(WP)IRPH/ICPIRPH/2.3/001/RPH(2)/2006-E
Report series number: RS/2006/GE/34(CHN) English only t l REPORT CONSULTATION ON HUMAN RESOURCE DEVELOPMENT IN MAKING PREGNANCY SAFER
' Convened by: WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR SOUTH-EAST ASIA REGIONAL OFFICE FOR THE WESTERN PACIFIC
Shanghai, China 26 - 28 September 2006
Not for sale
Printed and distributed by:
World Health Organization Regional Office for the Western Pacific Manila, Philippines
April2007
CONTENTS
SUMMARY ...... 1
1. INTRODUCTION ...... 2 1.1 Objectives ...... 2 1.2 Participants ...... 2 1.3 Appointment of Chairperson, Vice-Chairperson and Rapporteur ...... 2 1.4 Organization ...... 2
2. PROCEEDINGS ...... 3 2.1 Opening ceremony ...... 3 2.2 Overview of the consultation ...... 3 2.3 Presentation of background papers ...... 3 2.4. Presentation by WHO collaborating centres ...... 5 2.5 Presentations by professional associations ...... 6 2.6 Introduction to and familiarization with the IMP AC guidelines ...... 6 2.7 Presentation of"best practices" ...... 7 2.8 The role and responsibilities of WHO collaborating centres ...... 7 2.9 Group work ...... 7 2.10 Evaluation ...... 10 2.11 Field visit ...... 10 2.12 Closing ceremony ...... 10
3. CONCLUSIONS ...... 10
ANNEXES:
ANNEX 1 - LIST OF TEMPORARY ADVIERS, CONSULTANT, REPRESENTATIVES/OBSERVERS AND SECRETARIAT ...... 13
ANNEX 2 - AGENDA AND PROGRAMME OF ACTIVITIES ...... 19
ANNEX 3 - OPENING REMARKS OF DR HENK BEKEDAM ...... 23
ANNEX 4 - PRESENTATIONS OF BACKGROUND PAPERS ...... 27
ANNEX 5 - PRESENTATIONS OF WHO COLLABORATING CENTRES ...... 51
ANNEX 6 - PRESENTATIONS OF PROFESSIONAL ASSOCIATIONS ...... 93
ANNEX 7 - PRESENTATION ON INTEGRA TED MANAGEMENT OF PREGNANCY AND CHILDBIRTH (IMPACT) GUIDELINES, DR JELKA ZUPAN ...... 133
ANNEX 8 - PRESENTATIONS OF COUNTRY "BEST PRACTICES" ...... 155 NOTE
The views expressed in this report are those of the participants in the Consultation on Human Resource Development in Making Pregnancy Safer.
This report has been prepared by the World Health Organization Regional Office for the Western Pacific for governments of Member States in the Region and for those who participated in the Consultation on Human Resource Development in Making Pregnancy Safer, held in Shanghai, China from 26 to 28 September 2006. SUMMARY
A Consultation on Human Resource Development in Making Pregnancy Safer was held from 2G to 28 September 2006 in Shanghai, China.
The objectives of the workshop were:
(1) to share experiences and lessons on providing universal coverage of skilled attendants, capacity building and research on reduction of maternal, perinatal and newborn mortality and morbidity;
(2) to familiarize the participants with the WHO global and regional strategies on making pregnancy safer, and the manuals and guidelines on integrated management of pregnancy and childbirth; and
(3) to identify ways in which professional associations and WHO collaborating centres involved in maternal and newborn health can partner with governments in making pregnancy safer and in reducing maternal, perinatal and neonatal mortality.
The consultation targeted seven priority countries in the Western Pacific Region: Cambodia, China, the Lao People's Democratic Republic, Mongolia, Papua New Guinea, the Philippines and VietNam. The maternal, perinatal and newborn mortality rates in these countries are unacceptably high despite strong government commitment and purposeful activities. Mortality rates can be reduced through specific and deliberate efforts that focus on providing universal access to skilled attendants during pregnancy and at childbirth. Unfortunately, the health systems of these priority countries lack competent, motivated and supported health workers. Much more needs to be done to strengthen human resources in the health systems of the priority countries.
WHO has developed and disseminated several reports, strategy papers, manuals and guidelines, such as the evidence-based guidelines on the Integrated Management of Pregnancy and Childbirth (IMPAC). However, these guidelines have not been optimally disseminated and used by health professionals outside government institutions, such as obstetricians, nurses and midwives, who can contribute to making·pregnancy safer. The WHO collaborating centres involved in the areas of reproductive, maternal and child health can contribute towards human resource development in making pregnancy safer but have not been fully and directly involved in the use of these guidelines.
Thus, a consultation was organized for representatives of government, professional associations and collaborating centres to discuss these reports, strategy papers and guidelines; to share experiences and ideas; and to strengthen partnerships among them.
The three-day consultation was well received by the participants, and its objectives were met. The collaborating centres and professional associations (for obstetricians, gynaecologists, nurses and midwives) are now more aware of the ne~d for human resource development in making pregnancy safer, and of their roles in contributing towards this goal. - 2-
1. INTRODUCTION
A Consultation on Human Resource Development in Making Pregnancy Safer was held from 26 to 28 September 2006 in Shanghai, China. The consultation focused on human resource development in Cambodia, China, the Lao People's Democratic Republic, Mongolia, Papua New Guinea, the Philippines and VietNam. In these seven priority countries, maternal and newborn health status is still unsatisfactory, and maternal and perinatal mortality rates are still unacceptably high. Much more could be done in strengthening human resources if governments collaborated with professional associations for obstetricians, gynaecologists, nurses and midwives, and with the WHO collaborating centres involved in maternal and newborn health. WHO has formulated global and regional strategies for making pregnancy safer, and has developed several manuals and guidelines for the same purpose, such as the evidence-based Integrated Management of Pregnancy and Childbirth (IMPAC) guidelines. This consultation provided a platform for professional associations and collaborating centres to identify their roles in making pregnancy safer, especially in the area of human resource development, including the use ofthe evidence-based guidelines.
1.1 Objectives
(1) To share experiences and lessons on providing universal coverage of skilled attendants, capacity-building and research on reduction of maternal, perinatal and newborn mortality and morbidity.
(2) To familiarize the participants with the WHO global and regional strategies on making pregnancy safer, and the manuals and guidelines on integrated management of pregnancy and childbirth.
(3) To identify ways in which professional associations and WHO collaborating centres involved in maternal and newborn health can partner with governments in making pregnancy safer and in reducing maternal, perinatal and newborn mortality.
1.2 Participants
The consultation was attended by 30 temporary advisers who were representatives of professional associations (e.g. obstetricians, perinatologists, midwives), national policy-makers and managers ofhealth programmes (e.g. health system reporting, human resource development, making pregnancy safer), and the directors or managers of 10 collaborating centres on maternal and newborn health care. A consultant, six observers from relevant institutions and nine WHO staff members also participated (Annex 1).
1.3 Appointment of Chairperson, Vice-Chairperson and Rapporteur
Dr Wang Bin of China was appointed Chairperson; Dr Mario Festin, Board Secretary, Philippine Obstetrical and Gynecological Society, Inc., as Vice-Chairperson; and Dr Elizabeth Bennett, Key Centre for Women's Health in Society, WHO Collaborating Centre for Women's Health, as Rapporteur.
1.4 Organization
The agenda and programme of the three-day consultation are in Annex 2 - 3 -
2. PROCEEDINGS
2.1 Opening ceremony
Dr Henk Bekedam, WHO Representative for China, gave opening remarks on behalf of Dr Shigeru Omi, WHO Regional Director for the Western Pacific (Annex 3). Professor Cai Wei, Director-General of Shanghai Municipal Health Bureau, gave a welcome address.
2.2 Overview ofthe consultation
Dr Narimah A win, WHO consultant, outlined the activities and processes of the consultation, which were designed to meet the objectives. They were as follows:
(1) participant presentations (oral and poster) that focused on human resource development in making pregnancy safer;
(2) presentation of background papers-WHO Global Strategy for Making Pregnancy Safer, WHO Regional Strategy for Making Pregnancy Safer, and WHO Regional Strategy on Human Resource Development-followed by a synthesis and summary;
(3) familiarization with the IMPAC guidelines;
( 4) presentation of "best practices" by Mongolia, the Philippines and VietNam;
(5) two group work sessions: (a) participants work as country teams, and (b} participants work as organization teams;
( 6) brief review of the roles of collaborating centres; and
(7) field visit to a women and children's hospital.
2.3 Presentation of background papers
The Monir Islam, Director, Making Pregnancy Safer, WHO, Geneva gave the presentation on the global situation on human resourc.e development in making pregnancy safer and Dr Pang Ruyan, Regional Adviser, Reproductive Health and Ms Kathleen Fritsch, Regional Adviser, Nursing, gave the regional situation on making pregnancy safer and human resource development, respectively (Annex 4).
2.3.1 WHO Global Strategy for Making Pregnancy Safer
Dr Islam gave an overview ofthe state of maternal health, especially maternal mortality, throughout the world. He underscored the need for a global strategy in making pregnancy safer through his paper "Skilled Care At Every Birth: A Public Health Strategy". Relevant data on the global situation were given, with emphasis on unacceptable interregional and intercountry differences, largely due to the influence of poverty. Other evidence presented showed a correlation between maternal mortality and human resources, underscoring the importance of adequate quantity, distribution and competence of human resources for health in the effort to reduce maternal mortality. Dr Islam presented the work done in Uganda to demonstrate the importance of human resource mapping. He also reminded the participants ofthe importance of -4-
having a health system that could ensure the three basic elements of making pregnancy safer, i.e. recognition, referral and responsiveness. In conclusion, he described the following ways in which WHO helps health systems to promote skilled care at every delivery: advocacy, providing technical support (upgrading evidence-based norms, guidelines and developing programmatic tools), building national capacity, overcoming financial barriers, improving family and community response, building partnerships and monitoring progress.
2.3 .2 Regional Strategy for Making Pregnancy Safer
Dr Pang Ruyan described the situation of maternal and child health in the Western Pacific Region, with emphasis on maternal mortality rates and the vast differences among countries. Every year in the Region, there are 40 to 50 million pregnancies, with 30 000 to 50 000 maternal deaths. More than 90% of these deaths occur in the seven priority countries-Cambodia, China, the Lao People's Democratic Republic, Mongolia, Papua New Guinea, the Philippines and VietNam. She emphasized that in these countries, the poor and disadvantaged suffer the most. She highlighted the correlation between maternal mortality and the presence of a skilled birth I attendant at delivery. She also reiterated that skilled birth attendants must be able to deliver normal deliveries, recognize problems, and refer patients at the right time to the right facility. She described the current situation of health workers in the priority countries, noting inadequate and inappropriate training, poor access to information and knowledge, insufficient number and uneven distribution, low motivation and lack of supervision. She touched upon four human resource indicators: availability, competence, responsiveness and productivity. She concluded by outlining the five key elements of the strategic plan for the Western Pacific Region for 2006-2010:
(1) promote government commitment, politically and financially;
(2) provide support in the use and adaptation of evidence-based guidelines and standards;
(3) provide support in the training of skilled birth attendants;
(4) provide support to improve monitoring and evaluation; and
(5) strengthen partnerships in making pregnancy safer, and for this, there is need to optimize the resources of the professional bodies and collaborating centres.
2.3.3 Regional Strategy for Human Resource Development
Ms Kathleen Fritsch, Regional Adviser, Nursing, stressed that the performance of health systems depends considerably on human resources for health (HRH) and that health workforce
I The term "skilled birth attendant" refers exclusively to people with midwifery skills (e.g. doctors, midwives, nurses) who have been trained to proficiently manage normal deliveries and diagnose or refer obstetric complications. Ideally, skilled birth attendants live in, and are part of, the community they serve. They must be able to manage normal labour and delivery, recognize the onset of complications, perform essential interventions, start treatment, and supervise the referral of mother and baby for interventions that are beyond their competence or not possible in the particular setting. - 5 -
expenditures may account for 45% to 70% or more of government health expenditures. As in the previous two presentations, the correlation between HRH density and mortality rates was shown. The trends in HRH were described from the epidemiological, technological, social, economical, political and professional ,aspects. The key issues ofHRH were highlighted: overall shortages; skill imbalance; workforce maldistribution; poor remuneration and poor motivation; weaknesses in education and training; and limited capacity in policy development, planning and management. The presenter gave a brief overview of the regional strategy document, covering its vision, mission, framework for action and the three key result areas: (1) health workforce response to population health needs; (2) health workforce development, deployment and retention; and (3) health workforce governance and management). Ms Fritsch posed four key questions: (I) What is working? (2) What isn't working as well as it ought to be? (3) What are we doing and what difference is it making? (4)What aren't we doing that we should be doing? She concluded by summarizing the role of nursing and midwifery in making pregnancy safer: (1) nurses comprise the largest workforce group in most countries, (2) nurses and midwives provide the majority of health care services at all levels, and (3) nurses and midwives make measurable improvements in health care, and these are tangible.
2.3.4 Synthesis and summary
Dr Narimah A win synthesized the three background papers, thus merging the strategies for the two themes of"making pregnancy safer" and "human resource development". This was premised on the following two interrelated concepts: (1) making pregnancy safer has many strategies, and one of them is strengthening human resources; and (2) human resource development in health needs to be done for all facets of health, and one of them is making pregnancy safer. Besides the three background documents presented at this consultation, many other source documents are relevant to the subject, and they include: The World Health Report 2005; The World Health Report 2006; the May 2006 issue of Reproductive Health Matters, which was titled "Human Resource For Sexual and Reproductive Health Care", and the WHO document "Making Pregnancy Safer: The Critical Role ofthe Skilled Attendant". Dr A win also informed the participants that there are other guidelines in making pregnancy safer, such as the Integrated Management ofPregnancy and Childbirth (IMP A C) guidelines.
In many of the priority countries, making-pregnancy-safer initiatives are hindered by a lack of resources, especially human resources. One way of optimizing resources is to identify where these resources are and to involve them in the initiatives. Two such resources, which have not been fully utilized, are the WHO collaborating centres and professional organizations of obstetricians, gynaecologists, nurses and midwives, which can work with governments to make pregnancy safer. This consultation is therefore a good start to formally bring these partners on board so that they are made aware ofthe importance of human resource development in making pregnancy safer, and this will lead to better cooperation, especially when their roles are more clearly defined and described.
2.4. Presentation by WHO collaborating centres
Representatives of eight collaborating centres, and another centre that will soon be designated, made oral presentations supported by poster presentations (Annex 5). The centres described the work that they were doing in the areas of reproductive, maternal, perinatal, newborn and child health. They especially focused on their research and training in the areas of safe motherhood and making pregnancy safer. It was clear that, within this common area of health, there are differences among these centres in terms of the exact scope of work and focus area. From the presentations, it became clear that the collaborating centres have the interest and capacity to do more in strengthening human resource development in making pregnancy safer, - 6 -
and that there is great potential for them to be partners with the governments of the priority countries, although many of them highlighted the need for capacity strengthening
2.5 Presentations by professional associations
The associations of obstetricians, gynaecologists, midwives and nurses made a Joint presentation for each of the priority countries. The presentation focused on the main area of work of these associations, what they are currently doing on safe motherhood, and what form of cooperation with the government currently exists. There appears to be vast differences in the maturity and scope of work carried out by these organizations in the seven priority countries. A common theme is the shortage of skilled professionals. For example, the Lao People's Democratic Republic has only 35 skilled birth attendants, and Papua New Guinea has only 19 obstetricians. All the presentations highlighted the importance of having a stronger link between them and the governments in the quest for making pregnancy safer. Annex 6 shows the presentation of each country's professional association.
2.6 Introduction to and familiarization with the IMPAC guidelines
Dr Jelka Zupan, Department of Making Pregnancy Safer, WHO, stated that the objectives of this session were: to impart information on the IMPAC guidelines as to their content, assumptions and structure; to indicate the best use of these guidelines; and to obtain feedback from the participants as potential users. Dr Zupan introduced the Integrated Management of Pregnancy and Childbirth (IMP A C) care for mothers and newborn infants, its objectives and WHO's priority areas for country support (Annex 7).
She then stated that these guidelines are:
(1) a model public health tool that offers a limited range of carefully selected interventions that cater to most health needs of pregnant women and newborns;
(2) based on the concept of "essential care", which is globally applicable, and can be used for guidance for national policy, programmes and plans;
(3) problem (and not disease) centred;
(4) based on a broad public health perspective, offering a continuum coordinated and integrated care with cost-effective interventions requiring implicit standards of the health care delivery system;
(5) based on evidence that has been systematically and diligently reviewed; and
(6) provide sufficient operational details that are generic and flexible enough to be adapted to local situations, and can be used by practitioners, managers, policy-makers and teachers of the relevant disciplines in medicine.
She emphasized that a permanent and functioning health system is needed to effectively carry out the guidelines.
Dr Zupan then guided the participants on each ofthe three IMPAC guidelines:
(1) Pregnancy, Childbirth, Postpartum and Newborn Care (PCPNC);
(2) Managing Complications of Pregnancy and Childbirth (MCPC); and -7-
(3) Managing Newborn Problems (MNP).
For each of these guidelines, she explained the aims, target audience, contents, how they were developed, principles, structure and arrangement, and how they are to be used. Finally, so as not to have unreasonable expectations from these guidelines, Dr Zupan also cautioned what these guidelines are not. Case studies were used to familiarize the participants with these guidelines.
2. 7 Presentation of "best practices"
Three countries presented their "best practices" (Annex 8) to demonstrate how specific initiatives have contributed towards human resource development in making pregnancy safer:
(1) Mongolia- Expansion of Distance Learning on PCPNC;
(2) Philippines -Basic Obstetric Emergency Care; and
(3) VietNam- Module on Care for Newborn.
The participants found these examples of"best practices" to be useful information, and considered them applicable to some of the situations in the priority countries. They learnt that a best practice is feasible in any of the priority countries, and that these experiences can be exchanged among the countries.
2.8 The role and responsibilities of WHO collaborating centres
A background paper on WHO collaborating centres, which was prepared by Dr Reijo Salmela, Medical Officer, Situation Analysis, for Policy, WHO, was distributed to the participants. Dr Pang Ruyan gave a brief overview of the paper, which outlined the definition of a collaborating centre, the criteria for eligibility, the designation andre-designation processes and the management of the centres. Representatives of the collaborating centres expressed their satisfaction with the support given by the Regional Office.
2.9 Group work
Two group work sessions were conducted: (1) Partners in country; and (2) Helping each other.
2.9. I Partners in country
The participants were divided into seven working groups by country. For China and the Philippines, the working groups included professional associations and collaborating centre(s) stationed in those countries. For the other five countries, collaborating centres were assigned to other countries.
Each country discussed human resource development in making pregnancy safer, focusing on the allocation, training and incentives of the midwives. All of the countries concluded there is a shortage of midwives in the rural areas, that few midwives in the rural areas receive training, and that their working conditions are very poor.
When asked how the partners could contribute in the human resource development, the country teams gave several comments and suggestions: (1) establish national and local committees on making pregnancy safer or reproductive health, which should include professional - 8 -
associations, nongovernmental organizations and WHO collaborating centres; (2) promote the evidence-based manuals (PCPNC, MCPC and MNP); and (3) invite professional associations to be involved in the training, monitoring and supervision. The countries requested WHO to provide more financial support to the collaborating centres, and also asked the centres to report their work to their respective governments annually.
2.9.2 Helping each other
The three working groups for this session were assembled by domain, i.e. collaborating centre, profession association and government.
Participants from the WHO collaborating centres reported their group work on the following areas:
(1) How can WHO collaborating centres support governments, WHO country offices and regional offices in implementing the strategies for maternal and perinatal mortality reductions?
(a) Identify their strengths and weaknesses and the delineations of what they can do.
(b) Work in accordance with its terms of reference, especially ifthey include making pregnancy safer.
(c) Explore funding sources for skills training and getting authority from the government for personnel to participate.
(d) Coordinate with WHO Headquarters and form a network of collaborating centres in the Region for immediate support from experts.
(2) What should they do in the next five years to increase the coverage and quality of care provided by WHO collaborating centres.
(a) Advertise their training programmes on the Internet and accept or help match trainees.
(b) Post other information relevant to making pregnancy safer on the Internet.
(c) Increase cooperation for in-country collaborating centres.
(d) Help with the dissemination of relevant information to districts and health centres.
(3) How can WHO collaborating centres support the adaptation, dissemination and use of WHO guidelines?
(a) Assist governments in developing a national policy and guideline that would pave the way for adaptation, dissemination and use of WHO guidelines and manuals.
(b) Help in the development ofthe adapted version.
(c) Help in monitoring the dissemination and use of the guidelines. - 9 -
(d) Help in funding training programmes and in matching trainees to collaborating centres that offer training.
Participants from the professional associations reported their group work on the following areas:
(1) How can professional organizations work together to achieve the United Nations Millennium Development Goals?
(a) Strengthen collaboration in terms of professional activities, especially in improving training and services.
(b) Improve coverage and number of membership, especially in underserved areas.
(c) Form an alliance to share experiences and materials.
(d) Use e-mail and newsletters to communicate.
(2) What should professional organizations plan to do in the next five years?
(a) Distribute information on updates and new initiatives, especially among members of the Region.
(b) Provide continuing education to doctors, midwives, nurses, etc., especially to those who have not had training for a long time.
(c) Promote the importance ofthe professional organization in the regulation and improvement of the practice.
(d) Conduct and disseminate research findings on good practices.
(e) Explore funding sources and assist the government in the distribution of the funding.
(3) What is the role of professional organizations in the implementation ofWHO guidelines?
(a) Assist WHO or the government in updating, revising and/or reviewing WHO guidelines.
(b) Advocate the WHO guidelines to policy-makers for curricular change, programme implementation, service provision and professional regulation.
(c) Actively participate in the policy-making process, especially on making pregnancy safer (as an invitee or volunteer).
They also requested the WHO Regional Office to facilitate the formation of regional networks for sharing and communicating experiences and good practices. - 10-
2.10 Evaluation
On the last day of the workshop a feedback questionnaire was distributed to the participants. Twenty-one out of26 respondents thought that the three objectives of the consultation were met. Twenty-five participants indicated that they were able to express their ideas and to exchange their knowledge and experience with other participants.
Twenty-five respondents indicated that they learnt new skills and concepts that could be used in their respective countries, i.e. how to use the IMP AC guidelines; how to apply the guidelines on pregnancy, childbirth, postpartum and newborn care; and how to work with the WHO collaborating centres in their countries. When asked to rate their previous knowledge of the WHO IMPAC tools and the regional strategies, seven out of26 said they knew a lot, 14 had some previous knowledge, four knew only a little and one knew nothing at all.
Twenty-four out of26 participants mentioned that the poster presentation was very useful. They were also satisfied with the oral presentations, lectures from the resource persons, group work and discussions on the recommendations.
All of the respondents were satisfied with the working documents that were distributed. Twenty-one participants were very satisfied with administrative arrangements for the field visit and their accommodations.
2.11 Field visit
A visit was made to the International Peace Hospital in Shanghai. The hospital was built in 1952 with funds donated by the wife of China's leader at that time. The Soviet Union had given her money in appreciation of her commendable international work. The hospital is an extremely impressive institution that provides a wide range of maternal and child health services. The visit benefited the participants greatly.
2.12 Closing ceremony
On the third day, after the presentation on and discussion of the recommendations (see next section), the consl)ltation was formally closed, with a simple ceremony officiated by Dr Linda Milan, Director of the Division of Building Healthy Communities and Population, WHO Regional Office for the Western Pacific. The Director expressed her satisfaction with the successful conduct of the consultation, which met its objectives, and with the conclusions made.
3. CONCLUSIONS
The main conclusions of the workshop were as follows:
(1) All ofthe objectives were met. Participants gained a deeper understanding of human resource development in making pregnancy safer, and were able to identifY and clarifY their roles in this area.
(2) Human resource development for making pregnancy safer still remains a challenge in the priority countries. - 11 -
(3) The WHO collaborating centres and professional associations are more aware of the need for human resource development in making pregnancy safer, and of their roles in this area.
(4) Partnerships among the stakeholders already exist, but they need to be strengthened.
(5) Governments of priority countries are urged to continue to accord a high pnonty to maternal and child health and making pregnancy safer.
(6) Governments should increase the number of skilled birth attendants as a way to improve the human resourc.e situation in making pregnancy safer. This may require increasing the capacity of training institutions in these countries, making the midwifery profession more attractive to young people who have completed school and nurses, avoiding the placement/use of midwives exclusively in administration functions, and curbing the migration of midwives out of the countries.
(7) Governments should take steps to ensure that skilled birth attendants are distributed appropriately. They should consider doing an analysis of this distribution, such as a mapping of human resources, for better planning and management. Efforts should also be made to enhance their competence, responsiveness and motivation.
(8) Governments should consider giving performance-based incentives to health workers involved in making pregnancy safer, especially to those in rural areas. Health authorities should strengthen supervision, monitoring and evaluation in all making-pregnancy-safer activities, as well as enhance the technical quality of care, which may require processes such as licensing, accreditation and credentialing of facilities, personnel and processes.
(9) In-country partnerships between the government and professional associations of obstetricians/gynaecologists and of midwives, and between the government and WHO collaborating centres (where they exist) should be strengthened. An appropriate mechanism for these partnerships within the country should be identified. It is further recommended that the government should play a stewardship role in these partnerships.
( 10) Similar in-country partnerships should be forged and strengthened among the collaborating centres, and among the professional associations of obstetricians/gynaecologists and of midwives. A mechanism for effective communication should be created, using global networks such as International Federation of Gynaecologists and Obstetricians (FIGO) and International Confederation of Nurses (ICN).
(11) The evidence-based guidelines in making pregnancy safer, such as the Integrated Management of Pregnancy and Childbirth (IMPA C) guidelines, should to be used for developing national guidelines for two levels of care. Collaborating centres and professional associations are also encouraged to use these guidelines for their own purposes and their own target groups such as medical, nursing and midwifery schools.
(12) Collaborating centres should continue the commendable work that is being done in research and generation of evidence, in areas related to making pregnancy safer, and in skill development and training of health personnel for enhancing competence in making pregnancy safer.
(13) Professional associations should continue efforts in skill development and training of health professionals, among their own members, as well as assisting the government in such activities. They should also play an advocacy role for making pregnancy safer. - 12-
(14) Countries should continue to share and learn from one another's "best practices" in making pregnancy safer, thereby enhancing south-south cooperation.
(15) WHO at all levels should continue to provide technical assistance and other needed support in human resource development in making pregnancy safer to the priority countries, to collaborating centres and to professional associations. - 13-
ANNEX I
LIST OF TEMPORARY ADVISERS, CONSULTANT, REPRESENTATIVES/OBSERVERS AND SECRETARIAT
1. TEMPORARY ADVISERS
Dr Maria Elizabeth Ca1uag, Medical Specialist IV, National Center for Disease Prevention and Control, Bldg. 13, Department of Health, San Lazaro Compound, Sta. Cruz, Manila Tel:: (632) 895 7451 (Residence); (632) 711 7846/732 9956 (Office); Fax: (632) 711 7846; 711 6130 E-mail: [email protected]
Dr Dashzeveg Tsetsegee, Head of the Maternal Department No. 1, The Second Maternity Hospital Sukhbaatar District, Ulaanbaatar, Mongolia Telephone no .. : 992 82920; 253491; E-mail: [email protected]; tsetse [email protected]
Dr Mario Festin,_Board Secretary, Philippine Obstetrical and Gynecological Society, Inc., 56 Malakas Street, Diliman, Quezon City, Philippines Tel: (632) 435 2385; Fax: (632) 921 9089; E-mail: [email protected]; [email protected]
Dr Lahui Geita, Obstetrician, Madilon Hospital, P.O. Box 2119, Madang, Papua New Guinea Tel: 00 675 852 2022; Fax: 00 675 852 3716; E-mail: [email protected]
Dr Ishnyam Davaadorj, Reproductive Health Senior Officer, Ministry of Health, Steering Committee Member of the Mongolian Obstetric and Gynaecology Professionals Association, Government Building VIII, Olympic Street-2, Ulaanbaatar-48, Mongolia Telefax: 976 11 311777; E-mail: [email protected]
Professor Koum Kana!, Director, National Maternal and Child Health Center, France Street, Sangkat Srah Chak Khan Daun Penh, Phnom Penh, Cambodia Tel: 855 12 943 785; Fax: (855) 23 726257; E-mail: [email protected]
Professor Kruy Leang S im, Head of Maternity of Calmette Hospital, Address: Calmette Hospital, Moniving Boulevard, Phnom Penh, Cambodia Facsimile: c/o WHO 855 23 216 2111855 23 724892; Mobile: 855 11 835 819; E-mail: [email protected]
Ms Miriam Lovai, President, Papua New Guinea Midwives Society, P.O. Box 1893, Boroko, Papua New Guinea, National Capital District, Papua New Guinea Mobile no: 683 0694/692 0668; Tel: 301 3951 L1 (George Taudemo)
Ms Sambuu Narangerel, Midwife, First Maternity Hospital, U1aanbaatar, Mongolia Tel: 976 99138920; Fax: 976-51263822; E-mail: [email protected]
Dr Nguyen Due Hinh, Deputy Director, National Obstetrics-Gynecology Hospital, Vice-Chairman of Viet Nam Obstetrics-Gynecology Association, National Obstetrics-Gynecology Hospital, 43 Trang Thi Street, HaNoi, VietNam Tel: 84 4 9346745; Fax: 84 4 9346742; E-mail: [email protected]; [email protected] - 14-
Annex 1
Ms Ou Saroeun, Deputy· Chief of Nursing Division, National Maternal and Child Health Center, President of Midwife Association, France Street, Sangkat Srah Chak, Khan Daun Penh, Phnom Penh, Cambodia Tel: 855 12 914 235; Fax: (855) 23 426257; E-mail: [email protected]
Mrs Phan Thi Hanh, Chairwoman of VietNam Association of Midwives, 29 Hai Ba Trung Street Hue City, VietNam Tel: 84 054 820653; Fax: 84 054 847007; E-mail: [email protected]
Dr Keokedthong Phongsavan,_Deputy Chief of OB-GYN Section, Setthathirath Hospital, National University of Laos, Ministry ofEducation, P.O. Box 527, Vientiane, Lao People's Democratic Republic Tel: 856 21 351159 (205504931 mobile); Fax: 856 21 351160; E-mail: [email protected]
Ms Cecilia Banca Santos,_ President, Philippine League of Government and Private Midwives, Inc., Unit 401 The One Executive Office Building, cor. Martinez St., West Avenue, Quezon City, Philippines Tel: (02) 415 8439, 376 2771; Fax: (02) 415 8439; E-mail: [email protected]; [email protected]
Professor Truong Viet Dung, Director, Department of Training and Sciences, Ministry of Health, 138A Giang Vo Street, HaNoi, VietNam Tel: 84 4 8465456; Fax: 84 4 8430015; E-mail: [email protected]; [email protected]
Dr Khanthong Siharath, Deputy Director, Reproductive Health Project, MCH Center, Ministry of Health Vientiane, Lao People's Democratic Republic Tel: (856) 21 214010; Fax: (856) 21 214003; E-mail: [email protected]
Dr Chanheme Songnavong, Deputy Director, College of Health Technology, Department of Organizations and Personnel, Ministry of Health, Vientiane, Lao People's Democratic Republic E-mail: [email protected];
Dr Wang Bin, Director of Women's Health Division, Ministry of Health, Beijing, China Tel: 8610 68792310; Fax: 8610 68792321; E-mail: [email protected]
Dr Wang Linhong, Professor and Vice Director, Chinese Women's Health Care Association, Vice Director, National Centre for Women, and Child Health Care, Beijing 100088, China Tel: 86-10-64298136; 13311088556; Fax: 86-10-64296782; E-mail: [email protected]
Ms Wang Lixin, Vice Professor (Midwife) and Director, Nursing Department, Beijing Obstetrics and Gynecology Hospital, Beijing, China Tel. 8 010 85968413(0)/1 391 0713219; E-mail: [email protected]
WHO COLLABORATING CENTRES
Dr Elizabeth Bennett, Senior Research Fellow, Key C~ntre for Women's Health in Society, The University of Melbourne~ WHO Collaborating Centre for Women's Health, Levell Clinical Services Building, 305 Cardigan St. Carlton, Victoria 3010, Australia Tel: 61 3 83446031; Fax: 61 3 934 79824; E-mail: [email protected] ~ 15-
Annex 1
Dr Pat Brodie, Professor, Centre for Midwifery and Family Health, University of Technology, Sydney, P.O. Box 123, Broadway, NSW 207, Australia Tel: 02 9514 2977; Fax: 02 9514 1678; E-mail: [email protected]
Dr Masanori Fuj imura, Osaka Medical Centre and Research Institute for Maternal and Child Health, WIIO Collaborating Centre for Maternal and Child Health, 840 Mutodo-dto, :Uumi, Osaka 594-11 01, Japan Tel: +81 725 56 1220; Fax: +81 725 56 5682 E-mail: [email protected] (Dr Kinichi Kidoguchi); [email protected] (Dr Masanori Fujimura)
Dr Ersheng Gao, Director, Shanghai Institute of Planned Parenthood Research, WHO Collaborating Centre for Research in Human Reproduction, 2140 Xie Tu Road, Shanghai 200032, China Tel: +86 21 64049215; Fax: +86 10 64046128 E-mail: [email protected]; [email protected]
Dr Esmeraldo Ilem, Dr Jose Fabella Memorial Hospital, WHO Collaborating Centre for Research in Human ReproduCtion, Lope de Vega St., Sta. Cruz, Manila, Philippines Tel: 734 55 61 to 65; Fax: 735 7146; E-mail: [email protected]
Dr Virginia de Jesus, Chair and Director, Department of Obstetrics and Gynaecology, College of Medicine WHO Collaborating Centre for Research and Training in Human Reproduction, Philippine General Hospital University ofthe Philippines, Manila, Philippines Tel: 5245741; 5218450 local2357; 524 3518; Telefax: 632 524 1098 E-mail: [email protected]/[email protected]
Dr Zhu Liping, Shanghai First Maternity and Infant Health Hospital, WHO Collaborating Centre for Perinatal and Health Care, 536 Chang Le Road, Shanghai 200040, China Tel: 540 31429, 1337 1985042; Fax: 540 30109 E-mail address: [email protected]; [email protected]
Dr Xiaoming Shen, Shanghai Institute of Pediatric Research, WHO Collaborating Centre for Neonatal Health Care, Shanghai Jiao Tong University Medical School, 1665 Kong Jiang Road, Shanghai 200092, China Tel: 657 90000 Ext. 6703; Fax: 86 21 63842916; E-mail: xiaoyang sheng®yahoo. com. en
Professor P.C. Wong, Head, Department of Obstetrics and Gynaecology, National University of Singapore, WHO Collaborating Centre in Reproductive Health, National University Hospital, Lower Kent Ridge Road, Singapore 119074, Singapore Tel: (65) 6772 4285/4263; Fax: (65) 6779 4753; E-mail: [email protected]
Professor Zhao Gengli, Director, Research and Training Centre in Women, and Childrens Health WHO Collaborating Centre for Research and Training in Women's and Children's Health, Peking University, Beijing 100034, China Tel: (8610) 661 74284;Fax: (8610) 661 67629; E-mail address: [email protected] - 16-
Annex 1 2. CONSULTANT
Dr Narimah A win, Director, Division of Family Health Development, Ministry of Health, Block E 10, Putrajaya Administration Complex, Putrajaya, Malaysia Tel: (603) 888 34001/Mobile 6012 3129320; Fax: (603) 888 86150 E-mail: [email protected]/[email protected]
3. REPRESENTATIVES/OBSERVERS
ASIAN Dr Yadamsuren Buyanjargal, Project Coordinator, ADB Maternal Mortality DEVELOPMENT Reduction Project, JFPRIMON 38066, Mon, 1st Floor, Government Building VIII BANK Olympic street-2, Ulaanbaatar-48, Mongolia Tel: 976-11-319518; Mobile: 976-99190750; Fax: 976-11-321755 E-mail: [email protected]
INTERNATIONAL Dr Raj Karim, Regional Director, East & South East Asia and Oceana Regional PLANNED Office, 50450 Kuala Lumpur, Malaysia PARENTHOOD Fax: (603) 4256 6386 FEDERATION
HONG KONG Dr May Fok, Assistant Professor, School ofNursing, Faculty of Health POLYTECHNIC and Social Sciences, Hung Hom, Kowloon, Hong Kong, SAR, China UNIVERSITY Tel: 852 2766 6542; Fax: 852 2364 9663 E-mail: [email protected]
Dr Regina Lee, Assistant Professor, School of Nursing, Faculty of Health and Social Sciences, Hung Hom, Kowloon, Hong Kong, SAR, China Tel: 852 2766 6388; Fax: 852 2766 6407 E-mail: [email protected]
UNICEF/CHINA Dr Guo Sufang, National Programme Officer, UNICEF Beijing Office, China Tel: 8610 653 23131; Fax: 8610 653 23107 E-mail: [email protected]
UNFPA /CHINA Mr Peng Jiong, National Programme Officer, UNFPA Beijing Office, China Tel.: 8610 65320506 - 17-
Annex 1 6. SECRETARIAT
WPRO
Dr Linda L. Milan, Director, Building Healthy Communities and Populations, WHO Regional Office for the Western Pacific, Manila, Philippines Tel: (63-2) 528 99981; Fax: (63-2) 526 0279, 526 0362, 521 1036 E-mail: [email protected]
Dr Henk Bekedam, WHO Representative in the People's People's Republic of China, 401, Dongwai Diplomatic Office Building, 23, dongzhimenwai Dajie, Chaoyang District, Beijing 1000600, China Tel: (8610) 6532-7189; Fax: (8610) 65322359; E-mail: [email protected]
Dr Pang Ruyan (Responsible Officer), Regional Adviser, Reproductive Health, WHO Regional Office for the Western Pacific, Manila, Philippines Tel: (63-2) 528 9876; Fax: (63-2) 526 0279; 526 0362, 521 1036 E-mail: [email protected]
Ms Kathleen Fritsch, Regional Adviser in Nursing, WHO Regional Office for the Western Pacific, Manila Philippines Tel: (63-2) 528 9803; Fax: (63-2) 526 0279, 526 0362, 521 1036; E-mail: fritschk@wpro. who. int
WHO/CHINA
Dr Wen Chunmei, National Programme Officer, 401, Dongwai Diplomatic Office Building, 23, Dongzhimenwai Dajie, Chaoyang District, Beijing 1000600, China Telephone: (8610) 6532-7189; Facsimile: (8610) 65322359; [email protected]
WHO/MONGOLIA
Dr Radnaabazar Jargalmaa, Maternal and Newborn Health Project Coordinator, World Health Organization, c/o Ministry of Health, Government Building-S, Ulaanbaatar, Mongolia Tel: (976)11-32 7870; Fax: (976)11 324683; E-mail: [email protected]
WHO/CAMBODIA
Dr Severin von Xylander, Medical Officer, Child and Adolescent Health, World Health Organization 177-179 corner Pasteur (51), Sangkat Chaktomouk, Khan Daun Penh, Phnom Penh, Cambodia Tel: +855-(0)23-216010; Fax: +855-(0)23-216211; E-mail address: xy landers@cam. wpro. who.int - 18-
Annex 1
WHO/HQ
Dr Monir Islam, Director, Making Pregnancy Safer, World Health Organization, CH-1211 Geneva27 Switzerland E-mail address: [email protected]
Dr Jelka Zupan, Medical Officer, Making Pregnancy Safer, World Health Organization, CH-1211 Geneva 27 Switzerland E-mail address: [email protected] - 19-
ANNEX2
AGENDA
(1) Opening ceremony
(2) Orientation ofthe consultation
(3) Global and regional strategy on making pregnancy safer and achieving Millennium Development Goal 5
( 4) Presentations on experiences and lessons learnt on capacity building and researches on maternal and newborn health
( 5) Introdllction of the global strategies on human resource development in making pregnancy safer and the evidence-based manuals and guidelines on Integrated Management of Pregnancy and Childbirth (IMPAC)
(6) Group work on identifying the roles of the professional associations, WHO Collaborating centres and governments in maternal mortality reduction and cooperation mechanism among them
(7) Group presentations and plenary discussions
(8) Field trip
(9) Closing ceremony -20-
Annex 2
PROGRAMME OF ACTIVITIES
Tuesday 26 September 2006
08:30 Registration
09:00 - 09:40 Opening ceremonies Opening remarks: Dr Henk Bekedam, WHO Representative, China Director-General, Shanghai Municipal Health Bureau
Introduction of participants Selection of officers for the meeting Group photo
09 :40- I 0:00 Coffee break
10:00-10:10 Orientation of the consultation and administrative announcements
10:10-10:30 Global Strategy on Making Pregnancy Safer Dr Monir Islam, Director, Making Pregnancy Safer, WHO/Headquarters
10:30- 10:45 Regional Strategy on Making Pregnancy Safer, especially in achieving the Millennium Development Goal ( 5) in the Region Dr Pang Ruyan, Regional Adviser, Reproductive Health
10:45-12:30 Presentation on experiences and lessons learnt on capacity building and research on maternal and newborn health
(a) WHO collaborating centres • Australia (1 centre) • China ( 5 centres)
12:30-13:30 Lunch break
13:30- 14:30 WHO collaborating centre (continuation) • Japan (1) • Philippines (2) • Singapore
14:30-15:30 (b) Presentation of professional associations: • Cambodia • China • Lao People's Democratic Republic • Mongolia
15:30-16:00 Coffee break - 21 -
Ahhex 2
16:30-17:30 Continuation (Presentation of professional associations) • Papua New Guinea • Philippines • VietNam
Wednesday, 27 September
08:30- 09:00 (a) Introduction of regional strategy on human resource development for health - Ms Kathy Fritsch
(b) Human resource development in making pregnancy safer - Dr Narimah A win
09:00- 10:00 Introduction and familiarization on the manuals and guidelines on Integrated Management of Pregnancy and Childbirth or IMPAC [Managing Complications in Pregnancy and Childbirth (MCPC), Pregnancy, Childbirth, Postpartum and Newborn Care (PCPNC) and Managing Newborn Problems (MNP)]
10:00- I 0:30 Coffee break
10:30-12:30 Continuation (Introduction ..... )
12:30- 13:30 Lunch
13:30- 14:30 Panel session, Q&A on the IMPAC modules
14:30-15:30 Panel discussion and experience sharing on best practices by: • Mongolia (Distance learning on PCPNC) • Philippines (Basic Emergency Obstetric Care) • VietNam (Strategy on Newborn Health Care)
15:30-16:00 Coffee break
16:00- 16:30 Orientation on WHO collaborating centres, their roles/responsibilities and the procedure of designation and redesignation
16:30- 16:40 Introduction to group discussion
16:40- 17:30 Group discussion by country (how to strengthen cooperation among the government, agencies and WHO collaborating centres)
Thursday, 28 September 2006
08:30-10:00 Group presentation
10:00- 10:30 Coffee break
10:30-12:30 Group discussion by centre and professional association
12:30-13:30 Lunch -22-
Annex 2
13:30- 14:30 Recommendations
14:30 Closing
14:45 Field trip - 23 -
ANNEX 3
Regional Consultation on Human Resource Development in Making Pregnancy Safer Speech by Dr Henk Bekedam 26 September 2006
Mr Cai Wei, Deputy Director General of Shanghai Municipal Health Bureau. Distinguished participants, ladies and gentlemen. Good morning!
I welcome all the participan ts who have travelled to Shanghai to participate in this Consultation. First of all, I would like to thank and express my great appreciation to the organizers of this meeting. In particularly , we are very grateful to the Government of the People's Repl!blic of China , the Ministry of Health, the Shanghai Municipality and, the Shanghai Municipal Health Bureau, for hosting this important meeting that will focus on the importance of human resources in making pregnancy safe.
Childbirth is the most dangerous moment in life- for both mother and baby. Whilst the majority of deLi veries take place without complications, it is critical that when treatment is needed, it is provided without delay and with expertise. It is hardly an exaggeration to say that making pregnancy and chil dbirth safer is also about safeguarding the of our world. future
Across the Western Pacific Region, there are 40 to 50 million pregnancies every year with more than 300.000 newborns dying within the first day of birth. As well, there are up to 50,000 maternal deaths with 40 per cent occurring in just five countries - Cambodia, the Lao Peop le's Democratic Republic, Papua New Guinea, the Philippines and VietNam. China's maternal mortality ratio is relatively low with 48 deaths per 100,000 live births. But- due to its size- China makes a substantial contribution to the remaining maternal mortality in the region.
Although it is difficult to predict who will experience childbirth complications, when they do present, maternal deaths and disabilities are avoidable and the medical solutions are welllmown. We know that there are three main reasons for morbidity and mortality during pregnancy or bi1ih- hemorrhage, .eclampsia and sepsis. And we know how to treat and manage those conditions.
The critical factors in managing the risk of childbirth are the presence of skilled birth attendants and a functional health system that can support the necessary treatment. A skilled birth attendant holds the key in recognizing and treating complications and, 'vhen necessary facilitating timely access to em erge~1 cy obstetric care. Without the expertise of a skilled attendant, women experiencing pregnancy or childbirth complications often have no chance. Access to skilled birth attendants can make the difference between life and death.
It's fair to say that access to skilled attendants and functional health systems across the region can help to prevent tens of thousands of deaths every year. Yet in Can1bodia and the Lao People's pemocratic Republic, over 90 per cent deliveries take place at home without skilled attendants. - 24 -
Armex 3
The challenge we face is not just medical or technical, it is strategic and organizational -how to make sure more women in the developing world can access skilled attendants.
Having access to skilled attendance is therefore a priority of the WHO's Making Pregnancy Safer strategy (2006 and 201 0). Over the next five years our most important task is to secure government commitment politically and financially, with the clear objective of ensuring skilled care at every birth, within the context of a continuum of care.
But developing countries have many specific human resource developmental barriers that we need to overcome to ensure that skilled birth attendants can effectively work in helping to prevent maternal deaths. Over the coming days you will be reflecting on the following challenges.
Firstly, a global shortage in health workers has led to many well trained midwives moving to richer countries, which offer more attractive remuneration, thereby depleting poorer countries ability to tackle their health challenges. This is particularly imminent in the Philippines where many nurses and midwives have migrated to Europe and the US.
Secondly, skill imbalances, with doctors and specialists over-represented at the expense of community-based health workers -a fact that is particularly true here in China, which has more doctors than nurses.
Thirdly, in nearly all countries there is an uneven distribution of skills with an over supply in urban centers and an under-supply in remote areas where communities and health systems are most vulnerable.
Fourthly, poor work environments- including low salaries, inadequate supplies and facilities, and poor management- mean that Health cannot attract and retain sufficient numbers of skilled workers.
And last but not least, a weak knowledge base for medical persmmel hampers the delivery of quality services.
So what can we do? The good news is that these problems have solutions. The bad news is that the answers involve sustained and committed effort. There are no short cuts.
Developing comprehensive health work-force strategies and undertaking forward planning will go a long way in addressing these challenges at a strategic level. Generally it requires a willingness on the part of governments to invest and ensure equity in the delivery of health services. And we must work to bring together the health, educational, and fmancial sectors to achieve three core objectives- coverage, moth·ation and competence. Coverage strategies promote numeric adequacy, appropriate skill mixes and outreach to vulnerable communities. Motivation strategies focus on adequate remuneration, a positive work environment, opportunities for career development, and supportive health systems. Competencies are advanced through educating for appropriate attitudes and skills, creating leadership, entrepreneurship, and innovation. - 25 -
Annex 3
Of these, motivation and competence are key aspects of human resource development for making pregnancy safer. Better pay and proper training are two simple and practical measures that can make an immediate difference to making pregnancy safer in the developing world.
Over the coming three days you will be discussing many of these elemt:uls ami more. Every country has its own story to tell- this is a great opportunity to share the challenges and successes of overcoming barriers to making pregnancy safer.
There is no panacea. Different measures will work in different countries. In Cambodia, where I worked prior to China, the contracting experience showed that offering a guaranteed living wage in remote areas made a difference - almost overnight -to skilled attendant coverage in remote areas. No doubt these are the kind of experiences you will be sharing and discussing over the course of this consultation as you consider on the yvay ahead.
This workshop will also consider the role of collaborating centers and national professional organizations in developing and maintaining maternal and child health standards. We strongly hope this workshop will support a strengthened role for these bodies in your respective countries, particularly in areas like developing and endorsing guid'elines and supporting training.
On behalf of WHO, I'd like to thank you all for your commitment to this issue and encourage your endeavours. I wish you fruitful discussions over the next three days and look forward to hearing the results.
Thank you.
-27-
ANNEX4
PRESENTATIONS OF BACKGROUND PAPERS ~ 28 ~ -29-
Annex4
Department of Making Pregnancy Safer Depa11ment of Making Pregnancy Sater
The ground reality
Skilled Care 't Every Birth . - a public health strategy ~ I ,~·..J 6( -...... ··--',..,,.,.,,:•!/1' -~-rc·; ' i/ic \ . -" "l,_ • ._: ..v ·.;;;,..:-_ ·- Dr Monir Islam --= ; • .., • . ~ ,.. .. / Director, Department of Making Pregnancy Safer WHO, Geneva, Switzerland
Making a difference In countries
Depa11ment of Making Pregnancy Safer Pregnancy and Childbirth The Ufa~m~ Risk of Maternal Death In Africa Is Staggering 0> Global Situation
•180-200 million pregnancies every year • 75 million unwanted pregnancies oSO million induced abortions o20 million unsafe abortions •20 million women suffer from maternal morbidity •600,000 die from complications o3 million newborns die within the first week of life •3 million babies are born dead
~- \1.'1f6, L ,'~IT'IIillllnlf1"' t.I Olo:Po ~-.twli.u niPr ...... r~t..u,.J:IGI Making a dlf'ference In countries m Md:Jn; • dltr.r •n ~• ln a OYn\r"t.l
Department of Making Pregnancy Sater Rich Poor Divide: Who should programme target Maternal Mortality Ratio in SAT 90 Hospital, Kerala, 1966-1997 80 - • Orissa 70 - • UP lfl. 60 - Assam !!. 60 -- :E 0 r--- - 3 40 ..::0 30 r- r-- - 20 .... 10 • Kerala 0 l J .... a= =r M itltf11~ l ttu:~~ li·U Jn. giW)v W(IJ'n al'l •n ln.!l 3 ANC vJslts Birth Attended birth contraceptives SBA
0 Poorest ftfth • Middle ftfth 0 Richest ftfth Sourct~: Challenges in Safe Motherhood Initiative in Kerala -30-
Annex4
O.partment of Mailing Pregnancy S.t.r O.Pirtm•nt of Making Prtgnancy Sater MMR in Thailand by regions in 1997-2001 Percentage Sal'e Deliveries, 1998·99
55 60
" - Norti!J 40 Soatb CoDa try 35 Ctatnal ;a Nnrth.,.•t Leat..ll0.111 2!1.111-40.111 u 40.111 -50.01 20 50.111-IKJ.II1 Source : RCH sJ~ 19518·99 i IKJ.II1-200111 15 • Data available for pnly 190 10~-----r------r------r----~ districts "•\ 1998 ,,, 1000 1001 ·ttn Mailing a difference In countries
o.,_rtment or Malting Pre;ntncy Stfllr DePII1mtnt flf Making Pr~ttnancy Sater for family planning Deliveries conducted by different providers Unmet need Percentage among married women 15-49,1990-2001
100 ~~------. 25 ~------
~M------
Bangladesh - India Nepal Indonesia Bangladesh India Indonesia Nepal l:li SA I TIBA I Others • For Spacing 0 For Limiting •Total
Department of Mlklng Pregnancy Safer due to who are mother or Cbangia& Causes of Maternal Mortality Percentage of women age 15-19 loc:rtasing HIV Prevalence ia a Zambian Hospital: currently pregnant, by single years of age Making a Case for Liakiag Materoal Health Care aad PMTCf
60 ~------,
16 16 17 18 19
• Bangladesh D India • Indonesia • Nepal ...... ,- ~ dtrrerenc:eln countrlls ....__ -.-- ... ,..._, .. _ _., .... -~,·---l-...... ,-•l"'Wftttlfttla M<~klng a dtffllrenceln countrltls - 31 -
Annex4
Department of Making Pregnancy Safer Department of Making Pregnancy Safer
Global PMTCT Response by 2004 Countries with established PMTCT programs Number of visits for antenatal care per region
Number of visits D 4+ visits 0 2-3 visits 0 1 visit
LatinMiddle America/Caribbean EasUNorth Africa ji~~~~ Sub-Saharan Africa
Developing coun:: ::;1==~==~==~==~~2 0% 20% 40% 60% 80% 100'/o %of women reporting one or more antenatal visits
[a} exduding Chins (Source: WHO end UNICEF, 2003)
Department of Malrtng Pregna~y Safn Department af Making Pregnancy serer
Usina SAM to look at inequities: Health Jllff by district: (ns ) doctors, nunes, and midw1vu per I 0,000 popLt!ation . excludi~ Kampala and linjldi5tricts
J FeWflrdoC'for&;.I'IW)fl! nurse!! I ...... llllj ......
...... " • • ,,., I hwor d Department of Making Pregnancy Safer Department or Making Pregnilncy Safer N~o r ~r.• ,_. ,oo,coo Stnk•Anlla.:llly~lll.t . UP "A 2004 --· ---·----_, .....,.._.,- - ~ -.--·-- :::::.:=.'":""~..r_-:.::::::.:::..."7.'"______...... ,_. _- .... - 32- Annex4 Location of facilities providing emergency blood transfusion, by district ~JOI'I ot ~ nP~ •ooi~~~o~>~g~ i .,•ect!i•lir1 ll• • ~h .A !ti!a!li!hy' MI!It!ift ~ M!r!t! . MCI -··- ~~ . .' •I .I .._ .. ___.. k_ .. ___._ ·'•. -·----.... - -G Milking • dlrl'etenu In cuMmtrlet Dep1r1ment of Making Pregnancy Safer Recognition Recognition Referral n n n Department of Making Pregnancy Safer IRecognition Referral Responsiveness n n n The hope and opportunities ... the evidence - 33- Annex4 Department of Making Pregnancy Safer Department or Making Pregnancy Safer Maternal Mortality Trends over time in Japan 600 460 400 360 '"' /\. 300 a: :E250,. ' '- 200 ~ 160 ' 100.. " "· ....~~~ ...~~~ ...~ ... ~ ....~~~ ...o. .... ~ ...~~ ...o.~~ ...o."o~ ...'*f::l .._o.~~ ....,o.o.~ ~"~ Year -MMR 1850 1860 1870 1880 1890 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 Department of Making Pregnancy Safer Depa J!11 ent erMA ~ I"'/ P r.eg~ AII- !f. !;,ih·r· Ma:lerrmrMmt:tlit) ~inee the 1969s in Mahtysia, Sri Lanka and Thailand Important Land Marks (Japan) 460 o 1868: Regulation for birth attendants 400 o 1874: Introduction of licensing for birth attendant ~ 360 o 1875: Opening of school for birth attendant ~ 300 o 1988: Formation of birth attendant association ~ 260 • 1899: National standardization of birth attendants ~ 200 regulation ; 160 o 1916: Health and hygiene fact finding mission :!! 100 • 1920: First National census 60 ISGO 1SG4 1968 1972 1S7G 1S80 1S84 -+-Thailand -Sri Lanka -Malaysia M""'' • dlflo""" '" cou"'"" ·~ Department or Making Pregnancy Safer 0 "1'flil'II ~!MI ~ S~!1'5r8d f!'Ocn 2000 w 11 I I ~ •- 1 I "I - .<= :c1: 1600 ~ 1600 ·"'·' " •I-!-- o y ~ 0 0 0 0 0 ~ MM R(I SSO) 1000 ~ 0 1000+ w 000 1..._, OJ: lSI 500-999 ~ "C b. 250-499 "iii <00 ., ~ X 100-249 "iii 200 : .. .. :; ' ' ~"-....J...._....:.:.~--=-~-----=-"'-.. ISI. < 100 0 ' ;F. 20 40 60 80 10 0 20 50 60 .. .. hllllo e! L~ . I "' tiUNIVERSITYcwABEROEEN "' ""' ...... -a. % skj!led attendant at de!iyeN % Deliveries attended by a Doctor Moklog • dm.•eocelo couo~lu '6 - 34- Annex 4 O.~rtmentofMIJclna PtegntncySafer Best practices: Active managellli!nt of the 3'4 phase and implementation and results reduction of PPH ·~ 3.5 .... ~- Un ofu:ytadlt Blood &1111s{usWm 2.5 '\. D•ring Ill stq~ of IDbour '\. ~ · ... 2003 2004 2.005 2003 2004 zoos 0 Ao11'fe men.;ement or u,. 3rd ~%of Post ptrh.mhemonhage n phase Donel!ik Oblast maternity, Ultnline Making a dltl'erence In countries II JSI hoh1ther and lnf11111 project in coli WHOIMPS Department of Mlklng Pregnancy Safer Skilled Care at Every Birth Way forward ~ltno a dif'fon nn 1n ~urrll le 1 Making a dtfhrence In co\utiries Oe,.rtment ot' Making Pregnancy Safer Department of Making Pregnancy Safer Asking the right questions to get the right answers ... • Right people in right place in right time • Training (skill and competency) and skill retention • Political Commitment and deployment • Employment • Appropriate investment • Policy changes • Planning, costing, management and supervision • Right strategy • Supplies and logistic • Transport • Policy and legislations • Demand creation • Monitoring progress -for taking evidence based • Public/Private/NGO mix decisions Over all improving health system responses and quality of services • Time - 35- Annex4 Deptrtment of' Making Pregnancy Safer Depar1ment of' Making Pregnancy Safer I Promoting: Skilled care for every birth- a health system respons • Advocacy • Norms and Technical support o Updating evidence based norms and guidelines, developing programatic tools o Building national capacity and providing support for: Making Pregnancy Safer • Development of evidence based strategy and implementation Department- Making a plan • Improving ac;c;QEE to ggrg; Improving hoglth 'YEtQm raEpons.o dttterence m countnes • Improving quality of care • Overcoming financing barriers • Improving individuat family and community response • · Building partnership • Monitoring progress Making a dltterence In countries IJ Department of' Making Pregnancy Saftlr Department of Making Pregnancy Safer Good quality maternity services will save newborn lives 4 million newborn deaths- When? LatinA~&the Mot•dewlopedtegio.-. Ceribb-n ,_ I--.,IIII•.._Liou.oltlll.h• .. '"l-,w. "'uDII1~-~~~~~~H-lM11 11 ...1-..,oldoiii'IO! Making • dl'Ptrtn~ In oo~ntt141s OepariJTient of Making Pregnancy Safer Department of Making Pregnancy Safer What Happens to the Children Why are they orphan? When a Parent Dies? 200 :;. ID. 150 ...-~ 8 Boys • Girls ~ 100 .:. l 50 :c:!! u 0 No Parent Dies Father Dies Mother Dies -36- Annex4 Dtp411rtrnant of M.lklng Pre;rwney sat.r !Why No more poor options for poor people don't poor people? - 37- Annex4 • WHO I Western Pacific Regional Office 8 WHO I Western Pacific Regional Office Every Minute in the world Regional strategy on 380 Women become pregnant making pregnancy safer maternal 190 Women face an unplanned or unwanted pregnancy 110 Women experience a pregnancy-related ~nmrlir.atinn Ur 1-'ang f 8 WHO I Western Pacific Regional Office • WHO I Western Pacific Regional Office Regional Situation Millennium Development Goals Every year • Eradicate extreme poverty and hunger 40 to 50 million pregnancies • Achieve universal primary education 30 000 - 50 000 maternal deaths • Promote gender equality and empower 300 000 newborn die on the first day of birth women More than 90% of those deaths occur in the countries • Reduce child mortality of Cambodia, China, Lao People's Democratic • Reduce maternal mortality Republic, Papua New Guinea, the Philippines and VietNam. • Combat HIV/AIDS, malaria and other diseases In these countries, the poor and disadvantaged population suffer the most. • Ensure environmental sustainability r8 WHO I Western Pacific Regional Office I • WHO I Western Pacific Regional Office MMR&NMR wit.h hospital delivery and births attended THE CAUSE OF MATERNAL MORTALITY by skilled professionals GLOBAL ESTIMATES Country MMR NMR Hospital Delivery by (1/100 000) (1/1 000) delivery rate skilled (%) attendants (%) Cambodia 437.0 37.30 9.9 32.0 25% China 50.2 21.00 76.0 - Lao PDR 530.0 36.20 12 0 9.0 Mongolia 98.0 11.37 99.2 36 7 15% Papua New Guinea 330.0 32.00 44.8 3.0 Philippines 172.0 17.00 380 35.2 Solomon 295.0 12.00 43,0 - Viet Nam 130.0 15.00 79.0 - - 38- Annex4 -WHO I Western Pacific Regional Office I -WHO I Western Pacific Regional Office I The leading causes of maternal deaths The leading causes of Other ~ 13 in VietNam maternal deaths in APH bJ Papua New Guinea Ectopic* .. (168 cases) Uterus rupture 4.9% Abortion- Obst.labour"'"' ~4 4.7% 11.5% ltypor1onoien" (_ Ectopic & Other Surrical 21.3% ~v? Malana & Anaemia: ~"·15 Sepsis , Haemorrhage• i I ~ 41% PPH 30 ln1ection 16.6% 0 10 20 30 40 • WHO I Western Pacific Regional Office 8 WHO I Western Pacific Regional Office Maternal mortality by region in China The relationship between skilled attendant at delivery ·~ rr=~;;;,======~~~~------l and maternal mortalitv in develooina countries CINutritlonalanem1a Ill 120 • y DQbstnJcted labor ~ D Puerperal sepsis unear (Y) :a,oo OEdampsia D oHemOI'Thage ~ g M f------J 0 o' :;! 60 8. 40 .c -:;"' ~ 20 D 20 30 40 50 60 70 80 90 1!0 11 R.lftJ IV Rlnf \ ~aJU ¥1 sldhd alill-!'dllnt at~111ry R.aalon • WHO I Western Pacific Regional Office a WHO I Western Pacific Regional Office i MMR&NMR with hospital delivery and births attended by skilled professionals Skilled birth attendant: Country MMR NMR Hospital Delivery by (11100 000) (1/1000) delivery rate skilled (%) attendants (%) Deal with normal delivery Cambodia 437.0 37.30 9.9 32 0 recognize the problems and decide China 50.2 21 .00 76.0 - on the right action Lao PDR 530.0 3620 12.0 9.0 to refer the women at the right time Mongolia 98 0 11 .37 992 36.7 and in the right way. Papua New Guinea 330,0 32.00 44.8 3,0 Philippines 172.0 17.00 38.0 35.2 Solomon 295.0 12.00 43.0 - VietNam 130.0 15.00 79.0 - - 39- Annex 4 • WHO I Western Pacific Regional Office J8 WHO I Western Pacific Regional Office Women Receiving Skilled Care during Delivery Current situation of Health IDO ,------==;----, workers in priority countries 90 -········---·······-····················· ..•••• - ...... ___, --·- so --·-··------·- ---· .....------Inappropriate and inadequate training 70 -•--n•OOO ...... ~--- ··---- with curricula that are not needs-based 60 •••••• •••••••u ...... • Poor acc9&i to information and 50 -~~ ----·---~ -- _c::]__ knowledge resource --~--- 40 ,....---·· ·-.. Poonst ... ~ .... . J O ••••••-~~•••••u• • Inadequate number and in-even 10 ···-----·-··· ... c:::J .... . Rfc.hat distribution .• .Qoiqli~ -- 10 ··········-··-··· Low motivation and poor policy C•mbodla, lOOO Phlhpp1nl!'~ 1991 Vlet Nam,lOOO • Lack of supervision 8 WHO I Western Pacific Regional Office I 18 WHO I Western Pacific Regional Office Human resource indicators Distribution of health workers in selected countries of the Western Pacific Region to assess health workforce performance CouDtry Detuity per 1000 population Dimensions Possible indicators Pby!lliciau Nunu Midwinll Au!llralia 2.47 9.71 Available Staff ratios, Absence rates, waiting time Japaa 1.98 7.79 0.9 Korea 1.57 !.75 0.19 Individual: prescribing practice Competence Malay1ia 0.70 1.35 0.34 Institutional : readmission, live births and Cambodia 0.16 0.61 0.2J cross infection Cbiu 1.06 LOS 0.03 Responsiveness Patient satisfaction, assessment of LaoPDR 0.58 I. OJ responsiveness MoagoU. 2.63 l . ll 0.24 PNG o_os 0.53 Productivity Occupied beds, outpatients, PbilippiueJ 0.58 1.69 0.45 interventions delivery per worker or ViefD.am O.Sl 0.56 0.09 facility S011rc.: Workin111011111herforheelth Thewortclhnllh report 2006 • WHO I Western Pacific Regional Office Objectives Regional Goal 1) To support governments to develop evidence To reduce by 2015, based strategies and policies on maternal and MMR by 75% of its newborn mortality reduction particularly in the 1990 level and to priority countries. contribute to the 2) To support government efforts to reduce reduction of infant unwanted pregnancies,increase contraceptive mortality by use rates. reducing neonatal 3) To support countries and areas to improve the deaths health and nutrition status of women of all ages, especially pregnant and nursing women. -40 ~ Annex4 • WHO I Western Pacific Regional Office • WHO I Western Pacific Regional Office Strategic Plan for 2006-2010 How to achieve To promote government commitment, politically and MPS? financially, to reduce maternal mortality To provide support to countries and areas for the uiM.eminatiol1, adaptation and implemcntotion of evidence-based standards and guidelines for effective maternal and neonatal care To provide support to countries and areas for training of skilled attendants to provide continuum care for mothers and newborns • WHO I Western Pacific Regional Office • WHO I Western Pacific Regional Office Strategic Plan for 2006-2010 Main lessons learnt • Putting in place the health workforce needed To empower the individual, family and community to for scaling up maternal and newborn health increase their awareness of the importance of services towards universal access is the first neonatal health maternal and and most pressing task. up the staggering shortages and to improve monitoring and • Making To provide support health workers evaluation of maternal and newborn health imbalance in the distribution of in many countries will remain a major challenge for years to come. To strengthen partnerships for sustainable Making Pregnancy Safer programmes in countries and areas • Using different resource to improving the of the Region service capacity (competence) at different levels is very important. - 41 - :;f,i Annex 4 HRH - "The stock of all individuals engaged in the ft& CONSULTATION ON HUMAN • promotion, protecTion or ... £.1~ improvemenT of the health RESOURCE DEVELOPMENT IN 'Jl~lAL· of populations" ~ MAKING PREGNANCY SAFER A.b . t~) t.~~ ~ ~l\ ~ - - · • Health system ~;..fomance depends an ..vc\rkers Kuthleen f-'t•itsGh HRH detemine what services will be ottered; when, where, Regional Adviser. Nursing to what extend - intel' 27 September 2006 Nurses/Midwives and Other Health Workers Save Lives! Demographic Trends: Ageing Trends and Issues ulations and Workforces 600 million > 60 years old (Global in Epidemiological. Technological ;• • 2000): 2, 000 million by 2050!1 • ' · - 300 million in Asia Pacific region demographical Cl:i (10% increase by 2025) · Professions Acceleration of NC[)s and chronic degenerative diseases : disability; • Social senile dementia; musculoskeletal; Health services visual impairment; etc. Need to a~commodate needs of older persons; implications • Economical and delivery for health services across the continuum of care: ·Workforce implications (health/welfare - skills/knowledge in care giving, counseling, insurance, gerontology, geriatrics, · Political rehabilitation, long-tem care, continuum of care, etc.) ·Ethics /legal - care of tho teminolly ill; palliative care; chronic care ravi.slon in mano ment; etc. -42- Annex4 Nurses/Midwives and Social Context Other Health Workers on • Public /consumer /client expectations Personal and family well-being • Mnni IP. workforce and patient population ·~· ~ . Demands /reliance on family l ~ · . and community for care ' Violence in workplace /on- the-job injuries Workers on the move... Economic trends ... - > global • Growing global challenge • Rising costs of health care, as well os shortages and increasing demands ( 4 patient out of pocket payments for core million shortage) in a number of countries • Mainly from poorest to richest countries • Consequences and impacts on health High consumer expectations ~ desire for services and remaining workers choice and voice • Complex challenge to manage with many • Competitive wages, salaries and benefits factors involved ~ • Privatization - growing Technological Professional Issues · Wider array of health workers · Rapid increases/advances in health technology · Changing/overlapping scopes of practice; changing work environments · Internet information and services · More specialisation, more regulation · Ethics/practices; Inter-professional · e-health (telemedicine; e-learning; relationships etc.) · Quickly out-dated knowledge ,, " -43- Annex4 Health-Poverty Trap Stewardship Dr, lndu Bhushan. o Governance /leadership Policies and reforms - doin_g more with le~s; decentralisation; public-private m1x; etc. o Disputes I industrial actions Regulatory and quality issues; access to nealth services by the most vulnerable Health Service Changes HRH Key Issues 1970s & 80s - 1990s - Managed care Overall shortages Coordinated care for 2000s specific populations Skill imbalances 1990's -Quality -Safety - Increased access o Workforce mal-distribution for underserved - Partners o Unsatisfactory I poor remuneration, - Economic incentives - Ethics I legal to reduce cost - Insurance working conditions and environments - Complexity of - Holistic I patient- interventions centered care; Weak knowledge I knowledge gaps community-centered o Education and training weaknesses core Limited I lack of capacity in policy development, planning, management " Health Worker Density by Skill Imbalances Region ~ More ;...,;. _ _ doctors Neglected ~~ ::::,:::7" /unattractive fields ~~ More clinicians than public health Gender issues Some countries with shortages in specialist or public health fields ,, -44- Annex4 Health Workforce Working Conditions and Remuneration Mal-distribution Unsatisfactory and poor in most countries - very low pay/remuneration • Urban bias - better Lack of/inadequacy of equipment, supplies worker : population ratio including drugs, logistics, supervisory Eg. In Cambodia, 85% of the support, etc. population reside in rural areas, l.imitod non-monatary inc:antivac cuc:h as: yet only 13% of government housing, safety and security, social /family workers are there support "Public-private sector shifts Low morale; retention and performance problems; etc. ,,, " for Health Professional Weak Knowledge and Issues Education Knowledge G'aps Low priority: institutional I organizational /structural issues; Lack of I inadequacy of workforce data - faculty capacity. skills, systemic information I data problems: compos ition, distribution; etc .. technology I equipment; sustainability of Training: intakes; quality; information management systems inappropriate curricula and content: etc. Limited HRH research capacity to generate No linkages with useful information and "best practices" service/employment needs {"HRH paradox" - most expensive resource Limited career opportunities in which we know little about.) some areas of work Lack of trained /experienced HRH Multi -skilling researcher /planners I managers. II Standards and Quality of Education Education and Training Issues Cont'd) Content "Education for the health professions is in need Relevance: little on management, of a maJor overhaul . Clinical education simply la ethics, communication. working as has not kept pace or been responsive enough to team. etc; information the shifting patient demographics and desires, management; inadequate changing health systems expectations, evolving []:,· consultation. practice requirements and staffing . arrangements, new information, a focus on Delivery of training improving quality, or new technologies." Didactic; modalities; hospital -Institute of Medicine (2001) versus community settings; self directed learning Core competencies - All health professions should be educated to: deliver patient Access to training centered care, as members of interdisciplinary Limited intake spaces/facilities; teams, emphasizing evidence-based practice, quality improvement approaches and funding; policies informatics. (gender/pregnancy); entry criteria -45- Annex4 Education and Training Issues Challenge to integraton of service delivery for priority health programs (Cont'd) Competence and up-skilling - Registration: continuing education; (all workforce categories); demonstrated competence. etc. Recognition of education and training - Standards; accreditation: local vs overseas (non-return); cross-border recognition, etc. " What Needs to be Done? HRH Financing and Investment Better coordinate in-service HRH perceived as 'liability" rather than training and decentralize a "resource" training whenever possible Integrate supervision Opportunity for increased development Harmonize remuneration and partner support - 'fiscal space" incentives Rethink service activities Other modalities - salary and responsibilities supplementation; payment of posts; incentive programmes linked to quality Collaborate with patients performance indicators, etc. Plan for emergencies n Leadership and Commitment Advocacy Human Resources for Regional Health Strategy: Partnership and networks Country-based and country-led, with Vision appropriate external partner support Mission Statement Guiding Principles ~ Sound strategic framework for action -46- Annex4 Mission Statement Vision Cognizant of the role of WHO in Achieve equitable access to quality leadership and partnerships for health services for all and effective health, the WHO in the Western health system performance through Pacific Region supports its Member a balanced distribution of a States in strengthet\it\9 their competent and supported health capacity to plan, educate, manage workforce. and develop their health workforce to equitably meet their population health needs. " Framework for Action Goal Three focus areas (Key Result Areas) The health workforce in countries and areas will be responsive to 1. Health workforce response to population population health needs and will health needs (demand) promote equitable access to quality 2. Health workforce development, health services and improved health deployment and retention (supply) outcomes. 3. Health workforce governance and management " KRA #1: Health workforce KRA #2: Health Workforce Response to Population Health Development, Deployment and Needs Retention Strategic objective 1 : · Strategic ob jecfive 2. 1: Enabling the delivery of effective health services by · Ensuring that health workforce addressing workforce size and planning and development is an distribution. integral part of the national • Strategic objective 2.2: Addressing development plan and responsive to workforce needs, including the workforce environment, to ensure needs. population and service optimal workforce retention and participation. u " -47- Annex4 KRA #2: Health Workforce KRA #3: Health workforce Governance Development, Deployment and and Management Retention • Strategic objective 2. 3: Improving the · Strategic objective 3: Strengthening quality of education and training to health workforce governance and meet the skill and development needs of management to ensure the delivery of I h~ workforce In changing service cost-effective, evidence-based, quality environments. and safe programmes and services. 11 What can we do? Wh(lt c(ln we do? Connecting Care Giving between Connecting Care Giving across the Households and Health Facilities to Continuum for Maternal, Newborn Reduce Maternal, Newborn and and Child Health Child Deaths '~T Pl.A.CES OF CARE GIVJNG prtgnuq""' Pt " Nursing and Midwifery Foul" Key Questions Contributions to Making Pregnancy Safer Strategic Objectives What is working? What isn't working as well as it ought to Nurses and midwives comprise the largest be? workforce group in most countries in the world What are we doing and what difference Nurses and midwives provide the majority of is it making? health care services, at all levels of care What aren't we doing that we should be Measurable improvements nurses and doing? midwives make in health care around the world are tangible -48- Annex4 HUliN RESOURCE DIVELOPIENT ~~ llK~NI PREGNlNCING SAFER Narimah Opening speech of WR: ~- Many strategies, one of them is HRD 3 elements - coverage cE@)- Many strategies, - competence one of them is for - motivation MPS {Cambodia's experience) MPS Regional Strategy (Or Pang Ruyan) · Human Resource Development Indicators for HRD: are they Broad Perspective (Kathy Fritsch) - available - competent Trends and issues: - responsive - Epid and demo - productive -Social (expectation) 6 Strategies: -Economic - government commit -Political - EB practice - Technology - skilled attendants - Professions* (see next slide) - empower - H. service (reforms) - M&E - Partnership -49- Annex4 Professional: - wider array, overlapping scope • WHR 2005 (make Every Mother 8r. Child Count) with POLICY BRIEF on - work environment "Rehabilitating the Workforce: The Key changing To scaling up MNCH" - more spec., more • WHR 2006 (Working Together For regulations Health) - knowledge out-dated • RH Matters - May 2006 (Human - ethics Resource for SRH Care) APPLY THESE TO MPS • Making Pregnancy Safer : The Cri~i(:al Role of the Skilled Attendant (WH.O, 2004 - road strategy paper ~ In addition to these ...... more specific 1 detailed ~ (e.g. IMPAC) Who is doing what ? How much ? What else to do ? "' RESOURCES in priority countries - numbers So, what do we do ? - expertise - distribution • Get these "partners" on board, - time immediately Not being optimally used • Not the individuals only: RESOURCES also include: Processes Institutional culture to work closely with Research, evidence Ministry of Health Manuals/tools • Give them - overall awareness • PARTNERSHIP to be strengthened 11 - detailed guidance .. -50- Annex4 So this consultation is a good start Also, smart partnership requires: • Be aware • one another • knowing • Know the global and - strengths rP.gional strategies - weakness • Know the modules • communicate well, effectively • Have commitment • compromise, negotiate • Share our aspirations .. • transparency and trust • Identify your roles " .. -51 - ANNEX5 PRESENTATIONS OF WHO COLLABORATING CENTRES -52- -53- Annex5 ~Goals: WHO Collaborating Center for N~uuatal H~aHh Car~ • Reduce neonatal mortality • Promote children's physical and Shanghai Institute of Pediatric Research mental development in China Shanghai Xin-Hua Hospital Shanghai Children's Medical Center .. Strategies: ~ Histori~al Profile: • Develop and implement the appropriate • Neonatal mortality and child health care improving techniques to improve neonatal health care • Critical neonatal transport • Train the specialists, nurses, and health • Newborns and infants hearing screening professionals for local institutes in impoverished • High-risk neonates follow-up rural area • Developmental Dysplasia of Hip (DDH) screening • Reinforce health education and health promotion • Early childhood development in impoverished rural areas in China - Objectives: • Reduce the incidence of severity congenital Major activities and projects: abnormality infants • Reduce the infant mortality and prevent later development of disabilities Healthy mother means healthy baby • Prevent the high-risk pregnancy and unsafe abortion -54- Annex 5 ). Congenital abnormality screening .. Follow high-risk infants • Prior to conception risk screening • Reduce neonatal mortality · N11onatal riiEUEcitation • Antenatal screening · Neonatal transportation system • Neonatal screening • Early intervention to improve the life quality ' Down's syndrome, Hypothyroidism, PKU, hearing loss, Hearing loss DDH Development Dysplsia of Hip · PKU Hypothyroidism ,/ Genetic scientists, obstetricians, pediatrician • Long term follow-up ,/ Reduce the high-risk pregnancy and congenital -' Multi-department collaboration, Multi-hospital joint effort abnormalities .1 Continuing to improve and promote *Prevent adol_escent girl pregnancy • Recruiting and training volunteers " Medical school students • Conveying safe sex information to high school students - Contraception methods • AIDS/SID prevention • Safe abortion Volunteers are the key points to success -55- Annex 5 Outline Strategies and activities on D Brief introduction of SIPPR safe motherhood in SIPPR 0 General situation of maternal mortality in China D Strategies on safe motherhood in Dr. Ersheng GAO SIPPR D Approaches to actualize strategies Shanghai Institute of Planned D Activities we have carried out Parenthood Research D Issues encountered Brief introduction of SIPPR 0 Affiliated to SIPPR D History • Key Laboratory for Research & Development of • Started technical cooperation with Contraceptive Drugs and Devices (1990, SFPC) WHO/HRP in 1979 • Shanghai Center for Research & Development • Consecutively designated as WHO CC in RH (1994, MOH _& SMCST) since 1983 • BoKang Reproductive Hospital (2003) • Now it is one of the two national level research institutes in FP and RH Professional researchers 0 Staff member Total number 182 Scientist and Technicians 160 Administrative staff 15 Logistics personnel 7 -56- Annex 5 Education level of researchers D Research Area • Contraceptive development • Toxicology & pharmacology • Clinical trail • Epidemiology • Social Science • Basic medical research D Research projects 1978-1990 126 1990-1996 196 General situation of maternal 1997-1998 102 mortality in China 2002 113 2003 175 2004 170 2005 131 Maternal Mortality Rate in China Proportion of New-method Delivery and (1990-2004) Hospitalized Delivery(%) Year New-method Deliva!}: HosEilalized Deliva!}: Total Urban Rural Total Urban Rural 1980 91.4 98,7 90,3 ...... 1985 94,5 98 7 93.5 43·-.7 73.6 364 1990 94,0 98.6 94.0 50.6 74.2 46,0 1995 89.3 87.6 58.1 70.7 50.2 2000 96.6 98 9 95.2 72,9 84,9 65,2 2001 97.3 99.0 961 760 87.0 69.0 2002 96.7 98.8 960 78.8 89.4 71 .6 2003 96.4 98,7 948 79.4 89.9 72,6 2004 97.5 99,2 964 828 91 .4 77.1 2005 97 8 99,2 969 85.9 93.2 81 ,0 -57- Annex 5 Cause of Maternal Death in Surveillance Evaluation of maternal deaths Region in 2004 2000-2004 (%) Diseases Total Urban Rural Avoidable In MMR % MMR % MMR % Year Avoidable better Unavoidable Not clear Obstetrics Hemorrhage 21.6 45.2 6.7 33.3 30.3 46.1 cond~ion Pregnancy induced 5.4 11_3 0.6 2.2 8.5 13.5 2000 26.7 hypertension 63.5 8.8 1.0 Amniotic fluid embolism 4.8 10. 0 1 7 67 6.8 10.8 2001 40.1 41.8 17.8 0.3 Heart diseases 47 9.6 4 7 17 8 48 7,6 2002 47.5 38.8 12.8 0.9 Liver diseases 11 2.2 06 2.2 1 4 2.2 2003 43.1 422 13.5 12 Puerperal infection 0.6 1.3 00 0.0 1 0 1.6 2004 42.2 40.0 15.2 2.6 Total 48.3 100.0 26 1 100.0 63 0 100.0 Factors resulted in avoidable Strategies on safe motherhood maternal deaths,2000-2004 (%) Factors 2000 2001 2002 2003 2004 D Promote contraceptive use and health Women and their families education to reduce unwanted pregnancy Kno'Ntedge and skills 33 7 26 6 38 0 45 8 31 .2 Attitude 13 8 14 0 13 0 66 12 2 D Promote accessibility of SRH service Resources 75 10 9 53 33 85 D Explore risk factors during pregnancy and Health care system implement intervention to make pregnancy Knowledge and skills 43 1 42 4 39 4 350 42 3 safer 00 1 7 24 09 21 Attitude D Promote quality care of comprehensive FP Resources 08 09 00 09 11 service, esp. counseling service Management 08 04 1 0 1 9 1 6 Other factors 03 31 09 56 1 0 D Strengthen capacity building in MCH Total 100.0 100_0 100.0 100.0 100 0 Approaches to actualize strategies D Prevent unwanted pregnancy • Promote effective contraceptive use D Reduce unsafe abortion Evaluate systematically and surveillance on • Explore factors that influence use of current existing contraceptive methods, emergency contraceptive Introduce and develop new methods • Train service providers in FP station to Educate adolescent and unmarried about • observe strictly the service guidelines SRH and regulations School education for in-school students, Help parents to practice family sex education, • Study on the safety and efficacy of Educate migrant adolescent through abortion drug produced domestically community, Publicize RH knowledge in various ways, e.g., internet -58- Annex 5 0 Make pregnancy safer 0 Promote post-delivery care • Explore factors that may result in • Provide counseling service unsafe pregnancy • r.::.rry nut hnm.,..vic:it ::.nrl fnllnw-ur • Promote timely contraceptive use after • Promote hospitalized I health delivery personnel assistant delivery 0 Promote high quality SRH counseling • Improve evidenced knowledge service technique and skill of MCH • Carry out training program to build up counseling capacity among FP service personnel providers Activities in SIPPR : Activities in SIPPR : Prevent unwanted pregnancy Prevent unwanted pregnancy D Evaluation and improving of current Cl Education to and studies on existing contraceptive methods unmarried adolescents and the • Multi-center clinical trial on implant , and OC (WHO, CONRAD • Study on causes of unmarried pregnancy and RU486+ Tomaxifen preventive countermeasures (SSTC) establishing surveillance system on side effects of contraceptives (SPFPC) • Study on barriers in providing RH service to D Development of new contraceptive unmarried sexually active population (WHO) methods • Misoprostol & Mifepristone, Sino gestodene • Comparative study of different sex education oral pills, a single-rod contraceptive implant, and RH service models (WHO ,JHU) Nuva-Ring with progesterone Activities in SIPPR : Activities in SIPPR : Prevent unsafe pregnancy Make pregnancy safer Cl Studies on reducing induced abortion • Prospective study on the effects of • Investigation of KAP on and accessibility of caesarean section on maternal and emergency contraceptive among women in infant's health (SNSF) Shanghai, WHO • Study on safety and efficacy of combining • Study on physical-psychological model in domestic produced Mifepristone & reducing maternal and infant mortality, Misoprostol in pregnancy termination (South-south Collaboration) -59- Annex 5 Activities in SIPPR : addressed Publicize information and train Issues to be service providers IJ Migrant and poor pregnant women do not obtain enough health service IJ Tran!lated WIIO Reproductive llealth IJ Prurl::!ssiunals illlr~::!alllrl>l::!l..lur~ and FP Library (RHL 5,8) and publicized the Chinese service are lack of evidenced techniques versions nationwide and counseling skills. IJ Building up sex and RH counseling capacity IJ Sex and RH education to adolescents can among family planning service providers effectively improve their KAP through parents and schools THANK YOU '• - 60- Annex 5 ,.,.... ·_ : "1f . ' . ~\'iit\9 Crsnftetr for ,.., ~~!f)> •-e~ ~--- ~ ·· '&'& . ~~~ cP ~1t.: ~1983-1987 }= . ~ 1987- 1991 WHO Co II abo rating Center for Research and ~p !ihanghai Fir.st Maternity &. '~ ~1991-199~ TrRinin~~: nn MRtArnRI _ and Infant Care Infant Health Hospital ~ 1995 1999 ~ 2001-2005 }=> Zhu Liping WHO Collaborat ing Center ~ 2005-2008 for Per i nata I Hea Ith Sept.2006 WHO Collaborating Center for ~ Goals & Objectives] Perinatal Health l Shanghai Women's l Shanghai First Maternity & J "' To col\abor~.te . with WHO in supporting the national Health Institute Infant Health Hospital health progrt .rnrnt:s in training the chiefs of l maternal and child health centres and institutes H with a vi!w 1o s'h•cngthening the national maternal lShe.nghoi Quality Control J and chilo heulth :;ervice network ] Center on Obstelr:~ ./ To collaborate 1~ith WHO in arranging training 19 dist rict/county --~) programmes in dcv· ~lopirtg countries in the field of MCH instit ute Pert nat al Centers f >r maternal and infant care :»heart disease > Prenatal Diagnosis I )> hegatic disease ./ To take an a ;j ive p lr't i~ collaborating with WHO in :» G M )> Premature I conducting hE:o.lth rt:se~rch in maternal and infant IC ommuni ty I care health center ll Hospitals with obs tet ric ser vices I - - -·------·-·· -·- ---·------' ,------···--··· ~ Development] I Qualified Perinatal Health Care I Making Motherhood Safer ISafe matherbood package r I Hospital Delivery r .51 I TBA (tr.Uned birth att Annex 5 Maternal health care and MMR in Shanghai ~ Strategies ] 350 nn 300 '\ TBA • Network & Regulation ~ 250 • Training & Research 200 \.'\ Hosoital d~liv~rv '\ 150 • Quality Control & Maternal Audit II ISafe matherhood pockoge I 100 \. 68N_ JJ 1 q\lolifiod porinotal health care I • Health education & Promotion 50 30' -- 2~ - 1949 1955 1980 1990 -- I I IFlow chart of maternal health care in Shanghai I ~ Training] ~ -....;::-r'l""' " .,\11 -· - Early registration Regulation on safe 2,. At community health center motherhood International - "" ~ In Shanghai Training courses for MCH workers ~- from Mongolia, Iran and Korea National • Advanced obstetric services . . • Progress of women's health care • New approaches of management ,'DI •• of obstetric emergencies Research Breastfeeding Program ...:- ' I ~ Training courses on neonatal asphyxia '~~ resuscitation ' . I .·-r ;~ ,, ,/ ~Training courses for midwives ...... i> Training courses for those engaged in prenatal screening and diagnos ' ~Training courses for maternal il .jf health education workers ~ . .~}1.0~. . ( Mot her-friendly Childbirth Program ,. ~ . · -62- Annex 5 Training trainers c:::::) Qualification On-spot Appraisal Quality Control Changes of Maternal Mortality Rate in Shanghai • Appraisal for hospitals with obstetric service • Maternal audit ~ Case reporting ~ Investigation ~ Audit ~ Feedback ~ Intervention - 63 - Annex 5 Changes of proportion of maternal death Intervention measures ' • Set up related centers for high risk pregnancies Shanghai resident . .,... l:nl • Set up low-cost maternity hospital for . immigN>nl immigrant pregnant women . j~ ~ l 1.-u- 1m ... , !Oit. ..I Distribution of 10 hospitals !Results I • Pujlng community health c::J ~ cer~tcr'- Mlnhang District • Xinchang community health a~ center- Nanhui District •Total beds: 257 • Jiading district MCH a •u hospital l!l'l •Total No.of delivery: 12,529 • Chongmlng county MCH Ollt:ll hospital l!!l3 • Maternal death: 0 - ¥: 'i'l! • ro;*p ~:f:Q r:,O~~·,.. !l5 Perinatal Mortality Rate: 4.65%o • Songj l at~g district • hospital • Luod/an hcspltcJ- kos district ( From Aug. 2004---July 2005) • Pudoft9 new area M.CH hosplta.l • Qbdan community ho:lptfol ferudan district • Jlr~ we i community ho.spltot Jinshon district !Results I !Results I Changes ofMMR for P.rcgnancy complica ted with hepatic disease~ ICba n ~es of MM1!. f~r P regnancy complicated with heart diseases I {Pnor-post companson of setting u-----p the center fo r heart diseases) (Prior-post comparison of setting up the center for hepatic diseoses) '·' ~ "' ) 1 ~~._,...... ~ '-' • F=' F ,,. ...' I I ,. .., ' ~ ...... , ... ·~ • ..... ~ 1 9 79- 9 3~ ' 1979-93q;. 1994-04~ 1994.-04. -64- Annex 5 Rapid Increase of Delivery from Immigrants of Macrosomia 120000 tOQOOO ·- .80000 60000 ~0000 2~ 20000 l l L [ ------~ 0 t ~ t ~ ~ ~6 t~!7 t9'18 t~!! 20QO lOO t 3002 2003 200o 200o ~ 1991 1992 1993 1994 1996 1996 1997 1998 1999 2000 2001 2002 2003 2004 Increase of Cesearean Section Rate 60 ~------, ::t======~=====~~~:::::::::j 3 0 ~------~--~~~~------~ 2 0 ~~~~~------~ lOu------1 Thanks -65- Annex 5 General information ~Women's and Children's Health Center of Peking University Strategies and Activities (Beijing Medical University)-- established in 1986 on Safe Motherhood ~WHO Collaborating Center for Research and Training in Maternal and Infant Health-- designated in 1988 Women's and Children's Health ~WHO Collaborating Center for Research and Training in Center of Peking University Women's and Children's Health -- redesignated and 26-29 Sep. Shanghai China renamed in 199 8 General information Strategies of Center Tbe center is located at the First Hospital Peking University (Founded in 1915). • To improve women's and children's bealtb through is a general teaching hospital. multi-disciplinary and women's whole life study, This hospital professional training and development of health There are 28 clinical departments, 12 technical education and bealtb promotion departments, 6 research institutes and 10 rese~rcb centers. • To explore feasible, available and sustainable intervention measures to improve maternal and infant Tbe hospital bas undergraduate and postgraduate health program as well as tbe programs for further study. In 1991, tbe hospital set up the Women and Children's • To use abundant human and research resources in Hospital, which was appraised by WHO as a baby tbe hospital and Peking University to implement friendly hospital in 1993. MCH studies and projects J Major researches and projects Strategies and Activities (safe motherhood) Using the brochure ofMCH care to help pregnant women and mothers seeking health 1. Intervention study on integration package care and obtain MCR maternal and child healthcare in 5 Tibetan knowledge The contents of brochure counties including nutrition of (2004-2005, supported by UNICEF and WHO) pregnant women, identifying danger sign of pregnancy and ..... • M~r.o ."-• "' • ""- Objectives: illnes~ of child, making childbirth plan and •!• To explore feasible and available integration package promoting hospital delivery, maternal and child healthcare in rural areas breastfeeding and "+' complementary feeding "' - •!• To improve reproductive age women's KAP ofMCH --. .;, - - I •!• To enhance health workers' professional skills ~ ~c:-~J ~ ·r· - ~~~ - -66- Annex 5 Strategies and Activities Antenatal healthcare, child health care and filling in Using MCH record card to improve the quality of MCH MCHcard. services and integrate perinatal and child health care. The contents of card including antenatal care (refer to WHO PCPNC ) and 2rowth monitorin2 for child, 1£ 1 · ~· ... ., · ~· > ~:;· ' j;t - :::.a~ ! ...- .. -· .,.. _____ ~ .•..:. , "!tr .~ •• •• ~ •• J •• ~• • Strategies and Activities Strategies and Activities To mobilize government Using participatory methods to train health supporting and cooperate with education and professional skills for health NGO (Women's Federation ) workers and women's leaders from project Women's leader to disseminate counties/townships and explain MCH brochure Achievements and Issues Major researches and projects The MCH brochures and MCH record cards were (safe motherhood) effective carriers to implement the integration package MCH services. 2. Improvement quality of Maternal Women's leader could take advantage of the brochures Mortality Auditing (MMA) to carry out health education activities. (2005-2006, supported by MOH, WHO, Tbe using of MCH record cards could improve tbe UNICEF) quality of MCH services. Objectives: Tbe facilities and equipment at county/township hospitals were quite obsolete and impeded tbe To revise criterion ofMMA reference of development of maternal bealtb care services. international experience (Beyond the Numbers) The shortage of township and village doctors and lack To improve the MCH management ability of of basic skills bad a serious impact on providing medical staff and the quality ofhealth care for essential MCH services. pregnant women and neonate to reduce the MMRIIMR in project areas - 67- Annex 5 Main activities Main activities • To translate "Beyond To organize two the numbers" WHO national workshops on publication criterion and methods • To oreanize national ofMMA experts' seminar to • To involve about 250 discuss revising participants from 23 criterion of MMA provinces and and decide training prefectures in national methods and decreasing MMR contents program areas Major researches and projects Achievements and Issues (safe motherhood) To develop a new criterion of MMA and it is tested in 3. Study on the Influencing Factors of national decreasing MMR grogram areas. Caesarean Section (CS) and the Impact of Most provinces have fin ished the implementation plan Different Delivery Modes on Short-term according to new criterion ofMMA and local conditions. Psychosomatic Health of Both Mothers and Lack of human resources and financial support especially Infants in Beijing. for collecting data of death cases happened at home. (2004-2005, supported by WHO) may To interview family members and health workers Objective bring some dissensions for medical management. •!• To investigate the reasons of difficult controlling the CSR and the impact of delivery modes on psychosomatic health of the mothers and infants within 6 months. Conclusions and suggestions Major researches and projects (safe motherhood) The main influencing factors were fetal distress, maternal age, elderly primigravida, pregnancy complications, fetal overweight/macrosomia and 4. A pilot study on family and Community participating requested by the pregnant women and their family. in maternal and child healtbcare in rural areas No difference in the effect of CS I vaginal delivery on (2006-2007, supported by WHO) the psycho-physical health of the mother and baby in objective short term follow up study in big city. •:• To explore health education model for community and family to Obstetricians are confronting the challenge of how to take part in MCH care in rural area. strictly control the indications of CS. Methods: According to baseline survey to develop health education Need to further study on the long term effect of the materials, test different methods of health education and delivery mode and antenatal nutrition for controlling evaluate the feasibility and availability of each method. fetal overweight. -68- Annex 5 Major researches and projects Major researches and projects (safe motherhood) (safe motherhood) S. To organize and implement project of 6. Maternal & Child Health Care Support Project prevention and treatment of RTIJSTI. in four counties of :'olingxia Hui Autonomous Region ( 2005-2007, supported by MOH, WHO-SPP,UNFPA) (2006 2010, 3upportcd by Swodioh International One of the main contents include promoting syphilis Development Cooperation Agency, UNICEF ) screening for pregnant woman and the prevention of RTVSTI during pregnancy and delivery, training Purpose: relevant knowledge and skills for health workers. • To reduce maternal and neonatal mortality in the four counties ofNingxia by 10% by the end of2009 . Main Strategies • To develop improved policies for maternal and peri/neonatal survival To use an empirical approach to reducing delays and obstacles at every step of the pregnancy road • To improve quality of care for hospital delivery and neonatal care by developing and ensuring respect of standards of care and user friendliness To try to increase further the quality. replication, sustainability and leverage of project results and lessons. - 69- Annex 5 I Towards Improving the Outcome of Pregnancy ! Masanori Fujimura, MD, Osaka Medical Centre and Research Institute for Maternal and Child Health, Osaka, Japan. WHO Collaborating Centre (Maternal and Child Health) Regional ization of Perinatal/Neonatal Care. • To establish the efficient tertiary perinatal unit (obstetric unit and neonatal intensive care) • To establish the regional NICU network Neonatal Intensive Care Unit (NICU) 1981-2000 Extremely Low Birthweight lnfants(<1000g): 1,025 = The most efficient way for investment. <500g 72 (7%) , 23weeks : I Regional Perinatal & Neonatal Network has been Successful I The Neonatal Mutual Cooperative System since 1977: Has established a regional network of 32 NICUs in Osaka. Offers the intensive neonatal care which is: easy to utilize, quick to serve, efficient in transport, best match of patient illness and care level required. ie; best use of medical resources In doing so NMCS has shown its: success in encouraging the "transfer in utero", success in early transport of sick newborns, success in establishing a regional database, success in cooperation of level II and III NICUs. Concept of Regionalization and Use of Computer I Improving Survival Rate -by Gestational Age- 1 Period-! (1980-89) Period-2 (I 990-2000) 1«!1 IIIII Regionalization of Perinatal Care IIIII I 101 c.ouuu ~ I. NICU and High-Risk Obstetric Facilities -to be competent ~ Died $;\ 2. Bed Occupancy Information Service -to be quick 11'1 3. Neonatal Transport Service -to be efficient ~~ ~ ' 4. Perinatal Data Base -to be retrievable ,1[\ I I~ 1111 Alive I l~ I Use of Computer Technology l~ !Ill I. For quick and up-to-date communication. 1111 i Ql I Ill 2. For analysis of perinatal data base. !IHUNHMVHH~31J2~~~5U~nn4141UU !1nDN~Htl3HI31HU~35MU~UU414!Un Assessment of service efficiency Geslation{wb) Gesiationlwbl Scientific studies N=I9,620 N=22,050 Safety and monitoring NMCS-Osaka - 70- Annex 5 I Resusci tation Ut i I iza tion Does Improve in the Region Factors a ffecting Mortality Yearly Changes in Resuscitation Techniques ~'MCS-O s aka Period-! (1,980-1989) Period-2 ( 1990-2000) loN:,.IOr,l"OiW lOll ICOl _s~ _io k«• sco.nt. - 0.021 71 O.OOtl2 oO.IIUS -17..83237 * 0.00000 n 801 8 ir1h w11 i - O.OOOOl 0.00000 -0.07885 ·U3UQ ,.. 0..00000 Yearof b.rth - 0.0030< 0.0 0045 -0..075g,g - 7.61270 * O.DDDOO 6111 101 Ha1u!le!U\!an U.UIO oJJ U.VU1YJ U.U CI U8 ..l ~~ &!lift .... o.uuooo s •• 0.00489 0.00452 0.009BO 1..Jl91BD 0.2.7 936 401 101 -0.00538 - ().56067 0..58148 Tra n ~;f• r w11v - 0.00 2.11 Q.!l 04 B.2 ._ No 0.00001 D.D OOZS 0.00038 ... ., H" ~ 201 D'""o (\ 01 nn~ ~ Hnnn ~ ~~~M!~J ~~ ~~~u~ n~n~nnn~»n n ~~~~nR ~ o~ ud NMCS-Osaka Gestation NMCS-Osaka Mortality of Pre term Inf ant s has Improved ! Inborn, Osaka Perinatal Center I To establish an efficient tertiary perinatal unit Mortality of Extremely Preterm Infants -Yearly Trend- (obstetric unit and neonatal intensive care) 0/ % /O 80 ,....___ Gestational week 70 ...... , ...._<2Cw{n=107) 60 ...... -o-tC.25w{317) I 50 ---...... ""'lr-U,27w(3!0) = The most efficient way for investment. ~- 40 "t1...., ------"'\. '\. 30 -*"'28,29w(511) ---...... """ '\. 20 :"-...... ,_ tO ~ /" 1981- 1985- 1989- 1993- 1997- 2001- lmproyf ng Spnrjual Ra te did NQT rft"i"lt. nht!: l nvrraso jn Disabi l i t ies Requirement for In t ensive Care I [ Routine Care based on E vi dences Mortality & Disability ofinfants (< lOOOg) -Yearly Trend- Standard of Intensive Care Use of closed incubator with 80-90% environmental humidity, 100$ 3 Years • Ventilation strategy •oied Intermittent positive pressure ventilation, •oa Intrauterine Growth, Resuscitation at Birth & Ventilation Stress are Important Determinant of Future Gogn i ti ve Function Perinatal Factors and Cognitive Function at School Age Perinatal Factors which affect the Cognitive Infants Born IPPV days -0 .223 0.070 -0.287 -3.183 0.002 0.101 BirthHC SO 4.781 1.550 0.260 3 084 0,003 0 175 5 min Apgar score 2.781 1.057 0.239 2.630 0.010 0.211 R2: cumulative contribution IPPV: Intermittent Positive Pressure Ventilation !Q Born in 1984-92!F, The Best Strategy for Better Cognitive Outcome could be : 7-12 years of age :\=135 R=OA75, p Jso% Survival Rate = 23 weeks 3 days Survival Rates of Infants less than 24 weeks of Gestation (bam between 1990-2000 at 112 hospitals of Japan neonatologists network) .St.trvl.\'11 R•tt(%) No, of Admisson Survival and Risk of Disabilities in Infants Borr J0 ,------~ · 10 r.=~~~~ lc:::::::l ~a , d /tdmtnon .. ._·I...... :....::•:::• ·.:::"..::"::.:N:.::I"'•::.:' '"::::J' 22 and 23 weeks .. .." 30 " " I ,. ,. ···~. . ~~ 21 22 o 1 2 3 4 5 6 o 1 2 3 4 5 6 (days) we~k f-22weeks of gestate -1 f-23weeks of gestate -1 -72- Annex 5 Surv iva 1 and Risk of Di sabilities born <24weeks Survival and Risk of Disabilities born <2 4weeks The Facts Conclusions Osaka Medical Centre for Maternal and Child Health Osaka Medical Centre for Maternal and Child Health Survival rate for 22 weeks gestation 17 (birth weight 478g±51) 22 weeks was 29.4% alive= 5(29.4%) 23 weeks was 50.7% Died =12(70.6%) 23 weeks 67 (birth weight 568g±82) alive= 34(50.7%) Mortality rate died = 33(49.3% l less than 50% for infants after 23 weeks 3days. Mortality was less than 50% for infants born after 23 weeks 3days. Major causes of deaths The disability rate intracranial hemorrhage in 20, 20% of 22 weeks respiratory failure in 7, septicemia in 7, 23.5% of 23 weeks circulatory failure in 5. Death of age which are similar to disability rate for 24-28 weeks! within 7 days (25), <4 weeks (13), 4w-6 mo (5) after six months (2) LIMIT OF VIABILITY IN EXTREMELY L-B-W INFANTS It depends where he/she is looked after. 1. Taking an example for gestation (ex. 24w), examine annual trend of mortality and Incidence of sequelae 2. Expected type may be; Cognitive Function type 1: Increasing mortality : not suited for this gestation type II: no change in mortality : re-evaluate unit routine type Ill: decreasing mortality : Which group of sequelae rate among survivors? A increase : limit of viability at this gestation 8 no change: acceptable but not enough c decreasing: limit of viability at more Immature week Placental Chorioamnionitis and IQ Antenatal glucocorticoid and IQ IQ = 86.8 92.5 NS Mean= 92.7 91 .1 96.0 87.5 93.0 111 1<0.,------, 10 1<0 IQ \2C 120 100 100 60 ,, 60 60 om 0 !37 = 111 16 29 ~0 60 n 2D L NO CAM CAM l___QI'OSTEROID G-11111ll 12-17rrg 18-:!Smg 27-47111ll I Antenatal betamethasone I - 73- Annex 5 Neonatal Mutual Cooperative System Resources ofNMCS Very Low Birthweight Infants (<1500g) [NMCS register I Birth register] Number ofNICU 32 Subspecialties 10o.mr. r-- Pediatric Surgery 12 90.o• L------..----u--..------J Neurosurgery ll 90.o• 1------ll ~~~----th-r:r-11:---:--1 Ulrlbn ~~ Pediatric Cardiology 7 "·" 1----fl--TriiHH irlti!-II'H I-~EI.-t.ll-lliH•~--1 w Cardiac Surgery 5 so." 1--hiHif+·-11-1~1-tHHI-ti-IHiiiHI:-flili!lillrt ~ Neonatologists/Pediatricians 177 "·" l-...-~f.tll-tll-fl- fl-lfll-liHI-11-l't-111-HHJHiit11lilt1 ~ NICUNurses 528 40.,. 1-JI-I'J-}JI-lll-l-l-ll-ll-ll-lll-lii-1 1-{1-11-HHIHiil-ltli iiHii Special Care Beds 287 JO.o. l-l~I-HHif-l' l-lt-lr l-ti-IIHI-llllt+lllHiiltli111t111 Intensive Care Beds 128 lfl Neonatal Monitors 231 "" 1 ~1 ECMO Beds "·" 111, HI~.JI-ll 'l-lii-IIHJti-IJ-ft-IIH 3 '·" lll.lUIJJLJ:I.!.I.aJ11JIJIIJ..I.J.IJLLLLIJw..a~...... _..,_,...... ,11 1 Neonatal Ambulance 8 ~ ~ ~ ~ ~ ; ~ ; ; ~ ; ; ; ; ~ NMCS-O.saka Years NMCS-Osaka Number of Admissions -Hospital, Birth weight Neonatal Transport Birth weight (g) I[J<500g • SOCg-- 0 IOOOg- • 1500g- 0 ~OOOg- 0 2500g- I I] Obstetric • Neonatal 0 Triangul 8000 7000 6000 5000 N 4000 3000 2000 0 nnm n , nmma.~J 1000 wm~~U~%UM~~~H~M%%U ~ ~w:mwu s gllD~ 0 121J 4 I ! 22 5 1 II 2 ~ 24 23 ~ ~ 10 15 2! I' 11 25 27 11 10 2i 20 21 26 It Years Hospital Number NMCS-Osaka NMCS-Osaka - 74- Annex 5 Slagle 33,94!~ Twias 3,884 ~ Admission ofMultiple Births Neonatal Deaths Jl.7% 10.2% [NMCS admissions I All Osaka] Triplets42S Quads .(4 ..J.Uio Ol% ------Period-1 ""' ,------1980-89 ,,. ~------~~---1 '"" 1------ll--- -11--- Multiples 1801 10% ""' 1------,.--11---11---11--:::-tl~ U U J t llll J ill U lO II U ill• II II U uP loll. 41 Q U Qu•ds Triplets ,.,. 1------· · lrllrll------·-~~-·· ,.,. 1001 1- 161 ,.,. 1---·•••-t-•---1-41-41-ll-lHHHH ·11-•-1---11- ... Period-2 '" ,.,. 1--+-11--t-+... - a--1-41-11-IHHHHHHI-11-11--11- 1990-2000 "" '•,.l.__I ..."' .... 11.1 Multipl"s 2578 "' 12.7% '" "' .. qununu"411 41U Ynrofblrth unr•drilt ii« M I+Q NMCS·Osaka Gestation (wks) NMCS-Osaka Cerebral Palsy, Retinopathy and Size of NICU ELBW infants born in 1995 Neonatal Mortality Cerebral Palsy Retinopaty of Prematurity Class A, ELBW admission >20/year, n =275 Class a, 10-19, n =277 Class c, <10, n =205 National Survey in Japan, 1999 Decreasing last de cade Neonatal Mortality (/1000, <28days, Japan 2003) D ;fB tili;,J?I :£0 f 71}¥ FnJjfU_:IJ ' ltJI · nfl"'l~ d:t 1 a 'F 0.6 16 ~ Ill 1.6 33 .. Ill 1.9 % 2 1!: Iii' 0.8 16 !Q 3i 1,6 33 tlJ ~ Ul 100 3 li 1.1 16 -t- • 1.6 33 10 !lo1 1.9 100 4 !it ")i! 1.2 16 - !( 1.6 36 15 /11 2.0 '" 4 Pi~ UJ 1.2 16 Iii 1.6 38 ~ 11\l 2.D 6 Jill 1.3 16 *UJ 0 1.6 36 l!il 2.0 7 •~ J;! 1.4 16 'ii: 1\tj 1.6 36 ua* 2.0 7 it Jll 1.4 24 ~~llllll 1.7 40 tt. Ill 2.1 7 a; .. 1.4 24 :IIi ;1: 1.7 4C ll # 2.1 7 a Jll 1.4 24 ~ Iii 1.7 40 ill. II 2.1 11 ll .. 1.5 27 'ii: Ill 1.8 40 111 lllJ 2.1 11 lt ~ 1,5 27 loliili/11 1.8 40 ~ 2.1 11 a lli 1.5 27 ~ til 1.8 45 *116 2.2 11 .. 111 1.5 27 ~ll;i.U 1.8 46 1'1 *Jg 2.4 11 i4' 1.5 27 1! 1.8 47 ll 2.8 • 1.8 • 16 Ill •m 1.6 27 !it • Ph • 1990~ 1995~ 2000~ l d i(~!f!~t:~·- l:S:'~J1~;.r.Tj~~7"):-~ X 1 G:::G ~~~::-:•=rril'J~!D ;r Y$--a-'!: -75- Annex 5 Neonatal Mortality(Gestation at Birth) Neonatal Mortality (Birthweight) 1993-1998, N=569 1993-1998, N=569 180 60 160 140 50 !'1 120 40 I z 100 Z3Q 80 '· 60 20 f----1 ~ • . rJ . 40 ' 20 c-'TRSFf 10 ~ H1= ~i I ~t 1 .~ ::Fn !Til ·igmt i 0 rnf , : J& . 1'1 0 (499 500 1000- 1500- 2000- 2500- I unknown !I 22 23 24 !I !! 27 28 29 JO 31 32 3J 34 35 36 37 JB 39 42 '1'1!1 t!Ml!\lr., " " IBirth weight (g) I NMCS, OSAKA NMCS,OSAKA IJapan NICUs Network, 2003 Mortality and Birthweight (NICU admissions) I Mortality of Very Preterm Births (N=42, Born in 2003) 100% n=1476 90% 80% ... u Gestation N I Deaths . +" .,.; 70% [r Mortali ty ~ .--< 22 32 24 60% +""'.... 23 90 29 32% 0 :E 50% 40% 24 119 38 32% 30% 25 176 22 13% 20% f- 26 178 25 14% 10% f- 27 202 20 10% j m-n n n n _..., n ..., 0% ~ 797 158 20% o0 .::P o" o" o" o" o" o" o" o" /JP ,.,-o /' ,o ,,> ,,• ,. ,• ,'' ,'~ ,. Japan NICUs Network o' o' o' Japan NICUs Network, 2003 Mortality (<1000g) Variation between NICUs Standardized Mortality Rate for Birth Weight - 35 30 ~ 20% 10% -; 25 ~ e> .c"' I ~ 20 '0 !" .E 15 -""',., 'lij 10 t:: ::;:0 0 l ui ~ n n _ 1 :Z ~ .t t I 7 I I 101 1 U I:It 41 511U I I t ~ ~ O r!U l3 1 4.2 iU tl llU~ 8 -» . ;l:1:f.t~ :I 3-~ :J: 53:!i ",37 Center number - 76- Annex 5 The MISSION The VISION -77- Annex 5 Terms of Reference Aims of the Department PROGRAMS FOR SERVICE 8 PROGRAMS 8 These programs the department as a and in collaboration agencies RESIDENCY TRAINING PROGRAM: Rotations Residency Training Program: first year second year third year fourth year gynecologic maternal and fetal anesthesia pathology oncology medicine reproductive maternal and fetal endocrinology medicine OB-GYN maternal and fetal and infertilitv r ultrasound medicine trophoblastic OB-GYN diseases OB-GYN ultrasound OB-GYN infectious ultrasound OB-GYN diseases section urogynecology ultrasound family planning trophoblastic OB-GYN section diseases research section infectious ' diseases section ..... ~ -78- Annex 5 8 Programs for Training and FELLOWSHIP TRAINING IN VARIOUS SUBSPECIALTIES: Graduates of the PGH •• Perinatology Fellowship ••0 Training Program provide service to various places in '1!.1..,. the country ' •••••• -' legend: I • • •• [8] Philippine• General Hospital • Perinatologist Infectious Diseases in{)bstetrics and Gynecology l Programs for Training: Short Courses -79- Annex 5 The section of maternal and fetal medicine holds High Risk Clinics for patients with complicated pregnancies and Teen Mom Clinics for first time mothers 17 years old or younger to address their specific needs. 8 Programs for Research • PUBLICATIONS completed by the residents and fellows with the supervision of the The department, spearheaded consu~ants, from 2001 to 2005_ by the Perinatology Section, came out wrth a book on the 87 of these studies were geared MANAGEMENT GUIDELINES towards improving maternal and of COMMON PERINATAL fetal health care. CONDITIONS in the Philippine Setting, Many of these studies were published in local and international journals and made an impact on 08-GYN practices. - 80- Annex 5 8 Programs for Research 8 Programs for Research PUBLICATIONS • PUBLICATIONS This book won the National Academy of Science and Technology Awards Outstanding The department, through the Monograph given by the efforts of the Trophoblastic DtoiJdllll 1e11l ur 3<-ie~r<-e o~~nd Technology (DOST) in 2001. Disease Section, launched a book on GESTATIONAL TROPHOBLASTIC DISEASE Adapted by the Philippine Obstetrical and Gynecological with Philippine Experience. Society (POGS) as one of ~s reference handbooks, 8 Programs for Research Collaboration between the Centre and WHO: Training Courses Training in the Management of Complications of Pregnancy and Childbirth It is designed to enhance the participants' knowledge The Creation of Clinical and skills in obstetrics, provide them with clinical Practice Guidelines by experience in the management of complications of of performing meta-analysis pregnancy and childbirth, and update them of recent published researches in trends in the speciatty different aspects of maternal fetal health for inclusion in the It makes use of the WHO manual- "Managing Cochrane Data Base for the Complications of Pregnancy and Childbirth" purpose of adapting these Conducted 3 courses (1 month duration) and 1 course (2 guidelines to the Philippine months duration) for 6 physicians from Cambodia, 16 . Headed by: setting Mario R Feslin, MD, MHPed physicians from Mongolia and 8 physicians from Laos from April- October 2001 Collaboration between the Centre and WHO: Training Courses @Training of Trainers in the Mal) gement of Complications of Pregnancy aJ.(l Childbirth 8 It is designated not only to enhant basic knowledge and skills in obstetric and but also to dev lop their capabilrty to train other physicians' in the manageme 1 of obstetrical complications 8 This includes lectures and skills 1 ining for planning of training, development of instructionS' I design and teaching methods in clinical training 8 Conducted 2 courses (1 month dur ion),for 8 physicians from Cambodia and Mongolia for Nove ber to February 2004 - 81 - Annex 5 Collaboration between the Centre, DOH and WHO: Training of Trainers on PBOT 8 Problem-Based Obstetrical Training (PBOT) modules ~ ~ .- 1 ~& ~ 5 modules based on MCPC ~training of 20 regional directors of the ;"'·~•~- t1 . Department of Hea~ (DOH) on the fi1 implementation and evaluation of the """"'· curriculum MCPC is now translated to other languages and has a worldwide circulation of 22 million. A second edition is currently being prepared . Lessons Learned: Problems, Hindrances and Obstacles @There is a need for clearer delineation of responsibilities among @project members from WHO, PGH and DOH with regards to the MCPC. @The fellowship training could be expanded further if there was a specific budget allotted for postgraduate fellows-in-training. @There is a need for more linkages with district and regional hea~h centers in order to make the training programs more attuned with the needs of the country. @Greater research output can be achieved if more funding could be allotted for the implementation of research projects. - 82- Annex 5 MATERNAL MORTALITY /100,000 LIVEBIRTHS 8.6 Consultation on Human Resource Development in Making Pregnancy Safer PC Wong 29.8 Department of Obstetrics and Gynaecology Cbief, National University Hospital Head, National University of Singapore WHO COLLABORATING CENTRE IN REPRODUCTIVE HEALTH PERINATAL MORTALITY /1000 LIVEBIRTHS & STILLBIRTHS Approaches to Reduce Mortality • Reduction of fertility l9.8 • Legalisation of abortion • Improvement of pregnancy care 16.6 (antenatal I intrapartum) 10.8 • Enhancement of socioeconomic status Reduction of Fertility- Family Planning REDUCTION OF FERTILITY 1966 1969 1972 1974 IEugenic Board I Voluntary Amendment Sterilisation of Sterilisation on Act Voluntary application by FAMILY DISINCENTIVES INCENTIVES Sterilisation Decision individuals PLANNING POLICY POLICY No-age barrier, Act transferred >40YO: with <:4 30 days from Eugenic children. application to Waiting time Board to Husb!lild's sterilisMion reduced to 7 registered consent waiting period. days. No of medical necessary No of children children J. to practitioners J. to 3. 2. with consent of patient. - 83- Annex 5 Reduction of Fertility- Family Planning Reduction of Fertility- Family Planning 1966 1969 1972 1974 1966 1969 1972 1974 IEugenic Board I Voluntary Amendment IEugenic Board I Voluntary Amendment Sterilisation of Sterilisation of Sterilisation on Sterilisation on Act Voluntary Act Voluntary application by application by Sterilisation Decision Sterilisation Decision inrlivirlli RI > imtivithtRI~ NUiig~:baulllJ, Act transfernd Nu Hilt lllluit l, Act tranif~rr<:d >40YO: with 40YO: with ~4 30 days from Eugenic children. Waiting time children. Waiting time application to Board to appli~;ation to Board to Husband's sterilisation reduced to 7 registered Husband's sterilisation reduced to 7 registered consent waiting period. days. No of medical consent waiting period. days. No of medical necessary No of children children .J, to practitioners necessary No of children children -!. to practitioners .J, to 3. 2. with consent .J, to 3. 2. with consent of patient. of patient. Reduction of Fertility- Family Planning Disincentive policies 1966 1969 1972 1974 • Increasing accouchement charges for increasing birth orders eg IEugenic Board [ Voluntary Amendment rate for first child was S$350 whilst for the fifth was S$1 000, Sterilisation of • School admission priority - lower priority for the choice of on Sterilisation Act Voluntary primary schools for third and subsequent children. application by Sterilisation Decision • No paid maternal leave for delivery of third and subsequent fodividuals No age barrier; Act transferred children. >40YO: with~ 30 days from Eugenic • Taxation policy- no income tax relief given to the 4th and children. _application to Waiting time Board to subsequent children born on or after August 1973. Husband 's sterilisation reduced to 7 registered • Housing subsidy allocation - low priority to be given to large consent waiting period. days. No of medical families for allocation of housing grants. necessary No of children children -1- to practitioners -!.to 3. 2. with consent of patient. Incentives negative sanctions • Waiver of delivery charges in government maternity Tangible hospitals • No accouchement charge made for mothers who accept sterilisation after delivery Government does not impose • For subsidized patients, ward charges may also be waived. • Delivery charges also waived if husband underwent sexual legal measures on sterilisation w1thin I month of delivery. those not restricting • Medical leave family size to the stipulated TWO. • Up to 28 days of fully paid leave granted to those mothers who underwent sterilisation after delivery. - 84- Annex 5 Incentives Abortion Legislation IBefore 1967 1967 1968 1974 • Continuation of employment for non-Singaporeans I I I I I I I • For couples holding Singapore marriage certificate where I Legal abortion National Family lFirst AbortionJ INew Abortion partner is non-Singaporean, both partners must be sexually restricted to Planning& Bill Act sterilised after delivery of 2•d child if they wish to secure cases in whom Population Board continued 11mploym11nt in Singapore. maternal life oot up Liberali&id to Possible to do \vas endangered include cases • Monetary stipend Extended abortion abortion up to deemed <30 and family income Abortion Legislation Abortion Legislation IBefore 1967 I I 1967 I I 1968 I I 1974 I IBefore 1967 I I 1967 I I 1968 I I 1974 I Legal abortion Legal abortion National Family First Abortion New Abortion National Family First AbortionJ I New Abortion I II to l restricted to Planning& Bill Act restricted Planning& Bill Act cases in whom Population Board cases in whom Population Board maternal life maremallife set up Liberalised to setup Liberalised to Possible to do was endangered Possible to do was endangered include cases include cases Extended abortion abortion up to Extended abortion abortion up to deemed deemed to (I) eugenic 24 weeks of to (I )eugenic 24 weeks of unsuitable to unsuitable to cases eg pregnancy by a cases eg pregnancy by a continue continue congenital fetal registered congenital fetal registered pregnancy for pregnancy for abnormalities abnormalities medical family, social medical family, social (2) victim of sex (2) victim of sex practitioner and economic practitioner and economic crime crime reasons reasons Abortion Legislation LEGALISED ABORTION IN SINGAPORE 1968 I" AbortioD Bill ll,SU IBefore 1967 I I 1967 I I 1968 I I 1974 I ~ 1974 New AbortJoD Ad 18 669 Abortion 1 Legal abortion National Family IFirst Abortion II New Bill Act ~ 18,2T9 restricted to Planning& ••.soo ),734 cases in whom Population Board Liberalised to maternal life setup Possible to do 12,749 include cases was endangered Extended abortion abortion up to deemed to (I )eugenic of unsuitable to 24 weeks cases eg pregnancy by a continue congenital fetal pregnancy for registered abnormalities medical family, social (2) victim of sex practitioner and economic crime reasons - 85- Annex 5 CRUDE.... BIRTH RATE/1000 POPULATION TOTAL FERTILITY RA TEIRESIDENT FEMALE t1T Abortl011. BW 40 ' 4.66 ~.~ INFANT MORTALITY RATE/1000 LIVEBIRTHS DEATHS RELATED TO ABORTION 49 . ~ Has been 0 since 1980s Improved pregnancy care Improved pregnancy care • Anaemia • Identify risk factors • Conduct of delivery • Skilled birth attendants • Routine haemoglobin (100%) • Fe and folic acid • Eclampsia • Early identification & • Postpartum • Use ofuterotonics referral haemorrhage • Medications - MgSo4 & anti-hypertensive • Emphasis on cleanliness • Puerpural sepsis • Proper sanitation and • Use ofpartograms clean water supply • Obstructed labour better than routine antibiotics - 86- Annex 5 of Enhancement Millennium Development Goals socioeconomic factors Eradicate extreme poverty and hunger • More women received formal education Achieve universal primary education Promote gender equality and empower • Reduced poverty I malnutrition women • Delayed marriage Reduce child mortality Improve motcrnol hcolth • Better fertility regulation Combat HIV/AIDS, malaria and other • Avoidance of harmful traditional practices diseases Ensure environmental sustainability Develop a global partnership for development September 2000 Where are we today ...... GoalS: Improve Maternal Health Every year, at least SZ9,000 women die in preenanc.y or childbirth. 99•1. o£ in the developing world. Target 6 these occur • Reduce by three-quarters, between Maternal Death 1990 and 2015, the maternal mortality ratio • Indicator 16: Maternal mortality ratio • Indicator 17: Proportion of births attended by skilled health personnel More than 80 percent of maternal deaths worldwide are due to five direct causes: haemorrhage, seps1s, unsafe abortion, obstructed labour and hypenensive disease of pregnancy Continue...... Current focus points ...... • Maternal Health • Up to 15 per cent of pregnant women in ALL population • Increase the number of births attended by skilled health personnel fatal complications- 20 • paying special attention to the postpartum period, when a high groups experience potentially percentage of maternal and newborn deaths occur. million women each year. • Making pregnancy safer • For every woman who dies in childbirth, around 20 more • Extend the continuum of ~l!m.J2Y.JIY!!ified oersonnel. for mothers, suffer injury, infection or disease- touching approximately 10 newborn babies and children • The~e mcludc. optimizing antenatal care for the detection and million women each year. prevention ond tre•tment ofHIVIAIDS and sexually transmitted 1nfec.tfons.. malaria and malnutrition, and mother to child • Complications resulting from unsafe abortions account for transmission of diseases, 13% of all maternal deaths. • Reproductive health • Only 58 per cent of women in developing countries deliver • To integrate .~.P~tiy_e and ~xu I h.~a hh service_! across the health with the assistance of a professional (a midwife or doctor), and syste·m and the primary care.. centre. • Provide t.QQ!~ to measure access to these services and monitor only 40 per cent give birth in a hospital or health progress in this area, ensuring that equity issues are taken into account_ - 87- Annex 5 · Australia SINGAPORE · Brunei Darussalam Countries in the WHO Western Pacific Region - Cambodi11 · ChiT18 · Cookl.o;lands - Fiji • Japan · Kiribati - UoPeople'sDemocratic ...... ,... Statistics Human Resources - Mushe.lllslands- · Micronesi11(Fcdcratcd Statesol) Totolpopululon:4..Jl&,ll00 ·-·-- -MOIIj!Ollito -Nauru l.UrpfftlplllllllllS,liJO-'j: l &,l4& 1- -Ncw:Uo.land WEST EAST -Niue -Palau lf•d!hr 11/o " ~""" • ~ q .... lllrt~o mlr tr-•f' • Health Legislation ·Papua New Guinea Regional Office for the Western PaCific l00l):&l,lnl,3 An Act (No 5 oriOOI) to establbh tlu Huhh Pmmqlltn B9erd ·"b.itipJ11N1 P 0 Box 2932 A11Act(Nt 5or199'7)toprovldotorthtrf1ll1nUonortm!l.ls.ll • i.J!p uhll.o; !!f KerLI AduhmortolltyraJt(porl000):92151 1000 Manila """""""'AnAct(No46dl99'llO"'I'bllsblboShii•Pato~ Totolhnllhupond]lurtptrnpl!o{lnUS, An Act (No 2-' ot U'74) rtl1tln1l0 ttrm!n•Uqn gt prpnonsx Philippines 1003):1,156 An Act (No 25otl9'74)td1Ungtotrt11ran.tfarWim!.!c:..a.tl. J.!t.lillJ.!!l! <=:> Total hnllh npondlture u% otCDP (1003): -Tonga -Tuvalu .. _ ,,..~ FJgur~ucror2004unlcDindic•!Cd -Vi.lt N... How can We Help .... How can We Help .... reflecting WHO policies and priorities reflecting WHO policies and priorities Providing advic~ At tertiary level IHUMAN RESOURCES Our experience I •Health policies, good D practices, clinical guidelines •Improving access to health information •Upgrading of facilities •Translating knowledge into policy and action ~ ·Human resources •Back up professional support •Leadership •Sharing and reapplying experiential knowledge •Regional health library •Training of healtb personnel \=J •Building support and •Fostering an enabling environment •Collaborating works donations •Leveragmg e-Health Areas: •Audit/statistics D cs •Prenatal care Methods •Skilled care at birth D •Providing trainers Millennium Developmental Goals •Emergency [S •Distant consultation Regional Health obstetric care l •Clinical fellowship Library •Operative skills Tertiary support Training of health personnel • Critical care • "Trainer for the trainers" • Mass casualty • Distant learning programme • Intrauterine transfer • Clinical fellowship • Management of complicated obstetric • Regional seminars and conferences cases • Distance consultation via e-web or email. - 88- Annex 5 Areas of coverage Regional Health Library • Prenatal care • Policies, good practices and guidelines • Skilled care at birth • Administrative arrangement • Logistic maintenance • Emergency obstetric care • Human resources development • Operative skills • Rcscnrch information • Surgery and office procedures • Collaborating networks Subspeciality care • • Tools for monitoring and auditing • Oncology, MIS and reproductive medicine Collaborating works ..... • Standardization eg definition, workflow, policies • Synthesis and dissemination of information • Scientific and technical information they need ror the THANK YOU FOR conduct of their activities and which these activities generate; and • Information of interest to the country's national health ATTENTION development YOUR • Technical corporation on national health development • Research, Development and Research Training in Human Reproduction • Epidemiological information and mass casualty disaster - 89 - Annex 5 SYONEY SOUTH W - ~~oll.ll1 llllhl ltl IIISWIIIHEA!J"Ii UTS:NURSING, MIDWIFERY & HEALTH (FMNH) UTS:NURSING, MIDWIFERY & HEALTH COLLABORATING IN THE WESTERN PACIFIC REGION COLLABORATING IN THE WESTERN PACIFIC REGION Global WHO Collaborating Centres AI present there are approximately 36 global WHO Collaborating Centres for Pat Brodie Nursinq and Midwifery: Professor of Midwifery Practice Development Midwifery & Health, Faculty of Nursing, ·~ 3 in WPRO Republic of Korea, Japan and Philippines: UTS •:• 4 in SEARO 2 in Thailand and 2 in India; and ·:· 18 in AMRO; Sydney South West Area Health Service ·:· 2 in EMRO; ·:· 6 in EURO; and •:• 3 in AFRO. There is approximately 900 Collaborating Centres in the wor1d Proposed WHO Collaborating Ce-ntre for the D('velopment of ...... WIRO • -0100 .• Nurs•ng, M1dw1tcry & Health ·...... '· ..... •iA UN IVERSITY Ot ~.. , T(C•t-.::L00•'" ON~'"Y THE FACULTY OF NURSING, UTS:NURSING, MIDWIFERY & HEALTH COLLABORATING IN THE WESTERN PACIFIC REGION MIDWIFERY AND HEALTH Proposed WHO Collaborating Centre • Research and development -Education The impetus and rationale for the UTS Faculty of Nursing, Midwifery & Health to become a designated WHO Collaborating Centre (CC) is two fold: -Practice -Policy •:• The Faculty's extensive history of regional work in human resources for health, education, regulation , policy and capacity bu ilding ; -Workforce •:• The identification of a regional need for an enhanced geographic coverage for health development in the WPR, specifically the South Pacific, Australia and New Zealand This need was identified and articulated at the South Pacific Ch ief Nursing Officers' Alliance Meeting in the Cook Islands in 2004 (SPCNO 2004). - 90- Annex 5 + J... u . r;. ,I ~f · ... ,1 ' UTS:NURSING, MIDWIFERY & HEALTH UTS:NURSING, MIDWIFERY & HEALTH COLLABORATING IN THE WESTERN PACIFIC REGION COLLABORATING IN THE WESTERN PACIFIC REGION Summary of some of the UTS Faculty for Nursing, Midwifery & Summary of some of the UTS Faculty for Nursing, Midwifery & Health past and present WHO and regional projects. Health past and present WHO and regional projects. 1 SAMOA: Safe Mothemood Review (1999-2001 ), Maternal Death Review INDONESIA (Cont.): Curriculum development and capacity building and protoool dovolopmont (2000·2001 ), itrong\honing roll•oo,..tivo f•.,..llty rPii=tlinnc;hirt pc;f"'hlic;hPri hPtwPPn IITR "'"rt Ain"'w.:.n lnc;tihlfA nf HArtlth development between UTS Faculty of Nursing, Midwifery and Heallh and Sciences to develop and International standard BN program. (2003- the National University of Samoa (NUS) (2004 ongoing) (UTS and NUS ongoing) of understanding established ) Mental heatth practice and memorandum REGIONAL: tnstfp ated and coordinated a WHO Regional Chief Nurses curriculum development Summit on emerging_d isease and lessons fiX>m SARS. (2003 ·ongoing) 2. PAPUA NEW GUINEA: Intensive Care and Mental Heatth curriculum and 7. SOUTH PACIFIC: Collaboration with South Pacific Chief Nursing Officers practice developmenL (Mid -late 1990's) Alliance (SPCNOA) to develop supportive approaches to building 3, REGIONAL: Collaborative wort< with WP/SEAR Regulatory Authorities leadership capacity in the regions of WPRO and SEAR. (2004 • ongoing) Regulatory Technical Meetings. (1999- ongoing) 8. INDIA: IL.Hiranandani Hospital, Mumbai India. Capacity building with 4. INDONESIA: Sister Schools Programs in Central Kalimantan and South hospital staff to enhance service delivery quality to International standard Sulawesi. Capacity building with teaching staff to increase the quality of of patient care (2004- ongoing) Nursing and Midwifery Education and Administration {World Bank funded) (2002·2004). UTS:NURSING, MIDWIFERY & HEALTH UTS:NURSING, MIDWIFERY & HEALTH COLLABORATING IN THE WESTERN PACIFIC REGION COLLABORATING IN THE WESTERN PACIFIC REGION Summary of some of the UTS Faculty for Nursing, Midwifery & Health The Key Strength Areas (KSA) in nursing, midwifery and health CC: past and present WHO and regional projects. Reaources for Health: workforce , migration , ethical recruitment 9. INDONESIA: Post Tsumam i reconstruction project: Improving Clinical Teach ing & Learn ing in Pre-Service Programs , Conducted at the Edur:atlon: curriculum development, accreditation Politeknik Kesehatan Naggroe Aceh Darussalam (PKNAD) and the School of Nursing at the University Syiah Kuala (USK), Banda Aceh Regulation: mutual recognition, competency Naggroe Aceh Indonesia UTS FNMH have been chosen as development, protection of the public organisation of preference for further work in this region with JTA International. AusAID funded (2005- ongoing) Pollr:y & SetV/r:e Development: models of service delivery, quality and safety, preparedness and emerging for postgraduate nursing 10- SOUTH PACIFIC: Building leadership capacity diseases and other heBrth service ctisis and midwifery education in the Pacific. WHO sponsored workshops with regional nurse leaders from Tonga, Fiji, Cook Islands and Samoa. Cspsclty Building: equity; skills development and preparedness, Exploring Midwifery credentialing , clinical leadership development and leadership in all above areas education in the Pacific (2005 · ongoing) Reaearch: design, implementation and utilization UTS:NURSING, MIDWIFERY & HEALTH COLLABORATING IN THE WESTERN PACIFIC REGION Global and Regional Challenges for Nursing and Midwifery Data Collection: •!• Data availability and reliability; ·:· Difficulties in data gathering; •:• Difficulties in collecting data over time and sustaining data collection; ::::==....._.. "'.::.:.:::'" •:• Insufficient registration of workforce planning systems; -,==----==.: .. ·:· Lack of accessible and lor shared data files ; - categories of personnel; •!• Difficulty in defining/differentiating •!• Resources limitations- human, techn ical equipment; and - - •!• Required computer skills - 91 - .< Annex 5 UTS:NURSING, MIDWIFERY & HEALTH UTS:NURSING, MIDWIFERY & HEALTH COLLABORATING IN THE WESTERN PACIFIC REGION COLLABORATING IN THE WESTERN PACIFIC REGION Draft Core Data Domains and Indicators Draft Core Data Domains and Indicators Demographics Workforce Par1icipation •!• Country Population ·:• Number of hours worked in an average week (tabulated with age and sex) ·~· CurumlnUtlll.J~t ur !ltufl:!~~IUI1db (~luL.k) •:. Job Classification (broad description of roles and levels within •!• Current number of Professionals working (head count FTE) organisations) •:• Personnel by Age Group •!• Principle clinical practice (described by practice, client group or field) •!· Gender Mix •:• Principle role of health professional (descriptions include of different roles} Current numbers of registered/licensed Professionals Workforce Distribution •!• Current number employed •!• Type of employment •!• Qualifications (including licence /registration) •:• Geographic location of employment •!• Number and type of services in geographic location UTS:NURSING, MIDWIFERY & HEALTH UTS:NURSING, MIDWIFERY & HEALTH COLLABORATING IN THE WESTERN PACIFIC REGION COLLABORATING IN THE WESTERN PACIFIC REGION Draft Core Data Domains and Indicators Working Collaboratively ·WHO WPR HRH - IMS Project Workforce Additions •!• Education and training {number of students, age, sex, full time, part time, •!• Wor1d Heallh Organization (WHO) headquarters, number of graduates, number of expected completions, number of •!• WHO Western Pacific Regional Office (WPR), student providers) •!• University of Technology, Sydney (UTS) Faculty of Nursing, Midwifery •!· Migration (number of individuals joining workforce from overseas) and Health •!• Workforce re-entry (number of people expected to re-enter the workforce) ·:· Stakeholder Group Workfon;e Losses •:• Other selected regions, partners and countries •!• Retirements {making assumptions about retirement age is no longer The Project aims to support member states in the regions to provide improved possible) indicators and information to aid human resource planning that wm ultimately •!• Dealhs (not always readily available) have an impact on improved patient care_ •!• Migration (mobility of professional is hard to capture) •!• Wastage (individuals leaving the profession or number of unknowns) UTS:NURSING, MIDWIFERY & HEALTH COLLABORATING IN THE WESTERN PACIFIC REGION Future work with proposed WHO Collaborating Centre for Nursing Midwifery Health and Development •:• Ongoing Regional Capacity Building Projects ·!• Host WHO WPR Regional Meeting - Second Regional Summit WHOIWPR Leadership Summit Building Leadership Capacity and Disease Prevention in the Region •:• Update Western Pacific and South East Asian Regional Nursing and Midwifery Regulatory Authorities Meeting Country Profiles •:• Set up a Regional Policy School -92 - -93- ANNEX6 PRESENTATIONS OF PROFESSIONAL ASSOCIATIONS ·.,. -94- ····.~ '. -95- Annex 6 Make Pregnancy safer CAMBODIA y "' '9''' Presented by Prof. KOUM KANAL AiJcMmiMI,._ Director \ INOI4l r National Maternal and child Health Center bfltndl. 1 --"'"'"" · ~MALAYSIA ~ •• ~., •...,,. l The Near History of Cambodia GEO-SOCIO DEMOGRAPHY 1953 rndependence from France Surface areas_···--·-·"--.. ··".. --... ·-··- · ~ · -·.181,035 km2 Populatlon.___ , ______.. _ ...... - ...... 11437656 75-79 Occupied by Pol-Pot . Massacre of the intelligent Unban popul mti~n . __·-·-·-···-- ···-·---·-··-··15.1"/. led the destruction of social system. "'nnual ~pulation growth rate_···-······--·-·--·······-··2.41', 89 The end of Cold War· ·Civil war grew more 1', of Population under the poverty line(1999) 36"1. severe. "/,of Poor population in the rural nation wide(1999) 90"1. 91 Paris Treaty· ·Going into UNTAC era # ~pulation from 0-4 11.51'. 15.91'. 93 The 1st General Election under control of # ~pulation from 5-9 UNTAC· ·Start of the first Democratic Gross domestic product per capita(2002) US$360 Government "'nnual per capita income(1999) US$250 2003 Tho 3rd ""•rol Election (Source CDHS 2000) Socio economic Indicators Health and Demographic indicators 1'. of illitterated women* 321'. Live expectancy (2000) female65y.o. Male 59y.o. 1'. of men finished primary school* 7"1. Fertility Rate (2005) 3.4 1', of women finished primary school* 41'. Maternal mortality Rate(2000) 437/IOO,OOOL.B . 1', of families access to the electricity nation wide* 171. Infant mortality Rate(2005) 65/1,000L.B. 1'. of the rural families access to the electricity • 91', Under 5 mortality Rate(2005) 83/1,000L.B. % of population using water from out side at the dry season 301', 1'. of Under 5 stung(2005) 371. 'roof families having sanitation"' 2l'ro "!.of Children under weight(2005) 36"/, Persons per doctor ,1998 6,808 "!.of TB incidence (2001) 540/100,000 ~pulations Person per health worket,1998 598 % of Malaria incidence (2001) 8/1,000 ~pulations HIV/AIDS Prevalence among 15-49y.o. 2.8"/o (Source CDHS 2000) HIV I AIDS prevalence among pregnant women attending ANC clinic 2.2"/. (source CDHS 2000; Preliminary results CDHS 2005 ) 1 -96- Annex 6 Most important RH Problems National Health System Very high maternal and peri-natal infant mortality rates(Highest in the region ) r.nu~p,~ hy Fr.lnmpsia, Abortion, Infection for mothers and Diarrhea, ARI,Dengue Fever ,Communicable Diseases for infant & Malaria Low access to family planning services Low coverage for ante natal care nd ~ •• I : Re ural Hospita l Lack of access to essential obstetric care at CPA) Sp u~ n zed services district level Higl1 quality standard Com llmU!f t o tM In I,vel Reduce Child Mortality Improve maternal Health Indlcotors Benchmarks Targets Indlcoto<'S S.ncfu"orks To.,... Vclue Ycor 200, 2010 20" Value Year 200, 2010 201, Maternal mortality ratio (1100,000 live births) 437 1997 343 243 140 10, under 5 mortality rote(perl,OOO li~ births) 124 2001 8' 6' Total ferflllty rate 4 1998 3.8 3.4 3.0 Inf4Plt Mortality rate Cpu 1,000 live births) 95 1998 60 ~ Proportton of birth ot"tended by skilled health 32 2000 60 70 10 pcrso..,.l(ll.) of children under 1 year immunized 41.4 2000 "'80 8' 90 Proportion Proportion of I'Mr(lt.d liiON" Uil~ I!IOdef'n 18., 2000 30 44 60 against moasles (%) birth spacing_methods(%) of children aged 6~59 months 28 2000 70 80 90 Proportion Percentage of pregnant women with 2 or more 30.5 2000 60 90 A capsules (•to) reeeived Vitamin ANC constllt. from skill health puSOt!Ml (ll) 11drt.n UM!er 1 year immunized 43 2000 80 90 "' Proportion of dt Prcportfo111 of lJrcgftSJ'!If vron:oc:n with iron 66 2000 ~ 39 33 against DPH (7.) " d Health Sector Strategic Plan Midwifery competencies (2003-2007: Ministry of Health) TRADITIONAL NEW Competing a partograph Taking an antenatal history Performing AMTS (active Identifying 2nd stage management Jrd stage) Manually removing a placenta Managing 2nd stage Recognizing & treating a Managing a normal birth newborn infection Assessing Apgar scores Recognizing & treating postpartum sepsis Assisting with immediate Reco?cnizin.g & treating breastfeeding ecamps1a Newborn resuscitation 2 -97- Annex6 Institution Primary Secondary Sub-Total Midwife coverage 2006 Midwives Midwives MoH 2 20 22 Nat. Hosps + Kuntha 4 119 123 Midwives are working in different institutions Bopha I throughout the health sector. These include: CENAT I 2 3 the t:ent1·ul MoH, nutionol PI'Oyi'Utns, 11ut iut1ul NCHALJ~ 4 4 hospitals, PHDs, ODs, RHs, HCs, HPs, and NMCHC I 108 108 private clinics (PP). PHD 31 158 189 OD 23 115 138 Total number of midwives in these institutions: RH 150 533 683 2,965 (primary and secondary) HC 817 780 1.597 NGOs and provincial private clinics were not HP 18 I 19 included due to unavailability of data. Private Clinic 79 79 Grand Total 1.046 1.919 2.965 Midwife coverage 2006 Midwife coverage 2006 Prirm.ry vs Secondary Midwives in 2006 (n=2,965) PHD OD RH HC HP 24 77 69 936 57 Source: Personnel Department, MoH 2006 Midwife coverage 2006 Midwife coverage 2006 Conporison d ll'ldv.lves' Site d 11\bk (n=2,62S) l\llciWfe Coverage at HCs (...... ,.) a~-e~NJMN a .HCWth1MN C I-Cv.4th2MI\& C HCv.flhJ,.,..... •HC'Mthmorvltlan3 f!NI,II. 3 -98- Annex 6 Midwife coverage 2006 Training cycle PM (HCs & RHs) SM (HCs & RHs) MoH 1,775 1,847 Standard Actual 967 1,313 Needs 808 534 HC MW in service Training Courses !" 1. NMCHC HC MW Training Course - supported by JICA, UNICEF, etc. 2. Life Saving Skills (LSS) - supported by RACHA {USAID) etc. 3. Four Month Course - (supported by GTZ etc.) \... ./ lSA unified training checklist Referral Hospital {RH) M W PMTCT in Cambodia Background in service Training Courses - 1991- The first HIV case reported - 1993- The first AIDS case reported 1. NMCHC RH MW Training Course - 1998- National Center for HIV/AlDS, Dermatology and Sils - For five weeks, 16 trainees (NCHADS) established - ANC, Clean & Safe Delivery, EOC, PNC, Newborn - 1999- National AIDS Authority established Care, Nutrition (Breastfeeding), EmOC, etc. - PMTCT Technical Working Group set up - 2000- National Policy on PMTCT prepared - supported by JICA etc. - 2001- PM TCT program launched 2. Life Saving Skills (LSS) - 2003- PMTCT program started expansion - For 10 days, 6 trainees Current status of PM TCT - Delivery, Postnatal care, Newborn care, breast 310counselors/HCWs trained on PMTCT. feeding etc. 12 out of 310 HCWs were selected to be Counseling trainers. 51 PMTCT sites have been implemented in 31 ODs of 18 - supported by RACHA etc. provinces/city. 4 -99- Annex 6 Objectives of PMTCT Program in Cambodia To enable women to avoid HIV infection through counseling especially pregnant women. To enable HIV sero-positive women to avoid unwanted pregnancies To protect HIV-infected women and children from stigmatization and discrimination; and To prevent Vertical transmission in HIV infected pregnant women through prophylactic means. Cambodian Obstetric- Cambodian Midwives Association Gynecologist Association (SCGO) (CMA) Established in 199'4, supported by UNICEF, Established since June 1997 USAID (through PACT, SEATS, RACHA and Re-elected in 2004 and 2007 CEDPA), British and Netherlands 150 members Mission: Strengthening the implementation of CMA joined as member of the International National healtli. policies and strategies Confederation of Midwives (ICM), White through 1mprov1ng knowledge and sl 5 - 100- Annex 6 Making Pregnancy Safer 0 Matemal Health Status & Resource Actions in China 0 .Challenge In Making Pn;~afer Wang Linhong, Deputy Director, Professor 0 Intervention Actions ____ Chinese Woman's Health Care Associations National Center for Women and Children's Health, China CDC 0 Expectation Wang Llxln, Associate Professor (Midwife)< Representative of Midwife _. ./ " ,.-· -- National MCH Human Resource National Health Status f200~1 There are 3000 MCH Institutions In China, accounting for 1% of all medical institution • By the end of 2005, China has a total of 1.3 billion population . Three-tier MCH Network In Rural Area In China, 2005 No. of No. of Tier No. of MCH Staff • There are approximately 368 million women Institution Staff in reproductive age group (age from 15 to 49), County MCH 1,526 66,665 55,316 which account for about 28% in total Institution Township population 40,907 1,012,006 200,000 Hospital • There are 16.71 million live births in 2005. Village Source: Cbia1 Swistie&l Yurbooic"200!1, Natioa.al Bun:au ofSWiltics o(Chiu. 583,209 ~1.6,532 - 300,000 National Health Status National Health Status Matemal Mortality Ratio in China from 1990 to 2005 Infant Mortality Ratio in China from 1991 to 2005 Source: MOH, China, 2006 1 - 101 - Annex6 National Health Status Maternal Services Rate in China from 1992 to 2005 Challenge In Making Pregnancy Safer Soiii'CI: MOH,China,l006 • Big gap between urban and rural, eastern and western areas in maternal and infant mortality. MMR IMR Big cities 10-20/1 00,000 Under 5/1,000 Average cities 30-40/100,000 5-1511,000 Rural areas 50-1001100,000 15-2511,000 Remote areas Over 200/100,000 Over 30/1,000 Matltl'lal Mlll'lllllty' R.te 11111110,00CII. CN!ta. 2D05 ChaUenqe In Msltlnq Preqnancv Safer • Medical resource, especially the MCH service capability, • Obstetric hemorrhage is still the main cause of is too inadequate In rural areas. maternal deaths in China, especially In rural area, which cause nearly half maternal deaths. Over 60% medical Issues, which Involved to maternal deaths, happened In township hospitals and village health stations. 0 0 0 Obstetric hemorrhage mortality in China. from 2000 to 2005 Soum: MOll,. Cbir.a. 2006 Sourco: MOH. Ctina. 2006 2 - 102- Annex6 Challenge in Making Pregnancy Safer • Labor monitoring • Poor health status of migrant population • Delivery assistant, Including episiotomy, ate • Management ot the third stage of labor • MMR: 71.58/100,000 live births • Birth attendants in rural areas (trained nurses and TBAa) • MMR: 130-450/100,000 live births in 8 provinces • Basic perinatal health and newbom care • Identify soma complications ot pregnancy • Poor health awareness among reproductive age • Retar prevnant women to appropriate medlcallnatltutlona women ProVIde polltpartum care Support tor breaatteedlng __..- - __. -- otl'er family plannlnglnform ~ n Jnd-WI'YI- Challenge In Making Pr11gnancy Safer • Human resource of Midwives Intervention Actions • 1 : 4000 childbirth • Without specialized system of midwife • Without specialized higher education • Without specialized professional association Professional Support !F"!Stnenl~then systemic antenatal care for each • Formulating national guidelines pregnant woman • Revise national guideline and routine of maternal • Risk-screening for complications health care • Functioning referral systems • Constitute the standard of emergency aid centre in county lever • Emphasis of childbirth attendance by skilled • Constitute the management criterion of three-tier care providers referral network • Promoting hospital delivery • Translation WHO document into Chinese version Birth attendance training • Supervision Emergency obstetric c.llnl (postpartum h~motrhage, • Developing tools for better monitoring, neonatal resuscitation .••••• ) r-.....:.:.::.'u ::.:a:.:tl::;:on -~.~-~ . 91Jic!ance 3 - 103- Annex 6 Ptvfeaaional Support Pro'"'jonal SIIPJ!otf hort-lt9rlm trainings for generalization of • Long-term technical guidance appropriate technology • National and provincial expert • Essential perinatal and obstetric services (clean were sent to work in lower delivery) level hospitals for certain • Emergency obstetric care (first aid) period • Assessment of labour • Mother friendly services. • Neonatal resuscitation • Responsibility midwifery during the whole process • ALSO ( advanced life • Doula in delivery (husband participation in delivery) support in obstetrics) • Comfortable and homey environment • PMTCT National and International Projects • Population health education • National Project of Reducing Maternal Mortality Ratio & Eliminating Tetanus in Newborn (China Government) • Promoting hospital delivery I clean delivery • Started up In 2000, coverad with 12 provinces • The major symptoms of complications • In 2006, expanded to 23 provinces, 1000 counties • Where and when to seek care for complications RMB 440 million Yuan In financial support • Exclusive breastfeeding • RMB 164 million Yuan to Improve facilities • STD/HIVIAIDS prevention 730,000 poverty maternities • Family planning 1,200 professional experts Involved MMR reduced 26.8% Hospital delivery rate lncraased 28.4% International Projects Expectation • Reproductive Health/Family Planning (RH/FP) 61h Country Program. (UNFPA) • Focus on western, rural and remote areas • 30 counties (cities) In 30 provinces • Integrated management of pregnancy and • Piloting of the Mother and Baby package (UNICEF) childbirth • 46 counties (cities) in 12 provinces • Improving practical skills of childbirth assistants • MCH Project of Health IX in China (World Bank). • Further hospital delivery promotion • 106 counties In 6 provinces, • Interventions for severe maternal morbidities • Severe Maternal Morbidities Audits. (WHO) • International cooperation and communication • 3 counties In 3 provinces 4 - 104- Annex 6 Presentation of the representative of Lao PDR. At the Workshop: Human Resource Development in Making Pregnancy Safer Shanghai, China. 26-28 September,2006 Area: 236,800 square Km Populatioa: 5,6 millioa Capital city~ Vieatia~ae Country Profile Country Profile ( cont') • Population: 5,621,982 • Health Centers: 739 • Area: 236,800 km2 • Health staff: 11,504 • Density: 23,7 • GDP: 500 USD • Provinces: 17 • Education: 78% • Crude birth rate: 34,7 • Districts: 141 • Crude death rate: 9,8 • Villages: 10,553 • Life expectancy: 61 : 21 • Central and Provincial hospitals o Female: 63 • District hospitals: 127 o Male: 59 Country Profile (cont') Country Profile (cont') • MMR: 405/100.000 LB • Vaccination : 65% • IMR: 70/1 .000 LB • Water supply: 67.15% • U5MR: 98/1.000 LB • Sanitation: 45.68% • TFR: 4.5 • AIDS prevalence: 2.02% • ANC: 38% • IBN coverage: 60% • Delivery at hospital: 16% • Population in remote area: 80% • Post natal care 14% • CPR: 38% 1 - 105- Annex6 J Six Major Directions for Health Development Health Situation in Lao PDR to the year 2020 • A. Health policy and health strategies • To strengthen the capability of health staff in term of attitudes, ethics and technical skills in order to ensure high quality services e~ Health policy: Well being of the population by o To improve community- based health promotion and disease providing quality health care services, accepted prevenllon by the society. • To improve and expand hospital service at all levels and in remote areas e~ Health strategies: Strengthening of the capacity of • To promote the utilization of traditional medicine by integrating health staff, improving community-based health modern and traditional care promotion and prevention, expanding health • To promote scientific and research activities for health facilities of good quality at all levels. development • To ensure effective heatth management, including administration, finance and health insurance systems B. MCH Situation Reason of the high maternal and infant mortality rate Problems encountered • Low utilization of health services by • Mother and child mortality rate are still high. population • Women of ethnic groups can't access to health services due to their beliefs, language and poverty • Low quality of MCH services • High fertility rate • The level of understanding of people on • Low contraceptive use rate hygiene and MCH care is still low • Referral system is not good • Health services net work is insufficient in the promotion of MCH Target to be achieved in 2010 J Target to be achieved in 2010(cont') • Reduce infant mortality rate under 1 from • Family planning from 36% to 50% 70/1.000 live birth to 55/1.000 and under • Only breastfeeding for the first 4-6 months 5 from 98/1.000 live birth to 75/1.000 from 24% to 50% • Reduce maternal mortality rate from • Vaccination from 65% to 85% 405/100.000 live birth to 300/100.000 • Extend MCH service network from 18% to 50% • Antenatal care from 38% to 50% • Use of ORS from 45% to 85% • Clean and safe delivery from 16% to 30% • Treat diarrhear and acute respiratory • Post natal care from 14% to 30% in 201 0 infections from 55% to 85% 2 - 106- :· Annex 6 ITo readdress the MCH problems • Strategy 2 • Strategy 1: -Promote MCH services at all levels Improve maternal and child health care: Form MCH mobile team -· Standard !ii:!IVIt:l:! ut~vt~lu~t~t.l alt~d<.;h lt~vel Improve referral system Continue to develop instruction manuai"MCH practice guideline, EmOC and Pregnancy, Delivery, Post and Continue to develop Maternal Waiting Neonatal Care" Home at district level Continue EmOC training in each level delivery house at village TBANHVs training Build Provide necessary materials, medical equipment, drugs, vehicles etc .. I. Strategy 4 • Strategy 3 Improve documentation system - Upgrade knowledge and understanding of - Improve management of MCH the population on the importance of MCH organization and service at all levels services through media such as Radio :::-"''··· plugs, health workers announcements • Strategy 5~~t. during village meetings - Cooperate and collaborate with the Departments of MOH, National MCH, medicai education institutions, donors, and etc .. to monitor and evaluate MCH services at all levels. Health staff education and Faculty of Medical Sciences training system • Department of Medicine 11 + 7 years • Faculty of Medical Sciences in National " Plus two year lnlemship Program (Family Medicine Specialisl Program) University of Laos • Department of Phannacy 11 + 6 years • College of Health Technology • Department of Dentistry 11 + 6 years • Public Health schools • Residency Programs 3 years o Paediatrics Obstetrics and Gynecology, Internal Medicine, General Surgery, Anesthesiology, Ophtalmology, Radiology 3 - 107- Annex 6 I College of Health Technology • Nursing section:• TN 11 + 3 years Public Health schools * BNS 2,4 years • Assislctnl pllctllllctt:y St:!t:liun 11 + :3 yt:!ctrs • Nursing section 11 + 2,5 years • Physical therapy section 11 + 3 years • Primary Health Care section 8 + 3 years • Laboratory section: *BML 2,4 years *Laboratory technician 11 + 3 years • Hygiene Inspection section 11 + 3 years • Radiology section 11 + 3 years Frame work for Human resources development Plan in the health sector Communities Health in Rural Area 1. Main problems 2 Policy 3. Strategies 4. Target s. Plans Main problems Policy • The quality of training is low • The proportion of trained staff is also low • To provide efficient and effective pre-service and in service training for health staff relevant • Inadequacy of Health Manpower to the need of the population • Lack/shortage of foreign language ability • Lack/shortage of finance support for the training institutions (resource facilities) • Lack of management and coordination in different training courses 4 - 108- Annex 6 Strategy Targets develop the training curriculum • Review • There will be specialists in all fields in the • Develop post graduate training in different central level and in the larger provinces fields • Laboratory assistants trained to Boohclor'a • Provide teaching materials and vehicles to degree level should be in post (central, health institutions regional and Epidemiology center) • Develop English training courses at different • Train staff locally and abroad training institutions health • Health training institutions will have an up-to • Integrate planning, monito~ing and evalu~tion date training and teaching materials for between different projects 1n order to avord practical field works for students and overlapping (economize) teachers Plans Plans ( cont') • Continue to train laboratory assistants up to • Provide in service training for staff in country Bachelor's degree and abroad by using government budget or grants from International organizations • Continue to train diploma nurses and diploma • Supply equipment and materials to health midwife up to Bachelor's degree training institutions • Continue the existing postgraduate training • Enhance the community participation in courses in all fields (surgery, OBGY, ped, maternal and child services public Internal medicine, tropical medicine, • Organize English courses in public health health) System of Nursing Education fSP~cifi~t;aining andle~~j,;Q~ '4:,- Key directions i 6 months( midwife) Primary ...... __...... -! Health care , surgery, ~eadiatrics , • To decentralize the pre-service medical education ...... --~ ..... --.. l anesthesiology, lntens1ve care, i ,..-n'"' • ~ !'~! Manage mont, Cli~!:~~!~!!~ .. ~~ system .!'. : • To facilitate access to professional health staff ..------,,; fs-;~h~I;Mw··;o~~~~···~·--· working in remote rural area lJ:-~~ ti n ulng educat~~ : ~ . • To improve the qualifications system for health i workers • To improve the education system • To organize and sustain continuing and medical education and training for all health workers • To enhance the culture of teaching and learning of health workers 5 - 109- Annex6 Human Resources Development Plan in I Human Resources Development Plan for Making Pregnancy Safer ( cont') Making Pregnancy Safer Short term: • Long Term: *Regular upgrade knowledge and skills for o SpP.r.ific: Training and Learning: 4-6 months on '>l"fVir:-.1" rm:wirlP.r!'\ nn ANr.,FP, l=ITI Midwife Course *Regular upgrade knowledge and skills on o Upgrade diploma nurse and midwife to Bachelor EmOC, EOC for service providers at Ob-Gyn Degree on Midwife (continuing education) wards o Bachelor Degree on Midwife (5 years for high school graduates) *Upgrade knowledge and skills on cesarian • Continue the existing postgraduate training courses section, ultrasound in some provinces. in all fields (surgery, OBGY, ped, Internal medicine, tropical medicine, public health) 6 - 110- Annex 6 I ROLE OF PROFESSIONAL SOCIETIES IN MONGOLIA IN MAKING PREGNANCY SAFER Dr. D. T etsegee, Second Maternity hospital Ms. S. ~ arangue.l, First Maternity hospital Country profile • Capital: Ulaanbaatar • Area: 1.6 million sq. Jan. Population: 2.5 million (2005) • In urban: 60% • In rural: 40% • Admin. division: 21 provint:es (aimag), 343 •own and 1222 bach • Population constitution: Men-49% Women-51% Children under 15 years- 32.6o/o Women of age 15-49 years - 28.3% • Life expectancy: 63.5 J RH human resource in Mongolia Maternal mortality rates • 26.64 doctors per I 0,000 population Matomol mortality rato por 1 00000 • 31.3 nurses per I 0,000 population • 2.4 midwifes per 10,000 population • Ratio of doctors per I 0,000 population in urban and rural areas 43:16,5 • Health Sciences University provides physicians 6 years and residency trainings 1.5-2 years • Medical college trains nurses and midwives 4 years 5 6 1 - Ill - Annex 6 n ant mortality rate Causes of maternal mortality (per 1000 live births) Causes of mate mal deaths 45 40 • Sepsis 50~~~~35 30 23~ 25 20 0 Cb ..SIS CO"ll'iclli'lg pregnancy "10 5 0 Hl95 1996 1997 1 !l!il6 Hl'!il9 2000 2001 2002 2003 2004 2005 7 8 I Briefly on the I ,----M..,•o'"'n"'g'"'o,!lilalf Federation of Obstetricians and Gy, eca/ogists (MFOG) MFOG (cont'd) • Mission: • Non governmental organization Together- Bring the RH Service in Mongolia to • Established in 1994 the Global Standards • Branches at allll provinces, 4 in cities (300 melnbers) • Goal: • Forum of networking of OBGYNs and for their professional To Improve the Health Status of Our Mothers and development Children • The Steering Committee consist of 9 members • Annual consultative meeting • Quarterly meeting of the Steering Committee 9 • MFOG is a member of AOFOG since 1994. (pre-congress in 2005) 10 I I . Objectives: . MFOG Strategies m... ~~~~-~ 1. To build c.ilpadty building of OB-GYNs doctors, enhance knowledge and skills assist them, 1. Buildinz RH service that is compatible with international standard unique national approaches 2. To improve quality and standards of RH services in through 2. Providing more financial and social incentives for RH workers living in Mongolia, remote areas to ensure that they stay in the service loDzer J. To intensify activities of making pregnancy safer 3. Oreanizing training including family members, spouse-s. individuals on family planuing, antinatal cue, child-birth, post-partum care etc, 4. To influence stable reduction of maternal and child mortality rates 4. Protectiog the rights of the Federation members, seek for more opportunities for both international and domestic trainings, e:~panding the ~. To protect OBGYN doctors' professional ri2hts, partnership, 6. To motivate and dedicate members S.Deepen research and scientific studies in the RH sector 11 12 2 - 112- Annex 6 I J MFOG achievements Collaboration ofMFOG with national and international organizations • N11rse:s A550ci•tiou {Tnun•JVI. l••atuae:tl or pri.CbU) • Development of Reproductive Health Clinical BSUM (Distaacc le-arning ou PCPNC ttacbing materials, curriculum) Guideline~ and Standards & Protocols • WHO (Tniaing of PCPNC, ENC, G•ldellaes, MMR re¥iews, interaatioDalaDd "lltion11J m"ti"llf) • 'Development of Curriculum and Standards of • UNFPA (Establishiag Male RH strvku In Mongolia aud traiuiag for Kn'ict Training Material for PCPNC providen, RTI I STI Social fraacbisiag servites atadolesceat RH service sites io seleded proviaces u4 proviace!, RB aatioaal strategy) • Active Involvement in Development of National of • UNICEF (Midwifery training, a.tritioa, social mobili;zatioa) Maternal Mortality Reduction Strategy2005-2010 • ADD (developing guidelines aad curriculum for FGPs, soum midwives aad bagb fieldsben, Maternal death rtlliew) • Organization of National and International • GTZ (training for RH service providers from selected 6 proviaces Conferences (AFOG) • AOFOG (active participation on some activities orgaaiud by tbe Organization) 13 14 I J The Mongolia11 Nurses Association~ Objectives • Established in 1996 • To defend professional rights of members • To enhance nurses' knowledge and skills, • Non governmental organization • To take part in consultations and workshops, • Membership is on a voluntary basis (Nurses and • To encourage to train nurses at the local and overseas Midwives) institutions • To share knowledge and experiences with Associations of Goal: To improve the health and well being of other countries Mongolia people through consolidation of • To translate and adaptation professional textbooks and professional knowledge and experience of members journals • To collaborate with MOHand international organizations 15 16 I J The Mongolian Nurses Association MNA achievements • Branches -9 in districts in the capital city • 200 I sisterhood relationship with Japanese NA -21 in provinces • 2002 became member of ICN • 7800 nurses and 1500 midwives in Mongolia (Health • Monthly Newsletter (Nursing) for networking statistics indicator) • Regular continuing education training in collaboration with • 5600 members WHO, JNA, ICN, UNFPA,UNICEF - 82.7% of them are nurses • 30 nurses completed Leadership for Change program in - 12.4% midwives 2005 - 4 .9% paramedical workers 17 18 3 - 113- Annex 6 I I Collaboration of MNA with national and international organizations Priority Issues on MPS • WHO (Training, meeting and conferences, supplis and • Insufficient collaboration between national and equipment) international Associations • WHO/ICN (leaderi'hip tnining of 30 mlriei completed) • Shortage of doctors and midwives in rural areas UNFPAIUNICEF (training on RH, Nurses day, Congress) • Large number of doctors, but few midwives and nurses • MOH (Policy and standards, training) • Poor motivation and incentive system, working conditions • Pre service curriculum is outdated, lack of textbooks and • HSUM (Curriculum, training) teaching materials and facilities • WHOJUNFPA (plans to establish National and Aimag • High prevalence rate of STDs and abortion level midwifery Associations in 2006) 19 20 I I Priority Issues on MPS Ways to address the challenges • Lack of English language knowledge, thus access to • Modem equipment supply information is limited ·• Improvement of services and building of capacity of staff • Limited involvement of MPS providers in research • More in service trainings and internships • Excessive workload of gynecologists and obstetricians and • Enhance knowledge and skills ofRH workers midwives • Involvement of national and international organizations in • Incompetence of professional skill and knowledge RH activities • Lack of equipment for obstetrical and emergency services • Involvement of GOs and NOGs in RH activities • Poor access to MPS services for migrant citizens • Private hospitals' involvement in RH activities 21 22 1 I Ways to address challenges (cont'd) • Knowledge of population about the protection of Thank you for your attention! their health; • Incentives for RH workers • Study on high mortality rates and address the issue 23 24 4 - 114- Annex6 I Priority Issues on MPS • Poor infrastructure developments • Insufficient collabration of GOs and NGOs in safe moth11rhood a~:tivities • Shortage of RH workers in rural areas, poor motivation and incentive system • Insufficiency of physicians to diagnose reproductive health diseases in rural areas • High prevalence rate of STDs • Lack of professional textbooks and materials 25 5 - 115- Annex 6 !lapua Jletn ~uinea CONSULTATION ON HUMAN RESOURCE 0 1Lanb of tbe mnexpedeb OBSTlrnUCr.AN k GYNEACOLOGIST PRESIDENT. PNG MIDWIFERY ASSO( PNG Indicators for Reproductive Health Iron Deficiency Anaemia 30% Total population 5.8 million (85% rural, 800 dlalect•lculturea, 56% lltera~cy) Tetanus Toxoid Coverage 69% Annua l Population Growth ra1o 2.8 Infant Mortality Rate 77/1000 Total fertility rate 4.1 Ne onat al dea t h rate 35/1000 Contraceptive prevalence rate 19% Maternal Mortality Ratio 370/100 000 Perinatal Mortality Rate 55/1000 Range 200 • 625 Antenatal coverage 77.5% Supervised deliveries 38% Challenges to Safe Motherhood Challenges to Reproductive (NHP 2001- 2010) Health (Family Planning) Maternal Mortality is unacceptably high. Most maternal deaths are due to postpartum Information on the availability of reproductive hemorrhage and infection health services are inadequate • Maternal nutrition Is poor and rates of maternal Family Planning and services for STis are anaemia and low birth weight of the newborn are inadequate and inaccessible unacceptably high Specific programs for adolescent sexuality and Services provided for women In health facilities and maternal child health clinics are Inadequate sexual health are inadequate There are not enough qualified midwives In rural Program delivery and coverage are greatly affected facilities by lack of resources, poor management, law and Supervision and staff training are Inadequate order, geographic terrain and other factors. • There are inadequate medicine, vaccine, and other supplies 1 - 116- Annex 6 Priorities - Family Planning National Health Plan 2001 - 2010 Expand family planning and sexual health services and Improve their q ...llty Improve access to family planning advice and methods Improve access to quality Information on reproductive health Improve mena1amant af aa•ually tran•miMatl h•feotlen• Priorities - Reproductive Health lmpt'ova staff supervision and training Involve women and adolescents In the design and Implementation of family planning and sexual health Expand and Improve gynecological, pre and post natal programs services and supervised deliveries. Improve the referral system for gynecological problems and complications of pregnancy. Improve staH su.,arvlslon and training. Improve the supply of medicine, vaccines and other supplies. Improve community awareness and education. Policies - Family Planning Reproductive Health Policies - All couple and Individuals shall have access to Information needed to decide freely and responsibly the number, spacing and timing of their children acc:us to Jnfonn.atlon and Pre and post natal care and deliveries shall be provided All adole!icents ~hall have free of charge advice on sexual health and family planning family All women shall have access to a trained birth attendant All health facilities shall provide high quality planning services that emphasize client needs, sensitive women with complications of pregnancy shall have Every choice of methods and comprehensive access to specialist medical care counseling, priority Information a qualified midwife in avery health centra There shall be All family planning clinics shall make available sexually transmitted Infection treatment and cancer screening services Women and adolescents shall be Involved In the design and Implementation of family planning and sexual health programs. Financial Ensure allocation of extra funding for Summary of recommended supplementary staff training (midwives, strategies for PNG obstetricians), refurbishment of health facilities to a minimum standard end providing equipment for communication and EmOC. Government Commitment Advocacy Raise the profile of matemal mortality with parliamentarians and public Wider access Promote greater understanding of tha servants multl·sectoral dime..,.lona of matemal and engage other disciplinary • Ensure matemal mortality reduction health education and features prominently in discussions with groups (govemance, development) In getting the Finance and Planning Ministries and social sector response right at other partners In poverty reduction health level. strategies national Mobilise civil society, working with existing alliances and networks 2 - 117- Annex 6 Human rights • Promote women's and reproductive rights National and Provincial Departments of Health as a fnlmework for accelerating maternal mortality reduction, building on International and national human rights Action Plans Prepare annual action plans and ensure all commitments. policies and strategies from the NHP are Implemented or In the process of implementation. Safe Motherhood Establish Provincial committees which Committee include medical staff, planners and community spokespeople. Supervision Visit all health f•cllltles on an annual b•sls to review Safe Motherhood plans and actions. Provide supportive supervision following ln·servlce training. VHV (TBA) Regular contact between VHVs and health staff. Emphasis on early Identification of Emergency Obstetric Define minimum levels of obstetric problems, health promotion and community participation emergency obstetric for emergency Care care for referral plans. district hospitals, health centres and Aid Posts. Design plans to gradually upgrode Health Education •Targeted health promotion strategies that facilities, equipment and staff emphasize the Importance for pregnant skills. women to have a delivery plan. •Communication that addresses Developmen of resource materials for radio, posters and community education. Mother Friendly • Finalise guidelines, endorse, •Employ positive Health Facility Implement and follow up. Images and proctlces. •IEC to address pregnancy, childbirth, family planning and STis. Men's Programs Initiate programs to Increase men's Community • Initiate two way dialogue with NGOs, participation In reproductive consultation CBOs, women's and community health - focusing on family planning, organization to work towards better gender issues, pregnancy and communication between health staff and childbirth. Emphasize supportive role of the community. men In decision making and practical e.g. Follow up complaints, invite women's matters. organizations to prepare birthing kits, fund raising for waiting houses, etc. Waiting houses • Pilot and evaluate waiting houses in selected areas with both government and church medical services. 3 - 118- Annex 6 Trained Staff Increase number of DGO trainees to staff provinces Midwives Increase annual graduates up to 70 per all annum Support to midwifery schools for extra clinical staff Public practice for MOH 8 Year Go-roka Madang UPNG So pas Total Private practice II UOG LSON PAU Sacondment to UNIC EF 1 2004 20 20 40 1 2005 15 20 20 15 70 Medical School 2006 15 20 20 15 70 Overseas 2 2007 15 20 20 15 70 nmber company 1 2008 15 20 20 15 70 19 2009 15 20 20 15 70 Total 2010 15 20 20 15 70 Total 90 140 140 90 460 Implementation ofpolicies and strategies Doctors • Short courses to update and upgrade all doctors on emergency obstetric care All labour ward In provincial hospitals manned by registrars and RMOs WHO Plan Review status of WHO Plan of Action with WCHP staff before completion of project. Identify areas that have not been completed. Health Workers Priority to Safe Motherhood and reproductive health in all In-service training. Classroom, on the job and attachment summary Implement mother friendly guidelines at NHP 2001·2010 Ensure all health staff receive health policies and all health facilities form of reproductive strategies Implement 'whole site training' where the entire health facility Is trained to reproductive health Instead of taking out one or two health workers to attend • rofres hot coursct .. Quality of Care Evidenced based Prepare summary of current practices practice as recommended by WHO and Attitudes Operational research to understand health distribute to all health facilities. workers' attitudes and understand factors that Encourage staff to Include support Influence behaviour personnel for women in labour, encourage upright delivery and active management of third stage. Discourage routine practices such as routine episiotomy and routine ARM. MM reporting Standardize reporti ng on all matemal deaths. Confidential enquires Into all m at em al deat h s withi n health facilities. Regular follow up w ith communities for v erbal autopsy. Follow up and Inve-stigation of 'n•ar mlsse.s'. 4 - 119- Annex 6 Referral systems Family Planning RJodlo Increase number of HF radios and estebllsh 24 hour access at provincial centres for prompt Access advice, treatment and notification on referrals. at community Increase FP counseling and level supplies to the Aid Post steff Vasectomy • Develop policy guidelines as to the cadre of health worker who can carry out vasectomy Transport Ensure all health facilities have emergency and the training required transport plans Develop and Implement a strategy to expand vasectomy services nationwide Contraceptive FHS needs to take responsibility for supply assessing annual contraceptive needs, ensuring funding and monitoring supply. Health Follow up health promotion materials produce Promotion under PFPP, complete unfinished work and analyse gaps In FP materials production. lntersectoral Conduct regular forums for NGOs, CBOs, collaboration faith based organisations and health staff to coordinate family planning activities and messages. 5 - 120- Annex 6 Outline Philippines • Demographic Situation - Population Professional Organizations 0.... - Vital Statistics M&tc:rnnl nnd other mortnlity otntictict - Service access and utilization rates Ph ilippine Obstetrical and Gynecological So ciety - Skilled birth attendance rates Philippine League of Government and Private Midwives - Health Human resource situation Philippine General Hospital • Professional Organizations Jose Fabella Medical Center Department of Health • Philippines - Philippine Obstetrical and Gynecological Society - Ph ilippine League of Government and Private Midwives U U rt~plno Oolo(otlol\ Population Data ,. ,, DE:\I 1m ...- twi,;,;. !Ufl P•p.U.IIon(7ll ) 60JO} 6U!6 '""6..!64 lO ~Ja j l~ ~ ~ •= - '"",.,. - ~ "' ....., l0!6! nw.: L " leutnulu at r.,w.-. Uwt !C.SJ n uo ~ .... 9!,!1! I~OIJ J!1.J)l ,..... ~ u:.: 6L~ T.I § = ~i - Jr~ ! Estimate Population - 2005 ,Jf• • - · =-•Jill'~.~ . ~. . - - 85.3 Million /--· -- ., .~ -=- - J N . """""'"'" Oo!ot-• W HO "'ootlfl t OO'>HolrlnJ 1'.....-.qo s.tw .r JIIN "''~ " tto1•t•llwn""'Wi1a ...... _.,..,..,.~ r " r • .,....nq S. ,tl'- ~ = ~iM I Pw>r"~ J~ Population and Vital Statistics Life Expectancy and Mortality 1S POPtL.\ TIO;\" Cl BR.\CTIRlSTICS 1222 liD. Pujo ( lfdllfrrxpt tr an~ Popgi.Jtion dhrrtbutlon("•) = !OZ0-: 0 :~ Cobm .;80,1 alb~bo(p•,"ir~d) !010-:0I~ ~ 15918 70.98 ----,--w "~~ ·"'9S 51.9- """" '"",...,, 75 . ~; ?6=3 1i:; Proponictn ofptuo• • CrMt btnloro r ~ JCBitJ• llithdi'l.lbl.tit)• Lu oliac cnul ~ ! 001 !00! MLt c ~ ; 0_6 : Crdrdntlororo tCDRJ• ofm•nalif!,· ... 311 ,!}.! ,... 0.66 0.6: 3~.93 : 396.m c ..o~.n .. ol ...... ro.l O\$ft~10ftbe!Je111 50.~1') ~;. o:~ 7'0 . ~~ > lo 200• l'hM ..pno Dofolu:l•n "> WHO on ..tl nt on Molrlnt Protn.,.qo S.t Annex6 Morbidity Health Professionals Lndia=: cauu'i Regh:ttnd hfalth ~ ill! of morbidiry l002 !003 ~ ~ profrssionah Domist 1.19l 1.039 47.335 Pnoumonia 65!.~8~ 7!4.581 509.:!74 Modu:alll'ChiioloP,t 1.83f U511 49.~5 Dlmbetl disea~ 84~ . 526 726.320 615692 Mtd.u:allabomcny :tclmicu.a il 96 3136 Brow:hitis 694,836 629 ,968 604,101 ~Mimlif.,. 1 JRO I iHI: :J<. ,~,. l"nlloeaz.1 •!19.88) .:8-1.388 -Gl-216 =-1\une 7.19 5 10.0!3 38l..t1j Hyponen.X.. 318 . ~2 1 304.690 32!.390 Kuttr.loDist chentiaD 190 ~80 !::.J;s Tub.mllosis (allfi,..,.,) no.g,; a-t~l 9~ .079 Optomotnst 70 55 9AH Di~a~of~hMrt ~7.~ 5:!.~7 JO.Jgg Pbmmci~ 1.65" l.6J~ 5!.171 Mol aria .W.5-l3 39.!194 28549 -======- PhyCcian :!.16J. ~.168 98.:!.i0 Cbicl:ODj>OX 24.359 28.600 26.137 l'b)-.ic.al~st 1 .~6 l.l"l 19AH Mm1es 2~.~9~ 24.639 24.816 ~tiooalthco-apist 205 157 !.:!80 Arur:e lawt!r respra:o~· tract Radiologic teclmologisl 410 :!53 5.8-!5 iDfuuOil 16.96g 19. 3~0 169.069 X-~- reclmologist 49 59 8.~ lOCII "'lllpp.,o Dolo&olk>n t<> WMO "'""tlnl on MPinl P'rol""""J Softo• 1001 Phllppl"o Clololatl"" to WHO ...... Or> l't... lr>l Pcolf"anq" Sot ..r SI!OII&"t.l,]00' ,...... ,p... _. e>c. Vital Statistics [ Mortality Statistics !001 !002 :!003 J Rt-eistnr-d forr:'ll dt-athsb 9.61! 9.3-U YITAL STATISTICS ~·" !000 !001 !002 In.fabtdnths 2i.114 ~6.1!9 ~3.7i8 !000 !001 ~ IDfant mortaUty ratr Rtgf.sttrtd lin birth'51 1 7156~0 1.7 ,~ .093 1.665 773 (JNI·J,rmtn-.bir6u) ;s.: I~~ U.3 ).1alt 91S2-B 89~ 3-1::! &665~! Foma!r g,g 197 &n.781 800.:!52 llitt-nul dt':tths 1.!98 :. I~ 1.8()l Crodf birth r.u~ 23 1 ~ -0 cLO Y;J.tf'l''ll.d mortaUtJ nit' (pll· J,()f)Onu'dyearpoplla:ion } (pn·J.OfJ!Jtn .. biniu) 16 I :03.1 JO~l .Vot~t : Dnuis~UV.nlddup :o:o:al'ichuloc~ RtEi.'Sttrtd dulho;b 3156.931 3& 1.SJ• 396.297 "ToakiDC~c~ or~mcned,l.L"'to!binh ~w. ~17• .;Q4 2.:!5.879 .H.l530 "TotJ.ls~ ClSMDflm~p!.Kt-o fd_e.a:h F"""lo 1.:19 ~1i 155 955 lEJ-.: 67 •ronls~cao:t"lo!ltldet:ummrdplactor~~ H C:rudt duth ratt 4.9 5C So11ru. ~SO. Hea.i:b acd. V1:1l S:;anmcsDmsiec. ti~ Soart!'ne illpor!:. f.;m·l.O'J?rni~·tm po;mla-rion I IOOI,..,.I,ItloOolo&OCiontDWI-IQ..,ootlr>lonMOICinzPro('lon MATERNAL HEALTH PROFILE 2 - 122- Annex 6 Antenatal Care Antenatal Care ToMe q 1 AtT!.... nl s«• A ...... s ....._, who had a lh.. blnh '" d•e fl~-. yean Pf-"1"8 dM ~un."e)' by _,t.netal c.,.. tANCI pro ,.,lllppon.. •·laler durlns p~_,cy f- the mor. reoc."l bl,.., ei;CCM'dlne to b...,l..graund ~k&r-rinlco.. :!003 Not.:lr~-*'-f'ICI,.~ ~Pcf-d '" u.io u~u.l.iolJ- '"'" ( " -' ) "' ;t.· "' l 1001 ,.,llppiN Dolo1ol;len 1D WHO "'"'llnl on Molllnl Proi"Mq Sliltor 1006 l'tlllpplno OoloP'!on lD WHO IIOHtln.l on Moklr>a ..,..I"A"CJ U~r ...... ,.,.:t\1111 _,...,•u~ Danger Signs Tetanus Toxoid UJ!t?,& Tmnll'tyNid!!lrs.tforn P•rc.nt d.wibutioo ol wonwn '.\:00 h.ad .a :i··• birth in :tw fr•• ~··.JR pr.Qdins !Mo wn~· tr. nuii"'Mr al tww!tJS toli:Oid irtjKt.om rR»iud ""''"I J"l"~ lot ttt...... I'I'IOSir.o~n:birth a«ordin!;10b.:K:ki!P'oundctw.xtH'"St~ Ph:lppnM1003 di!W- \ .•,.. ...lffd !.or.o=-. s...... Two Of Don't "-u,.,bl!r ,..,. hal'dl _, :z.; bitoodiiJ Hlr~ldlt Oi;;; ..... l'oicrl One mor• ~now or ~ t!,Kllor, n~\ ~ To 1:-IJ u.-1- :l.-.l 1 ~ 1000 uo~ •Quality antenatal care includes educating pregnant women about conditions during pregnancy that they should recognize 8 as dangerous ~=~~~~~,~~~~~~~~~~~t~~~~ ~~~~v~~~n":~?oJ:~~~~~ 2~~re •Patients lack being informed about the danger signs to watch n injections during pregnancy out for during pregnancy 7 out of 10 pregnant women received iron supplements, a protection against anemia of pregnancy. JMl_,.~o.lof-IDWHO .. collnf-"".a...ll"r•JnAACr.tal• l'IOf ...,. ..., ... Q•••..-" • WHO ...... on """""- Prop-, wwr il•••.. J•N lhwt~itlloJo)- Maternal Health Efforts are needed to improve maternal health: Delivery Care Over 60% of babies are delivered at home, T.ab!t?- P!attP'Rrll:,y!)· Firarc ~,~ . Peau:at Di.tihlltl•n ef DirtU hT many with the Att,.,ufllntfAtllf"ttl:•hlltl'JifJI•,2fW'Il ~:diRfitlwonrJ! .... !tlilh .. ""'rh•~~Jll'~inatt..MK•f'Y ~- ~oldfot.\M')' ~10~ assistance of a hilot Urllc:cnted ctwo~ctwil:rics.. Ph I pp ...-t ZOOl (Traditional Birth Attendant) ,.... :!B 1 .t u r \ 61"' } o~ One in 3 mothers who delivered in a non institutional setting received post-natal care within 2 days of Only 38 percent of births were delivered in a health delivery facility. ... ~ta'lfoi!PID "'ootlnf:""'"""""'l'••znoncyS~toc lDI:I. l'to Upfotl6 Dolopdoro lllO WMO .,.._ ..... on Moklnf f'no ..... 3 - 123- Annex 6 How does the Philippines compare in I Delivery Care I terms of medical assistance at delive ? Bangladesh, 2000 ~ Pefa.nt dl$lribtbon of li\·e bir:I'K il'l the rr.-. ~ precedms the~''"'" ir'!o peBOr!PfOI.idi"! anis"..snot> duril"t!: deli\- ~- . accordlns to boc~Wound charactlfflrik:s Pl'l•llppil'loK :oos Nepal, 2001 R~iili~ l l.w:~ro.O 'lumb.r ckil~ittc ~;;: ';:;;;;;;,.. 1 Cambodia, 2000 .. ~ Tot.J (.,. . 15.1 :kr _., ~ ...~. 02 0 . ~ ,) _100,0 695-' '·' 1999 ~:lf~ ~lfl'letlbDnll~n :~ ~... ~IJ)>O II qualified pMOn India, !Soomidem::l in m.a~ PHILIPPINES, 2003 Only 60% were attended by a health professional . Doctors delivered in hospitals Indonesia. 2002-2003 Midwives delivered in government health centers Vietnam, 2002 86 . HilotfTBAs delivered in homes Mr>l"'·~~ll."!!*""" ""'H~"'~~ ... !"•..,..r• · ~..., .... lOOIPhllppiMOoloJUiontowttO"'•otlnlon ... olr.lnJ~NI"OI> Maternal Health Delivery characteristics • In the NDHS, only 7% of live • The DOH thrust is towards institutional or births were delivered by health facility based delivery and away from Caesarean section home deliveries. • POGS CNS Statistics are at • Continuing programs to educate health 20-26% (hospital based data) professionals and mothers in the importance of • 28% of babies have birth EMERGENCY OBSTETRIC SERVICES weights below 2.5 kgs (low birth weight) which are high • In remote or far-flung areas where home risk for M/M deliveries are inevitable, it is necessary that these • LBW has direct correlation be attended by skilled birth attendants or with the mother's poor health professionals. nutritional and health status of mother during pregnancy 111111 Phalpplno Dol•pr:lon to WHO "'••tlr>1on MOl<~ Pr•l"onCJs..l- 1f...,,lf'-llo ~~~· Post-Natal Care Initial Breastfeeding Perc•nt dlstrlbutio., of •~on••n ""hotoe l ...t "• bori:h In th• r,,. ,, • .,,.... prec...:llnH tt.. •YI"o.,.. occ ... ,...ed ouHid• & h..,.lth f....,ilitv b) tl.,..,lns of podn•t.l c•••- acc:ordtr>S to I::J;:ac~.t~round c:h.:u--=t.rl~ttlc., f"hl••p• p•n.s2003 Background Ever Breastfed Brea.stfed breastfed within I within I Characteristics hour of day of birth birth Total ~ll-- 11.4 )H.6 0~ H .l 1000 ~ . 8;-"-1- Philippines , lncludesworlen,o,.·ho r~h · ~~ ~41 checkup.l.fter41 dii.YS 86.5 54 80.4 Only half of women received postnatal checkup within seven days of delivery One in three women did not receive any postnatal check-up at all Postnatal care is important to detect complications after birth both for the mother and baby 200' "'llpplne D.. •1•1ton to WHO m••""lor> ...... ~NI"II'IC)' Slli'te< lOO.Ph.lppiMD•I•J.U:ontowttO ... ntlnJonMoldniP••I""" 4 - 124- Annex 6 Problems in accessing health Professional Organization care • Mothers have problems • Goals accessing health care when . . .trr.·· they are sick ,, -.- • Strategies - Getting money for treatment . ... • Objectives of the organization (67%) was often cited; making - 28% did not want to go alone; • Activities/ projects carried out in - 27% have difficult access pregnancy safer because of the distance • Human Resource Development - 26% is having to take transport to go to the health facility :UMI"hr1"1""1"golot1donl0 ~o ...... -.-MoWrn:~' "r-7....,... JM~ P"'o~ ,... OoloiP ...... ,."!o¥110., L.. Gro t ~U l'!olo.iOt .,.lfl Philippine Obstetrical and Gynecological Society P~GS 111.68• 2006 l OOI ,...IpjiNO... t ~•Wl10"'o o.._,l on M ...... P..,ronqou ~OII.ptj~t:.;lo'"*-""'Wl'IQ"""'~ ... W-"!fl'l • ,_.,.~ Shlw•.,....lt .. :SO...... ltcl &M!iiZU ---~ ..... ,.. The Philippine Obstetrical The objectives of the MISSION We are a Society of and Gynecological Society Society are: competent. cnmpanlon.atf!, (POGS) is a professional - A) to adhere the art and God-fearing obttetrician organization founded in science of Obstetrics and gynecologlrts committed to Gynecology, serve th!. Filipino peopte 1946 composed of mrough excellent hl!illth are physicians certified to - 8) to enhance the deliVery by ad.,..ridng the art profess ional growth and provide comprehensive and $clence. of reproductive welfare of its members, and health, enhoncing proressiOfUI care. reproductive health - C) to promote the growth •od me welf>re of in; common good through the nremlien mrougn tr>inlng ond :a involvement of the research, fos-tering w-omen' advocacy progro~ms . and ~ ~!._ ~ members in community upholdinl tlu! highest ethical care. ~ ~Ill health nandards or pro~ctlce, JH6Phlllpplroo Dolorotl.., ao WHO "''"tlnf'"l'loltlrll ""I""" 5 - 125- Annex 6 Vision Activities .. The POGS, the leading organization in reproductive Pursuant to the Presidential the year 2 0 I 0. Proclamation No. 569 every March . ·~:aiiiDZ'!r '. ·, health by .. ~~_ ';,'.- envisions significant reduction in maternal and perinatal morbidity I 0 has henceforth been marked as .• ·-..J 100f l'hllpplne OololotiOtl ta WHO moo Activities IHuman Resource Development I Maternal and Fetal Welfare • Number of Members - Maternal and Perinatal Audit - Fellows - 1896 Nationwide Statistics - Diplomates - 295 - Pregnancy and Delivery - Junior and Associate - 637 Indicators • Number of Accredited Hospitals - 140 Accreditation and Membership - Standards for members • Number of Training Centers- 90 Continuing Education - For Physicians and for Midwives Process of Accreditation Clinical Practice Guidelines - Submission of Cases. Oral and Written Exam - Continuing Education lOOf l'hllpp... o Ool•l•llon.., WHO "'ut1n1on HoldnJ "''I"""CJ Softor lON """""'""" O.... t•n-•¥notO "' "' -~",..~II!IIIIV • rr-l l..oflor 'lllutfli.IJ. UIU ~oi.l Mt SITUATIONER As of December 31, 2004 there are 143,973 midwives registered at the Professional Regulation Commission No. of Midwives Local Government Unit: 17,191 (excluding casual, job order, sanitary inspector item and nursing attendant position ) Retained Hospital 270 PHILIPPINE LEAGUE OF GOVERNMENT Nursing Attendant 3,149 AND PRIVATE MIDWIVES, INC Phil. General Hospital 448 Private midwives database is still being collated l OQf P!ol ... lrM Ooltpi 6 - 126- Annex 6 ~~---v_l_s_lo_N__ __ ~ MISSION A WELL-ORGANIZED AND Establish a strong and well-organized institution RECOGNIZED INSTITUTION that is recognized and supported both by COMMITTED TO AND RESPONSIVE government and non-government entities, FOR THE UPLIFTMENT OF here and abroad MIDWIVES TO BECOME EFFECTIVE and AND EFFICIENT HEALTH CARE Strengthen the knowledge, attitudes, skills and PROFESSIONALS FOR THE practice of midwives through capacity and FILIPINOS capability building programs relevant to their needs and to the Filipinos they serve. IMoll~~ l;llol o,.U..bl W H:a• •• III!Ji_"'t..._...,'"~ t .W '"" -~ ··llloo1oi • Rl•" "' Wt'ICI·n·,.··· ""' "" .. ~·,... ·· Jloll'~ l a..llo' ~ -1 1>1 • Jlh&n(Jioi, J IU PHILIPPINE LEAGUE OF GOVERNMENT ~- --~- AND PRIVATE MIDW~;~ · INC. CHAPTERS • ~ League of Overseas Filipino lnslitutlonallza.tlon af PLGMI local chapters in all major ~~'&:2 Midwives : ~ provinces and cities all over ~ _ Hong kong · · the country. -;:.__- \,(.'') 0.~· ·_::_= ~~· ~i~~:~ ,.r,~b ~-· - &.Q - ~s . ; _, ~- JOU "'nlpftln• D•I•J~on U> WHO ,._.tin( on Mole In I F'••rnon<'1 Sol tot -.::::::=:::.. -~ .. Prime -moving involvement of the PLGMI in the White Ribbon Alliance. ·It is an international coalition of organizations formed to promote increased public awareness of the need to make pregnancy and childbirth safe for all women - in developing as well as developed countries. Conduct of 31 well attended MIDWIVES QUALITY ENRICHMENT PROGRAM an alliance which is dedicated WORKSHOP nationwide covering approximately 3,000 midwives and 2 National to all mothers who died during MidQuaSEP sessions covering approKimately 5,000 midwives It aims to equip lhe midwives with kno>Medge, skills and positive attitudes on quality service anchored on pregnancy and childbirth competent and ethical midwifery practice. It prepares the midwives to an entrepreneurtal career management towards a sustainable and continuously improving systems. Ttle MidQuaSEP structures a sustaining feedback mectlanism from the WHITE RIBBON ALLIANCE PHILIPPINES midwives and from the mothers they served l004 ..... 1Jppn.D.!ol-ltloWI-IO"'••lWII""I-IolclniP•o...-qos.I- lNt .,,h. o.t.,,.,.-...... , ""'t'~ ...... JJt!l ...... ,. <>~ • •••f'W'ol) :a.ot -UH llo.o."ffi •L lllll 7 - 127- Annex6 Midwives role in the Millennium Development Goal WHAT TO DO PLGPM Goal 4: Reduce child Mortality Target 5 . Reduce children under five mortality rate by two-thirds by Implementation of expanded 2015. immunization. implementation of Newborn screening (Republic Act 9288) Alliance with pediatric societies 1001 "'UipplrM Doloroaon 111 WHO mutlnf on Hoklnf '''l"W>t)' Soll'tll• 51!..,.....,1001 GOAL 5 : Improve Maternal Health Target 6. Reduce maternal mortality rate by three-quarters by 2015 (half by 2000, ha~ by 2015) Strict implementation of Partograph -Active participation as advocate of White /')~ Ribbon Alliance as safe motherhood initiative ' - - Alliance with Philippine Obstetrical and Gynecological Society (POGS) lHI"'IIppltNOolorotlonCI:IWHO"'utlnfonl'loklniiP•oi"OMJS"""' ,_,,....,1001 FHI LI FFINES Fhillpplne Obstetrl cal and Gynecological Society - Dr. Mario Festin Philippine League of Government and Private Midwives -Mrs. Cecilia Banca-Santos Fhilippine General Hospital -Dr. Virginia de jesus .l',:e Fabella Medical Center ::::...... ~o.~·~•wHo .... """'- ~rlieraldo llem 8 - 128- Annex 6 VIETNAM DELEGAIION VIETNAM DELEGATION ' \11 \I' ..... \h.(\(, ,. I .. Consultation on Truong Viet Dung MD, PhO,PR Human Resource Development Nguyen Due Hinh MD., PhD Hanoi Medical University Ph an Thi Hsnh Midwife Hanoi Medical University Head of Dept Sc Resear & Training President in Making Pregnancy Safer National Hosprutl for Ob-Gyn MOH of VN Midwives Assoc Vice president of VN OG Assoc SHANGHAI, CHINA 2006 Oct, 26 to 28 Vietnam national plan on Safe motherhood in viet nam 2006 - 2010 1~- s. · - . Vietnam 1 Population: 81 million (2003) (\ki,IP•hl-. 1 Women: 50% of population • Women of reproductive age: 55% of all women Sottrce. P.ea!th StafJstlcs approved Yearbook 2003 By Vice Minister Sworr!Lake Tran Chi Liem MD., PhD 1100) Sept 12, 2002 1 - 129- Annex6 Safe motherhood situation Safe motherhood is one of the most important contents of • Very high maternal mortality ratio in the national strategy on some mountainous provinces reproductive health in (4 ·1·1 1 ·1 oo ooo In cao Bang) Vietnam • High perinatal mortality (22 I 1 000) Ministry of Health Maternal mortality ratio Direct causes of mrerna I mortality Object '- Uterhe Malion'A'idotOo [ l1M Ectopic -l ru~1ure, pregnancy, North mruntoinousor,g,gion 411 4.7% o!ll'lolo South CQI'lh;;l rQgion "911 hfectiono, ------Ccnlr;;l Highl;nd~;o I lm 1el'll\, ._ Mck o"' River oat<~ 1<1:1 Rod Rivw Doll<~ ... SoaJ.h.f:Otd ro9 en . 4$ S0111t11 : N5'f!Or1{Ji 'SliMlY 2001, ~ Peri-natal mortality rate (%o) Causes of peri-natal mortality Sou roo : Ptof. 1'~ 7b i'T'r~ng Cl>llfo. SIK'oO yin 7 pNot pto ...,..,. .., 2001 2 - 130- Annex 6 General objective Safe motherhood situation by 2010 1 Anternatal care : 88% 1 Reducing maternal mortality rate • Post-partum care : 73% to 70 (from 165/1 00000) • Deliveries are assisted 1 Reducing perinatal mortality rate by a trained attendant : 86% to 18%o (from 22,2%o) • Mothers received 11 Reducing low birth weight rate to 2 TT vaccination shots : 88% 25% (from 36,7%) Specific objective Specific objective 1. Promoting the assesibility to 3. Safe abortion Obstetric care or/and essential 4. Strengthening management and neonatal care services human resources 5. Improving the quality of 2. Improving the quality of obstetric information, education and and neonatal care services. communication (IEC) activities Specific objective SOLUTION 6. Intensifying logistic system • Providing sufficient and quality 7. Improving other conditions of services to mother and newborns maternal and child health 1 To be aware that every pregnant 8. Accelerating motherhood related woman faces risk of obstetric researches complications • Ensuring clean and safe delivery in health facilities 3 - 131 - Annex 6 SOLUTION SOLUTION 1 and 1 Giving priority to address the "three Diversifying IEC activities delays" increasing quality of counseling, 1 Ensuring neonatal care conditions and mobilizing community participation reterral in health centres 1 Strengthening supervision and evaluation 1 lntergrating SM with primary health effectiveness care activities • Improving and effectively applying • Ensuring safe abortion in health ~~ 1 researches on safe motherhood facilities ~.A '--- 1J Indicators for the mountainous and Indicators for the mountainous and remote regions remote regions 1 70% of pregnancy and delivery related 1 100% of traditional birth attendants shall complications shall be promptly referred to receive training in clean delivery the higher level of care 1 90% of deliveries at home shall be 1 70% of newborn with complications shall assisted by trained birth attendants receive appropriate care and be referred 1 100% of deliveries at home shall use to the higher level of care clean delivery kits 1 65% MCH staff have refresher training on National Guidelines on safe motherhood 4 • 132- - 133- ANNEX7 PRESENTATION ON INTEGRATED MANAGEMENT OF PREGNANCY AND CHILDBIRTH (IMPAC) GUIDELINES Dr Jelka Zupan - 134- - 135- Annex 7 ' .~ :! WOfld He~1lth . ,'t World Health I t t d M t f ~~.J Organizatron !ilt.J: Organization n egra e anagemen 0 Pregnancy and Childbirth (IMPACN) Care for mothers and newborn infants Making Pregnancy Safer Set of WHO Guides for Essential Practice Integrated Management of Pregnancy and Childbirth {IMPACN) Dr. Jelka Zupan MNP World Health Organization PCPNC (2•• edition) MCPC Department of Making Pregnancy Safer Provontive measures and care Management of complications Primary level facility Secondary level facility home, community ---· ·i i ---"' .= ~ World Health ~;\. World Health ., Or9anizatron '1>:.. _)1 organiZat•on Maternal and perinatal mortality - Objective WHO priority area for country support Information about the guidelines Prevention and care in pregnancy, childbirth and - Content postpartum - Assumptions - Reduction in the number and severity of pregnancy, obstetric - Structure and neonatal complications; improve pregnancy outcomes Best use on countries - Reduction in pregnancy related complications due to indirect causes of death (endemic conditions) Supporting material Reduction in maternal deaths and stillbirths due to pregnancy complications • Encourage feedback - Including complications due to (unsafe) abortion Reduction in neonatal deaths due to perinatal complications. --. Family planning ~ ·t World He.alth ~ 111,\ World Healto ~ Organllat1o, ~J Or~an j zatror. IMPAC IMPAC- essential Model Public Health Tool A limited range of carefully Basis for country policy, selected effective plans and programs Other interventions Frequency and Guidance for national complexity of - Limited resources guidelines events - Prevention of waste Operational details Caters for most health care Essential needs of pregnant women All women and her babies and their infants. Concept of essential care - globally applicable. Pregnant women • 1111 iii --· 1 - 136- Annex 7 ~fo~~ World Health '· -Jl.;i World Health WHO Technical Consultation on ~J Organization IMPAC guides ~ Organization model process, systematic and Prevention of Postpartum transparent Haemorrhage (PPH) • Leading cause of maternal mortality. • Guidelines integrate recommendations of 10 WHO programmes Active management of third stage reportedly reduces the risk of PPH by 62 %, • Systematic search for evidence - Reproductive Hea~h Library • Objective -WHO recommendation on definition, elements - Cochrane and evidence for: • If ino;;uffiGif"nt PvirtPnr.P.· r.nn~P.n~tt~ nf flXJ'lflrl:i - BP.st methods, best practices External review (over 200 experts from 50 countries, - Requirements for safe use under conditions of limited including agencies) resources - Needs - Use of active management in the home setting with - Resources -feasibility of proposed care skilled attendant Process for regular review of evidence and updating of guidelines ·- --= · ~··~· , !II " ·' :'> wortd_Heatth IMPAC =Model product .) WorldHealth 1:1 Orgamzat1on ' Organ 1zat1on Target audience Comprehensive and focused Guidelines for practice (not for professional groups) Women & baby centred Focus on cost-effective Health care providers Problems (not diseases) interventions with dual effect on the mother and Managers of health care services Broad public health the newborn perspective Policy makers (packages, health system requirements) and Continuum of Organization Teachers of medicine, obstetrics, paediatrics and midwifery presentation of materials co-ordinated Resource sensitive integrated care Implicit standards for the Sufficient operational health care delivery system details Generic but flexible To be adapted to local circumstances ------~ · •• • (~\ World "ealth World Health Organil~tion Organizatio'1 Use in countries ~ requirements Implementation Basis for national guidelines A permanent infrastructure Essential adaptation Functioning health care system - epidemiology, national standards, new evidence - Human resource development & management - language, terms - Organization of services Adaptation of national guidelines for various sub-national - Equipment, drugs and supplies and service settings - Information & management system - Laws and regulations Without removing the key strengths: decision-making - Financing tables, repetitiveness, emergency sections, information FAQs and counselling boxes Respect the evidence Adaptation guide available --- c.:: ----=. " -~ ~ . ··-· 2 - 137- Annex 7 !. ~,\ WOrld Hoalth ~;~ World .Hoalth i_~l Organization Use in countries - -~ Orgamzat1on Cost of IMPAC Little or no adaptation IMPAC as a basis for costing for scaling up towards the universal coverage with Universities, professional schools maternity care in the World Health Report 2005: > Annual per capita cost for Western Asia and Pacific -$0.5 - Strengthen teaching capacity and revision of training - Curricula, text books Moderate Scale Up - Protocols and practices at their teaching basis -hospitals, health centres Research and development agenda Standard for maternal and perinatal death reviews - for going "Beyond the Numbers" ~~ .). World .Hoalth ~ Orgamzat1on Terminology Skilled birth attendant Midwifery care Obstetric care Neonatal care Antenatal care Childbirth Postpartum, postnatal Newborn Perinatal .. _.. ~ i 3 - 138- Annex 7 ~,:a,). World Health ~\ World Health ~'!;.'I Or9anization .-J~J' Organ1zat1on Outline of the presentation Integrated Management of Pregnancy and Childbirth {IMPAC) What is Pregnancy, Childbirth, Postpartum Pregnancy, Childbirth, Postpartum and Newborn Care and Newborn Care (PCPNC)? What is its aim? (PCPNC) What are Its contents? How is it structured? A guide for essential practice What are the Second edition assumptions? How can it be used? Dr. Jelka Zupan World Health Organization How was it developed? Department of Making Pregnancy Safer 1) Warfel He~lth ·~~ World Health Organizal!on What is PCPNC ? ~ Organization What is PCPNC ? Essential clinical practice Antenatal care Low and medium resource settings Childbirth (labour, delivery and immediate postpartum care) All pregnant women and newborn infants and baby Postnatal care for the mother and the newborn Continuum from pregnancy to postpartum, mother At primary health care level Normal care + initial care for complications - care at the facility (health center, hospital) - athome Prevention and control of endemic conditions {tetanus, Referral -mother, baby (both) to a higher level malaria, STI, TB, anaemia- nutritional, parasitic) and nutrition - Elective- planned Prevention of mother-to-child transmission of HIV - Emergency Role of the partner, family, community Post-abortion care Total >50 interventions --- wo.= I ( ~,\ World Heah '> ~ '< World Health r ~ OrganizatiOn What is its aim? ~~Orga niz a tion Prudent use of resources Guidance on quality, safe and efficient care Correct and rational use of based cost effective interventions Evidence - essential drugs and I.V. fluids Rational organization of care on-site tests Simple diagnostic and clinical decision making based on - equipment and supplies sings, symptoms and few basic tests - guidance on correct dosages of drugs and fluids Attention to: Infection control measures - Appropriate communication, Ensuring continuity of care - Respect for privacy, dignity and confidentiality - scheduling next routine visit Advice, counselling and information for healthy home practices - follow-up visit - Health providers linking with the community and ensuring support Recording care and reporting events (birth, death and the cause) Information sharing among levels II ~ ~~ 1 - 139- Annex 7 ~~~ ~ World He.1lth ~ Or~;~tm : .zatlon What is its content? How is it structured ? Introduction, how to use the Inform and counsel on guide HIV/AIDS (G) Alfa-numerical page numbering Coloured pages for easier cross-referencing and Principles of good care (A) Woman with special needs (H) navigation: Quick check and rapid - Warm colours; care ci:>:>'=':>::OIII'='11lc1111.J Community support for management (B) maternal and newborn - Cold colours: additional information health (I) Antenatal care (C) Various formats for of information Newborn (J,K) Childbirth: labour, delivery, immediate postpartum (D) Equipment and supplies (L) • Postpartum mother (E) Information and counseling sheets (M) Preventive measures (F) ---= Records and forms fi · ~ il .. ~ · 1':'21\ World _Health f2 -\ World Heillth ~ Organ1zal1on How is it structured ? ~ Organizat ion Principles of good practice Decision making charts Key sequential steps for normal and abnormal deliveries Treatment and information pages Information and counselling sheets Equipment supplies and drug lists Rapid laboratory tests Details of treatments Examples of selected records 1 ~ ~~ World Heiilt ~ ' ~ \ Worid He Assessment, classification and management Initiating each contact with the woman with assessing Colour coding for life-threatening conditions and providing immediate management and referral to a higher level if necessary: - Shock - Vaginal bleeding green : no abnormal conditions; continue - Convulsions (eclampsia) 0 normal care and preventive measures - Severe abdominal pain (according to the pregnancy status: ruptured uterus, obstructed labour, abruptio placentae, 7 ~~~;'~ ~~~~~:~~;fm~~~e=l~ puerperal or post abortion sepsis, ectopic pregnancy) care levfJI - Dangerous fever _ red : serious complication which - Labour ,8 :~ :~~tw::!~r:~:~~:~~~~~~~!~~~ - Other danger signs ofeare 2 - 140- Annex 7 · ~ World Health ~":t World Health Decision-making _il Org anization ro.f'lfJ Organization Antenatal care (C) Quick Check l?.:~prd clS>C'>.<; mcnt and management (RAM) • V ·\ World Heallh Antenatal care ff~'t 'r< World Health I Organization ~1!) OrganizrJtion Detection and management of pre-eclampsia Childbirth (D) labour, delivery/birth Assessing woman's and fetal status on admission, stage of labour, Support care through labour (nutrition, companion, pain relief) • Guidance on specific care through each stage of labour ·-- .... Partograph use ·;.::s:.-=.-..::.:.-:::::..~ .. ·-· Constantly monitoring for danger sings, Providing initial treatment and - referring to higher level of care - if not possible, advising on emergency procedures Management of selected abnonnalities Active management of third stage of labour ___ = -= -" • IIIJI ~ 8 ' '~11 World Heallh ' .~) World Health ~Ji Organization Childbirth - birth planning ~15! 0£ganiza tion Childbirth Decision making - key sequential steps Respond to o~nLIIl problcru an adntiMion 04 Fm;t stage of labour (1) when the 1'0man rs not u1 actiVe ratoour DS ... ______·-· .._. __ _ ·-...... - ·----~-______... ~~~;~------· - :=.:.---- ·-·---a_____ ,_... ______·---.:a ·--...,g ___ ... __ ... --.::.:::...=,";, ·--· · - ·----- ...... ,..._ ------ooO <:! -.. .__...... __ _.., ~ · 3 - 141 - Annex 7 ~~,) World Health ~ ~.\ World Health ~J Organization !(..:~ organization Responding to problems Childbirth Childbirth - immediate postpartum care, Respond to problems tmmedtately postpartum (3) D24 mother and baby first 12-24 hours t RAM, Referral to higher level of care if complications of abnormalities observed ~· ~.) World Health counselling World Health ~ 'Organization Family planning Organization before discharge Routine postpartum care - mother and baby COUI/SElOtl BIRTH SPACINGANDrA~11LYPI.Jl.llli/IG .~e-•aq ..,._.,._ ~I ~lfiUOJJ ... _ !to.. o]d l 1M I Routine care in the first week after childbirth for mother ~ · .. ··~--·-,...... ·==--;.~.";=:==---==.:.•.,:.. and baby and after the first week, ensuring preventive ...... ~--~...... ·=1.-·-··-..,_.....,,..._- ,___ _ measures Assessing for the most common complications during those periods and with special focus on - Detecting infection, anaemia. infection, depression, for the ==-:::::fii:i2--=---,....- mother and infection, feeding difficulties - Responding to maternal concerns ... -- ~=:;:..., Enhancing, adapting information, advice, and ==--~;$!' • ....,_ counselling for home care and care seeking ------~------·-,_, ·- - = -- - = Counsel on btrth spactng and famtly plannmg 027 • - 11!1 • {~~.~ WorldHealth ';:& \ World Health Newborn resuscitation ~ .l' Orgamzatlo!l Essential newborn care ·~ Organiznt1on Key steps and decision making All and especially for small infants • Monitoring closely for danger signs continuously and ...... , ---~-______...... _.. systematically soon after birth and before discharge -·_ ...... _ home ., ___ , ___ _, .. ~-~ Referring for higher level of care after providing pre ...... - ...... - ~ --·-.----··IZI ..... referral treatment ---··-----_ • Thermal protection, support for exclusive breastfeeding, hygiene and cord care ·--·----- .·-·...... _ .... ____..... _ ...... ·---·--·-·-·... - ...... -·---··--···------Resuscitation ,_,.._..,_ .... _... _., ______Immunization • Advising mother for home care, follow up, danger signs and care seeking - - ii:i::. 1111 i i • !!1 . 4 - 142- Annex 7 ' ~\ World Health I :af,) world Hoolth ~Organization ~ Organizat•on counselling Newborn - assess breastfeeding Breastfeeding • ...... - ·-·- ·-·--·="::'--:::-.... ----...... ---...,.. · ...... =~-==.. ~ .... §;Y..£ ·-::=-::::.·- -- :::~ ·, :e:!!.-:---- m:=:::=:-- 1~~- ~-~..:.: .... ~~~ ... ,.-..... - ... .,-.~- .::,.... :::. ~::.::""' ...... ~ ; t::;,~-:_:.--;----..--.. '"""' ___ .. _ -...... ,._.. -~ ·-·-··--·.,. ·------· =r..._ .... '":::-=-=-=·-::-:==-"'··"'.. ~-"'-"'=-' ""· _..... __ .,._...... ·::.:"..-:."o!.--.. -·---··..--.-·-· ·--...... _...... -~--... ·· ·=~=-:==:-...::,':\:.~~-- .,.....,..,.~ ------·~ .. ..., -~::;.:==::.,:.=-.:::..,...... __ .-.. -..=:::...... _._...... ,....,,.,~--~ ...... ,. ... "'_ .. ,., .. World He(1lth World HE'c1lt h Newborn Organization OrganizatiOn Mothers breasts care of a small baby !1 • • - ' I • ...... ,. __ ...... ____ -...... """ -...... ·-·=·-·-- - ·------·--=~~~- ·--.... -••toli~Cl...... -- . ·-·-··--.=::...... - ...·- ...., ::.=:":.-~-- ·-...... -a ~'h World Health -~.} World Ht>c1lth Reaching out for all women and ~ _J Or~anizrtt1o1 ~ Organizatron Information and counselling newborns II !!:!!~~!!! ..... --~--...... -~ .. ..., ...... ___ ·--...... ~ ... -~.,~-- ..... __ :a:::~::~~:~"'i:!:.,.-:::; · - 01_.. ..,_,_,._ ... ···-~e...... -- - -'1•1 ..-·····-"R"'·- -~...... _. ,....,, ·--...... --· ·-· .... ·----.-..... _,-,t.. --,.. :;;:;;.."' ~ · ~··-·---- ...... , ...... - ...... -··--·-.- ~....,.- ...... - :===~·- ·------·"...... --·-"..... _··-- .,. __ ...... _...... ,,_,...... _.._...-- Women living •with violence •HIV i •After abortion 5 - 143- Annex 7 Working with women, families and '~1 World Health ~ Organization Labour record communities ···" llo.· ~- . .... " ...... World Health , \ World Health Organizntion RECORDS AND FORMS ~~ Organization Referral record Simplified partograph Rclnrruln~ ord N2 - I - ~ I I I I I --~-~ ___..,_ io • ...... ii (~ World "ealth L" ts <'"!J;-1 World Health HIV in pregnancy and prevention of 1;1-~ Orga,ization IS ~y Orgamzat1on Equipment, supplies, drugs and laboratory tests mother-to-child transmission of HIV ._,,.,.,...... ______.. .. __ , __ ... _ . .... _,.. _,_ ·--··-·-_ ... -- ,,•r·,,._.,,. ._ .. ..,...... ·-,. .. ·-·""" ~-...... ,n ...... _..... _ ....·::£:..:;:== ,...... ,.- ;'~:: •'-·--··..,--- • • 6 - 144- Annex 7 ~ ~} World Health On site tests Maternal HIV ,_,..') Organization Perlt>rmRapidHIVt:est L6 Respond to observed srJ!ns or volunteered problcrns (4) C10 :~.=::, ::-~::::"J:.- -. ·~·_.. _ ·--·-,...._ · • .:::.~.... ~-- .iffia ....-.. "'.'...... "'1" _----·-·:._~~..:- ~..:....._· ______ ==._= =--~=- ...... ·~------ World Heolth for HIV Organization Maternal HIV infection Treatment details - ARV ·--~- ... -,..._.,.....~ -..-..-.....--..a-...... -~·..... - __ .... " ______,...lltlq,...... ,,.,.., .,.. ____ .... • .::-.:::~=·~-·.,...':1 ... _____ ,... __ ," ___ ,. -·--.---·"_,...... _ ~ • u.-..... - ••- ..... --- -...-.~--- ...... u ____.....,. ..._ .... ____...... ~...... ===~LII.__ : -- --- ...... _ -=:.~..::------*-, , ...... ,,.,_ ...... -~-~---.... ____u. ... __ __.. _ ·:=:.te: =-,....,..-.---·----.-.... -.... =-==: :t::~::..----·- :=.·:.·--~'"':=-·--..-.=::::.:. .. , .... _ - . .::.!~:.~-=.: ;7'·-·-r-:" -=""''"_,,,__,.... Miuft-.. '1"•-•-1..,._..,. __ .... l:ill .. ---.~-··-·-·- .... - ·~.:=:-..;:-_-::·-··------;::, ::."::~---- ···-·~.---...... --.-_...... ~~L -·- .. .. -·~-- ·-··--·..-r:r:J ..... ·-·-· - "'~---",...._--- :::::.-e:;-..:=..·=::::....-.-·--_, __ _ -.....------· ... ~ ====-.- ...... ·---·--·--•"'·===~~.. ___.._ ,_... .. _,___ __ ._ ---- ... - World Health Counselling on infant feeding options O.ganizatior. Home delivery tf(rfl\[ Ofll\'f:RY 8Y S ~U£0AITEI61Hr u..~ ...... il .... ---.:~·· ...... ' "" ""lt1 ~it'Jtl~')l t lt-:idllt l\ ..... ~- : :;..~=~.. ...,. •hoiftM"""""' ...... tl ······---....----...... ,_ -•. ,,...... ___ _.....,...... _ ,., ... _.. _,.,...... ·-···--.. .UilOINMI) ..... _ ·~:::..===~-====:::.-..::.::::.·-- ...... ·-·-~· ·-IMAtl-•""•··-...------... ---"'1----...... - .. ..,....-~ . ._, r--.----._... "'-'_"_ ...... -...... ·-·-----..-.-•lillfll ...... _,..,... .. _ • .,..._ · ------~ ...... , ...... --~-....--. 7 - 145- Annex 7 ~ · ~11 World Health World Health ":tt__ ~ • Organ ization Home delivery Organization How is it different from other guidelines? Ant cna1JJ I I: cr c C1B Entry point: pregnant woman/newly born infant (routine or for complications) ~mctherendtsnByon ..,riU!!;!.r.(!! I\Flt-li Cijtc11jet Care described "as provided" ~ilnl!-ll'n.,_..,....,_· ~- ~ -~~~-..-...--,. __ ~ --·~~-·-·----·--__ ,....._,ll.... lll ... lo•L .... ::..=..---10--.-...... _,...... __ a-.-·- ...,...... Emphasis on clinical decision-making :-.=.=_ .. ._. ___ ...... --...... ---~...... Care described as provided ~ l~l-".&.l.o..A.....I""'fU...,'oLo .... al...... il..ll.• ...... ,...... ,... - -- .. _ __ ~-.~-jiiiiUI. :r~~~~~----·~-·~~ Simple, consistent standards of care ...... __...... ,__,._.w ...... Balance between clarity, simplicity and detail ::r..:r,.::.::r:.":':=-··-~--·--··~ .ldvlseondllnrpslgns. ~· :::~__.::-:101::--., ...... _ -·1111!1...... - - ...... - Integration ...... ,__ .,. .., ...... ,_.-.a--~~..-....., - ...... - ..... -,.. (Resources: limited) ·--·-•~.....----•u-. .. ·--.-.. :=..-:--,~---' ... _,..., __ ,"'_ .. ~ Assumptions 1!1'~.\ World Health It~\ World .Health [1\t.~ Organization What are the assumptions? ~_/ Orgamzatron What are the assumptions? About services organization, resources and alternatives, About endemic diseases - prevalent for example: .High prevalence of anaemia due to Single healthcare worker at primary health care level .. iron deficiency (skilled attendant) able to provide all services for the .. hookworm infestation woman and her baby .. malaria For emergency care available 24/24, 717 -high transmission area - Falciparum Secondary (Referral) healthcare distant (all pre Maternal syphilis and gonorrhoea referral treatments needed) About support groups - available .•• "' Iii f ~) World Health (~ \ World Healt~ ::--'" Orgam;:.atro:-t Assumptions ~ Or2anizatro:1 How can it be used? To adapt /revise/develop national care standards .' .~ll~r:PII·JH~ I!Ul'·[Pl"o ito<. lHf ~~l_!l[l[ Along with other materials and activities in practice for frequent (routine) procedures For rare conditions - job aids In education and training Health providers need to have the skills required to carry out practices Criteria for Beyond the Numbers -= --- -= •• ..~ · 8 - 146- Annex 7 ~. 2.\ World Health ~J Organ ization Accompanying material What is generic PCNC not? Users guide (A guide to familiarise with the material) Does not cover all conditions/complications Adaptation guide a self-standing tool: does not have all necessary Training modules: It is not information to carry out all the procedures in the guide - Midwifery modules (revised)- 6 - Antenatal care (field testing) It is not a training tool - PMTCT (link with WHO/CDC course -field testing) It is not for all settingsnevels of mortality - Essential newborn care course (PCPNC) It must be adapted to local circumstances and settings Family planning- Decision making tool (needs, resources, local belief system) Handbook for communication change It cannot be implemented without strengthening the Standards healthcare system ---· - ~= II ~ · ~~ 'I World Heolth rm Organization t:~ow was it developed? Review of evidence Technical review by WHO departments Over 100 experts from 35 countries reviewed and commented Consensus where evidence lacking 9 - 147- Annex 7 IMPAC and the mother Preventive measures Management of Integrated Management of Pregnancy and Childbirth Emergency pre-referral complications care (IMPAC) Secondary care level Primary care level Managing Complications in Pregnancy and Childbirth (MCPC) A guide for midwives and doctors • • Dr. Jelka Zupan World Health Organization Department of Making Pregnancy Safer / Format Care for normal birth Newbom resuscitation ;- .... r~ \ w..icl "' '" ' r::r'i 01:-'='1•~-<~~: i"'~Jili !P" ' '~'be il p ••"'"'""' What is its purpose and who is the audience? What is MCPC ? » Improved quality, safety and efficiency of emergency care > Evidence based interventions during and following pregnancy and childbirth > Symptom-sign based approach » Reduction of » Emergency obstetric care • Maternal mortality. morbidity and disabilities • Stillbirths » Elective obstetric care • Neonatal problems Pregnancy, Childbirth and Postpartum » Referral hospital with basic laboratory f<;~cilities, selected • Immediate newborn care essential drugs and supplies, blood transfusion » Team of providers > Unknown practices Physicians - generalists Symphisiotomy • Residents • Nurses • Craniotomy • Midwives » Teachers of medical, nursing and midwifery > Decision makers IIA • il r~ 1 ~, 1d ~"t ·,"" r ~~~ lf't tJI · ...-. What are its contents ? > Practical guidance for managing major conditions that » Detailed description of anatomy, physiology, pathology cause mortality in the mother and her newborn > Detailed classification of diseases » Academic terminology > Simple diagnostic and clinical decision making based on > Chapters based on disease classification symptoms, signs and basic tests > Non-emergency conditions except normal labour, childbirth and newborn care principles » Practice based on evidence and programmatic evidence » Management based on effective low-cost options suitable for limited resource settings 1 - 148- Annex 7 ~) =~~~~ How is it structured? > Table of contents > Section 1: Clinical Principles (C) > Introduction Rapid initial assessment, talking with women and > How to use the manual families > Abbreviations Emotional & psychological support > List of diagnoses Emergencies & General Care principles Clir ri~.;al u~~ uf i.Jiuuu dr rd nuid~ > Section 1: Clinical Principles (C) Antibiotics, analgesia, anaesthesia > Section 2: Symptoms (S) Operative care principles > Section 3: Procedures (P) Provider and community linkages > Section 4: Annexes Normal labour, childbirth & newborn care principles Newborn care principles Provider and community linkages lii•.i ~~ \?"'!fd l-:t.lftn ~Of~n • .IAT .O , How is it structured ? How is it structured ? > Section 2: Symptoms (S) > Section 3: Procedures (P) Bleeding Anaesthesia of labour Headache, convulsions, high BP Induction and augmentation Operative vaginal delivery Unsatisfactory progress of labour, malpresentations, of placenta shoulder dystocia Manual removal Repair of genital lacerations Labour with overdistended/scarred uterus Caesarean section Fetal distress/prolapsed cord/decreased movements Manual vacuum aspiration, D & C Fever Hysterectomy Abdominal pain Craniotomy, symphysiotomy Difficulty in breathing Prelabour rupture of membranes > Section 4: Appendix (A) Immediate newborn conditions or problems Essential drugs • Index ill i i ll i i t'~ \ WDrfd 1- U IIh ~ 0. 1,j ll' '\ l ill1~ How is it structured ? How to read the MCPC > Sections are separated by coloured paper > Start at the beginning ? > Cross references between sections and chapters · Become familiar > liberal use of tables, boxes and illustrations > Start at chapter of interest? > Balance between clarity, simplicity and detail Use it when required · Read the rest when time is available > Understand and internalise 2 - 149- Annex 7 f~ iMM:Iid W f!ill'\."1 r ~o.~;~~n ' l.,\110, How to use the MCPC Developing MCPC l> Adaptation - essential changes Alternatives on setting, epidemiology, national standards of disease l> Obstetric practice guidelines prepared for use in control programs developing countries New evidence l> Change from diagnosis based text book to symptom-sign Not changing basic principles and evidence based practices based approach l> Institution-specific protocols l> Contributions and critical reviews from several experts ~ Roforonoo manual for practitioner& l> Decision makers and managers l> Standards and criteria for maternal and perinatal death l> WHO-HQ collaboration with JHPIEGO reviews l> Support from UNFPA, UNICEF and World Bank l> Training l> Endorsed by FIGO & ICM Pre-service l> Reviewed in different regions • In-service • Learning resource package (JHPIEGO/AMDD) l> Translated into many, many languages l> Translation - instructions 3 - 150- Annex 7 ~)~ld . HuttJI ~J""Ch;riuhcY.I IMPACN and the newborn Preventive measures World Health Organization Emergency pre-referral care Management of II Primary care level complications ---· Secondary cal9 level Managing Newborn Problems > Essential pregnancy care for ensuring optimal fetal development Managing > Childbirth care to ensure safe birth, A guide for doctors, nurses and midwives matemaland ~ lmmflrli~IP "~"' AfiPr hirth, inr.l11rlinQ fetal resuscitation, to ensure smooth complications transttlon to extrauterine IWe > Breaslfeeding, warmth, hygiene Dr. Jelka Zupan > Addttional.care for LBW babies Department of Making and counselling for home =- Sater > lnformaUon Pregnancy care Managing Geneva newbOrn > Monitoring for danger signs, early problems detection, pre-referral management > Sefe referral I > Follow up care of at rtsk Infants ·--· • ~H e .llt-. O!~IVI"l ll l! O't Managing Newborn Problems Challenges to creating a newborn (MNP) manual for low-resource settings li> Practical guidance for managing major conditions originating -~·----- • Newborn health problems in the perinatal period that cause major mortality in the • Evidence based interventions newborn • Clear, precise, practical guidance li> Sign-based approach • For doctors and nurses and li> Prudent use of resources midwives • Referral hospital in li> Emphasis on clinical assessment and decision-making • Lower resource settings li> Limited use of diagnostic methods li> Limited number of treatment options Endorsed by li> Least invasive treatment choices and for the shortest UNFPA, UNICEF, World Bonk Professional Or ..nlullons: possible period •FIOO li> Specific, detailed, directive • i!+e-. •lnlanurtlonoJConfo•rllllon of -lvoa - -=- •lnlamotlonoiPao What is its aim ? Who is the audience? li> Improvement of quality, safety and efficiency of care > Referral hospital with basic laboratory facilities, selected essential drugs and supplies, blood transfusion li> Management based on effective low-cost options suitable for limited resource settings li> Team of providers li> Promotion of Physicians -generalists • Evidence-based interventions • Residents • Practice based on programmatic evidence • Nurses li> PromotioA of decision making, communication, privacy, • Midwives dignity li> Teachers of medical, nursing and midwifery li> Decision makers li> Role of parents li> Follow up 1 - 151 - Annex 7 What is its contents? ~> Identification of problem ,...,.__ M:J-·0..·-·· ::::..~- ----(lopC-15). ~> Correct assessment & classification -a.-lot·--.. -··-Ill.....,, __ ,41...... • 0.-.... first, then less serious IJ11.F.J.-P4t) Most critical, !We-threatening signs evaluated .r.r__..,...._.__ ....,,_ ... .. _.,... _,_ ones -. .... ,___.... _, Signs lead to diagnoses -...,...... ___.- 0...... _, 1~ DiaRnoses lead to treatment ' I ~> Timely and correct management • -=~-:-::-:-...... ,=-=·· ""-=.... = . ~.:=-~---- • ---"<1-__,,...... J I------··-...... -....- ,..._.,._.-- ...... ---- _--..,~ ~ .. ·-- .. • essential drugs and supplies ...,..._ __ .. _"'_ ...... ~-.....--- :::;:..,~..::;.·---.. --<1- ¥- How is it structured? How is it structured? ~> Table of contents ~> Balance between clarity, simplicity and detail ~> Introduction How to use the manual ~> Sections are separated by colored paper Abbreviations List of diagnoses ~> Cross references between sections and chapters ~> Section 1: Assessment, Findings and Management ~> liberal use of tables, boxes and illustrations ~> Section 2: Principles of Newborn Care ~> Different from PCPNC ~> Section 3: Procedures Multiple morbidities • ?? Number of algorithms ~> Section 4: Annexes (records, drugs, equipment, supplies) = I • Section 1: Assessment, findings and Section 1: Assessment, findings and management (F) management (F) > Rapid assessment and immediate management PROBLEMS -BABY, cont. > Organizing care of the sick or small newborn vomiting and/or abdominal distension > Further assessment and management diarrhea > Problems: BABY bleeding and/or pallor small baby swelling on scalp multiple findings (most often sepsis of asphyxia) skin and mucous membrane problems breathing difficulty umbilicus red and swollen, draining pus or foul smelling mother with history of uterine infection or fever during labor or after eyes red, swollen or draining pus birth, or rupture of membranes >18 hours before birth birth injury convulsions or spasms birth defects abnomal body temperature MOTHER Jaundice asymptomatic newborn or mother w~h hepatitis B, tuberculosis, lethargy or other non-specific signs diabetes or syphilis low blood glucose/feeding dWficulty mother w~h HIV I- 2 - 152- Annex 7 Section 3: Procedures (P) Section 2: Newborn care principles (C) > Maintaining normal body temperature > Resuscitating a baby who was not breathing > Feeding and fluid management > Measuring body temperature > Oxygen therapy > Taking blood samples > Measuring blood glucose > Antibiotics > Giving injections > Infection prevention > Intradermal injeotiona > Clinical use of blood > Establishing an intravenous line > Immunization > Blood transfusion ;.. Assessing growth > Inserting a gastric tube > Communication and emotional support > Lumbar puncture > Transfer and referral > Administration of rectal paraldehyde > Discharge and follow-up > Incision and drainage of abscess •= Section 4: Annexes How is it differentfrom other guidelines? > Records > Entry: ill or small baby (not a disease) > Lists of equipment, supplies and medicines > Emphasis is on clinical diagnosis and management early recognition of problems clinical, not laboratory, diagnosis simple, consistent standards of treatment minimal number of procedures > Change from diagnosis-based text book to symptom-sign based approach > Clinical decision making • What are not in MNP? How to read the MNP? > Detailed description of anatomy, physiology, pathology > Start at the beginning? > Detailed classification of diseases • become familiar > Academic terminology > Start at chapter of interest? • use it when required > Chapters based on disease classification • read the rest when time is available > Non-emergency conditions except breastfeeding > Understand and intemalise = WHO SEAAO. New Oetli 2002 ' WHO SEARO, N«w0dli2002 3 - 153 - Annex 7 How to use the MNP? What are the greatest challenges? l> Adaptation - essential changes l> Strengthening managing newborn problems at facilities l> Institution specific protocols providing care as described in PCPNC (comprehensive l> Reference manual for practitioners obstetric care) l> Training: pre-service, textbook for students, in-service l> Purchase of equipment, medicines, supplies by managers l> Special attention to kangaroo mother care and protection, promotion and support of breastfeedins:J at those 8tnndord for auditing prnotioc for !lupcrvi:Jors institutions l> Organization of services for the health authorities l> Standard and criteria for neonatal death review l> Learning package available from JHPIEGO l> Implementation guide (in preparation)- volunteers? How was it developed? WHO documents on maternal and newborn health l> WHO-HQ collaboration with JHPIEGO l> Evidence used where available (presented separately) · lacking for many items · consensus of experts www.who.inUreproductive-health l> Contributions and critical reviews from many experts from all over the world ,.. Reviewed in different regions Thank you l> Evidence: Cochrane RHL Questions? Maternal and Newborn Health Reference Library (in preparation) Standards for maternal and newborn care 4 - 154- - 155- ANNEX8 PRESENTATIONS OF COUNTRY "BEST PRACTICES" - 156- - 157- Annex 8 A Pilot Study: Distance Learning Course on Pregnancy, Childbirth, Postpartum and Newborn care for primary Expansion of Distance health care workers at the aimag and soum levels in learning on PCPNC Mongolia Improving the quality of health care services is one nationwide in Mongolia of the main requirements for a reduction in maternal and newborn mortality in Mongolia. With 98.6 deaths per 100,000 live births, the A t.:ullctiJuration project maternal mortality ratio is still unacceptably high between HSUM, MOHand as is infant mortality at 30 per 1000 live births. WHO country office Complications of pregnancy and childbirth are major causes of morbidity and mortality Mongolia team especially in the rural and western aimags. 27 September,2006 Shanghai, China The goal of the pilot study Project activities Rural physicians should function as both primary care )> Development training curriculum and physicians as well as general obstetricians and preparation of training materials gynaecologists. The curriculum contained 4 modules. 1. Basic communication skill with pregnant women, fundamentals of Rural Obstetrician-gynaecologists provide primary care checking status of pregnancy, preventive high risk obstetrical care, birth plan management skills, and emergency management in post for women of all ages, tending not only to problems of abort1on. the reproductive health, and newborn care but also to 2. Improving skills for delivery and postpartum care, general medical problems such as STP, Tuberculosis 3. Prevention of HIV/AIDS and other infectious diseases. etc .. 4. Care for the (lewbom baby with the appropriate clinical skills end supporting theoretical knowledge through usl~ lhe evidence- based recommendations of Pregnancy and Childbirth 'Pregnancy, Childbirth and Newbom Care: A Guide ror Essential Pr~cl!ca' (IMPAC Guidelines) . Project activities (cont) Project activities (cont) 'I> Pilot testing 'I> Clinical practice Physicians in Uvurkhangai, Domed, Bayankhongor, ; The participants received clinical practice training at Khentii and Zavkhan were selected for the CD based the First, and Second Maternity Hospitals and at the distance learning because of the aimags high maternal Maternal and Child Health Research Center with four and newborn mortality rates and because of the areas clinical rotations: pregnancy, childbirth, postpartum, and remoteness. newborn care. ; Each trainee recorded his/her training report and the trainees were awarded certification 1 - 158- Annex 8 Project activities Achievement by pilot study on PCPNC Training evaluation and monitoring results l> The trainers had meeting with the participants and gave pre- and post test of their knowledge and skills . .. ThP. prP.-r:ifo;t::mr.P IP::~mino tP.;t p::~rtir.ip::~nt.; ::~vflrl'IQP. !\C:orP. was 32.5% compared to the post distance learning test score of 84.3%. l> The pre- and post-test by the Postgraduate Training Institute of the Health Sciences University of Mongolia documented a very significant increase in the average participants knowledge and skills. ~~--- - Background Goal and objectives In 2005, with supPOrt from WHO counl!y office and the Western Pacific Goal: Regional ollice, the Health Sciences .University of Mongolia Improve the health mothers and children in rural areas of developed a pilot project 0111ralnlng rural health workers in Mongolia Mongolia. The following activities were undertaken: > Development curriculum on PCPNC based on WHO training Objectives: guides on PCPNC and MOH adopted materials. l> To expand videoconference facilities in Darkan-uul, > Improvement of adopted materials for distance learning Gobi-Aitai, Dornogobi, and Dornod aimags. > A distance Ieeming was completed on PCPNC through CD l> To develop curriculum and training learning materials for > The facilitators had practice training In Ulaanbaatar c~y. videoconference. > Extra funding supported videoconference facility linking 3 aimags. (Darkhan-Uul, Domogobi and Gobi-Aitai). l> To conduct videoconference on reproductive health at > The videoconferences were conducted two times between Health Sciences University and medical colleges of selected three aimag, HSUM and Manila. When connected Darkan-uul, Gobi-Aitai, Dornogobl, and Dornod airnags. videoconference, medical workers and physicians, who work l> To build capacity of national aimag and soum level remote area, could study video lesson on PCPNC and immunization. facilitaties. This program approved to be very successful in building knowledge, skills of rural health workers. Output Benefits l> The videoconference network l> Travel cost and time will be saved l> Development of teaching and training materials and l> Improvement in the quality of Distance learning videoconferencing. l> The physicians and medical workers, who work in the l> Improvement of health care workers knowledge and remote area's hospitals, could attended postgraduate skills on PCPNC continuing training successfully and completely on subjects such as pregnancy, childbirth and newborn care. l> Improved telemedicine capacities for these remote health facilities 2 - 159- Annex 8 Project management Implementing organization The Health Sciences University of Mongolia The Postgraduate Institute of Health Science (HSUM) managed the overall project and University (HSUM) and the medical colleges of cooperated with World Health Organization Darkhan, Dornogobi and Gobi Alti aimags. (WHO) and the medical colleges of Darkan-uul, Gubi-AIIdi, Dv111~v1Ji, dllli Dv111V\.I i:lilllays Collaborating partners Thank you for your attention Health Sciences University of Mongolia, World Health Organization, Ministry of Health , and Maternal and Child Health Research Center 3 - 160- Annex 8 Curent of newborn care I-- • Newborn care are still problem r~ODULE CARE FOR NEWBORN • Neonatal mortality 18-20/1000, account for 70% among <1 year • Most of mortality causes could be solved I guyen Due Hinh ~ anoi Medical University ~ ational Hospital for OG Mobility of diseases Main causes of death in newborn ,, ,, Distribute mortality rate by age Gaps in newborn care SIJ I- • Newbuml:;cm:: uut .lll:f ... ..,,;vcoy 45 40 • Resuscitation in delivery room · 35 30 • Follow up after discharge t:zs • Delay detective severe symptoms :w 15 • Poor transport and lack of medical service 10 •IOuatity newborn care in low level very limit 1 - 161 - Annex8 Basic elements distribute to care for Cc ntinuing follow up: From pregnancy up to newborn babies p o~t neonatal Collaboration with mother child health program: One imP_OJ:ta ot conte_ot J)_f_m2.t h_e_r child health Antenatal care: examination for pregnant • Suitable with policy women, nutrition consultant, early detection • Continuing care high risk mother, vaccination, safe delivery... • Pregnant period until 20 days Neonatal care: regular essential care for • Systems care from community to family every newborn, especial in the first week • Base on available medical care system of such as: temperature, breast feeding, national umbilical, eyes care; jaundice and early detective abnormal signs ... Quality care • Remaining NEwborn care in community level Co~tinuing follow up: From family up to rhedical service system Co eperation with mother c/1ild h~ a lth p_rogram: • Improve quality of antenatal care • Safe delivery Fe mily to community In prove quality newborn care Base on medical coordinators, • Improve knowledge and skill on essential care for attendaces newborn • Training for all health workers about resuscitation in delivery room • Distribute essential medical equipment and instrument and drug Newborn care in district hospital I Module of newborn care in community • Essencial care for every babies •. Clean delivery room warm , avoid draft. enouqh light ( lamp if not enough natural light) 1- • Take care rorneWllurn,.,...,.pt,.,.omotJ:tr.te"'rn""'.------1 - Nutrition sufficient: by sonde, cup • Heater - temperature • Ambu bag, mask - Antibiotic (oral, IM, IV) • Warmer bed - oxygen therapy • Bed for mother - Resuscitation : ambu bag, mask • The pl ace for cons ul ta nt, ed ucation , and - Jaundice management: phototherapy material for education and teaching - Low birth weight management • Essential drug : : vi tami n K1, BCG , Hepatitis B • CPAP management • Take care during referral of newborn 2 - 162- Annex 8 Medtcal eqUipment tor Module newborn care in district level province hospital • .scale --• Sud~~~~------~ I- • CPAP machine • Essential care for ever newborn • Phototherapy • Warmer bed system • Care for newborn problem • Newborn resuscitation : Ambu bag, face masks, a blade - Sufficient nutrition: by sonde, cup, TPN urliilUIJaliun ( lJidUIO , i:I IUOlfaGil t:Oil tube ...) • Warmer bed for transport - Stable temperature • Oxygen souse -antibiotic (oral, IM, IV) • Mother bed - Oxygen therapy • Ambulance • Collaboration between family and community level Cont•• - Guideline for referral 1- ~ten:~ car61'1- ··'"-M - Resuscitation by mask or endotracheal during transport tube -To Establish a system communication betwwen different levels - Jaundice management: phototherapy - Care for low birth weight • Collaboration betwwen district and province hospital - CPAP management -Giudeline for newborn problem - Blood transfusion management in different level -To Organise newborn care unit in district • Care for newborn transport hospital and neonatology - Transffer knowledge and skill for districts and province hospital Po~t newborn care room Equipment for province hospital • cale Delivery room • Suction pump 1- 1- • Apn ..o , "''"~ • Scale • CPAP • Resusciatation wammer bed • Phototherapy • Resuscitation equipment: ambu, mask, • Oxy bottle + pressure meter ~ndotrachea l tube ... • Endotracheal tube • Resuscitation warmer • Warmer bed for transport • Endotracheal blade • pxy resoure • Face masks different size • ~other bed • ~mbula[lce 3 - 163- Annex 8 Care of newborn during transport Essencial drug Communication to up level r- r--• Allip1xmn, l"en,cnnne lu iUCOSe - general situation of patient (5%,10%,20%) :.;entamicin management locloxacillln -Normal saline 0,9% Estimate time to arrive Vnr.r.ine: ~loramphenico l • Training afelne - BCG, hepatitis B, polio, tetanus Preparing before transport Phenobacb!tal Care of newborn during transport Bood and plasma Paraldehyte management during transport VUaminKl • Mean transport Activities • Collaboration between family and community level - Guideline for referral Collaboration between family and - • ~e.s1a.blls_b_a_~stem care__neW_.""-'-'orn-----1 community level during transport - To Establish a system communication - Training on safe mother childhood, between different levels essential newborn care, follow up post • Collaboration between district and neonatal care for medical coordinators province hospital - Guideline for newborn problem - Publish document for attendance and EC management in different level for mother - To organise newborn care unit in district hospitar and neonatology - Support for family to access medical - Transfer knowledge and skill for districts services when they needed and province hospital Indicators for evaluation Co~t. . C 'Jmmunity level Hospital/eve/ f- - Time-examrntng-during-pregnan-...,,1cr------t - Percentage-examination at l.,o~•" ,;, ,,.. uu• . · ~ - Percentage delivery in community level pregnancy - Percentage of newborn received vitamin K1 at - Percentage delivery at community birth Percentage of CS, forceps - Percentage of .newborn received BCG -percentage newborn need resuscitation after ~ Percentage of newborn received hepatitis B birth - Percentage of newborn to be follow up at home - Percentage of low birth weight after discharge - Percentage of newborn referred - Percentage of newborn received breastfeeding - Mortality rate after birth - Cause of death - Mortality rate 4