medical surgical document for nursing students

1. FOCUSED ANTENATAL CARE
(FANC).
• What is FANC?
• Definition: It is personalised care
provided to a pregnant woman which
emphasizes on the woman’s overall
health, her preparation for childbirth and
readiness for complications ( emergency
preparedness ).
• It is timely, friendly, simple and safe
service to a pregnant woman.

2. • ANC is the care provided by a skilled health
care professionals to pregnant women and
adolescent girls in order to ensure the best
health conditions/outcomes for both mother
and baby during pregnancy

3. Components of ANC
• Risk Identification
• Prevention And Management Of Pregnancy-
related Or Concurrent Diseases
• Health Education And Health Promotion

4. AIM OF FANC.
• To achieve a good outcome for the
mother and baby and prevent any
complications that may occur in
pregnancy, labour, delivery and
postpartum.

5. FOUR COMPREHENSIVE
ANTENATAL VISITS.
• 1st visit : < 16 weeks.
• 2nd visit : 16 – 28 weeks.
• 3rd visit : 28 – 32 weeks.
• 4th visit : 32 – 40 weeks.
• During FANC visits, ensure that the
following have been accomplished.

6. CONTENTS OF THE 1ST VISIT.
• Obtain information on:
• Personal history – name, age, address
• History of present pregnancy.
• Obstetric history.
• Medical history.
• Perform physical examination.
• Lab test e.g.VDRL, Hb, blood group.
• Provide iron and folic acid, administer
tetanus toxoid as per the Kenya
guidelines.

7. Ct on CONTENTS OF THE 1ST
VISIT.
• Refer woman when complications arise
that cannot be managed at that facility,
e.g. severe anaemia.
• If the 1st visit is after 16wks, give in
malaria endemic areas: sulfadoxine/
pyrmethamine ( IPT) 3 tablets once to be
taken at the facility under
supervision(DOT).
• Mebendazole 500mg stat.

8. Ct on CONTENTS OF THE 1ST
VISIT.
• Assess the need for specialised care
e.g. diabetes, heart disease, epilepsy.
• Development of an individual birth plan
• Advise on complications and danger
signs.
• Health promotion, questions and
answers, and scheduling the next
appointment.
• Maintain complete records.

9. CONTENTS OF 2ND VISIT.
• Obtain information on:
• Personal history- note any changes
since 1st visit.
• Present pregnancy- e.g.abnormal
changes in body features, s&s of
anaemia.
• Obstetric history.
• Medical history.

10. Ct on CONTENTS OF 2ND
VISIT.
• Perform physical examination e.g. blood
pressure and pulse, fundal, height,
oedema.
• Lab tests e.g. urine, repeat Hb if at 1st
visit was below 7.0g/ml.
• Provide iron if Hb is <7.0g/ml, tetanus
toxoid in line with national guidelines,
administer mebendazol 500mg stat after
1st trimester

11. Ct on CONTENTS OF 2ND
VISIT.
• Re-assess for complications and
possible referral.
• Advice, questions and answers, and
scheduling the next appointment.
• Maintain complete records.

12. CONTENTS OF THE 3RD VISIT.
• Obtain information on:
• Personal history- note changes since
2nd visit.
• Present pregnancy- abnormal changes
in body features, signs of anaemia.
• Obstetric history.
• Medical history.
• Perform physical examination.

13. Ct on CONTENTS OF THE 3RD
VISIT.
• Lab test – urine, Hb if Hb at previous visit was
below 7.0g/ml.
• Provide iron continue if Hb is<7.0g/ml, consider
further investigations. Tetanus toxoid in line
with national guidelines. Administer IPT in
malaria endemic areas.
• Re-assess for complications and possible
referral.
• Advice, questions and answers, and schedule
the next appointment.
• Maintain complete records.

14. CONTENTS OF THE 4TH VISIT.
• Obtain information on:
• Personal history- note changes since 3rd
visit.
• Present pregnancy- note changes in
body features, symptoms and events
since 3rd visit, review individualized birth
plan.
• Obstetric history
• Medical history

15. Ct on CONTENTS OF THE 4TH
VISIT.
• Perform physical examination.
• Perform the following tests: urine, Hb if
Hb at previous visit was below 7.0g/ml
or signs of anaemia are detected on
examination.
• Provide iron if Hb<7.0g/ml, consider
further investigations. Administer IPT in
malaria endemic areas.

16. Ct on CONTENTS OF THE 4TH
VISIT.
• Re-asses for complications and
possible referral.
• Advice, questions and answers, and
schedule the next appointment.
• Maintain complete records.

17. LATE ENROLMENT AND
MISSED VISITS.
• It is very likely that a good number of
women will not initiate ANC early enough
in pregnancy to follow the focused four
antenatal visits. These women, particularly
those starting after 32 weeks of gestation,
should have in their first visit all activities
recommended for the previous visits, as
well as those which corresponds to the
present visit. It is expected, therefore, that
a late first visit will take more time than
a regular first visit.

18. Comparison between WHO FANC
model and WHO ANC Model
WHO FANC model WHO ANC Model
First trimester
Visit 1: 8-12 weeks Contact 1: up to 12 weeks
Second trimester
Visit 2: 24 -26 weeks Contact 2: 20 weeks
Contact 3: 26 weeks
Third trimester
Visit 3: 32 weeks
Visit 4: 36-38 weeks
Contact 4: 20 weeks
Contact 5: 26 weeks
Contact 6: 20 weeks
Contact 7: 26 weeks
Contact 8: 20 weeks
Return for delivery at 41 weeks if not given birth

19. Key recommendations of the new
2016 WHO ANC Model
• Nutritional interventions:
 Healthy eating and keeping physically active to stay
healthy and prevent excessive wt gain
 Undernoursished populations to increase daily energy
and protein intake to reduce risk of LBW neonates and
also balanced energy and protein dietary
supplementation to reduce risk of stillbirths and SGA
neonates
 Daily oral IFAS with 60mg to 65mg elemental iron and
400mcg (0.4mg) folic acid to prevent maternal
anaemia, puerperal sepsis, LBW and preterm birth

20. Cont… Key recommendations of the
new 2016 WHO ANC Model
• Maternal assessment:
• fetal assessment:
• Preventive measures: antenatal prophylaxis with anti-D
immunoglobulin in non-sensitized RH-negative pregnant
woman at 28 and 34 weeks of gestation to prevent RhD
Isoimmunization
• Antihelminthic after 1st trimester
• TD vaccination
• In malaria-enemic areas IPT of Sulfadoxine-pyrimethamine,
to be started in 2nd trimester, at least 3 doses 4 weeks apart
• Oral pre-exposure prophylaxis (prep) containing tenofovir
disoproxil fumarate is an additional prevention choice for
women at substantial risk of HIV infection

21. Cont…Key recommendations of the
new 2016 WHO ANC Model
• Health systems interventions to improve the utilization and
quality of antenatal care:
 Each pregnant woman should carry her own case notes during
pregnancy
 midwife-led continuity of care models in which a known
midwife or small group of known midwives supports a woman
throughout antenatal, intrapartum and postnatal continuum
 Group ANC provided by qualified health care professionals
may be offered as an alternative to individual ANC for
pregnant women in the context of rigorous research,
depending on a woman’s preferences and provided that the
infrastructure and resources for delivery of group ANC are
available

22. Cont…Key recommendations of the
new 2016 WHO ANC Model
 Packages of interventions that include household and
community mobilization and antenatal home visits to improve
ANC utilization and perinatal health outcomes
 Task sharing to promote health-related behaviours for MNH to
a broad range of cadres including lay health workers, auxillary
nurses, nurses, midwives and doctors is recommended
 Policy- makers should consider educational, regulatory,
financial and personal and professional support interventions
to recruit and retain qualified health workers in rural and
remote areas
 ANC models with a minimum of 8 contacts to reduce perinatal
mortality and improve women’s experience of care

23. Summary of the 2016 ANC model
guidelines
• Nutritional interventions
• Maternal and fetal assessment preventive measures
• Interventions for common physiological symptoms
• Health systems interventions to improve utilization and
quality of ANC
• ANC Models with a minimum of 8 contacts are
recommended to reduce perinatal mortality and
improve women’s experience of care
• The new model recommends first contact during the
first 12 weeks’ gestation, with following contacts taking
place at 20, 26, 30, 34, 36, 38 and 40 wks of gestation

24. Services offered in each contact visit
contact
s
weeks services
1st trimester
Contact
1
Up to 12
wks
Baseline investigations, FBC, blood grouping, UA/midstream urine
culture, RBS, HIV, TB screening, VDRL.
/RPR, Early US, HX and clinical examination, education on danger
signs, nutrition, breastfeeding, hygiene and common symptoms
Nutritional supplementation: IFAS, calcium
BP AND WT.
HB to be taken once in each trimester
2nd trimester
Contact
2
20 wks Early obstetric US at 18-20 wks
IPTs-SP from 13 wks, 4 wks apart until delivery in malaria endemic
areas
Deworming using mebendazole 500 mg
Contact
3
26 wks Indirect coombs test for RH-VE mother prior to Anti-D
administration

25. Services offered in each contact visit
3rd trimester
Contact weeks services
Contact 4 30 wks • Clinical examination,
obstetric abdominal
exam and risk
assessment
• Birth preparedness
advice
Contact 5 34 wks
Contact 6 36 wks
Contact 7 38 wks
Contact 8 40 wks

26. Justification of the new 2016 ANC
Model
• Evidence suggesting increased perinatal deaths in 4-visit
ANC model
• Evidence supporting improved safety during pregnancy
through increased frequency of maternal and fetal
assessment to detect complications
• Evidence supporting improved health system
communication and support around pregnancy for women
and families
• Evidence indicating that more contact between pregnant
women and respectful, knowledgeable health care workers
is more likely to lead to a positive pregnancy experience
• no difference in health outcomes between ANC Models
with 8 contacts and those of 11 to 15 contacts

27. The new 2016 WHO ANC MODEL
• Advocates for 8 contacts with the 1st visit in 1st
trimester

28. Group ANC
• Is another alternative model
• It integrates the usual individual preg health
assessment with tailored group educational
activities and peer support, with the aim of
motivating behaviuor change amon women,
improving pregnancy outcomes and increasing
women’s satisfaction

29. Cont…..Group ANC
• Interventions involves
• Self-assessment activities
• Group education with facilitated discussion
• Socialization activities

30. Preventive measures
• IFAS: when anaemia (HB less than 11g/dl), the dose of
elemental iron is increased to 120 mg until HB rises to
normal or higher
• Vitamin A: Not recommended unless in areas when vit A is
deficient. When indicated, give daily or weekly up to
10,000IU per day or weekly dose of up to 25,000IU to
prevent night blindness
• Tetanus/Diphtheria vaccination
• IPTp: given in malaria endemic areas. 1st dose in second
trimester at 13 wks, and given one month apart, up to 3
doses. If HIV + and on septrin, do not give SP
• Deworming: Given in second trimester, either albendazole
400mg or mebendazole 500mg single dose only

31. Tetanus diphtheria vaccination (TD)
• If a preg woman has not been previously vaccinated or her
immunization status is unknown, she should receive 2
doses one month apart with the second dose ggiven at
least 2 wks before delivery. 2 doses protect for 1-3 years
• Third dose is recommended 6 months after second dose,
which extends protection to at least 5 years
• Two further doses in the two subsequent years or during
two subsequent pregnancies
• If a woman has had 1-4 TD injections in the past, she should
receive one dose of TT during each subsequent pregnancy
to a total of 5 doses (5 doses offer protection throughout
the childbearing years)

32. Mandatory ANC profile
• TB
• HIV
• VDRL
• Blood sugars
• Full haemogram
• BS for malaria
• Blood group and rh factor
• urinalysis

33. OBJECTIVES OF FANC
• Early detection and treatment of problems
• Prevention of complications using safe, simple
and cost-effective interventions
• Birth preparedness and complication
readiness
• Health promotion using health messages and
counseling
• Provision of care by a skilled attendant

34. OBJECTIVES OF FOCUSED
ANTENATAL CARE.
• 1. Early detection and treatment of
problems.
• Service providers should identify
existing medical, surgical or obstetric
conditions during pregnancy such as:
• Severe anaemia ( Hb < 7gm/dl ).
• Vaginal bleeding.
• Pre- eclampsia ( increased B.p, severe
oedema ).

35. • STI’s, HIV/AIDS, TB and malaria.
• Chronic diseases ( diabetes, heart or
kidney problems ).
• Decreased / absent foetal movement.
• Foetal malpresentation after 36 weeks.

36. Why disease detection and not
risk assessment?
• Risk approach is not an efficient or
effective strategy for maternal mortality
reduction.
• Every pregnancy is at risk: risk factors
cannot predict complications e.g. young
age does not predict eclampsia. Research
showed that the majority of women who
experienced complications were considered
low risk ( 90% of women considered to be
high risk, give birth without experiencing a
complication ).

37. • Risk factors do not predict problems.
Most high risk women deliver without
problems and most women who
develop life- threatening complications
belong to the low risk group.
• Every pregnant delivering or postpartum
woman is at risk of serious life-
threatening complications.

38. 2. Prevention of complications.
• The service provider should ensure
prevention / protection of complications
by providing:
• Tetanus toxoid to prevent maternal and
neonatal tetanus.
• Iron/ folate supplementation to prevent
anaemia.
• Use of IPT and ITNS to prevent
malaria / anaemia.

39. • Ensure environmental hygiene to
prevent intestinal worms.
• Presumptive treatment of hookworm
infection with mebendazole 500mg
STAT anytime after the first trimester.
• Basic maternal and newborn care.

40. 3.Birth preparedness and
complication readiness.
• Service providers should discuss
components of birth plan which include:
• place of birth,
• skilled attendant,
• Transportation,
• funds,
• birth companion,

41. • Items for clean and safe birth and for
newborn.
• Knowledge of danger signs: what to do
if they arise.
• Choose decision maker.
• Emergency funds.
• Emergency transport.
• Blood donor.

42. • Discuss birth partners/companions
with your clients.
• A birth partner/ companion may be the
father of the baby, a sister, a mother-in-
law, mother or an auntie.
• A birth partner/ companion should be
involved in making the individual birth
plan ( IBP ).

43. • A birth partner/ companion can provide
support to the woman during
pregnancy at the antenatal clinic and
during delivery.
• Make sure that clients at your clinic
know that you welcome birth partners/
companions.

44. Individual Birth plan (IBP) ensures
that the client:
• Knows when her baby is due.
• Identifies a skilled birth attendant.
• Identifies a health facility for delivery/
emergency.
• Can list danger signs in pregnancy and
delivery and knows what to do if they
occur.
• Identifies a decision- maker in case of
emergency.

45. Cont….. IBP
• Knows how to get money incase of
emergency.
• Has a transport plan incase of
emergency.
• Has a birth partner/ companion for the
birth.
• Has collected the basic supplies for
the birth.

46. CONT…..IBP
• 15% of all pregnant women develop
life- threatening complications requiring
obstetric care.
• These women could die if nobody is
there to make timely decisions at
home and in the health facility, no
plans for referral or transport have
been made, no plans on how to meet
new financial demands are made.

47. Specific transport questions for
the client:
• Where will you deliver?
• Where will you go incase of an
emergency?
• Where is it located?
• How will you get there?
• Have you made this journey before?
• How much will it cost to arrange for
the transport and how will you raise it.

48. Mother – baby package.
• One pair of sterile rubber gloves or
clean plastic bags that can be worn
over the hands where gloves are not
available.
• Soap.
• Cotton wool.
• Clean, unused razorblades.
• Thread or string.

49. • Clothing for the baby and mother.
• Money to pay for transport, hospital
fees, etc.
• Sanitary towels, napkins.

50. Danger signs in pregnancy.
• Any vaginal bleeding in pregnancy
(APH, Abortion ).
• Severe headache or blurred vision (
high blood pressure, eclampsia ).
• Swelling on the face and hands ( high
blood pressure, eclampsia ).
• Convulsions or fits ( high blood
pressure, eclampsia ).

51. • High fever ( infection ).
• Laboured breathing ( pneumonia, heart
problems, severe anaemia ).
• Premature labour pains.
• Noticed that the baby is moving less
or not moving at all ( fetal distress,
IUD).

52. Other danger signs in pregnancy.
• Feeling very weak or tired ( anemia,
severe disease, multiple pregnancy ).
• Vaginal discharge ( STI ).
• Abdominal pain ( STI, early labour ).
• Genital ulcers ( STI ).
• Painful urination ( STI ).
• Persistent vomiting ( severe malaria etc ).

53. Danger signs during labour and
delivery.
• Severe headache/ visual disturbances.
• Sever abdominal pain.
• Convulsions or fits during labour.
• High fever with or without chills.
• Foul vaginal discharge.
• Labour pains for more than 12hours.
• Ruptured membranes without labour for
more than 12 hours.

54. cont …Danger signs during labour and
delivery
• Excessive bleeding during delivery.
• Cord, arm or leg prolapse.

55. Danger signs after delivery.
• Placenta not delivered within 30
minutes of baby birth.
• Excessive bleeding after delivery.
• Severe abdominal pain.
• Convulsions or fits.

56. • High fever with or without chills.
• Foul vaginal discharge due to
infections.
• Mood swings ( depressions ).

57. • Recognize danger signs and get
prompt medical attention!
• Acting quickly is important because a
woman could die in a short period of
time:
• In antepartum hemorrhage she can die
in just 12hours.
• In postpartum hemorrhage she can die
in just 2 hours.

58. • With complications of eclampsia, she
can die in as few as 12hours and with
sepsis in about 3 days.

59. • 4. Health promotion using health
messages and counseling.
• Encourage dialogue on the following:
• Nutrition.
• Rest and hygiene.
• Safer sex.
• Care for common discomfort.
• Use of IPT and ITNS.

60. Cont...Health promotion using
health messages and counseling.
• Drug compliance.
• Family planning, health timing and spacing of pregnancy.
• Early and exclusive breastfeeding.
• Newborn care.
• PMTCT
Also teach them about:
• Danger signs in pregnancy
• Prevention of STIs
• Avoidance of alcohol and tobacco
• Individual Birth Plan (IBP)
• To come to postpartum clinic immediately, 48 hours, 2 weeks,
at 6 weeks, 6 months and one year
• Immunization

61. Maintain the woman’s health and
survival through:
• Health education and counseling on:
• Danger signs in pregnancy.
• Adequate nutrition and hydration.
• Early and exclusive breastfeeding.
• Individual birth plan.

62. • Prevention and treatment of sexually
transmitted infections ( STIS ) and worm
infestations.
• Avoidance of alcohol and tobacco.
• Complication readiness plan.
• Don’t forget to counsel the mother on:
• To come to postpartum clinic:
immediately, 48hrs,2wks, at 6wks & 1yr.

63. • To visit well baby clinic ( MCH/FP clinic )
for immunizations.
• Follow up for exposed babies to TB
and HIV.
• To chose a postpartum family planning
method:
• LAM ( exclusive breastfeeding ).
• Progesterone only pills.

64. • Condoms.
• Postpartum IUCD.
• *Feeding options.
• Teach mother about importance of
immunizations:
• Inform her about the first-year
immunization schedule to protect children
from TB, polio, tetanus, diptheria, pertussis,
hepatitis B and measles.

65. 5. Provision of skilled care at
Birth.
• Currently, only 41% of pregnant women
receives skilled care at birth.
• By 2015, it is expected that three quarters
of pregnant women should receive skilled
care at birth.
• A skilled attendant offers services either
at the health facility or within the
community ( domiciliary practice ).
• FANC provides an opportunity to increase
skilled care.

66. The Role of men/fathers in antenatal
care
• Support and encourage women throughout
pregnancy
• Ensure mothers do not get STIs or HIV
• Ensure that they remain faithful (or use
condoms consistently and correctly)
• Encourage mothers to attend antenatal clinic
• Accompany their wives/partners to the health
facility and during childbirth

67. Service provider should educate
fathers about antenatal care
1. Fathers should make sure that the woman:
• Has enough nutritious food to eat and that she has taken
iron and folate tablets
• Is sleeping under a treated net and is able to get enough
rest
• Has 2 doses of SP (if from malaria endemic area) and
Tetanus Toxoid
2. Make sure that the couple has an IBP
3. Make sure that the couple know the danger signs in
pregnancy and labour

68. Maternal Death
"A maternal death is defined as the death of a woman while pregnant or
within 42 days of termination of the pregnancy, irrespective of the
duration and site of pregnancy, from any cause related to or aggravated by
the pregnancy or its management, but not from accidental or incidental
causes." Causes of maternal mortality maybe direct or indirect
• Direct Causes of Maternal Death
These result from obstetric complications of pregnancy, labour and the
puerperium and from interventions or any after effects of these events.
The Five major causes of direct maternal deaths in order of frequency are:
Haemorrhage, Sepsis, Hypertensive disorders, Complications of abortion
and obstructed labour
• Indirect causes of Maternal Deaths
They result from previously existing disease or disease that develops
during pregnancy which was not due to direct obstetric causes, but which
was aggravated by physiologic effects of pregnancy. The major causes of
indirect maternal deaths in our set up include Malaria, HIV/AIDS, and
anaemia.

69. Underlying causes of Maternal &
Neonatal Mortality
• The three delays
• There are three distinct levels of delay which contribute to maternal
morbidity and mortality: (Thadaseus and Maine, 1994):
• Delay in deciding to seek appropriate care. This could be due to:
socio-cultural barriers, Failure to recognize danger signs, failure to
perceive severity of illness, and cost considerations
• Delay in reaching an appropriate health care facility.
• This is due to: long distance to a facility, poor condition of roads,
lack of transportation and cost considerations
• Delay in receiving adequate emergency care at the facility.
• This may be due to: Shortage of staff, supplies and basic equipment;
unskilled personnel, user fees among others.

70. STRATEGIES TO REDUCE MATERNAL
AND PERINATAL DEATHS
• Safe Motherhood And Child Survival Initiative
• The Kenya Maternal and Newborn Health model (2009)
• International Conference for Population and Development (ICPD):
• Millennium Development Goals
• SDGs
• National Reproductive Health Policy 2007
• National Reproductive Health Strategy (NRHS): 2009- 2015
• The National Health Sector Strategic Plan (NHSSP II)-2005-2010: (i) The KEPH
Life-Cycle Cohorts (ii) Levels of Care in KEPH
• The Annual Operational Plans (AOPs) translate Kenya Essential Package for
Health and the National Health Sector Strategic Plan II 2005-2010 into
‘actionable’ operational plans.
• The Community Strategy
• Vision 2030
• The National Road Map for accelerating the attainment of MDGs related to
Maternal and Newborn Health in Kenya. (2008-2015)

71. SAFE MOTHERHOOD AND CHILD
SURVIVAL INITIATIVE
• Introduction
Safe motherhood is neither a simple nor a single
concept, and what is encompassed by the term
has evolved considerably since 1987.
• While the focus on maternal mortality has
remained, three other outcomes have now been
incorporated.
•
Maternal morbidity
•
Health of the newborn
•
Positive health of the mother

72. CONT
• Thus, the meaning of safe motherhood has
broadened, particularly in the early 1990s as has
the range of factors regarded as determinants of
poor maternal health, with women’s low
socioeconomic status seen as one of the root
causes.
• The Safe Motherhood mandate for the
reproductive health programme is assumed to
span across the continuum of pre-conception care,
antenatal care, labour and delivery, postpartum
and postnatal care and neonatal care (first month
of life).

73. cont
• The RH policy recognises that in at least 15%
of pregnant women serious obstetric
complications can occur that usually can not
be predicted or prevented in advance, and
therefore emphasises the need for all
pregnant women to have access to skilled
care, throughout pregnancy, delivery,
postpartum and postnatal periods.
• The most critical time for both the mother
and her baby is during childbirth and in the
first few hours afterwards

74. Definition of Safe Motherhood
Safe motherhood is a woman’s ability to have a safe
and healthy pregnancy and delivery. Making
motherhood safe requires action on three fronts
simultaneously:
• Reduce the number of high risk and unwanted
pregnancies
• •
Reduce the number of obstetric complications
• •
Reduce the cases of high fertility rate in women
with complications

75. The Key Components of Safe
Motherhood
• •
Focused antenatal care which research suggests
lowers the rate of maternal morbidity and mortality
• •
Safe and clean delivery so that all women deliver
under some type of supervised care, where referral
systems are established to provide emergency
treatment for life threatening complications of delivery
• •
Postnatal care that contributes to a woman’s ability to
enjoy sexual relations without pain and have safe
pregnancy and delivery in future
• •
Safe, humane and cost-effective postabortion
care

76. Safe Motherhood Initiative
• The Safe Motherhood Initiative (SMI) is a
supportive effort, which was launched in 1987, in
Nairobi, by WHO and its partners to focus the
world’s attention on problems related to
pregnancy and childbirth. Lack of commitment to
women’s health problems by the government
was seen as the major underlying cause of many
maternal deaths. To address this problem,
delegates to the Nairobi Conference in 1987
recommended the introduction of a Safe
Motherhood Initiative (SMI) to be
implementedby all countries.

77. Objectives of the Safe Motherhood
Initiative
• The conference described the Safe Motherhood Initiative as a global
strategy aimed at reducing
• maternal mortality by half by the year 2000 by creating circumstances
within which a woman is
• enabled to:
• •
Choose whether she will become pregnant
• •
Receive care for the prevention and treatment of pregnancy
complications
• •
Have access to trained birth attendants
• •
Have access to emergency obstetric complications if necessary
• •
Have care after birth
• •
Avoid death or disability from complications of pregnancy and
• childbirth
• In response, the Kenya government endorsed this plan of action to reduce
maternal mortality and morbidity.

78. Objectives of the Safe Motherhood
Initiative
• The scope of the Safe Motherhood Initiative has advanced
tremendously to encompass many action areas and now
includes safe motherhood through human rights for
women (Fathalla, 1997 and 2000; WHO 2001).
• The SMI differs from other health initiatives in that it
focuses on the well being of women as an end to itself.
• Thaddeus and Maine (1994) argued that, prevention of a
death of a pregnant woman is considered to be the key
objective, not because the death adversely affects children
and other family members but because women are
intrinsically valuable.

79. Summary of SMI Events:
Year Event Summary
1987 International Safe Motherhood
Conference(Nairobi, Kenya) –Safe motherhood
Initiative launched
Goal : 50% reduction in 1990 levels of maternal mortality by
2000 (and 75% reduction by 2015)
1987-1997 Safe Motherhood Initiative Involved:
• Enhanced Advocacy for Safe Motherhood
• Determine the Magnitude of the problem
• Institution of Effective interventions,
• Identify constraints to implementation,
• Address barriers to access
1997 Safe Motherhood Technical
Consultation(Colombo, Sri Lanka)
Ten key messages were formulated

80. The Eight Pillars of Safe Motherhood
• In order to reduce maternal morbidity and
mortality, efforts should be focused on the
eight pillars of safe motherhood as illustrated
in the diagram below.

81. Safe Motherhood + (plus)

82. Family Planning
• Good family planning ensures that individuals
and couples have the information and services
to plan the timing, number and spacing of
pregnancies.

83. Focused Antenatal Care
• This serves to prevent complications where possible
and ensures that complications of pregnancy are
detected early and treated appropriately. Four focused
antenatal visits are recommended, which emphasise:
• •
Taking two doses of sulphapyremethane (SP) during
pregnancy for malaria endemic areas
• •
Recognising signs and symptoms of malaria
• •
Recognising danger signs in pregnancy and where to
go for help
• •
Drawing up an individual birth plan, which should
include a mother/baby package, transport plans and
funds/money.

84. Clean and Safe Delivery
• Always ensure that all birth attendants have
the knowledge, skills, positive attitude and
equipment to perform a clean and safe
delivery and provide postpartum care to the
mother and baby.
• transmission (PMCT) of HIV are also key
components of safe motherhood.

85. Post Abortion Care
• Abortion is one of the major causes of maternal
morbidity and mortality. Health care workers and
facilities need to be well equipped to prevent
and effectively manage complications that arise
from the procedure.
• The patients’ psychological well being need to be
handled by an experienced health care worker to
cover trauma and suicidal tendencies as well its
occurrence in future.

86. Prevention of Mother to Child Transmission
of HIV (PMTCT)
• The government is in support of preventive
measures that would ensure little or no
transmission of HIV virus by any means.
PMTCT is a programme that was initiated in
the maternal child health care services to
protect the unborn baby from contracting the
virus.

87. Targeted Postpartum Care
• Maternal deaths in many cases happen during
the postpartum period.
• Close follow-up by skilled health care worker
would ensure early detection, prevention and
treatment of any pregnancy and delivery
complications, which may not have been
noted during pregnancy and delivery.

88. Neonatal Care
• The neonatal period is very sensitive, surveys
have shown that the majority of neonates in
this country do not survive.
• In Kenya more than half of the women deliver
at home and hence the need for closer
neonatal follow-up and observation as this
would lead to early detection and
management of complications that may arise
at this tender age.

89. Essential Obstetric Care
• Ensure that essential care for high-risk
pregnancies and complications is available to
all women who need it.

90. The Kenya Maternal and Newborn
Health model (2009)
Maternal and Newborn Health (MNH) Pillars
• Family planning and pre-pregnancy care– To ensure that individuals and couples
have the information and services to plan the timing, number and spacing of
pregnancies.
• Focused Antenatal Care – To prevent complications where possible and ensure
that complications of pregnancy are detected early and treated appropriately.
• Essential Obstetric Care – To ensure that essential care for the high-risk
pregnancies and complications is made available to all women who need it.
• Essential Newborn Care – To ensure that essential care is given to newborns from
the time they are born up to 28 days in order to prevent complications that may
arise after birth.
• Targeted Postpartum Care– To prevent any complication occurring after childbirth
and ensure that both mother and baby are healthy and there is no transmission of
infection from mother to child.
• Post Abortion Care – to provide clinical treatment to all women and girls seeking
care, for complications of incomplete abortion and miscarriage as well as
counselling and contraceptives.
• (Note that HIV PMTCT services are now integrated into ALL the pillars of MNH
and clean and safe delivery is part of Essential Obstetric Care)

91. Foundation Measures
• These eight strategic interventions must be delivered through primary
health care (PHC) and rest on a foundation of greater equity for women.
This recognises the fact that the eight pillars of SMI can only prevent
immediate causes of maternal death.
• Underlying causes of maternal death are often as a result of the poor
socioeconomic status of women and these issues require other strategies.
• In strengthening this foundation the Ministry of Health has indicated the
need for:
• •
Skilled attendants and enabling environment to provide quality care
• •
Supportive health systems: effective systems of referral, management,
procurement, training, supervision and health management information
systems
• •
Community action, partnership, and male involvement
• •
Equity for all/reproductive rights

92. Cont Foundation Measures
• When strategising, countries were encouraged to design
other non-health activities which could improve the
socioeconomic status of women such as providing formal
education for girls, giving women equal employment and
business opportunities as well as the empowerment of
women to make decisions within their own households.
These concepts are also dealt with in the section on gender
and reproductive health rights.
• The health sector, through the concept of PHC
(collaboration across ministries and sectors) should,
therefore, involve other ministries and organisations in
implementing a national and district safe motherhood
initiative.Maternal deaths are most likely to occur.

93. Emergency Obstetric Care
• Emergency Obstetric Care refers to a set of minimal
health care elements, which should be availed to all
women during pregnancy and delivery. It includes both
life saving and emergency measures e.g. Caesarean
section, manual removal of placenta, etc, as well as
non-emergency measures (e.g. use of the partograph
to monitor labour, active management of the third
stage of labour, etc.). Emergency Obstetric Care
functions are generally categorized as Basic Emergency
Obstetric Care (BEmOC) and Comprehensive
Emergency Obstetric care (CEmOC).

94. The signal functions to identify BEmOC
and CEmOC are:
Basic Emergency Obstetric Care includes:
• Administration of IV antibiotics.
• Administration of magnesium sulphate.
• Administration of parental oxytocics.
• Performing manual removal of the placenta.
• Performing removal of retained products.
• Performing assisted vaginal delivery (e.g. by
vacuum extraction).
• Performing newborn resuscitation

95. Comprehensive Emergency Obstetric
Care
• includes all the seven above, PLUS:
• Performing surgery (Caesarean section),
including provision of emergency obstetric
anaesthesia.
• Administration of blood transfusion.

96. CLIENT AND PROVIDERS RIGHTS
Clients Rights include:
• Right to Information
• Right to Access
• Right of choice
• Right to safety
• Right to Privacy
• Right to Confidentiality
• Right to Dignity
• Right to Comfort
• Right to Continuity of Care
• Right of Opinion

97. PROVIDERS’ RIGHTS
• Training
• Information
• Infrastructure
• Supplies
• Guidance
• Back up
• Respect
• Encouragement
• Feedback
• Self–expression

98. • END!
• THANK YOU!