SUSANA O. PABINGUIT, B.S.N., R.N.

DOH-Central Visayas
Outline of Presentation:
 Current Situation of Maternal and Child
Health

 DOH Issuances on MNCHN

 Essential Package of Maternal and Child

Survival Interventions

 Essential Newborn Care

Millennium Development Goals
Adopted by the UN General Assembly in September,
2000
Renewal of global commitment to peace and human
rights
Set specific goals and targets towards reducing
poverty and worst forms of human deprivation
Philippines has committed to craft its 2005-2010
Medium Term Philippine Development Plan
Eight goals that are holistic and interrelated, entailing
collaborative efforts of major stakeholders

Source: LGU Guide on MDG Localization

Millennium Development Goals (MDGs)
Goal 1: Eradicate Extreme Poverty and Hunger
Goal 2: Achieve Universal Primary Education
Goal 3: Promote Gender Equality
Goal 4: Reduce Child Mortality
Goal 5: Improve Maternal Health
Baseline : 209, Target: 109 (2000) 52 (2015)
Goal 6: Combat HIV and AIDS, malaria and other
diseases
Goal 7: Ensure environmental sustainability
Goal 8: Develop a global partnership for
development
MDG 4 & 5 and Targets
Reduce Child Mortality
Reduce children under-five mortality by 2/3

Improve Women’s Reproductive Health

Reduce maternal mortality rate by 75%
Increase access to reproductive health services to
60% by 2005, 80% by 2010, 100% by 2015
Current Health Situation in the Philippines

Maternal Mortality Ratio:

162 per 100,000 live births

In other words…

If there were 10,000 babies born,

1-2 mothers died in pregnancy, labor,
delivery and post-partum period

So, instead of a happy arrival,

There was an unhappy departure.

Relatively Flat MMR Reduction, Philippines
Figure 2: Trend in Maternal Mortality Ratio
1990-2005

250

200 209 203 197 191 186 180 172 162

150

100

50
52.5
0
1990 1991 1992 1993 1994 1995 1998 2006 2015

MMR MDG
 Current Health Situation in the
Philippines

Under 5 Mortality Rate (below 5 years old):

36 per 1,000 live births

In other words…

If there were 1,000 babies born,

36 died before their 5th bday

So, instead of a Nursery School,

They entered a cemetery.

 Current Health Situation
in the Philippines

Infant Mortality Rate (below one year old):

27 per 1,000 live births

In other words…

If there were 1,000 babies born,

Almost 27 died before one year

So, instead of a happy 1st birthday,

They had a sorrowful death.
 Causes of Death in Children

Under-
nutritio
n
53%

The Philippines is one of the 42 countries that account for 90% of global under five
mortality
Source: CHERG estimates of under-five deaths, 2000-03; courtesy of Sobel HL.
Child Mortality Trends
80
70 72  Downward trend in
60 childhood deaths
50 52 but,
46  Slowed down in the
40 43 42

30
34 31.3 30
34 past decade
28
25  Neonatal mortality
20 18 17 17 16 remained unchanged
10
0
1988 1993 1998 2003 2008
UFMR IMR N MR
 When are the Newborns Dying?
Figure 3: Deaths of Neonates by Day of Life
Philippines 1998-2003
35

30 50%of
50% ofall
neonates
newborn die in the
deaths occur
in first two2days oflife
life
Number of deaths

25 the first days of

20
out of 4 newborn deaths occur in 3
15 the 1st week of life
10

0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28

21 July 2007
Day of Life

DOH. Child Survival Strategy. July 2007. Courtesy of Sobel HL.

 Poor birth spacing
 too young
 too old
 too close
 too many pregnancies
 too sickly - Mothers with:
* Prevalent infections (TB, Malaria, STI) or
* Lifestyle diseases (diabetes, hypertension)
 Maternal malnutrition
Mothers and newborns (0-28 days) dying every year…

Main causes of maternal deaths: Main causes of neonatal deaths:

1. Hypertensive disorder of pregnancy 1. Pre-term

2. Post-partum hemorrhage 2. Infection
3. Pregnancy with abortive outcomes 3. Asphyxia
 >80% of Maternal Deaths are due to
5 DIRECT OBSTETRIC COMPLICATIONS

15%
27% Hemorrhage
11%
Unsafe Abortion

Eclampsia

Obstructed Labor

Infection
11%
19% Other
17%

Indirect causes include anemia, malaria, and heart disease

 Attendants and Place of Delivery

38% 40%

Home , hilot
Home , MW
Hos pital

22%

Source: Philippine Health Statistics, 2003

Assessment
Very slow decline of MMR in past 20 years
Maternal deaths account for 14% of deaths among
women of reproductive age
Maternal death triggers other adverse consequences in
families: orphans, loss of family care provider
17 infants die per 1,000 live births within first 28 days of
life
Mostly within first week after birth
Half die during the 1st 2 days
Policy Developments
Administrative Order 2008-0029
(Sept. 9, 2008) – Implementing Health
Reforms for Rapid Reduction of Maternal
and Neonatal Mortality

Administrative Order 2009-0025

(Dec. 01, 2009) – Adopting New Policies and
Protocol on Essential Newborn Care
Policy Objective
Reduce maternal and neonatal mortality rates faster
from 2007 to 2015 in order to meet MDG targets

However, we need to understand features and

characteristics of maternal and newborn deaths to
focus our interventions.
Implementing Health Reforms for
Rapid Reduction of Maternal and
Newborn Mortality
General Principles of MNCHN
Integrated MNCHN Service Package
Core Service Package
(Life Cycle Approach)

 Pre-pregnancy package of services

 Complete pre-natal package
 Complete care during delivery
 Immediate postpartum and neonatal
 Emergency maternal and newborn service package
Pre-pregnancy package
Micro-nutrients (Iron w/ folic acid)
Tetanus-toxoid immunizations
Fertility awareness, birth spacing and FP counselling
Nutrition and healthy lifestyle
Oral health
Counselling and services on STD/HIV/AIDS
Management of lifestyle related diseases
Pre-Natal package
Monitoring of height and weight
Blood pressure determination and monitoring
Pregnancy test, urinalysis, CBC, blood typing, STI screening
Pap smear and acetic acid wash, blood sugar determination
Micro-nutrient supplementation
Tetanus toxoid
Malaria prophylaxis
Birthplanning
Pre-Natal package
 Counselling on FP methods ( LAM, BMF
contraceptives)
 Counselling on healthy lifestyle
 Prevention and management of bleeding in early
pregnancy
 Early detection and management of danger signs
and complications of pregnancy
 Assessment of fetal growth and well being
 Prevention and management of other diseases
 Provision of other support services
Childbirth Service Package Obstructed
labor

Monitoring progress of labor using the partograph

Identification of early signs/symptoms and
appropriate management
The 3 Cs of childbirth
No episiotomy and no fundal pressure
Active management of the third stage of labor
Essential Newborn Care Package
Post-partum service package
Physical Exam ( BP monitoring, pelvic exam)
Identification of early signs and symptoms of
postpartum complications like hemorrhage, infection
and hypertension
Micronutrient supplementation
Provision of FP services
Counselling on
 Nutrition
 Exclusivebreastfeeding up to six months
 neonatal care
Neonatal Care
(w/in 24 hours postpartum routine care)
Cord care
Vitamin K injection
Eye prophylaxis
Delayed bathing to 6 hours of life
BCG and Hepatitis B Immunization
Newborn screening
Birth registration
Counselling on post-partum/post-natal check-up, home care
and immunization
 Levels of Core Service Package
(Interventions)

BEmONC level
EmONC
CEmONC level
STRATEGIC PLANS FOR 2005-2010
Launch & implement the BEmOC & CEmOC strategy
BEmOC strategy – establishment of facilities for
every 125,000 population, can be reached within 30
minutes from each catchment brgy

CEmOC strategy – for every 500,000 population;

referring facility, reached within 1 hr. from BEmOC
facility
Basic Emergency Obstetrics and Newborn
Care (BEmONC) Bleeding
Parenteral administration of oxytocin in the third
stage of laborPre-eclampsia
Parenteral administration of loading dose of anti-
convulsant Infection
Parenteral administration of initial dose of antibiotics
Assisted delivery during imminent breech presentation
BEmONC (continuation) Bleeding
Bleeding &
infection
Manual removal of placenta
Neonatal death
Removal of retained placental products
Administration of loading dose of corticosteroids
for threatened pre-mature delivery
Newborn resuscitation w/ oxygen support
Essential Newborn Care
Comprehensive Emergency Obstetrics and
Newborn Care (CEmONC)

BEmONC
 Parenteral administration of oxytocin in the third stage of labor
 Parenteral administration of loading doses of anti-convulsant
 Parenteral administration of initial dose of antibiotics
 Assisted delivery during imminent breech delivery
 Manual removal of placenta (active management of 3rd stage of labor)
 Removal of retained placental products
 Administration of corticosteroids for threatened pre-mature delivery
 Newborn resuscitation
 Essential Newborn Care

 Operative delivery ( C. Section )

 Blood transfusion services
 Advanced life support management for low birth weight, premature and sick
newborn like sepsis, asphyxia, severe birth trauma, severe jaundice, etc.
MNCHN Service Delivery Network
End-referral facility (Provincial hospitals etc),
BEMONC functions + Blood transfusion &
Cesarean Section; Operates 24 hrs, with
CEmONC OB/surgeon, pedia, nurse, MW, med tech

BEmONC Normal vaginal delivery, imminent breech

FACILITY delivery, emergency drugs (antibiotics,
District Hospitals, RHUs MgSO4, oxytocin), Essential newborn
with SHPs care, FP services

Community Level Pregnancy tracking, birth planning, home visits and

follow-up, nutrition package; IEC on facility delivery
Service Provider: and FP; communication activities targeted to
RHU, BHS, WHT, BHT mothers and their families

TRANSPORTATION and COMMUNICATION SYSTEM

 Repositioning Family Planning as a Program &
Family Planning Commodities

From ...
Birth control
Population control
Limiting family numbers
Liquidating a race
Contraceptives
Birth spacing tools
To ...
Rights based: know, informed, choose, use
Health concerns: maintenance and sustenance;
prevention and control of diseases
Economic reasons/family financial stability
Continuum of service: MNCHN context
Inclusion of fertility problems
Inclusion of other modern methods available
 Life’s Events and Continuum of
Service

Conception Birth

Pregnancy Delivery 3-yr &

Pre-union:
3 years after
Premarital sex
Premarital counselling

INDIVIDUAL HOME COMMUNITY FACILITIES

Approaches...
Decentralized (social prep.; things not to expect)
Rights’ based (from the womb)
Life cycle
Life’s events

“sense of urgency, focus, consolidated efforts and

recognition on the MATERNAL, NEONATAL & CHILD
HEALTH AND NUTRITION (MNCHN) and its INTEGRATED
strategies”
Pregnancies and Deliveries ...
As emergencies whether for the so-called rich or poor
Maternal and infant deaths as reportable cases
Blood as a public good
Continuum of services from premarital/union
Pregnant Patient Rights
Facility modification
Imposed/Purposive messages
fbd or fbc
shp or sba
6mos. EB vs. LAM
3yrs spacing
TBAs ...
Incentives to refer deliveries

Join a Barangay Health Team or the Women’s Health

Team

Qualified TBAs provided educational assistance to

become midwives
Components ...
BEmONCs
CEmONCs
WBCs
3Tiered and 4Tiered Services
WHT/CHT
Training Centers
PhilHealth accredited MCP Plus (Unbundling)
Database
Tracking and Monitoring (TCL, Deaths daily)
Networks and birth plans including Blood Centers
 “BUNTIS Connection”
Facilities
Professionals
Blood
Transportation services
Communication services
Follow-up services

“GET CONNECTED!!!”
 Essential Newborn Care

Adopting New Policies and Protocol on Essential

Newborn Care (A. O. No. 2009 - 0025)
Objectives:
- Guide health workers and medical practitioners
in providing evidence-based essential newborn
care
- Define the roles and responsibilities of the
different DOH Offices and other agencies in the
implementation of the Newborn Care Protocol
 Essential Newborn Care
A package/bundle of interventions
Essential interventions in the first hour and first day to one
week of life
Emphasizes a core sequence of actions or steps
Some time-bound but doable even by a single health worker
caring for both mother and newborn
Rationale
If newborn mortality is not reduced by at least half, the
goal of reducing childhood mortality by two-thirds (MDG
Goal no.4) by 2015 would not be met.
 A Minute-by-Minute Assessment of Newborn Care
within the First Hour of Life in Philippines Hospitals (2009)
Intervention Percentage and WHO Standard
Median Time
Cord Clamp 12 sec Until pulsations stop
99% in < 1 min (1-3 mins)
Drying 97% at 1 min 100% Immediately
Immediate Skin-to-skin 9.6% at 5 min >90% (except those
contact needing resuscitation)

Put on cold surface 12% None

Not dried 2.5% None
Head not dried 6.2% None
Wash 84% at 8 min >6 hours
Temp taken before 17% All
Sobel, Silvestre, Mantaring, Oliveros, 2009
 Time-Bound Interventions

Within 30 After thorough Up to 3 minutes Within 90 minutes

Seconds drying Post-delivery Of age
Objective: Objective: Objective: Objective:
•To provide •To facilitate bonding •To reduce incidence •To facilitate initiation
warmth, prevent through STS anemia in term of breastfeeding
hypothermia (infection, and IVH in pre- through sustained
hypoglycemia) term contact

-Put on double -Put prone on chest/ -Remove 1st set of -Leave the NB on
Gloves abdomen in STS gloves STS contact
-Dry thoroughly -Cover w/ blanket, -Clamp and cut cord -Observe NB for
-Remove wet cloth bonnet after cord pulsations feeding cues
-Quick check of -Place identification (1-3 mins) -Counsel on
NB’sbreathing on ankle -Do not milk cord positioning and
-Do not separate -Active management attachment
-Do not remove vernix of labor ** Do eye care
Non-Immediate Interventions
 Vit. K
 Hepatitis B
 BCG
 Re-Examination of the newborn
- Weigh
- Look for malformations, etc.
- Feeding difficulties
 Cord Care
 Newborn Screening
 Unnecessary Procedures
Routine suctioning
Early bathing/washing
 Footprinting
Giving sugar water, prelacteals, formula and using
bottles and pacifiers
Application of alcohol, other subs on the cord stump
and bandaging the stump/ abdomen
 Immediate and
thorough drying Early skin-to-skin contact
of the newborn of the newborn to
mother’s skin

Properly-timed cord clamping Non-separation of the newborn from

and cutting the mother for early breastfeeding
initiation and rooming-in
Essential package of child survival interventions

1. Skilled attendance during pregnancy, childbirth

and the immediate postpartum

2. Care of the newborn

3. Breastfeeding and complementary feeding
4. Micronutrient supplementation

5. Immunization of children and mothers

6. Integrated management of sick children

7. Injury Prevention and Control

8. Birth Spacing
Challenges . . .
Expanded appreciation and advocacy of various factors
affecting overall health of mothers and children
Collaborative work with other health workers and local
government leaders
Advocacy towards good nutrition foundation e.g.
Breastfeeding initiation, exclusive breastfeeding,
rooming-in
 CLOSING THOUGHTS

The current state of maternal and child care needs

urgent action!
Maternal and Child survival package of
interventions will save thousands of lives
. . In
Let’s join
supporting
Each of us, as health workers and as individuals, have
HANDS!
to look inward to find ways and influence in
MNCHN
implementing the essential package of maternal and
Strategy!
child survival interventions.
Good day to all !