Public Health and Epidemiology

Primary Health Care

Definition: Primary Health Care (PHC) is the first level of contact of individuals, the family and the community with the national health system, bringing health care as close as possible to where people live and work. It is essential health care based on practical, scientifically sound and socially acceptable methods and technology, made universally accessible to individuals and families in the community through their full participation, and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination. It was declared at the Alma-Ata Conference (1979) and is the key approach to achieving "Health for All".

Principles of Primary Health Care:

1. Equitable distribution — health services should be shared equally by all people irrespective of their ability to pay; services must be brought to the people, especially the underserved rural and poor communities.
2. Community participation — people should be involved in planning, implementation and maintenance of their own health services; the community must take responsibility for its own health.
3. Focus on prevention — priority is given to preventive and promotive health care rather than curative care (immunization, safe water, sanitation, health education, nutrition).
4. Appropriate technology — use of simple, scientifically sound, culturally acceptable and affordable technology that the community and country can maintain (e.g., ORS, growth charts, trained local health workers).
5. Intersectoral coordination — health cannot be achieved by the health sector alone; it requires coordination with agriculture, education, water supply, housing, industry and other sectors.
6. Accessibility — services must be available, affordable and acceptable, with continuity of care at the nearest possible point to the people.
7. Community-based care — care is provided through community-level workers (ANM, FCHV, MCHW) with referral linkage to higher levels.
8. Social justice and self-reliance — health is a fundamental right; the community and nation should work towards self-reliance in health matters.

Classification of Family Planning Methods

Family planning methods are classified as follows:

1. Temporary (Spacing) Methods

• Natural methods: Lactational amenorrhea method (LAM), calendar/rhythm method, basal body temperature method, cervical mucus (ovulation) method, coitus interruptus (withdrawal).
• Barrier methods: Male condom, female condom, diaphragm, cervical cap, spermicidal foam/jelly/tablet.
• Hormonal methods: Combined oral contraceptive pills, progestin-only pills (mini-pill), injectable contraceptives (DMPA), subdermal implants (Norplant), emergency contraceptive pills.
• Intrauterine devices (IUDs): Copper-T 380A, hormonal IUD (Mirena), and other IUCDs.

2. Permanent (Terminal) Methods

• Female sterilization: Minilaparotomy, laparoscopic tubal ligation, tubectomy.
• Male sterilization: Vasectomy (no-scalpel vasectomy).

3. Emergency Contraception

• Emergency contraceptive pills, copper IUD insertion within 5 days.

---

Permanent Method of Family Planning (Sterilization)

Permanent methods are meant for couples who have completed their desired family size and do not want any more children. These are one-time procedures that give lifelong protection and require no repeated action.

A. Female Sterilization (Tubal Ligation / Tubectomy)

Procedure: The fallopian tubes are cut, tied, clipped or sealed so that the ovum (egg) cannot travel from the ovary to the uterus and the sperm cannot meet the egg. Since fertilization cannot occur, pregnancy is prevented. The ovary and uterus remain intact, so menstruation and hormone production continue normally.

Approaches:

• Minilaparotomy: A small (2–3 cm) abdominal incision is made, usually after childbirth (postpartum) or as an interval procedure; the tubes are located and ligated.
• Laparoscopic sterilization: A laparoscope is inserted through a small umbilical incision; the tubes are occluded with clips or rings (often done as an interval procedure).
• Tubectomy: A segment of the fallopian tube is removed and the cut ends are tied.

Timing: Postpartum (within 48 hours of delivery), post-abortion, or interval (any time in the menstrual cycle, preferably in the first half).

Effectiveness: More than 99% — one of the most effective methods.

Advantages: Permanent protection, no need to remember anything daily, no effect on lactation or sexual desire, no interference with intercourse.

Disadvantages/Side effects: Minor surgical risks (bleeding, infection, anaesthesia risk), transient abdominal pain, regret if the couple later wants more children; not easily reversible.

B. Male Sterilization (Vasectomy)

Procedure: The vas deferens (the tube carrying sperm from the testis to the urethra) is cut and the ends are tied or sealed. Sperm therefore cannot reach the semen, so fertilization is prevented. Sperm continue to be produced but are absorbed by the body. It is a no-scalpel vasectomy (NSV) when done through a tiny puncture without a scalpel, under local anaesthesia, taking about 10–15 minutes.

Effectiveness: More than 99%, but it is not immediately effective — the couple must use another method (e.g., condom) for about 3 months or until 20 ejaculations, and confirm azoospermia by semen analysis.

Advantages: Simple, safe, quick, can be done at health post level, no effect on sexual function or hormone levels, permanent.

Disadvantages: Mild scrotal pain/swelling, rarely infection or bleeding; not immediately effective; reversibility is difficult and not guaranteed.

Key Points to Remember

• Permanent methods are irreversible, so proper counselling and informed consent are essential.
• They do not protect against STIs/HIV — condom use is still advised.
• In Nepal, both services are available free of cost in government health facilities, and compensation/incentives are provided to acceptors under the national family planning programme.

Reproductive health is defined (ICPD, 1994) as a state of complete physical, mental and social well-being in all matters relating to the reproductive system and its functions and processes — not merely the absence of disease. Its main components are:

1. Maternal and child health — safe motherhood, antenatal, natal and postnatal care, safe delivery, and reduction of maternal and infant mortality.
2. Family planning — access to contraceptives, birth spacing, and the right to decide freely the number and timing of children.
3. Adolescent reproductive health — sexual and reproductive health information, counselling and services for adolescents, including menstrual hygiene and prevention of early pregnancy.
4. Prevention and control of reproductive tract infections (RTIs) and sexually transmitted infections (STIs), including HIV/AIDS — screening, treatment, and counselling.
5. Infertility prevention and management — diagnosis, counselling and treatment services.
6. Safe abortion services — safe, legal abortion and post-abortion care as permitted by law.
7. Reproductive cancers and other gynaecological problems — early detection and management of cancers of the cervix, breast and prostate.
8. Gender equality and elimination of gender-based violence — including sexual violence, harmful practices and discrimination.
9. Sexual health and sexuality education — correct information on sexual development, safe sexual behaviour and rights.
10. Counselling, information, education and communication (IEC/BCC) — raising awareness so people can make informed, voluntary choices.

In Nepal these components are delivered mainly through the National Reproductive Health Strategy, safe motherhood and family planning programmes, and adolescent-friendly health services at health posts and health centres.

Causes of Maternal Mortality in Nepal

Maternal mortality refers to the death of a woman during pregnancy, childbirth, or within 42 days of termination of pregnancy, from any cause related to or aggravated by the pregnancy. Nepal's Maternal Mortality Ratio (MMR) has fallen substantially over recent decades (from about 539 per 100,000 live births in 1996 to around 151 per 100,000 in recent estimates), yet it remains high compared to developed countries. The main causes are:

A. Direct obstetric causes (about 75–80% of deaths)

1. Haemorrhage (bleeding) — the single leading cause, especially postpartum haemorrhage (PPH). Common where delivery occurs at home without skilled attendance, and where anaemia is widespread.
2. Hypertensive disorders of pregnancy — eclampsia and pre-eclampsia, often unrecognised because of absent or inadequate antenatal care.
3. Sepsis/infection — unsafe delivery practices, unsterile instruments, delayed care-seeking, and unhygienic cord care.
4. Obstructed and prolonged labour — due to cephalopelvic disproportion, malpresentation, or young age at first birth, with no timely referral for caesarean section.
5. Unsafe abortion — though legalised in 2002, many women still resort to clandestine abortion due to stigma, cost, and lack of information.
6. Ectopic pregnancy and other complications — frequently diagnosed too late.

B. Indirect causes

7. Anaemia and malnutrition — very common among Nepali women; reduces tolerance to bleeding and infection.
8. Underlying diseases — tuberculosis, heart disease, hepatitis, malaria, and HIV.
9. Early marriage and teenage pregnancy — immature pelvis and poor physical readiness for childbirth.
10. High parity and short birth intervals — repeated pregnancies deplete the mother's reserves.

C. Health-system and socio-economic causes

11. Three delays model:
    • Delay in deciding to seek care (ignorance, poverty, women's low decision-making power, preference for traditional birth attendants).
    • Delay in reaching care (remote hills and mountains, poor roads, lack of transport, no 24-hour emergency services).
    • Delay in receiving care (lack of skilled staff, blood, drugs, and equipment at health facilities).
12. Low utilisation of antenatal, delivery, and postnatal services — only a minority of births are attended by skilled providers in some districts.
13. Poverty, illiteracy, and gender discrimination — poor families cannot afford referral costs; women's health is given low priority.
14. Weak referral system and lack of awareness about danger signs.

---

Nepal Government Initiatives and Activities to Reduce Maternal and Newborn Mortality

Nepal has adopted a series of policies and programmes under the National Health Policy and the Nepal Health Sector Strategy (NHSS), aligned with SDG target 3.1 (reduce MMR to below 70 per 100,000 by 2030) and the Every Newborn Action Plan.

1. Policy and legal measures

• Safe Motherhood Policy (1998) and National Safe Motherhood Plan (2002–2017) — the foundation of maternal health programmes.
• Legalisation of abortion (2002) and expansion of safe abortion services through government facilities.
• National Health Policy (2019) and NHSS 2015–2020 / 2021–2026, prioritising maternal, newborn, and child health.
• Free maternity and newborn care — free delivery services, free caesarean section, and free newborn care in public facilities.

2. Service delivery programmes

• Aama Programme (2005) — cash incentive to mothers for institutional delivery (Rs 3,000 in hills, Rs 2,000 in Terai) plus free delivery care; Aama Suraksha Programme covers transport incentives for referral.
• Safe Delivery Incentive Programme (SDIP) — cash incentives to skilled birth attendants for conducting deliveries.
• 24-hour Emergency Obstetric Care (EmOC) — Basic and Comprehensive EmOC services in district hospitals and referral centres.
• Skilled Birth Attendant (SBA) training — training of nurses and ANMs to provide skilled delivery care.
• Expanded Programme on Immunization (EPI) — protects newborns from tetanus, measles, and other diseases.
• Newborn Care Programme — Essential Newborn Care, Kangaroo Mother Care (KMC), and newborn resuscitation training.
• CB-IMNCI (Community-Based Integrated Management of Newborn and Childhood Illness) — management of newborn and child illness at community level.
• National Free Health Care Programme — basic health services free of cost.

3. Human resources and infrastructure

• Deployment of ANMs and nurses at health posts and birthing centres.
• Establishment of Birthing Centres at health posts to bring delivery services closer to communities.
• Female Community Health Volunteers (FCHVs) — about 52,000 FCHVs mobilised for health education, referral, and counselling.
• Referral transport schemes and maternity waiting homes in remote areas.

4. Awareness and demand-side activities

• Safe motherhood counselling, birth preparedness and complication readiness (BPCR) plans.
• Radio, FM, and community awareness programmes on danger signs and institutional delivery.
• ANC and PNC home visits by FCHVs and health workers.
• Iron and folic acid supplementation and deworming to control anaemia.

5. Monitoring and quality improvement

• Maternal and Perinatal Death Surveillance and Response (MPDSR) — to review and prevent maternal and newborn deaths.
• Health Management Information System (HMIS) — tracking of maternal and newborn indicators.
• Quality Assurance and accreditation of birthing centres.

6. International commitments

• MDG 5 and now SDG 3 targets, Every Woman Every Child, and Nepal's commitment to the Global Strategy for Women's, Children's and Adolescents' Health.

Conclusion Maternal and newborn mortality in Nepal is caused mainly by haemorrhage, eclampsia, sepsis, obstructed labour, unsafe abortion, anaemia, and the three delays in care-seeking. Through the Safe Motherhood Policy, Aama Programme, free delivery care, SBA training, birthing centres, FCHV mobilisation, and MPDSR, the Government of Nepal has achieved a remarkable decline in MMR. Continued strengthening of remote-area services, blood supply, and quality of care is essential to reach the SDG target by 2030.