Maternal and newborn

health status in Nepal

Status of Maternal Health in Nepal
 Introduction

• Different policies and strategies have highlighted the importance of

safe motherhood for improving overall health status of women.

• Ministry of health and population, family welfare division has adopted

following strategies to reduce risk during pregnancy and childbirth
and address factors associated with mortality and morbidity:
Introduction contd…
• Promoting birth preparedness and complication readiness
including awareness raising and improving availability of
funds,transport and blood supplies.
• The safe motherhood programme (Aama suraksha programme)
promotes antenatal checkups and institutional delivery.
• The expansion of 24 hour emergency obstetric care services
(basic and comprehensive) at selected public health facilities in all
districts.
Target of GON on maternal health as a part of the SDGs

Indicators 2015 2019 2022 2025 2030

Maternal Mortality Ratio 258 145 106 86 70

Live birth attendant by SBA (%) 58 68.5 73 79 90

Source:Nepal’s sustainable development goals,baseline report june 2017,National planning

commission,Government of Nepal
1. According to NDHS, 2016 MMR is……
a. 539 deaths per 100,000 live births
b. 281 deaths per 100,000 live births
c. 239 deaths per 100,000 live births
d. 180 deaths per 100,000 live births

ANSWER: C

2. Nepal is expected to limit the figure of MMR up to……….. by 2030 in

order to advance towards Sustainable Development Goals.
a. 60 deaths per 100,000 live births
b. 70 deaths per 100,000 live births
c. 80 deaths per 100,000 live births
d. 90 deaths per 100,000 live births
ANSWER: B
 Maternal deaths in Nepal

• Nepal has achieved significant progress in Maternal health

demonstrated by decreasing maternal mortality ratio in Nepal.

• MMR is a key performance indicator for efforts to improve the health

and safety of mothers before, during and after childbirth per country
worldwide.
Trends in MMR in Nepal
Maternal death Contd…

• According to maternal mortality and morbidity study,2008/09 in

Nepal, 69% of maternal deaths accounted due to direct causes while
remaining 31% occurred due to indirect causes
 Direct causes of maternal deaths % Indirect causes of indirect maternal %
deaths

Hemorrhage 24 Heart disease 7

Eclampsia 21 Anemia 4
Abortion 7 Gastroenteritis 4
Obstructed labor 6 Hepatitis 3
Puerperal sepsis 5 Pneumonia 3
Complications of C/S and BT 2 Septicemia 2
Retained placenta 1 Typhoid 1
Ruptured uterus 1 Epilepsy 1
Inversion of uterus 1 Malaria 1
Pulmonary embolism 1 TB 1
Total 69 Rabies 1
Others 3

Source: Maternal Mortality And Morbidity Study,2008/09

 Institutional delivery
• Delivery at health facility with assistant from SBAs is one of key
approach to reduce maternal death and minimize possible complications
which can occur during delivery.

• MoH initiated Maternity Incentive program in 2005 to provide free

delivery services in government and non-governmental health facilities.

• In addition, mother also received transportation cost if she comes to

health facility for delivery. ( Aama program)
• 58% of deliveries are conducted by skilled birth attendants, and
57% of deliveries take place in a health facility.
1. According to the Nepal Maternal Morbidity and Mortality Study (2008–
2009) the leading cause of maternal death in Nepal is,
a. Hemorrhage
b. Eclampsia
c. Puerperal Sepsis
d. Pulmonary Embolism
ANSWER: A

2. According to NDHS,2016 percentage of institutional delivery in Nepal is,

a. 57%
b. 58%
c. 59%
d. 60%
ANSWER: A
 Antenatal care
• WHO recommends pregnant women to have at least of 8 ANC
contact.
ANC contd…
• MoH, family health division has recommended to conduct at least 4 ANC
visit in;
• 1st at 4 months
• 2nd at 6 months
• 3rd at 8 months
• 4th at 9 months

• According to the NDHS 2016,

• 84% of women received ANC from a skilled provider.
• 69% of women had at least 4 ANC visits.
ANC contd…
• Antenatal Incentive program

• Incentive for 4 ANC visit, institutional delivery and postnatal care:

NPR 800 (source: Annual report 2074/75)
Emergency obstetric care and birthing centers

• Basic emergency obstetric and newborn care (BEONC) and

comprehensive emergency obstetric and newborn care (CEONC)
services are very essential to help women during delivery.
 Postnatal care
• Larger proportion of maternal deaths occurs during postpartum period.

1. Three postnatal check-ups by GoN:

• 1st Visit-24 hours of delivery

• 2nd Visit- 3rd day

• 3rd Visit-7th day

• WHO recommendation:

• 1st Visit-24 hours of delivery

• 2nd Visit-on 3rd day

• 3rd Visit-7th day

• 4th Visit-6th week

PNC Contd…

2. The identification and management of complications of mothers and

newborns and referrals to appropriate health facilities.

3. The promotion of exclusive breast feeding.

4.Personal hygiene and nutrition and postnatal vit. A and iron

supplementation for mothers.

5. The immunization of newborns.

6.Postnatal family planning counselling and services.

PNC Contd…

• According to NDHS 2016,

• 57% of women reported having received a postnatal check in the

first 2 days after birth with most checkups occurring within 4 hours of
delivery.

• 42% of women did not receive any postnatal check.

1. WHO recommends pregnant women to have at least of ………..ANC
contact.
a. 4
b. 6
c. 8
d. 10
ANSWER: C

2. How many percentages of women completed their 4 ANC visits according to

the NDHS 2016?
a. 63%
b. 65%
c. 68%
d. 69%
ANSWER: D
1. Under the current Aama program, Nepalese woman who completed 4 ANC
visits and deliver in a health facility of mountain region is given a cash
incentive of,
a. Rs. 3800
b. Rs. 2800
c. Rs. 2500
d. Rs. 1800
ANSWER: A

2. Postnatal check-ups recommended by GoN is,

a. 1 visit
b. 2 visits
c. 3 visits
d. 4 visits
ANSWER: C
 Anemia
• Number of interventions being implemented in Nepal to reduce
anemia of women.

• Major interventions are:

• Supplementation of iron with folic acid tablets
• Deworming of pregnant women
• Postpartum vit. A supplements
• Promotion of the use of insecticide-treated mosquito nets in
malaria endemic areas.
Anemia Contd…

• The NDHS 2016 measured the hemoglobin level for 97% of eligible
women age 15-49 which revealed that 41% of women are anemic
with 33% mildly anemic,7% moderately anemic and less than 1 %
severely anemic.
Status of Newborn Health in Nepal
 Introduction
• Neonatal health is an important component of the National
Reproductive Health Strategy.

• The National safe motherhood program which also aims to reduce

maternal and neonatal mortality.

• In Nepal,

• Neonatal mortality rate: 21/1000 live birth

• Under 5 mortality rate: 39/1000 live birth

• Perinatal morality rate: 31 death per 1000 pregnancies.

Major direct causes of neonatal
death in Nepal
Disorders r/t GA, fetal growth

Hypothermia

Sudden neonatal 2 % Other

deaths 4% 5%
6%
Respiratory and cardiovascular
Congenital malforma- disorder of perinatal period
7%
tion and deformations (30%)

Infections (16%)

Complications of
pregnancy,labour and delivery
(30%)
Causes of neonatal death contd…

• Within respiratory and cardiovascular disorders, perinatal asphyxia

alone accounted for more than half of the deaths. Other causes
encompassed under this category were RDS, followed by congenital
pneumonia and meconium aspiration syndrome.

• The complications of pregnancy,labour and delivery included

conditions such as eclampsia, transverse lie, multiple pregnancy
and abruption placentae.

• Infections specific to the perinatal period included conditions such as

neonatal sepsis and pneumonia.
Causes of neonatal death contd…

• Prematurity and low birth weight included under disorders related

to length of gestation and fetal growth.
Q. the direct causes(medical causes) of newborn death in Nepal are
all except,
a. Hypothermia
b. Birth asphyxia
c. Sepsis
d. Inadequate care during pregnancy

Answer: D
 Evidence based practice intervening in
Nepal on newborn care

1.CARE OF THE NEWBORN IMMEDIATELY AFTER BIRTH:

• Immediate drying and additional stimulation:

• Newly born babies who do not breathe spontaneously after thorough

drying should be stimulated by rubbing the back 2–3 times before
clamping the cord and initiating positive pressure ventilation.

• No routine suction for all babies. In neonate born through meconium

stained amniotic fluids, suctioning of mouth and nose is in practice
before initiating PPV.
EBP on newborn Contd…
• Cord clamping: delayed cord clamping practice (After 1-3 minutes
following birth)

• Chlorhexidine for umbilical cord:7.1% chlorhexidine digluconate

(delievering 4% chlorhexidine) to the umbilical cord prevents
infection and saves newborn lives.

• Skin to skin contact in 1st hour of life to prevent hypothermia and

promote breastfeeding in newborn without complications.

• KMC for low birth weight babies as a routine care.

EBP on newborn Contd…

• Initiation of breastfeeding: With in 1 hour after birth or as soon as

possible after birth when clinically stable.

• Vit.K prophylaxis: 1 mg of Vit.K (IM) after birth to prevent

hemorrhagic conditions.
EBP on newborn Contd…

2. POSTNATAL CARE:

• Timing of discharge from the health facility: after 24 hours in

uncomplicated vaginal birth.

• Timing and no. of postnatal contact:

• At least three additional postnatal contacts are recommended for all

mothers and newborns, with in 24 hours of birth ,on day 3 (48–72
hours), between day 7–14.
EBP on newborn Contd…

• Home visits in the first week after birth are recommended for care of the
mother and newborn.

• Assessment of the newborn in every PNC visit for sing of,

1)stopped feeding well, (2) history of convulsions,
(3) fast breathing, (4) severe chest in-drawing,
(5) no spontaneous movement, (6) temperature >37.5°C,

(7) temperature <35.5°C,

(8) any jaundice in first 24 hours of life, or yellow palms and soles at any
EBP on newborn Contd…

• Practice of exclusive breast feeding from birth until 6 moths of age.

• Keeping newborn warm:

• Delay in bathing: after 24 hours of birth
• Appropriate clothing: 1-2 layers more than adult
• Rooming-in

• Newborn immunization: single dose of BCG vaccine for all infants as

soon as possible after birth to 1 year of life.
 Possible MCQs

1. In Nepal neonatal mortality rate is, (According to NDHS 2016)

a. 21/1000 live birth
b. 22/1000 live birth
c. 31/1000 live birth
d. 32/1000 live birth

ANSWER: A

2. Major direct causes of neonatal death in Nepal is,

e. Birth asphyxia
f. Congenital malformations
g. Infections
h. Hypothermia

ANSWER: A
3.According to WHO four focused visit are done at …….months of pregnancy.
a. 2,4,8 and 9
b. 4,6,7 and 9
c. 4,6,8 and 9
d. 4,5,8 and 9
Answer: C

4. Which is the common type of anemia during pregnancy?

e. Aplastic
f. Iron deficiency
g. Folate deficiency
h. Vit. B12 deficiency
Answer: B
5. Which is the rare type of anemia during pregnancy?
a. Aplastic
b. Iron deficiency
c. Folate deficiency
d. Vit. B12 deficiency
Answer: A

6. Opthalmia neonatrum is complication of,

e. HIV/AIDS in pregnancy
f. Syphilis in pregnancy
g. Toxoplasmosis in pregnancy
h. Gonorrhea in pregnancy
Answer: D
7. Which of the following is the highest priority intervention before
resuscitating the newborn with birth asphyxia?
a. Suctioning
b. Collecting blood
c. Intubation
d. Initiating positive pressure ventilation
Answer: A
8. Reason behind administration of vitamin K injection to a newborn is;
e. The vit. K will protect newborn from developing jaundice
f. Vit.K helps to develop active immunity in a newborn
g. Newborns are deficient in Vit.K. So,this injection prevents them from abnormal
bleeding
h. Vit.K promotes the growth of bacteria in the newborn’s bowel
Answer: C
9. When performing nursing care for a neonate after a birth, which
intervention has the highest nursing priority?
a. Obtain a glucose test
b. Give the initial bath
c. Give the vit.K injection
d. Cover the neonates head with a cap
Answer: D

10. Physiological anemia during pregnancy is result of,

e. Increased plasma volume of the mother
f. Decreased dietary intake of iron
g. Decreased erythropoiesis after first trimester
h. Increased detoxification demands in the mother’s liver
Answer: A
 References
Ministry of Health, Nepal; New ERA; and ICF. 2017. Nepal
Demographic and Health Survey 2016;cited on 30 th
sept.2019:412.http://www.mohp.gov.np.
Shrestha DR. Reproductive health national and international
perspectives,3rd edition (2020).
http://www.nhssp.org.np/Resources/PPFM/Review%20of%20Aama%
20Surakshya%20Programme%20in%20Nepal%20-%
20January%202020.pdf
 https://
apps.who.int/iris/bitstream/handle/10665/259947/WHO-RHR-18.02-e
ng.pdf