1. Complied and written by : Phyo Maung Maung Kyaw (B.Comm.H) Zonal Health Specialist, WVM 6/8/2014 1

2. Background Providing maternal, newborn, adolescent and child health care services with continuum of care approach developed in accordance with the National Health Plan and also in relation to short term strategic plans for reproductive health, child health development and adolescent health development Start implemented (200) townships at 2011 in Myanmar initiated in 10 townships by training health volunteers for Community Based implemented using three delivery channels Family oriented Population oriented Individual oriented implemented through rolling plans at the national level based on the information and periodic review of activities and integrated micro planning at the sub national level based on the local data and information. 6/8/2014 2 3. Organization Set Up 6/8/2014 3 4. Ministry of Health, Republic of Union of Myanmar Department of Health Admin MC D/C PH Nursing FDA (Now divided as Department Lab Plan HEB Basic Health School Health MCH WCHD Nutrition WATSAN Deputy Director Assistant Directors Medical Officers Staffs 6/8/2014 4 5. Millennium Development Goals (MDGs) that directly affect newborn, child and maternal survival Goal 4: Reduce child mortality Target 4a: Reduce by two thirds the mortality rate between 1990 and 2015 among children under five Indicators: 4.1 Under-five mortality rate 4.2 Infant mortality rate 4.3 Proportion of 1 year-old children immunized against measles 6/8/2014 5 6. Millennium Development Goals (MDGs) that directly affect newborn, child and maternal survival Goal 5: Improve maternal health Target 5a: Reduce by three quarters between 1990 and 2015 the maternal mortality ratio Indicators: 5.1 Maternal mortality ratio 5.2 Proportion of births attended by skilled health personnel 6/8/2014 6 7. Objectives of WCHD General objective To provide quality health care service for women, children and adolescent in order to reduce U5MR and MMR and to promote health development of women, children and adolescent. Specific objectives To reduce Under Five Mortality Rate and Maternal Mortality Rate according to MDGs. To ensure quality health service for children, adolescents and women. 6/8/2014 7 8. Why WCHD is important ???? Women and children (U12) population Majority about 60% Children Future of the nation Children and Women vulnerable of illness and death Most of disease associated that are preventable Children are inarticulate Including and directly related to MDG 4 and 5 and indirectly related to MDG 6 Including ELEMENTS of PHC 6/8/2014 8 9. 6/8/2014 9 Every year, more than 10 million children under the age of five are dying of preventable or treatable diseases. Some are directly caused by illness such as pneumonia, diarrhoea and malaria. Others are caused by indirect causes including conflict and HIV/AIDS, malnutrition, poor hygiene and lack of access to safe water and adequate sanitation . Thirty-eight percent (38%) of the estimated more than 10 million children under 5 deaths each year occur in the first four weeks of life, the neonatal period. 10. Problems of Maternal Health [Maternalmortalityratio(per100,000LiveBirth)inMyanmaris380(2005)] Postpartum Haemorrhage 31% Indirect causes 17% Eclampsia 11% Abortion related 10% Prolonged and obstructed labour 9% Puperal Sepsis 7% Hypertensive disease of pregnancy 6% Antepartum Haemorrhage 4% Ruptured Uterus 4% Embolism 1% Causes of Maternal Mortality,2004-2005 (MOH & UNICEF) 6/8/2014 10 11. Problems of Child Health U5MRinMyanmaris 98(2008) Preterm 34% Asphyxia 27% Infection 26% Congential 5% Other 5% Diarrhoea 3% Tetanus 0% Causes of Neonatal Deaths Source : WHO/CHERG 2010 Neonatal 40% Injuries 22% Other 12% Diarrhoea 12% Pneumonia 12% Malaria 2% HIV/AIDS 1% Measles 0% Causes of Under-Five Deaths,2008* Source : WHO/CHERG 2010 6/8/2014 11 12. Sign and Symptoms of Pregnancy Amenorrhea Morning Sickness Breast Change Bladder Symptoms Uterus Palpable Abdominally Abdominal Enlargement Fetal Heart Audible Quickening Pregnancy Test on Urine How to calculate the estimate of due birth date ???? English Calendar- LMP + 281 days or 9 months 7 days= EDD Burmese Calendar- LMP + 9 months 14 days = EDD 6/8/2014 12 13. Antenatal Care Aim and Objective To promote, protect and maintain health of mother during pregnancy To identify high risk pregnancy To provide special care for high risk cases To teach the mother the elements of child care, nutrition and personal hygiene and environmental sanitation Procedure of AN Care Registration: Visit (1) Within 3 months (as early as possible) (2) _ 6months, 7months of pregnancy (3) _ 8months of pregnancy (4) _ 9months of pregnancy Obstetric history Abortion, Elcamsia, PPH, APH, prolong Labour, History of previous delivery, Number of pregnancy, EDD, LMP , Time of Previous Birth or abortion date, etc. 6/8/2014 13 14. Antenatal Care Procedure of AN Care Personal History- Name, Age, Husband Name, Date of Visit, etc. Medical History- Underlying Diseases General Examination- Height, Weight, BP, Urine for Albumin, etc. Immunization TT *2 Last time should be 6 weeks before labor Examination of Abdomen- size of uterus , presentation and position of the fetus, Exclusion of Cephalo pevlic disproportion, detect of abnormalities General Advice- Birth Plan, diet, rest and exercise, clothing, care of breast Nutrient supplement and drugs: Vitamins and Minerals (Must take of Ferrous Sulfate mix Folic acid for 3months) and Mebendazole 500 mg single dose after first Trimester . Identify the risk pregnancy and timely referral. 6/8/2014 14 15. High Risk of Pregnancy Age below 18yrs and above 35yrs Time of pregnancy P1 and including above P5 Previous still-birth, intrauterine death, manual removal of placenta Body Temperature above 38C Short statured primi (140cm or 4 10and below) Body Weight below 84 lb. or 40 Kg and above 157 lb. or 70 Kg Suffer sever anemia Maternal Heart rate is irregular Anasarca or edema Multiple Pregnancy (Twin, hydramnios, etc.) Malpresentations, viz breech, transverse lie, etc (above 37 weeks) FHS (Start Hear 24 Weeks)- No hear, above 160 times and below 120 times Albuminuria Pre-eclampsia and eclamsia Underlying disease 6/8/2014 15 16. Danger Signs of During Pregnancy Menorrhea Anascarsa Severe Pain at Abdomen (Suspected ectopic pregnancy) Severe Vomiting Severe Headache Burred Vision Fit or Convulsions Unconsciousness Gush of Amniotic fluid and rupture of Amniotic sac Hyperpyrexia Pallor at lip, nails ,etc. (sever anemia) Respiratory distress Not sense of Quickening Prolapsed of cord and others from vagina 6/8/2014 16 17. Indicators for antenatal care Proportion of pregnant women who have at least one antenatal clinic visit Proportion of pregnant women who have at least four ANC visits Tetanus protection (2 times)at birth* Prevalence of syphilis in pregnant women The proportion of pregnant women with a written birth and emergency plan by 37 weeks of pregnancy Rate of HBMR record book (fully) have pregnant womens 6/8/2014 17 18. Sign and Symptoms of Labour True labour Regular uterine contraction Lightening Frequent micturition Showing Dilation of Cervix Descent of the presenting part Membrane rupture False Labour Uterine contraction depends on uterine segments Upper uterine segment Active contraction Stronger Muscle shorter and thicker Lower uterine segments Passive contraction Weaker Muscle weaker and thinner 6/8/2014 18 19. Intrapartum Care Aim and Objective Thorough asepsis Delivery with minimum injury to the infant and mother Readiness to deal with complications such as prolonged labour, antepartum hemorrhage, convulsions, malpresentations, prolapse of the cord, etc. Care of the baby at delivery- resuscitation, care of cord, care of the eye, etc. Procedure of Delivery Care Clean Delivery Place Clean Hand Clean Cord Cutter Clean Cord Clip Clean Mother Dress Clean Baby Dress Deliver with Skill Birth Attendant Birth Registration 6/8/2014 19 20. Danger signs for intrapartum transfer Sluggish pains or no pains after rupture of membranes Good pains for an hour after rupture of membranes, but no progress Prolapse of the cord or hand Meconium-strained liquor or a slow irregular or excessively fast fetal heart Excessive show or bleeding during labour (above 500cc) Collapse or delay during labour Retained placenta PPH or collapse maternal pyrexia in labour (38.0 C once or over) during labour malpresentation or breech presentation diagnosed for the first time at the onset of labour, taking into account imminence of birth maternal request for epidural pain relief either raised diastolic blood pressure (over 90 mmHg) or raised systolic blood pressure (over 140 mmHg) on two consecutive readings taken 30 minutes apart 6/8/2014 20 21. Objective of Postnatal Care To prevent complications of the postpartal period To provide care for the rapid restoration of the mother to optimum health To check adequacy of breast feeding To provide family planning services To provide basic health education to mother/family Duration of Postnatal Care After Birth to 6 weeks 6/8/2014 21 22. Postnatal Care Essential routine PNC for all mothers Assess and check for bleeding, check temperature Support breastfeeding, checking the breasts to prevent mastitis Manage anemia, promote nutrition and insecticide treated bed nets, give vitamin A supplementation Complete tetanus toxoid immunization, if required Provide counseling and a range of options for family planning Refer for complications such as bleeding (Retained Placenta, infections, or postnatal depression Counsel on danger signs and home care 6/8/2014 22 23. Essential routine PNC for all newborns Assess for danger signs, measure and record weight, and check temperature and feeding Support optimal feeding practices, particularly exclusive breastfeeding Promote hygiene and good skin, eye, and cord care If prophylactic eye care, it is still effective until 12 hours after birth Promote clean, dry cord care Identify superficial skin infections, such as pus draining from umbilicus, more than 10 skin pustules, and swelling, redness, and hardness of skin, and refer if the baby also has danger signs Ensure warmth after the first 24 hours, practicing skin-to-skin care, and putting a hat on the baby Encourage and facilitate birth registration Refer for routine immunizations Counsel on danger signs and home care 6/8/2014 23 24. Danger signs for the mother Excessive bleeding (Above 300 ml) Foul smelling vaginal discharge Fever with or without chills Severe abdominal pain Excessive tiredness or breathlessness Swollen hands, face and legs with severe headaches or blurred vision Painful, engorged breasts or sore, cracked, bleeding nipples 6/8/2014 24 25. Danger signs for the baby Convulsions Movement only when stimulated or no movement, even when stimulated Not feeding well Fast breathing (more than 60 breaths per minute), grunting or severe chest in-drawing Slow breathing (less than 30 breaths per minute) Fever (above 38C) Low body temperature (below 35.5C), Very small baby (less than 1500-2500 grams more than two months early) Bleeding (cord and others) Congenital deformation 6/8/2014 25 26. Key indicators for postnatal care (PNC) Mother/newborn receiving PNC within three days and subsequent visits Place where care is provided and type of care provider Timely initiation of breastfeeding within one hour after birth Sick newborns taken for treatment Case fatality rate of newborn complications (by cause if possible) 6/8/2014 26 27. Birth Spacing Target population- abortion and repeated abortion clients Eligible couple between 15-49 yrs 2-3 yrs interval only, not control population To promote health status of women, mother and child To reduce the IMR by giving effective and quality birth spacing To give the birth spacing 45 days after birth Explain her partner at the same time with consent May reduce HIV/AIDS and STD problem by usage of condom 6/8/2014 27 28. Family Planning To avoided unwanted birth To bring about wanted birth To regulate the interval between pregnancy To control the time at wish birth occurs in relation to the age of the parent To determine the number of children in the family 6/8/2014 28 29. Birth Spacing Methods Type of Birth Spacing Advantages Disadvantages Vasectomy/tubal ligation About 100% effective; no chemical or mechanical devices Is not usually reversible: surgery may have side- effects Birth Control Pill (OC Pills) and Injectable Contraceptives Is highly effective; requires no last minute preparation Has side-effects; especially in smokers Intrauterine device (IUD) Is highly effective; Requires no last minute preparation or drugs Has side-effects; may cause inflammation of genital organs; may be lost accidentally Condom Is easily available; does not affect physiology ; protects against STI Must be applied just before intercourse; may slip or tear Rhythm Involves no surgery, mechanical devices; drugs, or hormones; agrees with some regilous Is difficult to follow ; requires that womens menstrual cycle be regular; has a high failure rate 6/8/2014 29 30. 6/8/2014 30 Safe Motherhood AntenatalCare PostAbortionCare CleanandSafeDelivery FamilyPlanning PostnatalCare STDPrevention Equity for Women Primary Health Care Basic Maternal Care 31. Objective of Neonatal Care Establish and maintenance of cardio-respiratory functions Maintenance of body temperature Avoidance of infection Establishment of satisfactory feeding regimen Early detection and treatment of congenital and acquired disorders, especially infections 6/8/2014 31 32. Neonatal Care Cleaning the airway Apgar score (a score that is given after assessing the condition of a newborn baby in the five areas of heart rate, breathing, skin color, muscle tone, and reflex response) Care of the cord Care of the eye Care of the skin Maintenance of body temperature (36.5C-37.5C) Breast Feeding Neonatal examinations Measuring the body Timely Referral 6/8/2014 32 33. High Risk of Neonate Fast Breathing (above 60 or below 30) Difficult Breathing (wheezing, stridor, etc.) Weakness or Stiffness of Muscle Abnormal Body Temperature (above 38C or below 35C) although giving warming Have over 10 pustules at the body Difficult or cannot suck the milk , less than 5 times during 24 hrs. Convulsion Unconsciousness Jaundice or pale Abdominal Distention LBW (under 1500g) 6/8/2014 33 34. Major Problems in Child Low Birth Weight Malnutrition Infection and parasitosis Accidents and poisoning Behavior problems 6/8/2014 34 35. Danger Signs of Child (Common) Unable to drink/ breastfeeding Vomits everything Convulsions Drowsy/ difficult to wake Unconscious Chest in drawing Stridor during inspiration Fast breathing by age Neck Stiffness Bulging fontenelle Blood in the stool Skin pinch goes back slowly 6/8/2014 35 36. Age Alert Factors 1-4 Months Can not see to materials and Mother Face Not respond although stimuli of noise Not Smile although tease 6 Months Always Fix of Palm Not Strength of Health and Neck 9 Months Not Able to sit if not have support (Cannot support to body by hand for sitting) 1 Years Cannot speech of informal Not Able to stand 2 Years Not Able Call to Parents (Phay Phay , May May) 3 Years Not able to run Not able to speech by well 4 Years Although speech he face so difficulties and not understand to Another for that speech No play with another children and stay lonely 6/8/2014 36 37. Services of Child Health Care Nutrition Screening (Measure of Body Weight, MUAC) Nutrition Promotion Home based Care Prevention and Control of Communicable Diseases Administration to Supplements of Micronutrients and Macronutrients EPI IMCI - Early Diagnosis and Prompt Treatment (ARI, Diarrhoea, Fever, etc.) Counseling and Health Education to Parents Environmental Sanitation and Personal Hygiene Timely Referral 6/8/2014 37 38. Adolescence Health 6/8/2014 38 The term adolescence is derived from the Latin word adolescere meaning to grow, to mature. It is considered as a period of transition from childhood to adulthood. They are no longer children yet not adults. It is characterized by rapid physical growth, significant physical ,emotional, psychological and spiritual changes. They are not only in large numbers but are the citizens and workers of tomorrow. The problems of adolescents are multi- dimensional in nature and require holistic approach. A large number of adolescents in Myanmar are out of school, malnourished, get married early, working in vulnerable situations, and are sexually active. They are exposed to tobacco or alcohol abuse. 39. 6/8/2014 39 40. 1. Anorexia nervosa 2. Obesity & overweight 3. Adolescent pregnancy 4. Micronutrient deficiency 5. Emotional problems 6. Behavioral problems 7. Substance abuse & injuries 8. Sexually transmitted infection 9. Thinking and studying problems 6/8/2014 40 41. PREVENTION Health Education Skill Based Health Education Life Skill Education Family Life Education Counseling for Emotional Stress Nutritional Counseling Early Diagnosis and Management of Medical and Behavioral Problem 6/8/2014 41 42. Service of Adolescent Health Prevention of unwanted pregnancy , STDs and Abuse Happy Family Life Safe Motherhood care at home Social Development Counseling Services Health Education program 6/8/2014 42 43. Thank You So Much !! 6/8/2014 43