SUSANA O. PABINGUIT, B.S.N., R.N.SUSANA O. PABINGUIT, B.S.N., R.N.DOH-Central VisayasDOH-Central Visayas

Outline of Presentation:

Current Situation of Maternal and Child Health

DOH Issuances on MNCHN

Essential Package of Maternal and Child Survival Interventions

Essential Newborn Care

Millennium Development GoalsAdopted by the UN General Assembly in

September, 2000 Renewal of global commitment to peace and

human rightsSet specific goals and targets towards reducing

poverty and worst forms of human deprivationPhilippines has committed to craft its 2005-2010

Medium Term Philippine Development PlanEight goals that are holistic and interrelated,

entailing collaborative efforts of major stakeholders

Source: LGU Guide on MDG Localization

Millennium Development Goals (MDGs)Goal 1: Eradicate Extreme Poverty and Hunger

Goal 2: Achieve Universal Primary Education

Goal 3: Promote Gender Equality

Goal 4: Reduce Child MortalityGoal 5: Improve Maternal Health

Baseline : 209, Target: 109 (2000) 52 (2015)

Goal 6: Combat HIV and AIDS, malaria and other diseases

Goal 7: Ensure environmental sustainability

Goal 8: Develop a global partnership for development

MDG 4 & 5 and TargetsReduce Child MortalityReduce children under-five mortality by 2/3

Improve Women’s Reproductive HealthReduce maternal mortality rate by 75%Increase access to reproductive health

services to 60% by 2005, 80% by 2010, 100% by 2015

Current Health Situation in the Philippines

Maternal Mortality Ratio:

162 per 100,000 live births

In other words…

If there were 10,000 babies born, 1-2 mothers died in pregnancy, labor, delivery and post-partum period

So, instead of a happy arrival,

There was an unhappy departure.

Relatively Flat MMR Reduction, Philippines

Figure 2: Trend in Maternal Mortality Ratio 1990-2005

209 203 197 191 186 180 172 162

52.50

50

100

150

200

250

1990 1991 1992 1993 1994 1995 1998 2006 2015

MMR MDG

Current Health Situation in the Philippines

Under 5 Mortality Rate (below 5 years old):

36 per 1,000 live births

In other words…

If there were 1,000 babies born, 36 died before their 5th bday

So, instead of a Nursery School,

They entered a cemetery.

Current Health Situation

in the Philippines

Infant Mortality Rate (below one year old):

27 per 1,000 live births

In other words…

If there were 1,000 babies born, Almost 27 died before one year

So, instead of a happy 1st birthday,They had a sorrowful death.

Causes of Death in ChildrenCauses of Death in Children

Source: CHERG estimates of under-five deaths, 2000-03; courtesy of Sobel HL.

The Philippines is one of the 42 countries that account for 90% of global under five mortality

Under-nutriti

on53%

Child Mortality Trends Downward trend

in childhood deaths but,

Slowed down in the past decade

Neonatal mortality remained unchanged

72

52

43 4234

46

34 31.3 302528

18 17 17 16

0

10

20

30

40

50

60

70

80

1988 1993 1998 2003 2008UFMR IMR NMR

When are the Newborns Dying?

21 J uly 200721 J uly 2007

0

5

10

15

20

25

30

35

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28

Figure 3: Deaths of Neonates by Day of LifePhilippines 1998-2003

Day of Life

Num

be

r o

f de

ath

s

50% of neonates die in the first two days of life

DOH. Child Survival Strategy. July 2007. Courtesy of Sobel HL.

50% of all newborn deaths occur in the first 2 days of life

3 out of 4 newborn deaths occur in the 1st week of life

Poor birth spacing too young too old too close too many pregnancies too sickly - Mothers with:

* Prevalent infections (TB, Malaria, STI) or

* Lifestyle diseases (diabetes, hypertension)

Maternal malnutrition

Mothers and newborns (0-28 days) dying every year…

Main causes of maternal deaths:

1. Hypertensive disorder of pregnancy2. Post-partum hemorrhage3. Pregnancy with abortive outcomes

Main causes of neonatal deaths:

1. Pre-term2. Infection3. Asphyxia

>80% of Maternal Deaths are due to 5 DIRECT OBSTETRIC COMPLICATIONS>80% of Maternal Deaths are due to 5 DIRECT OBSTETRIC COMPLICATIONS

27%

19%17%

11%

11%

15%

Hemorrhage

Unsafe Abortion

Eclampsia

Obstructed Labor

Infection

Other

Indirect causes include anemia, malaria, and heart disease Indirect causes include anemia, malaria, and heart disease

Source: Philippine Health Statistics, 2003

Attendants and Place of Delivery

40%

22%

38%

Home, hilotHome, MWHospital

AssessmentVery slow decline of MMR in past 20 yearsMaternal deaths account for 14% of deaths among

women of reproductive ageMaternal death triggers other adverse consequences in

families: orphans, loss of family care provider17 infants die per 1,000 live births within first 28 days of

lifeMostly within first week after birthHalf die during the 1st 2 days

Policy DevelopmentsAdministrative Order 2008-0029 (Sept. 9, 2008) – Implementing Health

Reforms for Rapid Reduction of Maternal and Neonatal Mortality

Administrative Order 2009-0025 (Dec. 01, 2009) – Adopting New Policies and

Protocol on Essential Newborn Care

Policy ObjectiveReduce maternal and neonatal mortality

rates faster from 2007 to 2015 in order to meet MDG targets

However, we need to understand features and characteristics of maternal and newborn deaths to focus our interventions.

Implementing Health Reforms for Rapid Reduction

of Maternal and Newborn Mortality

General Principles of MNCHN

Integrated MNCHN Service Package

Core Service Package(Life Cycle Approach)

Pre-pregnancy package of services Complete pre-natal package Complete care during delivery Immediate postpartum and neonatal Emergency maternal and newborn service package

Pre-pregnancy packageMicro-nutrients (Iron w/ folic acid)Tetanus-toxoid immunizationsFertility awareness, birth spacing and FP counsellingNutrition and healthy lifestyleOral healthCounselling and services on STD/HIV/AIDSManagement of lifestyle related diseases

Pre-Natal packageMonitoring of height and weightBlood pressure determination and monitoringPregnancy test, urinalysis, CBC, blood typing, STI screening Pap smear and acetic acid wash, blood sugar determinationMicro-nutrient supplementationTetanus toxoidMalaria prophylaxisBirthplanning

Pre-Natal package Counselling on FP methods ( LAM, BMF

contraceptives) Counselling on healthy lifestyle Prevention and management of bleeding in early

pregnancy Early detection and management of danger signs

and complications of pregnancy Assessment of fetal growth and well being Prevention and management of other diseases Provision of other support services

Childbirth Service PackageMonitoring progress of labor using the partographIdentification of early signs/symptoms and

appropriate managementThe 3 Cs of childbirthNo episiotomy and no fundal pressureActive management of the third stage of laborEssential Newborn Care Package

Obstructed labor

Post-partum service packagePhysical Exam ( BP monitoring, pelvic exam)Identification of early signs and symptoms of

postpartum complications like hemorrhage, infection and hypertension

Micronutrient supplementationProvision of FP services Counselling on

Nutrition Exclusive breastfeeding up to six months neonatal care

Neonatal Care(w/in 24 hours postpartum routine care)Cord careVitamin K injection Eye prophylaxisDelayed bathing to 6 hours of lifeBCG and Hepatitis B Immunization Newborn screeningBirth registrationCounselling on post-partum/post-natal check-up, home care

and immunization

Levels of Core Service Package(Interventions)

BEmONC level

EmONC CEmONC level

STRATEGIC PLANS FOR 2005-2010Launch & implement the BEmOC & CEmOC strategy BEmOC strategy – establishment of facilities for every 125,000 population, can be reached within 30 minutes from each catchment brgy

CEmOC strategy – for every 500,000 population; referring facility, reached within 1 hr. from BEmOC facility

Basic Emergency Obstetrics and Newborn Care (BEmONC)

Parenteral administration of oxytocin in the third stage of labor

Parenteral administration of loading dose of anti-convulsant

Parenteral administration of initial dose of antibiotics

Assisted delivery during imminent breech presentation

Bleeding

Pre-eclampsia

Infection

BEmONC (continuation)Manual removal of placentaRemoval of retained placental products Administration of loading dose of

corticosteroids for threatened pre-mature delivery

Newborn resuscitation w/ oxygen supportEssential Newborn Care

BleedingBleeding &infection

Neonatal death

Comprehensive Emergency Obstetrics and Newborn Care (CEmONC)

BEmONC Parenteral administration of oxytocin in the third stage of labor Parenteral administration of loading doses of anti-convulsant Parenteral administration of initial dose of antibiotics Assisted delivery during imminent breech delivery Manual removal of placenta (active management of 3rd stage of

labor) Removal of retained placental products Administration of corticosteroids for threatened pre-mature

delivery Newborn resuscitation Essential Newborn Care

Operative delivery ( C. Section ) Blood transfusion services Advanced life support management for low birth weight,

premature and sick newborn like sepsis, asphyxia, severe birth trauma, severe jaundice, etc.

MNCHN Service Delivery NetworkEnd-referral facility (Provincial hospitals etc), BEMONC functions + Blood transfusion &

Cesarean Section; Operates 24 hrs, with OB/surgeon, pedia, nurse, MW, med techCEmONC

BEmONC FACILITY

District Hospitals, RHUswith SHPs

Community Level Service Provider:RHU, BHS, WHT, BHT

Normal vaginal delivery, imminent breech delivery, emergency drugs (antibiotics, MgSO4, oxytocin), Essential newborn care, FP services

Pregnancy tracking, birth planning, home visits and follow-up, nutrition package; IEC on facility

delivery and FP; communication activities targeted to mothers and their families

TRANSPORTATION and COMMUNICATION SYSTEM

From ...Birth control

Population controlLimiting family numbers

Liquidating a raceContraceptives

Birth spacing tools

Repositioning Family Planning as a Program & Family Planning Commodities

To ...Rights based: know, informed, choose, useHealth concerns: maintenance and sustenance;

prevention and control of diseasesEconomic reasons/family financial stabilityContinuum of service: MNCHN contextInclusion of fertility problemsInclusion of other modern methods available

Life’s Events and Continuum of Service

Pre-union:Premarital sexPremarital counselling

3-yr &3 years after

Birth

Delivery

Conception

Pregnancy

INDIVIDUAL HOME COMMUNITY FACILITIES

Approaches...Decentralized (social prep.; things not to expect)Rights’ based (from the womb)Life cycleLife’s events

“sense of urgency, focus, consolidated efforts and recognition on the MATERNAL, NEONATAL & CHILD HEALTH AND NUTRITION (MNCHN) and its INTEGRATED strategies”

Pregnancies and Deliveries ...As emergencies whether for the so-called rich or poorMaternal and infant deaths as reportable casesBlood as a public goodContinuum of services from premarital/unionPregnant Patient RightsFacility modification Imposed/Purposive messages

fbd or fbcshp or sba6mos. EB vs. LAM3yrs spacing

TBAs ...Incentives to refer deliveries

Join a Barangay Health Team or the Women’s Health Team

Qualified TBAs provided educational assistance to become midwives

Components ...BEmONCsCEmONCsWBCs3Tiered and 4Tiered ServicesWHT/CHTTraining CentersPhilHealth accredited MCP Plus (Unbundling)DatabaseTracking and Monitoring (TCL, Deaths daily)Networks and birth plans including Blood Centers

“BUNTIS Connection”FacilitiesProfessionalsBloodTransportation servicesCommunication servicesFollow-up services

“GET CONNECTED!!!”

Essential Newborn Care

Adopting New Policies and Protocol on Essential Newborn Care (A. O. No. 2009 - 0025)

Objectives:- Guide health workers and medical practitioners in providing evidence-based essential newborn care- Define the roles and responsibilities of the different DOH Offices and other agencies in the implementation of the Newborn Care Protocol

Essential Newborn Care

A package/bundle of interventionsEssential interventions in the first hour and first day to one

week of lifeEmphasizes a core sequence of actions or steps Some time-bound but doable even by a single health worker

caring for both mother and newborn

Rationale

If newborn mortality is not reduced by at least half, the goal of reducing childhood mortality by two-thirds (MDG Goal no.4) by 2015 would not be met.

Intervention Percentage and Median Time

WHO Standard

Cord Clamp 12 sec99% in < 1 min

Until pulsations stop (1-3 mins)

Drying 97% at 1 min 100% Immediately

Immediate Skin-to-skin contact

9.6% at 5 min >90% (except those needing resuscitation)

Put on cold surface 12% None

Not dried 2.5% None

Head not dried 6.2% None

Wash 84% at 8 min >6 hours

Temp taken before 17% All

A Minute-by-Minute Assessment of Newborn Care within the First Hour of Life in Philippines Hospitals (2009)

Sobel, Silvestre, Mantaring, Oliveros, 2009

Within 30 SecondsObjective:•To provide warmth, prevent hypothermia

After thorough dryingObjective:•To facilitate bonding through STS (infection, hypoglycemia)

-Put on double Gloves-Dry thoroughly-Remove wet cloth-Quick check of NB’sbreathing

-Put prone on chest/ abdomen in STS-Cover w/ blanket, bonnet-Place identification on ankle-Do not separate-Do not remove vernix

Up to 3 minutesPost-deliveryObjective:•To reduce incidence anemia in term and IVH in pre- term

-Remove 1st set of gloves-Clamp and cut cord after cord pulsations (1-3 mins)-Do not milk cord-Active management of labor

Time-Bound Interventions

Within 90 minutesOf ageObjective:•To facilitate initiation of breastfeeding through sustained contact

-Leave the NB on STS contact-Observe NB for feeding cues-Counsel on positioning and attachment** Do eye care

Non-Immediate Interventions Vit. K Hepatitis B BCG Re-Examination of the newborn

- Weigh- Look for malformations, etc.- Feeding difficulties

Cord Care Newborn Screening

Unnecessary ProceduresRoutine suctioningEarly bathing/washing FootprintingGiving sugar water, prelacteals, formula and using

bottles and pacifiersApplication of alcohol, other subs on the cord stump

and bandaging the stump/ abdomen

Non-separation of the newborn from the mother for early breastfeeding

initiation and rooming-in

Immediate and thorough drying of the newborn

Early skin-to-skin contact of the newborn to

mother’s skin

Properly-timed cord clamping and cutting

1. Skilled attendance during pregnancy, childbirth and the immediate postpartum

2. Care of the newborn3. Breastfeeding and complementary feeding4. Micronutrient supplementation

5. Immunization of children and mothers

6. Integrated management of sick children7. Injury Prevention and Control

8. Birth Spacing

Essential package of child survival interventionsEssential package of child survival interventions

Challenges . . .

Expanded appreciation and advocacy of various factors affecting overall health of mothers and children

Collaborative work with other health workers and local government leaders

Advocacy towards good nutrition foundation e.g. Breastfeeding initiation, exclusive breastfeeding, rooming-in

The current state of maternal and child care needs urgent action!Maternal and Child survival package of

interventions will save thousands of lives

Each of us, as health workers and as individuals, have to look inward to find ways and influence in implementing the essential package of maternal and child survival interventions.

CLOSING THOUGHTS

Let’s Let’s join join

HANDS!HANDS!

. . In . . In supporting supporting

MNCHN MNCHN Strategy!Strategy!

Good day to all !