Safe Motherhood

Dr. Durdana KhanAssistant Professor

Department of Community Health Sciences

Dated: November 4th, 2016

Outline…

Why to safe A “Mother” ?

A journey from human to human right

Millennium Development Goals

Goal 5

Sustainable Development Goals

Goal 1, 3, 5 and 10

Safe Motherhood Models

Case studies

Why to safe A “Mother”?

Every Minute in the World…

380 Women become pregnant

190 Women face an unplanned or unwanted

pregnancy

110 Women experience a pregnancy-related

complication

40 Women have an unsafe abortion

5 Babies are born dead

5 Newborns die

1 mother dies

Maternal mortality ratio by region, 1990, 2005 and 2013

Source: http://data.unicef.org/maternal-health/maternal-mortality#sthash.WW4wpPPI.dpuf

Balochistan's women suffer in silence

Source: http://www.dawn.com/news/1139853, PUBLISHED OCT 23, 2014 04:17PM

According to Pakistan Health

Demographic Survey (PHDS)

Balochistan stands first in terms of Maternal

Mortality Rate (MMR) as compared to other

provinces of the country

785 die in Balochistan as compared to 272 in rest

of the country, out of 100,000 women,

BIG reasons:

Long distances

Poor communication systems

Lack of basic health facilities

Safe Motherhood…

A journey to human Right

1930…

The League of Nations Health Section noted concerns

about maternal mortality

1978…

Primary Health Care sponsored by WHO and UNICEF

in Alma Ata

1985…

WHO with UNFPA, supported first community studies on

maternal mortality in developing countries

1976-85, The United Nations Decade for Women, focus

attention on women’s rights and health.

Safe Motherhood…

A journey to human Right

1987…

WHO, UNFPA and World Bank sponsored first

international Safe Motherhood Conference in Nairobi

The effective starting point of what came to be known

as the Safe Motherhood Initiative (SMI)

1989…

The World Summit for Children in New York

Maternal mortality was viewed within the context of

ensuring the survival and health of children

1990…(28th May)

International Day of Action for Women’s health

Safe Motherhood…

A journey to human Right

1990…

NGOs working in the area of safe motherhood, at a

very local level, engaging in community-based

research, participating in awareness-raising or public

education campaigns, promoting workshops, meetings

or media events and even delivering care

1998…

World Health Day devoted to safe motherhood, with

the slogan ‘Pregnancy is special: let’s make it safe’

2000…

Millennium Declaration defined MDGS

Safe Motherhood is…

“A human right….

We must empower women and ensure choices …Our

task and the task of many like us, is to ensure that in the

next decade safe motherhood is not regarded as a

fringe issue, but as a central issue”

James D. Wolfensohn

President – World Bank

MDGs

MDG:

Goal 5: Improve Maternal Health

Reduce Maternal Mortality by three quarters, till

2015

Indicators

MMR & % of births attended by skilled health

personnel

Sustainable Development Goals

(SDGs)

TARGETS

3.1: By 2030, reduce the global maternal mortality

ratio to less than 70 per 100,000 live births

3.2: By 2030, end preventable deaths of newborns

and children under 5 years of age, with all

countries aiming to reduce neonatal mortality to at

least as low as 12 per 1,000 live births and under-

5 mortality to at least as low as 25 per 1,000 live

births

Targets

3.7: By 2030, ensure universal access to

reproductive health-care services, including for

family planning, information and education, and the

integration of reproductive health into national

strategies and programs

Definition

Safe Motherhood…

“Encompasses a series of initiatives, practices,

protocols and service delivery guidelines designed to

ensure that women receive high-quality gynecological,

family planning, prenatal, delivery and postpartum

care, in order to achieve optimal health for the

mother, fetus and infant during pregnancy, childbirth

and postpartum”

Lifetime health

Problems

• Gender violence

• Certain occupational and

Environment health

hazards

• depression

Infancy and childhood

(0 – 9 years)

•Sex selection

•Genital mutilation

•Discriminatory nutrition/ health

care

Adolescence

(10 – 19 years)

•Early childbearing

•Unsafe abortion

•STDs and AIDS

•Under nutrition and

Micronutrient deficiency

•Substance abuse

Reproductive Years

(20 – 44 years

•Unplanned pregnancy

•STDs and AIDS

•Unsafe Abortion

•Pregnancy complications

•Malnutrition, especially iron deficiency

Post-Reproductive

Years (45 + Years)

•Cardiovascular diseases

•Gynecological cancer

•Osteoporosis

•Osteoarthritis

•Diabetes

Health related problems across a woman’s lifetime

Safe Motherhood

WHO strategies for safe mother hood are;

The safe motherhood is based on four pillars, which

should be delivered through the primary health care

on the foundation of equity for women.

These pillars are

Family planning

Antenatal care

Clean/safe delivery

Essential obstetric care

Four Pillars Model

Six Pillars Model…

Services needed for safe

motherhood…

Prenatal services

Home visit by the midwives

Establishment of prenatal clinics

Intra-natal services

One midwife per 1000 births or3000 population

Medical advise by MO

Maternity homes

Supply of sterilized kits for delivery

Diagnostic and lab facilities

Ambulance services

Post natal services

Home visit by the midwives or LHV

Welfare centers for milk supply

Postnatal clinics for mothers

Hospital beds for complicated cases

Dai trainings

Supervision

Antenatal care

Care of mothers during pregnancy is ANC

The aim is to achieve healthy mothers and

healthy child at the end of pregnancy

It begin soon after conception till the end of

pregnancy

Objectives

To promote and maintain the health of mothers

during pregnancy

To detect high risk cases and give them attention

To foresee complication and prevent them

To sensitize mother for need of family planning

To teach mother the art of child health care

Components

Careful and complete obstetric history

Mother history especially in respect of diabetes,

hypertension and renal disease

Regular antenatal visits

Antenatal visits

Visits

-1st visit as soon as possible

-After every 4 weeks till 28 weeks

-After every 2 weeks till 36 weeks

-Once a week till she deliver

Antenatal visits

Minimum Antenatal visits

At least 4 visits are required

1st visit at 6-16 weeks –or before 12 weeks to confirm pregnancy

2nd visit at 24 weeks for baseline of health profile

3rd visit 32-34 weeks to find out position and presenting part

Last visit At 36 weeks where to deliver the baby

In routine 1st visits

To confirms the pregnancy

to confirm that she is fit to bear the strain of pregnancy

To know baseline of health

To detect any abnormalities and advise suitable treatment like referral if she needs.

Complete general physical examination

Routine investigation…. Blood complete, urine complete ,BP.

Special investigation like blood sugar. Urine for albumin, RH factor, etc

Clean/Safe Delivery…

2 interventions strategies have been proposed

Essential Obstetric Care (EOC)

Emergency Obstetric Care (EmOC)

EOC is a key to reducing maternal mortality

Essential obstetric care Emergency obstetric care

A broad strategy with

array of services:

Family planning

Antenatal care, intrapartum

and postpartum care

Focuses on all pregnant

women – based on the

concept of risk assessment

These are prompt intervention

measures:

Blood transfusion,

Intravenous antibiotics,

Caesarean delivery, vacuum

or forceps delivery

Focuses on prompt

identification; referral and

treatment of women with

obstetrical complications

AIMs of EOC…

To accelerate country-level action to improve

maternal health by focusing on preventing,

detecting and managing the major causes of

maternal mortality

Increased coverage (availability, accessibility

and utilization) as well as the performance of

EOC facilities

Levels of EOC…

Health center level (basic EOC)

District hospital level (comprehensive EOC)

Health center level (basic EOC)

One or more trained worker(s)

Equipment Required:

Oxytocics, antibiotics, manual placental,

removal, assisted delivery, MVA for incomplete

abortion

District hospital level (comprehensive EOC)

General physicians and nurses

Blood transfusion, intravenous antibiotics, MVA for

incomplete abortion,

Surgical obstetrics – Caesarean section, repair of

vaginal, cervical or perineal tears or episiotomies

etc.

Neonatal resuscitation

Anaesthesia

Post-Natal Care…

Also, Postpartum Care

Care of the mother after delivery

Objectives…

To assess a woman in the postpartum period

properly

To be able to recognize and respond to

abnormalities recognized in the postpartum

period

To give proper counseling to postpartum

mothers

Schedule Return Visits

All postpartum women should have at least 2 routine postpartum visits

1st visit: 1st week postpartum, preferably within 48 -72 hours.

2nd visit 6 weeks postpartum

Women who do not return for postpartum visits should be visited at home

Components of Postpartum Care Visit

Early detection and management of

complications

Complication readiness

Promoting health and preventing disease

Woman-centered education and counseling

Steps to follow in Post partum care

1) Assess for emergency signs.

Vaginal bleeding

Fever

Pallor

Looks very ill

* Do not make a very sick woman wait, attend her

immediately.

2) Greet the mother. Make her feel comfortable

3) Assess breastfeeding

When, where delivered

Is there any difficulty?

Painful breast/abdomen? Fever?

Hard to void urine?/ Hard to pass stools?

Bleeding since delivery

Family Planning?

Other concerns?

Check records: complications, treatment during delivery?

Assess…

Postpartum Care

Providing GOOD CARE during

postpartum visit:

Make the woman comfortable

Tell the woman you will examine her

Wash your hands before and after

examining woman.

Maintain privacy

Inform and explain findings to woman

Is there any difficulty breastfeeding?

Observe how mother breastfeeds for at least

4 minutes

Is baby positioned well?

Is baby sucking effectively?

Assess breastfeeding…

Routine Postpartum Care

Mother feels well

BP, pulse & temperature

normal

No breast problems,

breastfeeding well

Uterus well contracted

No problem with urination

No pain or other concern

Give any treatment

or prophylaxis due

Iron

Vitamin A

Tetanus

Advise and Counsel

Health education

Schedule return visit

Abnormalities in Postpartum Period...

Elevated BP

Pallor

Vaginal Bleeding

Foul smelling lochia

Dribbling Urine

Pus or perineal pain

Feeling unhappy

Vaginal discharge

Breast Problem

Infection/ Breast abscess

Sore or cracked nipple

Engorgement

Insufficient milk

Cough or breathing

difficulty

REFER

ADVISE AND COUNSEL…

Postpartum care and hygiene

Wash hands before handling baby

Wash perineum daily

Have enough rest and sleep

Nutrition

Eat a greater amount and variety of healthy foods

Spend more time on nutrition counselling with thin women and adolescents.

Importance, benefits and management of breastfeeding

Teach correct positioning and attachment for

breastfeeding

Support exclusive breastfeeding for the first 6 months of

life

Encourage breastfeeding on demand

Need to avoid supplementary feeds

Encourage Breastfeeding

Counsel on importance of family planning

Inform about all contraceptive choices in postpartum

period (ideally done antenatal)

Facilitate free informed choice for all women

Reinforce that non-hormonal methods (LAM, barrier

methods, IUD and sterilization) are best options for

lactating mothers

Discuss other method options for the breastfeeding &

non-breastfeeding woman

Birth Spacing & Family Planning…

PRE / POST ABORTION CARE FOR

COMPLICATIONS

Create awareness about dangers of abortion

Detection and early management of complications of

abortion

Counseling to post abortion cases including advice

regarding FP to avoid recurrence.

INFANT HEALTH CARE

Resuscitation of the newborn.

Early and exclusive breastfeeding.

Management of infection (ophthalmia

neonatorum and cord infections).

Congenital abnormalities.

LBW and malnutrition management.

Weaning.

Safe and aseptic circumcision

Immunization.

PREVENTION AND MANAGEMENT OF STDs AND

HIV/AIDS

Information for prevention

Screening and management

DETECTION OF CANCER

BREAST

Inform and train for self examination.

Early detection and management.

Screening for breast lumps.

Supporting, counseling, rehabilitation.

CERVEX

Pap smear.

Early detection and management.

Levels and Practices of RHTertiary Level

(Teaching, Specialist Hosp)

Gynecologists, pediatricians

all services

Secondary Level

(Tehsil and Dirtrict Hosp)

Doctors, antenatal, postnatal, family planning, immunization,

normal/complicated delivery

Primary Level

(BHUs and RHCs)

LHVs, TBAs, Doctors, antenatal,

Postnatal, family planning, immunization

Normal dilivery

Community

TBA’s LHVs, Midwives

Antenatal, Postnatal, Family Planning, immunization

FACTORS INFLUENCING

PROVISION OF RH SERVICES

Number of service delivery points

Geographical, physical and social

accessibility

Proper advertisement of services

Quality of care

Case Studies…

Mumtaz et al. BMC International Health and Human

Rights 2011, 11(Suppl 2):S4

http://www.biomedcentral.com/1472-698X/11/S2/S4

Case study 1 - Shida

Case study 2 - Zainab

Findings

• Five maternal deaths in the last 5 years in a population of less than 2000 people.

• Despite availability of health services that include

1. Qualified physician - private clinic 20 minute drive

2. Two rural health centres - 20 minutes.

3. Basic health unit - 15 minute drive.

4. Large district hospital - 90 minute drive.

Discussion

Objective of this research is to explore the underlying

contextual factors that explain why some women

experience adverse maternal outcomes, while others do

not.

See that despite differences in details, the stories of

Zainab and Shida illustrate how rigidly structured castes,

poverty and gendered devaluating of women prevent

women from using lifesaving health services right at their

disposal

Caste and poverty

Both women belonged to lower

castes

Both women were Kammi, although

Zainab was married into a poor Mianne

family

Of the five maternal deaths in the village,

4 were Kammi women and one Mirza

Caste and poverty

Both women were poor

Data show poverty is not merely inherited or

accidental, but the consequence of numerous

structural factors intersecting to create and

perpetuate economic and social vulnerability in

certain groups of people

Chronic poverty and low castes act synergistically

Gender

Gender inequalities also emerge in

these case studies

Domestic violence is a gendered phenomena and

violence during pregnancy well documented

Serves to perpetuate male power and is sustained by a

culture of silence and denial of the seriousness of the

health consequences of the abuse

Reference

Mumtaz et al. BMC International Health and Human Rights 2011, 11(Suppl

2):S4 http://www.biomedcentral.com/1472-698X/11/S2/S4

Safe Motherhood: a brief history of the global movement 1947–2002

Carla AbouZahr World Health Organization, Geneva, Switzerland

file:///C:/Users/durdana/Desktop/PMC/Lectures/4th%20year%20MBBS

/Reproductive%20Health/History%20of%20safe%20motherhood.pdf

Thank You