Background
Method
Document identification and selection
Review process
Key areas | Review questions |
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1. The document
| • Purpose (what is the main purpose of the document?) • Type of document (is it a policy/strategy/planning document? Progress/assessment report? Training/guideline? • Focus on newborn or stillbirth or both (does it mention newborn, perinatal care explicitly?) • Geographic focus (what type of geographic area is the key focus of the document--National? Topography specific? Development region?) |
2. Document development
| • Process (what led to the formulation of this document? Why was the need felt to formulate this document?) • Developers (which department, section formulated it?) • Stakeholders (who were the stakeholders involved?) |
3. Values, definitions and language
| • Social or Medical focus (what is the key focus of the policy?) • Key perspective/approach in deciding to reach perinatal care (right based, woman-centered, gender, etc.) • Equity groups (have they targeted vulnerable groups or disadvantaged groups e.g. teenage mothers, scheduled castes/indigenous and ethnic minorities?) |
4. Health outcomes and health access
| • Prevention of stillbirths • Prevention of neonatal deaths • Access to care during pre-pregnancy, pregnancy, delivery, postpartum period |
5. Strategies for action
| • The strategies in providing perinatal and neonatal care such as at home, in community, and in health facility • Care across the continuum from pre-pregnancy to postpartum • Integration of perinatal and neonatal care with maternity and child survival and other interventions • Inter-sectoral collaboration, collaboration across departments • Other government departments and agencies involved such as UN, bi-lateral agencies, INGOs • Specific target groups |
Results
Perinatal survival—Low focus before 2000
Policies after 2000— ‘Newborn focused’ but low priority in addressing stillbirth
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National Policy on Skilled Birth Attendants, 2006 (Supplementary to Safe Motherhood Policy, 1998, [29];
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National Safe Motherhood and Newborn Health Long Term Plan (2006–2017) [27];
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Mother’s Protection Program-Implementation Guideline, 2013 (revision on Safe Delivery Incentive Guideline, 2007 and 2009, [30];
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Maternal and Perinatal Death Surveillance and Response (MPDSR) Guideline, 2014 [31] and;
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Community Based Integrated Management of Neonatal and Childhood Illness (Program Management Module, 2015) [32].
National Neonatal Health Strategy, 2004
The policy recognized the strength of addressing problems in mothers and babies’ health in a continuum:Every vulnerable Nepali newborn has the greatest right to be taken care of and therefore we have to immediately invest resources to improve their health and survival (p. ii) (Secretary, Ministry of Health and Population [Nepal])
Although it mentioned that priority should be given to remote and disadvantaged areas, it did not explicitly identify regional variation in neonatal death rates and did not provide any regional/ecological specific priorities. Hence, the significantly higher neonatal death rates in the mountain areas are not specifically highlighted, nor are mountain-specific strategies outlined to address them, except generally stating that priority should be given to remote and rural areas.The mother and her baby should be treated as one entity and to be successful; any range of interventions that seek to prevent perinatal and neonatal deaths must address both maternal and neonatal factors. (p.1)
The main policy intention remained focused on promoting institutional births and prevention of neonatal deaths during childbirth or shortly after birth. This policy also devised strategies to institutionalize provision of newborn care from Nepal’s healthcare system. To do this, the policy set neonatal care at four different levels: (1) home/community level, (2) primary healthcare level, (3) district hospital level and zonal, (4) regional and central hospital level (p. 12). It sets forth five key intervention areas related to birth registration; behaviour change engaging mothers, husbands and mothers-in-law; healthcare delivery by Skilled Birth Attendants (SBAs); ensuring supplies and logistics; and research in areas of quality of care including verbal autopsy studies (pp. 4–7).… proven interventions addressing causes of maternal and neonatal complications at family and community levels will be the primary focus for immediate impact. These interventions will require the establishment of a chain of care linking families and communities with the health system. (p. 2)
National Policy on skilled birth attendant, 2006
The policy stood on the research evidence that improving access to skilled attendants at birth prevents a large proportion of maternal and neonatal deaths. Citing the Nepali context where the majority of women were still giving birth at home, the policy explicitly conflated skilled attendance with institutional births and treatment of obstetric complications.… it is important to encourage women to deliver in facilities with skilled attendants with access to Emergency Obstetric Care (EmOC). This will require 24 hours a day and 7 days a week, women-friendly services that are culturally sensitive and affordable to all families, especially those in poor and underserved areas. (p.1)
The policy also outlined the expansion of birthing units in health institutions, and encouraged NGOs and communities to establish community based birthing units at the local level (pp. 8–9).The SBA will work in close partnership with other essential health care providers at community level and be supported and guided by a strong District Health Team that has the capacity to deal effectively with emergency obstetric complications … . Secretary of Ministry of Health and Population (p. i)
National Safe Motherhood and newborn health long term plan (2006–2017)
Another difference of this document from previous documents is that this document acknowledged the role of multiple sectors to ensure equity and access to care in maternal and newborn health:Equity issues in access and utilization of safe motherhood and neonatal health (SMNH) services are not mentioned in the original NSMLTP and are of critical importance if the most needy members of society are to be targeted and the MDGs achieved. (p. 2)
The plan also duly recognized the needs of women to be understood in complex social contexts:Since safe motherhood and newborn health are not purely health issues, they warrant a multi-sectoral approach and the role of other sectors is particularly important in enhancing access and promoting equity. (p.1)
The plan set eight strategic outputs to ensure progress in the health of mother and babies. These were: equity and access; delivery of quality maternal and newborn care; public private partnership; decentralization; and human resource development, mainly focusing on training of SBAs; information management; physical asset management and procurement; and finance such as financial safety nets. The plan also emphasized the need to understand local knowledge about the context of maternity and newborn care:The needs of women are treated as paramount throughout the NSMNH-LTP, not simply as individuals, but as members of families and communities.
The plan identified access in a broad sense that would consider not only physical and financial access but also the cultural and behavioural aspects of service providers:Activities will advantageously use local knowledge, perceptions and values, relevant traditional practices, preferences and beliefs to enhance knowledge and awareness and will be sensitive to conflict issues. (p. 7)
The service delivery output of the plan emphasized reaching socially excluded groups, and encouraged the 24-h availability of skilled staff and district-specific strategies to increase service access:Access embraces financial, institutional and infra-structural factors including, but not limited to, funding, transportation and education. It also relies upon positive and welcoming service provider attitudes, trust, honesty, responsiveness, accountability and quality service delivery both at established facilities and through outreach programmes. (pp. 7-8)
With regards to public-private partnerships, the plan sought increasing involvement of NGOs, private sector hospitals and academic institutions. In decentralization, the plan sought to ensure planning and supervising capacity with local government, ie the District Health Office and health institutions. Likewise, as a financial strategy, it sought to implement equity through creating financial safety nets for the poor and socially excluded. Regarding the information system, the plan highlighted collection and use of data according to ethnicity, caste and wealth.At service level, efforts to improve the effectiveness of the system will focus on ensuring 24-hour availability of skilled staff with essential drugs and equipment, good community and inter-facility linkages and feedback systems to promote further improvements. Remote areas present an even greater challenge and require additional focused efforts, which will be covered by district specific strategies. (p.10).
Mother’s protection program, implementation guideline, 2013
This guideline expanded the concept of birthing units (pp. 23–25) by setting specific criteria. These criteria included physical infrastructure and space with one separate birthing room; equipment; living quarters (accommodation) for the SBA; 24-h presence of a SBA including support staff; good referral network; friendly behaviour towards the woman and her visitors and the respect of a woman’s privacy while giving birth. In addition, the guideline made it necessary to report monthly on the number of obstetric complications managed (p. 20). The new obstetric reporting form included reporting to the district and central department of neonatal deaths, stillbirths and babies resuscitated for asphyxia management by each health institution. To encourage registration of birth and deaths, the guideline made a provision for a provider incentive for home births only upon submission of the report of the either birth or the death registration of a baby.Mothers who came for four focused antenatal visits and also gave birth in health institution, will be provided rupees 400 [about 4 USD] from pregnancy and delivery incentive during discharge from health institution. (p. 6)
Maternal and perinatal death Surveillance and response (MPDSR), guideline 2014
Strategically, this document aimed at linking the information system with the quality improvement process at a health institution level. The purpose was to enable real-time monitoring of deaths and assessment of the interventions employed.:“MPDSR underlines the critical need to respond to every maternal and perinatal death, so that the information obtained from that death might be acted upon to prevent future deaths” (p. 3) … every death can provide information that can result in actions to prevent future maternal and perinatal deaths (p. 25).
The above statement identified notification of every death, but so far it prioritized notification and review of every maternal death occurring both at institutions and in communities; whereas, for perinatal deaths this applied only at institution level. Hence, it is likely to miss a considerable number of deaths occurring in communities, and more so in the remote mountainous areas which still have high perinatal deaths.The notification of every maternal and perinatal death also permits the measurement of maternal mortality ratios and perinatal mortality and the real-time monitoring of trends that provide countries with evidence about the effectiveness of interventions. (p. 3)
Community based integrated Management of Neonatal and Childhood Illness (program management module), 2015
Key values (approach, underpinning principles) | Strategies (strategic interventions) |
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National Neonatal Health Strategy 2004 | |
• Access to care and survival as the greatest right of every vulnerable newborn • Mothers and babies’ health in a continuum from pre-pregnancy to postnatal • A linkage of care across home, community and health institution • Gender equality in newborn care | • Focusing on proven interventions addressing causes of maternal and neonatal complications • Promoting institutional births and preventing newborn deaths during the process of childbirth or shortly after birth • Institutionalising provision of newborn care from Nepal’s healthcare system: (i) home/community; (ii) primary healthcare; (iii) district hospital; (iv) above the district hospital at zonal, regional and central hospital level • Setting forth five key interventions: (i) registration of all births and deaths; (ii) targeted behaviour change of women, their husbands and mothers-in-law; (iii) strengthening health service delivery—focus on SBAs, focus on postnatal care of mother and baby; (iv) service management--mainly about ensuring supplies and logistics; (v) and research focussing on quality of care, and verbal autopsy |
National Policy on Skilled Birth Attendant, 2006 | |
• Women-friendly services that are culturally sensitive and affordable to all families, especially those in poor and underserved areas | • Pregnancy and birthing care by an Skilled Birth Attendant [An accredited health professional such as a midwife, doctor or nurse] • Focus on (i) production of SBAs by in-service training and incorporating SBA skills in pre-service curricula of ANM, SN and Doctor training; and (ii) deployment of SBAs to health institutions • Availability of 24 h a day, 7 days a week emergency obstetric care in a close partnership with health workers other than SBAs • Encouraged NGOs and communities to establish community based birthing units • SBA to be supported by: strong referral back-up by a district health team, including supportive supervision; effective partnerships with other health workers, volunteers and TBAs, safety and security |
National Safe Motherhood and Newborn Health Long Term Plan (2006–2017) | |
• Equity and women centred care • Equity in access and utilisation of health services for newborn babies including safe motherhood services among the needy • Access embracing financial, institutional and infra-structural factors including, but not limited to, funding, transportation and education; and positive and welcoming service provider attitudes, trust, honesty, responsiveness, accountability • Multi-sectoral approach as underlying value to address Safe Motherhood and Maternal and Newborn Health (SMNH) issues; the role of other sectors is particularly important in enhancing access and promoting equity • Women understood not simply as individuals, but as members of families and communities functioning within complex relationships and social expectations | • Eight strategic outputs to ensure progress in the health of mother and babies: (i) Equity and access: empowerment of individuals, groups and networks with the maternal and newborn care related Behaviour Change Communication (BCC) messages and promotion of birth preparedness and non-discriminatory interpersonal communication between providers and clients; (ii) Delivery of quality maternal and newborn care: 24-h availability of skilled staff with essential drugs and equipment, good community and inter-facility linkages and feedback systems; (iii) Public-private partnership; (iv) Decentralisation: planning and supervising capacity of District Health Office; (v) SBA training; (vi) Information management: collection and use of data according to ethnicity, caste and wealth; and supplement quantitative with qualitative information from; (vii) Physical asset management and procurement; and (viii) Finance such as safety nets for poor and socially excluded |
Mother’s Protection Program, Implementation Guideline, 2013 | |
• Ensure the right to health as a fundamental constitutional right of every citizen in accordance with the provision of Nepal’s interim constitution 2006 • Financial incentives to improve health outcomes, providing incentives to encourage women to come to institution to have their babies as well as pregnancy check-ups | • The intention of the policy is clear on promoting institutional birth by allocating incentives to women to come to institutions for pregnancy check-ups and birthing; to service providers to motivate them to provide birthing care at institutions; and to health institutions to encourage them to strengthen birthing and emergency obstetric care • Expands the concept of birthing units by setting specific criteria such as separate birthing room, living apartment for SBA, equipment, 24-h presence of a SBA including a support staff, good referral network, friendly behaviour to woman and her visitors, and the respect of a woman’s privacy • Obstetric reporting to the district and central department of neonatal deaths, stillbirths and babies resuscitated for asphyxia management by each health institution. • Birth or the death registration of a baby, providers receive incentive of home births only if births or deaths are registered by parents |
Maternal and Perinatal Death Surveillance and Response (MPDSR), Guideline 2014 | |
• Value of a life of every mother and every baby; every death can provide information that can result in actions to prevent future maternal and perinatal deaths • Self-reliant and sustainable approach to the improvement of healthcare for women and their babies | • Linking the information system with quality improvement process at a health institution level; real-time monitoring of deaths and assessment of interventions employed. Two main focuses are on: (i) Notification of every death, and (ii) review for further actions to prevent future deaths |
Community Based Integrated Management of Neonatal and Childhood Illness (Program Management Module, 2015) | |
• Reaching care to disadvantaged and marginalised groups • Provision of quality care through a single integrated package of interventions for newborn and under-five children • Community based care | • Takes into it the lessons from CBNCP, and merges the package with IMCI--thus making a single package for managing newborn and all under-5 years old children’s health problems • Despite the community based in its title, still focuses mainly on promotion of institutional births and strengthening of quality of care from health institutions to prevent neonatal deaths • Focus on strengthening the capacity of institutions to manage and treat newborn babies’ complications such as infection, asphyxia and low birth weight • Added a component which describes treatment of baby’s cord infections by using an antiseptic ointment, chlorhexidine • Does not consider management of asphyxia as local health volunteers’ job, which however was considered in previous version—the Community Based Newborn Care • Envisioned developing one to two birthing centres per district to ensure quality referral care for newborns with complications |
Discussion
Agenda setting | What is going on in policy discourse | Policy considerations (questions) to ask during future policy making |
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Prevention of stillbirths | ||
Still not an agenda in policy making, low competing priority | Intention to begin to report stillbirths (occasional statements), but not yet focussed | • Is the technical/epidemiologic separation of stillbirths and newborn death having any social implications? Has this influenced realization of seeing mother and baby as a single unit in any way? Has it affected district/primary healthcare level, how? • Has perinatal survival been considered as an agenda of health promotion, and if so, what could that mean? • Have the policy approach/strategies been community based, empowering individuals and communities, or merely focussed on attempting to correct health behaviours? • Does policy community and implementing units need further realization that perinatal survival is not just a medical issue? • Have health systems (primary health care) been considered to leverage delivery of perinatal healthcare in developing countries? Or are the programmes being implemented just as vertically based technical packages? |
Neonatal Survival | ||
An agenda in policy, healthcare system, but pre-dominantly viewed as a vertical technical/medical initiative | Intention to integrate newborn in child and maternal health within health sector |