Maternal and child health

1. Maternal, Neonatal and Child Health Services
FEDERAL DEMOCRATIC REPUBLIC OF ETHIOPIA
MINISTRY OF HEALTH 1

2.  Section 1: Introduction
 Section 2: Learning Objective
 Section 3: Operational Standards
 Section 4 : Implementation Guidance
 Section 5 : Monitoring and Evaluation Tool
2

3.  An effective care to prevent and manage
complications during ANC, labor and delivery, and
postnatal likely to have a significant impact on
reducing maternal deaths, stillbirths and early
neonatal deaths.
 Besides the maternal and perinatal mortality
burden during labor and the early postnatal period;
the high neonatal and U5 mortality should
equivocally be addressed.
 Hence the standardization of MNCH services are
vital important.
3

4. By the end of the training; participants would be able
to
 understand and list the national MNCH operation
standard.
 describe the implementation guidance of the
MNCH chapter.
 have a good knowledge to apply on how to use
the MNCH checklists and measures of indicators.
(Monitoring and evaluation tool)
4

5. 1. The hospital ANC unit provides individualized,
client centered and evidence based care to clients on
all working days and high risk mothers should be seen
in the referral clinic.
2. The hospital should ensure provision of
Comprehensive Emergency Maternal and Newborn
Care (CEmONC) services
3. The hospital should ensure women and child
friendly services at all MNCH units including pain
management.
5

6. 4. The hospital ensures all equipment, essential
drugs, supplies and reference materials are available
in maternity and pediatric units
5. The hospital should ensure the provision of
intrapartum care as per national protocols
6. The hospital should provide comprehensive
postnatal care in the facility as per national standards
7. The hospital should ensure provision of family
planning (with focus on long term methods) and
comprehensive abortion care services following the
national guideline and policies.
6

7. 8. Maternity and pediatric units should undertake CQI
activities by conducting regular review meetings and
audit programmers.
9. Hospitals have established separate pediatric OPD,
emergency and triage services.
10. Hospitals have comprehensive Neonatal Care
service that includes NICU, KMC, mother’s room and
isolation rooms.
11. Hospitals have separate Pediatric Wards
composed of separate critical, general, SAM, isolation
and procedure rooms.
12. Midwives should implement the midwifery
process at all hospitals for all admitted patients.
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8. Content
 Roles and Responsibilities
 Rules and Norms
 ANC
 Labour and Delivery
 Postnatal Ward
 Caesarean Section
 Maternity waiting rooms
 Case management
 Family Planning Services
 Comprehensive abortion services
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9. The unit will be led by obstetrician and gynecologist
or IESO and he/or she will be responsible for ;
Planning and monitoring
Arrange training
Prepare schedule for the unit
 Ensure availability of drugs, Supplies and
equipment
 Ensure the proper Handover mechanisms
Auditing of service quality
Report and action Plan.
9

10.  ANC unit, labor and delivery ward, and postnatal
ward
 Easily accessible*
 MNCH rooms should be clean, well ventilated,
illuminated and the temperature should be
comfortable for laboring mothers.1
 Mothers should be treated with respect and dignity
 Respectful maternity and newborn care norms
should be applied to all clients 1
 Pain should be managed appropriately
10

11.  Pain should be managed appropriately
 Maternity unit should do Audits regularly
Audit every month. (eg. Evidence based care
-) MDSR-immediately within 72 hours),and
the other audit as specified.
Client/mom’s satisfaction survey every 3
months-
The audit and satisfaction survey data should
be displayed and visible for action and usable
Case Based Discussion (CBD) for complicated
and reportable cases should be held at least
every week
11

12.  Community involvement at least once every 3
months.
 Midwives should implement the midwifery process
at all hospitals for all admitted patients.
12

13.  ANC service open throughout working days by
skilled professionals
 All service providers trained on FANC.
 Universal Iron Folate supplementation for 3 months
should be given at their first ANC visit
 Laboratory investigation result should be available
within the same day of sample collected
 All ANC services should be delivered free of charge
including U/S.
 All ANC services delivered should be evidence
based as to the guideline and updates,
13

14.  HIV positive pregnant and lactating mothers and
their exposed infants should get option B+
guideline
 DBS should be done preferable at 6 weeks of age in
the MNCH clinic.
 Mother-infant pair cohort should be followed for
18 months and documentation in the register
should be proper.
 Partners’ testing should be encourage in all means.
 Referral clinic should be staffed by obstetrician or
IESO and high risk mothers should be referred to.
14

15.  All mothers who come for ANC should be
counseled on
 birth preparedness, complication readiness,
and danger signs
 immunization,
 infant feeding,
 family planning,
 HIV, and
 nutrition.
 Mothers better be allowed to hold their ANC
follow up summary form* after 36 weeks.
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16.  Is the time between the first stage to third stage of
delivery.
Laboring mothers triage protocol should be available
and addresses the following major area;
Laboring mothers should be allowed to go
directly to the labor ward.
Triage/reception with clear admission criteria.
Log book at triaging site or reception for
laboring mothers who are in false or latent phase
of labor.
Rapid assessment tool and client flow in labor
and delivery posted at reception and emergency
triage.
16

17. Rapid assessment of laboring mothers to advance
care
17

18.  Flow chart for triage and registration of laboring
mothers
18

19. • Rooms clean, well ventilated, illuminated and the
temperature should be comfortable for laboring
mothers.1
• Emergency drug cabinet should be available with
essential drugs labeled and the expire date
updated.
• Functional refrigerator with temperature
monitoring chart.
• All essential functional medical equipment. 2
• Functional clock, weighing scale, head lamp and
tape meter.
19

20. • Sufficient space to the standard *
• Allow Oral fluids and light food during labor.
• Allow the accompany of Family member/support
person
• Functional bathroom and toilets with door with
hand washing basin and soap- for mother and
accompany
• Running water and soap for hand washing for the
staff.
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21. • At least four beds for first stage of labor and two
delivery coaches for second stage of labor.
• ICU or HDU available near the nursing station for
seriously ill patients.
• Partograph: Complete and consistently be used for
all laboring mothers in active phase.
• Third stage labor should be managed actively.
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22. Documentation should be clear and complete and
check weather the following items are in the record
• Date and time of admission,
• Identification and previous obstetric history,
• Vital sign at admission findings of BP, PR, Temperature,
• lie and presentation,
• FHB,
• uterine contraction,
• cervical status (dilatation and effacement),
• membrane status (intact or ruptured),
• molding and
• station should be documented.
22

23. Laboratory investigation should be done for laboring
mother at presentation
• HGB,
• blood GP and RH,
• VDRL for syphilis and
• HIV testing should be done for all and
The safety assessment checklist should be done
• Safe childbirth check list should be used for all.
• Delivery coach is comfortable with all accessories
and
• Mothers are allowed to deliver in their preferred
position.
23

24. • Routine immediate essential new born care should
be available-1
• All midwives should be trained on Helping Babies
Breath (HBB)
• NICU should be available for advanced care and
should be adjacent to labor ward.
• Delivery summary should be completely filled on
form.
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25. • The post-natal beds should be clean and
comfortable with accessories and bed sheet.
• Comprehensive post-natal care for at least
24hrs
• Maternal BP, PR, temperature, uterine tone
(contraction), vaginal bleeding checked
every 15min for the first 2hrs.
• Neonates are checked for breathing normal,
color; pulse rate, breast feeding and cord
tie security.
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26. Mother should be counseled for danger signs for
mother :
• vaginal bleeding,
• fever,
• foul smelling vaginal discharge,
• severe abdominal pain,
• safe sex,
• abnormal body movement and
26

27. neonate:;
 failure to suck,
 jaundice,
 Cyanosis-bluish discoloration
 fever,
 abnormal body movement,
 difficulty of breathing
27

28. Fully functional operating theatre with staff should
have;
• one table dedicated for cesarean section and it
should be adjacent to the labor and delivery ward.
• Appropriate and adequate cesarean section team
member available 24/7;
 OBY/GYN or IESO,
 anesthetist,
 scrub nurses and
All essential drugs and functional equipment for
cesarean section
28

29. • Safe surgery check list used for all
surgeries-1
• Documentation complete for all cesarean
sections-2
• Conduct Cesarean section Audit every three
month and as necessary.
• Rate and indications for C/S should be
displayed in white board every month. -*
• Spinal anesthesia used in the absence of
contraindication
29

30. Definition:
“Residential facilities where mothers who live
remotely can wait before giving birth at a health
facility.” national
The admission criteria for MWH
any mother who is pregnant for >8 months,
irrespective of her gravidity, parity, medical
and obstetrical history but who resided >10
Km distances.
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31. Background overview
The clinical causes of most maternal deaths in
Ethiopia are;
• hemorrhage,
• anemia,
• eclampsia,
• obstructed labor and
• unsafe abortion.
All of these complications are preventable and hence
should be managed with evidence based care as to
the national guideline.
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32. Family planning clients shall receive information,
education and counseling on;*
 Sexual and reproductive health,
 family planning and
 STI/HIV/AIDS.
• Ensure the accessibility and availability of full range
of family planning services with particular
emphasis on long term methods.
• FP Services delivery should be patient centered,
evidence based, timely, and clients should be well
informed about the benefit and adverse effect.
• Document the clients’ decision and preference of
the method
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33. • Staffs should have received;
• appropriate training,
• demonstrate competent skills and
• the services should be evidence based
including use of national guideline and
policies.*
33

34. The abortion care services provided to women, as
permitted by law, are safe, affordable and accessible
to
Reduce deaths and disability from unsafe
abortion and complications through effective
management and/or stabilization and referral
34

35.  Integrating abortion care services into other
sexual and reproductive health services.
Help women to;
 Make free and informed decisions regarding their
pregnancy,
 be more informed about health services and
 follow up care needed, and
 feel more emotionally comfortable with their decisions,
Through supportive, nondirective reproductive
health counseling
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36.  Prevent unwanted pregnancies through
contraceptive services, including counseling and
method provision
All working staffs should
 receive appropriate training ,
 demonstrate competent skills and
 the services should be evidence based including use of
national guideline and policies.
The hospital should also ensure availability of safe
abortion services including medical and surgical
options as permitted by the law.
36

37. Content
 Emergency and triage services
 Pediatric OPD
 Comprehensive Neonatal Unit
 EPI Clinic
 Pediatric indicators
 Appendices
37

38.  Pediatric triage is separate from central triage
 Emergency treatment room set next to the triage
area
 ETAT trained professionals and active ETAT
service
 Drugs, equipment and supplies available and
labeled (annexed)
 Necessary guidelines and job aids available
 Emergency lab tests (Hgb, BG, Cross m, glucose,
BF)
 Further management by a senior professional
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39.  Separate from adult OPD
 Adjacent to the pediatric emergency room
 Emphasis on IMNCI target diseases (U5)1
 Space requirements, equipment and guidelines2
 Play ground
 Physicians or IMNCI trained professionals should
manage children under 5 years
 Components of pediatric OPD:
 ORT corner
 Regular OPD rooms
 Pediatric specialty clinics including pediatric ART
room
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40.  Adjacent to the Labor Ward
 Components:
 NICU
 KMC room
 Mothers’ waiting rooms
 Isolation room for infectious cases
 Resuscitation/procedure room
 Essential drugs, supplies and equipment available
 Trained professionals
 NB care GLs and job aids (updated)
40

41.  Providing all the primary series of vaccinations
 Supply of all the primary vaccines maintained
 Cold chain and storage of vaccines as per NGL
 EPI GLs and job aids
 MCH nurse(s) with special training in EPI
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42.  Separate from adult wards
 Components:
 Therapeutic feeding room (complicated SAM)
 Pediatric ICU or at least dedicated room for critically
ill children adjacent to nurses station
 Isolation room for children with communicable
diseases (e.g measles)
 Procedure/ resuscitation room with good light
source
 Room (or corner for primary hospitals) for pediatric
surgical cases
 Essential supplies, drugs and equipment (annexed)
42

43.  Case management GLs available
 Child friendly room paintings
 In-patient care guidance
 Frequency of sick child evaluation by
physician/nurse and documentation
 Vital signs monitoring
 Emphasis for nutritional and pain
management
43

44. Proportion of HWs
assigned at
pediatric triage and
emergency unit
trained in ETAT
# of HWS with ETAT
training/Total # of HWs
assigned to the
unit*100
Bi-annually
A) A) Cumulative # of
LBW newborns
admitted to the
KMC room
B) B) Survival rate of
LBW (<2000gr)
newborns admitted
to the KMC room
A) Total number of LBW
NBs admitted to the
KMC room from
beginning of year to
end of reporting period
B) # of LBW NBs admitted
to KMC room that
survived/Total # of NBs
admitted to KMC
room*100
Quarterly KMC register
44

45. Proportion of
children admitted
to pediatric wards
for whom vital
signs are
measured Q 6hrs
# of charts with
documented v/s q
6hrs/Total # of
charts
assessed*100
Quarterly Patient
charts
Proportion of U5
children admitted
to the ward for
whom growth
monitoring is
done
# of charts with
documented
growth
monitoring/Total
# of charts
assessed*100
Quarterly Patient
charts
45

46. Case fatality rate
for newborns
NB deaths in the past
3 months in the
hospital/Total # of
hospitalized NBs in the
same period*100
Every 3
months
HMIS register
% of essential
drugs and
equipment
available in the
pediatric
emergency unit
Number of essential
drugs and equipment
available in the
pediatric
emergency/Total
number of essential
drugs and equipment
listed in the annex*100
Every 6
months
46

47.  Appendix 1: List of Emergency Drugs and Equipment for Child
health
 Appendix 2: List of NICU equipment and essential drugs for child
health
 Appendix 3: List of guidelines and job aids for child health
 Appendix 4: List of pediatric ARVs and OI drugs
 Appendix 5: Facility, Supplies and Equipment for Pediatric OPD and
ART Clinic
 Appendix 6: Facility, Supplies and Equipment for Pedia
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48.  Checklist & Indicators to measure attainment
of each Operational Standard.
48

49. Thank You
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