maternal and child healt anh d family planning

World Health Organization ^йж Organisation mondiale de la Santé

EXECUTIVE BOARD Provisional agenda item 8 EB93/INF.DOC./3 Ninety-third Session 13 January 1994

Maternal and child health and family planning

This document presents a tabular summary o f action in response to priorit ies set and

recommendat ions made at the sixth meet ing of the Expert Comm i t t e e on Ma te rna l and Ch i ld Hea l th , in

1975, as well as the needs which have emerged since 1975, and related fami ly p lann ing policies and

programmes.

The summary was presented to the seventh meet ing of the Expert Comm i t t e e in December 1993.

i

PRIORITIES SET AND RECOMMENDATIONS MADE AT THE SIXTH MEETING OF THE EXPERT COMMITTEE, IN 1975： HIGHLIGHTS OF SUBSEQUENT ACTION, ACHIEVEMENTS, PERSISTENT PROBLEMS AND EMERGING NEEDS

Priority needs or

concerns identified

by the 6th Expert

Committee in 1975

Recommendations of

the 6th EiKpert

Committee in 1975

Policy and programme

response: WHO or

other since 1976

Achievements

(data from HFA

evaluation 1985 and

1991)

1983-

1985

1988-

1990 Remaining problems Emerging needs

Inadequate coverage Extend PHC and

support systems of

care to underserved

WHA32.42 1.(2)-

Promote free services

for periods of high

risk; primary health

care.

WHA31.55 - M C H

coverage:

strengthening PHC.

WHA46.18 - M C H

and FP for health.

Prenatal care (%):

Developing countries: 48 65

of which least

developed: 45 53

Childbirth - trained

attendant:


of which least

developed: 36 32

Infant care:


of which least

developed: 36 56

Those most in need

(women, children, migrants,

rural and urban poor,

refugees, aged, young)

continue to have limited

access to services. Trends

may be getting worse in

some regions.

Coverage is a more

complex issue than simply

ensuring the availability of

services. Use of services

involves perceptions,

motivation, cultural and

economic accessibility.

Services still suffer lack of

infrastructure,

overstretching and

management deficiencies.

Structural adjustment

and cutbacks in public

services. Placement of

charges may decrease

use of essential care.

Uneven population

growth, distribution,

migration, urbanization,

need to be built into

health planning.

Equity not being

addressed.

Perinatal period and

early childhood

neglected

Give priority - ensure

intersectoral

coordination - M C H

integration with

overall services and

part of

socioeconomic

development

WHA45.22 - Newborn

health as part of safe

motherhood; four

essential needs.

WHA34.22 - Breast-

feeding promotion to

improve infant and

young child health -

promotion of code.

See above

Breast-feeding

protection,

promotion and

support.

Pressing needs include:

strengthening training in

lactation management,

clean delivery, resuscitation

and thermal control.

Maternal nutrition,

infection control and

decrease energy

expenditure to decrease low

birth weight, sustaining

immunization coverage.

Toxic environmental

exposures, substance

abuse, H IV /A IDS

management, child

neglect/abuse,

psychosocial factors

affecting health and

development.

EB93/INF.DOC. 3

Priority needs or

concerns identified

by the 6th Expert

Committee in 1975

Recommendations of

the 6th Expert

Committee in 1975


response: W H O or

other since 1976

Achievements

(data from HFA 1983- 1988-

evaluation 1985 and 1985 1990

1991)

Remaining problems Emerging needs

Need for integration

of M C H within PHC

Develop a basic

package for delivery

within primary health

care according to

local needs, social

and cultural

characteristics and

resources

WHA32.20 on the

Alma-Ata Declaration

and the HFA strategy.

WHA32.42 - Follow-

up to Alma-Ata

WHA46.18 - MCH/FP

Various component

elements developed:

Immunization - EPI;

infection control -

ORS, sick child case

management;

essential obstetric

care and the

mother/baby

package; FP as an

essential element of

MCH.

Many countries lack an

integrated delivery system

for MCH/FP in PHC.

"Vertical" programmes with

own management,

information and training

strategies supported by

external funding.

Need for further

decentralization and focus

on first referral level.

Risks that aggressively

set targets without an

overall health

development and PHC

strategy will distort

programmes.

Development of district

health systems.

Care for mothers and

children fragmented

and not family

focused

Use of all contacts of

mother and child

with health workers

to provide

simultaneous delivery

of integrated

promotive,

preventive, curative

and rehabilitative

action

WHA46.27 -

International year of

the family

The concept of

"missed

opportunities"

applied EPI in some

countries; Patient

Flow Analysis

techniques applied to

providing integrated

MCH/FP care in

some countries.

Vertical management,

information and training

structures for technology

specific activities persist.

Rehabilitation not

developed or integrated.

Integration of TBA training

supervision support in

MCH/Safe motherhood.

Evaluation of TBA

programmes and their

impact.

Need for supporting

legislation in health.

Coordination of policy.

Coordination with

private sector especially

NGOs.

Identification of high-

risk families and

support systems.

EB93/INF.DOC./3

Priority needs or

concerns identified

by the 6th Expert

Committee in 1975

Recommendations of

the 6th Expert

Committee in 1975


response: WHO or

other since 1976

Achievements

(data from HFA

evaluation 1985 and

1991)

1983-

1985

1988-

1990 Remaining problems Emerging needs

Health workers are

not aware of factors

influencing health,

nor the actual and

potential of other

sectors

Modify training for

intersectoral

orientation. Draw on

community personnel

and resources,

support from

community leaders.

WHA46.17 - Health

development in a

changing world.

Special attention to

women and

development, children

and young people.

Little progress other than

advocacy in the areas of

MCH/FP not translated

into training and

collaboration; campaign

approach is less effective

than using existing

infrastructure where access

to facilities exists.

Incomplete understanding

of linkages between health

status and developmental

and behavioural activities.

Limited experiences in

community involvement.

No clear mechanism for the

involvement of and

coordination with non-

government sector.

Emphasis on target

setting and technologies

fails to put attention on

(1) the understanding

of the underlying basis

of vulnerability, and

(2) the need for a PHC

and district supported

infrastructure to "carry"

programmes.

Need orientation of

health workers on

prevention of unhealthy

lifestyles and linked

diseases including HIV,

AIDS, STDs, cancer,

stroke, cirrhosis,

accidents.

Need for strategic

alliances with other

sectors, particularly

education and

environment.

EB93/INF.DOC./3

Priority needs or

concerns identified

by the 6th Expert

Committee in 1975

Recommendations of

the 6th Expert

Committee in 1975


response: WHO or

other since 1976

Achievements

(data from HFA

evaluation 1985 and

1991)

Continued high levels

of malnutrition and

its long-term effects,

particularly as a

result of infections

and close child

spacing

Develop effective and

feasible interventions

during pregnancy,

lactation, childhood

and adolescence and

encouraging and

facilitating BF and

weaning

W H A resolutions on

infant and young child

feeding, International

Code of Marketing of

BM Substitutes, and

micronutrients;

Innocenti Declaration;

Plan of Action of

International

Conference on

Nutrition

WHA45.34 - code.

W H O / U N I C E F

meeting on young

child feeding

WHA46.7 -

International

Conference on

Nutrition.

WHA31.53 -

immunization.

WHA35.31 -

immunization.

Low birth weight

Developing countries:

of which least

developed:

Safe water supply:


of which least

developed:

Contraceptive use

(%)••


of which least

developed:

Effective

immunization during

pregnancy and

childhood should be

adapted to local

conditions

Develop

immunization

procedures as

integral part of M C H

care with other

complementary

approaches

Targets set by

WHA44.33 -

Child summit goal.

WHA46.33 -

Poliomyelitis.

WHA46.36-

Tuberculosis.

WHA42.32 - Neonatal

tetanus.

Global coverage:

DTP3:

BCG:

Polio:

Measles:

TT2:


Emphasis on the role of

men and other family

members in prevention and

management of problems.

Elimination of harmful

traditional practices

affecting women and

children's health.

Addressing attitudinal

change and training of key

health personnel closest to

women and children in

need of care.

Raising status of women

and girls especially by

ending the traditional

discrimination against the

girl child.

Nutritional and care

implications of children

having children;

periconceptual

nutrition; implications

of low birth weight and

childhood nutrition

status for adult disease.

Coverage decreased slightly

1991; vertical programmes.

Sustainability (costs) and

political commitment.

Strengthen management

logistics support, laboratory

services.

Interaction between

H IV infection and

other immunizable

childhood infections

and diseases.

1983- 1988-

1985 1990

13

24

68

49

34

8

22

12

55

30

% % % % %

S390858034

% % % % %

к^

о о 4

4 4 5 5 2

EB93 INF.DOP3

Priority needs or

concerns identified

by the 6th Expert

Recommendations of

the 6th Expert

Committee in 1975


response: W H O or

other since 1976

Achievements


evaluation 1985 and 1985 1990 Remaining problems Emerging needs

Committee in 1975

Recommendations of

the 6th Expert

Committee in 1975


response: W H O or

other since 1976 1991)

Need for linking Integrate FP WHA41.9 linking FP Integration FP is not integrated in Build on concept of

M C H and FP education and care in to health and widespread for other areas of health care. reproductive rights and

demonstrated but not M C H and other development - urging MCH/FP FP denied to unmarried choice.

generally applied in health care. FP integration with Coverage = women - need for new Needs for adapting to

policies or Education and MCH. FP integration in legislation. adolescent RH .

programmes legislation requires WHA30.44 - Health M C H generally Links between FP and Need for coordination

multidiscipline legislation in health accepted - often not STD/AIDS prevention not MCH /FP with

approach. services strengthening operational in many operational. STD/AIDS

PHC. countries. Need to address large programmes.

WHA38.22 - unmet need for

Adolescent contraception through

reproductive health. innovative approaches.

WHA32.42 - Alma Look at the effective

Ata: MCH, nutrition, implementation of FP as

family planning and intervention strategy for

immunization essential Safe Motherhood.

PHC aspects. Concept of quality of care

needs to be accepted and

generalized.

EB93/INF.DOC./3

Priority needs or

concerns identified

by the 6th Expert

Committee in 1975

Recommendations of

the 6th Expert

Committee in 1975


response: W H O or

other since 1976

Achievements



1991)


Need to define

essential M C H care

package and provide

suitable training,

including community

Provide integrated

training for all levels

of health workers,

including

undergraduate

medical education

Programme packages

developed: EPI,

diarrhoeal disease，

safe motherhood -

mother/baby package.

Joint UNFPA/

U N I C E F / W H O

statement on TBAs'

safe motherhood

initiative.

WHA30.48 - Health

manpower

development,

midwifery and nursing

training.

WHA36.11 - Nursing,

midwifery: role in

providing health

services for effective

PHC development.

WHA42.27 - Training

nursing, midwifery

personnel, reorient

education, legislation

and regulations.

Training modules for

specific technologies:

EPI, CDD , AR I ,

SMI, sick child.

Training package for

TBAs; master

trainers for TBAs.

Little integrated training,

undergraduate medical

training virtually unchanged.

Territoriality and inertia.

Integration of TBA in

M C H services not

addressed adequately in

many countries.

Effective approaches for

community involvement and

mobilization. Persistent

issues remain unsolved, i.e.

supervisory referral and

logistical backup support

from M C H services.

Need emphasis on IEC

component of services.

Need for alternative

learning methods for

clinical and programme

problem solving.

Need to reorient M C H

training and approach.

Need to define the

minimum

information for all

aspects of M C H for

planning, monitoring

and evaluation for

programme impact

Develop simple,

reliable information

systems for local use

in monitoring

programmes,

channelling to

regional and central

levels with feed-back

WHA42.44 - Public

information and health

education

International driven

targets have raised

awareness of

information needs.

"Bottom-up" methods

developed.

Quality of information

remains poor when used in

one-way flow;

dissemination, adaptation

and application of methods

Risk of overloading of

information systems

and burdening system

through ad hoc systems.

EB93/INF.DOC./3

Priority needs or

concerns identified

by the 6th Expert

Committee in 1975

Recommendations of

the 6th Expert

Committee in 1975


response: W H O or

other since 1976

Achievements



1991)


School health

programmes not

realizing potential.

Not involve students

or teachers in PHC

and community

development.

Teachers to be used

for health education.

Strengthen school

health programmes

with full participation

of students, teachers

and nurses aides

Launching concept of

comprehensive school

health programmes.

Progressive

implementation of

comprehensive school

health programme

including services

health education,

healthful

environment and

other health-related

components.

Develop of school health

policy, legislation and

ñnancial support.

Intersector coordination

between health and

education sectors.

NGOs, teachers unions and

private sector making

fragmented and meagre

efforts.

Missed opportunities for

improving coverage of

information and services for

children and their families.

Empowerment of

families through

school - health.

Reduce cumulative

impact of risk factors.

EB93/ZF.DOC./3

TABLE 2. NEWLY EMERGING NEEDS IN MCH/FP

Newly emerged needs

(1975-1993) - not

identified by the 6th

Expert Committee

meeting，1975

Policy and programmes'

resolutions Achievements Remaining problems

Women's health -WHA38.27 (1985) on women, health 1975- 1985- -Sexual discrimination: violence

and development 1980 1990 against women; son preference;

-WHA38.22 (1985) on maturity before -Increased women's global -Malnutrition and anaemia;

childbearing and promotion of life expectancy at birth: 62.1 65.9 -High-risk fertility patterns;

responsible parenthood -Increasing cancer incidence.

-WHA39.18 (1987) on implementation Regions:

of the Nairobi Forward-looking

Strategies for the Advancement of Africa 49.5 53.6

Women North America 77.3 79.2

-WHA42.42 (1989) on women's health Látin America 65.8 69.5

-WHA42.32 (1989) on neonatal tetanus Asia 58.9 63.9

(EPI) Europe 75.8 77.7

-45th World Health Assembly: technical

discussions on women, health and

development

- U N 34/180 (CEDAW)

-UNFPA Amsterdam Declaration

EB93/INF.D0C./3

Newly emerged needs

(1975-1993) - not


Expert Committee

meeting, 1975



Maternal health -WHA39.18 (1987) s.a.

-WHA40.27 (1987) on maternal health

and safe motherhood

-WHA45.5 (1992) on strengthening

nursing and midwifery

-WHA46.17

1983- 1988-

1985 1990

Establishment of health-for-

all global indicators

concerning maternal health:

-Prenatal care: global

coverage by trained

personnel (per 100 live

births) 58 67

-Immunization of pregnant

women: global coverage by

tetanus toxoid vaccination

in % 24 34

-Childbirth attendance:

global coverage by trained

personnel (per 100 live

births)

-Establishment of maternal 53 55

health and safe

motherhood programme

1987:

Guidelines and training

modules for midwives and

ТВ As; mother/baby

package; research on

maternal mortality;

women's health database

1983 1991

-Global maternal mortality rate (per

100 000 live births): 390 370

-Regions:

Africa 640

North America

Latin America 270

Asia 420

Europe 29

-Global annual total of 500 000

maternal deaths.

Women and H I V -Paris Declaration on Women, Children

and AIDS (1989)

-WHA43.10 (1990), adoption of Paris

Declaration

-Establishment of the

Global Programme on

AIDS (1987)

- > 3 million HIV-infected women in

world (1992);

_ cumulative total of > 600 000 AIDS-

cases among women (1992).

EB93/IZF.DOC./3

Newly emerged needs

(1975-1993) - not


Expert Committee

meeting, 1975



Women and children in

difficult circumstances

-International Convention

on the Rights of the Child

-Operationalizing policy, coordination

and collaboration in multisectoral

approaches;

-Violence to and abuse of women

and children in situations of war and

displacement.

Quality of care -WHA45.34 -Quality of care recognized

in BFHI - including links to

breast-feeding support

groups

-Discrepancy between coverage arid

impact; lack of community/health

system partnership; social distance of

health providers and community;

need for communication skills.

Traditional practices

affecting women and

children

_ WHA46.18 -Network of NGOs in 26

countries

-Inter-African

Communique

-Accelerating local action,

programme developmeiit linked to

discrimination and their social status.

EB93/INF.DOC./3

-л.

гчз FAMILY PLANNING POLICIES AND PROGRAMMES： A REGIONAL PERSPECTIVE

Regions Policies and programmes Coverage* Demographic evolution

(latest data) Unmet needs Reorientation

Latin

America

and the

Caribbean

High population awareness;

emergence of a regional

"population consciences"

population policies often part

of national development

plans. By and large

governments have

internationalized population

programme; establishment of

national commission;

population issues are part of

development plans;

establishment of sectoral

programme strong health and

women's rights component in

many countries.

1992: Modern

methods

prevalence

10-74%

Latin America:

Crude birth rate 30/1000

Average population

growth rate 2.2%

Caribbean:


Average population

growth rate 1.4%

43% of married women

who want no more

children are not using

any contraceptive

method.

Estimated 4.6 million

unsafe abortions per year.

-From contraception to reproductive

health of population

-Increasing modern contraceptive use

-Addressing adolescent reproductive

needs

-Building partnership with Government

and NGOs

-Improving management

-Towards sustainability

Africa Highest birth rates in the

world; population issues are

part of political agenda.

32 countries with public

sector FP; 17 with

government support to

private FP programmes;

population distribution high

concern; integration of M C H

and FP as national policy and

major outlet for FP (not

always operationally

supported by some donors in

the past).

1988-89: Any

method range

from 5% to 50%;

Modern methods

from l%-40% but

with only a very

few countries with

> 10%

Highest birth and population

growth rates globally


Average population

growth rate 3.0%


who want no more


any contraceptive

method.



FP remains

-constrained to M C H services.

Few countries made thrust towards

community-based distribution of

contraceptives and involvement of

private sector.

- N e e d to explore variety of channels

through ^diich FP services can be

delivered safely and effectively.

EB93/INF.DOP/3


(latest data) Unmet needs Reorientation

Middle Recognition of health and

East development implications of

population growth;

acceptance of integration of

M C H and FP increasing;

slow progress of FP

programmes even in the few

countries with strong

commitment; still high rate

of population growth but

widening acceptance of the

health rationale for family

planning.

1988: Any

method 10%-

63%; Modern

methods 6%-45%


Average population

growth rate 2.8%


who want no more


any contraceptive

method.

Estimated 380 000 unsafe

abortions per year.

The term FP was not acceptable

officially in several countries. The

population rationale of FP is not

relevant for many E M R countries.

Today, FP as a component of M C H is

the usual norm in most countries.

Reproductive health awareness is an

important target in most M C H

programmes.

The global and national women's health

movements include fertility regulation

as a basic human right.

Asia Nearly all countries have

population policies and

measures implementation of

programme facilities by

strong planning tradition and

experience; FP programmes

in place and successful for at

least 2 decades; status of

women strongly linked to

programme success.

Modern methods

South Asia: 34%

East Asia: 5-74%

South-east

Asia: 4-62%

South Asia:


Population growth rate 2.3%

South-east Asia:

Crude birth rate 21-43/1000

Average population

growth rate 1.3-3.5%

East Asia Pacific:

Crude birth

rate 10.5 to 31.9/1000

Average population

growth rate 0.64-3.3%


who want no more


any contraceptive

method.



South-east Asia: less

than 50% of women in

child bearing age practice

contraceptives.

In Asia Pacific, family planning will be

better integrated with other health

programmes especially primary health

care; national family planning and

population policies will emphasize

health benefits of family planning more;

health will be more integrated with

other social and economic sectors.

1990 - Bhutan endorsed a population

policy and adopted small family norm.

1989 - Myanmar adopted position of

maintaining the population growth rate

without intervention but included child

spacing in routine health and welfare

activities.

Maldives are making contraceptives

available at the PHC level in spite of

population policy of non-intervention.

EB93/INF.DOP/3

Co


(latest data) Unmet needs Réorientation

Europe FP services generally widely

available; abortion still major

means for regulating fertility

in many eastern European

countries and many former

republics of the USSR.

Average in

western Europe:

70%

West Europe:


Average population

growth rate 0.1%

East Europe:


Average population

growth rate 0.2%

Migrant groups,

adolescents，and

traditional families

outside FP network.

Estimated 260 000 unsafe

abortions per year (excl.

Republics of the former

USSR which is estimated

at 2.1 million).

FP just starting in Central Asian

Republics, changes in abortion

legislation under review or made in

several countries.

* Contraceptive prevalence among women in fertile age married or m union.

II

II

EB93/SF.DOP/3

maternal and child healt anh d family planning

Documents