new born care: A payment to the health facility for the provision of free sick
new born care. Health facilities are reimbursed for a set package of care cost : 'Package
0' no cost, 'Package A' NPR.1000, 'Package B' NPR. 2000 and 'Package C' NPR. 5000.
Health facility can claim as high as combination of A+B+C NPR.8000, depending on
medicines, diagnostic and treatment services provided. Incentives to health worker for
sick new born care: A cash payment of NPR. 300 are made to health worker providing all
forms of service packaged. This is to be arranged form the health facility reimbursement.

Ten Action Messages for Safe Motherhood

The Safe Motherhood Initiative (SMI) has defined 10 key action messages for safe
motherhood:
1. Advance safe motherhood through human rights.
2. Empower women: ensure choices.
3. Make a vital economic and social investment in safe motherhood.
4. Delay marriage and first pregnancy.
5. Recognize that every pregnancy faces risks.
6. Ensure skilled attendance at delivery.
7. Improve access to quality reproductive health services.
8. Prevent unwanted pregnancy and address unsafe abortion.
9. Measure progress.
10. Utilize the power of partnerships.

MATERNITY CARE
• Maternity
– the state of being pregnant; the period from conception to birth when a woman carries a
developing fetus in her uterus . There are several criteria being used to asses the health
service of mother:
• Age at first pregnancy

20
• Total fertility rate
• Median birth interval
• Body mass index and prevalence of malnutrition
• Percentage of mother received antenatal services
• Percentage of pregnancy women receiving iron tablets, TT vaccine, Vit.A, Vit. C and Vit. D
• Contraceptive Prevalenece rate(CPR) .
❖ PURPOSE OF MATERNITY CARE
The purpose of maternity care are:
a. To reduce maternal and infant mortality and morbidity.
b. To ensure that pregnancy causes no harm to the mother and to keep the fetus healthy
during the antenatal period.
c. To improves health outcomes for women by identifying treatabl complications such as
gestational diabetes, preeclampsia, and ectopic pregnancies.
d. To teach the mother elements of child care, nutrition, personal hygiene, family planning
and environmental sanitation.

ACTIVITIES FOR MATERNITY CARE:

1. Care before pregnancy
2. Care during pregnancy
3. Care at birth
4. Care after birth

1. Care before pregnancy:

✔ Improving health & status of woman
✔ Improve nutrition of girls
✔ Discouraging early marriage & early child bearing
✔ Promote safe sexual practices
✔ Provide opportunities for sex education 2
2. Care during Pregnancy:
✔ Improve nutrition
✔ Immunization – TT
✔ Screening; malaria, syphilis, etc
✔ Improve communication and counseling for birth preparedness and counseling of
danger signs, medication & exclusive breast feeding.
Special attention during pregnancy
✔ Monitor and treat pregnancy complications such as anaemia, preeclampsia and
bleeding.
✔ Promote voluntary, counseling & testing (VCT) for HIV

21
 ✔ Reduce risk of mother to child transmission of HIV
3. Care at birth:
✔ Skilled attendance at birth
✔ Five cleans for example, clean-hand, clean-surface, cleancord tightening,
clean-cord cutting & clean-clothes.
✔ Initiate immediate EBF at least within an hour
4. Care after birth
✔ Ensure early postnatal contact
✔ Promote exclusive breast-feeding
✔ Maintaining hygiene.
✔ Provide immunization to child

Basic maternity care (guideline)

• All pregnant women should have access to basic maternity care.
• All women, families, and communities should be aware of the special needs of pregnant
& lactating women in terms of nutrition, rest, antenatal, delivery & postpartum care.
• Communities should be informed about the signs & symptoms of complications & be
aware of the need to plan for emergency transportation to the health center or hospital.
• At all levels of the health care system – community, health center & hospital – people
should have appropriate knowledge & skills to manage normal pregnancies & deliveries to
detect, manage and /or to refer high-risk cases & complications
• All pregnant women should have minimum four antenatal visits (at least 20 min duration
each) for prevention, early detection, and management of complications.
• Antenatal care should comprise:
– health promotion
– assessment
– management and /or referral through history-taking, physical examination, and
laboratory test, where necessary
– tetanus toxoid immunization
– iron and folate supplementation
– malaria prophylaxis
– hookworm treatment; and
– STD management.
• Antenatal care sessions should be used as an opportunity to provide information to
women and their families about danger signs and symptoms during pregnancy & delivery
& to help them develop & appropriate delivery plan, based on the women’s history &
health status.
• All women & birth attendants should be aware of the requirements for a clean delivery.

22
 • All health care providers should be trained and practice clean & safe delivery techniques
and avoid unnecessary vaginal examination and episiotomies.
• All women & their birth attendants should be aware of the need to refer cases of
prolonged or obstructed labor to a higher level of care. All institutional deliveries should
be monitored using an appropriately adapted version of a partograph in order to prevent
prolonged labor
• All women should receive a postpartum visit within the first week of delivery in order to
ensure early detection and management of hypertension, haemorrhage & sepsis.
• The postpartum period should also be used to provide support to breast- feeding & is an
opportunity to provide family planning information & services

23