Millennium Development Goals 4 and 5

Accelerating a Unified Strategy to Save Mothers, Newborns and Children

Mario C. Villaverde MD, MPH, MPM
Undersecretary of Health

At current rate of decline, the Philippines is unlikely to reach the MDG target for MMR by 2015
250
209

200 150 100 50 0 1993

172

162
140

52

1998

2006

2015

Hypertension, post-partum hemorrhage and severe abortive outcomes are the leading direct causes of maternal deaths
pregnancy with abortive outcome, 10.50% other complications related to pregnancy, 45.10% postpartum hemorrhage, 17.70%

hypertension complicating pregnancy, childbirth and puerperium,

26.60%

Source: Philippine Health Statistics, 2003

Most maternal deaths occur during labor, delivery and the immediate post-partum period

Percent of maternal deaths in developing countries

0-1 day

2-7 days

8-14 days

15-21 days

22-30 days

31-42 days

Day of maternal death after delivery

Source: X. F. Li et al., International Joumal of Gynecology & Obstetrics 54 (1996): 1-10

UFMR and IMR targets are likely to be reached by 2015 but pace of reduction has decelerated due to very slow decline of NMR
80 70 60 50 40 30 20 10 0 1988 1993 1998 2003 2006 2015

UFMR

IMR

NMR

Neonatal events account for most of the direct causes of under-five mortalities

Undernutrition

53%

Source: CHERG estimates of under-five deaths, 2000-2003

Majority of newborns die due to stressful events surrounding delivery

Number of deaths

50 percent of neonatal deaths occur in the first two days of life

Day of Life

Undernutrition, high fertility rates and unmet needs for family planning are major underlying factors that worsen morbidity and mortality outcomes for mothers and children

Nutritional factors Obvious hunger Hidden hunger Fertility factors High fertility rate High unmet needs for family planning and reproductive health Incidental illnesses Malaria, HIV/STIs, TB, chronic diseases

Maternal and newborn deaths are influenced by the place of delivery and who assists in the process
Most mothers prefer to give birth at home with the

assistance of TBAs
where mothers and newborns are distanced from life-saving interventions provided in health facilities by health professionals during intrapartum period, maternal and neonatal deaths are high

Mothers do not routinely choose to deliver in health

facilities and avail of professional services due to several barriers

hostile hospital system, poor interpersonal skills of staff, financial, physical, social and cultural constraints are deterrents to actual service utilization

Policy Issues and Policy Options

Separate programmatic strategies for mothers and

children do not address the need to congregate or integrate actions around labor, delivery and immediate post-partum where most of the deaths occur
DOH needs to institute a unified strategic framework

for maternal and newborn care that is linked with child survival strategies and will maximize the delivery of service packages and ensure a continuum of care across the life cycle stages

Policy and Strategic Thrusts

4-Tierred Service Delivery Model

Catchment population per facility Distance from any home (travel time)
4th tier: CEmONC

Services: All BEmONC services, blood transfusion, cesarean section

Parenteral drugs for mothers and neonates, imminent breech delivery, removal of retained products of conception; manual removal of retained placental fragments, BTL, vasectomy, IUD insertion; neonatal resuscitation, oxygen

500,000

< 2 hours

125,000

< 30 mins

3rd tier: BEmONC

2nd tier: Basic Essential Obstetric & Newborn Care (BEONC)

1st tier: Community-based teams

Normal spontaneous vaginal deliveries, antenatal and postpartum care, essential newborn care; services for women of reproductive age; FP, nutrition package

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

Infrastructure and Service Package Development

First Tier Community-based teams
Womens Health Teams

Second Tier Basic Essential Obstetric and Newborn Care (BEONC)

RHUs/BHSs, birthing facilities, private clinics

Third Tier Basic Emergency Obstetric and Newborn Care (BEmONC)

Selected RHUs, district/core district hospitals, private hospitals

Fourth Tier Comprehensive Emergency Obstetric and Newborn Care (CEmONC)

Provincial hospitals, regional hospitals, medical centers

Human Resource Development

TBAs and Community Health Workers Defining roles and incentives in Womens Health Team Training TBAs as professional midwives Regulating TBA practices Midwives, Nurses and Doctors Upgrade skills of midwives, nurses and doctors for BEONC, BEmONC and CEmONC Mandates for midwives Develop as team of professionals
Midwives at basic level Midwives, nurses and doctors at BEmONC and CEmONC

Information System, Health Education and Advocacy

Database, information and surveillance system Establishing sensitive indicators for performance and outcomes Improving data quality, disaggregation, timeliness Analyzing and acting on data

Health Education and Advocacy IEC / health education and advocacy

National and local policy makers / decision-makers TBAs / CHWs Health professionals (MW/N/MD) Pregnant women / families

Financing Schemes
Free access for mothers Minimal or zero co-payment especially for indigents Cash transfer vouchers for transport Incentives for institutional and individual providers PhilHealth reimbursement share Performance-based incentives Incentives for local government participation PhilHealth capitation fund Government grants

Implementing and accelerating a unified strategy to save mothers, newborns and children is possible
Focusing interventions on the direct causes of deaths Integrating maternal, newborn and child health

interventions Shifting from home-based TBA-assisted births to facilitybased professionally-assisted births Targeting high-risk and low performing areas to fast track attainment of goals Empowering mothers to utilize life-saving packages Developing incentive and disincentive mechanisms to influence positive behaviors from health providers and consumers