Emergency Obstetric Care
The halving of maternal mortality in Nepal, between 1996 and 2006, from 539 to 281 deaths per 100,000 live births, was a huge achievement. However one woman still dies in childbirth every four hours. Efforts are still needed to make childbirth much safer.
Skilled birth attendance, as a part of quality Comprehensive Emergency Obstetric and Neonatal Care (CEONC) services, is critical to reducing the number of mothers dying during, or as a result of, child birth. Our Maternal Mortality and Morbidity Study of 2008/9 found that over 40% of maternal deaths occurred in hospitals, often as a result of inadequate or inappropriate treatment.
Recognising the importance of CEONC and the challenges faced by hospitals, we supported the Family Health Division to establish a national fund for CEONC services. This enabled the contracting of skilled providers for caesarean section (CS) services and the purchase of specialist equipment and supplies. These inputs benefited other national programmes such as skilled birth attendant training, public information campaigns and Aama (free delivery care and cash incentives for mothers to deliver in a health facility).
We also conducted a study on the readiness of health facilities for CEONC services. This covered 18 public sector CEONC sites across all five development regions and geographical zones. We carried out in depth interviews with district health managers and health workers. Secondary data was collected from maternity and operation theatre registers, the Health Management Information System (HMIS) and CEONC monitoring reports. The results led to recommendations on staffing, career progression for service providers, funding, infrastructure and the monitoring of CEONC services.
We supported the Ministry of Health to ensure that all CEONC districts had at least one obstetrician/ gynaecologist or general practitioner (MDGP), one or two advanced skilled birth attendants (ASBA - graduate doctors with CS training), plus an anaesthetics assistant and operation theatre nurse. We developed a career structure for MDGPs to make CEONC a more attractive profession for doctors, planned additional ASBA training and promoted the Diploma in Gynaecology and Obstetrics course. We also provided leadership and management orientation for hospital management committees, directors and managers.
Our Remote Areas Maternal and Neonatal Pilot (RAMP) project informed government plans for working in remote areas by identifying strategies to increase use of maternal and newborn health services. A study on costs and outcomes was also undertaken to examine whether to scale up to additional districts. In the remote district of Taplejung, we piloted a package of interventions to improve access to and use of maternal and neonatal health services at different health service levels.
- We ensured facilities were CEONC ready by upgrading them to the required standards, protecting budgets for repair and maintenance and improving re-supply systems.
- We improved the quality of monitoring data, including completion of maternal and perinatal death forms, in order to better inform decision making.
- We supported the appointment of a CEONC mentor to supervise and monitor CEONC providers in district hospitals, and create an environment to support the delivery of high quality CEONC services. This led to an increase in the availability of CS services from an average of six months to nine months per year.
- The RAMP project led to a significant improvement in ANC visits made at recommended times, from 25.2% to 47.8% of pregnant women. There was also a major increase in the institutional delivery rate, from 24.5% to 61.9%.
Skilled birth attendance increased from 45.3% in 2013 to 56.4% in 2015
In RAMP districts there was a significant increase in 4ANC visits made by pregnant women at recommended times from 25.2% to 47.8%
The institutional delivery rate in RAMP districts rose from 24.5% to 61.9%
Staff skills improved by 57% leading to 7 additional days per month when CS services could be provided