Safe Motherhood Initiative: Definitions and Pillars

Dr. Olive Sentumbwe-Mugisa Family Health and Population Officer, World Health Organisation

Components of Reproductive Health

Safe motherhood Family Planning Unsafe abortion STIs including HIV/AIDS Adolescent Health Infertility Menopause and Andropause Cancers of the RH Organs( Cervix and breast) Gender Issues (Gender Based Violence, Obstetric Fistula, Female Genital Mutilation, Male Involvement)

Definition of Safe Motherhood

Safe Motherhood means that no woman, fetus or baby should die or be harmed by pregnancy or birth. Safe Motherhood begins with the assurance of basic safe living as a girl and a woman in society. Safe Motherhood is founded on freedom to choose when and whether to have children, and encourages active participation during health care. Safe Motherhood is founded on freedom from discrimination of any form. Safe Motherhood values the girl child, respects the freedom to choose when and whether to have children, and encourages active participation during health care.

Definition of Safe Motherhood

Safe Motherhood implies the availability, acceptability, and easy access to health care for a womans prenatal, birth, postpartum, family planning and gynaecological needs Safe Motherhood requires involvement and commitment from each community and the nation to fairly allocate resources that promote the health of all women and infants. Safe Motherhood means: social equity for women, maternal health care in Primary Health Care, Essential Obstetrics for all and Family Planning for all couples.

Why is maternal mortality an important issue? 1

Pregnancy is not a disease, it is one of the most important moments in the life of a woman,perhaps one of the noblest achievements The birth of a baby is a moment of great joy for the mother, the father, the rest of the family, the village, the whole community Reproduction is key to society
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Introduction
Making motherhood safe for the worlds women calls for national governments, multi-lateral and bi-lateral agencies , non-governmental organisations (NGOs)and civil society to make maternal health a top priority There is a need to ensure that the necessary political and financial resources are dedicated to this effort. Safe motherhood is a vital, compelling and costeffective economic and social investment. Promoting womens health improves not only individual health, but also the health and survival of womens families, labour force and the well-being of communities and countries.

The Health of the mother and newborn are entwined

120 Stillbirths and neonatal deaths per 1000 births 100 80 60 40 20 0 Africa
Source: WHO estimates 2000

Neonatal deaths per 1000 live births Stillbirths per 1000 births Maternal deaths per 10'000* live births

120 Maternal deaths per 10'000* live births

80

40

0 Asia Latin America &More developed the Caribbean regions

The burden
For women of reproductive age, pregnancy and childbirth are the leading causes of death, disease and disability, accounting for at least 18% of the global burden of disease in this age group. Yet pregnancy is perceived to be a normal event

African countries with greatest numbers of neonatal deaths

country Range in neonatal deaths Number of deaths

Range in maternal deaths

1 2 3 8 6 4 16 5 9 7 24 10 27 21 11

Nigeria RD Congo Ethiopia Tanzania Uganda Kenya Cte d'Ivoire Angola Mali Niger Ghana Mozambique South Africa Madagascar Burkina Faso

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

255,500 130,900 119,500 44,900 44,500 43,600

50%

90%

42,800 40,100 36,900 31,700 29,200 28,500 23,000 22,500 18,600

When are the world 4 million newborn deaths occurring?

About 30% of neonatal deaths are on the day of birth

30 25

Proportion of deaths

20 15 10 5 0 0

More than 70% of neonatal deaths are in the first week ~ 3 million deaths

nd most verag for th a hen n co est es Bir w e

w wh is lo babi d e car rs an of the mo

st w abies e fir b

k is ie ee d

ey: k

10

15 Days of life

20

25

30

Daily numbers of death in 37 countries during the first month of life - based on 38 DHS datasets (2000 to 2004) with 5,763 neonatal deaths

4 million newborn deaths Why?

Almost all are due to preventable conditions

Definition of maternal death

The death of a woman while pregnant or within 42 days of termination of 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.
WHO-International Statistical classification of Diseases and related Health Problems,tenth 12 Revision,1992 (ICD-10)

Where maternal deaths occur

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It can be done, and it has been done It is not a matter of money only
MMR, deaths/100,000 live births 1960 1970 % decline Malaysia 250 150 66% Sri Lanka 260 150 73% Thailand 420 260 62% Kerala state (India), figures of 2006, MMR of 95 when for the whole of India is 254
Currently, Malaysia-28, Sri Lanka-47, Thailand-44
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Causes of maternal deaths: percent distribution

Other causes 23% Other direct 2%

Haemorrhage

26%

Abortion 8% Obstructed labour 13% Eclampsia 6%

Sepsis 22%

Four Pillars of Safe Motherhood

SAFE MOTHERHOOD
EMERGENCY OBSTETRIC CARE

ANTENTAL CARE

BASIC MATERNITY CARE PRIMARY HEALTH CARE EQUITY FOR WOMEN

CLEAN/SAFE DELIVERY, NEWBORN CARE AND POSTNATAL CARE

FAMILY PLANNING

Family Planning
Family Planning is the practice of spacing children that are born using both natural (traditional) and modern (artificial) birth control methods. Birth spacing promotes the health of the mother, children and the father. There are two types of birth control methods: natural and modern (artificial). The modern methods are further subdivided into short-term, long-term and emergency contraception methods.

Antenatal Care
Ante-natal care is defined as a planned programme of medical management of pregnant women directed towards making pregnancy and labour a safe and satisfying experience with an outcome of a healthy baby and mother.

Safe Delivery
Refers to ensuring that the mother experiences a clean and safe delivery This area refers to both normal vaginal birth and other modes such as C/S and vacuum extraction A Skilled attendant is recommended Provision of emergency Obstetric and newborn care when needed.

Postnatal Care
Postnatal care: This is health care given to a mother and baby after childbirth up to 6-8 weeks.

Emergency Obstetric Care

This is urgent medical care given to a woman for complications related to pregnancy, labour, delivery and puerperium.
Basic EmOC includes parental (administered by IV) antibiotics; parental oxytocic drugs; parental sedatives for eclampsia; manual removal of placenta; manual removal of retained products; assisted vaginal delivery. Comprehensive EmOC: includes surgery (caesarean section); anaesthesia; and blood transfusion in addition to all of the basic EmOC

Newborn Care
Ensure normal breathing Thermal care-keeping baby warm Cord care Immunisation as per schedule Appropriate infant feeding/breast feeding

Evidence from the Lancet

Cause-specific effect of intervention packages delivered at different periods
Reduction: all-cause neonatal mortality 10-50% Incidence of neural tube defects: 40-85%
10-20% 10-30% 20-55%

Nature of intevention (main elements of intervention packages) Antenatal/ intrapartum/ postnatal Preconception Family care: clean home delivery, hygienic cord care, thermal care, breastfeeding promotion Folic acid supplementation
Antenatal care: physical exam, tetanus toxoid, detection and treatment of syphilis and pre- eclampsia Malaria ( intermittent presumptive treatment) Detection and treatment of asymptomatic bacteriuria Incidence of prematurity or low birthweight

Antenatal

Skilled maternal and immediate neonatal care Intrapartum Emergency obstetric care: management of complications- obstructed labour, haemorrhage, hypertension, infection Extra care for low birthweight infants: extra warmth, hygiene, feeding Case management for pneumonia Emergency neonatal care: management of serious ilness

Skilled birth care:20-30%; Resuscitation: 5-20%; 10-15%

Postnatal

20-40% 10-35% 15-50%

Family and Community Practices for promotion of New Born and Maternal heath
Early initiation of and exclusive breastfeeding Keeping the neonate warm Hygienic cord and skin care Routine postnatal care through home visits at critical moments Home care for LBW infant -Skin to skin Early recognition of danger signs by caregivers and prompt care seeking Antenatal visits, TT vaccination, IPT ITN use by pregnant women, mothers and infants Family Planning Delivery by a skilled worker Maternal Nutrition Male involvement

The components
Family Planning expansion of service delivery points; improvement of communication through community based and social marketing approaches; training of service providers to enhance technical skills and improve attitudes; guaranteeing the availability of family planning commodities and supplies at all levels; improvement of family planning logistics management (LMIS/HMIS); enhancement of political and community support and participation in family planning activities; improvement of record keeping; strengthening of the follow-up, supervision and referral systems.

Antenatal Care
Information, education and communication on risk factors and warning signs and symptoms during pregnancy. prevention and management of anemia; provision of iron and folic acid supplement; screening for pre-eclampsia and diabetes; Examination of the mother to evaluate the pregnancy; early detection and referral or management of mothers with high risk pregnancies; immunization against tetanus; syphilis screening and treatment; HIV information, testing, treatment and referral; prevention and management of malaria; ARVs for prevention of mother-to-child transmission of HIV Infant feeding counselling

Delivery Care
Information on signs of labor, what to expect and what to do Monitoring labour and documenting Referral if it becomes necessary Clean supplies / Warm clothing Drugs required for pain relief and delivery Communication with the family members especially the spouse HIV testing and counseling Infant feeding options

Post Natal care and newborn care

Information on danger signs , what to expect and what to do Immunization for both mother and baby Infant feeding options Maternal wellbeing Responsible fatherhood Family planning options Resumption of sex Post Natal Clinic

Current status
Only 48% of Women attend the recommended 4 times during ANC Only 52% of women deliver in health units Only 14% of HFs offer EmOC Only 23% of women get post partum care during the first 2 days following child birth

Challenges
Insufficient awareness on danger signs, safe motherhood in general Low status of women- decision making Inadequate male support Poor Education level Poor health seeking behavior High/ uncontrolled fertility

Why we must take action and The costs involved

While the needless suffering and death of a woman when giving life to the next generation is sufficient cause for action in itself, there are also other significant social and economic considerations. Families lose her contribution to household management and provision of care for children and other family members;

Children suffer most: when a mother dies, surviving children are 3 to 10 times more likely to die within two years than children who live with both parents; motherless children are likely to get less health care and education as they grow up.
Communities lose a vital member whose unpaid labour is often central to community life; The economy loses her productive contribution to the work force

What Can Be Done

Even in low resource settings, improving maternal health is possible. What is needed is a strong political commitment. Governments, international agencies, NGOs and other development partners need to make concerted efforts to safeguard maternal health by;
Reallocating investment in health care to support the most cost-effective interventions Investing in maternal health care services and making them available, especially in poor and rural areas

Framework for Promotion and Implementation of Community-based interventions

Information and Education Materials: danger signs, birth preparedness and emergency plan Mobilisation of key stakeholders and community leaders Support to existing community organizations and structures: associations, NGOs, etc.

Proposed ways to accelerate the change of the situation

Government Stewardship Parliaments and similar institutions should step into the process The importance of functioning health systems Integrated approach Introduction of mandatory regular analysis of maternal deaths Active involvement of civil society Local research to inform the people and local institutions/entities Additional resources and International Solidarity

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Framework for Promotion and Implementation of Community-based interventions Community component in referral system
Organisation of transport (common transport mechanisms) Communication systems (telephone, radio communication)

Community-based financing schemes Community-based surveillance system for the health of the mother and newborn (birth and death registrations, audits)

Strengthening the referral system

Emergency transportation Communication

The Safe motherhood day and commemoration week

Annual events have been held in Soroti, Kamwenge ,Kayunga Mayuge etc.27th October Patron is the first lady A national report is usually produced We are in preparation for this year Districts are encouraged to conduct district specific activities

For Change to Happen

We need to follow it up

Accountability at all levels

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WHO, Rivers of life

Thank you!