Tobacco and Health: World No tobacco day 31st May

Tobacco and Health: World No tobacco day

31^st May is celebrated as world no tobacco day. This year the slogan for world no tobacco day 2016 is “Get ready for plain packaging”. WHO and the secretarit of the WHO framework convention on tobacco control are calling countries to get ready for plain packaging of tobacco products. This slogan intends to make marketing strategy somewhat ineffective by advocating plain packaging of the tobacco products.  

Why Plain Packaging?

Plain packaging of tobacco products is a significant demand reduction measure. It reduces the attractiveness of tobacco products, restricts use of tobacco packaging as a form of advertising, limits misleading packaging and labeling and increases the effectiveness of health warnings. It can act as a measure of tobacco control.

Why should marketing of tobacco be controlled?

Tobacco is a notorious substance, which contains addictive nicotine making one physically dependent upon it. It also contains several other chemicals that almost affect every organ of the person. Tobacco can be taken in several forms. Smoking is very popular way of inhaling tobacco. Dried tobacco leaves are mainly used for smoking in cigarettes, cigars, pipe tobacco, and flavored shisha tobacco (waterpipe tobacco). They can be also consumed as snuff (powdered tobacco leaves is sniffed through nose), chewing tobacco, dipping tobacco and snus (khaini). This addictive tobacco has many deleterious effects on Health ranging from chronic conditions to cancer.

Tobacco and its deleterious effect on Health

In 2008, the World Health Organization named tobacco as the world's single greatest cause of preventable death.

Smoking has established relationship with lung cancer long ago in twentieth century. Smokers are more likely than nonsmokers to develop heart disease, stroke, and lung cancer. Smoking is estimated to increase the risk for coronary heart disease and stroke by 2 to 4 times and developing lung cancer by 25 times in both men and women.

Smoking can cause lung diseases such as COPD including emphysema and chronic bronchitis by damaging airways and the small air sacs (alveoli) in the lungs. Smoking can act as trigger for asthma attack. Even people who smoke fewer than five cigarettes a day can have early signs of cardiovascular disease.

It can cause cancer almost anywhere in the body:

• Bladder
• Blood (acute myeloid leukemia)
•  Cervix
•  Colon and rectum (colorectal)
• Esophagus
• Kidney and ureter
• Larynx
• Liver
•  Oropharynx (includes parts of the throat, tongue, soft palate, and the tonsils)
• Pancreas
• Stomach
• Trachea, bronchus, and lung

Smoking also increases the risk of dying from cancer and other diseases in cancer patients and survivors. Smoking harms nearly every organ of the body and affects a person’s overall health. Smoking causes diminished overall health, increased absenteeism from work, and increased health care utilization and cost.

Smoking reduces the fertility capacity of both men and women and if a woman smokes during her pregnancy, she mightn’t have healthy pregnancy. There is an increased risk of Preterm delivery, Stillbirth, Low birth weight, Sudden infant death syndrome, Ectopic pregnancy, Orofacial clefts in infants with smoking. Smoking affects the health of teeth and gums and can cause tooth loss. Smoking is also one of the causes of type II diabetes mellitus and can make it harder to control. The risk of developing diabetes is 30–40% higher for active smokers than nonsmokers. Quitting smoking cuts risks of various diseases. Ten years after quitting smoking, risk for lung cancer drops by half.

Many people are not aware of such harmful effects of smoking and its intensity and amplitude of those detrimental effects and they continue using tobacco products. However, It is believed by the tobacco industry that smokers are adequately informed of health risks of smoking. However, there is significant gap in knowledge of health risks. Health warnings on tobacco products are a primary means of communication with smokers regarding risk of tobacco use. Similarly this approach of plain packaging could play in vital role in reducing the ludicrous desire towards tobacco products due to its attractive outlook.

A message!!

Even though we celebrate one World No tobacco day. Lets work together to make all the days a year No tobacco day. We can make many healthy and may be lung cancer become once again rare disease in the world.

Sources:

Centers for Disease Control and Prevention. Smoking and tobacco Use: Health Effects of Cigarette Smoking.  Accessed from: http://www.cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/effects_cig_smoking/ on 30 May 2016.

Robert N Proctor. The history of the discovery of the cigarette–lung cancer link: evidentiary traditions, corporate denial, global toll. Tob Control 2012;21:87-91 doi:10.1136/tobaccocontrol-2011-050338

D Hammond, G T Fong, A McNeill, R Borland, K M Cummings. Effectiveness of cigarette warning labels in informing smokers about the risks of smoking: findings from the International Tobacco Control (ITC) Four Country Survey. Tobacco Control. 2006;15(Suppl III).

WHO. World No Tobacco Day 2016: Get ready for Plain Packaging. http://www.who.int/campaigns/no-tobacco-day/2016/en/

Aama Program of Nepal

Aama Programme of Nepal

Aama programme is currently one of the important strategic approaches to achieve safe motherhood. This element is a way to achieve the strategy of national safemotherhood and newborn programme of Nepal to reach its goals and objectives.

The strategies of safe motherhood are:

• Promoting birth preparedness and complication readiness including awareness raising and improving the availability of funds, transport and blood supplies.
• Encouraging for institutional delivery.
• Expansion of 24‐hour emergency obstetric care services (basic and comprehensive) at selected public health facilities in every district.

It is basically a financial incentive scheme meant to assist women and her family financially for child bearing. This scheme first came as maternity incentive scheme. Maternity incentive scheme later evolved into Aama program in 2009. Under this scheme, certain amount of money is provided to women, health institutions and health workers in order to enable women to access health care and to encourage health care workers to provide quality care. This can also be termed as demand side financing.

Timeline

In 2005: Maternity incentive scheme (MIS): It provides specified incentives to women as a travel cost based on geographical region to deliver in health facilities in order to improve their health outcomes and those of their babies.

In 2006: MIS was renamed as the safe delivery incentive programme (SDIP)

In 2009: SDIP was further evolved into Aama Program, which comprises i) free institutional delivery care, characterized by the removal of user fees for all types of deliveries. (health centers provide the service free of charge and reimburse the amount of money later) and ii) the safe delivery incentive programme (SDIP), a cash incentive to women and care providers, which was initiated in 2005.

In July 2009: Aama Program also incorporated incentive to women, who completes 4 ANC visits and delivers their babies at health institutions and completes one postnatal visit.

Initiation

The Aama Programme was introduced to reduce financial barriers to women seeking institutional delivery. It aims to increase the number of institutional deliveries and thereby reduce maternal morbidity and mortality. The Aama Programme has evolved and matured over the years.

Factors for Initiation

  Number of factors played role in initiating Aama Program. Following are the major factors:

• Major financial support from UK, DFID: Prioritized safe motherhood
• Political commitment: government had a commitment to providing tangible benefits to the population.
• High cost of deliveries to household impeding institutional delivery

 

The Aama program is currently functioning in 1000 health institutions in the public sector, ranging from central hospitals to peripheral level health facilities. In addition it has started to enroll most not-for-profit institutions [community, mission and non-governmental organization (NGO)-run hospitals].

Cash payment to women	Incentives to the health facility	Incentives to health workers
For institutioonal delivery (ID): NPR 1,500 in mountain districts NPR 1,000 in hill districts NPR 500 in Tarai districts	NPR 1000 if <25 beds for a normal birth NPR 1500 if >25 beds for a normal birth NPR 3000 for a complicated birth NPR 7000 for a caesarean section (This amount includes the cost of drugs, supplies, instruments and the incentive to the health worker, and can be spent at the discretion of the health facility management committee)	NPR 300 per delivery at a health facility, paid out of reimbursement NPR 100 per delivery assisted at home (This has been reduced to promote institutional delivery) (The provider incentive (NPR 100) for attendance at home deliveries requires a birth registration form as proof that the health worker was in attendance)
NPR 400 will be given to woman if she attends 4 ANC visits at within first 4 months, Second visit: 6 months Third visit: 8 months Fourth visit: 9 months And must have an institutional delivery

Impact of AAMA programme:

Motivates mother and family for institutional delivery

Management of complications on time when they have institutional delivery

Reduce the cost of delivery care to households

Reduces the risk of catastrophic expenditure

Increases Antenatal care, thus helping in identifying the high-risk pregnancy early and allowing time to prepare mother and family for safe delivery

Decreases maternal mortality and morbidities

Lowers neonatal deaths and morbidities

A long way to go through: Critical Analysis:

There are no two opinions that it has played crucial role in increasing uptake of institutional delivery. Over 10 years from 1996 to 2006, the percentage of deliveries in a health facility in Nepal increased from 7.6% to 14%, and by 2009 this had further increased to 22.5%. The Aama programme has contributed to this increase, alongside many other policies including the earlier SDIP, training of SBAs and community factors, such as increased female education.

Aama program is a blanket approach; it provides specified amount of money to women based on geographical region regardless of their socioeconomic status.

Strengthening the capacities of existing health facilities is equally vital and must be identified by all the stakeholders, when the women and the newborns develop any complications, they should have all the capacities to manage it and efficient referral system that won’t delay their management.

Currently, there are 80 MOHP facilities in 53 districts that are able to provide basic emergency obstetric care services (BEOC), including complications not requiring surgery. In addition, there are 46 MOHP facilities in 33 districts able to provide comprehensive emergency obstetric care (CEOC) including caesarean sections (MOHP 2010). There should be expansion of BEOC and CEOC services even at the grass root level to the extent possible.

As the health centers are provided fixed amount of money per case, there is possibility that they tend to reduce the hospital stay and the indicated interventions. However on other side this might check unnecessary interventions that could have practiced if the fee for service payment system was existent.

The coverage of institutional delivery and skilled birth attendants remains low. The Skilled Birth Attendance Policy of 2006 has set a target of 60% of births to be attended by a trained health worker by 2015. However, according to Safe motherhood findings from Nepal Multiple Indicator Cluster Survey 2013, the percentage of skilled birth attendant at delivery is 55.6% and the percentage of Institutional deliveries is 55.2%. This clearly shows that we are halfway to the universal coverage of institutional delivery and skilled birth attendants indicating many women and newborns at risk while child bearing.

To reinforce this, in 2010, a Safe Motherhood Bill was drafted, which defines the rights of women to quality reproductive health care and maternal and newborn health care, and provides a legal framework, with accountability mechanisms, to enable them to exercise these rights.

To download national policy on skilled birth attendants: Click here

Sources:

• Bhusal CL, Singh SP, BC RK, Dhimal M, Jha BK, Acharya L, Thapa P, Magar A. Effectiveness and Efficiency of Aama Surakshya Karyakram in terms of Barriers in Accessing Maternal Health Services in Nepal. J Nepal Health Res Counc 2011 Oct;9(19):129-37
• Upreti SR; Baral SC; Tiwari S; Elsey H; Aryal S; Tandan M; Aryal Y; Lamichhane P; Lievens T: Rapid Assessment of the Demand Side Financing Schemes: Aama programme and 4ANC, 2012. Ministry of Health and Population; Nepal Health Sector Support Programme and HERD, Kathmandu, Nepal
• Baral G. An Assessment of the Safe Delivery Incentive Program at a Tertiary Level Hospital in Nepal.  J Nepal Health Res Counc 2012 Jan;10(20):118-24
• Department of Health Services. Annual Report. 2068/69.
• Ministry of Health and Population. National policy on skilled birth attendants. 2006. Nepal.
• Sophie Witter, Sunil Khadka, Hom Nath and Suresh Tiwari. The national free delivery policy in Nepal: early evidence of its effects on health facilities. Health Policy and Planning 2011;26.

Safe Abortion Policy in Nepal

Safe Abortion Policy in Nepal

In the past before enactment of safe abortion law in Nepal, many women were incarcerated for different durations for abortion related crimes as the act of abortion was considered a criminal act in Nepal before its legalization in March 2002. The bill received Royal Assent in September 2002 with the Procedural Order enabling the implementation of the new law receiving final approval in December 2003. First safe abortion was carried out in 2004. (Note: Procedural Order authorizes the implementation of legal services and specifies the required conditions and framework before final parliamentary approval)

The Muluki Ain 1854, the basic legal code for the kingdom of Nepal, prohibited and characterized abortion as an offense against life, making no exception even when pregnancy threatened a woman’s life. Jail punishment of 1 year, 3years or 5 years for committing abortion with pregnancy of 12 weeks, 25 weeks and beyond 25 weeks respectively was provisioned in the Muluki Ain. The revision in 1963 banned abortion except when the woman’s life was at risk. Up to one-fifth of women in Nepali prisons before 2002 were convicted on the basis of illegal abortion, with many branded as murderers (homicide).

Even though the new abortion law legalized the abortion under specified conditions, the ingrained fear and stigma still prevails in the society and many women are still terminating pregnancy by unskilled persons to maintain privacy and secrecy. Nonetheless, legalization of safe abortion in Nepal in 2002 has gradually paved its way in our nation. 

First National Safe Abortion Day was celebrated on 26th September 2015 in Nepal. Safe abortion care is integrated in safe motherhood program of Nepal to make it more accessible and acceptable. Safe abortion service is scaled up in all the districts up to primary health care center level (PHCC).

Abortion law:

The new law legalizes abortion under the following conditions:

·      Up to 12 weeks of gestation on the request of the pregnant women.

·      Up to 18 weeks of gestation in case of rape or incest.

·      At any gestation if the pregnancy is detrimental to the pregnant women's physical and mental health as certified by an expert physician.

·      At any gestation if the fetus is suffering from a severely debilitating or fatal deformity as certified by an expert physician.

·      Listed medical practitioners will provide comprehensive abortion care services.

·   Only the pregnant woman holds the right to choose to continue or discontinue the pregnancy. If the pregnant woman is less than 16 years of age or not in a position to give consent (mentally incompetent), the nearest guardian or relative can give consent for abortion services.

·      The law prohibits termination of pregnancy of any gestation for the sole purpose of sex selection and there is provision of punishment to parties, care provider and the individual doing abortion if this is done with sole purpose of sex selection.

Picture 1: Nepali Safe Abortion Logo

All the pregnancy doesn’t end into a viable baby. From the period of conception to the full term of the pregnancy, various outcomes might occur. One of the outcomes of the pregnancy is abortion. Abortion might be induced or spontaneous. Many women conceive unwanted and untimely pregnancy as they lack comprehensive knowledge to practice contraceptives and they will be obliged to induce abortion. Likewise ignorance, unavailability and inaccessibility of contraceptive services, failure of contraceptives force many couple to have induced abortion. Unlike the past period when the fertility was very high and joint family was almost universal, nowadays our desire of children is determined by the decreasing fertility trend. There is a social pressure to small family norm and having a child is economically challenging as well as the steep childcare cost and women’s involvement in the formal employment sector equally pressurize the need of small family size demanding careful family planning and contraceptive utilization.

We must celebrate the national and international commitment to make abortion care accessible to its citizen in short span of time after legalization of abortion through the efficient utilization of existing health workers such as staff nurses and ANMs as service providers in the health system. Legalization of safe abortion has certainly played pivotal role in decreasing pregnancy associated mortality and morbidity, reducing fertility and alleviating many other complications. However, Abortion shouldn’t be used as a method of contraception and family planning. It is not totally free of adverse effects. Occasional hemorrhage, accidental uterine injury, infections and stress and anxiety may deteriorate women’s health sometimes. Abortion is an option but not the solution. Effective use of contraceptives, its easy availability and accessibility assist in averting many abortions and its complications.

What is unsafe abortion?

An unsafe abortion is “a procedure for terminating an unwanted pregnancy either by persons lacking the necessary skills or in an environment lacking the minimal medical standards, or both” (World Health Organization 1992). About 20 million, or nearly half, of the induced abortions annually are estimated to be unsafe. As opposite to unsafe abortion, safe abortion is a medical intervention to terminate the pregnancy by skilled trained health care professional in a well-equipped environment meeting all the minimal medical standards.

Why right for Safe abortion is required?

·      Every year 22 million unsafe abortions occur in the world, resulting in the death of an estimated 47000 women and disabilities for an additional 5 million women (Source: Safe abortion: technical and policy guidance for health systems, WHO 2012).

·      Everyone is entitled to sexual and reproductive rights.

·      Clinical indications like

o   Genetic abnormality in the fetus

o   Gestational

o   Cardiovascular diseases such as sever hypertensive disorders

o   High risk of uterine injury

o   Trophoblastic disease

o   End-stage cacers, end stage AIDS

o   Rupture of membranes befor fetal viability

o   Intrauterine infection

What are the consequences of unsafe abortion?

When the abortion was not legalized, it was difficult to estimate the maternal mortality related to abortion. However, many of the deaths were associated with unsafe abortion. Many of the deaths and complication might have gone undocumented.

The common complications following unsafe abortion are Hemorrhage, infection, sepsis, trauma, necrotic bowel, poor wound healing, infertility, consequences of internal organ injury (urinary and stool incontinence from vesicovaginal or rectovaginal fistulas and bowel resections), phychologic damage

Concept of reproductive health rights

International Planned Parenthood Federation (IPPF) recognizes and believes that the right to decide whether or when to have children is implied by the right that all persons have, to decide freely and responsibly the number and spacing of their children and to have access to the information, education and means to enable them to exercise this right, and further recognizes that special protection should be accorded to women during a reasonable period before and after childbirth, and, therefore, commits itself to the following: (IPPF Charter on Sexual and Reproductive Rights, 1996)

1. All women have the right to information, education and services necessary for the protection of reproductive health, safe motherhood and safe abortion and, which are accessible, affordable, acceptable and convenient to all users.

2. All persons have the right of access to the widest possible range of safe, effective and acceptable methods of fertility regulation.

3. All persons have the right to be free to choose and to use a method of protection against unplanned pregnancy, which is safe and acceptable to them.

Reproductive rights, according to the ICPD, "rest on the recognition of the basic right of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children and to have the information and means to do so, and the right to attain the highest standard of sexual and reproductive health." There should be equality of men and women with regard to "the same rights to decide freely and responsibly on the number and spacing of their children, and to have access to the information, education and means to enable them to exercise these rights." Reproductive rights, according to the ICPD, also include the right "to make decisions concerning reproduction free of discrimination, coercion and violence, as expressed in human rights documents."

Sources:

Lisa B Haddad, Nawal M Nour. Unsafe Abortion: Unnecessary Maternal Mortality. Rev Obstet Gynecol. 2009; 2(2): 122–126.

Family Health Division, Department of Health Services, Ministry of Health and Population. National Safe Abortion Policy. Final Draft, August7, 2003

 Ghazaleh Samandari, Merril Wolf, Indira Basnett, Alyson Hyman, Kathyryn Andersen. Implementation of legal abortion in Nepal: a model for rapid scale-up of high-quality care. Reproductive Health.2012. 9:7.

Center for Research on Environment Health and Population Activities (CREHPA): Women in Prison in Nepal for Abortion: A Study on Implications of Restrictive Abortion Law on Women’s Social Status and Health Kathmandu; 2000.

Essentials of Safe motherhood

How can we make motherhood safer? 

This is actually food for thought if you are determined to contribute in making motherhood safer or if you are working in such field. A mother will give birth to a healthy child without adverse events, if the mother herself is healthy. 

Pillars of safe motherhood: 

Motherhood can be made safe when some interventions are carried out. These are termed as pillars of safe motherhood. These pillars are essentials to achieve safe motherhood. Safe motherhood is founded on those elements. The pillars that supports safe motherhood are 1. family planning 2. Antenatal care 3. obstetric care 4. Post natal care 5. Abortion care 6. STD/HIV control. This can be achieved when women’s basic rights are granted and when primary health care is available for everyone. 

Figure 1: Pillars of Safe motherhood

First of all let’s glance into a story, there was a girl named Rita in a rural area of Nepal. Her parents were only literate. They didn’t have knowledge of healthy behavior, nutrition. She already had few other siblings. She was wasted. Her mother served them with staples whatever they had, mainly carbohydrates. They used to harvest black gram but they traded it for rice. They could have served that pulse but they weren’t aware of its importance. They just thought their children shouldn’t be hungry. When Rita reached the age of seventeen, they married their daughter with a young boy from neighborhood. Rita became pregnant within one year. She had short stature, She was very thin, and anemic. They had a sub-health post nearby but the in-charge was unavailable most of the time and they didn’t know they had to go to health center regularly for checkups during pregnancy. After some months she went in labor pain and she suffered prolonged labor, as they weren’t prepared to take her any health center, they just waited at home. Finally a baby boy was borne, who had low birth weight. However, she had post partum hemorrhage and she was hurried to the district hospital. It was very late. Nonetheless, the hospital had good provision of blood transfusion and the Red Cross had adequate blood of her group. At least they saved her life with proper management.

A house will be strong, if its foundation is solid, and if the bricks we add one after another are strong enough. A seed has to be planted in fertile land and when the seed sprouts, we need to water it and add the manure to make it strong and healthy and it will produce healthy seeds in the future. In the aforementioned scenario, there are many pit falls and the girl suffers a lot and she gives birth to a low birth weight child putting at more risk of infection. she got teenage marriage and subsequent pregnancy because of her family and the community, she couldn't have antenatal care because of her own ignorance, unavailability of health care providers. It was her good luck she survived the childbirth because of emergency obstetric care. Nonetheless her health and health of the baby is still at risk due to lack of continuum of care.

What is Continuum of care? 

The concept of continuum of care is an approach to integrate the care that a woman should receive to have safe motherhood or safe childbirth. The "Continuum of Care" for reproductive, maternal, newborn and child health (RMNCH) includes integrated service delivery for mothers and children from pre-pregnancy to delivery, the immediate postnatal period, and childhood. Families and communities, outpatient services, clinics and other health facilities, should provide such care. The Continuum of Care is very important for the health of the both women and the newborn child. 

There are two dimensions of continuum of care: 

1. Stages of the life cycle (Time): In simple language this is continuous care that a woman should get in her lifetime at every stage of life from her own family, community and health facilities.
 

Adolescence and Pre-pregnancy: Lets start with adolescence; adolescence is the stage at which boys and girls develop secondary sexual characteristics and is an important phase to establish healthy behavior. Adolescents should get all the information about reproductive health including contraceptives, conception, and sexual education, sexually transmitted diseases. They need to have proper nutrition for their proper development and maturity. They need to be well equipped with everything to be ready to be pregnant. They should be well informed about healthy behavior, childcare, child bearing, health care centers. They should be ready economically. They need to have good support system. 

Pregnancy: when a woman is pregnant, she needs to have support from her family, health care centers. Adequate and appropriate antenatal care from the health center and adequate nutrition supplementation, rest, birth preparedness are required during pregnancy. Birth: the current safe motherhood policy encourages institutional delivery by skilled birth attendants. Transportation facilities from home to health center, skilled health workers, blood transfusion services, facilities for complicated pregnancy, everything should be in place to ensure uneventful birth. This should be provisioned for every pregnant woman. 

Post natal period of mother: Adequate care should be provided during post natal phase of the mother so that she could take care of the baby and the family as a whole. Information and counseling about he contraceptives is equally important to women and her family.

Like wise care during neonatal period, infancy and childhood is very crucial as these are directly linked with future stages of life.

2. Places where the care is provided:

With respect to the place-of-care dimension of the continuum, MNCH interventions can be delivered:

• at a household and in a community – community level/home services;
• through outreach from first-level facilities (includes immunization, antenatal, postnatal care delivered from/at village health posts) – first level/outreach services;
• at district hospital or referral hospitals – referral level services (includes diagnostics, treatment, care, counseling and rehabilitation).

 
There should be continuity of care at different place linking the various levels of home, community, and health facilities.  Linking interventions in this way is important because it can reduce costs by allowing greater efficiency, increase uptake and provide opportunities for promoting related healthcare elements (e.g. postpartum/postnatal and newborn care).

RMNCH continuum of Care showing the stages and places to link to achieve safe motherhood.

Safe Motherhood Program in Nepal: Evolution and Impact

Safe Motherhood Program: Evolution and Impact in Nepal

Safe motherhood program is one of the much talked and focused program for Nepal and is a priority for the government of Nepal’s Health sector Strategy. Many mothers died in past while giving birth to their children. Back in 1996, as per the data of Nepal family health survey, 539 women died out of one lac live births due to child bearing and many suffered other complications like fistula, Prolapse. Women, in Nepal, were like birth machine back in the time even when the maternal mortality in Europe and America was decreasing rapidly. Total fertility rate of Nepal was very high. During 90s decade women were likely to have more than four children in their lifetime. Unsafe abortion was another dark side of maternal health. Before the legalisation of safe abortion in 2002, many maternal deaths might have gone unnoticed and underreported.

Women’s health was in dire condition demanding immediate attention to it.  If we compare today’s condition to the past when our mothers were at high risk of maternal mortality and morbidity, we must applaud the effort of our policy, our policy makers, program implementers and health care professionals, advocacy and investment from governmental and non-governmental agencies. Today we have total fertility rate of 2.1, many women will not have the risk of morbidity and mortalities related to multi-parity, we have policy to encourage institutional deliveries, we have health professionals skilled in birth procedure, contraceptives are easily available, Abortion is legalized. We have come very far from past perilous state of women’s health.

This evolution was possible due to safe motherhood initiative, which was a result of the first international Safe Motherhood Conference in Nairobi jointly sponsored by WHO, UNFPA and the World Bank in February 1987. 

This initiative consolidated the attention and action of all the governmental and international sectors for improving maternal health. When women’s health advocates like Allan Rosenfield, Deborah Maine presented the fact that the maternal health is highly neglected amid maternal and child health, maternal health got the momentum to move forward.

In the 1990s, a series of global conferences organised by the United Nations identified maternal mortality and morbidity as an urgent public health priority, and mobilised international commitment to address the problem. 

International Conference on Population and Development (ICPD) in Cairo in 1994 focused on the reproductive health right that also specifically addresses the women’s health. In 1995, the Fourth World Conference on Women (FWCW) in Beijing gave substantial attention to maternal mortality and reiterated the commitments made at the ICPD. In September 2000, 189 countries at the UN Millennium General Assembly in New York endorsed a series of Millennium Development Goals that aim to reduce poverty worldwide. One of the Millennium Development Goals is the reduction of maternal mortality by 75 percent between 1990 and 2015 and Nepal had the goal of reducing maternal mortality to 134 per one-lac live births by 2015. However,  the current mortality rate is 229 per one lac live births according to maternal mortality, and morbidity study 2008 of Nepal.

To continue the commitment made in millennium development goals, one of the targets in sustainable development goals is to reduce global maternal mortality ratio to less than 70 per 100,000 live births by 2030.

National safe motherhood program in Nepal was initiated in 1997 with the aim of reduction of maternal mortality and morbidities. This has been able to address the three delays, causing obstetric emergencies. The three delays are: i. delay in seeking care, ii. Delay in reaching care, iii. Delay in receiving care.

To reduce the risks associated with pregnancy and childbirth and address factors associated with mortality and morbidity three major strategies have been adopted in Nepal:

• Promoting birth preparedness and complication readiness including awareness raising and improving the availability of funds, transport and blood supplies.
• Encouraging for institutional delivery.
• Expansion of 24-hour emergency obstetric care services (basic and comprehensive) at selected public health facilities in every district.

After realizing newborn health is an integral part of maternal health, the National safe motherhood plan (2002-2017) has been revised and the revised Safe Motherhood and Neonatal Health Long Term Plan (SMNHLTP 2006-2017) guides our current actions and programs of safe motherhood. 

Some of the vital interventions under National safe motherhood programs in Nepal are:

1. BirthPreparedness Package and MNH Activities at Community Level

2. Uterine Prolapse

3. Human Resource

4. Emergency Referral Fund

5. Safe Abortion Services

6. Aama Program
7. Emergency Obstetric Care

(Note: I will be covering these topics in the future posts.)

Investment in maternal health not only reduced the maternal mortality and morbidity but also improved the children’s health. It is in fact most cost effective approach to improve health and well being of the population.

To download National Safe Motherhood Plan (2002-2017): click here

To download the revised Safe Motherhood and Neonatal Health Long Term Plan (SMNHLTP 2006-2017): Click here

 Sources:

1. Yagya B. Karki. Fertility Levels, Patterns,  Trends in Nepal. Chapter 12. http://cbs.gov.np/image/data/Population/Monograph_vol_1_2(1-10,11-21)/Chapter%2012%20%20Fertility%20Levels,%20Patterns%20and%20Trends%20in%20Nepal.pdf
2. Allan rosenfield, Deborah Maine. Maternal mortality- A neglected tragedy Where is the M in MCH. The Lancet. 1985. http://www.eldis.org/vfile/upload/1/document/0708/DOC18134.pdf
3. DS Mallla, K Giri, C Karki, P Chaudhary. Achieving Millennium Development Goals 4 and 5 in Nepal. BJOG. 2011.
4. MOHP. Annual Report 2069/70. Department of Health Services, Nepal
5. Carla Abouzahr. Safe Motherhood: a brief history of the global movement 1947-2002. British Medical Bulletin, Vol. 67. 2003.