Maternal service are fundamental

1. Maternal Health Services
By:
Endalamaw .f
12/10/2022 1

2. Presentation outline
• Antenatal care
• Delivery care
• Postpartum care
• Post abortion care
• Essential obstetric care
• Family planning
• Challenges
12/10/2022 2

3. 1. ANTENATAL CARE
• Care given to pregnant women so that they have safe
pregnancy and healthy baby
• All pregnant women should have a minimum of four
antenatal visits (at least 20 minutes duration each) for
prevention, early detection and management of
complications
3

4. ANTENATAL CARE…#2
• Antenatal care should comprise health
promotion, assessment, management and/or
referral through history-taking, physical
examination, and laboratory tests, where
necessary; tetanus toxoid immunization; iron
and folate supplementation; malaria
prophylaxis; hookworm treatment; and STD
management.
4

5. ANTENATAL CARE… #3
• Antenatal care sessions should be used as an
opportunity to provide information to women
and their families about danger signs and
symptoms during pregnancy and delivery and
to help them develop an appropriate delivery
plan, based on the woman's history and
health status
5

6. 1. TRADITIONAL ANC
• Ritualistic rather than rational
• Emphasis of visits is on frequency and
numbers of visits, rather than on essential
goal-directed elements of each visit
6

7. TRADITIONAL FOCUS OF ANC
• Emphasis on risk screening (identifying women who
would face problems) through history taking,
physical and laboratory examination
• Providing ( TT immunization, iron/folate
supplementation ..) and treatment as appropriate
• Education on maternal health and nutrition
• Assigning number and timing of ANC visits
– Every month - Up to 28 weeks of gestation
– Every 2 weeks - 29 to 36 weeks
– Every week - 37 weeks and above (for “normal”
pregnancy, not the same for all countries).
7

8. When is risk screening effective? …#2
• The whole (pregnant) population is included
• Conditions screened should include major
causes of morbidity and mortality
• When increased risk is detected, appropriate
actions should be taken
• Adequate services should be available at the
referral level
8

9. When is risk screening effective?...#3
• Women at risk should be able to reach the
referral services
• Care providers must be motivated to
implement the system
• The strategy must show reduction in maternal
morbidity and mortality
9

10. CRITICISM AGAINST TRADITIONAL ANC
• Risk approach does not distinguish those who would
develop complications from those who would not
– Only 10-30% of high risk women experience
adverse outcomes.
– many women categorized as “low risk” do develop
complications but are never told how to recognize
or respond to them
• Consumes scarce resources.
• Currently it is recommended to conduct goal
oriented interventions that have evidence of being
effective.
10

11. 11
Limitations of risk approach
More than 10 years of experience has shown:
 “Risk factors” cannot predict complications
 Risk factors” do not appear to be good indicators of
complications.
 The majority of women who experience
complication were considered “low risk;” while the
vast majority of women considered to be “high risk”
give birth without complications.

12. 12
2. Goal-directed/focused approach
• Because of the above limitations many literatures strongly
suggested that:
• All pregnancies should be regarded as “at risk” of developing
a complication and be managed with the greatest care
• The focus of obstetric care should be shifted from predicting
complications through identification of “risk factors” to
‘detecting signs and symptoms of actual problems and
Educating women, men and family members about danger
signals and complication readiness’

13. 14
Basic components of the new Approach
• First Visit- first trimester (12 weeks)
• Second visit- close to 26 weeks
• Third visit-around 32 weeks
• Fourth visit- between 36 and 38 weeks
• Post-partum visit-within one week of delivery
• Late enrolment and missed visits- after a
missed appointment
• Special recommendations-twines, Spacing
between visits

14. Evidence-based ANC interventions known
to be effective
Delivery of ANC care
• 4-5 ANC visits w /proven effective
interventions (ie, goal oriented visits).
– Similar maternal results as for higher numbers of
ANC visits
• Midwife or general practitioner offers same
effectiveness of care as ob/gyn shared care
(similar clinical effectiveness in ANC)
15

15. Evidence-based ANC interventions known
to be effective … #2
• Prevention, detection, investigation of anemia
and treatment of iron-deficiency anemia
reduces maternal anemia.
• Detection, investigation and treatment of
hypertensive disease in pregnancy/
pre-eclampsia, controls disease (reduces case
fatality among women and newborns)
16

16. Evidence-based ANC interventions known
to be effective …#3
• Treatment of Eclampsia reduces
–case fatality among women and newborns,
–recurrent convulsions (MgSO4)
• Prevention of obstructed labor
–Reduces C-section and death
17

17. Evidence-based ANC interventions known
to be effective … #4
• Breastfeeding counseling
–Increases rates of exclusive breastfeeding
• Follate supplementation
–Reduces risk for neural tube defects
18

18. Evidence-based ANC interventions known to be
effective … #5
• Immunization against tetanus and promotion of
clean delivery
– Prevents maternal and newborn tetanus
• Screening for infection: syphillis, gonorrhea
– Reduces fetal loss, LBW, maternal/infant
morbidity
• Screening for infection: bacteriuria
– Prevents pyelonephritis, preterm delivery,
LBW
19

19. ANC use
• Most start ANC follow up during the second trimester (24.4%)
• On average, the proportion that received at least one ANC
increases by 3.4% per annum.
2016 EDHS
• Antenatal care: The proportion of women age 15-49 in
Ethiopia who received antenatal care (ANC) from a skilled
provider has increased from 27% in 2000 to 34% in 2011, and
62% in 2016.
– Thirty-two percent of women had at least four ANC visits
during their last pregnancy.
• Components of antenatal care: Pregnant women are more
likely to have their blood pressure measured (75%) and blood
sample taken (73%), than to have their urine sample taken or
to have received nutritional counselling (66% for both). 20

20. ANC use
• the receipt of four or more ANC by women increased
by rate of 2.6% per annum for the entire country.
 rural area at 5.4% per annum
 Urban at 1.3% per annum
In 2019 mini-DHS
• Percentage receiving ANC from a skilled provider was
73.6%
• Percentage with 4+ ANC visits was 43%
• Percentage delivered by a skilled provider was 49.8%
• Percentage of women with a postnatal check during
the first 2 days after birth was 33.8%
21

21. 12/10/2022 22

22. 2. DELIVERY CARE
• Aims
– Clean and safe (atraumatic) delivery
– Recognition, early detection and management of
complications at health centre or hospital (for
example, haemorrhage, eclampsia,
prolonged/obstructed labour)
• Strategy
– All women and birth attendants should be aware of
the requirements for a clean delivery: clean hands,
clean delivery surface, clean cord cutting and care
23

23. 2. DELIVERY CARE … #2
– All health care providers should be trained in and
practice clean and safe delivery techniques and
avoid unnecessary vaginal examinations and
episiotomies.
– All women and their birth attendants should be
aware of the need to refer cases of prolonged or
obstructed labour to a higher level of care.
– All institutional deliveries should be monitored
using an appropriately adapted version of a
partograph in order to prevent prolonged labour.
24

24. THE FIVE CLEANS IN DELIVERY CARE
• Clean hands
• Clean delivery surface
• Clean perineum
• Clean cord cutting
• Clean environment
25

25. SKILLED ATTENDANT AT BIRTH
• Most maternal deaths are due to a failure to
get skilled help in time for delivery
complications.
• Skilled attendant refers exclusively to people with
midwifery skills (for example midwives, doctors
and nurses) who have been trained to proficiency
in the skills necessary to manage normal deliveries
and diagnose, manage or refer obstetric
complications.
26

26. Minimum set of skills for the skilled
attendant
• Take a detailed history, ask relevant questions,
demonstrate cultural sensitivity, and use good
interpersonal skills.
• Perform a general examination, identify
deviations from normal, and screen for
conditions that are prevalent or endemic in
the area.
• Take vital signs (temperature, pulse,
respiration, blood pressure)
27

27. Minimum set of skills for the skilled
attendant … #2
• Auscultate the foetal heart rate.
• Calculate the estimated date of delivery.
• Provide appropriate intervention (including referral)
for intrauterine foetal death, malpresentations and
abnormal lies at term, multiple pregnancy, poor
nutrition and anaemia, pre-eclampsia, rupture of
membranes prior to term, severe vaginal bleeding
28

28. Minimum set of skills for the skilled
attendant … #3
• Perform an abdominal examination identifying
abnormalities and factors that place the
woman at risk
• Assess the effectiveness of uterine
contractions
• Perform a vaginal examination
• Use the partograph
29

29. SKILLED ATTENDANT AT BIRTH
• Majority (2/3) of maternal deaths occur + 48 hours
after delivery
• Most complications are neither preventable
nor predictable, but most complications are
treatable
• Complications amenable for intervention:
– Eclampsia
– Obstructed Labor
– Puerperal Sepsis
– Obstetric Hemorrhage (assumes the attendant is
available from onset of labor to 48 hours postpartum)
30

30. When does most mothers die?
12/10/2022 31

31. Trends in Ethiopia
• Increasing trend in the professionally assisted
delivery although the actual level is extremely low.
• The proportion of women who were assisted by
health workers were estimated to increase by 5.6%
per annum in the total sample.
6.6% per annum in rural and 3.6% per annum
for the urban.
• The proportion of women who will be assisted by
skilled workers will be 20.9% by 2015.
 6% in the rural and 54.5% in the urban
32

32. Delivery according to 2016 EDHS
• Delivery: Institutional deliveries have increased from 5% in
2000 to 10% in 2011, and 26% in 2016.
• During the same period, home deliveries decreased from 95%
in 2000 to 90% in 2011, and 73% in 2016.
12/10/2022
Introduction to RH for 33

33. TRADITIONAL BIRTH ATTENDANTS (TBAs)
• A birth attendant (TBA) who initially acquired her
ability by delivering babies herself or through
apprenticeship to other TBAs.
• A TBA may have undergone subsequent extensive
training and is integrated in the formal health care
system – Such a TBA is often known as a Trained
Traditional Birth Attendant (TTBA).
• TBAs attend most of deliveries (28%) in Ethiopia
and other less developed countries.
• Globally there is debate on the effectiveness of TBA
training and their roles in preventing maternal and
infant morbidity and mortality
34

34. TBAs and Maternal Mortality
• Is there evidence that TBAs have been
proven to reduce maternal mortality?
NO
35

35. Factors for Delivery
• women with secondary and higher education,
and women from the wealthiest households
were most likely to utilize delivery care
services.
• birth order of children – more use for first
birth
• Exposure to mass media
• Wealth, husband education
36

36. Skilled Care at Delivery and Maternal
Deaths (Regional Comparisons, 1995-2000)
66
39
35
67
84
92
190
220
560
940
110
64
Percent of births assisted by skilled attendants, 1995-2000
Number of maternal deaths per 100,000 live births, 2000
Sub-Saharan Africa
South Asia
Middle East and
North Africa
Latin America/
Caribbean
East Asia
and Pacific
Central, Eastern
Europe/ Baltics/ CIS*
37

37. Intrapartum Care Strategies
• Health facility-based with skilled attendant
• Home-based with skilled attendant
• Home-based with community health worker
38

38. Health Centre Intrapartum Care (HCIC)
• Health centre with basic emergency obstetric
care
• Team of health personnel with midwives as
the main providers
• Targets all intrapartum women
• Emphasis is on non-intervention and
watchfulness
39

39. HCIC …
• HCIC strategy includes:
– Purely preventive best practices
– Avoidance of iatrogenic procedures
– Early detection and firstline management of
complications including life-threatening ones
• HCIC strategy has the potential to prevent
obstetric deaths (MMR to below 200)
40

40. HCIC …
• Issues in HCIC strategy
– Health centre vis-à-vis hospital
– Preference for place of delivery
– Availability and type of skilled personnel
– Time a mother spends in a health centre
– Availability of service 24 hours a day
– Linkage with CEmOC facility
• What are your opinions?
41

41. Other Intrapartum Care Strategies
• Skilled Attendant at Home
– Normal delivery, preventive functions and some
emergency first aid can be delivered
– Meets women’s demands for home delivery
– Increases coverage for remote areas
– Successfully adopted in Malaysia and Netherlands
to reduce MMR
42

42. Skilled Attendant at Home
• However, there are challenges that limit the
effectiveness of home-based strategy
– Home conditions can be extremely basic
– Inefficiency in coping with emergencies
– Supervision needs are onerous (difficult)
– Links and transport to CEmOC facilities
• What are your opinions?
43

43. 3. POSTPARTUM CARE
• The main life threatening complications of the
postnatal period include haemorrhage, anaemia,
genital trauma, hypertension, sepsis, urinary tract
infections and mastitis.
• All women should receive a postpartum visit within
the first week of delivery in order to ensure early
detection and management of hypertension,
haemorrhage and sepsis.
– However, all women should be assessed within 24 hours
after delivery.
44

44. 3. Postpartum care….#2
• Management of complications at health
centre or hospital (haemorrhage, sepsis and
eclampsia)
• Promotion and support to breastfeeding and
management of breast complications)
• Information and services for family planning
• STD/HIV prevention and management
• Tetanus toxoid immunisation
45

45. 3. POSTPARTUM CARE … #3
NEWBORN CARE
• Resuscitation
• Prevention and management of hypothermia
• Early and exclusive breastfeeding
• Prevention and management of infections including
ophthalmia neonatorum and cord infections
• Recording of birth weight and referral of newborn
for immunisations and growth monitoring
46

46. PPC Distribution
47

47. What factors affect PPC uptake?
• Residence
• Maternal education
• Partner education
• ANC uptake
48

48. 4. Abortion & post abortion care
MORTALITY DUE TO UNSAFE ABORTION
• Worldwide, 20 million unsafe abortions occur each
year
• 47,000 women die each year as a result of
complications following abortion.
• 1 in 8 pregnancy related deaths are due to unsafe
abortion.
• MORTALITY IS THE TIP OF THE ICE BERG
49

49. COMPREHENSIVE POSTABORTION CARE
• Emergency treatment of incomplete abortion
and potentially life threatening complications
• Postabortion family planning counselling and
services
• Links between postabortion emergency
services and the reproductive health care
system.
50

50. EMERGENCY TREATMENT FOR POSTABORTION
COMPLICATIONS
• Initial assessment to confirm the presence of
abortion complications.
• Medical evaluation(brief history, limited physical and
pelvic examinations)
• Prompt referral and transfer if the woman requires
treatment beyond the capability of the facility where
she is seen.
• Stabilization of emergency conditions and treatment
of any complications
• Uterine evacuation to remove retained products of
conception
51

51. POSTABORTION FAMILY PLANNING
• Informing, Educating and counseling about family
planning (“ Favorable time”)
• Opportunity for approaching groups that normally
routinely do not use services .
• Initiating family planning immediately (Ovulation
returns rapidly)
52

52. 5. Essential Obstetric Care: Definition
• The elements of obstetric care for the mother and
newborn needed for the management of normal and
complicated pregnancy, delivery and the postpartum
period.
• 75% of maternal deaths can be prevented by skilled
health care providers backed up by emergency
obstetric care (EmOC).
53

53. OBSTETRIC CARE: CATEGORIES
• Essential Obstetric Care (EOC)
– Basic EOC (BEOC)
– Comprehensive Essential Obstetric Care (CEOC)
• Emergency Obstetric Care (EmOC)
• Obstetric First Aid (OFA)
Guidelines jointly issued in 1997 by WHO,
UNICEF, and UNFPA, recommended that
for every 500,000 people there should be four
facilities offering basic and one facility offering
comprehensive essential obstetric care
54

54. Basic Essential Obstetric Care (BEOC)
• BEOC encompasses the management of normal and
complicated pregnancy, childbirth and the postpartum period
for mothers and newborns.
• Services at the health centre level include at least the
following:
– Administration of parenteral antibiotics
– Administration of parenteral oxytocic drugs
– Administration of parenteral anticonvulsants
– Intravenous therapy including fluid replacement
– Assisted delivery (vacuum extraction)
– Removal of placenta and retained products of conception
– MVA
55

55. Comprehensive Essential Obstetric
Care (CEOC)
• CEOC includes BEOC plus the following additional
services:
– Anaesthesia
– Blood transfusion
– Surgical obstetrics including
• Caesarean delivery
• Repair of high vaginal or cervical tears
• Laparotomy (surgical treatment of sepsis,
hysterectomy, removal of ectopic pregnancy)
56

56. EMERGENCY OBSTETRIC CARE SERVICES
Basic EmOC services Comprehensive
EmOC Services
Administer parenteral oxytocic drugs All Basic EmOC
services, plus
Administer parenteral Antibiotics Perform blood
transfusions
Administer parenteral anticonvulsants
for pre-eclampsia and eclampsia
Perform surgery
(Caesarean
sections)
Perform manual removal of placenta
Perform removal of retained products
Perform assisted vaginal delivery
57

57. Obstetric First Aid (OFA)
• Obstetric first aid is that part of EmOC that is
performed at the more peripheral levels of the
health system
– Early recognition of obstetric emergencies
– Administration of parenteral antibiotics
– Administration of parenteral oxytocic drugs
– Administration of parenteral anticonvulsants
– Referral and transport arrangements
58

58. Comparison of Comp EOC, BEOC and EmOC
Type of care ComEOC BEOC Em OC
Surgical obstetrics X X
Anesthesia X X
Blood replacement X X
Mxt of problems of pregnancy X X
Medical treatment X X X
Manual procedures X X X
Monitoring of labor X X
Neonatal special care X X
59

59. 60

60. Family Planning (FP)
– 41 % of pregnancies are globally unwanted
– 22 % end up in induced abortion
– FP alone can avert a third of maternal deaths
– FP can prevent 90 % of unsafe abortion deaths and 20 %
of other obstetric deaths
– Access to emergency contraception can reduce
unintended pregnancies by half
61

61. Elements of Successful FP Program
• Well-trained, supervised and motivated staff
• Strong leadership and good management
• Communication and outreach strategies
• Supportive government policies
• Free or inexpensive services for the poor
62

62. Remember
• Maternal mortality will decline only in the
context of broader efforts like
– Educating women and girls
– Improving their legal rights
– Improving their economic status
• Broader health strategies also important
– Nutrition: macro and micronutrients
– Prevention and treatment of infectious and
chronic diseases
63

63. Experiences of Countries that Reduced
Maternal Mortality
• Reduction of maternal mortality in developing
countries is feasible
– with modest public health expenditure
– when appropriate policies are adopted, focused
wisely, and adapted incrementally
64

64. National Policy Framework and Strategies
on Maternal Health
65

65. I. Health Policy
• Components of the Policy include
– Democratization and decentralization
– Preventive and curative health care
– Equitable and acceptable standards of health
service to all segments of the population
– Intersectoral collaboration
– Accessibility of health care for all
66

66. I. Health Policy …
• Priorities of the Policy include:
– IEC for health awareness and self-reliance
– Special attention to the health needs of women
and children
– Special attention to rural populations and urban
poor
– Emphasis to control of communicable diseases
and diseases related to malnutrition
67

67. I. Health Policy …
• Strategies include:
– Assuring maternal health care
– Intensifying family planning
– Appropriate maternal nutrition
– Encouraging paternal involvement
– Identifying and discouraging HTPs
– Developing the referral system
– Deploying qualified and motivated personnel
68

68. II. Plan for Accelerated and Sustainable
Development and Eradication of Poverty
(PASDEP)
• National development plan for 2005/6-
2009/10
• Main objective was poverty reduction
• Focused on efforts to achieve the MDGs
• Health sector development plan part of
PASDEP
69

69. III. Health Sector Strategic Plan (HSDP)
• 5 year rolling plan for the health sector,
Designed to achieve goals of MDG and
PASDEP
• Maternal health is one of the focus areas
• Plans to extend services to rural areas and
villages and households
70

70. Implementation Modalities
1. Health extension services program
– Health education and communication
– Family health services
• FP services
• ANC
• Clean and safe delivery
• PNC
• Recognition of danger signs and referral
71

71. Implementation modalities …
2. Accelerated expansion of PHC coverage
– Aims to achieve universal coverage of PHC
– 1 health facility within 10 km for all by 2010
• Constructing, equipping and staffing health facilities
– BEmOC at the health centers
– CEmOC at the district hospital
72

72. Implementation modalities …
3. Health sector financing strategy
– Aims at increasing resource flow to the health
sector and improving efficiency
– Aims to increase overall per capita health
expenditure from 5.6 USD to 9.6 USD
– Encourages establishment of community health
care insurance scheme
73

73. Implementation modalities …
4. Health sector human resource development
plan
– Aims to overcome shortage, maldistribution and
reduced productivity
– Targets to increase ratio of midwives to reproductive
age women from 1:13,388 to 1:6,759
5. Strengthen health MIS and M & E
– Complete and timely submission of reports
– Evidence-based planning
– M & E
74

74. IV. National Reproductive Health
Strategy
• Six priority areas including:
– Maternal and neonatal health
– Fertility and family planning
• Goals include:
– Reducing maternal and newborn mortality
– Reducing unwanted pregnancies
75

75. Reproductive Health Strategy …
• Strategies to reduce maternal mortality
– Empower communities to recognize to risks and
respond appropriately
– Ensure access to core package of maternal services
– Create supportive environment
• Strategies to reduce unwanted pregnancies
– Create acceptance and demand for FP
– Increase access and utilization of FP
– Delegate provision of all FP methods at the lowest
possible level
76

76. Reproductive Health Strategy …
Key Actions
• Community level
– Support community initiatives to promote RH
– Innovative informational campaigns to raise
awareness
– Enlist religious and other leaders
77

77. Reproductive Health Strategy …
• Systems level
– Integration of maternal health services between
community and facility
– Increase human resources capacity
• HEW
• Midwifery training
• Masters program in EmOC
– Norms and standards of service provision
• Policy level
– Coordination at the health sector level
78

78. • Required reading
1. Ethiopian RH strategy
2. HSTP (2015/16-2019/20)
12/10/2022 79

79. Thank you
80