National Medical Standard For Maternal And Newborn Care-2022

 National Medical Standard For Maternal And Newborn Care (2022)
Volume III: Maternal and Newborn Care

Table of Contents

Executive summary

Ending preventable maternal and newborn mortality is a priority of Nepal's 2015 Constitution, National Health Policy 2019, Nepal Health Sector Strategy (NHSS, 2015-2020), the Right to Safe Motherhood and Reproductive Health Act (RSMRHA), 2075 (2018), and the Nepal Reproductive and Safe Motherhood Road Map 2030. To put these policies into action, every pregnant woman and newborn should have access to evidence-based standardised Antenatal Care (ANC), safe labor and childbirth, and Postnatal Care (PNC) delivered in a humane, respectful, and nondiscriminatory environment.

Women around the world frequently find mainstream maternal and newborn care unacceptable due to a perceived lack of respect, privacy, and confidentiality, as well as a fear of stigma and discrimination, particularly for vulnerable women. Because of their geography, ethnicity, wealth, education, and disability, these women are less likely to receive institutional maternal and newborn care.

Current Situation

According to the Nepal Demographic and Health Survey (NDHS) 2016, while 94% of health facilities across all provinces provided ANC, only 84% of women who had given birth in the five years preceding the survey had received ANC from a skilled provider, a 25% point increase since 2011. Sixty-nine percent of women had four or more ANC visits. The figures for care during labor and childbirth are even more concerning. Only 50% of health facilities nationwide provided normal vaginal delivery services (the lowest being 23% in Province 2 and the highest being 83% in Province 6). Skilled Birth Attendants (SBAs) performed 58% of the deliveries, and 57% of the deliveries took place in a health facility. Only 57% of mothers and newborns received a PNC check within two days of birth. Of the total number of pregnancies, 81% were live births, 9% were induced abortions, 9% were miscarriages, and 1% were stillbirths.

Rationale for Revision

In accordance with international goals, the Government of Nepal (GoN) seeks to improve the quality of maternal and newborn care at all levels of health care. Standard protocols and job aids at service delivery sites could reduce risks and improve care quality. There are numerous Reproductive, Maternal, Newborn, Child, and Adolescent Health (RMNCAH) standards and protocols in Nepal. However, several are out of date and do not fully align with other existing and emerging policies and strategies. Care standards must be updated on a regular basis to ensure evidence-based, high-quality care. WHO is the World Health Organization.

The GDG has recommended that standards, guidelines, and protocols be revised at least every five years. Reproductive health care in Nepal is provided in accordance with the three volumes of the National Medical Standards (NMS) on Reproductive Health Care. Volume I (1991) Contraceptive Services is intended to provide accessible, clinically oriented information to policymakers, district health officers, hospital directors, clinical supervisors, and service providers to guide the provision of reproductive health services. In 1991, the "National Medical Standard for Contraceptive Services" was published for the first time.  This was expanded and published as "National Medical Standard for Reproductive Health Volume I: Contraceptive Services" in 1995. It was revised and republished in 2001 and 2010 to accommodate new technology, and it is currently being revised again in 2020.

"National Medical Standard for Reproductive Health Volume II: Other Reproductive Health Issues" follows "National Medical Standard for Reproductive Health Volume I: Contraceptive Services." It was approved on January 8, 2004. This book serves as a standard reference document for essential clinical materials and tools that aid in patient care and service delivery on other reproductive issues. However, this volume has yet to be revised. Volume III, National Medical Standard (NMS) for Maternal and Newborn Care Volume III, was created in 2007 and revised once in 2009.

The international, regional, and national legislative and policy landscapes have changed since the first revision of NMS Volume III in 2009. Many continuing and emerging issues have shaped the context of maternal and newborn care over the last 25 years; additional areas will emerge over the next ten years, in which these transformative innovations will most likely have a profound impact.

 

Purpose and Objectives

An important component of this work was revising standards of care for maternal and newborn health services. The revised standards formed the basis of operating procedures for maternal and newborn service delivery in Nepal to achieve best practices. To align with WHO’s normative function a rigorous approach to revising standards has been followed: the existing published and grey literature has been reviewed and analysed, based on which a structure for WHO standards of care for mothers and newborns has been adopted.

 
Revision Process

Under the leadership of the Family Welfare Division (FWD) an expert team of four consultants, comprising a gynaecologist/obstetrician

and public health expert, paediatrician, anaesthesiologist, and nurse and midwife were involved for the revision process. A Technical Working Group (TWG) was identified. This was a joint effort by various stakeholders, partners and officials. The United Nations Children’s Fund (UNICEF) provided technical assistance in coordination with Nepal Health Sector Support Programme (NHSSP) and the

Simulation Society of Nepal (SSN). Peer review was done by the five professors from faculty of obstetrics and gynaecology, midwifery, paediatrics, and anaesthetics under the leadership of the Nepal Society of Obstetrics and Gynaecology (NESOG).On 17 January 2020 the first meeting was held, under the chairmanship of FWD, with the team of consultants, UNICEF, NHSSP, and WHO, to discuss the revision process of the existing National Medical Standard for Maternal and Newborn Care (NMS) Volume III 2009: Maternal and Newborn Care. The meeting agreed that:

1. In order to ensure the quality of the NMS Volume III 2020, and that it both matches with international standards and is aligned

with the country contextual needs and trends, the document requires re-writing rather than just updating. This might require an

extension of the consultants’ number of days and efforts

2. A national standard be prepared that can be followed by local levels to prepare protocols as per their contextual needs

3. Sections on septic abortion and sexual health be included in NMS Volume II as the current NMS Volume III 2009 does not cover this area

4. Anaesthetic complications in obstetrics be included in NMS Volume III 2020, in addition to routine anaesthetic procedures/care in obstetrics

5. A TWG be formed; a provisional schedule of first draft development, workshops with TWG members and submission of the final draft for peer review was decided

6. In regard to international standards, there were discussions around the number of ANC visits, the Sexual and Reproductive Health Road Map, ANC/PNC guidelines etc.

7. Based on decisions taken at the second meeting, held the end of January 2020, the revised volume adopted: impact, including the achievement of Sustainable Development Goals (SDGs), particularly SDG 3: to ensure healthy lives and promote well-being for all at all ages. 

Further, over the past two decades, maternal and newborn care has been increasingly recognized as an economic priority by the government of Nepal. 

Moreover, with the promulgation of its Constitution in 2015, Nepal replaced a unitary government with a federal system of government. The country is administratively divided into 753 local government units, seven provincial governments and a central government. With the new federalism in place there are concerns regarding the need for clarity in marking out the authority of different layers of government with diverse economic and legislative potentials. 

However, federalism presents an opportunity to attain wide coverage for maternal and newborn health care and for it to be endorsed in the health sector. Legislation and quality standards in support of this, together with sound financing, human resources and logistics, will facilitate, empower and strengthen the provincial government to work on Nepal’s national health priorities

There are altogether 8 chapters with the headings as follows:

• Chapter 1. The Principles and Standards for Maternal and Newborn Health Care
• Chapter 2. Preconception, Birth Preparedness, Complication, Readiness, and Care of Vulnerable Women
• Chapter 3. Management of Antenatal Period
• Chapter 4. Management of Labour and Childbirth
• Chapter 5. Management of Postnatal Period
• Chapter 6. Newborn Care
• Chapter 7. Obstetric Anaesthesia
• Chapter 8. The Clinical Governance for Maternal and Newborn Health Care

WHO SHOULD USE NMS VOLUME III 2020? 

The principal users of NMS Volume III 2020 might be: policy makers; programme managers and health planners at national, district and facility levels; maternal and newborn health professionals; NGOs, including private-sector health organisations, involved or interested in the provision of maternal and newborn health services; and community organisations interested in improving maternal and newborn health care practices.

For details 

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