Maternal and Child Health and Family Planning

i World Health Organization ^йж Organisation mondiale de la Santé

EXECUTIVE BOARD Provisional agenda item 8 EB93/INF.DOC./3 Ninety-third Session 13 January 1994

Maternal and child health and family planning

This document presents a tabular summary of action in response to priorities set and recommendations made at the sixth meeting of the Expert Committee on Maternal and Child Health, in 1975, as well as the needs which have emerged since 1975, and related family planning policies and programmes.

The summary was presented to the seventh meeting of the Expert Committee in December 1993. EB93/INF.DOC. PRIORITIES SET AND RECOMMENDATIONS MADE AT THE SIXTH MEETING OF THE EXPERT COMMITTEE, IN 1975： HIGHLIGHTS OF SUBSEQUENT ACTION, ACHIEVEMENTS, PERSISTENT PROBLEMS AND EMERGING NEEDS

Priority needs or Achievements Recommendations of Policy and programme concerns identified (data from HFA 1983- 1988- the 6th EiKpert response: WHO or Remaining problems Emerging needs by the 6th Expert evaluation 1985 and 1985 1990 3 Committee in 1975 other since 1976 Committee in 1975 1991)

Inadequate coverage Extend PHC and WHA32.42 1.(2)- Prenatal care (%): Those most in need Structural adjustment support systems of Promote free services Developing countries: 48 65 (women, children, migrants, and cutbacks in public care to underserved for periods of high of which least rural and urban poor, services. Placement of risk; primary health developed: 45 53 refugees, aged, young) charges may decrease care. Childbirth - trained continue to have limited use of essential care. WHA31.55 - MCH attendant: access to services. Trends Uneven population coverage: Developing countries: 41 53 may be getting worse in growth, distribution, strengthening PHC. of which least some regions. migration, urbanization, WHA46.18 - MCH developed: 36 32 Coverage is a more need to be built into and FP for health. Infant care: complex issue than simply health planning. Developing countries: 43 64 ensuring the availability of Equity not being of which least services. Use of services addressed. developed: 36 56 involves perceptions, motivation, cultural and economic accessibility. Services still suffer lack of infrastructure, overstretching and management deficiencies.

Perinatal period and Give priority - ensure WHA45.22 - Newborn See above Pressing needs include: Toxic environmental early childhood intersectoral health as part of safe Breast-feeding strengthening training in exposures, substance neglected coordination - MCH motherhood; four protection, lactation management, abuse, HIV/AIDS integration with essential needs. promotion and clean delivery, resuscitation management, child overall services and WHA34.22 - Breast- support. and thermal control. neglect/abuse, part of feeding promotion to Maternal nutrition, psychosocial factors socioeconomic improve infant and infection control and affecting health and development young child health - decrease energy development. promotion of code. expenditure to decrease low birth weight, sustaining immunization coverage. Priority needs or Achievements Recommendations of Policy and programme concerns identified (data from HFA 1983- 1988- the 6th Expert response: WHO or Remaining problems Emerging needs by the 6th Expert evaluation 1985 and 1985 1990 Committee in 1975 other since 1976 Committee in 1975 1991)

Need for integration Develop a basic WHA32.20 on the Various component Many countries lack an Risks that aggressively of MCH within PHC package for delivery Alma-Ata Declaration elements developed: integrated delivery system set targets without an within primary health and the HFA strategy. Immunization - EPI; for MCH/FP in PHC. overall health care according to WHA32.42 - Follow- infection control - "Vertical" programmes with development and PHC local needs, social up to Alma-Ata ORS, sick child case own management, strategy will distort and cultural WHA46.18 - MCH/FP management; information and training programmes. characteristics and essential obstetric strategies supported by Development of district resources care and the external funding. health systems. mother/baby Need for further package; FP as an decentralization and focus essential element of on first referral level. MCH.

Care for mothers and Use of all contacts of WHA46.27 - The concept of Vertical management, Need for supporting children fragmented mother and child International year of "missed information and training legislation in health. and not family with health workers the family opportunities" structures for technology Coordination of policy. focused to provide applied EPI in some specific activities persist. Coordination with simultaneous delivery countries; Patient Rehabilitation not private sector especially of integrated Flow Analysis developed or integrated. NGOs. promotive, techniques applied to Integration of TBA training Identification of high- preventive, curative providing integrated supervision support in risk families and and rehabilitative MCH/FP care in MCH/Safe motherhood. support systems. action some countries. Evaluation of TBA programmes and their impact.

EB93/INF.DOC./3 EB93/INF.DOC./3 Priority needs or Achievements Recommendations of Policy and programme concerns identified (data from HFA 1983- 1988- the 6th Expert response: WHO or Remaining problems Emerging needs by the 6th Expert evaluation 1985 and 1985 1990 Committee in 1975 other since 1976 Committee in 1975 1991)

Health workers are Modify training for WHA46.17 - Health Little progress other than Emphasis on target not aware of factors intersectoral development in a advocacy in the areas of setting and technologies influencing health, orientation. Draw on changing world. MCH/FP not translated fails to put attention on nor the actual and community personnel Special attention to into training and (1) the understanding potential of other and resources, women and collaboration; campaign of the underlying basis sectors support from development, children approach is less effective of vulnerability, and community leaders. and young people. than using existing (2) the need for a PHC infrastructure where access and district supported to facilities exists. infrastructure to "carry" Incomplete understanding programmes. of linkages between health Need orientation of status and developmental health workers on and behavioural activities. prevention of unhealthy Limited experiences in lifestyles and linked community involvement. diseases including HIV, No clear mechanism for the AIDS, STDs, cancer, involvement of and stroke, cirrhosis, coordination with non- accidents. government sector. Need for strategic alliances with other sectors, particularly education and environment. Priority needs or Achievements Recommendations of Policy and programme concerns identified (data from HFA 1983- 1988- the 6th Expert response: WHO or Remaining problems Emerging needs by the 6th Expert evaluation 1985 and 1985 1990 Committee in 1975 other since 1976 Committee in 1975 1991)

Continued high levels Develop effective and WHA resolutions on Low birth weight Emphasis on the role of Nutritional and care of malnutrition and feasible interventions infant and young child men and other family implications of children its long-term effects, during pregnancy, feeding, International Developing countries: 22 13 members in prevention and having children; particularly as a lactation, childhood Code of Marketing of of which least management of problems. periconceptual result of infections and adolescence and BM Substitutes, and developed: 12 24 Elimination of harmful nutrition; implications and close child encouraging and micronutrients; Safe water supply: traditional practices of low birth weight and spacing facilitating BF and Innocenti Declaration; Developing countries: 55 68 affecting women and childhood nutrition weaning Plan of Action of of which least children's health. status for adult disease. International developed: 30 49 Addressing attitudinal Conference on Contraceptive use change and training of key Nutrition (%)•• health personnel closest to WHA45.34 - code. Developing countries: 34 women and children in WHO/UNICEF of which least need of care. meeting on young developed: 8 Raising status of women child feeding and girls especially by WHA46.7 - ending the traditional International discrimination against the Conference on girl child. Nutrition. WHA31.53 - immunization. WHA35.31 - immunization.

Effective Develop Targets set by Global coverage: Coverage decreased slightly Interaction between 4 % S39085803%4 immunization during immunization WHA44.33 - DTP3: 1991; vertical programmes. HIV infection and 4к^ % % procedures as Sustainability (costs) and other immunizable pregnancy and Child summit goal. BCG: 5 о % % childhood should be integral part of MCH WHA46.33 - Polio: political commitment. childhood infections 5 adapted to local care with other Poliomyelitis. Measles: % % Strengthen management and diseases. о EB93 conditions complementary WHA46.36- TT2: 2 % % logistics support, laboratory 4 approaches Tuberculosis. services. WHA42.32 - Neonatal INF.DOP3 tetanus. EB93/INF.DOC./3

Priority needs or Achievements Recommendations of Policy and programme concerns identified (data from HFA 1983- 1988- the 6th Expert response: WHO or Remaining problems Emerging needs by the 6th Expert evaluation 1985 and 1985 1990 Committee in 1975 other since 1976 Committee in 1975 1991)

Need for linking Integrate FP WHA41.9 linking FP Integration FP is not integrated in Build on concept of MCH and FP education and care in to health and widespread for other areas of health care. reproductive rights and demonstrated but not MCH and other development - urging MCH/FP FP denied to unmarried choice. generally applied in health care. FP integration with Coverage = women - need for new Needs for adapting to policies or Education and MCH. FP integration in legislation. adolescent RH. programmes legislation requires WHA30.44 - Health MCH generally Links between FP and Need for coordination multidiscipline legislation in health accepted - often not STD/AIDS prevention not MCH/FP with approach. services strengthening operational in many operational. STD/AIDS PHC. countries. Need to address large programmes. WHA38.22 - unmet need for Adolescent contraception through reproductive health. innovative approaches. WHA32.42 - Alma Look at the effective Ata: MCH, nutrition, implementation of FP as family planning and intervention strategy for immunization essential Safe Motherhood. PHC aspects. Concept of quality of care needs to be accepted and generalized. Priority needs or Achievements Recommendations of Policy and programme concerns identified (data from HFA 1983- 1988- the 6th Expert response: WHO or Remaining problems Emerging needs by the 6th Expert evaluation 1985 and 1985 1990 Committee in 1975 other since 1976 Committee in 1975 1991)

Need to define Provide integrated Programme packages Training modules for Little integrated training, Need for alternative essential MCH care training for all levels developed: EPI, specific technologies: undergraduate medical learning methods for package and provide of health workers, diarrhoeal disease， EPI, CDD, ARI, training virtually unchanged. clinical and programme suitable training, including safe motherhood - SMI, sick child. Territoriality and inertia. problem solving. including community undergraduate mother/baby package. Training package for Integration of TBA in Need to reorient MCH medical education Joint UNFPA/ TBAs; master MCH services not training and approach. UNICEF/WHO trainers for TBAs. addressed adequately in statement on TBAs' many countries. safe motherhood Effective approaches for initiative. community involvement and WHA30.48 - Health mobilization. Persistent manpower issues remain unsolved, i.e. development, supervisory referral and midwifery and nursing logistical backup support training. from MCH services. WHA36.11 - Nursing, Need emphasis on IEC midwifery: role in component of services. providing health services for effective PHC development. WHA42.27 - Training nursing, midwifery personnel, reorient education, legislation and regulations.

Need to define the Develop simple, WHA42.44 - Public International driven Quality of information Risk of overloading of minimum reliable information information and health targets have raised remains poor when used in information systems information for all systems for local use education awareness of one-way flow; and burdening system aspects of MCH for in monitoring information needs. dissemination, adaptation through ad hoc systems. planning, monitoring programmes, "Bottom-up" methods and application of methods EB93/INF.DOC./3 and evaluation for channelling to developed. programme impact regional and central levels with feed-back EB93/ZF.DOC./3 Priority needs or Achievements Recommendations of Policy and programme concerns identified (data from HFA 1983- 1988- the 6th Expert response: WHO or Remaining problems Emerging needs by the 6th Expert evaluation 1985 and 1985 1990 Committee in 1975 other since 1976 Committee in 1975 1991)

School health Teachers to be used Launching concept of Progressive Develop of school health Empowerment of programmes not for health education. comprehensive school implementation of policy, legislation and families through realizing potential. Strengthen school health programmes. comprehensive school ñnancial support. school - health. Not involve students health programmes health programme Intersector coordination Reduce cumulative or teachers in PHC with full participation including services between health and impact of risk factors. and community of students, teachers health education, education sectors. development. and nurses aides healthful NGOs, teachers unions and environment and private sector making other health-related fragmented and meagre components. efforts. Missed opportunities for improving coverage of information and services for children and their families. TABLE 2. NEWLY EMERGING NEEDS IN MCH/FP

Newly emerged needs (1975-1993) - not Policy and programmes' identified by the 6th Achievements Remaining problems resolutions Expert Committee meeting，1975

Women's health -WHA38.27 (1985) on women, health 1975- 1985- -Sexual discrimination: violence and development 1980 1990 against women; son preference; -WHA38.22 (1985) on maturity before -Increased women's global -Malnutrition and anaemia; childbearing and promotion of life expectancy at birth: 62.1 65.9 -High-risk fertility patterns; responsible parenthood -Increasing cancer incidence. -WHA39.18 (1987) on implementation Regions: of the Nairobi Forward-looking Strategies for the Advancement of Africa 49.5 53.6 Women North America 77.3 79.2 -WHA42.42 (1989) on women's health Látin America 65.8 69.5 -WHA42.32 (1989) on neonatal tetanus Asia 58.9 63.9 (EPI) Europe 75.8 77.7 -45th World Health Assembly: technical discussions on women, health and development -UN 34/180 (CEDAW) -UNFPA Amsterdam Declaration

EB93/INF.D0C./3 EB93/IZF.DOC./3 Newly emerged needs (1975-1993) - not Policy and programmes' identified by the 6th Achievements Remaining problems resolutions Expert Committee meeting, 1975

Maternal health -WHA39.18 (1987) s.a. 1983- 1988- 1983 1991 -WHA40.27 (1987) on maternal health 1985 1990 -Global maternal mortality rate (per and safe motherhood Establishment of health-for- 100 000 live births): 390 370 -WHA45.5 (1992) on strengthening all global indicators nursing and midwifery concerning maternal health: -Regions: -WHA46.17 -Prenatal care: global Africa 640 coverage by trained North America personnel (per 100 live Latin America 270 births) 58 67 Asia 420 -Immunization of pregnant Europe 29 women: global coverage by tetanus toxoid vaccination -Global annual total of 500 000 in % 24 34 maternal deaths. -Childbirth attendance: global coverage by trained personnel (per 100 live births) -Establishment of maternal 53 55 health and safe motherhood programme 1987: Guidelines and training modules for midwives and ТВ As; mother/baby package; research on maternal mortality; women's health database

Women and HIV -Paris Declaration on Women, Children -Establishment of the -> 3 million HIV-infected women in and AIDS (1989) Global Programme on world (1992); -WHA43.10 (1990), adoption of Paris AIDS (1987) _ cumulative total of > 600 000 AIDS- Declaration cases among women (1992). Newly emerged needs (1975-1993) - not Policy and programmes' identified by the 6th Achievements Remaining problems resolutions Expert Committee meeting, 1975

Women and children in -International Convention -Operationalizing policy, coordination difficult circumstances on the Rights of the Child and collaboration in multisectoral approaches; -Violence to and abuse of women and children in situations of war and displacement.

Quality of care -WHA45.34 -Quality of care recognized -Discrepancy between coverage arid in BFHI - including links to impact; lack of community/health breast-feeding support system partnership; social distance of groups health providers and community; need for communication skills.

Traditional practices _ WHA46.18 -Network of NGOs in 26 -Accelerating local action, affecting women and countries programme developmeiit linked to children -Inter-African discrimination and their social status. Communique

EB93/INF.DOC./3

-л. EB93/INF.DOP/3 гчз FAMILY PLANNING POLICIES AND PROGRAMMES： A REGIONAL PERSPECTIVE

Demographic evolution Regions Policies and programmes Coverage* Unmet needs Reorientation (latest data)

Latin High population awareness; 1992: Modern Latin America: 43% of married women -From contraception to reproductive America emergence of a regional methods Crude birth rate 30/1000 who want no more health of population and the "population consciences" prevalence Average population children are not using -Increasing modern contraceptive use Caribbean population policies often part 10-74% growth rate 2.2% any contraceptive -Addressing adolescent reproductive of national development method. needs plans. By and large Caribbean: Estimated 4.6 million -Building partnership with Government governments have Crude birth rate 24/1000 unsafe abortions per year. and NGOs internationalized population Average population -Improving management programme; establishment of growth rate 1.4% -Towards sustainability national commission; population issues are part of development plans; establishment of sectoral programme strong health and women's rights component in many countries.

Africa Highest birth rates in the 1988-89: Any Highest birth and population 77% of married women FP remains world; population issues are method range growth rates globally who want no more -constrained to MCH services. part of political agenda. from 5% to 50%; children are not using Few countries made thrust towards 32 countries with public Modern methods Crude birth rate 45/1000 any contraceptive community-based distribution of sector FP; 17 with from l%-40% but Average population method. contraceptives and involvement of government support to with only a very growth rate 3.0% Estimated 3.3 million private sector. private FP programmes; few countries with unsafe abortions per year. -Need to explore variety of channels population distribution high > 10% through ^diich FP services can be concern; integration of MCH delivered safely and effectively. and FP as national policy and major outlet for FP (not always operationally supported by some donors in the past). Demographic evolution Regions Policies and programmes Coverage* Unmet needs Reorientation (latest data)

Middle Recognition of health and 1988: Any Crude birth rate 35/1000 57% of married women The term FP was not acceptable East development implications of method 10%- Average population who want no more officially in several countries. The population growth; 63%; Modern growth rate 2.8% children are not using population rationale of FP is not acceptance of integration of methods 6%-45% any contraceptive relevant for many EMR countries. MCH and FP increasing; method. Today, FP as a component of MCH is slow progress of FP Estimated 380 000 unsafe the usual norm in most countries. programmes even in the few abortions per year. Reproductive health awareness is an countries with strong important target in most MCH commitment; still high rate programmes. of population growth but The global and national women's health widening acceptance of the movements include fertility regulation health rationale for family as a basic human right. planning.

Asia Nearly all countries have Modern methods South Asia: 57% of married women In Asia Pacific, family planning will be population policies and South Asia: 34% Crude birth rate 35/1000 who want no more better integrated with other health measures implementation of East Asia: 5-74% Population growth rate 2.3% children are not using programmes especially primary health programme facilities by South-east South-east Asia: any contraceptive care; national family planning and strong planning tradition and Asia: 4-62% Crude birth rate 21-43/1000 method. population policies will emphasize experience; FP programmes Average population Estimated 10.3 million health benefits of family planning more; in place and successful for at growth rate 1.3-3.5% unsafe abortions per year. health will be more integrated with least 2 decades; status of East Asia Pacific: other social and economic sectors. women strongly linked to Crude birth South-east Asia: less 1990 - Bhutan endorsed a population programme success. rate 10.5 to 31.9/1000 than 50% of women in policy and adopted small family norm. Average population child bearing age practice 1989 - Myanmar adopted position of growth rate 0.64-3.3% contraceptives. maintaining the population growth rate without intervention but included child spacing in routine health and welfare activities. Maldives are making contraceptives available at the PHC level in spite of population policy of non-intervention. EB93/INF.DOP/3

Co EB93/SF.DOP/3 Demographic evolution Regions Policies and programmes Coverage* Unmet needs Réorientation (latest data)

Europe FP services generally widely Average in West Europe: Migrant groups, FP just starting in Central Asian available; abortion still major western Europe: Crude birth rate 12/1000 adolescents，and Republics, changes in abortion means for regulating fertility 70% Average population traditional families legislation under review or made in in many eastern European growth rate 0.1% outside FP network. several countries. countries and many former East Europe: Estimated 260 000 unsafe republics of the USSR. Crude birth rate 13/1000 abortions per year (excl. Average population Republics of the former growth rate 0.2% USSR which is estimated at 2.1 million).

* Contraceptive prevalence among women in fertile age married or m union.