NATIONALPOLICY

SEXUAL REPRODUCTIVE,MATERNAL NEWBORN,CHILD

&ADOLESCENT HEALTH
(SRMNCAH) POLICY

MINISTRY OF HEALTH

REPUBLIC OF LIBERIA

REVISED

JULY, 2015
FOREWORD
Sexual Reproductive, Maternal, Newborn, Child & Adolescent health
(SRMNCAH) are about the critical health areas that address the health
and well-being of women, adolescents, their partners and off-springs.
The attainment of the Millennium Development Goals (MDGs) is
closely linked to the improvement in SRMNCAH. They both form
integral components of a nation’s development agenda. The government
of Liberia is committed to improving SRMNCAH in a bid to strengthen
health care services towards the attainment of the post MDGs
development goals..

Emerging from nearly fourteen months of nationwide Ebola Virus

Disease (EVD) emergency that negatively impacted the delivery of basic
health services, Liberia is currently faced with numerous challenges in
restoring essential health services, including . SRMNCAH services.
These issues are particularly grave given that the maternal mortality
ratio appears to have increase based on the 2013 LDHS report,
increasing from 994/100,000 in 2007 to 1072/100,000 in 2013.

Liberia remains amongst countries in Sub-Saharan Africa with high

adolescent fertility rate, high unmet need for family planning, and an
increasing trend of sexual and gender-based violence (SGBV). These
indicators highlight the need for a robust and comprehensive
SRMNCAH policy to guide the planning and implementation of
evidenced-based, high impact interventions that will improve the sexual
and reproductive health of Liberians.

This Policy provides concrete areas of focus as outlined in the Maputo

Plan of Action for ensuring that Liberia meets its commitment to women
and children as set forth in the MDGs and the post MDGs. It addresses
reproductive health and rights challenges faced by citizens of Liberia
and calls for strengthening the health sector by increasing resource
allocation to improve access to SRMNCAH services.

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This document is designed to be used by policy makers, program
managers,planners and service providers at all levels in both the public
and private sectors. It forms the basis and mandate for all SRMNCAH
activities, setting the national strategic direction for improving
SRMNCAH in Liberia.

It will also enable the Ministry of Health (MOH) forge new partnerships
with other government sectors, communities, non-governmental
organizations, development partners and the private sectors that are
critical for the delivery of essential SRMNCAH services.

On behalf of the Ministry of Health, I convey my gratitude to all

members of the Reproductive Health Technical Committee (RHTC) for
dedicating their time to finalizing this Policy. The Ministry is also
grateful to line ministries, county health teams, especially reproductive
health supervisors, training institutions, health institutions, professional
organizations, local and international NGOs, development partners and
individuals who meaningfully contributed to the finalization of this
National SRMNCAH Policy.

Francis N. Kateh, MD, MPH

Deputy Minister/Chief Medical Officer, RL
Ministry of Health

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Acknowledgement

We sincerely thank the Family Health Division for providing the needed
leadership in the revision of the policy. Our sincere thanks also go to the
H4+ SIDA Partnership and other partners for their technical and
financial support to the process;
1. WHO,
2. UNFPA
3. UNICEF
4. IMC
5. LPMN
6. CHAI
7. Jphiego
8. SCI
Dr. Obed Dolo is recognized for his dedicated technical inputs and
guidance throughout the revision of this policy.
We are confident that the continuous partnership will strengthen the
synergy for the actualization of the reduction of Liberia’s unacceptably
high maternal and newborn morbidity and mortality, as well as increase
access to and utilization of quality SRMNCAH services.

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Table of Contents
FOREWORD............................................................................................2
Acknowledgement....................................................................................3
Acronyms..................................................................................................6
1.0 Introduction......................................................................................7
2.0 Situation Analysis.............................................................................8
2.1 Socio-economic situation.................................................................8
2.2 Demographic and health situation....................................................9
2.3 Morbidity and Mortality.................................................................10
2.3.1 Gynecological Problems 11
2.3.1.1 Sexually Transmitted Infections (STIs) 11
2.3.1.2 Infertility 11
2.3.1.3 Reproductive Tract Cancers 12

2.3.2 Nutrition 12
2.3.4 Obstetric and Newborn Complications 13
3.0 Policy Foundation...........................................................................13
3.1 Rationale, Mission, Vision, Goal and Objectives...........................13
3.2 Guiding Principles..........................................................................14
4.0 Policy Orientation...........................................................................15
4.1 Organization of the Policy15
4.2 Levels of Service Delivery 15
4.3 Essential SRMNCAH Services and rights 15
4.4 Access and Utilization of SRMNCAH Services 19
4.5 Financing and Management of SRMNCAH Services 20
4.6 SRMNCAH Human Resources 20

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 4.7 Infrastructure 20
4.8 Supply Chain 21
Drugs and medical supplies 21
4.9 Leadership and governance 21
SRMNCAH Partnership and Coordination 21
5.0 Monitoring, Evaluation and Policy Review...................................21
Surveillance 21
5.1 Monitoring Framework 21
5.2 Performance evaluation and review 21
6.0 Enabling Environment....................................................................22
6.1 Legislation 22
6.2 Regulation 22
7.0 Policy Implementation....................................................................22
7.1 Assumptions 22
7.2 Risks 22
7.3 Prioritization 22
References...............................................................................................24
Annexes..................................................................................................24

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Acronyms
ANC Ante-Natal Care
ARV Anti-Retroviral
ASRH Adolescent Sexual and Reproductive Health
AfT Agenda for Transformation
AYD Adolescent & Youth Development
BEmONC Basic Emergency Obstetric and Newborn
Complications
BLSS Basic Life-Saving Skills
BCC Behavior Change Communication
EPHS Essential Package of Health Service
CDC Center for Disease Control
LDHS Liberia Demographic Health Survey
ICPD International Conference on Population and Development
SRMNCAH Sexual Reproductive, Maternal, Newborn and
Adolescent Health
UNICEF United Nations Children Education Fund

CEDAW Conference for the Elimination of All Forms of

Discrimination against Women
CHAI Clinton Health Access Initiative
CHT County Health Team
CHV Community Health Volunteers
CM Certified Midwife
CPR Contraceptive Prevalence Rate
CWIQ Core Welfare Indicators Questionnaire
EmONC Emergency Obstetric and Neonatal Care
CEmONC Comprehensive Emergency Obstetric and Neonatal Care
EVD Ebola Virus Disease
ENA EmONC Needs Assessment
ENC Essential Newborn Care
FGM Female Genital Mutilation
FHD Family Health Division
GBV/SGBV Gender-Based Violence/Sexual Gender-Based Violence
gCHV General Community Health Volunteer
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CHW Community Health worker
GOL Government of Liberia
HBLSS Home-Based Life-Saving Skills
HCT HIV Counseling and Testing
HIV Human Immunodeficiency Virus
HMIS Health Management Information Systems
HPV Human Papiloma Virus
IEC Information, Education, and Communication
IPC Infection Prevention & Control
IDSR Integrated Disease Surveillance & response

LDHS Liberia Demographic and Health Survey

LMIS Liberia Malaria Indicator Survey
LPN Licensed Practical Nurse
MARPs Most At-Risk-Populations
MSM Men Having Sex With Men
MD Medical Doctor
MDG Millennium Development Goal
MDSR Maternal Death Surveillance and Response
MICAT Ministry of Information, Cultural Arts and Tourism
Malaria in Pregnancy
MISP Minimal Initial Service PackageMIP
MOH Ministry of Health
MOE Ministry of Education
MOGDSW Ministry of GenderChildren and Social Protection
MOU Memorandum of Understanding
MVE Manual Vacuum Extractor
MYS Ministry of Youth and Sports

NACP National AIDS and STI Control Program

NGO Non-Governmental Organization
NHP National Health Policy
ORS Oral Rehydration Solution
PA Physician’s Assistant
PAC Post Abortion Care
PCT Program Coordinating Team
PPE Personal Protective Equipment
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PEP Post-Exposure Prophylaxis
eMTCT Prevention of Mother to Child Transmission
PRS Poverty Reduction Strategy
RH Reproductive Health
RHSC Reproductive Health Steering Committee
RHTC Reproductive Health Technical Committee
RN Registered Nurse
RM Registered Midwife
RNM Registered Nurse Midwife
SBA Skilled Birth Attendant
SRMNCAH Sexual and Reproductive Health
SCI Save The Children International
SOP Standard Operating Procedure
STI Sexually Transmitted Infection
TTM Trained Traditional Midwife
UNDP United Nations Development Program
UNFPA United Nations Fund for Population Activities
WHO World Health Organization
WRA Women of Reproductive Age

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1.0 Introduction

The improvement of sexual and reproductive health (SRH), particularly

the reduction of maternal, newborn and child morbidity and mortality,
feature among the key challenges for the Government of Liberia (GOL),
as stated in the 2007-2011 National Health Policy (NHP). While there
have been substantial gains in child and infant mortality, maternal and
newborn mortality rates remain unacceptably high.

Maternal mortality ratio is estimated at 1072/100,000 while newborn

mortality rate is 26/1,000 live births (LDHS 2013). As a signatory to
several guiding international resolutions and conventions that strive to
improve SRMNCAH, such as the International Convention on
Population and Development (ICPD), the Millennium Development
Goals (MDGs), and the Convention for the Elimination of
Discrimination and all Forms of Violence Against Women (CEDAW),
Liberia is committed to fulfilling its commitment to the SRMNCAH
needs and services of its citizens.

In an effort to combat high maternal and child mortality, the

Government Of Liberia (GOL) developed and adopted the Road Map for
Accelerating the Reduction of Maternal and Neonatal Morbidity and
Mortality and an Operational Plan 2011-2021.Complementing these
documents are several policies and plans that provide additional details
on SRMNCAH issues, including the National Policy and Strategy for
Community Health and the National Strategy for Child Survival.

While poor SRMNCAH indicators in Liberia are largely due to limited

access to quality health Services, the Ebola Virus Disease (EVD)
emergency crisis has further devastated the health sector in Liberia.

Following nearly 14 months of a devastating national health emergency,

the GOL remains committed to building a resilient health system aimed
at improving the health of the Liberian people in pursuit of the
country’s Agenda for Transformation (AFT). The Ministry of Health
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(MOH) aims to provide affordable, accessible, equitable, reliable and
comprehensive health care to every Liberian. The Essential Package of
Health Services (EPHS), spells out the essential SRMNCAH services at
all levels of health care service delivery.

The development of this Policy seeks to address the SRMNCAH needs

of the Liberian population and is consistent with the vision of the GOL
through the MOH to improve equity in health and increase access to and
utilization of quality health services aiming for a healthy population and
social protection for all.

The definition of SRMNCAH is aligned with the global definition of

health as per WHO and the ICPD +10 Program of Action as the state of
complete physical and social wellbeing and not merely the absence of
disease or infirmity in all matters relating to the reproductive system and
its functions and processes. This implies that people including
adolescents are able to have a satisfying and safe sex life as well as the
capability to have children and the freedom to decide if, when and how
often to do so. It also means the right to appropriate health care services
that enable women to go safely through pregnancy and childbirth and
provide couples with the best chance of having healthy infant.
2.0 Situation Analysis
The situation analysis describes the current status of SRMNCAH in
Liberia and provides in depth information regarding the socio-economic
status and the demographic and health situation.

2.1 Socio-economic situation

Customary laws and practices often deny women and girls their sexual
and reproductive rights, especially in rural areas. However, recent
legislation, including the rape and inheritance laws, has been enacted to
address some of these issues.

The high illiteracy rate among women, estimated at 59% (CWIQ 2007),
has a negative impact on women’s health. The Contraceptive Prevalence
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Rate (CPR) is 15% among married women without education and 29%
among women with secondary education. Currently only 39% of women
have completed primary school compared with 62% of men. Similarly,
only 10% of women have completed secondary school compared with
23% of men (LDHS 2013).

In addition, cultural beliefs about the need for many children are strong,
as many parents tend to rely on children for support during old age.
Therefore, in the minds of populations, more children equal more socio-
economic stability later in life.

Rape and other acts of sexual violence are prevalent in Liberia. In a

recent evaluation report of the SGBV Joint Program, (Liberia SGBV
Joint Program Evaluation report, 2013) it was found that rape accounted
for 68% of SGBV cases. Domestic violence ranks second to rape
accounting for 26% of all SGBV cases reported. The evaluation also
revealed a high level of exposure of young women and girls to sexual
exploitation and abuse (SEA) and that most perpetrators are family
members who are often known by the victims. 15% of rape result in
pregnancy, wife abandonment and rejection (Liberia SGBV Joint
Program Evaluation report, 2013).

The socio-economic situation in Liberia has gravely impacted access to

basic social services over the years. According to the 2013 LDHS, 94%
of married men and 66% of married women were employed; but only 30
percent of employed married women interviewed said they decide on
their own how to use their earnings.

Female genital mutilation (FGM), sometimes referred to as female

genital cutting (FGC), is embedded in the traditional Sande society of
Liberia. The prevalence of FGM in rural Liberia is estimated at 72%.The
2013 LDHS revealed that the percentage of women who have undergone
FGM has fallen among younger age cohorts. In the cohort aged 20-24,
the rate fell from 58.4% in 2007 to 39.8% in 2013. In addition, 39.3% of
current members among the general population want FGM to be
abolished and this figure rises to 47% in rural areas.

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2.2 Demographic and Health Situation

The population of Liberia is relatively young. Recent health statistics

indicate that of the total population of 4.5 million, approximately 56% is
below the age of 21 years. Liberia’s estimated population growth rate is
2.1% (2008 National Census). The life expectancy at birth is 61 years
for men and 63 years for women (WHO, Global Health Observatory,
2013).

The results of two consecutive Demographic and Health Surveys

indicate a relative decline in fertility levels from 5.2 in 2007 to 4.7 in
2013 (LDHS, 2013). Postponement of first births has contributed to a
general fertility decline in Liberia. In 2013, the medium age at first birth
was similar to the 2007 LDHS findings of around age 19. (LDHS, 2013).

The uptake of family planning services in Liberia has witnessed a steady

improvement over the last 5 years from a contraceptive prevalence rate
(CPR) of 11% to 20% and an unmet need from 36% to 31% (LDHS
2013). Notwithstanding, the 2013 LDHS revealed that only 17% of
adolescents use any contraceptive method.

Liberia continues to strive towards the attainment of the Abuja target of

the health budget representing 15% of the national fiscal budget. The
Country has made significant progress in increasing its national health
budget from 8.39% to 12.39% in the last three years (MFDP 2015). The
number of health facilities has also increased from 618 in 2010 to 656 in
2014 (MOH, Investment Plan for building a Resilient Health System,
2015-2021). Irrespective of the gains made, there are still challenges. In
terms of health facility functionality, 13% of all facilities did not have
access to safe water, 43% had no functional incinerators, while 45% did
not have a primary power source for emergency lighting. (Health
Investment Plan, 2015-2021). Furthermore, national health care access is
estimated at only 71%.

The health workforce of the country is plagued by several unfavorable

factors. Approximately 41% of government health workers are not on
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the payroll; the health workforce has skills gaps and is not equitably
distributed, thereby making it unfit for purpose couple with disincentives
to performance and weak regulation of workforce production and
practice, workforce attrition and underperforming and poor alignment of
production pipelines to needs.

Be that as it may, there has been a 37% increase in the density of core
health professionals between 2010 and 2015 from 6.3 to 8.6%/1,000
population. The public health workforce included 117 physicians
(0.03/10,000 population), 436 physician assistants (0.08/1000), 2,137
nurses in both RN and LPN categories (0.4/1000), and 659 midwives
(0.12/1000). This presented a 30% increase for physicians and a 50-60%
increase for other three cadres of health professionals since 2009.

The gains and progress made in the health care system were reversed by
the Ebola Virus Disease (EVD) Outbreak. This devastating EVD
emergency resulted to the near closure of all routine health services,
severely affecting the delivery of optimum SRMNCAH services
nationwide. The country lost approximately 189 health workers out of
nearly 389 infected health work force. The impact of the EVD crisis on
the provision of SRMNCAH services was further exacerbated by
mistrust among clients and service providers, fear among health workers
which led to rejection of the sick and pregnant women in need of skilled
health care services. This resulted to a shift in the burden of care
provision from formal health service delivery to informal including drug
stores/pharmacies, home treatments, and traditional (herbalists and
TTMs) care providers.

The 2013 LDHS revealed teenage pregnancy ratio among 15-19 years at
31%. The EVD emergency anecdotally showed an increase in teenage
pregnancy as access to Family Planning (FP) services were limited as
well as the nationwide closure of basic health services especially
sexuality education and services.

In building a resilient health system following the EVD outbreak, the

government remains committed to strengthening a collaborative

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partnership with other key sectors and partners using investment and
multi-sectorial approaches.

2.3 Morbidity and Mortality

The country has experienced significant progress towards achieving
MDG 4. The infant and under-five mortality rates have declined from
72/ 1,000 live births and 110/ 1,000 live births in 2007 to 54/1,000 and
94/1000 live births respectively in 2013. Meanwhile, the maternal
mortality ratio has worsened over the last five years from 994/100,000
live births in 2007 to 1072/100,000 live births (LDHS, 2013). Post-
abortion complications, one of the major causes of maternal mortality,
made the situation even more complex.

Although 96% of women have had one or more antenatal care (ANC)
visits, only 56% of deliveries occur in health facilities and 61% of
deliveries are attended by a skilled provider (LDHS 2013). 71% of
women who deliver at the health facilities received postnatal care during
the first two days after birth.

2.3.1 Gynecological Problems

Gynecological problems are relatively common in Liberia and made

worse by the inadequate health services available to address them. The
policy will focus on the most common ones that contribute to the high
morbidity and mortality amongst the population.

2.3.1.1 Sexually Transmitted Infections (STIs)

Sexually transmitted infections (STIs) are prevalent, with 50% of
women and 17% of men who were interviewed reported having had
STIs in the 12 months preceding the 2013 LDHS.

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2.3.1.2 Infertility

Global infertility prevalence rates are difficult to determine, due to the

presence of both male and female factors which complicate any estimate
which may only address the woman and an outcome of a pregnancy
diagnosis or live birth. In Sub-Saharan Africa, primary infertility is
estimated at 1.9% while secondary infertility is estimated at 10.5%
(Mascarenhas et al, 2012).

For a woman, infertility (or a state of subfertility) can manifest itself in

the following order:
1. the inability to become pregnant
2. an inability to maintain a pregnancy
3. an inability to carry a pregnancy to a live birth

When a man and a woman attempt to have a child or to expand their

family, the causes and the difficulties encountered can be complex.
Many simple as well as more complex medical interventions can be
attempted to help a couple or an individual to reach a state of pregnancy
or to be able to maintain a pregnancy which results in a live birth.

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2.3.1.3 Reproductive Tract Cancers

Reproductive tract cancers including breast cancer constitute major

public health problems in Liberia. These conditions remain a major
silent killer of women due to limited facilities for proper screening,
diagnosis and treatment. Liberia like other Sub-Saharan countries, has
placed limited to non-existent priority to the prevention or management
of reproductive health tract cancers although the conditions are not rare
in the country..

2.3.1.4 Menopause
Overall, 13 percent of women age 30-49 in Liberia are menopausal. The
proportion of menopausal women increases with age, from 4 percent
among women age 30-34 to 56 percent among women age 48-49.
Anecdotally, psychological instability associated with morbidity is
increased among menopausal women and varies among women age 48-
49.

2.3.1.5 Human Immunodeficiency Virus (HIV) & AIDS

The HIV prevalence among the general population aged 15-49 years is
estimated at 1.9% with women accounting for 2.0% and men 1.7%
(LDHS,2013), Though the rate among general population is 1.9%, the
rate among key populations is much higher. According to the 2013
Integrated Bio-Behavior Surveillance Survey (IBBS) conducted among
Most At risk Population (MARPs) in Liberia in 2013, men who have sex
with men (MSM) is 19.8%, among female commercial sex workers
(FSW) is 9.8%, and among drug users is 5%.

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2.3.2 Nutrition

Nutrition plays an important role in the overall mental, physical growth

and development of humans. Among women aged 15-49 with a child
born in the past 5 years, 62% received a vitamin A dose postpartum;
during the pregnancy of their last birth, 21% of women took iron tablets
for the recommended period of time, and 58% took deworming
medication.

Thirty-two percent (32%) of Liberian children are stunted, 6% were

wasted and 15%were underweight. Almost all children (98%) are
breastfed at some point in their life, 55% under 6months are exclusively
breastfed, while 44% 6-8 months are breast fed along with
complementary foods. 60% of Liberian children age 6-59 months
received vitamin A supplements in the 7days beforehand, 56% received
deworming medication in the preceding 6 months, 99% live in
households with iodized salt.

2.3.4 Obstetric and Newborn Complications

The EmONC Needs Assessment (ENA) conducted in 2010 revealed that

only one health center and hospital qualified as BEmONC and
CEmONC facilities nationwide.

However, most county referral hospitals and health centers have the
capacity to provide some signal functions of BEmONC and CEmONC
services.

Obstetric fistula is very common in Liberia, accounting for an estimated

86% of cases of fistulae operated on between 2007 and 2011. Obstetric
fistula is a childbirth injury caused by prolonged, obstructed labor
without timely medical intervention, usually a caesarean section.
Additionally, more than 80% of fistula survivors experienced the
condition during childbirth. (Zonta International Report, 2011).

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3.0 Policy Foundation

3.1 Rationale, Mission, Vision, Goal and Objectives

Rationale:The Policy provides the institutional framework and guidance

to the delivery of quality SRMNCAH services to the population in a
coordinated, integrated, and harmonized approach.

MISSION: To create an enabling environment for reducing morbidity

and mortality related to Sexual and reproductive conditions by ensuring
universal access to quality sexual and reproductive health services.

Vision: Ensuring a healthy population with social protection for all.

Goal: To create an enabling environment for increased access to and

utilization of SRMNCAH services in Liberia

Objectives

1. To ensure the provision of quality essential SRMNCAH services and

rights;
2. To ensure equitable access and utilization to quality SRMNCAH
services and rights
3. To ensure sustainable financing and effective management systems
for SRMNCAH services.

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3.2 Guiding Principles
To ensure effective and sustainable implementation of SRMNCAH
programs, the present Policy is underpinned by the following guiding
principles:
 Equity and accessibility: Recognizing the fundamental right to
health and the particular needs of underserved populations,
especially those of women, youth and populations most at risk in
the provision of services;

 Community participation: Meaningfully involving beneficiaries

in planning, implementation, monitoring and evaluation of
programs and activities to ensure ownership and sustainability;

 Complementarity: Building on existing national instruments for

the provision of health services and health system strengthening;

 Partnership and Coordination: Promoting partnership,

collaboration and joint programming among stakeholders and
sectors as well as a clear definition of roles, recognizing the
comparative advantage of key players to avoid duplication and
enhance synergies;

 Stewardship: Ensuring government-driven leadership for effective

interventions that are planned and implemented according to
national priorities and the specific needs of the population;

 Quality: Building on a clear understanding of local knowledge,

practices, perceptions and behavior in relation to SRMNCAH,
including gender sensitivity, confidentiality, and responsiveness; as
well as meeting the health needs of the populations with evidence-
based low cost high impact interventions.
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  Transparency and accountability: Promoting a sense of
responsibility and good governance at all levels in the
implementation of the Policy;

 Sustainability: Recognizing the need for optimal allocation of

resources for appropriate interventions, as well as strengthened
managerial capacity to ensure cost-effectiveness and sustainability
of SRMNCAH programs.

4.0 Policy Orientation

The policy environment for SRMNCAH will be aligned with the
National Health Policy representing a commitment for improved health
care services for all.

The Policy shall also help to coordinate different actors, both inside and
outside of government, in order to reach a common goal. It will also
ensure that all women and children have the opportunity to achieve the
highest standard of health, both by supporting the development of
resilient health system, and by creating an environment that promote
health more broadly.
4.1 Levels of care and system organization
The level of care in this policy is consistent with the National Health
Policy; and will maintain three levels of care: primary, secondary and
tertiary. These will be provided through four health care sub-systems
as described below. County Health teams and implementing partners
are responsible for staffing facilities based on each facility workload.
Secondary and tertiary levels staffing should consider reasonable,
weekly shift requirements and ensure the appropriate number of
clinicians and general health providers to provide 24 hour quality
services everyday. Other daily operating requirements shall include
emergencies, labor and delivery services available 24 hours each day
and outreach programs for the facility’s catchment population.

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4.2.1 Essential SRMNCAH Services and rights

Essential SRMNCAH services shall be provided at all levels of health

service delivery as defined in the EPHS. Its components will include
maternal and newborn health, infant and child nutrition, EmONC, family
planning, GBV/SGBV, reproductive tract diseases, and adolescent
health with special attention to capacity building of service providers,
male and community involvement.

High-quality services are essential for delivering effective SRMNCAH

interventions. To achieve SRMNCAH services of the highest quality in
accordance with the EPHS, the GOL shall:
a) Ensure that the capacity of service providers at all levels meets the
increasing demand for SRMNCAH services by providing high-
quality pre- and in-service education;

b) Ensure the development and implementation of human resource

strategy to orient, train, retrain and deploy health system workers;

c) Ensure that the performance of service providers meets national

and international standards through regular monitoring, on-the-job
supportive supervision and performance appraisals;

d) Ensure that all facilities are continuously equipped with adequate

drugs, vaccines including hepatitis B commodities and other
essential supplies and PEP;

e) Uphold adherence to the accreditation system for the delivery of

the EPHS and future health care packages to ensure compliance
with national and international standards of SRMNCAH care;

f) Establish a quality assurance program to continuously monitor and

guide further improvements in the quality of SRMNCAH services;

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 g) Supply service providers with the appropriate tools and guidelines
for effective service delivery.

4.2.3Maternal and essential newborn health

Where reductions in the maternal mortality have been achieved, they

have been so by the provision of emergency obstetric care (EmONC) for
the five main complications of pregnancy and childbirth: obstetric
hemorrhage, eclampsia, obstructed labor, puerperal sepsis and the
complications of incomplete and unsafe abortions.

To improve maternal and newborn health and reduce pregnancy-related

morbidity and mortality, the GOL shall:

a) Promote the perinatal approach to ensure the integrated delivery of

maternal and newborn care services;
b) Ensure that all maternal and perinatal deaths are notified to the
appropriate authorities at all levels of the MOH;
c) Maintain a system for maternal and perinatal death reviews,
including maternal and newborn mortality review in health
facilities and communities;

d) Ensure that all births are notified to the nearest health facility;
e) Allocate and provide adequate resources for a functional and
effective referral system linking all levels of the health service
delivery system;
f) Ensure that all health facilities provide:
i)_Focused ANC including elimination of mother-to-child
transmission (eMTCT) and malaria in pregnancy (MIP)
prevention and control and a minimum of four visits per normal
pregnancy;
ii).Comprehensive care for normal labor and delivery;
iii).Comprehensive postnatal care beginning in the first seven days
of delivery;
iv).Basic and comprehensive EmONC in accordance with the
EPHS

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 g) Provide essential drugs, medical supplies and equipment for
SRMNCAH services;
h) Provide protocols and guidelines on SRMNCAH, including
EmONC, to all health facilities;
i) Ensure an adequate number of and appropriate support for health
traininginstitutions, especially in the area of SRMNCAH;
j) Strengthen competency-based training of health providers to
ensure improved performance and quality service delivery;
k) Strengthen the skills of Community Health workers including
Trained Traditional Midwives (TTMs), to carry out their defined
roles in the delivery of SRMNCAH services at community level;
l) Advocate for the integration of nutrition education, essential
nutrition actions and food supplementation programs with
SRMNCAH services and training;
m)Support the development and delivery of related mental health
services, including addressing the issues of pregnancy-related
(antenatal and postpartum) psychosis and depression;
n) Ensure the delivery of comprehensive SRMNCAH services for
disabled and mentally ill persons.

4.2.4. Child Health

The policy shall provide guidance on child health in accordance
with the national Child Survival Strategy and EPHS. The minimum
package of care shall consist of the following:
a) Home and Community-based interventions;
b) Health Facility-based interventions;
Outreach Interventions;
4.2.5. Family planning

To enhance family planning services and increase the CPR, particularly

in an effort to reduce maternal mortality and teenage pregnancy, the
GOL shall:

a) Ensure the availability and provision of a full range of contraceptive

methods, including long-term and emergency contraceptive methods,
condoms and lubricants in accordance with the EPHS;

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b) Uphold the principle of informed choice and rights for individual
women, men, couples and young people to determine their method of
contraception, including long-term methods;

c) Ensure the provision of emergency contraceptives for the prevention

of unintended pregnancies, particularly for rape survivors as part of post-
exposure prophylaxis (PEP);

d) Ensure that family planning counseling emphasizes dual protection

against STIs/HIV and unintended pregnancies;
e) Ensure that the provision of adolescent and youth-friendly family
planning services are in line with reproductive right standards;
f) Increase access to family planning services by strengthening
community-based family planning provision, awareness and
sensitization using multi-media channels;
g) Promote male involvement in SRMNCAH programs and services.
h) Advocate for political mobilization around provision of a complete
method mix;
i) Support training and supervision of service providers and equip
facilities to deliver quality comprehensive post-abortion care services,
including family planning;
j) Ensure the integration of services for prevention and management of
infertility;
k) Ensure the integration of FP services into existing health programs
such as EPI, HIV/AIDS programs, TB, Malaria and nutrition;
l) Increase the uptake of FP during postpartum care.

4.2.5 Gender-based violence and sexual gender-based violence

(GBV/SGBV)
To provide quality prevention and care services to the population and
survivors of GBV/SGBV, the GOL shall:

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 a) Promote advocacy and social mobilization aimed at preventing and
reducing the incidence of GBV/SGBV, especially rape and FGM;
b) Establish a system for reporting sexual violence to facilitate the
appropriate management of cases of GBV/SGBV;
c) Ensure the availability and accessibility of comprehensive services
for survivors of GBV/SGBV, including collection of medico-legal
evidence, PEP, and emergency contraception;
d) Strengthen collaboration between the health, social and legal
sectors for early reporting, treatment and long-term legal, medical
and psychosocial support for survivors and prosecution of
perpetrators;
e) Encourage schools to incorporate information on GBV/SGBV
prevention and response into education curricula.
f) Support community fora for the prevention, reporting and
mitigation of GBV/SGBV

4.2.6 Gynecological Problems

To effectively prevent and manage diseases of the reproductive system,

the GOL shall:

a) Ensure the provision of appropriate prevention, counseling, and

management services of reproductive tract cancers and infections,
including STIs and HIV/AIDS and breast cancers;
b) Promote dissemination of appropriate information, education and
communication (IEC) and behavior change communication (BCC)
on reproductive tract infections, including STIs and HIV/AIDS, at
all levels of care;
c) Provide protocols and guidelines for the management of STIs
including HIV/AIDS;
d) Ensure the availability of essential drugs and diagnostics for
reproductive tract cancers and infections, including anti-retrovirals
(ARVs), drugs for syndromic management of STIs and
opportunistic infections, and diagnostic supplies;

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 e) Integration of HIV and STI services for individuals of post-
reproductive age;
f) Establish early detection programs for reproductive tract cancers at
all levels of health care delivery system;
g) Establish programs for the prevention of reproductive tract cancers
Human PapilomaVirus (HPV) and other cancers screening.

4.2.7 Adolescent Ssexual and Reproductive Health (ASRH)

To ensure that adolescents have adequate access to the full range of SRH
services, the GOL shall:

a) Ensure the scaling-up of adolescent-friendly SRH and Rights services

including FP targeting adolescents and young people at both community
and facility levels;

b) Institute programs to increase the utilization ofASRH services by

adolescents;

c) Promote the integration of adolescent health issues into existing

health programs and service delivery including schools and youth
programs;

d) Ensure the availability of and access to STI and HIV prevention and
management, including HIV testing and counseling (HCT) and
appropriate information for safe sex targeting youth;
e) Ensure that youth are incorporated in health decision-making,
particularly in the area of ASRH
f) Establish guidelines, protocols and standards for ASRH
g) Define the ASRH package of care including the pregnant adolescents
at all levels of the system
h) Collaborate with other line Ministries and institutions providing AYP
(Adolescents and Young People) services

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i) Establish database on ASRH issues including teenage pregnancy and
integrate into the HMIS
j) Establish and monitor the availability of youth friendly services
nationwide;
k)Strengthen the management structure of ASRH programs at all levels

l) Integrate ASRH issues into the current national supervision tools

m) Increase the number of skilled ASRH service providers at all levels

4.4 Access and Utilization of SRMNCAH Services

The current level of access to SRMNCAH services is limited. Access

will be augmented to address the high maternal and newborn mortality
and morbidity rates.

Policy Objective: To increase access to and utilization of SRMNCAH

services. In order to ensure that all those in need of SRMNCAH services
are able to access them,the GOL shall:

a) Strengthen available health infrastructure and provide additional

structures for under-served areas to ensure the equitable
distribution of health service delivery facilities throughout the
country;
b) Ensure that all facilities provide SRMNCAH services in line with
the EPHS;
c) Provide outreach services and put in place a functional referral
system, including transport and communication systems, to bring
services closer to populations in rural areas;
d) Ensure that continuous IEC/BCC interventions are provided to
communities, especially young people, to empower populations
and create demand for and increase utilization of SRMNCAH
services, particularly for skilled facility deliveries;
e) Pursue continuous dialogue with cultural and religious bodies to
ensure that cultural and religious practices are in harmony with the
GOL’s commitment to achieving of the SRMNCAH policy goals;

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 f) Foster client confidence in the health care delivery system by
ensuring the provision of reliable, quality, client-centered services
in line with the EPHS.

4.5 Financing and Management of SRMNCAH Services

Provision of SRMNCAH services requires a significant sustained
investment of financial and managerial resources.

Policy Objective:
To ensure sustainable financing and effective management systems for
SRMNCAH services;
To attain uninterrupted provision of SRMNCAH services at all levels,
the GOL shall:

a) Increase financial support to SRMNCAH programs as part of the

national health budget;
b) Explore alternative financing mechanisms for SRMNCAH services
to alleviate the financial burden from individual households;
c) Mobilize additional resources from partners and other sources for
SRMNCAH care services;
d) Strengthen management support systems, including HMIS,
procurement, supply chain management, and logistics, in
accordance with the National Health Plan;
e) Ensure the use of standardized health service management tools
and procedures by all implementing partners.
4.6 SRMNCAH Human Resources
The production and education of midwives is hindered by the limited
number of training institutions in Liberia. Only four of the eighteen (18)
health training institutions run midwifery education programs. In
addition, living conditions in the rural areas and low salaries result in
high rates of staff attrition, especially in the counties further from the
capital.

In an effort to improve the performance of skilled attendants, in-service

training in Emergency Obstetric and Newborn Care (EmONC) and Basic
Life-Saving skills (BLSS) for health care providers began in 2004. Due
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to the rapid turnover of skilled attendants, continuous education and
skills development are required for existing staff at both the managerial
and service delivery levels. .

4.7 Infrastructure
The infrastructure plan of this policy is aligned to that of the National
Health Policy and Plan 2011-2021 and the ensuing addendum of the
National Investment Plan for Building a Resilient Health System 2015-
2021. Increasing access to PHC is a key objective of the National
Health Plan. Since health clinics and health centers make up more than
90% of health facilities, they are essential for increasing access to PHC.
The infrastructure plan prioritizes restoring and reforming the capacity
of health clinics and health centers to provide the SRMNCAH services.
Considering the impact of the EVD crisis in the country, the government
is prioritizing reengineering of the existing health infrastructure in terms
of functionality and ability to conform to infection prevention and
control (IPC) best practices so as to ensure the delivery of high quality
services at national, county, district, facility, and community levels.

4.8 Supply Chain

Improved logistics management information system (LMIS) is important
for tracking and accounting for the supply of drugs and other health
commodities. To ensure constant availability of safe and effective
pharmaceutical and medical supplies to all segments of the population, a
strengthened supply chain management system is essential in supporting
the delivery of Essential Package of Health Services.
The Policy will also ensure that the range of the internationally defined
lifesaving commodities will be made available and used at all levels of

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the health care delivery system. Particular attention will be focused on
ensuring reproductive health commodity security at all times.

4.9 Leadership and governance

Investment will be made in strengthening governance and leadership at
all levels to ensure an enabling environment. At the community level,
efforts will be made to re-enforce community engagement in planning
and management of health services. In addition, particular attention will
be paid to government’s role in regulating health facilities to ensure
quality standards are met in collaboration with the Reproductive Health
Technical Committee (RHTC).
Partnership will also be supported and strengthened with the private
health sector, including faith based institutions and concessions.
Coordination shall remain the hallmark of the Policy, where the Program
Coordinating Team (PCT), the County and District Health Teams will be
continuously strengthened to coordinate partners and resources for
implementation and monitoring of SRMNCAH Programs.

5.0 Monitoring, Evaluation and Policy Review

The MOH shall support the roll out of the Road Map to Reduce
Maternal and Neonatal Mortality and facilitate national guidelines,
standards, and protocols at the national and county levels to guide
implementation of the policy. The MOH shall also develop a human
resource plan for training, employment, and retention of qualified health
workers.

The MOH through the Family Health Division (FHD) shall have overall
responsibility for monitoring and implementation of the Policy,
including the coordination of all agencies, institutions and organizations
involved in the provision of SRMNCAH services in the country.
For coordinated implementation, the MOH will set up a Reproductive
Health Steering Committee (RHSC) to provide policy direction and
advocate for funding and support of SRMNCAH and a Reproductive
Health Technical Committee (RHTC) to guide planning and

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implementation. All activities related to SRMNCAH in Memorandum
of Understanding (MOUs) between the MOH and implementing partners
shall be in line with the provision of the Policy.

Supervision, monitoring and evaluation mechanisms, including the

HMIS, for timely availability of data for planning, programming and
decision-making, will be strengthened, integrated, and streamlined. A set
of defined indicators for measuring coverage, utilization, quality, and
resources, as well as monitoring output and impact will be employed.

Monitoring and evaluation of SRMNCAHprograms and services will be

aligned with the principle of integrated disease surveillance and response
(IDSR) with specific emphasis on maternal and newborn disease
surveillance and response (MNDSR) at all levels of health service
planning and delivery.

Evaluation will be done annually, making use of existing tools where

appropriate, and will be built into SRMNCAH program activities from
the planning stage. Midterm and year-end reviews of the implementation
of the Policy will be undertaken to inform revision or development of
new policies. The Policy calls on the GOL and partners to support
operational research on SRMNCAH in order to inform policy
development and decision making.

6.0 Enabling Environment

In order to ensure the establishment of an enabling environment that
would address issues around SRMNCAH, appropriate legislations and
regulations shall be adopted, developed, and enforced.

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6.1 Legislation and Regulation
A national Reproductive health Law has been developed and awaits
enactment. This law is based on the Public Health Law of Liberia and
focuses on reproductive health and rights. Liberia is also signatory to
relevant international legislations including Convention on the
elimination of all forms of violence and discrimination against
women(CEDAW), Convention on the Rights of the Child (CRC).
Mechanisms will be put in place to ensure enforcement of all national
and international legislations relating to SRMNCAH7.0 Policy
Implementation
Policy implementation shall be guided by the following:

7.1 Assumptions
The key assumptions will include:

 Civil and political stability will continue;

 Liberia will remain Ebola free and be prepared to respond to
emerging diseases, disasters and other emergencies;
 Government of Liberia and partners will continue to provide
generous financial support and technical assistance for policy and
program implementation;
 The number and quality of SRMNCAH health workers will
increase;
 Access to health care services will continue to increase;
 Adequate and sustainable logistics, equipment, supplies, drugs and
improved road network and communication;
 Attractive remuneration and benefits for health workers,
motivating and minimizing attrition and sustaining retention of
staff.
7.2 Risks
 Inability to raise the required funding;
 Inability to absorb available resources

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  Emergence of outbreaks and disasters
 Insufficient fiscal space to maintain operations for the expanded
system
 Inappropriate institutional mechanisms and governance
 Poor partner (and Government) aligned to plan priorities
 Economic uncertainties
 Poor coordination of investments

References

Annexes

Annex 1. Terms of Reference for the Reproductive Health Technical

Committee

The Sexual and Reproductive Health Policy of Liberia provides a

framework forcoordinating and monitoring reproductive health activities
in Liberia. Coordination iscentral to a well-designed, comprehensive and
focused SRMNCAH program.

Currently, SRMNCAH interventions are fragmented and poorly

monitored and coordinated, making it difficult to determine the quality
and effectiveness of these interventions. It is also challenging to readily
assess the efficiency of resource use. Strategic partnerships and
strengthening the capacity of the MOH are integral to improving
coordination and monitoring.

A more empowered central MOH that can support and guide actors at
the county level will improve the provision of quality SRMNCAH
services.

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The Reproductive Health Technical Committee (RHTC), appointed by
the MOH,shall be comprised of medical, public health, and other
relevant professionals fromboth the Government and partner
organizations in order to facilitate collaborativeplanning,
implementation, and monitoring at the central level.

Objectives

The RHTC is a multi-sectoral, multidisciplinary body that shall provide

technicaladvice and guidance to the Family Health Division (FHD) and
its partners on a fullrange of SRMNCAH programming in Liberia.
Decisions and recommendations made by the RHTC will apply to all
sectors involved in offering SRMNCAH services.

Responsibilities

The RHTC shall have the following responsibilities:

 To deliberate, analyze, and make recommendations on all

SRMNCAH service delivery issues;
 To pass decisions and recommendations to MOH for
consideration,approval and implementation;
 To collaborate with other technical committees in fostering a
comprehensiveapproach to SRMNCAH;
 To support information dissemination on SRMNCAH, including
minutes of meetings,SRMNCAH data, annual reports, periodic
releases or newsletters, documentaries,etc.;
 To provide technical oversight and support in the development and
revision ofnational SRMNCAH strategies, programs, policies,
standards, procedures, andplans;
 To support the MOH in advocacy and mobilization of resources for
SRMNCAHactivities;
 To appoint standing and ad hoc sub-committees to perform
specific tasks;
 To recommend modifying membership and hiring additional
advisors and consultants as necessary;

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  The central RHTC will be integral in supporting the establishment
of RHTCs at thecounty level and creating the required linkages and
feedback mechanisms.
 TheseCounty Reproductive Health Technical Committees (C-
RHTCs) will coordinate; decentralized SRMNCAH activities and
programs at the county levels, including:
 Monitoring and promoting the accessibility of services in terms of
location,
 integration, hours of service, and waiting time;
 Collaborating with other health partners in the county for the
effective delivery
ofSRMNCAH services;
 Supporting information dissemination on SRMNCAH;
 Facilitating and encouraging the development and implementation
of quality
assurance mechanisms;
 Organizing and following up on trainings provided in SRMNCAH;
 Participating in strategic planning at the county level for service
delivery.

TERMS OF EXISTENCE

The RHTC is a perpetually active body unless otherwise decide by the

MOH. The RHTC shall meet once a month with more meetings and
events as needed anddecided by the members.

STRUCTURE

The structure of the RHTC is outlined as follows:

Chairperson: The Director of the FHD will hold this position

permanently. In theabsence of the Chairperson, his/her designee will
assume the position of ActingChairperson. The Chairperson shall:

 Serve as executive officer of the RHTC;

 Preside over all meetings;
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  Communicate the decisions and recommendations of the RHTC to
theMOH and stakeholders for further action;
 Ensure the implementation of recommendations made by the
RHTC, bothat central and county levels
 Appoint Chairpersons of the sub-committees with approval by
themembers of the RHTC.

Recording Secretary:The Recording Secretary is an elected

positiondetermined by the membership of the RHTC. The
responsibilities of theRecording Secretary are to:

 Record the minutes of all meetings;

 Prepare and disseminate the minutes of RHTC meetings within
sevenworking days of the sitting of the Committee;
 Keep a simplified and organized record system for RHTC records;
 Work closely with the Administrative Secretary in handling RH
records.
Administrative Secretary: The Administrative Secretary is an elected
positiondetermined by the membership of the RHTC. The
responsibilities of theAdministrative Secretary are to:
 In collaboration with the Chairman of the RHTC, prepare the
agenda for all
 meetings;
 Follow up on deliberations of each meeting in collaboration with
the other
 members of the Secretariat;
 Prepare reports in collaboration with the other members of the
Secretariat;
 Handle all logistical and administrative matters of the RHTC.

SUB-COMMITTEES
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The RHTC shall maintain the following Standing Subcommittees:

Service Delivery Committee: This committee shall be appointed by

theChairperson with the consensus of the RHTC. The Service Delivery
Committee shall:

 Recommend a comprehensive package of SRMNCAH services in

accordance with nationally health policies and plan;
 Develop an integratedsupervisory tool for SRMNCAH service
delivery;
 Recommend the provision of appropriate equipment and
commodities toSRMNCAH service delivery points;
 Update service delivery standards and protocols for SRMNCAH as
needed;
 Support the expansion of SRMNCAH services to the community
level;
 Development of relevant job AIDS for use at all levels of
SRMNCAH service delivery;
 Design appropriate tracking mechanism for SRMNCAH
interventions at all levels.

Policy Committee: This committee shall be appointed by the

Chairperson with theconsensus of the RHTC. This committee shall
undertake the following:

 Ensure that SRMNCAH policies and guidelines are within the

framework of theNational Health Policy and other population
policies for Liberia as well aswithin internationally established
frameworks for SRMNCAH;
 Update, review, and maintain SRMNCAH policies and protocols
as needed;
 Work closely with the MOH in the development of new policies
andguidelines.

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Education Committee: This committee shall be appointed by the
Chairperson withthe consensus of the RHTC. This committee shall
undertake the following:

 Participate in the review, development and approval of pre- and in-

serviceSRMNCAH curricula for all cadres of health workers;
 Help to identify needs for pre- and in-service training in
SRMNCAH;
 Track SRMNCAH training;
 Initiate, support and promote the development and dissemination
of SRMNCAH
 information;
 Support SRMNCAH BCC.

Advocacy Committee: This committee shall be appointed by the

Chairperson withthe consensus of the RHTC. This committee shall
undertake the following:
 Participate in the review and adapt evidence-based advocacy tools
foruse by the RHTC.
 Advocate, mobilize and lobby for adequate resources for
SRMNCAH

ASRH committee:This committee shall be appointed by the

Chairperson withthe consensus of the RHTC. This committee shall
undertake the following:
 Monitor in-school and out-school programs that empower
adolescents with life skills;
 Identify opportunities for collaboration with other partners and
sectors( such as MOE,MYS,MOGDSW,MICAT, etc);
 Ensure the integration on ASRH in all health decision making and
development agenda;
 Promote awareness and sensitization on ASRH at all levels

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Annex2: EmONC

EmONC services should be as accessible as possible. The provision of

the different EmONC skills at clinics, health centers, or the county
hospitals will depend on the urgency of the intervention as well as the
levels of skills and facilities required.

It is known that approximately 10-15% of pregnant women will require

advanced obstetric care such as C- Section. The policy shall ensure the
provision of quality care for all obstetric and new-born care emergencies
in the appropriate care packageandsetting as per the EPHS.

Basic EmONC Package:

 Administration of parenteral antibiotics

 Administration of uterotonic drugs (i.e. parental oxytocics)
 Administration of anti-convulsant
 Manual removal of retained Placenta

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  Removal of retained products of conception (Post-abortion care
/PAC)
 Assisted vaginal deliveries (i.e. Mannual Vacuum Extraction/
MVE)
 Essential Newborn care (including basic newborn resuscitation)

Comprehensive EmONC Package:

 Administration of parenteral antibiotics

 Administration of uterotonic drugs (i.e. parental oxytocics)
 Administration of anti-convulsant
 Manual removal of retained Placenta
 Removal of retained products of conception (Post-abortion care)
 Assisted vaginal deliveries (MVE)
 Essential Newborn care (including basic newborn resuscitation)
 Blood transfusion
 Surgical intervention (C-Section)

Essential Newborn Care (ENC) Package:

 warmth, hygiene, immediate breastfeeding),exclusive
breastfeeding, newborn nutrition, and recognition and appropriate
actions in the case of danger signs (i.e. Basic newborn
resuscitation)

Annex 3: RH Care Provision in Emergencies (MISP)

The Minimum Initial Service Package (MISP) in emergencies such as

natural and man-made disasters will be provided to reduce mortality,
morbidity, and disability among population affected by crisis
particularly women and girls to prevent and manage the consequences of
sexual violence; prevent excess neonatal and maternal morbidity and
mortality; reduce HIV transmission; and plan for comprehensive RH
services in the early days and weeks of the emergency.

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The MISP includes a pre- packaged set of specially prepared kits
containing drugs and supplies aimed at facilitating the implementation of
priority RH services in the early phase of the crisis.

Annex 4: Human Resources for Sexual and Reproductive Health

The MOH will ensure the availability of a highly-motivated and

appropriately trained and skilled personnel to efficiently manage and
provide quality SRMNCAH services: This shall be done by:

 Determining and incorporating human resource needs for

SRMNCAH in the Human Resource Development Plan of the
MOH to ensure equitable deployment of skilled personnel;
 Ensuring that the curricula of all health training institutions include
all components of SRMNCAH in varying levels of detail;
Ensuring that personnel providing health services at all levels
receive pre- and in--service competency-based training in
SRMNCAH;

Taking into account county and district requirements as well as

national needs when defining specialized training for staff;
Linking promotion and in-service training with regular and
systematic performance appraisal;
 Developing strategies to increase the number of skilled
SRMNCAH staff; and
 Developing incentive packages to attract and retain skilled and
trained staff.

Definitions of Human Resources in SRMNCAH

The MOH of Liberia has declared that all institutional deliveries be done
by skilled birth attendants as a means of improving maternal and
neonatal outcomes in general. A skilled birth attendant (SBA) is a
trained health provider who has completed a set of course of study in
handling obstetric emergencies and is licensed to practice. SBA includes

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doctors, nurses, midwives, Physician Assistants, and Licensed Practical
Nurses (LPN), who:

 Can diagnose and manage complications during pregnancy and

childbirth, can assist in normal deliveries, and are linked to a
referral system for further care when necessary. The skills of an
SBA can be enhanced with Basic-Life Saving Skills (BLSS)
training.
 Auxiliary SRMNCAH personnel include TTMs, counselors, social
workers, peer educators, gCHVs, community mobilizers/health
promoters, and advocates.

The following personnel are involved in SRMNCAH activities at

various levels:

Coordinator: A technical expert in SRMNCAH who works at the central

level. The Coordinator will have one of the following qualifications:
RN, CM, RNM, or MD with gynecological training.The Coordinator has
the following responsibilities:

 Plans programs and activities to build the staff capacity;

 Writes proposals to advocate for increased SRMNCAH financial
and technical resources;

 Makes requisitions to ensure SRMNCAH commodities are in

country and at points of use;

 Monitors all SRMNCAH activities in collaboration with partners at

all levels;

 Establishes mechanisms to ensure that all births in the country are

registered.

Supervisor: A technical expert in SRMNCAH who works at the county

level. The Supervisor will have extensive experience in midwifery. The
Supervisor has the following responsibilities:

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  Supervises SRMNCAH programs and activities at the county,
district and health facilities;
 Monitors SRMNCAH activities in the county;
 Provides technical guidance and support to clinical staff on
SRMNCAH activities;
 Conducts training and logistical needs assessments;
 Conducts capacity building training for SRMNCAH staff;
 Reports to the Coordinator and County Health Team (CHT).

Clinicians: Staff assigned in clinics providing direct SRMNCAH

services to clients. Clinicians include Physicians, Certified Midwives
(CMs), Registered Nurse Midwives (RNMs), Registered Nurses (RNs),
Physicians Assistants (PAs), and Licensed Practical Nurses (LPNs).

Clinicians’ responsibilities include:

 Provide quality skilled services to pregnant women and mothers,

neonates, infants and children under age five, adolescents, women
and men of reproductive age, and all other clients seeking
SRMNCAH care;
 Works at the community level to ensure that all community
members and mothers, babies and adolescents in particular receive
quality and safe care;
 Reports to the RH Supervisor at the CHT.

Trained Traditional Midwives (TTMs)

While the MOH aims to increase institutional deliveries, Trained

Traditional Midwives (TTMs) and Traditional Midwives (TMs) still
perform more than 44% of deliveries in the country (LDHS 2013). The
MOH will remain involved with TTMs, as they constitute a well-
respected and enthusiastic resource for community health.

Howbeit, the MOH has redefined the role of TTMs from that of birth
attendants to that of birth supporters. TTMs are considered members of

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the cadre of CHV whose roles and responsibilities have been expanded
to focus on mobilizing families and communities to recognize maternal
and newborn danger signs and complications for early referral to the
next level to save lives. To keep this cadre of care providers motivated,
this policy shall support performance-based motivational packages for
TMs who refer pregnant women to the health facility for delivery.

The MOH has adapted Home-Based Life Saving Skills (HBLSS)

training for CHWs. The HBLSS training places emphasis on early
detection, basic first aid care services and referral at the community
level and the importance of prompt management of maternal and
newborn complications at the health facility by skilled providers.
Trainees will receive an ID card linking them to functional health
facilities under the supervision of the health facility’s MCH Supervisor,
who will conduct monthly meetings with the TTMs, collect reports,
provide feedback, and conduct in-service training in HBLSS. Due to the
importance and effectiveness of supportive supervision and follow-up,
the MOH emphasizes the two weeks in-service training in HBLSS and
immediate linkage to the clinic for close monitoring and follow-up for
TMs.

The responsibilities of TTMs include:

 Counseling on essential newborn care (warmth, hygiene,

immediate breastfeeding), exclusive breastfeeding, maternal and
newborn nutrition, and recognition and appropriate actions in the
case of danger signs;
 Providing and appropriate community-based post-partum and
neonatal care;

 Encouraging women to seek SRMNCAH care at health facilities

(ANC, labor and delivery, and postnatal care, as well as family
planning services);
 Recognizing and referring pregnant women with danger signs to
health facilities;

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  Assisting women, families and communities to develop birth
preparedness and complications readiness plans; educating women,
families and communities about danger signs in pregnancy, labor,
delivery, and post-partum and the recommended actions to take to
save lives;
 Educating and demonstrating desired behaviors at household and
community levels using Take Action Cards;
 Identifying all pregnancies, births, and maternal and newborn
deaths in their community and reporting to the health facility
during monthly meeting.

Annex 5: INFECTION, PREVENTION AND CONTROL

The policy shall promote the implantation of all Infection Prevention and
Control (IPC) SOPs and standards at all levels of the health care delivery
system. The intent is to ensure that IPC practices are institutionalized at
all levels. The MOH approved IPCs standards include:

 The keep safe /keep serving modules on universal precautions, safe

maternity practices and safe work environment
 Triage
 Isolation and referral
 PPE, both basic and enhanced as appropriate
 Waste management and disposal

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