Maternal health services were described including antenatal care (ANC), delivery services, and individual services. Key points included: 1. The new WHO ANC model recommends 8 contacts with a focus on the third trimester to detect complications early, including health promotion, disease prevention, and birth preparedness. 2. Institutional deliveries in Ethiopia have increased from 5% in 2000 to 26% in 2016 according to the EDHS, however home deliveries remain common in rural areas. 3. Delivery care aims to provide support through labor and monitor progress using a partograph while employing infection prevention practices. Skilled attendance at delivery is promoted to reduce mortality.

1. Maternal health services
Tesfaye Birhane ( PH, MPH-RH, Assistant Prof.)
Dessie, Ethiopia
Date: Dec./2022
1

2. Objectives
At the end of the session the students will
be able to:
 To describe reproductive health services
2

3. Targets for impact indicators, RH strategy (2016-
2020)
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Source: Ethiopia RH strategic plan, 2021-2025

4. The additional investment needed annually for SRH care
totals $31 billion in LMICs and varies widely across sub
regions
4
Guttmacher institute

5. Countdown to 2030 governance structure and evaluation framework
5
. Countdown to 2030 governance structure and evaluation framework

6. Reasons for low utilization rates for maternal health
services
 No physical access
 High costs
 Poor information
 Cultural preferences
 Lack of decision-making power by women
 Poor quality of care
 Delays in referring women from community health
facilities to hospitals
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7. Three-pronged approach to reproductive
health
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8. The six pillars of reproductive health
Six pillars of reproductive health, as a public health
issue.
– Positive approach: services free from stigma and
embarrassment.
– Knowledge and resilience
– Free from violence and coercion
– Proportionate universalism
– User-centered
– Wider determinants
8

9.  These pillars offer a longer-term vision and a new
framework for assessing unmet need, mapping
provision and identifying appropriate outcome
measures and/or information gaps
9

10. Maternal health services
 Several factors are contributing to the progress in
reducing maternal mortality:
 Advances towards UHC and improvements in
addressing inequities in access to and the quality of
sexual, reproductive, maternal and newborn health
care.
 Many health systems have adapted to respond
better to the needs and priorities of women and
girls and interventions aimed at reducing social and
structural inequities have increased.
10

11. Maternal health services
 UHC is aspiration that everyone receives good
quality health services, when and where needed,
without incurring financial hardship.
 That ambition constitutes a set of targets in the
United Nations Agenda 2030 for Sustainable
Development (SDG 3.8).
 In addition to supporting good health and well-
being, UHC also contributes to social inclusion,
gender equality, poverty eradication, economic
growth and human dignity
11

12. Universal Health Coverage Service Coverage
Index, 2017
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Source: The Sustainable Development Goals Report 2021

13. Outcomes of maternal health services
 Increased maternal and family satisfaction with ANC
services provided
 Universal screening services in all health facilities
 Pregnancy-related nutritional problems are prevented
and/or corrected
 Common pregnancy-related conditions are prevented
or detected early and treated
 Pregnant women are counseled to have safe and
successful pregnancy outcomes
 Pregnant women are counseled on postpartum family
planning
13

14. Density of health professional per 10 000 population, by WHO
region, latest year available
Source: WHO National Health Workforce Accounts Database,
2022
14

15. Outcomes of maternal health
services
 define quality as “the degree to which maternal
health services for individuals and populations
increase the likelihood of timely and appropriate
treatment for the purpose of achieving desired
outcomes that are both consistent with current
professional knowledge and uphold basic
reproductive rights.”
 Quality maternal and newborn care defined using
the Institute of Medicine (IOM) definition, i.e., care
that is safe, effective, patient-centered, timely,
efficient and equitable.
15

16. Outcomes of maternal health
services
 The IOM definition of quality care is
comprehensive and encompasses three key
components of quality: clinical (safe and
effective), interpersonal (patient-centered) and
contextual (timely, efficient and equitable).
 IOM defines patient-centered care as “care that is
respectful of and responsive to individual patient
preferences, needs, and values, and ensures that
patient values guide all clinical decisions.”
16

17. different levels of health system, delivery of quality
care and result in positive health outcomes
Source: Austin et al. Reproductive Health 2014, 11(Suppl 2):S1
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18. Measures of quality
 There are three key components to the
Donabedian logic model:
1. Structure: Refers to context in which healthcare
is provided;
2. Processes: Refers to whether or not good
medical practices are followed or not
3. Outcomes: In this framework outcomes can be
divided into two domains: including positive user-
experience, resulting in increased demand, and
the timely utilization of healthcare services
18

19. Measures of quality
 The structural component of the framework includes
inputs at three levels of the health system: community,
district, and facility.
 At the community-level, the impact of outreach
services, home visitation, financing platforms,
community mobilization/support groups and task
shifting to lay health workers were explored.
 Critical elements of the district-level were also
19

20. Measures of quality
 dimensions of governance, accountability, health work
force, infrastructure, community involvement and
participation).
 At the facility-level, there are dimensions of leadership,
health workforce, supplies, and technical capabilities.
 The delivery of care also addresses aspects of the work
environment: provider satisfaction, provider capabilities,
good environmental hygiene, evidence-based practices
20

21. Measures of quality
 ANC attendees are maintained in the
continuum of care with increase in ANC,
skilled birth attendance and postpartum care
coverage with reduced dropout
21

22. Intervention areas for maternal survival
 Interventions on reduction of maternal mortality focused on
the three areas:
 Reduction of the likelihood that a woman will become
pregnant;
 Reduction of the likelihood that a pregnant woman will
experience a serious complication of pregnancy or
childbirth; or
 Reduction of the likelihood of death among women who
experience complications.
22

23. Essential and Recommended to Prevent Maternal
Mortality
 Family planning
 Birth preparedness and complication readiness
 Identification and treatment of illness (preeclampsia,
previous cesarean)
 Immunization and prophylaxis (tetanus, malaria, HPV)
 Routine practices (clean delivery, active management of third
stage)
 Emergency obstetric care (management of shock, magnesium
sulfate)
23

24. 24

25. Principles of Preconception Care as a Basis for
ANC
 In the continuum of care, preconception/pre-
pregnancy care is the most ignored, but equally
important service for improving the outcome of
pregnancy.
 Comprehensive care in the continuum involves risk
assessment, prevention, treatment, and
psychosocial support that begins pre-pregnancy
and extends to the antepartum and postpartum
periods.
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26. Preconception care
 The purpose of preconception care is to clinically
evaluate, provide basic laboratory and imaging
investigations, and treat/correct identified disorders
for couple who are planning pregnancy.
 The preconception assessment may lead to
delaying the pregnancy or completely avoiding
pregnancy if the pregnancy is likely to endanger the
life of the woman.
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27. Summary of pre-pregnancy assessment,
counseling, and preparation
 Assessment
 Interventions
 Socioeconomic status
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28. Summary of pre-pregnancy assessment, counseling, and
preparation
 Potentially recurring obstetric complications
experienced during previous pregnancies
 Obstetric and gynecologic surgery: operative
delivery, cerclage, myomectomy
 Immunologic disorders: autoimmune diseases
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29.  Counseling nutrition
 Providing pre-pregnancy vaccination
 Counseling on lifestyle modification
 Adjusting medications
 Assessing vulnerability to domestic violence,
social discrimination and stigma, and ensuring
linkages to locally available services
29

30. 30
Individual services

31. ANC
 Key Principles of Antenatal Care
1. Implementing the new ANC model of eight
contacts schedule
2. ANC care should be woman-centered
3. De-medicalized ANC
4. ANC should be providing efficient and timely care
to all pregnant women.
5. ANC should be evidence-based:
6. ANC should be multidisciplinary:
31

32. ANC…
7. ANC should be holistic and concerned with
intellectual, emotional, social, and cultural needs
of women, their babies, and families and not
only with their biological care.
8. ANC should respect the privacy, dignity, and
confidentiality of women.
9. ANC providers should be motivated,
competent, and compassionate.
10. Women with special needs require care in
addition to the core components of basic care.
32

33. Antenatal Care
 Traditional ANC were used a “risk approach” to
classify women.
 Focused ANC- is a means that provides focus on
assessment and actions needed to make decisions, and
provide care for each woman’s individual situation.
 New ANC contact schedule
33

34. Purpose of antenatal care
To provide health education on key issues
To provide evidence based interventions and care which can
prevent and treat complications of pregnancy
To encourage skilled attendance at delivery
To discuss plans for emergency transport and funds in the case
of an emergency and to identify the nearest site of Emergency
Obstetric Care
To provide a link between women and the health care system
34

35. Goals of Focused ANC
 The new approach to ANC emphasizes the quality of care rather than the
quantity.
 For normal pregnancies WHO recommends only four antenatal visits.
 The major goal of focused antenatal care is to help women maintain normal
pregnancies through:
Identification of pre-existing health conditions
Early detection of complications arising during the pregnancy
Health promotion and disease prevention
Birth preparedness and complication readiness planning.
35

36. Identification of Pre-existing Health Conditions
 As part of the initial assessment, the provider talks with
the woman and examines her for signs of chronic
conditions and infectious diseases.
 Pre-existing health conditions may affect the outcome of
pregnancy, require immediate treatment, and usually
require a more intensive level of monitoring and follow-
up care over the course of pregnancy.
36

37. Health Promotion and Disease Prevention
 Counseling about important issues affecting a woman health
and the health of the newborn is a critical component of
focused ANC. Discussions should include:
 How to recognize danger signs, what to do, and where to get
help
 Good nutrition and the importance of rest
 Hygiene and infection prevention practices
 Risks of using tobacco, alcohol, local drugs, and traditional
remedies
 Breastfeeding
 Postpartum family planning and birth spacing.
37

38. Health Promotion and Disease Prevention
 All pregnant women should receive the following
preventive interventions:
 Immunization against tetanus
 Iron and foliate supplementation.
 In areas of high prevalence women should also receive:
 Presumptive treatment of hookworm
 PMTCT services
 Protection against malaria through intermittent preventive
treatment and insecticide-treated bed nets
 Protection against vitamin A and iodine deficiencies.
38

39. Early Detection of Complications
 The provider talks with and examines the woman to
detect problems of pregnancy that might need
treatment and closer monitoring.
 some conditions may be or become life-threatening
if left untreated.
39

40. Birth Preparedness and Complication Readiness
 Approximately 15 % of women develop a life-threatening
complication, so every woman and her family should have a
plan for the following:
 A skilled attendant at birth
 The place of birth and how to get there including how to
obtain emergency transportation if needed
 Items needed for the birth
 Collect money
 Support during and after the birth
40

41. ANC…
 Antenatal contact ≠ antenatal visit
 Contact indicates an active connection
between a pregnant woman and a health care
provider
 As per the 2016 WHO recommendation,
Ethiopia is replacing the previous four-visit
FANC model with the new ANC eight-contact
model
41

42. New WHO ANC contact schedule
42

43. Recommended maternal weight gain during
pregnancy and dietary diversification
Note: Major calorie sources are carbohydrate and fat foods. Steady increase of 1.5–
2 kgs weight per month is expected from 4 month of pregnancy. Cumulative
average increase of 10–12 kgs weight is expected from pregnancy till birth of a
43

44. ANC…
 The reason for increasing the number of contacts in
the third trimester is considering the increased risk of
complications to the mother and the fetus during this
period of gestation.
 This schedule enables the ANC provider to early detect
and treat potential maternal and fetal complications
before advancing to a severe or irreversible stage.
 It also gives room for the pregnant woman to share her
symptoms and worries with her care provider before
worsening.
44

45. ANC EDHS 2016
45
 62% of women who had a live birth in the 5 years before
the survey received ANC from a skilled provider at least
once for their last birth
 The proportion of women age 15-49 who received any
ANC from a skilled provider has increased from 27% in
2000, to 28% in 2005, 34% in 2011, and 62% in 2016

46. Timing and Number of ANC Visits
46
 WHO recommends 32% of women had at least four ANC
visits during their last pregnancy
 37% of women in Ethiopia had no ANC
 Rural women are more likely to have had
no ANC visits than urban women (41% and 10%,
respectively).
 Only 20% of women had their first ANC during the first
trimester,
 26% during their fourth to fifth month of pregnancy
 14% during their sixth to seventh month of pregnancy.

47. 47

48. 48

49. 49

50. DELIVERY SERVICES
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 Increasing institutional deliveries is important for reducing
maternal and neonatal mortality.
 However, access to health facilities in rural areas is more
difficult than in urban areas because of distance,
inaccessibility, and the lack of appropriate facilities.
 Although institutional delivery has been promoted in
Ethiopia, home delivery is still common, primarily in hard-
to-reach areas.

51. Trend
51
 Institutional deliveries have increased from
5% in 2000, 10% in 2011, and 26% in the 2016 EDHS.
 During the same period, a sharp decline in
home deliveries was observed, from 95% in 2000 to
73% in 2016.
 Institutional deliveries for women living in rural areas has
substantially increased in the last 16 years, from 2% in
2000 to 20% in the 2016 EDHS.
 Facility delivery among urban women has also increased
from 32% in 2000 to 79% in 2016.

52. 52

53. 53

54. 54

55. 55

56. 56

57. Delivery by Caesarean Section
57
 Access to caesarean sections can reduce maternal and neonatal
mortality and complications such as obstetric fistula.
 However, use of caesarean section without medical need can
put women at risk of short-term and long-term health
problems.
 The WHO advises that CS be done when medically necessary,
but does not recommend a specific rate for countries to achieve
at the population level.

58. CS…
58
 How many pregnant women should be delivered with
CS?

59. Delivery care
 It is the care given for women during delivery.
 Provide continuous emotional and physical support to woman
throughout labor.
 Use partograph to monitor fetal condition, maternal condition
and assess the progress of labour
 Use active management of third stage of labor.
 Use infection Prevention Practices as it accounts for 14.9% of all
maternal deaths.
59

60. THE FIVE CLEANS IN DELIVERY CARE
 Clean hands
 Clean delivery surface
 Clean perineum
 Clean cord cutting
 Clean environment
60

61. SKILLED ATTENDANCE
 The skilled attendance is defined as a process through
which a woman is provided with adequate care during
labor, delivery, and the postpartum period
 Percentage of births attended by a skilled attendant is
currently used to monitor MDG 5 progress
 Skilled attendance depends on;
 The presence of a skilled attendant
 The enabling environment
61

62. 62

63. Delivery care
 Two intervention strategies that have been proposed to deal with
delivery problem:
1. Essential Obstetric Care (EOC or EsOC), which, in some
definitions, includes a broad array of services including family
planning and antenatal, intrapartum, and postpartum care.
2. Emergency Obstetric Care (EOC or EmOC), which includes
more specific interventions such as blood transfusion,
intravenous antibiotics, cesarean section, the management of
abortion complications, and vacuum or forceps delivery.
63

64. Delivery care
 There is a fundamental difference between the two approaches:
 EsOC, in some definitions, focuses on all pregnant women and
is based on the idea that obstetric complications can be
predicted and prevented, employing the concept of "high risk."
 EmOC, on the other hand, focuses on the prompt identification,
referral, and treatment of women with obstetric complications
64

65. Provide emergency obstetric care (EmOC)
 Not only women at risk, but also women who are low risk may
develop complications.
 EmOC needs to be available as close as possible to where
women live to manage life threatening complications to the
mother or child.
 WHO estimates that world wide, between 10-15% of women
will need a caesarean section to safely deliver their infants.
65

66. International goals for EmOC
 Skilled attendance at every birth.
 At least 4 Basic EmOC sites (within 4 hours) and 1
Comprehensive site (within 12 hours) walk or for
every 500,000 population.
 At least 15% of births should take place in a health
facility.
 Case fatality in health facilities should be <1%
66

67. EOC
Basic EmOC Functions
 Performed in a health center
without the need for an
operating theater
 IV/IM antibiotics
 IV/IM oxytoxics
 IV/IM anticonvulsants
 Manual removal of placenta
 Assisted vaginal delivery
 Removal of retained products
 Neonatal resuscitation
Comprehensive EmOC Functions
 Requires an operating theater
 All seven Basic EmOC functions
PLUS:
 Cesarean operation
 Blood transfusion
67

68. Postnatal Care
 Post natal care is the care provided to the woman and her baby during the six
weeks period following delivery in order to promote healthy behavior and early
identification and management of complications.
 It should include assessment, health promotion and care provision.
 Care during the immediate postpartum period (6-24 hours) needs to be viewed as
part of care during delivery.
 If no skilled attendant is present at delivery, one should see the woman as early as
possible.
 WHO recommends a postpartum visit within 1-3 days, if possible through home
visits by community health workers.
68

69. post-natal care (PNC)
 The optimum number and timing of PNC visits
 First contact: within one hour if the mother is delivered
in a facility and first 24 hours if birth occurs at home.
 Follow up contacts are recommended at least at 2-3
days, 6-7 days, and at 6 weeks
 Extra contacts for babies needing extra care (LBW or
those whose mothers have HIV)
69

70. POSTNATAL CARE
70
 A large proportion of maternal and neonatal deaths
occurs during the first 24 hours after delivery.
 17% had a postnatal check during the first 2 days after
birth.
 Four in five women (81%) did not receive a postnatal
check

71. Patterns by background
characteristics
71
 Women who delivered in a health facility were much
more likely to receive a postnatal health check within
2 days of delivery than those who delivered elsewhere
(42% versus 2%).
 45% of urban women received a postnatal check-up
within 2 days compared to 13% of rural women.

72. 72

73.  The disparities in unintended pregnancy and
abortion among low, middle- and high-income
countries indicate a need for greater action to
achieve global equity in SRH.
 Continued investment is needed to ensure access
to the full spectrum of high-quality SRH care.
73

74. Essential routine PNC for all mothers
 Assess and check for bleeding and temperature
 Support breastfeeding and check for mastitis.
 Manage anaemia, promote nutrition and insecticide treated bed
nets, and give vitamin A supplementation
 Provide counseling and a range of options for family planning.
 Refer for complications such as bleeding, infections, or
postnatal depression.
 Counsel on danger signs and home care
74

75. Essential routine PNC for all newborns
 Assess for danger signs, measure and record weight, and
check temperature and feeding.
 Promote hygiene and good skin, eye, and cord care.
 Ensure warmth for the baby.
 Refer for routine immunizations
 Refer for complications
 Counsel on danger signs and home care
75

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