11

Maternal Health servicesMaternal Health services

Lecture 4 Lecture 4

March, 2012 March, 2012

Addis Ababa UniversityAddis Ababa University

22

Learning objectivesLearning objectives

At the end of this class the students will be At the end of this class the students will be able to:able to:

Identify the maternal health servicesIdentify the maternal health services

Explain the different approaches in maternal health Explain the different approaches in maternal health servicesservices

33

Contents Contents

ANCANC

Delivery servicesDelivery services

Post Natal carePost Natal care

Family planningFamily planning

Safe abortion & PACSafe abortion & PAC

44

Major maternal health services Major maternal health services

Antenatal CareAntenatal Care

Delivery servicesDelivery services

Postnatal carePostnatal care

Family planningFamily planning

Safe abortion & comprehensive PACSafe abortion & comprehensive PAC

55

Antenatal CareAntenatal Care(A N C)(A N C)

66

ANC…ANC… ANC is the care given to pregnant mothers so ANC is the care given to pregnant mothers so

that they have that they have safe pregnancy safe pregnancy and and healthy healthy babybaby..

ANC is still a big ANC is still a big pillarpillar of Safe Motherhood. of Safe Motherhood.

It needs to be linked with quality emergency It needs to be linked with quality emergency obstetric servicesobstetric services

A good safe motherhood services must be pA good safe motherhood services must be part art of a of a continuumcontinuum of services in which of services in which FPFP, , PACPAC, , intra-partumintra-partum and and postpartum carepostpartum care are all are all

provided and support one another.provided and support one another.

77

..

Po

stp

art

um

Car

e

Fa

mily

Pla

nn

ing

An

ten

atal

Car

e

Sa

fe D

eliv

ery

Ess

enti

al O

bst

etri

c C

.

EMOTIONAL AND PSYCHOLOGICAL SUPPORT

EQUITY

SAFEMOTHERHOOD

BASIC HEALTH SERVICES

Po

st a

bo

rtio

n C

are

Essential Health Sector Interventions for Safe Motherhood

88

Aims of ANCAims of ANC

1.1. Promote and maintain the physical, mental & Promote and maintain the physical, mental & social health of mother & baby social health of mother & baby

by providing education on nutrition, personal hygiene by providing education on nutrition, personal hygiene and birthing processand birthing process

2.2. To detect and treat complications during To detect and treat complications during pregnancypregnancy

3.3. To advise the mother on ways of carrying for To advise the mother on ways of carrying for herself during pregnancy and her babyherself during pregnancy and her baby

99

Aims ANC…Aims ANC…4.4. Develop birth Develop birth preparedness and complication preparedness and complication

readiness readiness planplan

5.5. To give TT immunization for mothersTo give TT immunization for mothers

6.6. To help women limit harmful behaviour such as To help women limit harmful behaviour such as smoking and alcohol consumption (smoking is smoking and alcohol consumption (smoking is associated with fetal growth restriction, preterm associated with fetal growth restriction, preterm labour, abruption and fetal uterine death).labour, abruption and fetal uterine death).

7.7. Help prepare mother to Help prepare mother to breastfeed breastfeed successfully, successfully, experience normal puerperium, and take good care experience normal puerperium, and take good care of the child physically, psychologically and sociallyof the child physically, psychologically and socially

1010

Effective ANCEffective ANC Care from a Care from a skilled attendant skilled attendant and continuity of careand continuity of care

Preparation for birth and potential complications Preparation for birth and potential complications

Promoting health and preventing diseasePromoting health and preventing disease

TT Immunization & education on nutrition, tobacco TT Immunization & education on nutrition, tobacco

and alcohol use and other behaviorsand alcohol use and other behaviors Detection of existing diseases & Rx Detection of existing diseases & Rx

HIV, syphilis, TB, other co-existing medical HIV, syphilis, TB, other co-existing medical diseases diseases

Early detection and management of complications Early detection and management of complications

1111

Approach to ANCApproach to ANC

There are two approaches to ANCThere are two approaches to ANC

Risk approach (standard western model)Risk approach (standard western model)

Goal-directed approach (New WHO Model)Goal-directed approach (New WHO Model)

1212

1. Risk Approach1. Risk Approach Risk approach is a managerial tool for health services Risk approach is a managerial tool for health services

to identify to identify people at riskpeople at risk as early as possible and as early as possible and intervene in order to reduce the risk. intervene in order to reduce the risk.

The basic concept behind this approach is that it The basic concept behind this approach is that it assumes all women in assumes all women in reproductive age group reproductive age group are are vulnerable to disease, death and disability. vulnerable to disease, death and disability.

However, However, all women are not equally vulnerableall women are not equally vulnerable and and this risk approach helps to identify mothers who are this risk approach helps to identify mothers who are at a at a higher risk higher risk than others with a than others with a lesser risklesser risk. .

1313

Purposes of risk approach Purposes of risk approach

Optimal use of existing resources for the Optimal use of existing resources for the benefit of the majority. benefit of the majority.

Minimum of care for all and diversion of Minimum of care for all and diversion of limited resources to those who most need them limited resources to those who most need them (high risks). (high risks).

1414

Criteria to identify high risk womenCriteria to identify high risk women

1. 1. Relation ships b/n the risk factors & adverse Relation ships b/n the risk factors & adverse outcomesoutcomes Causative Causative oror triggering triggering: E.g. maternal malnutrition, : E.g. maternal malnutrition,

low BW, placenta previa, congenital malformation…low BW, placenta previa, congenital malformation… Contributory factorsContributory factors:: E.g. grand multiparty can lead E.g. grand multiparty can lead

to transverse lie, cord prolapseto transverse lie, cord prolapse Predictive Predictive oror associative associative: e.g. : e.g. previous fetal lossprevious fetal loss

2. 2. Biological, medical and social conditionsBiological, medical and social conditions BiologicalBiological: : age, birth interval, weight gainage, birth interval, weight gain MedicalMedical:: diabetes, obstetric complications diabetes, obstetric complications SocialSocial:: work load, economic statuswork load, economic status

1515

Limitations of risk approachLimitations of risk approach

More than 10 years of experience has shown: More than 10 years of experience has shown:

““Risk factors” cannot predict complicationsRisk factors” cannot predict complications

Risk factors” do not appear to be good indicators of Risk factors” do not appear to be good indicators of

complications. complications.

The majority of women who experience complication The majority of women who experience complication

were considered “were considered “low risklow risk;” while the vast majority ;” while the vast majority

of women considered to be “of women considered to be “high riskhigh risk” give birth ” give birth

without complications.without complications.

1616

2. Goal-directed/focused approach2. Goal-directed/focused approach Because of the above, limitations many literatures strongly Because of the above, limitations many literatures strongly

suggested that:suggested that:

All pregnancies All pregnancies should be regarded as “should be regarded as “at riskat risk” of developing ” of developing

a complication and be managed with the greatest carea complication and be managed with the greatest care

The focus of obstetric care should be shifted from predicting The focus of obstetric care should be shifted from predicting

complications through identification of “risk factors” to complications through identification of “risk factors” to

‘‘detecting signs and symptoms of detecting signs and symptoms of actual problems actual problems and and

Educating women, men and family members about danger Educating women, men and family members about danger

signals and complication readiness’signals and complication readiness’

1717

1818

Basic components of the new Approach Basic components of the new Approach First Visit- First Visit- first trimester (12 weeks)first trimester (12 weeks) Second visitSecond visit- - close to 26 weeksclose to 26 weeks Third visitThird visit--around 32 weeksaround 32 weeks Fourth visitFourth visit- - between 36 and 38 weeksbetween 36 and 38 weeks Post-partum visitPost-partum visit-within one week of -within one week of

delivery delivery Late enrolment and missed visitsLate enrolment and missed visits- after a - after a

missed appointment missed appointment Special recommendationsSpecial recommendations-twines, Spacing -twines, Spacing

between visitsbetween visits

The first visitThe first visita) Hx Obtain information on:a) Hx Obtain information on:

Personal historyPersonal history Medical historyMedical history Obstetric historyObstetric history

b) Perform physical b) Perform physical examinationexamination

c) Perform the following tests:c) Perform the following tests: Urine testsUrine tests Blood: syphilisBlood: syphilis Blood-group &RhBlood-group &Rh Hemoglobin (Hb):Hemoglobin (Hb):

d) Assess for referrald) Assess for referral Calculate LNMP,EDDCalculate LNMP,EDD Assess risk according to the Assess risk according to the

WHO classificationWHO classification DecideDecide

e) Implement the interventions e) Implement the interventions based on the assessmentbased on the assessment

f) Advice, questions and f) Advice, questions and answers, and scheduling the answers, and scheduling the next appointmentnext appointment

g) Maintain complete recordsg) Maintain complete records

1919

2222

Delivery servicesDelivery services

2323

Delivery servicesDelivery services Most of the times labor and birth have natural Most of the times labor and birth have natural

and good outcome. and good outcome.

However, there are conditions during labor and However, there are conditions during labor and child birth that contributes to maternal child birth that contributes to maternal morbidity and mortality. morbidity and mortality.

Most of these conditions can be avoided by Most of these conditions can be avoided by providing good quality delivery services.providing good quality delivery services.

2424

Delivery…Delivery…

Aims of delivery careAims of delivery care

To provide clean and safe (atraumatic) deliveryTo provide clean and safe (atraumatic) delivery

Recognition, early detection and management of Recognition, early detection and management of complications at health centre or hospital complications at health centre or hospital

2525

StrategiesStrategies

All women and their birth attendants should be aware All women and their birth attendants should be aware of the requirements for a clean delivery of the requirements for a clean delivery

The 5 cleans of deliveryThe 5 cleans of delivery Clean handsClean hands Clean delivery surfaceClean delivery surface Clean perineumClean perineum Clean cord cuttingClean cord cutting Clean environmentClean environment

2626

Strategies…Strategies… Health Health workers training workers training to practice clean and to practice clean and

safe delivery and avoid unnecessary procedures.safe delivery and avoid unnecessary procedures.

All women and their birth attendants should be All women and their birth attendants should be aware of the need to aware of the need to refer cases of prolonged refer cases of prolonged or obstructed labor to a higher level of care.or obstructed labor to a higher level of care.

All institutional deliveries should be monitored All institutional deliveries should be monitored using an appropriately adapted version of a using an appropriately adapted version of a partographpartograph in order to prevent prolonged labor. in order to prevent prolonged labor.

2727

Current Strategic focusCurrent Strategic focus

1.1. Skilled attendant at every birth Skilled attendant at every birth

2.2. Access to obstetric careAccess to obstetric care

3.3. Emergency referralEmergency referral

4.4. Progress monitoring using process Progress monitoring using process indicatorsindicators

5.5. Commitment from the governmentCommitment from the government

2828

1. 1. Current Strategic- Current Strategic- Skilled attendantSkilled attendant

Skilled care: refers to the care provided to a refers to the care provided to a woman and her newborn during woman and her newborn during pregnancypregnancy, , childbirthchildbirth and and immediately after birthimmediately after birth by an by an accredited and competent health care provider.accredited and competent health care provider.

2929

Skilled…Skilled…

Skilled attendant: An accredited health professional such as a An accredited health professional such as a

midwifemidwife, , doctor, health officer doctor, health officer or or nursenurse

Who has been educated and trained to proficiency Who has been educated and trained to proficiency in the skills needed to manage normal pregnancies, in the skills needed to manage normal pregnancies, childbirth and the immediate postnatal period, and childbirth and the immediate postnatal period, and in the identification, management and referral of in the identification, management and referral of complications in women and newborns complications in women and newborns

(WHO, 2004).(WHO, 2004).

3030

Contributions of skilled attendants Majority (2/3) of maternal deaths occur within Majority (2/3) of maternal deaths occur within

24-48 hours before and after delivery. 24-48 hours before and after delivery.

Therefore, skilled attendants can reduce this Therefore, skilled attendants can reduce this through early detection of complication and through early detection of complication and referral. referral.

This can be achieved when emergency referral This can be achieved when emergency referral is in place and emergency obstetric service is is in place and emergency obstetric service is accessible.accessible.

3131

Contribution… Contribution… Status of skilled attendantsStatus of skilled attendants

The ICPD goals = 80% by 2005 and The ICPD goals = 80% by 2005 and MDG goal = 90% by 2015 World wide.MDG goal = 90% by 2015 World wide.

However, in 2005, World-wide = However, in 2005, World-wide = 63.3%63.3%

59.3% in less developed countries 59.3% in less developed countries 33.9% least developed countries. 33.9% least developed countries.

Ethiopia (DHS 2000 & 2005)Ethiopia (DHS 2000 & 2005) 5.6% in 2000 5.6% in 2000 5.7% in 2005 5.7% in 2005

3232

Contributions…Contributions… Over the last five or six decades, maternal death Over the last five or six decades, maternal death

decreased in decreased in MalaysiaMalaysia and and Sri Lanka Sri Lanka in response to in response to improved access to health care in rural areas and the improved access to health care in rural areas and the introduction of professional midwifery. introduction of professional midwifery.

More recently, More recently, China, Costa Rica, Egypt, Indonesia, China, Costa Rica, Egypt, Indonesia, Jamaica, Jordan, Mexico and Thailand Jamaica, Jordan, Mexico and Thailand have have reduced MM by increasing the availability of skilled reduced MM by increasing the availability of skilled attendants and improving the referral system for attendants and improving the referral system for emergencies.emergencies.

‘‘In general, the higher the proportion of deliveries In general, the higher the proportion of deliveries by a health professional, the lower the maternal by a health professional, the lower the maternal mortality ratio.’mortality ratio.’

3333

2. Current Strategic- Obstetric Cares2. Current Strategic- Obstetric Cares

Obstetric care categoriesObstetric care categories

Essential obstetric care (EOC)Essential obstetric care (EOC)

Emergency obstetric care (EmOC)Emergency obstetric care (EmOC)

Obstetric First Aid (OFAObstetric First Aid (OFA))

3434

Essential Obstetric care (EOC)Essential Obstetric care (EOC)

EOC EOC is tis the elements of obstetric care for the mother & newborn needed for the management of normal and complicated pregnancy, delivery and the postpartum period.

Two types of EOC Basic Essential Obstetric Care (BEOC)Basic Essential Obstetric Care (BEOC) Comprehensive Essential Obstetric Care (CEOC)Comprehensive Essential Obstetric Care (CEOC)

3535

BEOC Vs CEOCBEOC Vs CEOCType of care CEOC BEOC Surgical obstetrics X Anesthesia X Blood replacement X Mxt of problems of pregnancy X X Medical treatment X X Manual procedures X X Monitoring of normal labor X X Neonatal special care X X Family planning X X

3636

Emergency obstetric care (EmOC)Emergency obstetric care (EmOC)

Life Life saving functions saving functions which can prevent the death of which can prevent the death of women experiencing the start of complications during women experiencing the start of complications during pregnancypregnancy, , deliverydelivery or the or the postpartum postpartum period. period.

Is a medical response to a Is a medical response to a life treating conditionslife treating conditions

Not a standard for all deliveries Not a standard for all deliveries

Two typs:Two typs: BEmOC:BEmOC: at a health center by nurse, midwifeat a health center by nurse, midwife or MD or MD CEmOCCEmOC: : at district hospital with OR & professional with at district hospital with OR & professional with

surgical skill surgical skill

3737

BEmOC Vs CEmOCBEmOC Vs CEmOC

Type of care BEmOC CEmOC Administer parenteral oxytocic drugs

x X

Administer parenteral Antibiotics

X X

Administer parenteral anticonvulsants for pre-eclampsia and eclampsia

X X

Perform manual removal of placenta

X X

Perform removal of retained products

X X

Perform assisted vaginal delivery

X X

Perform blood transfusions X Perform surgery (Caesarean sections & laparatomy)

x

3838

Obstetric First Aid (OFA)Obstetric First Aid (OFA)

Part of EmOC that is performed at the more Part of EmOC that is performed at the more

peripheral levelsperipheral levels

Early recognition of obstetric emergenciesEarly recognition of obstetric emergencies

Administration of parenteral antibioticsAdministration of parenteral antibiotics

Administration of parenteral oxytocics Administration of parenteral oxytocics

Administration of parenteral anticonvulsants Administration of parenteral anticonvulsants

Referral and transport arrangementsReferral and transport arrangements

3939

OFA…OFA…

N.B.N.B. Emergency Referral from BEmOC to CEmOC is Emergency Referral from BEmOC to CEmOC is

crucial component of safe motherhood. crucial component of safe motherhood.

Because, the median time period between the Because, the median time period between the onset of complication to death of a mother is too onset of complication to death of a mother is too short for some complicationsshort for some complications

PPH = 2Hrs PPH = 2Hrs Ruptured uterus = 1 day Ruptured uterus = 1 day Eclampsia = 2 days Eclampsia = 2 days Obstructed labor = 3 daysObstructed labor = 3 days

4040

Models of Successful Delivery CareModels of Successful Delivery Care Place of delivery

Delivery attendant

Home BEOC facility CEOC facility

Non-Professional

Model 1 lay provider recognizes complications; family organizes access to EOC Facility

Professional Model 2 professional recognizes comps, family or provider organizes EOC referral

Model 3 Professional recognizes comps, provides BEOC; facility organizes referral to CEOC

Model 4 Professional recognizes comps, prof. provides B and C EOC care

4141

Models of delivery…. Models of delivery….

Which model is best for Ethiopia?Which model is best for Ethiopia?

Why?Why?

4242

Models of delivery….Models of delivery…. Model 1: Model 1: MMR>100, Perinatal Mortality Rate>30MMR>100, Perinatal Mortality Rate>30

E.g. Rural China: MMR 115 (1995)E.g. Rural China: MMR 115 (1995)

Models 2-4: Models 2-4: MMR<50, PMR<20MMR<50, PMR<20 E.g. Malaysia: MMR 50 (1970s); Malaysia: MMR 43 E.g. Malaysia: MMR 50 (1970s); Malaysia: MMR 43

(1980-90s)(1980-90s)

Model 4: no guarantee of MMR<100Model 4: no guarantee of MMR<100 E.g. US: MMR 12; Mexico City: MMR 114 (1988)E.g. US: MMR 12; Mexico City: MMR 114 (1988)

Models 2 and 3 optimum models with referralModels 2 and 3 optimum models with referral

4343

POSTPARTUM CAREPOSTPARTUM CARE(PNC)(PNC)

4444

PNC…PNC… Is Care given after delivery for mother and new born. Is Care given after delivery for mother and new born.

The main life threatening complications The main life threatening complications Haemorrhage, Haemorrhage, Anaemia, Anaemia, Genital trauma,Genital trauma, Hypertension, Hypertension, Sepsis Sepsis UTI and UTI and mastitis. mastitis.

Therefore, all women should be assessed within 24 Therefore, all women should be assessed within 24 hours after delivery & within the first week of hours after delivery & within the first week of delivery. delivery.

4545

Aims of PNCAims of PNC

Maternal careMaternal care Early detection & Mgt of Complications Early detection & Mgt of Complications

Promotion and support to breastfeeding Promotion and support to breastfeeding

Information and services for family planning, Information and services for family planning,

nutrition, hygiene etc.nutrition, hygiene etc.

STD/HIV prevention and managementSTD/HIV prevention and management

TT immunisationTT immunisation

4646

Aims of PNCAims of PNC

Newborn care Newborn care The main components of newborn care The main components of newborn care

include:include: ResuscitationResuscitation Prevention and mgt of:Prevention and mgt of:

HypothermiaHypothermia OphthalmianeonatorumOphthalmianeonatorum Cord infectionsCord infections

Early and exclusive breastfeedingEarly and exclusive breastfeeding Recording of birth weight and referral of newborn Recording of birth weight and referral of newborn

for immunisations and growth monitoringfor immunisations and growth monitoring

4747

PNC frequencyPNC frequency

At least 2 timesAt least 2 times In first day, if not, in first weekIn first day, if not, in first week

Check for complicationsCheck for complications Establish BFEstablish BF Family Planning Information Family Planning Information

With in 6 weeks With in 6 weeks Maintain care given during 1Maintain care given during 1stst visit visit Advise on breast feeding, immunization, personal care Advise on breast feeding, immunization, personal care

and family planningand family planning

4848

Thank You!Thank You!