Transcript Starting a Successful Antenatal Program

Starting a Successful Antenatal
Program
Global Missions Health Conference
Catherine Hoelzer, MPH, PA-C
Objectives
• To explain the magnitude and burden of maternal mortality
in the developing world
• Clarify the main causes of maternal mortality
• Detail Safe Motherhood essentials and goal of ANC services
• Define traditional versus focused ANC services
• To provide practical examples of how to provide motherfriendly ANC services
• Explain the problem of lack of qualified skilled birth
attendants and how we might help bridge the gap
• Share personal examples of what worked for us in Sudan.
Brief Introduction
World Outreach
The Goal and Challenge
• MDG is to reduce MM by 75% by the year 2015.
• We have a huge challenge to meet this goal:
• Currently MM is:
•About 1 in 6 women dying in poorest parts of the
world compared to about 1 in 30,000 in N. Europe.
• 99% of all maternal deaths occur in developing countries,
where 85% of population lives.
• Progress being made:
• From 1990 to 2008 maternal mortality ratio fell by 34%
on a global level.
• Biggest declines were seen in eastern Asia and northern
Africa (63% and 59%, respectively).
Definitions
• Maternal death
• The death of a woman while pregnant or within 42 days of termination of
pregnancy, irrespective of the duration and site of the pregnancy, from any
cause related to or aggravated by the pregnancy or its management, but
not from accidental or incidental causes .
• Maternal mortality ratio
• Number of maternal deaths during given time period per 100,000 livebirths
during same time period.
• Maternal mortality rate
• Number of maternal deaths in given time period per 100,000 women of
reproductive age, or woman-years of risk exposure, in same time period.
• Lifetime risk of maternal death
• Probability of maternal death during a woman’s reproductive life, usually
expressed in terms of odds
Maternal mortality ratio, 2008
Source: Trends in maternal mortality: 1990 to 2008, Estimates developed by WHO, UNICEF, UNFPA and The World Bank,
© World Health Organization 2010
The burden of maternal mortality
• Most deaths occur in subSaharan Africa. Risk of
dying is 1 in 31.
• Highest risk in
Afghanistan with 1 in 11
risk.
Source: Trends in Maternal Mortality: 1990 to
2008: Estimates developed by WHO, UNICEF,
UNFPA and The World Bank, 2010
Graph source:www.thelancet.com Vol 368
September 30, 2006
Maternal mortality ratios by medical cause
and world region
Source: Maternal mortality: who, when, where, and why, Lancet Series, Lancet 2006; 368: 1189–2000
Causes of maternal death
Source: The World health report: 2005: Make every mother and child count.
Where do deaths take place?
• Large proportion in hospitals
• 3 main types of cases:
• Women who arrive nearly dead too late to benefit from
emergency care
• Women with complications who didn’t receive timely and
effective interventions
• Women admitted for normal delivery who subsequently
develop serious complications and die with or without
having received emergency care.
Let’s talk about
SAFE MOTHERHOOD
“Four Pillars” of Safe Motherhood
To prevent maternal death, and perinatal infant death:
1. Give good antenatal care
2. Offer family planning advice
3. Practice clean/safe delivery
4. Provide essential obstetric care
Source: WHO, Maternal Health and Safe Motherhood Initiative, 1994
Traditional vs. Focused Antenatal Care
• Traditional ANC which focuses on finding risk factors does
not necessarily improve pregnancy outcomes.
• Focused ANC approach emphasizes quality over quantity of
visits.
• This new approach is based on 3 key realities:
1. ANC visits provide opportunity for early dx and tx of
problems for mother and prevention of problems for
newborn
2. Most pregnancies progress without complication
3. All women considered at risk because most
complications can’t be predicted.
Source: Focused Antenatal Care, www.accesstohealth.org
ANC recommended visit schedule
The WHO recommends 4 ANC visits for normal pregnancy:
1. In 1st trimester (ideally before 12 weeks but no later than
16 weeks)
2. At 24 – 28 weeks
3. At 32 weeks
4. At 36 weeks
Note: If problems are found the number of visits will likely
increase.
Goal of focused ANC services
• To help women maintain normal pregnancies through:
• Targeted health assessments and early detection of
potential problems in mother or newborn
• Individualized care that includes
•Preventive health services
•Supportive care
•Health education and counseling
•Birth preparedness and complication readiness
planning
Education is essential
• Health promotion should be a part of each ANC visit
• Discussion should include:
•How pregnancy progresses
•Birth preparation
•Danger signs and what to do
•Importance of rest, hygiene, nutrition
•Risks of using tobacco, ETOH and drugs
•Benefits of exclusive breastfeeding and child-spacing
•Protection against STIs and HIV
Women’s education and child health
• Every 1 year increase in
women’s education results
in a 9.5% reduction in child
mortality.
• Educating girls results in
higher rates of
employment, higher
wages, and lower maternal
and child mortality.
“Women hold up half the
sky." Chinese proverb
Source: Increased educational attainment and its effect on child
mortality in 175 countries between 1970 and 2009:
a systematic analysis; The Lancet, Vol 376 September 18, 2010
The role of
HEALTH SYSTEMS
Delivering Essential Health Services
• Minimum threshold set by WHO:
• 23 physicians, nurses, and midwives per 10,000 people
• Only 22% of 68 “Countdown Countries” met this criteria
• Together these countries targeted by WHO account for at
least 95% of maternal and child deaths worldwide.
• SSA faces greatest challenge
• 11% of world’s population
• 24% of global burden of disease
• Yet has only 3% of the world’s health workers.
Rural/urban worldwide distribution of
physicians and nurses
Source: WHO, Increasing access to health workers in remote and rural
areas through improved retention: Global policy recommendations, 2010
Skilled Birth Attendants
• A trained and accredited health professional; e.g., midwife,
doctor or nurse.
• Skilled attendants assist in more than 99% of births in
more developed countries versus 62% in developing
countries. In five countries the percentage is less than 20%.
• Currently lacking 4.3 million health workers globally.
• Play a crucial role in reduction of global burden of maternal
and neonatal deaths.
Neonatal and maternal mortality are related
to the absence of a skilled attendant
Source: The World health report : 2005 : make every mother and child count
Percent of SBA worldwide
Source: WHO, Proportion of births attended by a skilled health worker 2008 updates,
www.who.int/reproductive-health
So…..
WHAT CAN WE DO TO HELP?
Training TBAs
• TBAs continue to play an important role providing in many
developing countries by:
• Providing antenatal care.
• Giving assistance during labor and delivery, and initial
postpartum care.
• 2007 Cochrane review concluded, "The potential of
traditional birth attendant (TBA) training to reduce perinatal
mortality is promising when combined with improved health
services.“
• TBA training may improve perinatal mortality but not
maternal mortality, hence, skilled birth attendants are
recommended by WHO.
TBA Incentives
Helpful Training Resources
• Education material for
teachers of midwifery :
midwifery education
modules. – 2nd ed.
• Teaching Modules for
Midwives
• www.who.int
• Ten Steps of the MotherFriendly Childbirth Initiative
• www.motherfriendly.org
Serving
THE WOMEN OF OUR
COMMUNITIES
Women-Friendly Health Services
• Health services can be considered women-friendly when they:
• Are available, accessible and affordable.
• Provide safe and effective health and maternal care even
at the lowest level facility.
• Motivate providers, encourage their participation in
decision-making, and make them more responsive to user
needs.
• Empower users and satisfy their needs by respecting their
rights to information, choice, safety, privacy and dignity
and by being respectful of cultural and social norms.
Provide Preventive interventions
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TT immunization
Providing FS/FA
Deworming (Albendazole) once in pregnancy
IPT in 2nd and 3rd trimester (Fansidar 3 tabs stat) in malaria
endemic area
Providing ITNs in malaria and leishmaniasis endemic
regions
Protecting against Vit A or iodine deficiency in endemic
areas
Defibulation in areas of type III FGM
HIV testing and counseling and ARV for PMTCT
Attract women to the clinic
• Offer women-friendly health services
• Offer baby layette sets to women who birth in the clinic—get
your churches involved
• Provide LITNs to women who complete 2 TTs and/or 2 ANC
visits
• Start women’s groups that offer teaching programs:
• Health education
• English and/or literacy classes
• Cooking demonstrations
• Kitchen gardens/Moringa tree projects
The Moringa “Miracle” Tree
• The Moringa is a fast
growing tree that can
reach up to 3 meters in its
first year.
• It thrives in subtropical and
tropical climates, giving
fruit and flowers
continually.
• Moringa grows best in dry,
sandy soil and is drought
resistant.
Moringa oleifera
Source: http://www.miracletrees.org/growing_moringa.html
Nutritional powerhouse
How it can help your Mothers and Children
Get out in the community
• Our example is Jesus
• Don’t let the clinic
confine you
• Visit the women and find
out their needs
Love the
Unreached
Beautiful Fulani Woman
Rejoice in the fruit of your labors!
Questions?