reproductive health services in Egypt.pptx

The growing evidence base for
reproductive health services & changes
in technologies and costs .
By :
Ahmed Mohamed Samy Albohy
Assistant lecturer of obs. & gynecological department
Al-Hussien Hospital

Items :
Introduction :
Reproductive
health care :
Health care services
and technology
revolution :
1. Definition .
2. Adolescent care.
3. Premarital care.
4. Pre conceptional care.
5. Antenatal,natal,postnatal
care.
6. Indicators of maternal
health .????
1. Definition of health.
2. Spectrum of health .
3. Pattern of health .
4. Determinant of health.
5. Sources of population data
.
6. Family planning.
1. Health system elements .
2. Services .
3. PHC .
4. PHC services elements .
5. PHC principels .
6. Revolution of technology.

sources of population data :
1. vital registration statistics :
registration of births & deaths & marriages & divorces & migrations .
2. census :
 conducted by national government .
 to enumerate every person in a country .
 census is conducted every 10 years .
 Including : age & sex& marital status &
education & occupation & geographical location .
 2015 : population about 90.000.000.
5.

Population pyramid of Egypt :
_ Base is wide due to high birth rate .

SO you now know what is the important of
Family planning:
Family planning definition according to WHO is :
(( the ability of individuals and coupled to anticipate and attain their desired
number of children and the spacing and timing of their birth . It is achieved
through use of contraceptive methods and treatment of involuntary infertility )).
 According to 2017 estimates, 214 million women of reproductive age in
developing regions have an unmet need for contraception. Reasons for this
include:
• limited access to contraception . ???
• a limited choice of methods . ???
• a fear or experience of side-effects . ???
• cultural or religious opposition . ???
• poor quality of available services . ???
• gender-based barriers. ???
6.

 _ women constitute a large group of population and are considered a special risk group because of
childbearing .
_ so A healthy mother delivers a healthy baby leading to healthy community .
_ maternal health is mainly concerned with the healthy of women during pregnancy, childbirth and
post partum period to ensure appositive experiences and reduce maternal morbidity and mortality
so maternal health become a global concern as the lives of million of women in reproductive age
can be saved through maternal health care services .
_ Despite the efforts of to ensure maternal health care services, maternal morbidity and mortality
still high in developing countries. in the last two decades, about 287 000 women died during and
following pregnancy and childbirth in 2020. This number is unacceptably high.
( source WHO ) .
Reproductive health
Maternal health
Reproductive and sexual health
Safe motherhood = reproductive care and family planning services

 Learning objectives :
_Define maternal death (MM)& perinatal mortality.
_ Global causes of maternal death (MM).
_ Reproductive health care services in details.
_ 3 delay models and how to prevent .
_role of technology & costs.

Definition of maternal death ((from 10th revision of international statistical classification
of disease and health related program ( ICD_10) .))
Maternal Death (also referred to as maternal mortality )
 A maternal death is defined as the death of a woman while pregnant or within
42 days of termination of pregnancy, irrespective of the duration and site of the
pregnancy, from any cause related to or aggravated by the pregnancy or its
management but not from accidental or incidental cause.

 Pregnancy- related death :
death of a woman while pregnant or within 42 days of termination of pregnancy
irrespective of the cause of death .
 Late maternal death :
the death of woman from direct or indirect obstetric causes more than 42 days but less
than 1 year after termination of pregnancy .
Classification of maternal death causes: Causes of maternal death are divided into 2
groups:
- Direct maternal death: Deaths caused by obstetric complications (pregnancy
&labor& puerperium ) or interventions, misdiagnosis, improper management and
their consequences.
Examples : HGE & PE & Eclampsia & Infection & Obstructed labor .
- Indirect maternal death: Death caused by pre-existing underlying disease or by
pregnancy-induced aggravation of this condition
Examples : Hepatitis & anemia &CVS diseases & TB .

Global causes of maternal death:

MMR global trends:
 MMR in 1990 : 850 maternal death / 100.000 live births.
 MMR in 2000 : 400 maternal deaths / 100.000 live births.
 94% of maternal deaths occurs in developing countries .
 Young adolescents ( age 10- 14 y) face a higher risk of complications and death
as a result of pregnancy than another woman .
Source : united nations millennium development goals .

Reproductive health :
 Defined as : a state of complete physical , mental , social and
spiritual well being in all matters related to reproductive system
and do its function .
 Reproductive health services :
* adolescent care .
* premarital cere .
* preconception care.
* antenatal care .
* natal care (obstetric care ).
* postnatal and post abortive care.

Adolescent health care: (10 to 18 y )
_ follow up of general health status ((HB & HIGHT & WEGHT ))
_ health education ((reproductive and sexual education ))
_ detection and management of abnormalities as congenital anomalies as turner $ &
primary amenorrhea & delayed puberty and DSD .
 Premarital care: (PMSGC) :
_ it is a promotive and preventive care to prepare the couples having normal offspring .
_detection of hereditary diseases or potential risk to pregnancy
_educate partners for a healthy family life.
By:
* history taking of a family history of any disease (DM, HTN,…)
* personal history
* investigations by :
_ cbc & urine analysis & ABO group , RH Factor , blood sugar,
_ tests for hepatitis and AIDS
* immunization against : measles , hepatitis , tetanus toxoid .
* ttt of any medical disorders as anemia

Premarital care: ( PMSGC) :
 Premarital screening is defined as testing couples who are planning to get married soon for
common genetic blood disorders (mainly hemoglobinopathies, e.g. thalassemia and sickle
cell anemia) and infectious diseases (e.g. hepatitis B, hepatitis C, and HIV/AIDS).
 The premarital screening aims to give medical consultation on the odds of transmitting the
abovementioned diseases to the other partner/spouse or children and to provide
partners/spouses with options that help them plan for healthy family.
 The premarital screening reduces the spread of the abovementioned diseases and reduces
the financial burdens of their treatments as well. It reduces the burden on the state’s health
facilities and blood banks.
 The screening would avoid any future’s social and psychological problems of families. It helps
those who seek such medical check-ups feel at ease; premarital screening raises awareness
about healthy and sound marriages .(Premarital Screening, 2014, April 08).
 Premarital check-ups may include also testing for syphilis, gonorrhea, and other sexual-
transmitted diseases, blood grouping, resus factor, seminal fluid analysis, FSH, prolactin,
testosterone, estrogen hormones, among others.

Premarital care: ( PMSGC ) :
Consanguineous marriages in the Middle East:
 Consanguineous marriages or relative marriages (and more specifically first-cousin marriages) are so
common in the Middle East and North Africa (MENA) region .
 Consanguineous marriages constitute 42-67 % of all marriages in the Kingdom of Saudi Arabia, 54%
in Qatar, 40-54 % in the United Arab Emirates, 29-64 %t in Jordan, 21-33 % in Egypt, 44-63 % in
Sudan, and 40-45 % in Yemen .
 Children of consanguineous marriages are at increased risk for genetic-recessive diseases (e.g.
thalassemia, sickle cell anemia and cystic fibrosis) and congenital malformations (2.5 times higher than
the rate among the children of nonconsanguineous parents) due to the expression of autosomal
recessive gene mutations inherited from a common ancestor.
 The closer the biological relationship between mother and father, the higher is the likelihood that their
children will get identical copies of one or more harmful recessive genes .
 Offspring of consanguineous parents have higher neonatal, post-neonatal, and child mortality than
those of nonconsanguineous parents . In addition, consanguineous unions are more likely to result in
inborn error of metabolism diseases (for example mucopolysaccharidosis, phenylketonuria),

pre conceptional care :
 pre conceptional care :
it is asset of interventions that aim to identify and modify biomedical, behavioral and social risk
to woman health or pregnancy out come through prevention and management .
Nutritional
consideration
Medical conditions
and drugs
Screening and ttt
of STDs
Immunization Genetic counseling

Nutritional considerations :
1/ folic acid supplementation : 400 mcg daily started before pregnancy and cont., for 12 wks. post
conception to reducing the rate of (NT defect ).
2 / women taking folic acid antagonists or with history of prev., NT defect baby should take 5 mg of folic
acid daily starting 3 months before conception and cont., 12 wks. post conceptions .
3/ overweight women : risky of DM (GDM ) and HTN associated with adverse pregnancy outcome as
macrosomia , shoulder dystocia , IUGR , abortions or difficulty of conception due to insulin resistant SO
weight loss and diet control and medications improve these symptoms
4/ Bariatric surgery is increasingly common BUT women are directed to prevent pregnancy for 12 to 18
month after surgery ton stabilize and optimize nutritional status.
5/ low weight women : ( BMI < 18.5 Kg per m2 ) : risky for preterm birth , low birth weight , nutritional
deficiency , osteoporosis , and the infants are high risk of gastroschisis

Pregestational DM : most common disease affecting maternal fetal health .
1/_ Increasing risk for ??? 1st , 2nd , 3rd trimesters ( fetal and maternal complications)
2/_ Screening and diagnosis by ( RBS , HA1C . PPBS ) and screening of complications as CVS.
3/_ Most oral antidiabetics should be discontinued, and insulin started.
4/_ Metformin may be continued .
Chronic HTN :
1/_ must be classified as normal (<140/90) or mild to moderate or sever (>160/90)
2 _ ACE inhibitors and ARBS (angiotensin II receptors blockers ) and atenolol are contraindicated
with pregnancy and shifted to alpha methyl dopa and labetalol .
3/_ pregnancy risk of PET(x) , super imposed PET , accidental hge , IUGR.

Seizure disorders :
1/_ folic acid supplementation ??
2/ _ anti epileptic drugs as ( valproate {Depacon} , phenytoin {Dilantin } , carmazepine { Tegretol }
, phenobarbital ) are teratogenic ??
3/ _ monotherapy is recommended at the lowest effective dosage should be used.
 Thyroid diseases :
1/_ screening for subclinical hypothyroidism is not recommended .
2/_ But risky women must be screened, and subclinical hypothyroidism should be treated
3/_ During pregnancy thyroid replacement dosages typically need to be increased according to
gestation possibly by 30% .
4/_ In hyperthyroidism women achieving euthyroid before pregnancy is recommended
5/_ Propylthiouracil is preferred in 1st trimester .
6/_ Methimazole is preferred in 2nd and 3rd trimester .

 Asthma :
1/ _ inhaled corticosteroid are recommended .
2/ _ oral corticosteroids in 1st trimester is associated with cleft palate .
3/ _ in cases of sever asthma and oral corticosteroids are indicated >>> the risky of uncontrolled asthma to
mother and fetus is greater than risky of oral corticosteroids
 Acne :
_ isotretinoin should be avoided . As it is associated with miscarriage and birth defects
 Thrombophilia :
_ risky to develop venous and arterial clots during pregnancy
_ risky for PET , IUGR , ……
_ GENITIC COUNCLING for inherited thrombophilia
_ warfarin teratogenic and replaced by Heparin or lwo molecular weight heparin

Screening and TTT of STD
 According to CDC guidelines :
• Anyone ages 13 to 64 should be tested for HIV at least once in their life, as well as after any
potential exposure.
• Sexually active women under 25 years old should be tested for gonorrhea and chlamydia yearly.
• Women who are 25 years and older with multiple sexual partners or partners with an STD
should get tested for gonorrhea and chlamydia yearly.
• Pregnant people should be tested for syphilis, HIV, hepatitis B, and hepatitis C, and high risk
pregnant people should be tested for gonorrhea and chlamydia in early pregnancy.
• Sexually active gay men, bisexual men, or other men who have sex with men should be tested
for syphilis, chlamydia, HIV, and gonorrhea every 3 to 6 months if they have multiple or
anonymous partners.
• Anyone who practices sex that could put them at risk of infection or who shares drug injection
equipment should get tested for HIV yearly.

Screening and TTT of STD
 Most STIs can be tested by using urine or blood samples. check for:
• Gonorrhea
• Syphilis
• Chlamydia
• HIV
• Herpes simplex
 In some cases, urine and blood tests aren’t as accurate as other forms of testing. It may also take
a month or longer after being exposed to certain STIs for blood tests to be reliable.
 If a person contracts HIV, for example, it can take a couple of weeks to a few months for tests
to detect the infection.
 Use vaginal, cervical, or urethral swabs to check for STIs.
 Strictly speaking, a Pap smear isn’t an STI test. A Pap smear is a test that looks for early signs of
cervical or anal cancer.

 Chlamydial infection is the most frequently reported bacterial infectious disease in the United States, and prevalence is
highest among persons aged ≤24 years .
 Multiple sequelae can result from C. trachomatis infection among women, the most serious of which include PID,
ectopic pregnancy, and infertility. Certain women who receive a diagnosis of uncomplicated cervical infection already
have subclinical upper genital tract infection.
 For women, C. trachomatis urogenital infection can be diagnosed by vaginal or cervical swabs or first-
cervical swabs or first-void urine.
 NAATs ( nucleic acid amplification test ) that are FDA cleared for use with vaginal swab specimens and this screening
specimens and this screening strategy is highly acceptable among women
 Recommended Regimens for Chlamydial Infection Among Adolescents and Adults
 Doxycycline 100 mg orally 2 times/day for 7 days
 Alternative Regimens
 Azithromycin 1 g orally in a single dose
OR
Levofloxacin 500 mg orally once daily for 7 days
Chlamydial infection:

Gonorrheal infection :
NAAT sensitivity for detecting N. gonorrhoeae from urogenital and congenital anatomic
sites is superior to culture.
 Recommended Regimen for Uncomplicated Gonococcal Infection of the Cervix,
Urethra, or Rectum Among Adults and Adolescents
 Ceftriaxone 500 mg* IM in a single dose for persons weighing <150 kg.
 If chlamydial infection has not been excluded, treat for chlamydia with doxycycline 100 mg
orally 2 times/day for 7 days.
 * For persons weighing ≥150 kg, 1 g ceftriaxone should be administered.
 Alternative Regimens
 If cephalosporin allergy:
 Gentamicin 240 mg IM in a single dose Plus Azithromycin 2 g orally in a single dose
 If ceftriaxone administration is not available or not feasible:
 Cefixime 800 mg* orally in a single dose
 * If chlamydial infection has not been excluded, providers should treat for chlamydia with
doxycycline 100 mg orally 2 times/day for 7 days.

Herpes simplex infection:
 HSV NAAT assays are the most sensitive tests because they detect HSV from
genital ulcers or other mucocutaneous lesions;
 PCR is also the test of choice for diagnosing HSV infections affecting the central
nervous system (CNS) and systemic infections (e.g., meningitis, encephalitis, and
neonatal herpes).
 Recommended Regimens*
 Acyclovir 400 mg orally 3 times/day for 7–10 days
OR
Famciclovir 250 mg orally 3 times/day for 7–10 days
OR
Valacyclovir 1 gm orally 2 times/day for 7–10 days
 * Treatment can be extended if healing is incomplete after 10 days of therapy.
 Acyclovir 200 mg orally five times/day is also effective but is not recommended
because of the frequency of dosing.

syphilis:
Screening of non treponemal teste:
 Venereal Disease Research Laboratory [VDRL] .
 rapid plasma reagin [RPR] test.
Confirmed diagnosis by a treponemal test (i.e., the T. pallidum passive
particle agglutination [TP-PA] assay, various EIAs, chemiluminescence
immunoblots, or rapid treponemal assays).
Treatment:
 Penicillin G, administered parenterally, is the preferred drug for treating patients in all
stages of syphilis.
 Bicillin L-A® is the first-line recommended treatment for syphilis and the only
recommended treatment option for some patients.

HIV Infection:
 According to an algorithm for HIV diagnosis, CDC recommends that HIV testing begin
with a laboratory-based HIV-1/HIV-2 Ag/Ab combination assay.
 The following recommendations apply to testing for HIV:
• HIV testing is recommended for all persons seeking STI evaluation who are not already
known to have HIV infection. Testing should be routine at the time of the STI evaluation,
regardless of whether the patient reports any specific behavioral risks for HIV.
• CDC and USPSTF recommend HIV screening at least once for all persons aged 15–65 years .
• Persons at higher risk for HIV acquisition, including sexually active gay, bisexual should
be screened for HIV at least annually.
• All pregnant women should be tested for HIV during the first prenatal visit. A second test
during the third trimester, preferably at <36 weeks’ gestation, should be considered and
is recommended for women who are at high risk for acquiring HIV infection, women who
receive health care in jurisdictions with high rates of HIV.

Preconception care :
Immunization :
Immunization Recommendation
M.M.R _ vaccinate all nonimmune women who not pregnant.
_ avoid pregnancy (3 months) after vaccination
Tetanus , diphtheria , pertussis _ protect against neonatal tetanus
_ protect against neonatal pertussis
Varicella _vaccinate all nonimmune women who not pregnant.
_ avoid pregnancy (1 month) after vaccination
Hepatitis B _vaccinate all high-risk women before pregnancy.
Influenza _vaccinate all women who will be pregnant during influanza season .

Preconception care :
 For who ??
 HOW ??
 What is the investigations ??
Genetic counseling :

 Natal care :
Care of women during process of labor .
_Protect the health of mother and her baby during delivery and
identify high risk pregnancies.
_By well trained health personnel and hospital delivery is
mandatory for high-risk pregnancies.
Post natal care :
Care of women during puerperium (6wks ) after delivery
_restore and maintain health mother and baby.
_prevent complications .
_ encourage breast feeding.
NATAL and POSTNATAL care :

1: Delay in decision to seek care due to;
•The low status of women
•Poor understanding of complications
in pregnancy and when to seek medical
•Previous poor experience of health care
•Acceptance of maternal death
•Financial implications
2: Delay in reaching care due to;
•Distance to health centres and hospitals
•Availability of and cost of transportation
•Poor roads and infrastructure
•Geography e.g. mountainous terrain, rivers
3: Delay in receiving adequate health care due to;
•Poor facilities and lack of medical supplies
•Inadequately trained and poorly motivated medical
staff
•Inadequate referral systems

3 Delayed models:
 Values of Application of Three Delays Model to Maternal Mortality Scenarios at Sohag
Univeristy Hospital Bidirectional Cohort Study
Magdy Mohamed Amin, Mohamed Sabry Ibrahim, Ahmed Elsayed Ali* Department of
Obstetrics and Gynecology, Faculty of Medicine - Sohag University
The Egyptian Journal of Hospital Medicine (April 2021) Vol. 83, Page 812-816
 According to three delays model, we found that most cases of maternal deaths due to 1st delay 10 (50%),
that could explained as 8 cases of them were from rural areas where low socioeconomic status and lack of
awareness of obstetric complications. All cases developed preeclampsia had no knowledge about obstetric
complications and lack of importance of antenatal care.
 CONCLUSIONThisstudyshowed that the first delay is the most important delay in Sohag, especially in rural
areas, and the most important cause of death was preeclampsia and ignorance about its complications,
which was due to lack of antenatal care

3 Delayed models:
 The first delay can be avoided by
_ increasing the community awareness, by informing the pregnant woman about risks of her
pregnancy and encouraging her to receive antenatal care also the danger of home delivery and the
danger of delay to seek medical care and this will help in decreasing most of the indirect causes of
maternal death.
 The second delay can be prevented by
__improving health system especially primary care centers, ambulance services and infrastructure,
which is some sort difficult and need long-term national plan.
__Also by improving the communications between university and the ministry of health to ensure
better health care and to improve the outcome of the high risk cases. These communications between
them may be in the form of referral communications, exchange of experiences, social health
education and link with other specialties for cases that require multi-specialist management.
 Third delay can be avoided by
__training physicians, nurses and midwives so that they can provide high quality, skilled maternal
health care in the community, and by optimization the hospital needs with equipment to provide
timely and adequate care in a friendly manner with respect to women as prerequisites to save the
lives of women and newborns

Technology changes (revolution):

 There is a wide range of digital health strategies applied in SRH promotion and
knowledge dissemination, but the use of technology strategies seems to shift
overtime.
 For example, mobile phone and text messaging were the most frequent options for
the study conducted before 2015.
 Recent studies have integrated more social media-based strategies (e.g., internet-
based social media Facebook, WhatsApp, Twitter, Snapchat, Instagram, blogs, virtual
reality, online gaming) , and promoted more interactive technology (e.g., accepting
input from the users, interactive video games) or technology with tailored functions.
 Some studies suggested that these new social media strategies can be effective
and efficacious in rapidly promoting attitude and norm change around SRH (e.g.,
promoting safe sex norm, attitude, and condom use attitude) .

 There are several high-quality mobile apps (my choice by PPT, Safe Sex
Tips, Get S.M.A.R.T) developed for adolescent pregnancy prevention.
 These apps were based on recommended best practice guidelines for
pregnancy prevention and credible/reputable public health information
sources (e.g., US Center for Disease Control/CDC) .
 The availability of these apps is encouraging, but more evidence for underline
mechanisms is needed to understand how apps designed based on best
practice guidelines impact short and long-term SRH outcomes .

Take home massage:
 You can play and educate at same phone .
 A healthy mother >> healthy child >> health community .
 Revise ACOG guidelines and WHO recommendations of ANC .
 Don’t forget definitions of ( Health , RSH , Maternal Death , PHC ).

reproductive health services in Egypt.pptx

reproductive health services in Egypt.pptx

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