Monitoring Progress

The overall goal of the Nepal Safer Motherhood Project (NSMP) is to achieve a sustained increase in the availability and use of quality midwifery and obstetric services. To this end, the project works in three main areas:

Accurate monitoring in all of these areas is vital to measure if progress is being made towards meeting the project's overall goal.

The NSMP Logical Framework has undergone several revisions during the project's 7-year lifespan. These have been in response to both progressive thinking in safe motherhood and the changing security situation in Nepal. Project monitoring is closely linked to the logframe, but also provides NSMP with valuable feedback with which to improve its activities and meet community needs.

Measuring changes in maternal mortality rates cannot be used to directly inform programme progress or effectiveness. This is because it is difficult to accurately measure changes in ratesover a 3-5 year period.

However, changes can be measured using proxy data from facilities providing basic and comprehensive Essential Obstetric Care (EOC). Such data includes:

• The number and geographical distribution of facilities
• The percentage of births in these facilities
• The calculated 'met need' (the percentage of EOC cases predicted from statistical analysis which are met at health facilities)
• The rate of caesarean sections in Nepal
• Attitude surveys
• The performance of various institutions

Such issues are reflected in the project logframe.

Policy and Programme Development

NSMP actively seeks to influence the reform of health policy at the national level in a number of areas, including the abortion policy and nurse-led Post Abortion Care (PAC) services. In this regard, the project has worked with His Majesty's Government of Nepal (HMGN) to develop and test appropriate training courses for Maternal and Child Health Workers (MCHWs), midwives and anaesthetic assistants.

Project monitoring here involves pro-active communication with key stakeholders and concerned organisations. Follow-up surveys are implemented to assess progress and provide feedback - which influences future policy development and provides a strong, community-based voice with which to lobby the government.

Service Provision

Regular reporting and periodic inspections ensure that all NSMP-supported facilities are fully operational and that the project's defined Quality of Care goals are met. The monitoring covers physical facilities and equipment, waste disposal, maintenance and safe blood transfusions. During Phase 2 NSMP, monitoring has been extended to assess the state of these services as the project gradually withdraws its support from selected districts.

Increasing Access

Increasing access to available midwifery and obstetric services is vital if real health gains are to be realised. Project monitoring involves tracking progress in overcoming the five key barriers to accessing services:

1. Knowledge and attitudes
2. Finances
3. Transport
4. Health services
5. Institutions

Monitoring is carried out by staff and partners using a variety of participatory methods. These include doing knowledge and attitude surveys, recording the performance of emergency fund and transport schemes and using institutional assessment tools to gauge levels of political support for safe motherhood in the districts. External reviews and specialist studies are also undertaken in specific areas as outlined under Project Research and Reports.

Civil Conflict

In direct response to Nepal's steadily worsening security situation, NSMP now routinely monitors how conflict affects the ability of women to access safe motherhood. This involves partner organisations collecting community-level data, either from within communities themselves or from villagers visiting the district centres. A strict policy of confidentiality is adhered to - which minimises the risk of exposing partners or individuals to either Maoists or security forces. Data is used to plan project activities including future communications strategies.

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