The evolution of a quality of care approach for improving emergency obstetric care in rural hospitals in Nepal.

We describe the iterative process of developing a locally-appropriate quality of care approach and its role in emergency obstetric care (EmOC) programming in Nepal. We describe the context of maternal health issues in Nepal, the rationale for developing a quality of care approach within a model to improve EmOC, and outline the outcomes and catalytic effects of the process. The lessons learned during the development of this approach are detailed. The program developed and implemented a quality of care approach at three district hospitals in Nepal. This resulted in improvements in the structure, process and outcomes of EmOC in these institutions. The process also resulted in improved understanding of quality of care approaches on both local and national levels and the creation of a Nepalese quality of care evaluation framework for maternity services. While the theoretical concept of quality of care is difficult to translate into a concrete approach, we used a process in rural hospitals in Nepal that created highly motivated teams and improved the overall functioning of these hospitals.

Evolution of the postabortion care program in Nepal: the contribution of a national Safe Motherhood Project.

The objective of this review is to present the findings and lessons learned over the first 4 years (1999-2002) of implementation of postabortion care (PAC) services outside of major urban centers in Nepal, where a significant proportion of services are provided by nurses. The contributions made by a national Safe Motherhood project to the establishment of the National Postabortion Care Program including the promotion of nurse providers within an integrated program of emergency obstetric care services are highlighted. Clinical competency assessments and service utilization data from three district hospital-based postabortion service sites supported by the Nepal Safer Motherhood Project are analyzed. The relationship between the findings of this assessment and two previous assessments, one covering two districts and one nationwide, are discussed. This review found that nurses are at least as competent as physicians in providing postabortion care services. The inclusion of postabortion care into the emergency treatment of obstetric complications provided the environment needed for successful introduction of nurse-led PAC services. Competency-based training of nurse providers is the key to making life-saving postabortion care services accessible and affordable in Nepal. Ensuring that these nurse providers are able to implement services requires strategic planning, careful advocacy and support from physician colleagues as well as the presence of adequate infrastructure and equipment. The successful introduction of postabortion care services into three district hospitals also offering emergency obstetric care provides an example of how a nurse-led service can be integrated into an emergency obstetric care support project. The project's learning has influenced national policy on the expansion of the postabortion care program throughout Nepal.