The document provides background information on the implementation of maternal, newborn, adolescent and child health care services in Myanmar using a continuum of care approach. It was developed in accordance with the National Health Plan and short term strategic plans for reproductive health, child health development and adolescent health development. The services were initially implemented in 10 townships in 2011 and have since expanded to 200 townships. The services are delivered through family-oriented, population-oriented, and individual-oriented channels and coordinated at the national and sub-national levels.

1. Complied and written by : Phyo Maung Maung Kyaw
(B.Comm.H)
Zonal Health Specialist, WVM
6/8/2014
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2. Background
• Providing maternal, newborn, adolescent and child health care
services with continuum of care approach
• developed in accordance with the National Health Plan and
also in relation to short term strategic plans for reproductive
health, child health development and adolescent health
development
• Start implemented (200) townships at 2011 in Myanmar
• initiated in 10 townships by training health volunteers for
Community Based
• implemented using three delivery channels –
Family oriented
Population oriented
Individual oriented
• implemented through rolling plans at the national level based
on the information and periodic review of activities and
integrated micro planning at the sub national level based on
the local data and information.
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3. Organization
Set Up
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4. Ministry of Health, Republic of Union of Myanmar
Department of Health
Admin MC D/C PH Nursing FDA (Now
divided as
Department
Lab Plan HEB
Basic Health School Health MCH WCHD Nutrition WATSAN
Deputy Director
Assistant Directors
Medical Officers
Staffs
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5. Millennium Development Goals (MDGs) that
directly affect newborn, child and maternal
survival Goal 4: Reduce child mortality
Target 4a:
Reduce by two thirds the
mortality rate between 1990
and 2015 among children
under five
Indicators:
4.1 Under-five mortality rate
4.2 Infant mortality rate
4.3 Proportion of 1 year-old
children immunized against
measles
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6. Millennium Development Goals (MDGs)
that directly affect newborn, child and
maternal survival
Goal 5: Improve maternal health
Target 5a: Reduce by three
quarters between 1990
and 2015 the maternal
mortality ratio
Indicators:
5.1 Maternal mortality ratio
5.2 Proportion of births attended
by skilled health personnel
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7. Objectives of WCHD
General objective
 To provide quality health care service for women, children and
adolescent in order to reduce U5MR and MMR and to promote
health development of women, children and adolescent.
Specific objectives
 To reduce Under Five Mortality Rate and Maternal Mortality
Rate according to MDGs.
 To ensure quality health service for children, adolescents and
women.
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8. Why WCHD is important ????
Women and children (U12) population – Majority about 60%
Children – Future of the nation
Children and Women – vulnerable of illness and death
Most of disease associated that are preventable
Children are inarticulate
Including and directly related to MDG 4 and 5 and indirectly
related to MDG 6
Including ELEMENTS of PHC
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9. 6/8/2014
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• Every year, more than 10 million children under the age
of five are dying of preventable or treatable diseases.
• Some are directly caused by illness such as pneumonia,
diarrhoea and malaria.
• Others are caused by indirect causes including conflict
and HIV/AIDS, malnutrition, poor hygiene and lack of
access to safe water and adequate sanitation .
• Thirty-eight percent (38%) of the estimated more than
10 million children under 5 deaths each year occur in the
first four weeks of life, the neonatal period.

10. Problems of Maternal Health
[Maternalmortalityratio(per100,000LiveBirth)inMyanmaris380(2005)]
Postpartum
Haemorrhage
31%
Indirect causes
17%
Eclampsia
11%
Abortion related
10%
Prolonged and
obstructed labour
9%
Puperal Sepsis
7%
Hypertensive disease
of pregnancy
6%
Antepartum
Haemorrhage
4%
Ruptured Uterus
4%
Embolism
1%
Causes of Maternal Mortality,2004-2005 (MOH & UNICEF)
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11. Problems of Child Health
U5MRinMyanmaris 98(2008)
Preterm
34%
Asphyxia
27%
Infection
26%
Congential
5%
Other
5%
Diarrhoea
3%
Tetanus
0%
Causes of Neonatal Deaths
Source : WHO/CHERG 2010
Neonatal
40%
Injuries
22%
Other
12%
Diarrhoea
12%
Pneumonia
12%
Malaria
2%
HIV/AIDS
1% Measles
0%
Causes of Under-Five Deaths,2008*
Source : WHO/CHERG 2010
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12. Sign and Symptoms of
Pregnancy
• Amenorrhea
• Morning Sickness
• Breast Change
• Bladder Symptoms
• Uterus Palpable Abdominally
• Abdominal Enlargement
• Fetal Heart Audible
• Quickening
• Pregnancy Test on Urine
How to calculate the estimate of due birth date ????
• English Calendar- LMP + 281 days or 9 months 7 days= EDD
• Burmese Calendar- LMP + 9 months 14 days = EDD
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13. Antenatal Care
Aim and Objective
• To promote, protect and maintain health of mother during
pregnancy
• To identify high risk pregnancy
• To provide special care for high risk cases
• To teach the mother the elements of child care, nutrition and
personal hygiene and environmental sanitation
Procedure of AN Care
• Registration: Visit (1) – Within 3 months (as early as possible)
(2) _ 6months, 7months of pregnancy
(3) _ 8months of pregnancy
(4) _ 9months of pregnancy
• Obstetric history – Abortion, Elcamsia, PPH, APH, prolong Labour,
History of previous delivery, Number of pregnancy, EDD, LMP , Time
of Previous Birth or abortion date, etc.
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14. Antenatal Care
Procedure of AN Care
• Personal History- Name, Age, Husband Name, Date of Visit, etc.
• Medical History- Underlying Diseases
• General Examination- Height, Weight, BP, Urine for Albumin, etc.
• Immunization TT *2 – Last time should be 6 weeks before labor
• Examination of Abdomen- size of uterus , presentation and
position of the fetus, Exclusion of Cephalo pevlic disproportion,
detect of abnormalities
• General Advice- Birth Plan, diet, rest and exercise, clothing, care
of breast
• Nutrient supplement and drugs: Vitamins and Minerals (Must
take of Ferrous Sulfate mix Folic acid for 3months) and
Mebendazole 500 mg single dose after first Trimester .
• Identify the risk pregnancy and timely referral.
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15. High Risk of Pregnancy
• Age below 18yrs and above 35yrs
• Time of pregnancy P1 and including above P5
• Previous still-birth, intrauterine death, manual removal of placenta
• Body Temperature above 38’C
• Short statured primi (140cm or 4’ 10”and below)
• Body Weight below 84 lb. or 40 Kg and above 157 lb. or 70 Kg
• Suffer sever anemia
• Maternal Heart rate is irregular
• Anasarca or edema
• Multiple Pregnancy (Twin, hydramnios, etc.)
• Malpresentations, viz breech, transverse lie, etc (above 37 weeks)
• FHS (Start Hear 24 Weeks)- No hear, above 160 times and below 120 times
• Albuminuria
• Pre-eclampsia and eclamsia
• Underlying disease
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16. Danger Signs of During
Pregnancy
• Menorrhea
• Anascarsa
• Severe Pain at Abdomen (Suspected ectopic pregnancy)
• Severe Vomiting
• Severe Headache
• Burred Vision
• Fit or Convulsions
• Unconsciousness
• Gush of Amniotic fluid and rupture of Amniotic sac
• Hyperpyrexia
• Pallor at lip, nails ,etc. (sever anemia)
• Respiratory distress
• Not sense of Quickening
• Prolapsed of cord and others from vagina
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17. Indicators for antenatal care
• Proportion of pregnant women who have at least one
antenatal clinic visit
• Proportion of pregnant women who have at least four ANC
visits
• Tetanus protection (2 times)at birth*
• Prevalence of syphilis in pregnant women
• The proportion of pregnant women with a written birth and
emergency plan by 37 weeks of pregnancy
• Rate of HBMR record book (fully) have pregnant womens
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18. Sign and Symptoms of Labour
True labour
• Regular uterine contraction
• Lightening
• Frequent micturition
• Showing
• Dilation of Cervix
• Descent of the presenting
part
• Membrane rupture
False Labour
• Uterine contraction
depends on uterine
segments
• Upper uterine segment
Active contraction
Stronger
Muscle shorter and thicker
• Lower uterine segments
Passive contraction
Weaker
Muscle weaker and thinner
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19. Intrapartum Care
Aim and Objective
• Thorough asepsis
• Delivery with minimum injury to the infant and mother
• Readiness to deal with complications such as prolonged labour, antepartum
hemorrhage, convulsions, malpresentations, prolapse of the cord, etc.
• Care of the baby at delivery- resuscitation, care of cord, care of the eye, etc.
Procedure of Delivery Care
• Clean Delivery Place
• Clean Hand
• Clean Cord Cutter
• Clean Cord Clip
• Clean Mother Dress
• Clean Baby Dress
• Deliver with Skill Birth Attendant
• Birth Registration
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20. Danger signs for intrapartum
transfer
• Sluggish pains or no pains after rupture of membranes
• Good pains for an hour after rupture of membranes, but no progress
• Prolapse of the cord or hand
• Meconium-strained liquor or a slow irregular or excessively fast fetal heart
• Excessive “show” or bleeding during labour (above 500cc)
• Collapse or delay during labour
• Retained placenta
• PPH or collapse
• maternal pyrexia in labour (38.0 °C once or over) during labour
• malpresentation or breech presentation diagnosed for the first time at the
onset of labour, taking into account imminence of birth
• maternal request for epidural pain relief
• either raised diastolic blood pressure (over 90 mmHg) or raised systolic
blood pressure (over 140 mmHg) on two consecutive readings taken 30
minutes apart
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21. Objective of Postnatal Care
• To prevent complications of the postpartal period
• To provide care for the rapid restoration of the
mother to optimum health
• To check adequacy of breast feeding
• To provide family planning services
• To provide basic health education to
mother/family
Duration of Postnatal Care – After Birth to 6
weeks
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22. Postnatal Care
Essential routine PNC for all mothers
• Assess and check for bleeding, check
temperature
• Support breastfeeding, checking the
breasts to prevent mastitis
• Manage anemia, promote nutrition and
insecticide treated bed nets, give vitamin
A supplementation
• Complete tetanus toxoid immunization,
if required
• Provide counseling and a range of
options for family planning
• Refer for complications such as bleeding
(Retained Placenta, infections, or
postnatal depression
• Counsel on danger signs and home care
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23. Essential routine PNC for all newborns
• Assess for danger signs, measure and record weight, and
check temperature and feeding
• Support optimal feeding practices, particularly exclusive
breastfeeding
• Promote hygiene and good skin, eye, and cord care
• If prophylactic eye care, it is still effective until 12 hours after
birth
• Promote clean, dry cord care
• Identify superficial skin infections, such as pus draining from
umbilicus, more than 10 skin pustules, and swelling, redness,
and hardness of skin, and refer if the baby also has danger
signs
• Ensure warmth after the first 24 hours, practicing skin-to-skin
care, and putting a hat on the baby
• Encourage and facilitate birth registration
• Refer for routine immunizations
• Counsel on danger signs and home care
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24. Danger signs for the mother
• Excessive bleeding (Above 300 ml)
• Foul smelling vaginal discharge
• Fever with or without chills
• Severe abdominal pain
• Excessive tiredness or breathlessness
• Swollen hands, face and legs with severe headaches or blurred
vision
• Painful, engorged breasts or sore, cracked, bleeding nipples
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25. Danger signs for the baby
• Convulsions
• Movement only when
stimulated or no movement,
even when stimulated
• Not feeding well
• Fast breathing (more than 60
breaths per minute), grunting
or severe chest in-drawing
• Slow breathing (less than 30
breaths per minute)
• Fever (above 38°C)
• Low body temperature (below
35.5°C),
• Very small baby (less than
1500-2500 grams more than
two months early)
• Bleeding (cord and others)
• Congenital deformation
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26. Key indicators for postnatal
care (PNC)
• Mother/newborn receiving PNC within three days and
subsequent visits
• Place where care is provided and type of care provider
• Timely initiation of breastfeeding within one hour after birth
• Sick newborns taken for treatment
• Case fatality rate of newborn complications (by cause if possible)
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27. Birth Spacing
• Target population- abortion and repeated abortion
clients
• Eligible couple – between 15-49 yrs
• 2-3 yrs interval only, not control population
• To promote health status of women, mother and child
• To reduce the IMR by giving effective and quality birth
spacing
• To give the birth spacing 45 days after birth
• Explain her partner at the same time with consent
• May reduce HIV/AIDS and STD problem by usage of
condom
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28. Family Planning
• To avoided unwanted birth
• To bring about wanted birth
• To regulate the interval between pregnancy
• To control the time at wish birth occurs in relation to the age
of the parent
• To determine the number of children in the family
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29. Birth Spacing Methods
Type of Birth Spacing Advantages Disadvantages
Vasectomy/tubal ligation About 100% effective; no
chemical or mechanical
devices
Is not usually reversible:
surgery may have side-
effects
Birth Control Pill (OC
Pills) and Injectable
Contraceptives
Is highly effective;
requires no last minute
preparation
Has side-effects;
especially in smokers
Intrauterine device (IUD) Is highly effective;
Requires no last minute
preparation or drugs
Has side-effects; may
cause inflammation of
genital organs; may be
lost accidentally
Condom Is easily available; does
not affect physiology ;
protects against STI
Must be applied just
before intercourse; may
slip or tear
Rhythm Involves no surgery,
mechanical devices;
drugs, or hormones;
agrees with some
regilous
Is difficult to follow ;
requires that women’s
menstrual cycle be
regular; has a high failure
rate
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Safe Motherhood
AntenatalCare
PostAbortionCare
CleanandSafeDelivery
FamilyPlanning
PostnatalCare
STDPrevention
Equity for Women
Primary Health Care
Basic Maternal
Care

31. Objective of Neonatal Care
• Establish and maintenance of cardio-respiratory functions
• Maintenance of body temperature
• Avoidance of infection
• Establishment of satisfactory feeding regimen
• Early detection and treatment of congenital and acquired
disorders, especially infections
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32. Neonatal Care
• Cleaning the airway
• Apgar score (a score that is given
after assessing the condition of a
newborn baby in the five areas of
heart rate, breathing, skin color,
muscle tone, and reflex
response)
• Care of the cord
• Care of the eye
• Care of the skin
• Maintenance of body
temperature (36.5’C-37.5’C)
• Breast Feeding
• Neonatal examinations
• Measuring the body
• Timely Referral
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33. High Risk of Neonate
• Fast Breathing (above 60 or below 30)
• Difficult Breathing (wheezing, stridor, etc.)
• Weakness or Stiffness of Muscle
• Abnormal Body Temperature (above 38’C or below 35’C)
although giving warming
• Have over 10 pustules at the body
• Difficult or cannot suck the milk , less than 5 times during
24 hrs.
• Convulsion
• Unconsciousness
• Jaundice or pale
• Abdominal Distention
• LBW (under 1500g)
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34. Major Problems in Child
• Low Birth Weight
• Malnutrition
• Infection and parasitosis
• Accidents and poisoning
• Behavior problems
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35. Danger Signs of Child (Common)
• Unable to drink/ breastfeeding
• Vomits everything
• Convulsions
• Drowsy/ difficult to wake
• Unconscious
• Chest in drawing
• Stridor during inspiration
• Fast breathing by age
• Neck Stiffness
• Bulging fontenelle
• Blood in the stool
• Skin pinch goes back slowly
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36. Age Alert Factors
1-4 Months • Can not see to materials and Mother Face
• Not respond although stimuli of noise
• Not Smile although tease
6 Months • Always Fix of Palm
• Not Strength of Health and Neck
9 Months • Not Able to sit if not have support
(Cannot support to body by hand for sitting)
1 Years • Cannot speech of informal
• Not Able to stand
2 Years • Not Able Call to Parents (Phay Phay , May May)
3 Years • Not able to run
• Not able to speech by well
4 Years • Although speech he face so difficulties and not understand to
Another for that speech
• No play with another children and stay lonely
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37. Services of Child Health Care
• Nutrition Screening (Measure of Body Weight, MUAC)
• Nutrition Promotion
• Home based Care
• Prevention and Control of Communicable Diseases
• Administration to Supplements of Micronutrients and
Macronutrients
• EPI
• IMCI - Early Diagnosis and Prompt Treatment (ARI, Diarrhoea,
Fever, etc.)
• Counseling and Health Education to Parents
• Environmental Sanitation and Personal Hygiene
• Timely Referral
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38. Adolescence Health
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• The term adolescence is derived from the Latin word “adolescere”
meaning to grow, to mature.
• It is considered as a period of transition from childhood to adulthood.
• They are no longer children yet not adults. It is characterized by rapid
physical growth, significant physical ,emotional, psychological and
spiritual changes.
• They are not only in large numbers but are the citizens and workers of
tomorrow.
• The problems of adolescents are multi- dimensional in nature and
require holistic approach.
• A large number of adolescents in Myanmar are out of school,
malnourished, get married early, working in vulnerable situations, and
are sexually active.
• They are exposed to tobacco or alcohol abuse.

39. 6/8/2014
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40. 1. Anorexia nervosa
2. Obesity & overweight
3. Adolescent pregnancy
4. Micronutrient deficiency
5. Emotional problems
6. Behavioral problems
7. Substance abuse & injuries
8. Sexually transmitted infection
9. Thinking and studying problems
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41. PREVENTION
• Health Education
• Skill Based Health Education
• Life Skill Education
• Family Life Education
• Counseling for Emotional Stress
• Nutritional Counseling
• Early Diagnosis and Management of Medical and Behavioral
Problem
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42. Service of Adolescent Health
• Prevention of unwanted pregnancy , STDs and Abuse
• Happy Family Life
• Safe Motherhood care at home
• Social Development
• Counseling Services
• Health Education program
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43. Thank You So Much !!
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