SUSANA O. PABINGUIT, B.S.N., R.N.

DOH-Central Visayas
Outline of Presentation:
Current Situation of Maternal and Child
Health

DOH Issuances on MNCHN

Essential Package of Maternal and Child
Survival Interventions

Essential Newborn Care
Millennium Development Goals
Adopted by the UN General Assembly in September,
2000
Renewal of global commitment to peace and human
rights
Set specific goals and targets towards reducing poverty
and worst forms of human deprivation
Philippines has committed to craft its 2005-2010
Medium Term Philippine Development Plan
Eight goals that are holistic and interrelated, entailing
collaborative efforts of major stakeholders




Source: LGU Guide on MDG Localization

Millennium Development Goals (MDGs)
Goal 1: Eradicate Extreme Poverty and Hunger
Goal 2: Achieve Universal Primary Education
Goal 3: Promote Gender Equality
Goal 4: Reduce Child Mortality
Goal 5: Improve Maternal Health
Baseline : 209, Target: 109 (2000) 52 (2015)
Goal 6: Combat HIV and AIDS, malaria and other
diseases
Goal 7: Ensure environmental sustainability
Goal 8: Develop a global partnership for
development


MDG 4 & 5 and Targets
Reduce Child Mortality
Reduce children under-five mortality by 2/3

Improve Womens Reproductive Health
Reduce maternal mortality rate by 75%
Increase access to reproductive health services to 60%
by 2005, 80% by 2010, 100% by 2015

Current Health Situation in the Philippines

Maternal Mortality Ratio:

162 per 100,000 live births
In other words

If there were 10,000 babies born,
1-2 mothers died in pregnancy, labor,
delivery and post-partum period




So, instead of a happy arrival,




There was an unhappy departure.


Relatively Flat MMR Reduction, Philippines
Figure 2: Trend in Maternal Mortality Ratio
1990-2005
209
203
197
191
186
180
172
162
52.5
0
50
100
150
200
250
1990 1991 1992 1993 1994 1995 1998 2006 2015
MMR MDG
Current Health Situation in the
Philippines
Under 5 Mortality Rate (below 5 years old):

36 per 1,000 live births
In other words
If there were 1,000 babies born,
36 died before their 5
th
bday
So, instead of a Nursery School,
They entered a cemetery.
Current Health Situation
in the Philippines
Infant Mortality Rate (below one year old):

27 per 1,000 live births
In other words
If there were 1,000 babies born,
Almost 27 died before one year
So, instead of a happy 1
st
birthday,
They had a sorrowful death.
Causes of Death in Children
Source: CHERG estimates of under-five deaths, 2000-03; courtesy of Sobel HL.
The Philippines is one of the 42 countries that account for 90% of global under five
mortality
Under-
nutritio
n
53%
Child Mortality Trends
Downward trend in
childhood deaths
but,
Slowed down in the
past decade
Neonatal mortality
remained unchanged
72
52
43
42
34
46
34
31.3
30
25
28
18
17 17
16
0
10
20
30
40
50
60
70
80
1988 1993 1998 2003 2008
UFMR IMR NMR
When are the Newborns Dying?
21 July 2007 21 July 2007
0
5
10
15
20
25
30
35
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28
Figure 3: Deaths of Neonates by Day of Life
Philippines 1998-2003
Day of Life
N
u
m
b
e
r

o
f

d
e
a
t
h
s
50% of neonates die in the
first two days of life
DOH. Child Survival Strategy. July 2007. Courtesy of Sobel HL.
50% of all newborn deaths occur
in the first 2 days of life
3 out of 4 newborn deaths occur in
the 1st week of life
Poor birth spacing
too young
too old
too close
too many pregnancies
too sickly - Mothers with:
* Prevalent infections (TB, Malaria, STI) or
* Lifestyle diseases (diabetes, hypertension)
Maternal malnutrition

Mothers and newborns (0-28 days) dying every year
Main causes of maternal deaths:

1. Hypertensive disorder of pregnancy
2. Post-partum hemorrhage
3. Pregnancy with abortive outcomes
Main causes of neonatal deaths:

1. Pre-term
2. Infection
3. Asphyxia
>80% of Maternal Deaths are due to
5 DIRECT OBSTETRIC COMPLICATIONS
27%
19%
17%
11%
11%
15%
Hemorrhage
Unsafe Abortion
Eclampsia
Obstructed Labor
Infection
Other
Indirect causes include anemia, malaria, and heart disease


Source: Philippine Health Statistics, 2003
Attendants and Place of Delivery
40%
22%
38%
Home, hilot
Home, MW
Hospital
Assessment
Very slow decline of MMR in past 20 years
Maternal deaths account for 14% of deaths among
women of reproductive age
Maternal death triggers other adverse consequences in
families: orphans, loss of family care provider
17 infants die per 1,000 live births within first 28 days of
life
Mostly within first week after birth
Half die during the 1
st
2 days
Policy Developments
Administrative Order 2008-0029
(Sept. 9, 2008) Implementing Health
Reforms for Rapid Reduction of Maternal
and Neonatal Mortality

Administrative Order 2009-0025
(Dec. 01, 2009) Adopting New Policies and
Protocol on Essential Newborn Care




Policy Objective
Reduce maternal and neonatal mortality rates faster
from 2007 to 2015 in order to meet MDG targets

However, we need to understand features and
characteristics of maternal and newborn deaths to
focus our interventions.
Implementing Health Reforms for
Rapid Reduction of Maternal and
Newborn Mortality
General Principles of MNCHN
Every pregnancy is wanted, planned
and supported

Every pregnancy is adequately
managed throughout its course

Every delivery is facility-based and
managed by skilled birth attendants

Every mother-and-newborn pair
secures proper postpartum and
postnatal care (mother and child
survival package)
Integrated MNCHN Service Package
Pre-Pregnancy Services Antenatal care
Postpartum
and Postnatal Care
Care during Delivery

Financing
Health Facilities and Service
Packages
Human Resource
Health Products and
Pharmaceuticals
Other Support Systems

Core Service Package
(Life Cycle Approach)
Pre-pregnancy package of services
Complete pre-natal package
Complete care during delivery
Immediate postpartum and neonatal
Emergency maternal and newborn service package
Pre-pregnancy package
Micro-nutrients (Iron w/ folic acid)
Tetanus-toxoid immunizations
Fertility awareness, birth spacing and FP counselling
Nutrition and healthy lifestyle
Oral health
Counselling and services on STD/HIV/AIDS
Management of lifestyle related diseases
Pre-Natal package
Monitoring of height and weight
Blood pressure determination and monitoring
Pregnancy test, urinalysis, CBC, blood typing, STI screening
Pap smear and acetic acid wash, blood sugar determination
Micro-nutrient supplementation
Tetanus toxoid
Malaria prophylaxis
Birthplanning


Pre-Natal package
Counselling on FP methods ( LAM, BMF
contraceptives)
Counselling on healthy lifestyle
Prevention and management of bleeding in early
pregnancy
Early detection and management of danger signs
and complications of pregnancy
Assessment of fetal growth and well being
Prevention and management of other diseases
Provision of other support services


Childbirth Service Package
Monitoring progress of labor using the partograph
Identification of early signs/symptoms and
appropriate management
The 3 Cs of childbirth
No episiotomy and no fundal pressure
Active management of the third stage of labor
Essential Newborn Care Package


Obstructed
labor
Post-partum service package
Physical Exam ( BP monitoring, pelvic exam)
Identification of early signs and symptoms of
postpartum complications like hemorrhage, infection
and hypertension
Micronutrient supplementation
Provision of FP services
Counselling on
Nutrition
Exclusive breastfeeding up to six months
neonatal care


Neonatal Care
(w/in 24 hours postpartum routine care)
Cord care
Vitamin K injection
Eye prophylaxis
Delayed bathing to 6 hours of life
BCG and Hepatitis B Immunization
Newborn screening
Birth registration
Counselling on post-partum/post-natal check-up, home care
and immunization
Levels of Core Service Package
(Interventions)

BEmONC level
EmONC
CEmONC level
STRATEGIC PLANS FOR 2005-2010
Launch & implement the BEmOC & CEmOC strategy
BEmOC strategy establishment of facilities for
every 125,000 population, can be reached within 30
minutes from each catchment brgy

CEmOC strategy for every 500,000 population;
referring facility, reached within 1 hr. from BEmOC
facility
Basic Emergency Obstetrics and Newborn
Care (BEmONC)
Parenteral administration of oxytocin in the third stage
of labor
Parenteral administration of loading dose of anti-
convulsant
Parenteral administration of initial dose of antibiotics
Assisted delivery during imminent breech presentation
Bleeding
Pre-eclampsia
Infection
BEmONC (continuation)
Manual removal of placenta
Removal of retained placental products
Administration of loading dose of corticosteroids
for threatened pre-mature delivery
Newborn resuscitation w/ oxygen support
Essential Newborn Care

Bleeding
Bleeding &
infection
Neonatal death
Comprehensive Emergency Obstetrics and
Newborn Care (CEmONC)
BEmONC
Parenteral administration of oxytocin in the third stage of labor
Parenteral administration of loading doses of anti-convulsant
Parenteral administration of initial dose of antibiotics
Assisted delivery during imminent breech delivery
Manual removal of placenta (active management of 3rd stage of labor)
Removal of retained placental products
Administration of corticosteroids for threatened pre-mature delivery
Newborn resuscitation
Essential Newborn Care



Operative delivery ( C. Section )
Blood transfusion services
Advanced life support management for low birth weight, premature and sick
newborn like sepsis, asphyxia, severe birth trauma, severe jaundice, etc.


MNCHN Service Delivery Network
End-referral facility (Provincial hospitals etc),
BEMONC functions + Blood transfusion &
Cesarean Section; Operates 24 hrs, with
OB/surgeon, pedia, nurse, MW, med tech



CEmONC
BEmONC
FACILITY
District Hospitals, RHUs
with SHPs
Community Level
Service Provider:
RHU, BHS, WHT, BHT
Normal vaginal delivery, imminent breech
delivery, emergency drugs (antibiotics,
MgSO4, oxytocin), Essential newborn
care, FP services
Pregnancy tracking, birth planning, home visits
and follow-up, nutrition package; IEC on facility
delivery and FP; communication activities
targeted to mothers and their families

TRANSPORTATION and COMMUNICATION SYSTEM
From ...
Birth control
Population control
Limiting family numbers
Liquidating a race
Contraceptives
Birth spacing tools
Repositioning Family Planning as a Program &
Family Planning Commodities
To ...
Rights based: know, informed, choose, use
Health concerns: maintenance and sustenance;
prevention and control of diseases
Economic reasons/family financial stability
Continuum of service: MNCHN context
Inclusion of fertility problems
Inclusion of other modern methods available

Lifes Events and Continuum of
Service
Pre-union:
Premarital sex
Premarital counselling
3-yr &
3 years after
Birth
Delivery
Conception
Pregnancy
INDIVIDUAL HOME COMMUNITY FACILITIES
Approaches...
Decentralized (social prep.; things not to expect)
Rights based (from the womb)
Life cycle
Lifes events

sense of urgency, focus, consolidated efforts and
recognition on the MATERNAL, NEONATAL & CHILD
HEALTH AND NUTRITION (MNCHN) and its INTEGRATED
strategies
Pregnancies and Deliveries ...
As emergencies whether for the so-called rich or poor
Maternal and infant deaths as reportable cases
Blood as a public good
Continuum of services from premarital/union
Pregnant Patient Rights
Facility modification
Imposed/Purposive messages
fbd or fbc
shp or sba
6mos. EB vs. LAM
3yrs spacing


TBAs ...
Incentives to refer deliveries

Join a Barangay Health Team or the Womens Health
Team

Qualified TBAs provided educational assistance to
become midwives
Components ...
BEmONCs
CEmONCs
WBCs
3Tiered and 4Tiered Services
WHT/CHT
Training Centers
PhilHealth accredited MCP Plus (Unbundling)
Database
Tracking and Monitoring (TCL, Deaths daily)
Networks and birth plans including Blood Centers
BUNTIS Connection
Facilities
Professionals
Blood
Transportation services
Communication services
Follow-up services

GET CONNECTED!!!
Essential Newborn Care
Adopting New Policies and Protocol on Essential
Newborn Care (A. O. No. 2009 - 0025)

Objectives:
- Guide health workers and medical practitioners
in providing evidence-based essential newborn
care
- Define the roles and responsibilities of the
different DOH Offices and other agencies in the
implementation of the Newborn Care Protocol

Essential Newborn Care
A package/bundle of interventions
Essential interventions in the first hour and first day to one
week of life
Emphasizes a core sequence of actions or steps
Some time-bound but doable even by a single health worker
caring for both mother and newborn
Rationale

If newborn mortality is not reduced by at least half, the
goal of reducing childhood mortality by two-thirds (MDG
Goal no.4) by 2015 would not be met.
Intervention Percentage and
Median Time
WHO Standard
Cord Clamp 12 sec
99% in < 1 min
Until pulsations stop
(1-3 mins)
Drying 97% at 1 min 100% Immediately
Immediate Skin-to-skin
contact
9.6% at 5 min >90% (except those
needing resuscitation)
Put on cold surface 12% None
Not dried 2.5% None
Head not dried 6.2% None
Wash 84% at 8 min >6 hours
Temp taken before 17% All
A Minute-by-Minute Assessment of Newborn Care
within the First Hour of Life in Philippines Hospitals (2009)
Sobel, Silvestre, Mantaring, Oliveros, 2009
Within 30
Seconds
Objective:
To provide
warmth, prevent
hypothermia
After thorough
drying
Objective:
To facilitate bonding
through STS
(infection,
hypoglycemia)
-Put on double
Gloves
-Dry thoroughly
-Remove wet cloth
-Quick check of
NBsbreathing
-Put prone on chest/
abdomen in STS
-Cover w/ blanket,
bonnet
-Place identification
on ankle
-Do not separate
-Do not remove vernix

Up to 3 minutes
Post-delivery
Objective:
To reduce incidence
anemia in term
and IVH in pre-
term
-Remove 1
st
set of
gloves
-Clamp and cut cord
after cord pulsations
(1-3 mins)
-Do not milk cord
-Active management
of labor
Time-Bound Interventions
Within 90 minutes
Of age
Objective:
To facilitate initiation
of breastfeeding
through sustained
contact
-Leave the NB on
STS contact
-Observe NB for
feeding cues
-Counsel on
positioning and
attachment
** Do eye care
Non-Immediate Interventions
Vit. K
Hepatitis B
BCG
Re-Examination of the newborn
- Weigh
- Look for malformations, etc.
- Feeding difficulties
Cord Care
Newborn Screening

Unnecessary Procedures
Routine suctioning
Early bathing/washing
Footprinting
Giving sugar water, prelacteals, formula and using
bottles and pacifiers
Application of alcohol, other subs on the cord stump
and bandaging the stump/ abdomen




Non-separation of the newborn from
the mother for early breastfeeding
initiation and rooming-in
Immediate and
thorough drying of
the newborn
Early skin-to-skin contact
of the newborn to
mothers skin
Properly-timed cord clamping
and cutting
1. Skilled attendance during pregnancy, childbirth
and the immediate postpartum
2. Care of the newborn
3. Breastfeeding and complementary feeding
4. Micronutrient supplementation
5. Immunization of children and mothers
6. Integrated management of sick children
7. Injury Prevention and Control
8. Birth Spacing
Essential package of child survival interventions
Challenges . . .
Expanded appreciation and advocacy of various factors
affecting overall health of mothers and children
Collaborative work with other health workers and local
government leaders
Advocacy towards good nutrition foundation e.g.
Breastfeeding initiation, exclusive breastfeeding,
rooming-in
The current state of maternal and child care needs
urgent action!
Maternal and Child survival package of
interventions will save thousands of lives


Each of us, as health workers and as individuals, have
to look inward to find ways and influence in
implementing the essential package of maternal and
child survival interventions.


CLOSING THOUGHTS
Lets join
HANDS!
. . In
supporting
MNCHN
Strategy!
Good day to all !