Regional Strategic Framework for accelerating universal access to sexual and reproductive health in the WHO South-East Asia Region 2020–2024

REGIONAL STRATEGIC FRAMEWORK FOR ACCELERATING UNIVERSAL ACCESS TO SEXUAL AND REPRODUCTIVE HEALTH IN THE WHO SOUTH-EAST ASIA REGION 2020–2024

REGIONAL STRATEGIC FRAMEWORK FOR ACCELERATING UNIVERSAL ACCESS TO SEXUAL AND REPRODUCTIVE HEALTH IN THE WHO SOUTH-EAST ASIA REGION 2020–2024 Regional Strategic Framework for accelerating universal access to sexual and reproductive health in the WHO South-East Asia Region 2020–2024 ISBN: 978-92-9022-786-1 © World Health Organization 2020 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial- ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization. Suggested citation. A Regional Strategic Framework for accelerating universal access to sexual and reproductive health, WHO South-East Asia Region, 2020–2024. New Delhi: World Health Organization, Regional Office for South-East Asia; 2020. Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris. Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party- owned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. Printed in India

06 CHAPTER 1 TABLE OF CONTENTS Foreword i Acknowledgments iii Abbreviations v Executive Summary vii Chapter 1: Background 1.1 Introduction 01 1.2 Global and Regional commitments 03 1.3 Reproductive health status of populations of the SEA 03 Region – progress and challenges Chapter 2: Rationale, purpose, scope and guiding principles and approaches 2.1 Rationale 28 2.2 Purpose 28 2.3 Process of framework development 29 2.4 Guiding principles and approaches 29 Chapter 3: Core elements of the Regional Strategic Framework for SRHR 3.1 Vision, mission, goal of the Regional Strategic Framework for SRHR 31 3.2 Strategic outcomes 31 3.3 Strategic domains 32 3.4 Strategic outcomes, domains and key actions 35 3.4.1 Strategic Outcome 1: SRH services 35 • Core reproductive health services 35 1. Maternal and perinatal health 35 2. Family planning 44 3. Comprehensive abortion care 47 4. Infertility 49 5. Reproductive tract cancers 50 5.1 Cervical cancer 50 5.2 Breast cancer 52 6. Health sector response to intimate partner violence 53 7. HIV/STI related to SRH 54 • Specific population groups with limited access to SRH services 55 1. Adolescent sexual and reproductive health (ASRH) services 55 2. SRH services for the ageing population 56 3. SRH services for differently abled persons 57 4. SRH services in humanitarian crisis 57 5. SRH services for urban slum, difficult-to-access and 58 remote populations TABLE OF CONTENTS 3.4.2 Strategic Outcome 2: Health systems 59 1. Leadership/governance (stewardship) 59 2. Human resources for health 61 3. Health-care service delivery 63 4. Health information 66 5. Health financing 67 6. Medical products, vaccines and technologies 68 3.4.3 Strategic Outcome 3: Empowering individuals, 69 families and communities 1. Capacity building of individuals and communities 69 2. Male involvement 69 3. Mobilizing communities 70 3.4.4 Strategic Outcome 4: Fostering collaboration 71 Harnessing knowledge and experience for fostering 71 collaboration between countries and with Regional entities Chapter 4: Implementation of the Regional Strategic Framework for SRHR 4.1 Country leadership 73 4.2 Adaptation/implementation of the Regional Strategic Framework 73 for SRHR 4.3 Example of prioritization of strategies to develop a national SRHR 75 Framework in countries with high MMR and SBR 4.4 Reducing unmet need of contraception 79 Chapter 5: Monitoring system for the Regional Strategic Framework 80 for SRHR REFERENCES 86 ANNEXES 92 1. Definitions 94 2. Linkages between the key areas of SRHR and SDGs 95 3. Regional Flagship programmes 97 4. Evidence-based interventions for reproductive and maternal 98 and perinatal health 4A. Key interventions to reduce maternal mortality and stillbirths 107 5. Preconception package 111 6. Recommendations on ANC for a positive pregnancy experience, 112 mapped to eight scheduled ANC contacts 7. Recommendations on intrapartum care for a positive 114 childbirth experience 8. Recommendations on postnatal care for mothers and newborns 117 9. Recommendations for ensuring human rights in the provision of 121 contraceptive information and services 10. Regional and global strategies/guidelines of relevance to the 122 SRHR Strategic Framework List of Figures Figure 1: Causes of maternal death in the SEA Region 05 Figure 2: Trends in institutional deliveries 08 Figure 3: Deliveries by skilled birth attendants in institutions 08 and at home Figure 4: Inequities in coverage of essential interventions by wealth 09 and geography Figure 5: Unmet need for FP for spacing and limiting in the SEA Region 11 Figure 6: Putting growth in the context – the S-curve 12 Figure 7: Coverage of essential interventions for FP and maternal 13 health in the SEA Region Figure 8: Number of new cases of cancer in 2018 (females, all ages) 15 in the SEA Region Figure 9. Cancer of the cervix mortality and incidence in countries 16 of the SEA Region Figure 10: Health system building blocks 20 Figure 11: Density of health workers per 10 000 population 21 Figure 12: Density of nurses and midwives per 10 000 population, 2018 21 Figure 13: WHO framework for the quality of maternal and newborn 23 health care Figure 14: WHO Regional Office for South-East Asia: Improving the 24 quality of care for reproductive, maternal, neonatal, child and adolescent health Figure 15: UHC index and RMNCH sub-index 25 Figure 16: Strategic outcomes, domains and linkages to SDGs 32 Figure 17: Programme planning and management cycle 74 List of Tables Table 1: Progress of maternal mortality rate (MMR) and 05 stillbirth rate (SBR) Table 2: Stillbirth rates (SBRs), ARR, SDG target and expected status 06 at current ARR by 2030 Table 3: Coverage of essential interventions 07 Table 4: Fertility and FP indicators in the SEA Region 10 Table 5: Additional maternal deaths preventable by satisfying 12 unmet need in countries of the SEA Region, 2018 Table 6: Snapshot of policies and legal sources related to abortion in 14 the SEA Region countries Table 7: Cervical cancer screening implementation status 16 Table 8: Health system categories based on readiness to scale up 20 towards UHC Table 9: Strategic outcomes and strategic domains 33 Table 10: Regional and country goals and targets to be achieved 34 by 2030 Table 11: Summary of maternal and reproductive health (MRH) 76 situation in the SEA Region, 2019 Table 12: Obstetric transition: the pathway towards ending 77 preventable maternal deaths Table 13: Monitoring indicators for regional SRH strategy 81

iFOREWORD The WHO South-East Asia Region has made significant progress in strengthening sexual and reproductive health services and rights. Between 2000 and 2017 the Region reduced the maternal mortality ratio by more than 57%. Between 1990 and 2018 the Region reduced neonatal mortality by 60%. In 2016 the Region was validated to have eliminated maternal and neonatal tetanus. Several Member States have now eliminated mother-to-child transmission of HIV and syphilis. In line with the Region’s updated Flagship Priorities, all countries are striving to accelerate the reduction of maternal, neonatal and under-five mortality and achieve universal access to sexual and reproductive health services. To fulfil the Region’s Flagship Priorities, and meet applicable Sustainable Development Goal targets, in addition to the global Survive, Thrive and Transform agenda, sustained and accelerated action is needed, to which this regional strategic framework will contribute. By 2030 all countries should have a maternal mortality ratio (MMR) that is at least two thirds of their 2010 baseline. No country should have an MMR of more than 140 per 100 000 live births. Neonatal mortality should be at least as low as 12 per 1000 live births. Sexual and reproductive health services should be universally accessible, and all people should have their sexual and reproductive rights respected, protected and fulfilled. This regional strategic framework is divided into five chapters and is focused on achieving four outcomes, which cover the delivery of high-impact interventions in prioritized areas across the life course; health system interventions in support of the delivery of high-impact interventions; community mobilization to utilize the interventions for improved SRH and realization of rights; and fostering collaboration between Member States for accelerating progress through learning from best practices and innovations. The document provides key strategic directions and actions to help countries achieve the outcomes, which should be applied according to the local context. The regional strategic framework makes critical recommendations in two key areas of focus: reducing stillbirths and eliminating cervical cancer. Region wide, there is significant scope to reduce the burden of stillbirths, which are linked to maternal health status. As the strategy outlines, all countries should develop national action plans for the prevention and management of stillbirths, which should include 10 recommended interventions. On cervical cancer, which is the third most common cancer in the Region, countries can similarly accelerate progress by prioritizing the roll-out of quality screening and treatment services, and by achieving universal access for women and girls to the HPV vaccine. I urge all Member States, partners and stakeholders to leverage this strategic framework to continue the Region’s winning trajectory. WHO is fully committed to supporting Member States and working with its many partners to strengthen sexual and reproductive services and rights within the Region, and to achieve the targets and goals that we must. A Region in which all people have access to quality sexual and reproductive health services, and in which all people’s sexual and reproductive rights are fulfilled, is a Region that will be healthier, stronger and more sustainable. The future is ours to make. Dr Poonam Khetrapal Singh Regional Director WHO Regional Office for South-East Asia ii iii “Regional Strategic Framework for accelerating universal access to sexual and reproductive health in the WHO South-East Asia Region 2020–2024“ is the product of the contribution of several individuals. WHO would like to appreciate the contribution of programme managers from the Ministries of Health of Bangladesh, Bhutan, DPR Korea, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand and Timor-Leste. The valuable inputs provided by the Chair and members of WHO South- East Asia Technical Advisory Group on women’s and children’s health (SEAR-TAG) are appreciated. We acknowledge the expert advice and technical support of WHO Collaborating Centres, professional associations, UN partner agencies (H6), civil societies and development partners. ACKNOWLEDGEMENTS ACKNOWLEDGMENTS iv vABBREVIATIONS ABR adolescent birth rate ANC antenatal care ARR annual rate of reduction ART assisted reproductive technologies ASHA Accredited Social Health Activist ASRH adolescent sexual and reproductive health BEmONC Basic Emergency Obstetric and Neonatal Care BIMSTEC Bay of Bengal Initiative for Multi-Sectoral Technical and Economic Cooperation BMI body mass index BRICS Brazil, Russia, India, China and South Africa CAC comprehensive abortion care CBHS community-based health service(s) CBHW community-based health worker/service provider CEmONC Comprehensive Emergency Obstetric and Neonatal Care CPR contraceptive prevalence rate CRVS civil registration and vital statistics DALYs disability-adjusted life years DHIS District Health Information System DHS Demographic and Health Survey(s) EmONC Emergency Obstetric and Neonatal Care ENAP Every Newborn Action Plan EPI Expanded Programme on Immunization EPMM Ending Preventable Maternal Mortality FP family planning GBV gender-based violence GDP gross domestic product GLOBOCAN Global Cancer Incidence, Mortality and Prevalence GNI gross national income GSWCAH Global Strategy for Women, Children and Adolescent Health HIV human immunodeficiency virus HMIS Health Management Information System HPV human papillomavirus HRH human resources for health ICD-MM International Classification of Diseases – Maternal Mortality ICD-PM International Classification of Diseases – Perinatal Mortality ICM International Confederation of Midwives ICOPE Integrated Care for Older People ICPD International Conference on Population and Development IUCD intrauterine contraceptive device LMIS Logistics Management Information System ABBREVIATIONS vi mCPR Contraceptive Prevalence Rate for Modern Methods MDG Millennium Development Goal MDSR MATERNAL DEATH SURVEILLANCE AND RESPONSE MEC medical eligibility criteria MICS Multiple Indicator Cluster Survey MII Method Information Index MISP Minimum Initial Services Package MMR maternal mortality ratio MPDSR Maternal and Perinatal Death Surveillance and Response MVA manual vacuum aspiration NBBD newborn and birth defect NCD noncommunicable disease NGO nongovernmental organization NHWA National Health Workforce Accounts NICU neonatal intensive care unit OOP out-of-pocket PMTCT prevention of mother-to-child transmission PNC postnatal care PoA Programme of Action POCQI point-of-care quality improvement PPP purchasing power parity RMNCAH reproductive, maternal, newborn, child and adolescent health RMNCH reproductive, maternal, newborn and child health SAARC South Asian Association for Regional Cooperation SBA skilled birth attendant SBR stillbirth rate SDG Sustainable Development Goal SEA Region South-East Asia Region SOP standard operating procedure SPR selected practice recommendations for contraceptive use SRH sexual and reproductive health SRHR Sexual and Reproductive Health and Rights STI sexually transmitted infection(s) TAG Technical Advisory Group TFR total fertility rate UHC universal health coverage UN-IAWG United Nations Inter-Agency Working Group UN-IGME United Nations Inter-Agency Group for Child Mortality Estimation UN-MMEIG United Nations Maternal Mortality Estimation Inter-Agency Group UNFPA United Nations Population Fund VIA visual inspection with acetic acid WHO World Health Organization ABBREVIATIONS vii The concept of sexual and reproductive health and rights (SRHR) is critical to achieving the Goals of the 2030 Agenda for Sustainable Development, which contains several targets related to reproductive health. The 11 Member States of the WHO South- East Asia (SEA) Region are major signatories to several of the SRH-related human rights treaties and development agenda. The eight of Flagship Priority Areas of the WHO Regional Office for South-East Asia include three areas directly addressing SRHR: Flagship 3 – Accelerate reduction of maternal, neonatal and under-five mortality; Flagship 4 – Continue progressing towards Universal Health Coverage (UHC) with a focus on human resources for health (HRH) and essential medicines; and Flagship 6 – Scale up capacity development in emergency risk management in countries. The Flagship of Priority Areas, the Resolution of the WHO Regional Committee for South-East Asia on Ending Preventable Maternal, Newborn and Child Mortality in the South-East Asia Region (SEA/RC69/ R3) and the Joint Statement by H6 agencies on ending preventable maternal, newborn and child mortality (2015) further illustrate the commitment of the Region to achieving SRHR targets. The Regional Flagship Priority Areas 2019–2023 include three strategic objectives cutting across priority areas – sustaining achievements, accelerating progress to complete the unfinished agenda and innovating for solutions to achieve further results. The investments in improving availability, access and quality of SRHR services have contributed to significant progress in SRHR, notably, reductions in maternal and child mortality and unmet needs for family planning. The Region is facing a major change in demographics, with a significant young population and an ageing population. EXECUTIVE SUMMARY Situational analysis of sexual and reproductive health in the South-East Asia Region • Globally, between 2000 and 2017, the WHO SEA Region has witnessed the maximum reduction in the maternal mortality ratio (MMR); however, despite the progress, the Region still reports the third highest MMR. • The Region presents a mixed picture with regard to the level of MMR and annual rate of reduction (ARR). Seven of the Member States report an MMR of above 140/100 000 live births (the global upper level cut-off to achieve the SDG targets). While Nepal and Timor-Leste have achieved an ARR as recommended and are on track to achieve the SDG target in 2030, the remaining of countries, including those with low MMR, will have to accelerate efforts to speed up the reduction in ARR to achieve the 2030 country target of two-thirds reduction of MMR from the 2010 values. • Stillbirth rates (SBRs) are high in the Region and are linked to the maternal health status. Stillbirth is a marker of the quality of care during the antenatal and intrapartum periods. Maldives, Sri Lanka and Thailand have achieved the SBR country target for 2030 of 12 or less. The prevention of stillbirths has not been given due priority under maternal care and has not received adequate visibility in national programmes. • Sixty-two per cent of deaths of children under the age of five are neonatal deaths. While the Democratic People’s Republic (DPR) of Korea, Maldives, Sri Lanka and Thailand have achieved the SDG target of neonatal mortality rate (NMR) below 12, India, Myanmar and Timor-Leste need to accelerate their annual rates of reduction. • In general, the Region has witnessed an increase in antenatal visits, institutional deliveries and postnatal visits; however, Bangladesh, Myanmar and Timor-Leste report a coverage rate of less than 50%. Inequities in coverage and poor quality of services contribute to stagnant maternal mortality, neonatal mortality and stillbirth rates in Member States. • Sustained investments in family planning (FP) have contributed to a reduction in fertility, increase in the use of modern methods of contraception EXECUTIVE SUMMARY viii and decrease in unmet needs. Maldives, Nepal and Timor-Leste have high unmet needs. Discontinuation of contraceptive methods and unintended pregnancies and their consequences are concerns in many Member States. Evidence from the Region shows that further reducing the unmet needs can reduce maternal mortality by almost 30%. • Despite the high coverage of FP services, abortion continues to be an issue in the Region, accounting for 8% of maternal deaths. Coverage and quality of post-abortion care, especially with regard to FP, are matters of concern. • Cervical cancer is a significant public health problem in the SEA Region. In 2018, an estimated 158 000 new cases and 95 766 deaths occurred due to cervical cancer, which is the third commonest cancer in the SEA Region. Indonesia, Maldives, Myanmar and Nepal report an incidence of more than 20 per 100 000 women. Bhutan, Maldives, Sri Lanka and Thailand have introduced nationwide the vaccine for human papillomavirus (HPV). All Member States have initiated screening for cervical cancer using cytology (Pap smear) and/or visual inspection with acetic acid (VIA); however, nationwide coverage has been achieved only in Bhutan, Sri Lanka and Thailand. • The sexual and reproductive health of adolescents is a significant problem in the Region, and is getting increasing attention in the Member States. Early marriage is common in the Member States. Adolescent birth rate is high in the Region, though it has decreased over the years. It is high in Bangladesh, India, Nepal and Thailand. The demand satisfied with modern methods of FP among adolescents of 15–19 years is above 50% in all countries except India and Timor-Leste. Maternal conditions are one of the five leading causes of disability-adjusted life years (DALYs) lost among adolescents of 15–19 years in the SEA Region. • The burden of morbidity and mortality from sexually transmitted infections (STI) is significant in the SEA Region, and compromises the SRH of women, as well as newborn and child health. The HIV epidemic is not generalized in the Region. Maldives, Sri Lanka and Thailand have been validated for eliminating mother-to-child transmission of HIV and syphilis. Despite the well- known benefits of integrating STI and HIV services with SRH services, it is a major gap in almost all Member States except Thailand • Other important reproductive health problems identified in the document include infertility and intimate partner violence as well as reproductive health of special population groups such as the ageing population and differently abled populations. • The Member States of the SEA Region are vulnerable to different types of natural disasters. Strengthening emergency risk management is one of the four strategic imperatives of the WHO Regional Office for South-East Asia and scaling up capacity is one of the flagship programmes. Mortality and morbidity related to SRH are significant during disasters and maintaining essential health services is important. All Member States have developed national disaster preparedness plans of which SRH is a main component. • Urbanization is recognized as one of the changing needs of the Region. Rapid urbanization and growth of slums is a feature in many Member States of the SEA Region. The SRH indicators in the slums are worse than those in non-slum populations. • The level of achievement of the SRH indicators is strongly correlated with the level of development of the health system. Under the framework for health system strengthening, Myanmar, Nepal and Timor-Leste fall under category 1; Bangladesh, Bhutan, India and Indonesia fall under category 2; and the remaining under category 3. Countries in category 1 and 2 have poor maternal and perinatal indicators (Table 8 in the main document provides details of the categories). • Most of the Member States have not reached the WHO human resources threshold for doctors, nurses and midwives per 10 000 population (except for DPR Korea and Maldives). The SEA Region has significant health workforce challenges ranging from shortages and unequal distribution to retention, which has significant influence on SRH achievements. • While almost all the Member States have developed health information platforms, including the District Health Information System-2 (DHIS-2), of varying coverage and quality, completeness and accuracy of data collected are a major concern. EXECUTIVE SUMMARY ix • Countries of the SEA Region continue to have one of the highest out-of-pocket (OOP) payments at the time of health care and on an average 38% of the households pay from their pockets, which indicates inadequate financial health protection. A major reason is low public health spending. The UHC index and the reproductive, maternal, newborn and child health (RMNCH) sub-index for the Region are 63 and 66, respectively (Figure 16 in the main document provides country-wise information). • The sterling successes achieved by some Member States in effective coverage and impact and the lessons learnt create the potential for collaboration between countries in the Region and across the Region – thus promoting SDG 17. Rationale For developing the Regional SRHR Strategy Much progress has been made in reducing maternal and perinatal mortality and improving reproductive health of the people of the Member States in the SEA Region through favourable policies and investments in evidence-based interventions and health systems; however, there is still some unfinished business, to varying degrees in many countries. The landscape of SRH is changing, shaped by economic and social development including improvements in women’s education and participation in formal employment, urbanization, epidemiological and demographic shifts, creating a double burden in lower middle-income countries. The double burden is manifested in an increasing burden of noncommunicable diseases (NCDs) and associated risk factors adding to the complexity of SRH care, while the burden of preventable reproductive morbidity and mortality continues. Through the adoption of the 2030 Agenda for Sustainable Development, the Member States have confirmed their commitment to universal access to SRH services, ensuring financial protection and quality services and narrowing equity gaps. The commitment of the WHO Regional Office for South-East Asia through its Flagship Priority Areas creates an imperative to develop a new Regional Strategic Framework for SRHR. The new Strategic Framework should enable Member States to meet their commitments in the context of the changing landscape. Purpose This Regional Framework for Member States of the SEA Region aims to provide guidance to decision- makers and programme managers to (i) expand the scope of SRH services currently being implemented with regard to SRH issues and population coverage of evidence-based interventions aligned with recent guidelines; (ii) align with reforms of the national health system; (iii) achieve global commitments related to SRH through rights-based approaches; and (iv) share the lessons learnt and best practices. The broad Regional Framework and its contents need to be adapted to the national context, in accordance with national legislation, capacities, priorities and specific national circumstances, while ensuring the international commitment that Member States have already made. The strategy is rooted in the principles of human rights related to health and is guided by health system approaches that help to achieve the highest attainable standard of health and universal access. Vision A Region where the highest standard of sexual and reproductive health for all women and adolescents across the life course, in every setting, is enabled to realize the fulfilment of sexual and reproductive rights; and where the Member States work towards reducing inequities, leaving no one behind. Mission To support the Member States in the SEA Region to accelerate progress towards universal access to sexual and reproductive health services for all women and adolescents, built on the principles of human rights and public health, and with the full engagement and accountability of the governments, minimizing inequities within individual countries and in the Region. Goal Ending preventable deaths from reproductive ill- health and improving reproductive health and well-being of women and adolescents across the life course and realization of sexual and reproductive rights, through enabling policies, people-centred and quality health systems that are equitable, efficient and accountable, and changed/transformed health-seeking behaviour; thus, contributing to the achievement of SDG 3 and other SDG targets. EXECUTIVE SUMMARY xStrategic outcomes The Regional Strategic Framework for SRHR has four interdependent strategic outcomes, each of which has several strategic domains contributing to the outcome. 1. Quality, integrated, people-centred, evidence- based SRH interventions are available, accessible and responsive to the needs of individuals across the life course. 2. Strengthened and accountable health systems enable efficient and equitable coverage of SRH interventions. 3. Individual and collective capacity and awareness are maximized for reproductive well-being and seeking care when needed. 4. Collaboration between countries and with regional entities is fostered for accelerating progress towards universal access to SRH. Each outcome has strategic domains with interlinked prioritized areas and key actions. Outcome 1 includes core SRH services through the life cycle as well as SRH services for special population groups that have limited access to SRH services. The core SRH services include maternal and perinatal health, FP, comprehensive abortion care, infertility, reproductive organ cancers, health sector response to intimate partner violence, and HIV/STI. The special population groups that have limited access to SRH services include adolescent sexual and reproductive health (ASRH) services, ageing population, differently abled, humanitarian settings, urban slum populations and populations in remote and difficult to access areas. Outcome 2 has six health system domains, namely, leadership/governance, human resources, health-care service delivery, health information, health financing and essential medicines, commodities and technologies to deliver SRH interventions with quality and equity. Outcome 3 includes demand-related domains such as capacity building of individuals, male involvement and mobilizing communities for better SRH outcomes. Outcome 4 includes harnessing knowledge and experience for fostering collaboration between countries and with regional entities and other agencies. This concept is illustrated in the following diagram. EXECUTIVE SUMMARY Figure 16: Strategic outcomes, domains and linkages to SDGs Strategic Outcome 1: Life cycle and vulnerable groups Core services in life cycle • Maternal and perinatal health • FP • Comprehensive abortion care • Infertility • Reproductive organ cancers • Health sector response to intimate partner violence • HIV and STI Specific population groups that have less access to SRH services • ASRH services • SRH services for ageing • SRH services for differently abled • SRH services in humanitarian crisis • SRH services for urban slums and remote and difficult-to-access areas Strategic Outcome 2: Health system building blocks • Leadership/governance (stewardship) • Human resources for health (HRH) • Health-care service delivery • Health Information • Health financing • Essential medicines, commodities and technologies Strategic Outcome 3: Core approaches • Capacity building of individuals • Male involvement • Mobilizing communities Strategic Outcome 4: Harnnessing knowledge and experience for fostering collaboration between countries and with regional entities and other agencies 10 Reduce inequalities 3 Good health and well-being 5 Gender equality 17 Partnership for the goals xi Implementation of the Regional Strategic Framework Country leadership Country leadership is the key to the implementation of the Regional Strategic Framework for SRHR or adding its elements to the existing national SRH strategies and plans. Country leadership includes stewarding and coordinating effective implementation across sectors, subnational platforms, development partners, civil society organizations, professional associations, private sector, etc. The effective implementation of the strategy also requires strengthening of the planning capacity for SRHR programmes, particularly at the decentralized level. Strong programme management at the national and subnational levels is a key determinant of progress towards universal access to SRHR, reduction in maternal mortality and stillbirths and achievement of SDG targets. The regional training programme for building capacity for programme management at the national and subnational levels in Member States, developed by the WHO Regional Office for South-East Asia, provides an opportunity for capacity building. The Regional Strategic Plan can be adopted by countries as follows. In countries with an ongoing national SRH or RMNCAH strategy: • Most of the Member States have developed SRH or RMNCAH strategies in recent years. In those countries where the national SRH or RMNCAH strategy is at the end of the strategic cycle, a new strategic plan should be developed, by adapting the Regional Strategic Framework for SRHR, as relevant. Before developing the new strategic plan, a programme evaluation/review of the previous plan should be done (refer to Figure 18) • In countries where the strategic cycle of SRH or RMNCAH has not ended, countries should enter the planning cycle by doing a mid-term review of the implementation status of the strategy. In countries where there is no national SRH strategy: • Quick reviews should be done of the strategies and programmes related to maternal health, FP, cervical cancer, ASRH, etc. The Regional Strategic Framework should be adapted taking into consideration the findings of the reviews. Where there are gaps or missing elements, those should be added from the strategic framework. The framework provides an example of prioritization of strategies in countries with high MMR and SBR (different stage of obstetric transition) and is relevant for the seven Member Countries with an MMR above 140/100 000 live births and SBR above 12 per 1000 live births. A proposed Regional monitoring framework is also included in the strategic framework. EXECUTIVE SUMMARY CHAPTER 1 BACKGROUND 01 CHAPTER 1 1.1 Introduction The global understanding of sexual health, including its relationship with reproductive health, has evolved over time. The concept of “sexual and reproductive health and rights” (SRHR) was made central to health and development by the Programme of Action (PoA), ratified at the International Conference on Population and Development (ICPD) in 1994. The World Health Organization’s (WHO’s) first global Reproductive Health Strategy to accelerate progress towards the attainment of international development goals and targets was adopted by the 57th World Health Assembly in May 2004 (WHA 57.12) [1]. The global Reproductive Health Strategy covers five key areas – maternal and perinatal health; family planning (FP), including infertility services; abortion; sexually transmitted infections (STI), including HIV, reproductive tract infections, cervical cancer and other gynaecological morbidities; and sexual health – as well as several cross-cutting areas such as gender-based violence (GBV). In 2010, WHO published a framework for action on developing sexual health programmes. The right to sexual and reproductive health (SRH) is an integral part of the right to the highest attainable standard of physical and mental health. Reproductive rights derive from the human rights of individuals and couples to decide freely on matters related to reproduction and the right to attain the highest standard of reproductive health. Sexual health and reproductive health are inherently linked, both conceptually and at the point of programme or research implementation, but crucial aspects of sexual health can be overlooked when grouped under or together with the domain of reproductive health [2]. Services related to the prevention of human immunodeficiency virus (HIV) and STI, GBV, etc. are considered sexual health interventions. Definitions of sexual health and rights are given in Annex 1. Since the ICPD, the language around SRHR has evolved considerably and the Guttmacher–Lancet Commission on sexual and reproductive health and rights for all (2018) has developed an integrated definition that reflects an emerging consensus on the services and interventions needed to address the SRHR needs of all individuals (Annex 1) [3]. “REPRODUCTIVE HEALTH is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes. Reproductive health therefore implies that people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when, and how often to do so. Implicit in this last condition are the right of men and women to be informed of and to have access to safe, effective, affordable, and acceptable methods of family planning of their choice, as well as other methods of their choice for regulation of fertility which are not against the law, and the right of access to appropriate health care services that will enable women to go safely through pregnancy and childbirth and provide couples with the best chance of having a healthy infant.” (ICPD PoA Para 7.2). 02 CHAPTER 1 Reproductive health is critical to achieving the Goals of the 2030 Agenda for Sustainable Development, which contains several targets related to reproductive health. Specifically, target 3.7 calls for ensuring universal access to SRH care services, including FP, information and education, and the integration of reproductive health into national strategies and programmes by 2030. Likewise, target 5.6 calls for ensuring universal access to SRH and reproductive rights. Other targets in the 2030 Agenda related to reproductive health include reducing the global maternal mortality ratio (MMR) to less than 70 per 100 000 live births (target 3.1); ending preventable deaths of newborns and children under 5 years of age (target 3.2); and eliminating all harmful practices, such as child, early and forced marriage and female genital mutilation (target 5.3). Meeting the targets related to reproductive health can contribute positively to the achievement of other goals. The centrality of SRHR in achieving the Sustainable Development Goals (SDGs) is shown below and a list of SDGs linked to SRHR is provided in Annex 2. The Global Strategy for Women’s, Children’s and Adolescents’ Health (GSWCAH) (2016–2030) provides a roadmap for ending preventable deaths of women, children and adolescents by 2030 and for helping them achieve their potential for and rights to health and well-being in all settings [4]. The global strategy has three objectives: survive (end preventable deaths); thrive (ensure health and well-being); and transform (expand enabling environments). These objectives are aligned with 17 targets within nine of the SDGs. Two of these, including SDG 3, are on health, while the others are related to the political, social, economic and environmental determinants of health and sustainable development. Peace, justice and strong institutions Life on land Life below water Climate action Responsible consumption and production Sustainable cities and communities Industry, innovation, and infrastructure Decent work and economic growth Affordable and clean energy Clean water and sanitation Quality education Gender equality Good health and well-being Reducing inequalities Partnerships for the goals Zero hunger No poverty 03 CHAPTER 1 1.2 Global and Regional commitments The 11 Member States of the WHO’s South-East Asia (SEA) Region are signatories to major SRH-related international human rights treaties, ICPD PoA and its subsequent outcome documents, the Millennium Development Goals (MDGs), United Nations 2030 Agenda for Sustainable Development and its seventeen SDGs, Primary Health Care Declaration at Astana, Universal Health Coverage (UHC), GSWCAH, FP2020, etc. The strategic approaches of the WHO Regional Office for South-East Asia include addressing persisting and emerging epidemiological and demographic challenges, advancing UHC and strengthening robust health systems, strengthening emergency risk management for sustainable development and articulating a strong regional voice in the global health agenda. The eight Regional Flagship Priority Areas include three areas directly addressing SRHR: Flagship 3 - Accelerate reduction in maternal, neonatal and under-five mortality; Flagship 4 - Continue progressing towards UHC with a focus on human resources for health (HRH) and essential medicines; and Flagship 6 - Scale up capacity development in emergency risk management in countries. Over the past decade, there has been significant progress by Member States of the SEA Region to improve SRH, notably, reductions steady increase in maternal and child mortality, increase in the numbers of people living with HIV initiated onto treatment, and life expectancy at birth. 1.3 Reproductive health status of populations of the SEA Region – progress and challenges The Flagship Priority Areas, the Resolution of the WHO Regional Committee for South-East Asia on Ending Preventable Maternal, Newborn and Child Mortality in the South-East Asia Region (SEA/RC69/R3) and the Joint Statement by H6 agencies on ending preventable maternal, newborn and child mortality (2015) further illustrate the commitment of the Region to achieving SRHR targets. The Regional Flagship Priority Areas 2019 - 2023 include three strategic objectives cutting across priority areas - sustaining achievements, accelerating progress to complete the unfinished agenda and innovating for further solutions to achieve further results (see Annex 3). Accelerating reduction of maternal, neonatal and under-five mortality continues to be a focus area along with improving UHC and emergency preparedness. 04 CHAPTER 1 The population in the 11 Member States of the SEA Region accounts for 26% of the world population. The Region has four countries with the highest populations in the world and 19% of the population comprises adolescents aged 15–19 years. The Region is facing a major change in demographics, with a significant young population and an ageing population. Most of the SEA Region countries are low middle-income countries; and the disease burden presents a twin picture of high burden of maternal, newborn and child mortality with an increasing prevalence of noncommunicable diseases (NCDs). Keeping up its international and regional commitments to improve the SRHR situation, Member States of the SEA Region have invested in improving availability, access and quality of SRHR services. The impact of such investments are evident from the progress towards achieving the SDG targets related to health and gender; however, there remains unfinished business with regard to maternal and perinatal mortality and access to key SRHR interventions. Maternal mortality Globally, between 2000 and 2017, the WHO SEA Region has witnessed the maximum reduction in MMR - reduction by 57.3%, amounting to an average annual rate of reduction of 5% [5]. The point estimate for MMR in the SEA Region was 152 (192-102) per 100 000 live births in 2017 (see Table 1). Despite the progress, the Region still reports the third highest MMR. To achieve the target of two-thirds reduction in MMR from the 2010 levels, it is recommended that (i) no country should have an MMR more than 140 and (ii) maintain an annual rate of reduction (ARR) of ±6–7% [6]. Seven of the Member States report an MMR above 140. Bangladesh, India, Nepal and Timor-Leste showed an ARR of ±5% during 2000–2017. Three Member States of the SEA Region (Bhutan, Maldives and Timor-Leste) had achieved the MDG 5A target in 2015 (three of the nine countries had achieved 75% reduction in point estimates between 1990 and 2015 globally). Nepal and Timor-Leste are on track to achieve the SDG target in 2030 with the current ARR (6–7%) during 2010–2017. The other countries will have to accelerate efforts to speed up the reduction in ARR to achieve the 2030 targets. It should be noted that for the countries that have already achieved a low MMR, the recommended ARR to achieve the SDG targets may be unrealistic if high-impact strategies are not identified. Obstetric transition stage III is categorized as MMR 299–50 maternal death/100 000 live births, i.e. fertility is variable and direct causes of mortality still predominate [7]. This is a complex stage because access to services continues to be an issue for a large part of the population. However, since in this stage a high proportion of pregnant women access health services, the quality of care is one of the main determinants of health outcomes, particularly related to overburdened health services. Primary prevention, as well as secondary and tertiary prevention, is fundamental to improve maternal health outcomes in this stage. In other words, the quality of care, skilled childbirth care and adequate management of complications are essential for reduction in maternal mortality in this stage. Obstetric transition stage IV is categorized as MMR <50 maternal deaths/100 000 live births, i.e. maternal mortality is low. In this stage, the fertility rate is low and indirect causes of maternal mortality, in particular chronic-degenerative diseases, gain increasing importance. Figure 1 shows the causes of death. While the countries are struggling with preventable direct causes of maternal mortality, such as haemorrhage, pregnancy-induced hypertension (eclampsia/ pre- eclampsia), sepsis and abortion, the prevalence of maternal deaths due to indirect causes is increasing, especially in countries in obstetric transition stage IV. MATERNAL AND PERINATAL HEALTH WHO and global technical experts have categorized countries according to the stage of transition towards elimination of maternal deaths, called the stages of obstetric transition. Most of the countries are in obstetric transition stage III and two countries are in stage IV (see Table 1); their characteristics are described below (further details of obstetric transition are given in Chapter 4, Table 12). Nine Member States are in obstetric transition stage III whereas Thailand and Sri Lanka are in stage IV. 05 CHAPTER 1 Table 1: Progress of maternal mortality rate (MMR) and stillbirth rate (SBR) South-East Asia Region Member States Maternal mortality Stillbirth rate (SBR)/1000 total births (2015) Stage of obstetric transition (countries arranged in decreasing order of mortality) MMR 2017 (per 100 000 live births) EPMM*/SDG target 2030 two-third reduction of 2010 ARR 2010–2017 SDG 2030 target at 2010-2017 ARR Myanmar 250 99 0.9 Acceleration needed 20 III Nepal 186 95 7 On track to achieve target 18.4 III Bhutan 183 81 4.3 Acceleration needed 16 III Indonesia 177 77 3.6 Acceleration needed 13.2 III Bangladesh 173 80 5.7 Acceleration needed 25.4 III India 145 63 5.3 Acceleration needed 23 III Timor-Leste 142 64 6.2 On track to achieve target 17.8 III DPR Korea 89 37 2.5 Acceleration needed 13.5 III Maldives 53 22 3.5 Acceleration needed 7.7 III Thailand 37 15 1.6 Acceleration needed 5 IV Sri Lanka 36 14 1 Acceleration needed 4.9 IV SEA Region 152 66 4.8 Acceleration needed 21 III Figure 1 : Causes of maternal death in the SEA Region An estimated 61 000 women died as result of pregnancy and childbirth-related complications *EPMM: Ending Preventable Maternal Mortality Source: UN MMIEG 2019 Report; Lancet Report on Stillbirths 2015 Target status in 2030 is based on the 2010–2017 ARR and the assumption that all things will remain as in 2017 EMBOLISM SPEPSIS ABORTION OTHER DIRECT INDIRECTHYPERTENSION HAEMORRHAGE Source: Say L, Chou D, Gemmill A, Tunçalp Ö, Moller AB, Daniels JD, et al. Global causes of maternal death: a WHO systematic analysis. Lancet Global Health 2014;2: e323-e333 Moderate to high MMR >140/100 000 live births and moderate to high SBR >12/1000 births Countries where acceleration of ARR is needed urgently to achieve the SDG targets Countries which will achieve SDG target if they maintain the current rates of ARR Countries with low mortality – MMR <140 /100 000 live births; SBR <12/1000 total births* (except DPRK) SBR country target achieved M od er at e to h ig h m or ta lit y Lo w m or ta lit y 29%10% 31% 14% 2% 8% 6% 06 CHAPTER 1 Table 2: Stillbirth rates (SBRs), ARR, 2030 target and expected status at current ARR by 2030 Stillbirth Stillbirth rates (SBRs) are high in the Region and are linked to the maternal health status [8]. Stillbirth is a marker of the quality of care during the antenatal and intrapartum period. The SBRs range from 4.9 to 25.4 per 1000 births, proportionate to the maternal health indicators (see Table 2). Maldives, Sri Lanka and Thailand have achieved the country target for 2030 of 12 or less (see Table 2). The ARR of stillbirths (2%) is slower than that of MMR and under-five mortality. Stillbirths are mostly (almost half) intrapartum (earlier defined as fresh stillbirths) and are linked to the quality of care during the intrapartum period. Other antepartum causes include post-term pregnancy, maternal infections during pregnancy (malaria, syphilis and HIV), maternal disorders (especially hypertension, obesity and diabetes), fetal growth restriction and congenital anomalies (which occur mostly in countries in obstetric transition stage IV). An estimation of birth defects (2009) showed a prevalence of more than 50 per 1000 births, the highest being those related to cardiovascular defects, followed by neural tube defects [9]. Almost all the countries in the Region have included stillbirth prevention as part of the Every Newborn Action Plan. However, the prevention of stillbirths has not been given due priority under maternal care and has not received adequate visibility in national programmes. Neonatal mortality Globally, progress in reducing neonatal mortality is slower than reduction in mortality in under-five and the share of neonatal deaths relative to all under-five deaths has proportionately increased (due to reduction of deaths among 1–59-month-olds [10]. In the SEA Resion, the proportion of neonatal deaths is 62% of under-five deaths. The majority of neonatal deaths take place in the first 24 hours after birth due to pre-term births, intrapartum-related causes and birth defects (latter in low mortality countries), pointing to the importance of care during pregnancy and childbirth. According to estimates by the WHO Regional Office for South-East Asia, DPR Korea, Maldives, Sri Lanka and Thailand have already achieved the SDG neonatal mortality target for 2030 of <12 per 1000 live births. At the 2010–2018 ARR, India, Myanmar and Timor-Leste will fall short of the SDG target. SBR per 1000 births Median ARR (% current) Country target Expected status 2015 2000–2015 2030 2030 Bangladesh 25.4 3.4 Stillbirth rate of 12/1000 total births or less Acceleration needed Bhutan 16 3.4 On track to achieve target DPR Korea 13.5 2.4 On track to achieve target India 23 2.4 Acceleration needed Indonesia 13.2 1.9 On track to achieve target Maldives 7.7 5.9 Achieved target Myanmar 20 2.6 Acceleration needed Nepal 18.4 2.8 Acceleration needed Sri Lanka 4.9 2.9 Achieved target Thailand 5 2.9 Achieved target Timor-Leste 17.8 2.6 Acceleration needed Source: Lancet Report on Stillbirths 2015 Achieved 2030 target in 2015 Countries where acceleration of ARR is needed to achieve country target Countries which will achieve target if they maintain the current rate of ARR 07 CHAPTER 1 Table 3: Coverage of essential interventions While the coverage of four antenatal care (ANC) visits has increased (at least 80% in six countries), an analysis of the services provided shows that the proportion receiving the full complement of services as per WHO recommendations for a positive pregnancy is much less. Only five countries in the Region (Bhutan, DPR Korea, Maldives, Sri Lanka and Thailand) follow the minimum eight ANC visits prescribed by WHO. A minimum eight ANC visits with at least five visits during the third trimester are critical for reducing stillbirths. The coverage of selected critical activities carried out during antenatal check-up in the SEA Region is as follows: 93% pregnant mothers had their blood pressure measured, 62% had their urine tested and 55% had their blood tested. The WHO SEA Region has eliminated maternal and neonatal tetanus, with all districts across the 11 countries having reduced cases to less than one per 1000 live births; however, continued protection against tetanus is essential. A majority of the countries report high coverage (>80%) of protection against tetanus. Maldives, Sri Lanka and Thailand have eliminated mother-to-child transmission of HIV and syphilis; however, the coverage of syphilis and HIV testing during pregnancy is sub-optimal in the rest of the countries in the SEA Region (see details in the section on STI and HIV). Source: Latest Demographic Health Survey (DHS) by country (2009–2017); SEA Region-weighted average Coverage of maternal health interventions Table 3 shows population-based coverage of evidence-based maternal health interventions. The proportion of deliveries taking place in institutions – a setting where most of the interventions can be delivered – has increased by 80% in the Region over the past decade (see Figure 2); however, Bangladesh, Myanmar and Timor-Leste still have very low institutional deliveries (see Figure 2). Home deliveries are significant in five of the 11 countries (ranges 14–40%), probably not by skilled health personnel (see Figure 3). Despite the increase in deliveries by skilled birth attendants (SBAs) in all the countries, the decrease in MMR is not as expected. Poor access to referral facilities for emergency obstetric care, including transport, and poor quality of care are other reasons. Delays in seeking care when complications arise and delay in providing timely and appropriate care in the facilities continue to be challenges. The current status of access to functioning emergency obstetric and neonatal care (EmONC) as per international standards is mostly not known.1 The proportion of deliveries by caesarean section has increased, with seven Member States reporting unacceptably high rates (>10–15%) and low rate in one country (<5%) (see Table 3). South-East Asia Region Member States Essential interventions ANC four visits (%) Delivery by SBA (%) Institutional delivery (%) PNC within 2 days of delivery – mother (%) Delivery by C-section (%) Bangladesh 31 42 37 36 23 Bhutan 85 86 74 75 12 DPR Korea 94 100 95 98 13 India 51 81 79 62 17 Indonesia 91 98 74 87 17 Maldives 82 100 95 80 40 Myanmar 59 60 37 71 17 Nepal 69 58 57 57 9 Sri Lanka 98 100 100 99 31 Thailand 91 99 99 78 32 Timor-Leste 77 57 49 35 4 SEA Region 55 80 74 64 18 1 Five EmONC facilities per 50 000 population, of which one is CEmONC. The facilities are classified according to the capability to provide signal functions or life-saving services. BEmONC signal functions: administer parenteral antibiotics, administer parenteral uterotonic drugs, administer parenteral anticonvulsants, manually remove placenta, remove retained products of conception, perform assisted vaginal delivery, perform neonatal resuscitation; CEmONC signal functions: perform caesarean sections, perform blood transfusion. Less than 50%, CS >15% or <5% 50% to 80% >80% and/or CS is 5%-15% 08 CHAPTER 1 A majority of the countries of the SEA Region report high coverage (>60%) of distribution of iron and folic acid; however, the compliance is not known. Anaemia during pregnancy is a significant problem in the Region. Comprehensive postnatal care (PNC) for mothers and newborns can prevent a substantial number of maternal and neonatal deaths and complications. The coverage of PNC in the first 2 days of delivery is low (see Table 3) and the reason could be the practice of discharging women and newborns within a few hours of delivery and a high percentage of home deliveries by unskilled health workers. WHO recommends to keep the mother and baby in the institution for at least 24 hours after an uncomplicated vaginal delivery. The policies on PNC in Member States support institutional and home- based care within 2 days of delivery; however, only five countries (DPR Korea, India, Indonesia, Sri Lanka and Thailand) have a favourable policy of keeping the mother and the newborn in the institution for at least 24 hours after delivery [11]. Postnatal visits at home within the early days after delivery need improvement, even in countries where community- based health workers (CBHWs) are available. It should be noted that within countries, the differentials of coverage of interventions between subnational regions, rural and urban and the poor and rich are significant, as evident from the data from Demographic Health Surveys (DHS) (see Figure 4). Source: Latest DHS by country (2009–2017); SEA Region-weighted average Source: Latest DHS by country (2009–2017); SEA Region-weighted average Figure 2: Trends in institutional deliveries Pe r ce nt ( % ) Pe r ce nt ( % ) 2005 - 2010 2011 - 2018 Skilled birth attendant SBA (outside institution) Institutional delivery Unskilled home delivery Figure 3: Deliveries by skilled birth attendants in institutions and at home 100 09 CHAPTER 1 The quality of care at all levels of care is another major concern. Lack of adherence to standards of routine ANC and intranatal care and emergency care, lack of back-up care pathways for referral and transport are major gaps. There is evidence from national and regional studies which shows that women in labour are not treated with respect and sometimes abused by health providers [12]. Besides maternal mortality and morbidity, the quality gaps in essential interventions during the intrapartum and antenatal periods also impact stillbirths and early neonatal deaths. Increasing prevalence of risk factors such as obesity and NCDs (like diabetes and hypertension) among women increases the risk of complications during pregnancy and childbirth. These issues need attention as a country transitions from predominantly direct causes of maternal deaths to indirect causes of maternal deaths, risk factors and NCDs. Depression, especially during the postnatal period, is a serious condition that has implications for the mother and the newborn. There is a need to identify such conditions as emerging areas that need attention. Maternal suicide is also a concern in some Member States. Another important strategy to reduce maternal and perinatal mortality is the implementation of a preconception package of interventions, which has been shown to have a positive impact on maternal and perinatal health outcomes. It provides a platform for prevention, screening for communicable and NCDs and hereditary diseases that could have a short-term and long-term impact across the life course (details provided under the domain of maternal and perinatal health). Such a package of services is currently implemented nationally only in Sri Lanka. The status of maternal health is a marker of the strength of the health system and low levels of coverage are generally associated with poorly developed or organized health system (see Table 8), and in Chapter 4, Table 12 on health system category and maternal and perinatal health and FP status). Investments by Member States have increased the availability of skilled health personnel, improved the availability of essential medicines and supplies and improved maternal health records, including the implementation of home-based maternal health records. However, there are still major gaps, as discussed under the section on health systems. Figure 4: Inequities in coverage of essential interventions by wealth and geography Contraceptive met needs Contraceptive met needs Postnatal care (within 2 days) Postnatal care (within 2 days) Births by skilled health personnel Births by skilled health personnel Antenatal care 4 visits Antenatal care 4 visits Source: Latest DHS by country (2009–2017) 10 CHAPTER 1 Maternal death surveillance and response The Maternal Death Surveillance and Response (MDSR) system with inclusion of perinatal deaths or as a separate system has been initiated in all Member States. However, the quality of the surveillance and response at all levels is a major concern in most countries. The scale of coverage varies; India, Maldives, Myanmar, Sri Lanka and Thailand have rolled out nationwide MDSR. Myanmar and Timor-Leste also include reviews of community deaths. Assigning an accurate cause of death according to the International Classification of Diseases on Maternal Mortality (ICD-MM) is a major challenge. In most countries, nationwide reviews of stillbirths/perinatal deaths (facility and community) are not done. The civil registration and vital statistics (CRVS) systems are weak in most countries, especially concerning maternal and newborn deaths. FAMILY PLANNING The Region includes countries with the oldest FP programmes. Sustained investments in FP programmes by the Member States have contributed to a significant reduction in the total fertility rate (TFR) in the majority of the countries, with a weighted average for TFR in the SEA Region at 2.2; Bhutan, DPR Korea and Thailand report below replacement fertility level (see Table 4). South-East Asia Region Member States TFR* Adolescent birth rate (per 1000, 15–19 years)* CPR modern methods (%)* Unmet need (%)* Demand satisfied by modern methods (%)* Method information index (%) $ mCPR – FP S-curve stage* Bangladesh 2.3 113 57 11.9 72.6 N/A Stage 3 Bhutan 1.9 28 61.7 11.7 66 N/A Stage 3 DPR Korea 1.9 1 71 6.6 91.6 N/A Stage 3 India 2.1 51 50.6 12.9 71.9 32.4 Stage 2 Indonesia 2.4 36 59 10.6 77.1 34.4 Stage 3 Maldives 2.1 10 37 31.4 29.8 N/A Stage 2 Myanmar 2.3 36 52 16.2 74.9 25 Stage 2 Nepal 2.3 88 46.8 23.7 56 43.3 Stage 2 Sri Lanka 2.2 21 53.3 7.5 74.2 N/A Stage 2 Thailand 1.5 51 75.7 6.2 92.7 N/A Stage 3 Timor-Leste 4.2 42 25.7 25.3 46.6 46.9 Stage 2 SEA Region 2.2 54 53 12.5 73.1 Table 4: Fertility and FP indicators in the SEA Region Source: * Latest DHS by country (2009–2017); SEA Region-weighted average #Regional Office for South-East Region data $ Track.20 Index: Total fertility rate (TFR) >4, ABR >50, mCPR <50, unmet need is >18 :demand satisfied is <50% In summary, countries in the SEA Region with high to moderate MMR and slow ARR, such as Bangladesh, Bhutan, India, Indonesia and Myanmar, need to implement strategies applicable to the obstetric transition stage III for acceleration of reduction in the MMR and perinatal deaths. Other countries in the same group, such as Nepal and Timor-Leste, the need to sustain their achievements. Myanmar has the highest MMR and lowest ARR. Similarly, it has one of the highest neonatal mortality rates and one of the lowest ARR. Urgent action is needed to reduce both rates. India, Nepal and Timor-Leste have high neonatal mortality rates and the ARR is slower compared to other countries. These countries also have a high to moderate MMR. There is a need to accelerate the coverage of interventions to reduce neonatal mortality rates. Countries with low mortality rates (Sri Lanka, Thailand) have a very low ARR and need to expedite further reduction with appropriate strategies applicable to the countries in obstetric transition stage IV. 11 CHAPTER 1 The contraceptive prevalence rate for modern methods (mCPR) has increased in most countries; consequently, the unmet need has decreased, and the demand satisfied with modern methods has increased (see Table 4). Two Member States in the Region still report low mCPR, which is a concern. More than 50% of the primary and secondary facilities in the Region provide a variety of spacing methods; however, a few countries report a low availability of implants and intrauterine contraceptive devices (IUCD). Short-acting methods are the predominant method of choice in the majority of the countries. The increase in the use of traditional methods, which increases the risk of unintended pregnancies, is a concern. In general, the unmet need is low in countries of the Region with the exception of three countries (see Table 4, Figure 5). Unmet need is an indication of the violation of the right to access to services and methods, informed choice and quality of services. Unmet need during the postpartum period is one of the highest, but least recognized. Unmet need is an important contributor to unintended pregnancies with consequent abortions and complications, low birth weight and stunting. Unmet need is higher for limiting except in Maldives and Timor-Leste (see Figure 5). The quality of FP services is a major concern, as evidenced by the high discontinuation rates, particularly for short-acting methods. Poor quality of counselling, safety of services and follow-up care contribute to discontinuation. Informed choice is a major gap in the services, as is evident from the method information index (MII) per cent (see Table 4).2,3 Data on stockouts are not available in at least 50% of the countries and where data are available, they show stockouts of contraceptives that are predominantly used, which is a concern [13]. As seen in Figure 4, the gaps in equity between socioeconomic and other parameters seem to have narrowed. The adolescent birth rate (ABR) has decreased in almost all the Member States and is around 68 per 100 girls of the age of 15–19 years for the Region (range 13.7–113) (see Table 4). Ten per cent of adolescents of the age of 15–19 years have begun childbearing and the reported births are within marriage, and it is reported that a significant proportion are unwanted (25–28%) [14]. Contributory factors to high ABR in the Region are low contraceptive use, high unmet need early marriages (particularly in Bangladesh, India and Nepal) (see details under the section on ASRH). More information on barriers related to accessing contraceptives is given under the section on ASRH. Figure 5: Unmet need for FP for spacing and limiting in the SEA Region Source: Latest DHS by country (2009–2017); SEA Region-weighted average 2 MII is an index that measures the extent to which women were given specific information when they received FP services. The index is composed of three questions related to whether information was provided on other methods, side-effects and what to do if side-effects occur (FP 2020 core indicator). The reported value is the percentage of women who responded “yes” to all three questions. 3 FP 2020 countries in the SEA Region include all countries except Maldives and Thailand. Unmet need for family planning (%) Limiting Unmet need for family planning (%) Spacing 6.6 7.2 4.1 14.1 6.9 11.4 15.6 4.4 3.1 3.3 19.3 6 2.9 5.3 7.2 3.6 5.3 5.6 6.5 17.3 4.7 4.8 8.1 3 Bangladesh Bhutan DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand SEAR Pe r ce nt ( % ) Timor Leste 12 CHAPTER 1 Table 5: Additional maternal deaths preventable by satisfying unmet need in countries of the SEA Region, 2018 Country Unmet need for contraception (%, 2018) Number of maternal deaths in 2018 Proportion reduction in current mortality level by satisfying unmet need (%) Bangladesh 11.9 4822 27.9 Bhutan 11.7 17 35.3 DPR Korea 6.6 262 15.6 India 12.9 43 700 28.7 Indonesia 10.6 6357 22.9 Maldives 31.4 2 100.0 Myanmar 16.2 1534 47.3 Nepal 23.7 1056 62.8 Sri Lanka 7.5 91 22.0 Thailand 6.2 116 2.6 Timor-Leste 25.3 78 44.9 SEA Region countries 12.5 58 035 29.0 Source: Modified Table 3 of Tsui A, Li Q, Ahmed S. Maternal mortality reductions with contraceptive use and satisfying unmet need: results for 11 South East Asian Countries. WHO Regional Office for South-East Asia, 2019 Further investments in FP will help to reduce maternal mortality, as evident from a recent analysis done for the SEA Region using 2018 data (see Table 5). Almost 30% of maternal deaths can be reduced by satisfying unmet need for contraception. Most Member States are in Stage 2 of the S-curve (see Table 4 and Figure 6),4 which points to the opportunities for acceleration through continued demand creation, removing barriers and improving the quality of services, thereby maximizing the opportunities to reap the benefits of demographic dividend. Bangladesh and Indonesia are in Stage 3, which points to the need to reduce inequity, focus on long-term sustainability, continued improvements in quality and expanding the range of methods. It should be noted with caution that the reported high prevalence of contraceptives does not capture the discontinuation rates with methods and may give countries a false sense of security. 4 Stage 2: Growth: Length of period and speed of growth vary; but there is potential for rapid acceleration. During this stage, it is important to make sure there are no barriers to services by ensuring availability of contraceptives, high-quality services and continued demand generation. It is also during this stage that countries want to achieve and maintain rapid growth to maximize their ability to transform their population and benefit from the demographic dividend. Stage 3: High prevalence of mCPR – Growth slows and eventually stops as mCPR reaches its maximum. During this stage, efforts should prioritize equity in mCPR among different subgroups to ensure that no women are being left behind. Programmes at this stage need to focus on long-term sustainability, continued improvements in service quality, and expanding the range of methods available. Source: FP Track 20 classification Figure 6: Putting growth in the context – the S-curve MALDIVES NEPAL INDIA MYANMAR THAILAND DPR KOREABANGLADESH INDONESIA BHUTAN SRI LANKA TIMOR LESTE 13 CHAPTER 1 Figure 7: Coverage of essential interventions for FP and maternal health in the SEA Region Source: Latest Demographic Health Survey (DHS) by country (2009–2017); SEA Region-weighted average Summary of status of evidence-based interventions in maternal and perinatal health and FP needed for accelerating reduction in maternal mortality The GSWCAH has identified a list of evidence-based interventions for improving maternal and perinatal health and FP (see suggested list of interventions in Annexes 4 and 4A). The coverage of selected interventions is shown in Figure 7 and Table 3. The figure shows that the population-based coverage of essential interventions is less than 90% in high-mortality countries and needs to be accelerated (99% for achieving the optimal effect) [15] except in the case of caesarean sections, where the acceptable coverage range is 5–15%. The quality of services delivered is another concern, which has been discussed in the sections related to specific services. The quality of services is critical for achieving reduction in maternal and perinatal mortality. In all countries, disparities in coverage by economic quintiles is significant, especially with regard to skilled care at birth and caesarean sections. ABORTION An estimated 35.5 million induced abortions occurred each year in Asia during 2010–2014 [16]. The abortion rate per 1000 women aged 15–44 years was 36 (slightly decreased from the earlier estimate of 41 in 1990–94). The abortion rate is roughly about 36 per 1000 for married women and 24 per 1000 for unmarried women. The proportion of pregnancies in Asia ending in abortions is 27%. Of the estimated 25 million unsafe abortions worldwide each year, more than half took place in Asia [17].5 No estimates are available specifically for the WHO SEA Region. Globally, approximately 6% of maternal deaths are due to complications of abortions (see Figure 1) and in the SEA Region, this figure is around 8%. The data on the complications of unsafe abortions, such as bleeding, infections and chronic pelvic inflammatory disease, are not easily available. A well-known consequence of complications of abortion is secondary infertility. While there is overwhelming evidence to show that legality of abortions contributes to reducing unsafe abortion and its consequences, it is also evident that legality alone does not guarantee access and does not prevent onerous restrictions, which are not based on safety and erode the availability of safe and legal abortion services. Highly restrictive laws do not eliminate the practice of abortion, but more likely contribute to unsafe abortions. Table 6 gives an overview of available policies and legal documents related to abortions in countries of the SEA Region. As seen in Table 6, in most countries the law on abortion is nested within the penal code and makes abortion illegal, unless it is performed under specific 5 WHO defines unsafe abortion as a procedure for terminating a pregnancy that is performed by an individual lacking the necessary skills, or in an environment that does not conform to minimal medical standards, or both. ANC 4 visits PNC for mothers Institutional delivery Demand satisfiedSkilled birth attendant Pe r ce nt ( % ) 14 CHAPTER 1 conditions. Third-party authorization requiring certification of the procedure or spousal or parental authorization further restricts access. Abortion laws in India and Nepal permit abortion on more grounds compared to other countries in the Region, which permit it mostly in the case of risk to the life of the mother. Improving the quality and coverage of post- abortion care is crucial to saving lives and protecting women’s health and all countries accept the care as an essential reproductive health service; however, only six countries have post-abortion care guidelines and include FP. The quality of post-abortion care, especially with regard to FP counselling, is a concern in the SEA Region. Other gaps include the lack of a standardized package of services for abortion and post-abortion care, weak reporting mechanisms, incomplete data on abortion prevalence, research, etc. Table 6: Snapshot of policies and legal sources related to abortion in the SEA Region countries Bangladesh Bhutan DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Timor- Leste Thailand Reproductive Health Act General Medical Health Act Constitution Criminal/penal code * Civil code Ministerial order/decree ** Case law Health regulation/ clinical guidelines Essential medicine list Medical ethics code Document relating to funding Abortion specific law Law on medical practitioners Law on health care services Other Source: Global Abortion Policies Database, WHO Available documents * Section 416, The Penal Code, 2014 https://www.law.upenn.edu/live/files/4203-maldives-penal-code-2014 ** Fathwa released by the Fiqh Academy of Maldives (Government’s Council of Religious Scholars) that currently guides abortion service provision in the country Various studies show that the unmet need for FP, leading to unintended pregnancies, is a major reason for abortions (almost two-thirds of unintended pregnancies in Asia end in abortions). The high level of unmet needs in the Region is evident from Table 4 and is likely to end in unintended pregnancies. It is likely that unintended pregnancies are higher in the context of the growing preference for smaller families and better control over timing of births. Data on unmet needs among single, sexually active women are not available; this group is at very high risk of unsafe abortions due to sociocultural and economic factors. INFERTILITY With the advancement in treatment modalities for infertility and subfertility, the focus on infertility has increased in the global health arena. There are no data on prevalence of infertility in the Region. Infertility is not considered a serious public health issue because it does not cause death and is missed out in estimates of disability adjusted life-years (DALYs). All the Member States of the Region promote FP, the definition of which includes enabling couples to have a desired number of children; however, infertility is the most neglected 15 CHAPTER 1 Figure 8: Number of new cases and causes of cancer in 2018 (females, all ages) in the SEA Region Source: Globocan 2018 REPRODUCTIVE TRACT CANCERS The elimination of cervical cancer has been at the forefront of the global health agenda since the launch of the WHO Initiative for the Elimination of Cervical Cancer in 2018. The primary cause of precancerous and cancerous cervical lesions is infection with a high-risk or oncogenic HPV type. HPV is a group of viruses that are extremely common worldwide – there are more than 100 types, of which at least 14 cause cancer. A subset of HPV types is responsible for virtually all cases of cervical cancer. HPV 16 and 18, which together are responsible for approximately 70% of cervical cancer worldwide, are the most oncogenic types. Cervical HPV is the most common STI. Cervical cancer is the most common cancer among women living with HIV. Compared with women who are HIV-negative, women living with HIV have a several times higher risk of persistent HPV infection, are six times as likely to develop cervical cancer and are more likely to develop it at a younger age [18]. Cervical cancer is a significant public health problem in the SEA Region. In 2018, an estimated 158 000 new cases were reported and there were 95 766 deaths due to cervical cancer, which is the third most common type of cancer (see Figure 8). Cervical cancer accounts for approximately 27.8% of new cases and 30.7% of deaths among women of all ages globally. The crude death rate due to cervical cancer in the Region is 9.6 per 100 000 women, compared to the global crude death rate of 6.9 per 100 000 women [19]. Figure 9 shows the country- wise incidence of cervical cancer and associated mortality. Indonesia, Maldives, Myanmar and Nepal report an incidence of more than 20 per 100 000 women. Indonesia reports the highest while Sri Lanka reports the lowest incidence of cervical cancer. Nepal reports the highest mortality, while DPR Korea reports the lowest. component of FP. Assisted reproductive technologies (ART), ranging from simple to complex interventions, are available in almost all the countries, but financial and geographical barriers limit access to such services. The private sector is a major player in this area. Surrogacy is becoming a common practice and only three countries in the Region have passed surrogacy laws (India, Nepal and Thailand); however, the implementation of the law is a major concern. Most Member States do not have national policies and guidelines related to ART and surrogacy. 16 CHAPTER 1 The Member States are at various stages of implementing primary and secondary prevention interventions. Bhutan, Maldives, Sri Lanka and Thailand have introduced the vaccine for human papillomavirus (HPV) nationwide and most of the remaining countries are piloting the vaccine. All the Member States have initiated screening for cervical cancer using cytology (Pap smear) and/or visual inspection with acetic acid (VIA); however, nationwide coverage has been achieved only in Bhutan, Sri Lanka and Thailand. HPV DNA testing is being piloted in India (Kolkata), Sri Lanka and Thailand. In the SEA Region, the coverage of screening by any method is very low (see Table 7). “Screen and treat” approaches are being followed in countries that are using VIA as the screening method. Despite the availability of effective interventions, cervical cancers are generally detected in late stages and treatment is often not accessible. Countries do not have up-to-date data on the incidence, mortality and screening coverage of cervical cancer although population-based cancer registries are expanding. Table 7: Cervical cancer screening implementation status in the SEA Region Country Existence of national screening programme Type of national screening programme Most widely used screening methods in national screening programme Target population 35–45 years Coverage of national cervical cancer screening programme (%) Bangladesh Yes Opportunistic screening VIA 30–60 years Less than 10% Bhutan Yes Opportunistic screening VIA and PAP smear 25–65 years 56% DPR Korea Yes Pilot planned VIA for pilot 30–55 years Data not available India Yes Population-based screening VIA 30–65 years Data not available Indonesia Yes Population-based screening VIA 30–50 years 9.8% Maldives Yes Opportunistic screening PAP smear Not defined Less than 10% Myanmar Yes Population-based screening (planned) VIA HPV DNA for rural sector 30–49 years Less than 10% Nepal Yes Opportunistic screening VIA and PAP smear 30–60 years 10–50% Sri Lanka Yes Population-based screening PAP smear, HPV DNA piloted 35- and 45-year cohort 35 age cohort: 56.9% 45 age cohort: 16.9% Thailand Yes Population-based screening VIA and PAP smear 30–60 years 50–70% Timor-Leste Yes Opportunistic screening PAP smear Not defined Less than 10% Source: WHO Regional Office for South-East Asia (country data reported on June 2019, GHO accessed June 2019 Figure 9. Cancer of the cervix mortality and incidence in countries of the SEA Region ASR - age standardized rates per 100 000 (2018)Source: Globocan 2018 Cancer cervix mortality Cancer cervix incidence 17 CHAPTER 1 Breast cancer is the leading cancer among women in terms of incidence and mortality. Though the risk factors for breast cancer are known, minimizing the risks does not eliminate the cancer in most cases, especially in the developing world. Early detection improves breast cancer outcome and survival, which are the cornerstone of a breast cancer control programme; however, cost-effective screening methods are not available and are not advised in countries with weak health systems. Reproductive cancers are not reported among men in the regional report; however, Indonesia, Maldives, Thailand and Timor-Leste report prostate cancers. INTIMATE PARTNER VIOLENCE STI AND HIV INFECTIONS Intimate partner violence is one of the most common forms of violence against women in the Region and has serious implications for maternal and perinatal health. It is recognized as a key issue in the global recommendations on a positive pregnancy outcome. Intimate partner violence is manifested in physically, sexually or emotionally abusive acts. It is reported from studies that the frequency of intimate partner violence is high during pregnancy and has been found to be associated with maternal mortality and non fatal adverse health outcomes for the pregnant woman and her baby due to the direct abuse to the pregnant woman’s body, as well as the physiological effects of stress from current or past abuse on fetal growth and development. A higher rates of abortions, stillbirths, intrauterine growth retardation, preterm labour, low birth weight and neonatal mortality are reported. Higher risk of antepartum haemorrhage is also reported. In addition, long-term consequences such as higher levels of depression, anxiety and stress as well as suicide are reported. Other forms of GBV are not covered in this strategy. In the WHO SEA Region, the burden of morbidity and mortality from STI is significant, and compromises the SRH of women, as well as newborn and child health. HPV, an STI, is the cause of almost all cervical cancer. While most HPV infections clear up on their own and most precancerous lesions resolve spontaneously, in some women, HPV infection becomes chronic, and precancerous lesions can develop and progress to invasive cervical cancer. In women with normal immune systems, such cervical cancer may take 15 to 20 years to develop; in women with weakened immune systems, such as those with untreated HIV infection, it may take only 5 to 10 years. The epidemiology of STI in the Region remains highly heterogeneous. A very low incidence and prevalence of STI have been maintained over several decades in Sri Lanka and Thailand, while much higher and variable rates are reported elsewhere. An increasing prevalence of syphilis, gonorrhoea, chlamydia and hepatitis B is recognized especially among young people and key populations.6 The consequences of STI during pregnancy (abortions, stillbirths, fetal abnormalities, etc.) are recognized and also their contribution to infertility [20]. Recent reports (2019) indicate that hepatitis B infection has been controlled in Bhutan, Maldives, Nepal and Thailand. In the Region, the HIV epidemic is concentrated in key populations. In most countries, the prevalence of new infections has been on the decline in the general population, though the rates of decline are plateauing. However, there are reports of an increase in new infections among adolescents and women [21]. Every year, an estimated 1400 babies in the SEA Region are infected by HIV and 13 000 by syphilis through mother-to-child transmission. Triple elimination of HIV, syphilis and hepatitis B in pregnancy has been initiated in a few countries. Maldives, Sri Lanka and Thailand have been validated for eliminating mother-to-child transmission of HIV and syphilis [22]. In the rest of the Member States, interventions on prevention of mother-to-child transmission (PMTCT) of HIV are being implemented; however, in some countries, the interventions on Prongs 1 and 2, which focus on the prevention of HIV transmission among women of reproductive age and the prevention of pregnancy in HIV-positive women through the provision of FP services, are not sufficiently stressed.7 Non availability of HIV testing in all ANC facilities is a key barrier to reaching out to all HIV-infected pregnant women and providing interventions for PMTCT. Despite the well-known benefits of integrating STI and HIV services with SRH services, no such measures have been taken by most Member States, except Thailand. Screening for STI while providing maternal health (especially antenatal services) and FP services is not a universal practice, though recommended in the guidelines issued by the WHO Regional Office for South-East Asia Region. The Regional action plan for HIV emphasizes it’s integration with SRH services as a priority action under several of its priority areas. 6 Key populations include transactional sex workers, people who inject drugs, men who have sex with men, transgender and truck drivers. 7 Prong 1: primary prevention of HIV among women of childbearing age; Prong 2: prevention of unintended pregnancies among women living with HIV; Prong 3: prevention of HIV transmission from a woman living with HIV to her infant; and Prong 4: prevention of appropriate treatment, care and support to women and children living with HIV and their families. 18 CHAPTER 1 ADOLESCENT SEXUAL AND REPRODUCTIVE HEALTH (ASRH) SRH NEEDS OF THE AGEING POPULATION Adolescents constitute approximately 19% of the total population of the Region. The overall mortality among adolescents is 102 per 100 000 adolescents and an estimated 21 783 DALYs are lost per 100 000 adolescents, contributing to 13% of global DALYs [23]. Maternal conditions are second in order of causes of death among female adolescents of the age of 15–19 years; however, maternal conditions are one of the five leading causes of DALYs lost among adolescents of the age of 15–19 years in the SEA Region (the other causes being self-harm, depression, iron-deficiency anaemia and diarrhoeal diseases). Early marriage is common in Member States and though the proportion of those married before 18 years of age has decreased, it ranges between 26% and 59%, with Bangladesh reporting the highest proportion of early marriages. The ABR is high in the Region, though it has decreased over the years, however, it is still higher than 50 per 1000 adolescents of 15–19 years of age in Bangladesh, India, Nepal and Thailand (see Table 4). In the Region, approximately 10% of adolescents of the age of 15–19 years have begun childbearing (within marriage) [24]. Unwanted / unintended pregnancies, out-of-wedlock pregnancies among adolescents and barriers to abortion care potentially lead to preventable morbidity and mortality, in addition to social and economic burden. There are significant differences between the rich and the poor in the childbearing pattern among adolescent girls, with a higher proportion from poor families having begun childbearing. The demand satisfied with modern methods of FP among 15–19 year olds is above 50% in all countries except India and Timor- Leste; the unmet need for FP remains high particularly in Maldives and Nepal. Access of adolescents (especially the unmarried) to health services is limited in most countries of the Region due to legal, social, cultural and health system barriers, such as the attitudes of health service providers and issues related to privacy and confidentiality. In general, adolescents are thin (BMI <18.5 kg/ m2) in significant proportion in the Member States, which has implications for the birth weight of the child if they get pregnant. Iron deficiency anaemia is one of the leading causes of morbidity, which has implications for the individual and for fetal growth if they get pregnant. The prevalence of STI and HIV is reported to be high among adolescents. National policies and guidelines related to adolescents in most Member States include SRH as well as FP (though restricted in the case of the unmarried in most countries). In India, Nepal and Timor-Leste, policies do not allow unmarried adolescents access to any contraceptives, including emergency contraception. Indonesia and Maldives allow adolescents to access emergency contraception [11]. Countries are progressively improving the implementation of their national adolescent health programmes in terms of coverage and quality. The attitude of providers is another barrier in accessing contraceptives and other services by adolescents. Active ageing is the process of optimizing opportunities for health, participation and security to enhance the quality of life as people get older. In 2017, one tenth (9.8%) of the population in the SEA Region was above 60 years and is expected to increase to 13.7% by 2030 and to 20.3% by 2050 [25]. Currently, DPR Korea, Sri Lanka and Thailand have more than 25% of the population above 60 year of age. Ageing is recognized as one of the changing needs of the Region. The Regional Framework on Healthy Ageing in the SEA Region 2018–2022 has little focus on the SRH needs of the ageing population [26]. While almost all countries in the Region have policies for the ageing population, including health, the SRH needs of the ageing population are yet to be emphasized in these policies. At present, the data on the SRH needs of the ageing population are negligible. The drastic physical changes due to menopause, increased risk of reproductive cancers, etc., are currently not well recognized by the health system in most Member States and health services are inadequate to meet the emerging needs of the increasing population of older women. SRH NEEDS OF THE DIFFERENTLY ABLED The differently abled are a significant population in the Member States. Classifications of the differently abled vary among countries and the availability of data is an issue. The SRH needs of differently abled populations are not recognized, particularly those of women and girls who are more vulnerable to sexual abuse. There are no data on the SRH needs of the differently abled. 19 CHAPTER 1 SRH NEEDS IN HUMANITARIAN CRISIS HEALTH SYSTEMS IN SUPPORT OF SRHR SRH NEEDS OF URBAN SLUM POPULATIONS, REMOTE AND DIFFICULT-TO-ACCESS POPULATIONS The Member States in the SEA Region are vulnerable to different types of natural disasters, which occur year after year, causing much damage and loss of life. Strengthening emergency risk management is one of the four strategic imperatives of the WHO Regional Office for South-East Asia and scaling up capacity development in emergency risk management is one of the Flagship Programmes. In humanitarian settings, it is critical to provide SRH services as morbidity and mortality related to SRH are significant and timely provision of SRH services can prevent death, disease, disability related to obstetric complications, unintended pregnancy, sexual and other forms of violence against women, HIV infection, STI, etc. Minimum reproductive health services that need to be put in place at the outset of a humanitarian crisis (first 48 hours), called the Minimum Initial Services Package (MISP), have been developed by the United Nations Inter-Agency Working Group (UN-IAWG) to guide the managers and coordinators. Over the past few years, all Member States have developed national disaster preparedness plans in which SRH is a main component. A fully functional health system is a prerequisite for delivering good quality SRH services. The six health system building blocks identified by WHO are: service delivery, health workforce, information, medical products, vaccines and technologies, financing and leadership/governance (stewardship) (see Figure 10). These are critical for a strong health system that is resilient to withstand system shocks and to ensure continuity in the universal delivery of effective, quality reproductive health services across the life cycle in all settings. The gaps in health systems may vary among and within countries, but for achieving universal access to SRHR and sustaining the same, it is crucial to have an adequate, competent, well-distributed and motivated health workforce; effective service delivery models and platforms; an adequate, efficient and effective health financing system that enables access to services and protects from financial catastrophe; a well-functioning health information system that provides reliable and timely information for action; and an efficient leadership and governance (stewardship). The quality of care, which is also a determinant of universal access to SRH, among others, is undermined by limited human resources, poor infrastructure and lack of sustainable financing. Almost all Member States have decentralized health services (varying in degrees of decentralization); the capacity for stewardship of the health system is weak at subnational levels where the programmes are implemented. The private sector is a major player in the provision of SRH services, especially ANC and intrapartum care and FP services, in some countries. Most Member States do not have stringent measures to regulate the private sector and for monitoring quality and the violation of rights. Urban migration brings opportunities, but it also brings challenges for better health, especially SRH. Rapid urbanization and growth of slums is a feature in many Member States of the SEA Region. Urbanization is recognized as one of the changing needs of the Region. South Asia has one of the largest numbers of slum dwellers. There are little data on the reproductive health status of urban slum dwellers but evidence from a few studies shows higher fertility rates, higher prevalence of STI and HIV, violence against women, especially intimate partner violence, etc. Home deliveries by unskilled providers and higher maternal mortality and infant mortality are reported. These findings indicate poor access of slum populations to health facilities, the main barrier being financial. In general, urban slum populations are not covered by health insurance because of their migrant status. Data on remote and difficult-to-access populations due to geographical barriers (mountainous, islands, etc.) are not easily available but there is evidence from the DHS of Member States to show that mortality rates, especially maternal and neonatal mortality, and fertility rates are high due to lack of access to services. 20 CHAPTER 1 Figure 10: Health system building blocks Table 8: Health system categories based on readiness to scale up towards UHC Source: (i) Stenberg et al, Financing transformative health systems towards achievement of the health: Sustainable Development Goals. Lancet 2017; (ii) WHO Regional Office for South-East Asia: Improving newborn and child health. A strategic framework (2018–2022). Source: (i) Stenberg et al, Financing transformative health systems towards achievement of the health: Sustainable Development Goals. Lancet 2017; (ii) WHO Regional Office for South-East Asia: Improving newborn and child health. A strategic framework (2018–2022). Category Status Description Actions needed Categorization of countries of the SEA Region 1 Countries with poor performance across health system functions Countries have limited resources and low coverage of care • GNI (PPP)/GDP (PPP) per capita falls under 2500 AND • Less than 2.28 health workers per 10 000 population OR • SBA <90% • Require an engineering of their health system to build the foundations of strong health system institutions, AND • Require significant investments across the health system Myanmar Nepal Timor-Leste 2 Countries have invested in the foundations of health systems but institutional performance is poor and there are challenges related to health system efficiency and access This includes countries that: • have limited resources but are performing well in terms of SBA coverage • have fewer limitations in terms of economic resources but face challenges with respect to health worker density • have fewer limitations in terms of economic resources but are not doing so well on service coverage Countries with a combination of criteria: • Countries that are resource-constrained (GNI [PPP] per capita <2500) but perform well on a representative indicator for complex care (SBA >90%), signalling service delivery readiness that allows for quick scale-up for public service coverage, should resources be made available • Countries that are less resource-constrained (GNI [PPP] per capita >2500) but where key health workforce availability is limited (HRH <2.28), OR countries exceed the health workforce, i.e. >2.28 benchmark but are doing less well on service coverage and delivery of complex services (SBA <90%) • Scope for rapid health system scale-up to improve performance AND • Ensure greater domestic financing sustainability Bangladesh Bhutan India Indonesia 3 Countries with mature health systems This category includes: • countries with relatively high resource availability defined as a GNI (PPP) >5000 per capita, and high levels of delivery of complex care, defined as greater than 90% coverage of SBA (criteria b, d). • countries with high resource availability defined as a GNI- (PPP) >10 000 per capita (criteria b). • Ongoing support for health system transformation • Reorient models of care to address emerging challenges and existing inequities DPR Korea Maldives Sri Lanka Thailand MEDICAL PRODUCTS, VACCINES & TECHNOLOGIES IMPROVE HEALTH (LEVEL AND EQUITY) 21 CHAPTER 1 Member States have invested in strengthening their health systems over the years through positive policies and legal reforms, improving the availability of human resources, quality and distribution, increased financing, pro-poor financing schemes, infrastructure, efficiency of health-care delivery systems, engaging the private sector, etc. However, most Member States still need to further improve their health systems. Countries have been categorized based on a proposed framework for health system strengthening (see Table 8) [27,28]. There is a clear linkage to SRH achievements, especially those related to the maternal and perinatal periods (see Chapter 4, Table 11) and the strength of the health systems. The average health worker density (doctors, nurses and midwives) in the SEA Region increased from 21.5 in 2014 to 27.1 doctors, nurses and midwives per 10 000 population in 2017. Eight Member States had reached the WHO human resources threshold for doctors, nurses and midwives per 10 000 population of 22.8 (2006), but only two countries (DPR Korea and Maldives) have reached the revised threshold of 44.5 doctors, nurses and midwives per 10 000 population (see Figure 11). The Region has significant health workforce challenges, ranging from shortages, unequal distribution and retention. The shortage of nurses and midwives is evident from Figure 12 (similar pattern occurs in other countries, as shown in Figure 12). Figure 11: Density of health workers per 10 000 population Pe r 10 00 0 po pu la ti on Pe r 10 00 0 po pu la ti on Figure 12: Density of nurses and midwives per 10 000 population, 2018 Source: WHO SEA Region. Decade for health workforce strengthening in the South-East Asia Region 2015–2024. 2nd review of progress, 2018 Source: WHO Regional Office for South-East Asia Human Resources Division 2017 (or nearest year before 2017)2014 (or nearest year before 2014) MidwivesNurses 44.5/10 000: Global Strategy on HRH 2016 22.8 /10 000: World Health Report 2006 22 CHAPTER 1 In addition to the issues related to availability and distribution, competencies of health workers to meet reproductive health-care needs, workload related to implementation of interventions (especially maternal and perinatal), service delivery platforms, and mechanisms to ensure accountability of health workers to improve productivity and their performance are critical determinants of the population coverage of evidence- based interventions. Data on the availability and distribution of supervisors are not available in most settings; supervisors have a critical role to play in ensuring coverage and the quality of services. In many Member States, CBHWs are being used for delivery of various SRH interventions, especially those related to maternal, child and FP services. The WHO global strategy on human resources for health workforce 2030 encourages harnessing the potential of CBHWs. The 2018 WHO guidelines on community health workers also recommend the full integration of CBHWs in the health system [29]. Almost all Member States have developed health information platforms of varying coverage and quality, the most common one being the maternal and newborn tracking system, which includes information on pregnancy, birth and the postnatal period. The completeness and accuracy of data collected through Health Management Information Systems (HMIS) at health facilities and in communities and their reporting is a major concern. The District Health Information System-2 (DHIS-2), a web- based information system, is being used in almost all Member States (tailored to local country needs in most situations). However, it is not known how well the SRH data are incorporated, especially those related to abortions, adolescents and key populations, and used for programme planning. In most Member States, HMIS is not used for monitoring coverage of interventions due to incompleteness; the DHS is the main source of coverage data, which means missed opportunities to monitor coverage annually. The DHS also provides data on inequities. As discussed under the section on maternal and perinatal health, Member States have implemented the MDSR system and a few countries also include stillbirth surveillance; however, very few countries use the MDSR information to generate MMR, instead they depend on UN estimates. As pointed out in an earlier section, in most Member States, the CRVS system is weak on registration of births and deaths and does not generate data/under-report on maternal deaths, neonatal deaths or stillbirths or causes. Death declaration forms either do not include a pregnancy box or are not properly filled, leading to misclassification of deaths among women. Countries of the SEA Region continue to have one of the highest out-of-pocket (OOP) payments on health care and on an average, 38% of households pay from their pockets, which indicates inadequate financial health protection. Public spending on health in general is one of the lowest in the SEA Region. All the above factors contribute to the lack of protection of the poor and catastrophic health spending, which at a 10% threshold is high in some countries of the SEA Region and causes significant impoverishment [30]. All the Member States have developed policies/ guidelines for free reproductive health services for ALL women attending the public sector; however, it is not known whether the guidelines are adhered to. There is evidence to show that impoverishment is significant even after normal deliveries in the public sector [31]. Information on OOP expenditures on SRH is not available, even in countries where national health account analysis has been done. Through WHO’s leadership, the countries in the Region are committed to attain universal accessibility and affordability of essential medical products by 2030 and to strengthening regulatory cooperation and collaboration through the South-East Asia Regulatory Network, 2017 [32]. Stock-outs of life-saving commodities such as medicines for emergency obstetric care, contraceptives, supplies and equipment are common and negatively impact the coverage of SRH interventions. Major underlying reasons for stock-outs are weaknesses in the logistics management system – forecasting, quantification, last mile delivery of commodities, quality assurance, etc. and inadequate financing. The quality of SRH services, as noted in several of the thematic areas, is a major concern for the Region. Substandard services is a major reason for poor utilization of some critical services that are free and easily accessible such as maternal health and FP. In some settings where access is not an issue, poor quality has been identified as the reason for most deaths. The quality of care has been recognized as an imperative for achieving UHC as it focuses on people receiving the quality services they need, without financial hardships. QUALITY OF SRH SERVICES 23 CHAPTER 1 Figure 13 illustrates the framework for the quality of maternal and newborn health care, which is applicable to all SRH services. The framework covers two dimensions of quality of care – provision of care as well as experience of care. Although the framework refers to domains of quality of care within the context of facilities, it fully recognizes the importance of taking into consideration the perspectives of women, their families and their communities about the care they receive. Figure 13: WHO framework for the quality of maternal and newborn health care Considering the importance of good quality health- care services in hospitals in saving the lives of mothers and newborns, the WHO Regional Office for South-East Asia, in collaboration with partners, has been working with Member States to implement the regional model of quality improvement. Figure 14 illustrates the Regional framework for improving the quality of care for reproductive, maternal, neonatal, child and adolescent health. The framework suggests actions at the national and local levels. The methodology of point-of-care quality improvement (POCQI) has been introduced in nine Member States through regional and national training workshops to build capacity at the hospital level to form teams, use local data to define quality gaps and identify feasible solutions to address the quality gap and undertake quick PDSA cycles to test and adopt the solution as a sustained practice. Source: WHO: Standards for improving quality of maternal and newborn care in health facilities, 2016 Coverage of key practices People-centred outcomes Health outcomes 7. Competent, motivated human resources 8. Essential physical resources available O ut co m es Pr oc es s St ru ct ur e 24 CHAPTER 1 Figure 14: Improving the quality of care for reproductive, maternal, neonatal, child and adolescent health Source: WHO Regional Office for South-East Asia: Improving the quality of care for reproductive, maternal, neonatal, child and adolescent health in South-East Asia, 2015 4. IMPROVEMENT Implement solutions: Implementation of improvement activities to address the identified gaps with reference to the established standards Technical and QI training Collaborative problem solving meetings 2. STANDARDS Definition of standards of care Review of and agreement on standards for all areas and levels of care Development of guidelines and an assessment tool based on standards 3. ASSESSMENT (external baseline) Assessement of quality of care and identification of gaps with reference to the established standards 7. SCALING UP Scaling up to all hospitals and health facilities and communities 6. DOCUMENTATION AND DISSEMINATION Documentation and publication of quality improvement efforts Recoganizing and celebrating the achievments of the standards AS SE SS M EN T AS SE SS M EN T IM PR OV EM EN T IM PR OV EM EN T CHECK PLAN DOACT 5. MONITORING AND (SELF-) RE-ASSESSMENT Continuous monitoring of performance and provision of supportive supervision and (self-) assessments of quality of care to measure progress towards the achievement of standards 1. GETTING STARTED Identification of leadership and champions Defining roles at various levels (systematic process) 25 CHAPTER 1 DEMAND FOR SRH SERVICES Access to accurate information and experience of care are major determinants of the utilization of services. Information on SRH issues and rights enable individuals and communities to take action and/ or demand services and utilize services. The Region has rich experience with community-based health services (CBHS) and CBHWs, especially for maternal and child health and FP. CBHWs as well as informal community leaders have contributed to increasing the knowledge and coverage of services. However, there are still information gaps and mis-information related to SRH, particularly FP, maternal health, abortions (including post-abortion care), cervical cancer, etc. CBHWs, available in most countries, have a crucial role to play in educating communities as well as in providing community-based care (e.g. PNC). Men’s critical role in SRHR is well recognized, especially in the milieu of gender inequality and cultural barriers. The lack of male involvement in SRH is a major gap in the utilization of SRH services. Besides poor health literacy, other non-health factors such as access to digital media, roads, etc. affect demand. UNIVERSAL HEALTH COVERAGE SDG 3.8 aims to achieve UHC, including financial risk protection, access to quality essential health- care services and access to safe, effective, quality and affordable essential medicines and vaccines for all. UHC indicators include service coverage of essential interventions and financial risk (catastrophic spending on health). This dimension of service coverage of UHC means that all people receive the health services they need, of sufficient quality, without incurring financial hardships [33]. Coverage, quality and equity are parameters of UHC. The UHC coverage indicators, computed from the tracer indicators of coverage of essential services, include reproductive health indicators such as demand satisfied with a modern method of contraception among women aged 15–44 years and four or more ANC visits or births attended by skilled health personnel. The SEA Region has been tracking the coverage of essential health services in Member States (see Figure 7). Figure 15: UHC index and RMNCH sub-index Source: WHO Regional Office for South-East Asia HSD 2017; UHC and RMNCH sub-index scale 0 to 100 (with 100 being full coverage); RMNCAH sub-index calculated by the MCA unit RMNCH sub-indexUHC index S er vi ce c ov er ag e in de x (% ) 26 CHAPTER 1 POTENTIAL FOR FOSTERING COLLABORATION The SEA Region includes countries that have achieved sterling success in effective coverage and impact and have many lessons for other countries in the Region, in terms of best practices, innovations, etc. These lessons have not been fully evaluated and the potential to provide support to other countries has not been fully explored. A much- quoted achievement is the reduction of MMR in Sri Lanka through investments in the health system. Similarly, India’s community-based reproductive health services, public–private partnerships, etc. and Thailand’s initiatives in reducing adolescent pregnancies, merit promotion as lessons learnt, best practices and innovations as these have the potential to establish collaboration between countries in this Region and also across the regions. Summary In summary, SRHR covers a range of services, some unfinished issues from the past, some ongoing issues that have gained notice recently and some emerging issues. Prioritizing interventions according to the epidemiology of SRH and robustness of the health system are critical. Countries should strive to SUSTAIN the gains with sustained investments in health and increased allocations to SRH, ACCELERATE the coverage of evidence-based interventions, and identify INNOVATIVE ways of improving coverage and quality of services and delivery mechanisms for emerging issues through implementation research [34].8 Clearly, investments in SRH represent good value for money considering the dividends that can be reaped, including the realization of the rights of individuals. 8 Implementation research is the scientific inquiry into questions concerning implementation – the act of carrying an intention into effect, which in health research can be policies, programmes, or individual practices (collectively called interventions). CHAPTER 2 Rationale, purpose, scope and guiding principles and approaches CHAPTER 2 28 The broad Regional Framework and its contents need to be adapted to the national context, in accordance with national legislation, capacities, priorities and specific national circumstances, while ensuring the international commitment that Member States have already made. (i) expand the scope of SRH services currently being implemented, with regard to SRH issues and population coverage of evidence-based interventions aligned with recent guidelines; (ii) align with reforms of the national health system; (iii) achieve global commitments related to SRH through rights-based approaches; and (iv) share the lessons learnt and best practices. 2.1 Rationale 2.2 Purpose Much progress has been made in reducing maternal and perinatal mortality and improving reproductive health of the people of the Member States in the SEA Region through favourable policies and investments in evidence-based interventions and health systems, as discussed in the preceding sections; however, there is still some unfinished business, in varying degrees in many countries. This Regional Framework for Member States of the SEA Region aims to provide guidance to decision-makers and programme managers to: The landscape of SRH is changing, shaped by economic and social development including improvements in women’s education and participation in formal employment, urbanization, dietary and lifestyle changes, epidemiological and demographic shifts, creating a double burden in lower middle- income countries. The double burden is manifested in an increasing burden of NCDs and associated risk factors adding to the complexity of SRH care, while the burden of preventable reproductive morbidity and mortality continues. Reduced/shifting priorities and resources for SRH are apparent and could negatively impact the gains achieved. Little or no systematic information is available on some conditions of SRH that are devastating for individuals and families, such as infertility, abortion, sexuality-related issues and the quality of SRH care services. By adopting the 2030 Agenda for SDGs, the Member States have confirmed their commitment to universal access to SRH services and realization of SRHR (SDG Targets 3.1, 3.2, 3.7 and 5.6). In addition, through SDG Target 3.8 on UHC, including financial protection and access to quality services and essential medicines, and SDG 10 on reducing inequity, the Member States have confirmed their commitment to overcoming financial and quality barriers and inequity within countries. The commitment of the WHO Regional Office for South-East Asia through its Flagship Priority Areas creates an imperative to develop a new Regional Strategic Framework for SRHR. CHAPTER 2 29 • Right to highest attainable standard of health that includes availability of services in sufficient quantity; accessible in a non-discriminatory manner and can be accessed physically and financially; acceptable in the sense of being respectful of the culture of the individuals; and of good quality. • Accountability that ensures the duty bearers (the government and health providers) meet their obligations to respect, protect and fulfil people’s right to the highest attainable standard of reproductive health. • A life-course approach giving importance to each stage of life as each stage has implications for health and well-being. • A continuum of care approach that meets the SRH needs of people through the continuum of promotive, preventive, curative, rehabilitative and palliative care through the life course, prioritizing key SRH services aimed at individuals and families through primary care and referral care, and the population through public health functions, including surveillance and emergency preparedness. • Integrated service delivery to avoid fragmentation of services, making service cost-effective and cost- efficient (integration of different types of services, integration of promotion, prevention, cure and rehabilitation as needed), as well as integrated delivery of interventions across locations such as home, community health centre and hospital. • Gender-sensitive services to enable women to utilize services more and share information and concerns related to SRH, violence against women, etc. These are also critical for delivering rights-based services. • Culturally appropriate services: especially to difficult-to-access populations, people living with HIV and adolescents. • Partnerships with communities, between various sectors and levels of governance are critical for coordination and effective delivery of SRH services. 2.3 Process of Framework development The draft strategy was shared with relevant regional advisors of the Regional Office for South-East Asia and the feedback obtained has been incorporated. In addition, the draft has been shared during the Regional Technical Advisory Group (TAG) meeting on SRHR with representatives of ministries of health of Member States, professional associations of Member States, WHO technical officers posted in Member States and representatives of Regional UN offices. Relevant feedback has been incorporated. 2.4 Guiding principles and approaches The strategy is rooted in the principles of human rights related to health and is guided by health system approaches that help to achieve the highest attainable standard of health and universal access. 30 CHAPTER 3 Core elements of the Regional Strategic Framework for SRHR CHAPTER 3 31 The strategy rests on internationally agreed instruments and global consensus/declarations on human rights, which have been agreed upon by almost all Member States in the SEA Region. The proposed strategy takes into consideration the current global, regional and national strategies related to reproductive, maternal, newborn, child and adolescent health and those related to health systems. 3.1 Vision, mission, goal of the Regional Strategic Framework for SRHR A Region where the highest standard of sexual and reproductive health for all women and adolescents, across the life course, in every setting, is enabled to realize the fulfilment of sexual and reproductive rights; and where the Member States work towards reducing inequities, leaving no one behind VISION To support the Member States in the SEA Region to accelerate progress towards universal access to sexual and reproductive health services for all women and adolescents in respective countries, built on principles of human rights and public health, and with full engagement and accountability of the governments, minimizing inequities within individual countries and in the Region Ending preventable deaths from reproductive ill-health and improving reproductive health and well-being of women and adolescents across the life course and realization of sexual and reproductive rights through enabling policies, people-centred and quality health systems that are equitable, efficient and accountable, and changed/ transformed health-seeking behaviour; thus, contributing to the achievement of SDG 3 and other SDG targets MISSION GOAL 3.2 Strategic outcomes The Regional Strategic Framework for SRHR has four interdependent strategic outcomes, each of which has several strategic domains contributing to the outcome. The four outcomes cover the delivery of high-impact interventions in prioritized areas across the life course; health system interventions in support of the delivery of high-impact interventions; community mobilization to utilize the interventions, and collaboration between countries and with regional entities for accelerating progress towards improved SRH and realization of rights. The outcomes, if comprehensively addressed, should contribute to increased coverage of evidence-based interventions and sustained utilization of SRH services to achieve the Goal. The fourth strategic outcome relates to fostering collaboration between Member States and with regional entities such as the Association of Southeast Asian Nations (ASEAN) and South Asian Association for Regional Cooperation (SAARC) for accelerating progress through best practices and innovations (Figure 16). CHAPTER 3 32 3.3 Strategic domains A set of strategic domains is identified under each outcome, based on the needs in the context of the changing health and demographic scenarios, the gaps in services (coverage, quality, inequity) and challenges related to the realization of rights, identified in the SRHR landscape analysis in Chapter 1. Each domain includes a set of interlinked prioritized areas and key actions to guide the implementation of the strategy and help individuals and communities to meet their SRH needs across the life course. The strategic outcomes contribute to the GSWCAH objectives of Survive, Thrive and Transform as well as to the Regional Office for South-East Asia’s Flagship Programme objectives of accelerating progress while sustaining achievements and promoting innovations. In Member States which have achieved specific targets of the SDGs, the strategy should focus more on sustaining achievements and promoting innovations. STRATEGIC OUTCOMES 01 Quality, integrated, people-centred, evidence-based SRH interventions are available, accessible and responsive to the needs of individuals across the life course. 03 Individual and collective capacity and awareness is maximized for reproductive well-being and seeking care when needed. 02 Strengthened and accountable health system enables efficient and equitable coverage of SRH interventions. 04 Collaboration between countries and with regional entities are fostered for accelerating progress towards universal access to SRH. Figure 16: Strategic outcomes, domains and linkages to SDGs Strategic Outcome 1: Life cycle and vulnerable groups Core services in life cycle • Maternal and perinatal health • FP • Comprehensive abortion care • Infertility • Reproductive organ cancers • Health sector response to intimate partner violence • HIV and STI Specific population groups that have less access to SRH services • ASRH services • SRH services for ageing • SRH services for differently abled • SRH services in humanitarian crisis • SRH services for urban slums and remote and difficult-to-access areas Strategic Outcome 2: Health system building blocks • Leadership/governance (stewardship) • Human resources for health (HRH) • Health-care service delivery • Health Information • Health financing • Essential medicines, commodities and technologies Strategic Outcome 3: Core approaches • Capacity building of individuals • Male involvement • Mobilizing communities Strategic Outcome 4: Harnnessing knowledge and experience for fostering collaboration between countries and with regional entities and other agencies 10 Reduce inequalities 3 Good health and well-being 5 Gender equality 17 Partnership for the goals CHAPTER 3 33 Table 9: Strategic outcomes and strategic domains Strategic outcomes Strategic domains Strategic Outcome 1: Quality, integrated, people- centred, evidence-based SRH interventions are available, accessible and responsive to the needs of individuals across the life course. Strategic domains are grouped according to: (i) core reproductive health services, and (ii) specific population groups that have SRH needs but have limited access. Core SRH service domains, across the life course, delivered as single or packaged interventions through health system platforms • Maternal and perinatal health • Family planning (FP) • Comprehensive abortion care (CAC) • Infertility • Reproductive organ cancers • Health sector response to intimate partner violence • HIV/STI Domains focusing on specific population groups with limited access to SRH services • Adolescent sexual and reproductive health (ASRH) services • SRH services for the ageing population • SRH services for the differently abled • SRH services in humanitarian settings • SRH services for urban slum populations and remote and difficult-to-access populations Strategic Outcome 2: Strengthened and accountable health systems enable efficient and equitable coverage of SRH interventions. Domains of health system in support of improving access to SRHR • Leadership/governance (stewardship) • Human resources for health (HRH) • Health-care service delivery • Health information • Health financing • Essential medicines, commodities and technologies Strategic Outcome 3: Individual and collective capacity and awareness are maximized for reproductive well-being and seeking care when needed. • Capacity building of individuals • Male involvement • Mobilizing communities Strategic Outcome 4: Collaboration between countries and with regional entities fostered for accelerating progress towards universal access to SRH. • Harnessing knowledge and experience for fostering collaboration between countries and with regional entities and other agencies CHAPTER 3 34 Table 10: Regional and country goals and targets to be achieved by 2030 The impact and coverage targets to be achieved through the strategy are aligned with the global targets as follows. Indicator Regional target by 2023 Thirteenth General Programme of Work targets* Country SDG target to be achieved by 2030 Maternal mortality ratio (MMR) (per 100 000 live births) Reduce the Regional MMR by 30% from 152 per 100 000 live births* Reduction by two-thirds from the 2010 value and no country should have an MMR above 140 per 100 000 live births Still birth rate (SBR) (per 1000 total births) 30% reduction of the Regional SBR from the 2015 value 12 or less per 1000 total births Neonatal mortality rate (per 1000 live births) Reduce the Regional newborn mortality by 30% from the 2017 value* 12 or less per 1000 live births Adolescent birth rate (ABR) (per 1000 girls of the same age 15–19 years 10–14 years) Target not set (only reduction) Target not set Universal access to SRH: Proportion of women of reproductive age (15–49 years) who have their need for FP satisfied with modern methods 66% of women of reproductive age (15–49 years) have their need for FP satisfied with modern methods* SDG country target Proportion of women aged 15–49 years who make their own informed decisions regarding sexual relations, contraceptive use and reproductive health care 68% of women aged 15–49 years make their own informed decisions regarding sexual relations, contraceptive use and reproductive health care* SDG country target Cervical cancer incidence among women aged 30–49 years Cervical cancer screening at 35 and 45 years of age Target not set **Cervical cancer incidence is <4/100 000 women-years by the end of century 70% of women are screened with a high-precision test at 35 and 45 years of age; and **90% of women identified with cervical disease receive treatment (90% of women with pre-cancer treated; 90% of women with invasive cancer managed). Source: Global SDG targets, Essential Newborn Action Plan and Ending Preventable Maternal Mortality (EPMM) * WHO Global Programme of Work 13 ( GPW 13) 2023 targets ** Global strategy towards eliminating cervical cancer as a public health problem. CHAPTER 3 35 3.4 Strategic outcomes, domains and key actions 3.4.1 STRATEGIC OUTCOME 1 Quality, integrated, people-centred, evidence-based SRH interventions are available, accessible and responsive to the needs of individuals across the life course. • CORE REPRODUCTIVE HEALTH SERVICES • Each of the strategic domains includes a number of prioritized areas that contribute to achieving the objectives of the specific domain. • The prioritized areas address (i) the unfinished agenda on maternal, perinatal and newborn care, contraception, STI and HIV, for which high-impact, evidence-based interventions are available, and (ii) less well-known reproductive health conditions among women and men but have major implications for individuals and families. • Besides addressing curative care, the suggested actions also cover preventive and promotive care as well as follow-up care, as needed. • Key actions under prioritized areas refer to policy and health systems, as relevant. 1. MATERNAL AND PERINATAL HEALTH The main challenges in this section are gaps concerning quality, coverage and equity in maternal health services especially with regard to skilled care and EmONC. The other challenges are discussed in Chapter 1. The domain addresses the first dimension of UHC of the essential package of high-impact evidence-based SRHR interventions that need to be delivered along the continuum of the life course and SRH services to reach country and global targets. These interventions should be considered for inclusion in national health benefit packages (see Annex 4). The domain covers the implementation of major WHO strategies for eliminating preventable maternal mortality (supplemented with the recommendations from the Lancet series on maternal health 2016) [6,35]. More details are given in Chapter 4. Domain objective: Maternal and perinatal health intervention packages are accessible at all levels of the health system, congruent with the level of the facility, across the continuum of maternal and perinatal care, contributing to further improvements in maternal, fetal and newborn survival and health. CHAPTER 3 36 1.1 Prioritized area: Development and implementation of the preconception care package Preconception care is the provision of biomedical, behavioural and social health interventions to women and couples before conception occurs. It provides a comprehensive platform to deliver interventions that have a positive impact on maternal and child health outcomes and long-term impact across the life course. A few of the positive outcomes include the prevention of unintended pregnancies, complications during pregnancy and delivery, stillbirths, preterm birth and low birth weight, birth defects, neonatal infection and vertical transmission of HIV/STI [36]. • Development and implementation of a preconception care package to ensure good health and nutritional status of girls and women • Availability of and access to good quality and full package of ANC for a positive pregnancy experience • Availability of and access to good quality and respectful intrapartum care for a positive childbirth experience • Availability of and access to good quality EmONC (basic and comprehensive) • Access to PNC for survival and health of mothers and newborns • Development and implementation of a package for prevention and management of stillbirths • Improved quality and coverage of surveillance and response to maternal deaths and stillbirths • References to preconception care in other regional strategies are listed in Annex 10. • Annex 5 provides WHO recommendations for a preconception package including a strategy for country action. Develop the preconception care package (i) based on WHO’s policy brief on preconception care (see Annex 5) taking into consideration the existing programmes, epidemiological pattern of diseases and the capacity of the health system; (ii) include evidence-based interventions, as relevant (see Annexes 4 and 4A); and (iii) include referral pathways for those who need advanced services. Integrate the implementation of the preconception care package into other programmes/service delivery platforms, as appropriate, on adolescent SRH, maternal care, new-born care, FP, prevention and management of violence against women, STI/HIV, nutrition, etc. Conduct implementation/operations research on integrated delivery promotion and prevention and treatment elements, options on location and modality of delivering the package (CBHWs, facility-based care and referral) to ensure equitable access and quality services to all in the target group. K EY A C TI O N S To help countries achieve the objectives of reduction in maternal and neonatal mortality and in stillbirths, as well as improved survival of mothers and newborns, the following prioritized areas across the continuum of maternal and perinatal care have been identified. CHAPTER 3 37 1.2 Prioritized area: Availability of and accessibility to good quality ANC for a positive pregnancy experience WHO recommendations on ANC for a positive pregnancy outcome (2016) have much relevance for the Region for reduction of maternal and neonatal mortality and stillbirths. ANC provides a platform for integrating several programmes that have a direct impact on maternal and perinatal outcomes, including screening and management of morbidities, intimate partner violence and psychological status. Annex 6 gives the WHO recommendations for a positive pregnancy experience and should be used to plan for ANC in the Member States. There are 49 recommendations of which 19 are for all settings, 23 are for specific contexts and seven are non-recommended practices [37]. As evident from surveys, a few countries still invest in non-recommended practices and some countries implement context-specific recommendations without evidence. Such practices will not yield the desired positive pregnancy experiences; they may cause harm and waste of scarce resources. Issues related to the coverage and quality of ANC are discussed in Chapter 1. Review and update the current ANC guidelines, protocols and training package, based on the recommendations, particularly the eight contacts, timing and contents of services to be delivered at each visit (Annex 6). Advocate/initiate a policy dialogue for eight ANC contacts and their rationale (such as reducing stillbirths, improving institutional deliveries, opportunity to counsel about unnecessary caesarean sections, etc.). Develop plans for increasing the coverage of eight visits to at least 80% and sustaining them in countries that have achieved 80%. Strengthen capabilities for identification and management of: • Maternal morbidities, including heart diseases, undernutrition, overweight and obesity, diabetes, hypertension and mental health conditions, and take appropriate action to prevent lifelong complications in mothers and newborns. • Intimate partner violence Strengthen screening for syphilis, HIV, hepatitis B and referral pathways with the objective of eliminating mother-to-child transmission (linked to the core domain HIV/AIDS). Include birth preparedness and complication or emergency readiness plan for every pregnant woman, emphasizing institutional delivery (involving the woman and her family and the providers – community and facility as well as traditional birth attendants). Create awareness of the importance of ANC, including the first trimester visit, more frequent visits in the last trimester through innovative strategies such as the use of mobile apps (see Strategic Outcome 3). • Use the ANC clinics as a platform to create awareness of other aspects of maternal care, FP, newborn care, etc. and to promote male involvement. Conduct implementation research on the feasibility of increasing minimum ANC visits to eight and components of the care package at each visit and screening for important morbidities (see stewardship under Strategic Outcome 2). K EY A C TI O N S CHAPTER 3 38 Review and update or develop standards, guidelines, protocols and a training package for a positive childbirth experience based on the WHO recommendations on intrapartum care for a positive childbirth experience (see Annex 7) and their alignment with the essential newborn care guidelines at birth. Improve 24/7 access to skilled care in primary-level facilities for narrowing equity gaps and improving institutional deliveries. ALL PREGNANT WOMEN MUST BE GUARANTEED SKILLED CARE as per the WHO recommendations on intrapartum care. • Review/define minimum standards for a facility to conduct high-quality deliveries and use the criteria for the classification of facility deliveries. Use “WHO standards of care to improve maternal and newborn quality of care in facilities” (2016) to develop the standards. • Plan for 24/7 availability of such facilities and their periodic accreditation for compliance with national standards. • Improve the quality of care with emphasis on respectful maternity care, including regular communication with the woman and her family and allowing a companion of her choice to be present during delivery. • Improve essential newborn care at the time of delivery (linked to regional newborn care strategy). • Relevant references to ANC in other regional strategies are listed in Annex 10. • Annex 6 provides the WHO recommendations for a positive pregnancy experience mapped to eight scheduled ANC contacts. In situations where WHO’s home-based records or its adaptations are not currently in use: Encourage the use of home-based records to complement facility-based records for the care of pregnant women along the continuum of care for communication between providers and women and their families. In low coverage settings: Based on the identification of factors responsible for low demand (from the assessment), develop service delivery models to overcome the barriers and improve high coverage and quality of services (see service delivery, Strategic Outcome 2). K EY A C TI O N S 1.3 Prioritized area: Availability of and access to quality, competent and respectful intrapartum care for a positive childbirth experience All pregnant women need and must be guaranteed skilled care at birth, irrespective of the place of delivery, and access to EmONC when complications develop, as it is their right. Skilled care at birth constitutes three critical actions: in most situations, the actions include quality, appropriate, evidence-based and respectful care during labour, childbirth and immediate postnatal period; watching for complications; and immediate management of some complications and/or stabilization and timely referral to the EmONC facility. Annex 7 provides the WHO recommendations on intrapartum care for a positive childbirth experience (2018) [38]. High-quality intrapartum care reduces maternal and newborn mortality and stillbirths and is a triple investment. Though all Member States have launched favourable policies for institutional deliveries and skilled birth attendance, the coverage is not universal (Figure 2, Tables 3 and 4) [11]. K EY A C TI O N S CHAPTER 3 39 In locations with high home deliveries and deliveries by nonskilled birth attendants: Conduct studies/reviews on barriers related to the demand and supply side of low institutional deliveries. In locations where geographical access is difficult, consider developing “maternity waiting homes” as per the standards or similar structures to enable mothers to be closer to facilities and/or facilitate access to transportation. Consider establishing midwife-led units where an adequate number of midwives are present. Implement innovative ways of encouraging institutional deliveries of high quality through demand-side financing schemes, building on national and regional best practices. Ensure a birth preparedness plan for every pregnant mother (see under ANC). Develop a partnership with traditional birth attendants or others who support women during deliveries to facilitate referral of all normal deliveries and/or referral if complications are suspected. • References to immediate newborn care in other regional strategies are listed in Annex 10. • Annex 7, WHO recommendations on intrapartum care for a positive childbirth experience Improve access to 24/7 high-quality EmONC services. EVERY PREGNANT WOMAN MUST HAVE GUARANTEED ACCESS TO EmONC as complications are unpredictable. • Initiate regular EmONC needs assessments and improve/strengthen the facilities to perform the signal functions of EmONC (see Footnote 1) based on the findings of the EmONC assessment, congruent with the level of the facility and institute mechanisms to monitor its functionality. • Upgrade and improve the functionality of comprehensive EmONC (CEmONC) and neonatal intensive care units (NICUs) (latter linked to regional newborn care strategy) and monitor the functionality of both. Where feasible, establish obstetric high-dependency units and obstetric intensive care units. • Establish a referral mechanism with clear protocols for management, communications and transport. • Expand and improve the training of non-specialist doctors in CEmONC and obstetric anaesthesia, where necessary. • Establish mechanisms for continuous capacity-building of EmONC. The availability of and access to appropriate care during an emergency saves lives. Inequitable access to EmONC is a major reason for continuing preventable maternal and neonatal mortality. Fifteen per cent of all pregnant women experience life-threatening conditions. As noted in Chapter 1, in some Member States, the proportion of deliveries by caesarean section has increased beyond the recommended levels and is a major concern; of equal concern are the low levels of caesarean section below the minimum recommended level in certain countries. 1.4 Prioritized area: Availability of and access to 24/7 EmONC K EY A C TI O N S K EY A C TI O N S CHAPTER 3 40 Monitor the quality and coverage of caesarean sections. • Monitor the caesarean section rates at the population level (national and subnational) to identify underutilization (<5%) and over-utilization (>10%) of caesarean section rates. • Monitor the mode of delivery at the institutional level to track the trends of various modes of delivery and develop an action plan for rationalizing the use of caesarean sections. • Adopt the Robson classification system as a global standard for periodic assessment, monitoring and comparing the rates of caesarean section within and between health-care facilities. • Implement “WHO recommendations on non-clinical interventions to reduce unnecessary caesarean sections” (2018) to optimize the use of caesarean section as a life-saving intervention. • Improve the capacity to conduct other modalities of assisted vaginal deliveries, such as vacuum extraction. • Create public awareness of the risks of unnecessary caesarean section. At the individual level, through ANC counselling, women should be discouraged from requesting caesarean section when it is not medically indicated. Review and update or develop standards, guidelines, protocols and training package for postnatal care based on the WHO recommendations on PNC for mothers and newborns (see Annex 8) [39]. Institutional deliveries • Develop and implement a policy on delaying discharge for at least 24 hours for every facility birth with no complications to ensure PNC in the first 24 hours. • Make follow-up visits at home on day 3 (48–72 hours), between days 7 and 14 and at six weeks (preferably by skilled health personnel and where not possible, by CBHWs who are trained and supervised by skilled health personnel). • At each visit, follow the recommendations given in Annex 8. [39]. • Make additional visits and provide extra care to mothers and babies with complications. The postnatal period is a critical time both for the mother and the newborn and timely, high-quality PNC is crucial to reduce maternal and newborn mortality. In most countries, mothers and newborns with no complications are not kept in the institution for 24 hours, though the policies favour institutional and home-based care for two days after delivery. Home visits to postnatal mothers and their newborns are a concern even in countries with CBHWs. All Member States of the Region have introduced favourable policies [11]. 1.5 Prioritized area: Access to quality postnatal care (PNC) for all births for survival and health of mothers and newborns K EY A C TI O N S K EY A C TI O N S CHAPTER 3 41 Home deliveries • Develop policies for a visit by an SBA in the first 24 hours and provide services as per the guidelines. At least three additional postnatal contacts are recommended for all mothers and newborns, on day 3 (48–72 hours), between 7 and 14 days after birth and six weeks after birth. • Involve CBHWs who are trained and supervised by skilled health personnel. • Undertake home visits by skilled health personnel, where possible. • At each visit, follow the recommendations given in Annex 8. [39]. • In addition to the assessment of mother and baby, an integrated package of preventive services should be offered. • Counsel mothers and their family on nutrition, personal hygiene, newborn care, breastfeeding, immunization, and recognition of and response to complications/danger signals in mother and baby. • Counsel on the use of contraception (see details under FP). • Provide psychosocial support – recognition of conditions such as postpartum psychosis, depression, etc. Establish referral pathways for complications that are identified (from the community to hospitals and in between hospitals). Establish postnatal clinics, preferably at the community level, for integrated delivery of services to mothers and children, including FP services. K EY A C TI O N S In locations with high stillbirth rate • Develop national action plans for the prevention and management of stillbirths in consultation with stakeholders, including professional bodies/societies, and ensure the inclusion of modifiable risk factors, assessment of fetal well-being during pregnancy and labour, correct use of uterotonics, timely induction of post-term pregnancy, managing bereavement, management of the pregnancy following a stillbirth, etc. • Implement the 10 interventions recommended to prevent stillbirths, as relevant to the epidemiology of stillbirths in the country (see Annex 4A) through various service delivery platforms [40]. Strengthen the national focus on and accountability for the prevention and management of stillbirths by establishing a programme unit, as part of the maternal health division with responsibility for surveillance and response and research and linkages with the neonatal health programme. SBRs are high in the Region and are linked to the maternal health status. Almost half of all stillbirths are intrapartum (fresh stillbirths) and are linked to the quality of care during the intrapartum period. Stillbirth is a silent tragedy that has not received much attention in the Region. 1.6 Prioritized area: Availability and implementation of an action plan to prevent and manage stillbirths K EY A C TI O N S • References to immediate newborn care in other regional strategies are listed in Annex 10. • Annex 8 provides the WHO recommendations on PNC for women and newborns. CHAPTER 3 42 Strengthen and expand MDSR/MPDSR through the following actions. • Based on the findings of the Regional review on MDSR, develop/strengthen standard operating procedures (SOPs), and review formats for MDSR/MPDSR and training manuals based on global guidelines.9 • Strengthen the country capacity to use ICD-MM/ICD perinatal mortality (ICD-PM) [41,42]. • Build capacity for the review process and planning, and for implementing response in MDSR/ MPDSR [43]. • Scale up MDSR to all institutions and include all community maternal deaths as a national programme within the health sector. • Generate annual reports based on MDSR and use them for monitoring trends (see also under stewardship, Strategic Outcome 2) • Triangulate the data (MMR/cause of death) generated from MDSR, CRVS and HMIS. • To improve the identification of maternal deaths in CRVS, include a pregnancy box in the death declaration form. Strengthen stillbirth surveillance and response through the following actions. • Initiate/strengthen stillbirth surveillance and response based on global and regional guidance [44]. • Initiate/strengthen stillbirth surveillance in all newborn birth defect (NBBD) network hospitals of the SEA Region. • Develop a national training guide/SOP on perinatal mortality review and conduct training in surveillance and the use of ICD-PM. • Scale up stillbirth surveillance and response/perinatal death surveillance and response to cover all institutions. • Generate annual reports based on stillbirth surveillance. • Make stillbirths a part of CRVS, including a special report by a relevant national authority at the earliest. • Create groups/forums responsible for developing action plans in response to maternal/perinatal death review/enquiry and for follow-up. • Incorporate stillbirth surveillance and response into MDSR, where relevant. Strengthen “near-miss” case reviews as a process of assessing the quality of obstetric care within institutions, especially as more institutional deliveries are taking place [45]. Though preferable in settings where maternal deaths are fewer and the health system has the capability, such case reviews are applicable in all situations. • Based on the WHO guidelines on the identification of near-miss cases [46], develop a consensus on the definition of near-miss. Approaches to identify near-miss cases should be developed in consultation with professional societies of obstetrics/gynaecology, midwifery, public health, etc. • Build capacity to review near-miss cases and institute the same as an integral part of the assessment of the quality of obstetric care. All programme reviews should be part of the health system and staff should be designated with a dedicated budget. As discussed in Chapter 1, all Member States have initiated MDSR. A few countries conduct stillbirth surveillance and response separately and a few conduct combined maternal and perinatal death surveillance and response (MPDSR). The quality of surveillance varies, and the responses/actions have been weak in most countries. 1.7 Prioritized area: Improved quality and coverage of maternal death and stillbirth surveillance and response K EY A C TI O N S 9 Maternal and Perinatal Death Surveillance and Response: Materials to Support Implementation (unpublished draft). CHAPTER 3 43 Before initiating any of the key actions across the continuum of care, conduct periodic assessment of facilities for current practices in ANC (packages), preparedness for skilled care and EmONC, practices in PNC, skills of providers, supply systems, integration with FP and nutrition, monitoring psychological status, etc. (building on recent assessments). Professional societies of obstetrics/gynaecology, midwifery and neonatal/paediatrics, etc. should be involved in the process of design as well as assessment. Streamline and strengthen referral systems • Establish referral protocols, including stabilization of mother and newborn, care during transfer, communication with the woman and her family, communicating with the referral facility, including request for feedback, etc. • Organize a coordinated, well-maintained emergency transport service with centralized access phone numbers or a dispatch system ( the feasibility of the location needs to be worked out). Health system actions specific to this section • Improve availability and equitable distribution of SBAs (see priority actions under human resources, Strategic Outcome 2). • Develop models of care such as “midwife-led continuity of care” (see service delivery, Strategic Outcome 2). • Ensure that the health insurance schemes cover normal deliveries, transportation and complications irrespective of the place of delivery of the service, where applicable (see financing under Strategic Outcome 2). • Strengthen the supply system for 24/7 availability of medicines, supplies and equipment (see reproductive health logistics system, Strategic Outcome 2). • Establish mechanisms to monitor the quality of services including adherence to guidelines as well as coverage. Institute quality improvement mechanisms based on WHO’s global framework for quality improvement in maternal and newborn care and the Regional POCQI approach. • WHO recommendations on maternal health are a useful reference for identifying further key actions. PRIORITY ACTIONS FOR WHO • Advocate and provide technical assistance to countries to develop a preconception package and effective service delivery models. • Support a quality improvement framework for SRH based on WHO’s global framework for quality improvement in maternal and newborn care and Regional POCQI. • Support implementation/operations research on delivery strategies for preconception care interventions. • Advocate to countries to (i) change policies to increase ANC to a minimum of eight contacts and coverage to at least 80%; and (ii) develop models of maternal and perinatal care for universal access to maternal and newborn health in countries according to the needs and capacity of the country and provide assistance in the implementation of such models. • Provide technical assistance for (i) updating national guidelines on ANC, intrapartum care and PNC; (ii) developing standards and protocols as well as for strengthening MDSR and initiating/ improving perinatal death reviews or MPDSR; and (iii) developing a stillbirth action plan. K EY A C TI O N S CHAPTER 3 44 FP is one of the high-impact interventions for the reduction of maternal mortality in addition to providing skilled care and access to EmONC. By avoiding unwanted pregnancies, the risk of maternal mortality and newborn mortality and adverse pregnancy outcomes is reduced. The country-wise contribution of FP towards reducing maternal deaths is discussed in Chapter 1. FP also contributes to reducing stillbirths (see Annex 4A). The main challenges are related to skewed method-mix in favour of short-acting methods and high discontinuation rates leading to unintended pregnancies and their consequences such as unwanted births, abortions and complications. Poor quality of counselling and missed opportunities for counselling on FP during pregnancy, childbirth, postpartum and post-abortion periods result in stagnant mCPR in some countries. PRIORITY RECOMMENDATIONS TO COUNTRIES IN IMPLEMENTATION OF EVIDENCE-BASED INTERVENTIONS ARE DISCUSSED IN DETAIL IN CHAPTER 4 ON IMPLEMENTATION. Review and update national guidelines to align with the Medical Eligibility Criteria (MEC 2015) [47] for Contraceptive Use, Selected Practice Recommendations (SPR 2016) [48] for Contraceptive Use and FP Handbook [49] and orient programme managers, health service providers and professional associations. • Promote mobile apps on the MEC wheel and the use of the MEC wheel among providers to facilitate decision-making on contraceptive use [50]. • Review and revise the health system imposed contraindications/ restrictions related to age, parity, medical conditions, etc. (RMNCAH policy survey) [11]. 2.1 Prioritized area: Improved equitable access to quality services and a wide range of contraceptives to meet the reproductive goals of all couples K EY A C TI O N S • WHO, in collaboration with partners, to simplify EmONC tools for quick and comprehensive assessment and assist countries with a template for improvement plans. • Assist regulatory bodies (professional councils) and societies to maintain competencies in the workforce and to develop task shifting in delivery of interventions. • Plan joint actions with H6 partners. • Strengthen and sustain an effective monitoring and evaluation framework. 2. FAMILY PLANNING Domain objective: High-quality FP service delivery system sustained at all levels of the health system to reduce unmet needs of contraception through the reproductive cycle and reduce unintended pregnancies. CHAPTER 3 45 Ensure method choice by providing client-centred information, counselling and services to enable individuals and couples to freely decide and choose a contraceptive that best meets their reproductive intentions and also meets the eligibility criteria for the method. Method choice is a hallmark of the quality of care and realization of rights (see Annex 9 for ensuring human rights in the provision of contraceptive services). Sustain support to continuing users through counselling and quality services with emphasis on follow- up services including counselling. • Develop or improve systems to track clients for continuation or switching methods. Use innovative methods such as mobile apps to send reminders about supplies/injections. Ensure continuous availability of services including all methods of contraception to meet the changing needs of clients, depending on their ages and reproductive stages – newly married, postpartum, completed family, perimenopause (maximum unmet need among young and perimenopausal and postpartum). Adopt diverse service delivery approaches to expand method choice throughout the health system, especially in hard-to-reach areas, using CBHWs, mobile outreach services, etc. (see service delivery, Strategic Outcome 2). Harness the private sector to contribute to access to quality FP services with attention to client rights (see health service delivery, Strategic Outcome 2). Build the skills of all providers to provide unbiased, quality counselling, full information on all methods without imposing personal views and help clients to choose a method that aligns with the client’s preferences and eligibility and provide safe services and follow-up. • Incorporate the WHO FP Training Resource Package [51] into the national FP training programmes (basic and in-service) and also the use of mobile apps on MEC. Strengthen the health system for quality delivery of FP services • Include contraceptives in the essential service delivery package. • Ensure continuous availability of all contraceptives in all health facilities. A method not being available is a significant reason for unmet needs (see the reproductive health logistics system, Strategic Outcome 2). • Review the current HMIS and revise as needed to assist with easy tracking of defaulting clients or those who switch methods to take timely action to prevent unintended pregnancies. • Undertake in-depth analysis of DHS data on FP for planning for improving services. Develop strategies for delaying age at first pregnancy and for increased male involvement and participation (see the sections on ASRH and Strategic Outcome 3). K EY A C TI O N S CHAPTER 3 46 Create awareness among policy-makers and health service providers on fertility in the early months after childbirth and the importance of providing FP to prevent pregnancy as integrated care in the postpartum period. Offer contraceptive counselling and services as part of facility-based childbirth care before discharge from the health facility. Develop national guidelines/SOPs on postpartum FP based on MEC, SPR and FP Handbook and programming guidelines based on WHO’s programming strategies for postpartum FP [52] and postpartum compendium. Promote the use of mobile apps and compendium on postpartum FP [53] to effectively advise on the eligibility of methods during the postpartum period. Ensure that the review and revision of guidelines on ANC, intrapartum and postpartum guidelines integrate FP counselling and offer services during the immediate postpartum period. Checklists related to services should include FP counselling and services, as relevant. Provide FP counselling and services: • in the ANC clinic and ward, • in the postnatal ward, • at discharge after childbirth, and • at immunization of the child. In addition to the lactational amenorrhoea method, promote a wider mix of methods appropriate for the client (as per MEC) to ensure that no unintended pregnancies happen; specifically, long-acting reversible contraceptives in women with prior adverse pregnancy outcomes. Strengthen the post-abortion FP strategy to ensure early initiation of FP among women who had an abortion due to the risk of early return of fertility as discussed under post-abortion care. Provide competency-based training in newer postpartum FP methods such as post-placental insertion. Promote postpartum FP counselling and services through CBHWs. Postpartum FP is defined as the prevention of unintended pregnancy and closely spaced pregnancy through the first 12 months following childbirth (WHO). The continuum of care throughout a woman’s pregnancy, childbirth and postpartum provides an array of opportunities to counsel on FP and provide services. With increasing coverage of ANC and facility deliveries, the opportunities have increased to promote postpartum FP, but have not been optimally used. 2.2 Prioritized area: Improved Access to contraception in the post-pregnancy period to prevent unintended pregnancy K EY A C TI O N S CHAPTER 3 47 PRIORITY ACTIONS FOR WHO • Provide technical assistance for review of policies and guidelines to align with MEC and SPR using a rights-based approach in the provision of contraceptive information and services. • Disseminate evidence-based guidelines on MEC and SPR using mobile apps and postpartum compendium, in collaboration with UNFPA and other agencies. • Advocate for favourable policies and adequate financing of FP through government funding. Screen for STI and HIV during FP service provision and ensure the same through guidelines, training, etc. Promote dual protection using condoms along with another contraceptive when the risk of STIs and HIV is high. At each follow-up visit, STI/HIV risk should be assessed. Provide contraceptive services in HIV treatment and care centres (details are given in the section on HIV/STI). K EY A C TI O N S The integration of FP and STI/HIV services is critical for cost-effective and cost-efficient reproductive health outcomes. The Regional guidelines on STI explicitly stress the importance of integration. 2.3 Prioritized area: Strengthened integration of FP and HIV and STI services • References to integration of FP with maternal and child health services and STI/HIV in other regional strategies are listed in Annex 10. • Annex 9 provides WHO recommendations for ensuring human rights in the provision of contraceptive information and services. Domain objective: Capabilities of the health system strengthened to provide Comprehensive Abortion Care within the limits of the national laws and policies Despite the high coverage of modern methods of contraception, unintended pregnancies and unsafe abortions continue to contribute to maternal mortality. Besides the prevention of unintended pregnancies, the other main challenges are access to safe abortion services and post-abortion FP. 3. COMPREHENSIVE ABORTION CARE CHAPTER 3 48 Advocate to ensure the availability of CAC services in line with the legal provisions of the country. Review and revise the current guidelines and clinical protocols on safe abortion and post-abortion care to align with WHO recommendations on evidence-based medical [54] and surgical management of abortions [55] and post-abortion FP, according to the legal status of abortions. Within the boundaries of the law, provide safe abortion services to all groups of women, irrespective of their ability to pay. • Integrate abortion services into primary health care and UHC health insurance packages. • Where legal, provide evidence-based standardized CAC to terminate unwanted pregnancies, manage post-abortion complications and provide post-abortion FP counselling and services. • Strengthen the capacity of facilities at the primary level to manage complications of abortion using medical/surgical methods, as appropriate by providing counselling, post-abortion care and post- abortion FP counselling and services irrespective of the legal status on abortion in the country. • Strengthen community-level services for education on prevention of unwanted pregnancy by effective use of contraceptives, availability of legal abortion services and licensed providers. Certify and license eligible providers and facilities using standardized criteria within the framework of law. Certification and licensing of providers must be as that for other medical procedures. Licensing facilities should include criteria for licensing primary and referral facilities and should be the same for both the public and private sectors. Monitor periodically the quality of services to ensure safety of the clients. Develop checklists to monitor those aspects of care that support the rights of women – informed and voluntary decision, autonomy in decision-making, non-discriminatory behaviour, maintaining confidentiality and privacy for all women including adolescents. Conduct research on prevalence, reasons, providers, complications, etc. and use the findings to improve services. Implementation of the legal framework for abortions should be part of the research. Monitor the trend of maternal deaths due to abortions through the MDSR system. Strengthen the availability of data on abortions within the SRH data systems to assess the coverage of CAC services. K EY A C TI O N S After an abortion, fertility usually returns after three weeks. A majority of abortions are repeat abortions because of unintended pregnancies due to no use of contraception or incorrect use of short-acting methods. 3.2 Prioritized area: Access to post-abortion care including post-abortion FP One of the major barriers to safe abortion services is the legal restrictions to the provision of abortion services. Legality by itself is no guarantee for safe services but it improves access to safe abortion services. 3.1 Prioritized area: Availability of and access to CAC, according to the legal status of abortion CHAPTER 3 49 Strengthen post-abortion care by educating women at the time of discharge about complications to watch out for and which facility to go to. Strengthen post-abortion FP counselling and services through counselling of women before and after the procedure. K EY A C TI O N S PRIORITY ACTIONS FOR WHO • Provide technical assistance in developing national guidelines and protocols for CAC and integrate those with various national programmes in the health system approach to ensure availability of and accesses quality CAC as well as the use of MEC for determining appropriate contraceptive methods. Domain objective: Availability of and access to quality infertility information and services improved at all levels of health care, congruent with the level of the facility PRIORITY ACTIONS FOR WHO • Develop guidelines for standardized investigation, diagnosis and treatment of couples with infertility. • Assist with the review of current guidelines/ development of guidelines for ART facilities. Review and revise/develop policies, guidelines, standards and clinical protocols on prevention, diagnosis and treatment, congruent with the level of the facility. Review and revise/develop laws related to ART and regulations related to surrogacy. Review and revise, as needed, the national guidelines for accreditation, supervision and regulation of facilities providing ART facilities, including the provision of services for the poor. Conduct studies on the prevalence of primary and secondary infertility based on standardized methodology. K EY A C TI O N S WHO has developed guidelines for laboratory investigations and for diagnosis and treatment of male infertility. Currently there are no guidelines for investigation, diagnosis and treatment of couples but these are in the process of being developed. 4.1 Prioritized area: Availability of and access to quality information and services on primary prevention, diagnosis and treatment of infertility The main challenge is the lack of access to ART (geographical and financial), lack of policies and regulations related to ART services. 4. INFERTILITY CHAPTER 3 50 The public health goal of screening and diagnosis is to decrease the incidence and prevalence of cervical cancer and associated mortality, by intercepting the progression from pre-cancer to invasive cancer. The goal of treatment is to reduce the number of deaths (WHO). 5.1.1 Prioritized area: Availability of and equitable access to information and services for screening, diagnosis and treatment of cancer cervix uteri Review the current national programmes on the prevention and treatment of cervical cancer and identify bottlenecks and opportunities to accelerate the coverage of screening. Update the current national guidelines based on the recommendations of the global strategy for elimination of cervical cancer [56] as a public health problem (2020) and the proposed regional operational framework for elimination of cervical cancer. Develop/strengthen the national cervical cancer control plans, including appropriate strategies and guidelines for immunization, screening, treatment and care, including palliative care. Promote the screen-and-treat approach. Countries will need to expand the number of facilities where a single-visit screen-and-treat approach could be implemented. Promote pilot initiatives on alternate methods of screening (such as HPV DNA) and their potential to increase coverage, impact and cost–effectiveness. Strengthen health infrastructure with continuous availability of supplies and functioning equipment needed for screening and treatment of precancerous lesions (based on national policies and guidelines). 5. REPRODUCTIVE TRACT CANCERS The Regional Strategic Framework for SRHR focuses on cervical cancer based on the following rationale: cervical cancer is largely preventable and is one of leading causes of cancer among women in the SEA Region and the mortality is high. Effective and low-cost interventions for prevention and early diagnosis and treatment are available. All the Member States are implementing programmes on screening with varying levels of coverage. WHO has developed global and regional strategies for the prevention and management of cervical cancer. The strategy also briefly focuses on breast cancer. Domain objective: Availability of and equitable access to reproductive cancer prevention and control services improved across the life stages of women K EY A C TI O N S 5.1 CERVICAL CANCER Depending on the policies/strategies in the country, the cervical cancer prevention and management programme may spread across a few national programmes such as immunization (HPV vaccination), reproductive health (screening) and NCD (treatment and palliative care). The challenges facing the cervical cancer control programme are inadequate coverage of screening of women and quality of screening, non-availability/high cost of more efficient screening methods, access to the HPV vaccine and lack of updated information on incidence, mortality, coverage of screening, etc. (as discussed in Chapter 1). CHAPTER 3 51 Organize capacity-building of staff for screening and treatment of precancerous lesions, as appropriate using the training package of the WHO Regional Office for South-East Asia. Integrate screening and treatment services into the primary health care package by identifying opportunities to integrate with ongoing reproductive health services such as FP or child health programmes HIV/STI. Conduct implementation research on screening and treatment of precancerous lesions in primary health care settings. Advocate to include cervical cancer screening and treatment as part of the health insurance benefit package. Strengthen diagnostic, treatment and palliative care services as the essential service package for treatment of cervical cancer. Address the data gaps in prevention and control of cervical cancer, including through the establishment of population-based cancer registries. In countries that have introduced HPV vaccination, build on existing efforts to introduce HPV vaccination/review the coverage and costs involved in ongoing programmes in Member States. In countries that are considering introduction of HPV vaccination, carry out cost–benefit and cost effectiveness analyses to generate information for advocacy with policy-makers. In countries, where the vaccine has not been introduced – • undertake feasibility studies to identify an appropriate and efficient mode of delivery, experiences of introducing new vaccines in the country could provide some directions, • consider the introduction of the HPV vaccine and make applications to Gavi, as appropriate, • engage community leaders especially to get support for HPV vaccination, to mobilize communities and facilitate access to schools and other facilities to access adolescent girls. Leverage on the existing Expanded Programme on Immunization (EPI) infrastructure, the experience in supplementary immunization campaigns and school-based immunization to roll out HPV multi-cohort and routine vaccination. Reinforce communication preparedness and implementation to respond to rumours and vaccine hesitancy and maintain the achievements in the demand. K EY A C TI O N S The public health goal is to reduce HPV infections, because persistent HPV infections can cause cervical cancer (WHO). Introduction of the HPV vaccine, reaching the target age group, capacity of the health system to ensure adequate coverage and adequacy of funding are major concerns for the health system and have major sociocultural implications. Inadequate information about prevention and rumours as well as access to information are also major issues. 5.1.2 Prioritized area: Availability of and access to information and primary prevention services K EY A C TI O N S CHAPTER 3 52 Develop a comprehensive prevention strategy that includes age-appropriate information on SRH, safer sexual practices such as delaying sexual debut, decreasing the number of sexual partners, condom use, male circumcision where appropriate and cessation of tobacco use. Conduct health education in communities and in health facilities during antenatal and postnatal clinics, FP clinics, etc. about cervical cancer, its causes and natural history. • Educate women and girls about prevention and about importance of screening as well as vaccination, signs and symptoms of cervical cancer and encourage women to seek care. • Educate men and boys about cervical cancer, its prevention, prevention from HPV infection, etc. (linked to Strategic Outcome 3). Educating and creating awareness about cervical cancer prevention and treatment is critical for high acceptance of services by the community and for improved compliance with interventions. Though the risk factors for breast cancer are known, minimizing the risks does not eliminate the cancer in most cases, especially in the developing world. Early detection improves breast cancer outcome and survival, and these are the cornerstones of a breast cancer control programme. Population-based screening using effective methods such as mammography to identify individuals with an abnormality suggestive of breast cancer is cost- intensive and is not advised in countries with weak health systems. 5.2.1 Prioritized area: Availability of and access to information on early detection, diagnosis and treatment of breast cancer PRIORITY ACTIONS FOR WHO • Review the implementation of the cervical cancer prevention programme in Member States. • Update the Regional implementation framework for cervical cancer prevention and control based on global strategy on prevention and control of cervical cancer as a public health problem. • Provide sustained, harmonized support and align efforts for technical assistance, advocacy, capacity- building and resource mobilization (financial, technical, human) for cervical cancer control in Member States. • Support Member States for developing/updating national guidelines to strengthen country capacity for training of health-care workers on screening and management of precancerous lesions using the SEA Region training package on prevention. • Support capacity-building on monitoring/ evaluation and strengthening of national information systems for inclusion of data on cervical cancer screening and management. • Sustain advocacy for enhancing political commitment to achieving the Agenda 2030 targets on cervical cancer control in collaboration with countries. • Advocate for reduction of costs of the HPV DNA testing kit. 5.2 BREAST CANCER Breast cancer is the leading cancer among women in both the developed and developing world and is increasing with increase in life expectancy and change in lifestyles. K EY A C TI O N S CHAPTER 3 53 As per WHO recommendations, include breast cancer control within the context of national cancer control programmes and integrate with NCD prevention and control (linked to the SEA Region programme on NCDs). Promote early diagnosis or awareness of early signs and symptoms in symptomatic populations to facilitate diagnosis and early treatment, which appears to be the best strategy (“down-staging”) for low- and middle-income countries where resources are limited and health systems are strong or weak. • Breast self-examination is a good tool for creating awareness among women at risk rather than a screening method. Create public awareness on importance of breast self-examination through various SRH service delivery platforms. K EY A C TI O N S 6. HEALTH SECTOR RESPONSE TO INTIMATE PARTNER VIOLENCE Recognizing that health systems have a crucial role in a multisector response to violence against women, almost all Member States have initiated health sector responses. Intimate partner violence and its implications during pregnancy and after delivery are increasingly being recognized (though not well developed) as a key SRH issue. Since GBV will be addressed in a separate Regional guidance document, this document addresses only its linkages to SRH. Domain objective: Coverage and quality of health sector response to intimate partner violence is strengthened Review the existing guidelines on ANC and PNC, HIV, STI, adolescent health and FP for Identification of victims of intimate partner violence and management related to intimate partner violence. Review the current protocols on health sector management of violence against women and collaborate with concerned divisions to highlight response to intimate partner violence during pregnancy and postpartum period. Use the WHO guidelines on health care for women subjected to intimate partner violence as guidance. Build the capacity of health service providers (SRH) to identify cases of suspected violence and manage them with respect, maintaining privacy and confidentiality and providing highest quality of services. K EY A C TI O N S 6.1 Prioritized area: Availability of integrated services for diagnosis and management of intimate partner violence in health facilities • References to intimate partner violence given in global strategies are given in Annex 10. CHAPTER 3 54 Review current policies and programmes on HIV and STI for integrating Prongs 1 and 2 with FP, maternal health (and other reproductive health services) and modify policies and protocols as needed and institute changes in policy and protocols. Integrate FP services into HIV care and treatment • Actively promote FP counselling and referral services (to FP clinics) in STI and HIV treatment centres as part of case management to help avoid unintended pregnancies and thus contribute to elimination of mother-to-child transmission. Screening for STI and HIV in FP clinics has been discussed under FP services. • Promote the use of condoms (male and female), jointly by FP and HIV/AIDS and STI programmes. Strengthen prevention efforts among women of reproductive age (Prong 1) using opportunities of clinic contacts for their own needs or of their children. Integrate PMTCT strategies through antenatal, intrapartum and postnatal platforms. K EY A C TI O N S 7.1 Prioritized area: Availability of integrated SRH and HIV/STI services at health facilities • References to HIV and syphilis screening during pregnancy, elimination of mother-to-child transmission and key populations, prevention of transmission of HIV and STI among victims of violence against women are given in Annex 10. PRIORITY ACTIONS FOR WHO (SRH) • Sensitize policy-makers of Member States on intimate partner violence and its implications for women and children. • Assist in developing integrated clinical protocols and guidelines to manage GBV. Sexual transmission is the predominant mode of transmission of HIV in the Region; however, linkages between SRH programmes and HIV/AIDS and STI programmes have not been optimal in most Member States, both at the policy and programme implementation levels. The PMTCT programme has better integration with SRH programmes; however, Prongs 1 and 2 of the PMTCT programme are not well integrated as discussed in Chapter 1. Pregnancy and the postpartum period are periods when susceptibility to HIV transmission is high and it is important to ensure that preventive messages are included throughout these periods to respond to the changing sexual behaviours of partners. This point underscores the importance of promoting Prongs 1 and 2 within FP and maternal health services and repeated clinic visits for maternal care and FP services provide opportunities for prevention. The Regional guidelines on STI as well as HIV emphasize integration with SRH services. The focus of HIV and STI in the SRHR framework is limited to integration of HIV and SRH services. 7. HIV/STI RELATED TO SRH Domain objective: Policy linkages and service integration of SRH and national AIDS control and STI programmes strengthened CHAPTER 3 55 1. ADOLESCENT SEXUAL AND REPRODUCTIVE HEALTH (ASRH) SERVICES The main challenges faced by adolescents in accessing reproductive health services are due to legal, social, cultural and health system barriers (health service provider attitudes, privacy and confidentiality). The WHO Regional Office for South-East Asia Strategic Guidance on Accelerating Actions for Adolescent Health in South-East Asia 2018–2022 [56] has articulated actions for Member States to achieve adolescent health-related SDG indicators. Within the context of the existing strategy, particularly health service delivery models, the strategy will focus on SRH services for adolescents. In most Member States, ASRH services are delivered at hospitals at the district level or above, while some have implemented ASRH services at the primary health-care level and in school settings. 1.1 Prioritized area: Availability of quality, acceptable, full complement of ASRH services in the public and private sectors PRIORITY ACTIONS FOR WHO • Provide evidence-based advocacy and technical support for integration of HIV and SRH services (listed under actions for WHO and UNAIDS support in the Regional strategy on HIV). Domain objective: Coverage and availability of quality and acceptable comprehensive ASRH services accelerated Review the current laws and policies related to the provision of contraception to unmarried (linked to the section on FP) adolescents. Promote evidence-based advocacy for stringent implementation and monitoring of the legal age at marriage. Review and revise the current package of SRH services available to adolescents based on current evidence [57]. • Review and update the standards and job aids on ASRH services and include a preconception package, as feasible. • Strengthen adolescent-specific elements in the ANC, intrapartum care and PNC packages focusing on providing information to adolescent couples, as well as to family members and community members to enlist their support. • Review and update the section on the provision of FP methods based on the updated MEC. Develop strategies to focus on young married couples for delaying first pregnancy. K EY A C TI O N S • SPECIFIC POPULATION GROUPS WITH LIMITED ACCESS TO SRH SERVICES CHAPTER 3 56 2.1 Prioritized area: Integration of SRH services into health system policies and services for healthy ageing by adopting a life course approach Conduct research on the SRH needs of the elderly, especially women and incorporate findings into the current policies for the elderly. Develop national guidelines on care of menopausal women. Expand the scope of SRH services to include services for the ageing population at all levels of care by addressing SRHR issues in policies and essential service packages, making available services at the primary level and building the capacity of the health system. K EY A C TI O N S Develop innovative ways to deliver SRH services for adolescents such as social franchising, social marketing, social media and internet-based approaches, etc. (linked to service delivery, Strategic Outcome 2). Advocate to community informal leaders about the importance of SRH services for adolescents (linked to Strategic Outcome 3). Strengthen the monitoring and evaluation mechanism for ASRH, including assessment of coverage and quality of services. K EY A C TI O N S Domain objective: SRH services for the ageing population developed as a continuum of care across the life course PRIORITY ACTIONS FOR WHO • Provide technical assistance to develop an evidence-based intervention package for menopause care. • Support research on SRH issues of the ageing population. • Advocate for inclusion of SRH issues in policies, strategies and programmes on ageing. PRIORITY ACTIONS FOR WHO • Provide technical assistance in developing/updating package and service delivery models of SRH services for adolescents. 2. SRH SERVICES FOR THE AGEING POPULATION Ageing is recognized as one of the emerging needs of the Region. The SRH needs of the ageing population are not recognized in most national policies and programmes. The main challenges are paucity of data on the SRH needs of the ageing population and their exclusion from population-based demographic and health service surveys. This neglect has led to the exclusion of SRH issues in policies on ageing. CHAPTER 3 57 Assess the situation with regard to the SRH needs of differently abled persons in policies and services and their access to services. Raise awareness about the SRH needs of differently abled people and their vulnerabilities, especially abuse and unwanted pregnancies and access to services. Develop laws and policies to support improved access to SRH services and incorporate the same in national SRHR strategies, as well as strategies in care for differently abled persons. K EY A C TI O N S 3.1 Prioritized area: Availability of SRH services for differently abled persons Domain objective: SRH services for differently abled persons developed and expanded Domain objective: The Minimum Initial Service Package (MISP) and comprehensive SRH services are available in the appropriate phases of disaster PRIORITY ACTIONS FOR WHO • Support the development of guidelines and protocols for services for the differently abled. 4.1 Prioritized area: Capacity of the health sector to make available quality SRH services for all phases of disaster Review and revise the current health sector preparedness and response plan for inclusion of SRH package, especially the MISP [58]. Review the capacity-building plan for disaster preparedness ensuring competence in implementation of the MISP immediately after disaster and SRH services in recovery. Strengthen SRH programme implementation based on lessons learned in COVID-19 pandemic in maintaining of essential services, including SRH. K EY A C TI O N S 3. SRH SERVICES FOR DIFFERENTLY ABLED PERSONS 4. SRH SERVICES IN HUMANITARIAN CRISIS The main challenge is that the SRH needs of the differently abled are largely unrecognized in policies and programmes related to SRH in Member States. The main challenge is the implementation of SRH services in the acute phase of a humanitarian crisis when the maximum maternal and neonatal mortality takes place. CHAPTER 3 58 5.2 Prioritized area: Equitable access to SRH services for remote and difficult-to- access populations Assess current policies/strategies and access of remote and difficult-to-access populations to SRH services. Develop innovative models to deliver services to remote and difficult-to-access populations, including the use of digital technologies (e.g. telemedicine). K EY A C TI O N S Assess current policies/strategies and access of migrant/slum population to SRH services. Assess availability of disaggregated data for the urban slum population. Facilitate the designing service delivery models for the urban slum population in coordination with municipalities, etc. (linked to prioritized area “Strengthen monitoring of UHC”).K EY A C TI O N S 5.1 Prioritized area: Equitable access to SRH services for the urban slum population PRIORITY ACTIONS FOR WHO • WHO, as the lead health cluster agency among the UN agencies, to ensure inclusion of the SRH package including adequate budgetary provisions for disaster preparedness and response plans of countries and coordinates of capacity building on the MISP. PRIORITY ACTIONS FOR WHO Support countries to incorporate SRH services as part of the health sector initiatives under WHO’s urban health- care initiatives. Identify best practices for delivery of services to remote and difficult-to-access populations from Member States or other regions. Domain objective: Accessibility of urban migrants, remote and difficult-to-access populations to SRH services improved 5. SRH SERVICES FOR URBAN SLUM, DIFFICULT-TO-ACCESS AND REMOTE POPULATIONS The main challenge for the urban slum population is access to services, due to financial barriers, access to health insurance, opening hours of the health facilities, and health-seeking behaviour, etc. Geographical access is the main issue with remote and difficult-to-access populations. To achieve UHC, it is critical to reduce inequity. CHAPTER 3 59 Domain objective: Stewardship improved for efficient, effective and equitable delivery of SRH services and leadership/ governance (stewardship) functions cut across all the other health system domains 1. LEADERSHIP/GOVERNANCE (STEWARDSHIP) 3.4.2 STRATEGIC OUTCOME 2 Strengthened and accountable health systems enable efficient and equitable coverage of SRH interventions The Regional SRHR Strategic Framework recognizes that a functioning health system is important for the efficient and equitable delivery of health services. The coverage of essential SRH interventions is directly linked to the functioning of the health system. While relevant components of health systems related to specific services have been covered under Strategic Outcome 1, generic health system strategies relevant to SRH are covered under this outcome. Each element of the health system is critical for achieving UHC of SRHR and to ensure that all people receive the health services they need, of sufficient quality, without experiencing financial hardship. Therefore, having a sufficient number of health workers, essential supplies and financial protection is a prerequisite to achieve UHC. Sound health policies and health financing strategies are essential to ensure that no one is impoverished as a result of the costs of health care. 1.1 Prioritized area: Enhanced capability at the national and subnational levels to effectively carry out the functions of stewardship of SRH services Strengthen the capability of reproductive health managers. • Oversee and guide the overall provision of SRH service provided by both the public and private sectors and NGOs, ensuring equity, quality, compliance with standards and rights-based approaches. • In decentralized settings, build capacity of managers at subnational levels to: • oversee and guide the provision of SRH services based on national guidance, and • strengthen the SRH coordination mechanism. Establish or strengthen the Technical Advisory Groups ( TAG) on SRH for improving the technical guidance for SRH programmes with clear terms of reference. • Review gaps in laws and policies that are creating barriers in accessing services and advocate for changes to enable access to services [11]. Establish/strengthen the SRH coordination mechanism with relevant stakeholders such as the government, development partners (H6 partnership), donors and international NGOs/NGOs operating in the country to facilitate unified implementation of the plan for efficient use of resources. Incorporate and strengthen the SRH component in national health quality assurance initiatives at the national and subnational levels. K EY A C TI O N S CHAPTER 3 60 1.2 Prioritized area: Strengthened capacity for full spectrum of research and innovations to overcome barriers to accessing care 1.3 Prioritized area: Strengthened capacity for programme planning and management of SRH programmes Build in-country capacity for implementation research on topics identified under specific service domains on maternal and perinatal health, cervical cancer (Strategic Outcome 1). Undertake research on health system bottlenecks in implementing interventions identified in the strategy, e.g. integration of services, implementation of services at the district level such as community- based postpartum care. In situations where there is difficulty in scaling up programmes, conduct operations research on specific topics in clearly defined settings and contexts (e.g. institutional delivery). Build capacity for strategic planning and developing implementation plans (planning, managing and reviewing) based on RMNCAH programme management modules of the WHO Regional Office for South-East Asia. Conduct regular programme reviews to assess how effectively the implementation plans have been implemented. Perform oversight functions by monitoring trends in mortality, ARR and evidence-based intervention coverages. K EY A C TI O N S K EY A C TI O N S PRIORITY ACTIONS FOR WHO • Assist Member States in developing policies that are rights-based, result-oriented and equitable. • Support countries to build capacity for various forms of implementation research to meet country needs through effective health interventions, tools and delivery mechanisms through WHO Collaborating Centres. CHAPTER 3 61 The health workforce challenges related to availability, distribution and quality have been discussed in Chapter 1. The health workforce challenges have major implications for scaling up interventions and services and achieving SRHR goals. Task shifting and sharing is being promoted in many countries to help overcome the shortages. Not all the countries in the Region have midwifery cadres, and in such countries, nurses trained in midwifery perform midwifery functions; however, in recent years many Member States have initiated the process of establishing a separate cadre for midwifery. By definition, midwives should be allowed to conduct normal delivery and perform emergency functions [59]; however, not all midwives are allowed to conduct normal deliveries or perform emergency care. Data on SBAs (see definition) is also misleading as those counted do not meet the competencies identified in the definition. Strengthening quality midwifery education and training is recognized as critical in order to have competent midwifery cadres. Regional Strategic Directions for strengthening midwifery in the SEA Region 2020–2024 have been designed to guide Member States and partners to assess, develop and strengthen midwifery education and services in a systematic manner [60]. Skilled health personnel can perform various SRH functions as their training includes topics beyond midwifery [61]. A high degree of competency in life-saving tasks during pregnancy, delivery and postnatal period is critical for reducing maternal and neonatal mortality and stillbirths. 2.1 Prioritized area: Availability of skilled health personnel, educated, trained and regulated and equitably deployed 2. HUMAN RESOURCES FOR HEALTH Domain objective: Health professionals (SRH) educated, trained and regulated and skilled health personnel are available in adequate numbers and equitably deployed Skilled health personnel, as referenced by SDG indicator 3.1.2, are competent maternal and newborn health professionals who are educated, trained and regulated to national and international standards. They are competent to: (i) provide and promote evidence-based, human rights-based, quality, socioculturally sensitive and dignified care to women and newborns; (ii) facilitate physiological processes during labour and delivery to ensure a clean and positive childbirth experience; and (iii) identify and manage or refer women and/or newborns with complications (WHO). CHAPTER 3 62 Map the availability of skilled health personnel (SRH). • Support in developing a National Health Workforce Account (NHWA) to identify the types and availability of practitioners in RMNCAH area (specialist, nursing personnel, midwifery personnel and frontline health workers, their current functions, workload). The midwifery workforce is regulated through regulatory bodies/authorities that take responsibility for developing/maintaining quality midwifery services to respond to the needs of population health. Review the current regulations in nursing and midwifery to assess whether the regulations are enabling the provision of life-saving tasks and advocate to nursing/midwifery councils to change the regulations to enable midwifery trained personnel to perform signal functions. A robust midwifery education and training programme produces an adequate number of qualified midwives who are equipped with ICM (International Confederation of Midwives) essential competencies for midwifery practice. • Improve the quality of midwifery education following the framework for action [62]. • Develop a strategy to regularly update the midwifery competencies, especially recognition and management of complications. • Initiate competency assessment for midwifery educators and providers. • Consider expanding the training to include screening for cervical cancer, FP, infertility, abortion, intimate partner violence, ASRH, reproductive health care of the ageing population and the provision of reproductive health services during humanitarian crisis. Develop a plan for recruitment and deployment of those with midwifery skills to ensure distribution, especially in rural and remote areas based on needs, to meet the minimum requirements and monitor the same (link to Human Resources Master Plan). Review the existing system of supervision (supervisors, process and frequency) and supervisory tools. • Strengthen supportive supervision. The strategy identifies training as a key component under prioritized interventions and emphasizes that an integrated strategy should be developed for all services. 2.2 Prioritized area: Capacity building in SRH through integrated, competency-based training on SRHR to maintain competencies Review and implement the current pre-service training and continued professional development of doctors, nurses and midwives in SRH. Review the training curricula and update the content based on current evidence-based recommendations. Review and implement the current in-service training of doctors, nurses and midwives on various topics related to SRH in collaboration with training institutions and professional associations using the core task list as the standard. Train supportive staff/sub-specialites for transfusion medicine, obstetric medicine, etc. depending on the level of development of the health system (see Table 8). K EY A C TI O N S K EY A C TI O N S CHAPTER 3 63 Task shifting for optimizing the potential of the existing health workforce is considered crucial to overcome some human resource shortages to improve access and cost–effectiveness (as a short-term measure). Such considerations are critical for achieving UHC. Task shifting is the process whereby specific tasks are moved, where appropriate, to health workers with shorter training and fewer qualifications [63]. Where further additional human resources are needed, task shifting may involve the delegation of some clearly delineated tasks to newly created cadres of health workers who receive specific, competency-based training. Shortages of specialists in obstetrics/gynaecology and anaesthesia were referred to in Chapter 1. Training of non-specialist doctors to provide CEmONC and obstetric anaesthesia have been successfully attempted in some Member States. This is a temporary strategy till vacancies are filled. 2.3 Prioritized area: Optimizing the role of health workforce through task shifting for SRH services Determine which key interventions can be safely and effectively delivered by different cadres, based on the WHO recommendations for optimizing health worker roles to improve access to key maternal and newborn health interventions through task shifting [64]. • Build a consensus on the same with regulatory bodies and professional associations as well as community organizations, where possible. Develop a clear scope of practice for the cadres being considered for task shifting and the health system level where they will be posted. Provide competency-based training in the new tasks. Institute supportive supervision, monitoring the safety, quality and coverage of services. K EY A C TI O N S PRIORITY ACTIONS FOR WHO • Include the SRHR component in national HRH strategies, taking into consideration the skill mix, addressing education, recruitment, retention and performance, and define regulatory options, focusing on the production and distribution of skilled health professionals. • Consider developing a package for EmONC training, taking into consideration the previous efforts in the Region, in collaboration with the WHO Collaborating Centres. • Advocate and provide technical assistance for enabling countries to do task shifting in SRHR, where appropriate, based on the WHO recommendations. • In consultation with the human resources division, assist countries to develop a strategy for SRH health workforce development, taking into consideration the skill mix, and addressing education, recruitment, retention and performance. Define regulatory options, focusing on the production and distribution of skilled health professionals. 3. HEALTH-CARE SERVICE DELIVERY A range of different platforms are available to provide SRH services: public and private facilities, schools, mobile clinics, pharmacies, e-health and outreach strategies. Within each platform, the focus, content and organization of the services can vary. These platforms reflect the rich experiments over the years with various models of care to develop health services. CHAPTER 3 64 The prerequisites for initiating midwife-led continuity-of-care include a well-functioning midwife programme with adequate numbers and quality midwifery services. References to midwife-led continuity-of-care are given in Annexes 6 and 7 in the recommendations for ANC and intrapartum care. 3.1 Prioritized area: Developing midwife-led continuity-of-care during pregnancy, childbirth and postnatal period Midwife-led continuity-of-care models, in which a known midwife or small group of known midwives support a woman throughout the antenatal, intrapartum and postnatal continuum, are recommended in settings with well-functioning midwifery programmes (WHO). There is evidence that the model is cost- effective, of good quality and improves coverage by skilled health personnel, thus contributing to reduction in maternal and perinatal deaths and morbidity. In countries where midwives or nurses with midwifery skills are available in sufficient numbers, equitably distributed between rural and urban areas and meet the competency standards of ICM, establish midwife-led continuity-of-care units, as appropriate. Conduct implementation research on the feasibility of the model.K EY A C TI O N S Identify services that can be easily integrated along the continuum of care and develop policies and guidelines to enable integration at all levels of care. Build the capacity of the providers to deliver integrated services, including extension of services to the community.K EY A C TI O N S Integrated care is the management of delivery of health services so that clients receive a continuum of preventive and curative services, according to their needs over time and across different levels of the health system (WHO 2016) [65]. Integrated care facilitates efficient delivery of services as it uses different entry points and reduces structural silos to deliver comprehensive care for clients with multiple needs (as discussed above under FP and HIV/STI). It also improves the utilization of already scarce resources and client satisfaction. 3.2 Prioritized area: Strengthened integrated care across the life course Specific models of care, such as birthing centres, maternity waiting homes and community-based care, have been discussed under specific domains. The following models have a significant role to play in increasing the coverage of SRH services. Telemedicine and the use of other forms of digital medicine are relevant to provide care to difficult-to-access populations. The health service delivery models developed by Member States have been shared and modified to suit local situations. Some major challenges are to ensure equitable access, quality, coverage and continuity of care across the health system. When the coverage of essential interventions is low, in most cases, the reason is lack of effective service delivery models and platforms to reach the target groups. Domain objective: Health service delivery models strengthened/ developed, which integrate across services and locations for delivery of SRH services across the life course to improve equitable access, coverage and quality CHAPTER 3 65 Review and revise the current policies governing the private health sector in relation to the provision of high-quality SRH services. Harness the private sector to deliver quality SRH services at affordable costs for improving access to services such as maternal health, FP, abortion, infertility, etc. • Develop of sustainable business models of public–private partnership through a network of franchised private health institutions and providers. • Ensure social marketing of commodities. Develop systems for quality assurance of services in the private sector and also for cost containment to enable the poor to utilize the services. K EY A C TI O N S 3.3 Prioritized area: Enhanced involvement of the private sector in delivery of SRH services CBHS are considered a sub system of the overall health system, part of the continuum of care between health facilities and communities, and are recognized as a critical element of UHC. CBHS can help reach services to remote and difficult-to-access areas, where in general mortality and morbidity are high and accessibility is low. All Member States of the SEA Region have long years of experience in providing CBHS of varying quality and effectiveness and scope. CBHWs may or may not be volunteers and formally trained health professionals who focus on community work (nurses, public health midwives, public health inspectors, doctors, ASHA workers, etc.) and services may be run by public or nongovernmental agencies. 3.4 Prioritized area: Community-based health services (CBHS) for equitable coverage of SRH services Develop strategies to reflect the role of CBHS in policies and guidelines, including the type of provider and his/her employment status in relation to the health system. Develop a package of services for community SRH services, such as community-based PNC, FP, infant feeding, and newborn care. • Determine the task of promotive, preventive and curative care services, referral pathways, supplies and equipment and reporting channels. Build the capacity of CBHWs through initial training and continued training. Build capacity for supportive supervision to ensure the quality of services. K EY A C TI O N S PRIORITY ACTIONS FOR WHO • Assist countries to conduct reviews/assessments of current service delivery platforms in SRH care, with a focus on maternal and perinatal care and FP, to identify the capacity of the existing platforms to deliver high-quality services with optimal coverage and, based on the assessment, help countries to choose the best options. • Assist countries with implementation research on newly proposed models. • Assist countries with policy dialogue or technical assistance in planning CBHS and their evaluation. • Assist countries to assess and strengthen the frontline service delivery models on SRHR to achieve high coverage. CHAPTER 3 66 Monitoring of maternal health services across the continuum of pregnancy and childbirth care, continuation of contraceptives, and surveillance of maternal and perinatal deaths have been included under specific domains of Strategic Outcome 1. The interventions focusing on all information systems in relation to SRH services are given below. 4.1 Prioritized area: Improved and standardized household and facility-based SRH information systems Identify the core SRH indicators based on global and regional monitoring frameworks [66]. • Review and revise the HMIS, related to SRH services, to include all the necessary information. Based on the indicators developed for monitoring SRH services (see under stewardship), institute mechanisms to monitor SRH, especially with regard to coverage, equity in access, and quality. Strengthen disaggregation of data to identify pockets of inequity such as slum populations and remote and difficult-to-access populations. Combine the data generated from MDSR and perinatal surveillance with facility-based reports (strengthening of MDSR and perinatal death surveillance is covered under the domain on maternal and perinatal health). Build the capacity of (i) health service providers in collecting accurate and complete data; (ii) statistical experts to monitor the quality of the data, synthesize the information and promote its availability; and (iii) managers in applying the data to track progress. Promote the use of data in decision-making through programme planning and review (linked to the section on stewardship). Promote the use of home-based cards in SRH, as per the WHO recommendations [68]. Coordinate with the Department of CRVS to strengthen the coverage and quality of data on births, maternal deaths and perinatal deaths, and triangulate databases • Advocate for the inclusion of the pregnancy box in the death declaration form in consultation with the Department of CRVS. K EY A C TI O N S 4. HEALTH INFORMATION The information systems related to SRH are scattered and not connected through a common platform. The quality (accuracy and completeness) of information collected through HMIS at health facilities and their reporting a major concern. Domain objective: SRH information systems standardized, improved and integrated with DHIS-2 platforms, other relevant health information platforms and population-based platforms, such as census, household surveys and civil registration CHAPTER 3 67 Progressing towards UHC and improved access to SRH services require shifting the burden of financing away from individuals, especially women and girls, towards increased domestic public funding. Improvements in the use of the existing public resources for service delivery are important for efficiency, quality and equity gains, even where the context constrains funding for SRH services. Improved measurement and tracking of the resource flows for SRH services and products are needed for monitoring financial contributions from governments, donors, insurance companies and households. Responding to the catastrophic health spending, especially during pregnancy and childbirth, the Member States have made efforts to provide financial protection for maternal health. Such efforts have contributed to increased utilization of services. SRH services beyond maternal health and FP are not explicitly recognized in health benefit packages in many countries, leading to inequitable access to other critical SRH services, such as ASRH, CAC, infertility, reproductive tract cancers and reproductive health needs of victims of violence, and reproductive health needs of population groups such as ageing populations. In general, the information related to expenditures on SRH is limited even in countries where national health accounts analysis has been carried out. 5.1 Prioritized area: Adequate financing for SRH services and full coverage of SRH services under financial risk protection schemes Advocate with ministries of health to allocate more financial resources for RMNCAH services. Review the Member States current benefit packages under financial protection schemes related to maternal health and general medical insurance, and assess whether it has made a difference to OOP payments and catastrophic spending. Pay special attention to the coverage of slum populations and, remote and difficult-to-access populations. Conduct reproductive health sub account analysis as part of national health accounts. K EY A C TI O N S 5. HEALTH FINANCING Domain objective: Assured and sustained health protection for SRH services for all to reduce catastrophic health spending PRIORITY ACTIONS FOR WHO • Build country capacity to assess the accuracy of the data, synthesize information from various sources and apply the data. • Develop a Regional monitoring framework for SRH. PRIORITY ACTIONS FOR WHO • Assist countries to review their national health accounts and reproductive health sub health accounts (latter where it has been done) and/or strengthen capacity for reproductive health sub health account analysis. • Assist countries with analysis of the financial risk protection packages. CHAPTER 3 68 6.1 Prioritized area: Ensure availability of high-quality essential reproductive health commodities Review and revise the national list of essential drugs and devices, and diagnostics based on the list of global life-saving commodities for women and children [65]. Assess the current logistic systems that include regulations related to the procurement of products that meet WHO standards, their storage and distribution and Logistics Management Information Systems (LMIS). Pay special attention to the areas of commitment made in the Delhi Declaration on improving access to essential medical products in the SEA Region and beyond. Work in collaboration with regulatory authorities to strengthen regulatory mechanisms to assure the quality of SRH commodities. K EY A C TI O N S Progress towards SDG 3 depends to a large extent on access to quality medicines and health products for maternal and child health. The United Nations Commission on Life-Saving Commodities for Women and Children, 2012 had made 10 recommendations to increase the availability of and access to 13 low- cost, high-impact life-saving commodities. However, access in many low- and middle-income countries is hampered by systemic issues, such as lack of supportive policies and regulations, insufficient financing and skilled human resources, and weak supply chains. The quality of products, especially those that do not meet WHO’s prequalification criteria, is a major concern. Improving access to essential medicines has been a focus of the Region’s Flagship Priority on UHC, which was launched in 2014. Some key actions from the global recommendations given in the GSWCAH [4] are listed below. 6. MEDICAL PRODUCTS, VACCINES AND TECHNOLOGIES Domain objective: Quality reproductive health commodities available at all times, at all levels, with no stock-outs PRIORITY ACTIONS FOR WHO • Assist Member States to promote quality standards for commodities and supplies through assessment of indigenous products. • Assist countries to design health-related laws, regulations and standards, especially in the areas of regulations of medical products and technologies. Help in monitoring their implementation. CHAPTER 3 69 Individual and community capacity maximized for reproductive well-being and seeking care when needed 1. CAPACITY BUILDING OF INDIVIDUALS AND COMMUNITIES 2. MALE INVOLVEMENT Domain objective: Knowledge of individual women and adolescent girls on SRHR improved and capacities enhanced to improve reproductive health and seeking care Domain objective: Knowledge and support of men enhanced to improve SRHR of their partners and themselves The focus is on women and adolescent girls. The health impact of efficacious clinical and health system interventions must be maximized, while simultaneously addressing inequity and the needs of underserved groups trough strengthening the capabilities of individuals, families and communities to contribute to improved health. In 1986, the Ottawa Charter put forward the concept of creating an enabling environment where all people have access to information, life skills and opportunities for making healthy choices by empowering individuals, families and communities to optimize their health. Recently, this was reiterated in the global initiative on advancing primary health care with the new Declaration of Astana [68]. Develop communication strategies to share information on SRH, including self-care, using the WHO recommendations on self-care in SRH [69]. Raise awareness through information shared via various channels – home visits, in schools, in colleges, at workplaces, at health facilities and through social networks and digital technology about SRH issues, prevention, self-care and actions to be taken. Initiate different target-specific educational methods share information such as group education for ANC, youth camps, and educational sessions for pre-pregnant and pre-marital couples. Leverage digital technology to reach information to women and girls. K EY A C TI O N S 1.1 Prioritized area: Improving health literacy of individual women and adolescent girls on SRHR and skills in self-care Men play a critical role in the reproductive health- seeking behaviour of women. There are different models and rationales for involving men, including a view that considers men as gatekeepers and decision-makers for prompt access to maternal and newborn health services, both at the household and community levels; men as responsible partners of women and as an important subpopulation within the community; the need to address men’s own SRH needs; and men’s preference to be involved as fathers/partners [70]. 3.4.3 STRATEGIC OUTCOME 3 CHAPTER 3 70 Male involvement is listed below under various service domains. Review the SRH programmes and identify the gaps in and possible opportunities for male involvement. Develop and test innovative service delivery approaches for male involvement in SRH. Educate men through various channels on broadening their understanding of reproductive health issues among women and men. In addition to the importance of care and support to women during childbearing, postpartum care responsibilities in FP, prevention of HIV and STI, include the implications of intimate partner violence during pregnancy. Strengthen the capacity of providers to work with men to support them in their roles through educational sessions or clinics at convenient hours to enable men to participate in or accompany their wives to joint counselling. Review and identify SRH issues/areas that need community involvement, such as low coverage of ANC and high numbers of home deliveries with unskilled health workers. Enhance the capacity of CBHWs to educate community leaders, religious leaders and other gatekeepers, such as traditional birth attendants, on SRHR issues and the linkages between SRHR issues and development (linked to CBHS). Mobilize community support for changing laws, removing barriers especially with regard to adolescents, registration of births, maternal and neonatal deaths, community transport, reporting abortions, etc. K EY A C TI O N S K EY A C TI O N S 2.1 Prioritized area: Enhancing male involvement in SRHR 3.1 Prioritized area: Mobilization of communities for SRHR 3. MOBILIZING COMMUNITIES Domain objective: Communities mobilized for improved SRHR of women, men and adolescents in their communities PRIORITY ACTIONS FOR WHO • Develop and disseminate information on the impact of building capacity of individuals and communities for the prevention, promotion and treatment of SRH. • Assist Member States to promote self-care in reproductive health. • Assist Member States to review the related to SRH programmes to identify the needs of community participation, male involvement, etc. CHAPTER 3 71 The strategy under this outcome cuts across all core service and priority group domains as well as health system domains, using the best programmatic examples on the reduction of maternal mortality, health system design, innovations, etc. Document best practices and innovations in Member States, which lend themselves to South–South collaboration. Potential areas include MDSR, primary and secondary prevention of cervical cancer, midwifery, CBHWs, health insurance and institutional deliveries. Identify regional and inter-regional needs for capacity-building. Develop policies and strategies to enhance South–South collaboration based on best practices and Regional and inter-regional needs. Strengthen existing collaboration with the SAARC countries and expand its scope to include other areas. Strengthen collaboration with existing collaborative networks, such as BRICS (Brazil, Russia, India, China and South Africa) and BIMSTEC (Bay of Bengal Initiative for Multi-Sectoral Technical and Economic Cooperation; members include Bangladesh, Bhutan, India, Myanmar, Nepal, Sri Lanka and Thailand). Strengthen the existing H6 collaboration with United Nations partners to improve collaboration in SRH. K EY A C TI O N S 1.1 Prioritized area: Strategies developed to harness best practices and innovations for fostering collaboration between countries and with Regional entities and other agencies 1. HARNESSING KNOWLEDGE AND EXPERIENCE FOR FOSTERING COLLABORATION BETWEEN COUNTRIES AND WITH REGIONAL ENTITIES Domain objective: WHO Regional Office for South-East Asia’s contribution to improving the reproductive health of the populations of Member States strengthened through development of policies and strategies for South–South cooperation Collaboration between countries and with Regional entities fostered for accelerating progress towards universal access to SRH 3.4.4 STRATEGIC OUTCOME 4 72 CHAPTER 4 Implementation of the Regional Strategic Framework for SRHR 4.1 Country Leadership Country leadership includes stewarding and coordinating effective implementation across sectors and subnational platforms, which should contribute to improved access, equity, coverage of interventions and quality. Most Member States have a functioning national TAG on SRHR, which will be the ideal forum to work on the strategy development/adaptation. If a TAG is not available, it should be created or an existing mechanism should be used, which consists of representatives of the SRH division of the Ministry of Health, professional associations of obstetrics and gynaecology, paediatrics, neonatology, forums for general practitioners, nursing and midwifery associations, private health sector associations, NGOs, development partners, etc. Depending on the country structure, the national programme manager should take the lead in strategy development with key stakeholders. Some countries will use other forums or steering groups. This was strongly recommended by the WHO Regional Office for South-East Asia’s TAG on women and children. In countries where the H6 partnership exists, the forum can work with the TAG to develop/adapt the national SRHR strategy. For Member States, the regional strategic document is a generic document with proposed strategies and major activities for the reduction of mortality and morbidity, and meeting the SRH needs. The selection of country strategies and activities should be based on evidence on the current status of reproductive health, level of MMR and stage of obstetric transition (see Tables 9 and 10), level of SBR, level of mCPR and stage in the S-curve (see Figure 6), category of health system (see Table 8), etc. 10 WHO SEARO. Draft training modules on “Managing programmes to accelerate reduction in maternal, newborn and child mortality, 2019” – Modules1, 2 and 3 CHAPTER 4 73 Country leadership is the key to the implementation of the Regional Strategic Framework for SRHR or adding its elements to the existing national SRH strategies and plans. It is the driver for the key outcomes related to health systems, especially financing and community engagement, and is also critical for changing policies and laws to enable the implementation of the strategy. To further strengthen country leadership, it is important to work with stakeholders in other sectors of the government and beyond the government, such as development partners, civil society organizations, networks of adolescents, professional associations, the private sector, and research and training institutes. The steps for developing a national strategic or implementation plan are highlighted in Figure 17.10 Effective implementation of the strategy also requires strengthening of the planning capacity for SRHR programmes, particularly at the decentralized level. Strong programme management at the national and subnational levels is a key determinant of progress towards universal access to SRHR, reduction in maternal mortality and stillbirths, and achievement of SDG targets. Recognizing the gap in programme management, the WHO Regional Office 4.2 Adaptation/implementation of the Regional Strategic Framework for SRHR Figure 17: Programme planning and management cycle Planning implementation (every 1-2 years) Reviewing of implementation status (every 1-2 years) Use regional strategic guidance in developing NSP · Prepare for planning · Review implementation status · Decide on programme activities · Plan monitoring of implementation of activities · Plan for the next review of implementation status · Write a workplan and budget Managing implementation (ongoing) Strategic planning cycle Evaluate programme · Advocate · Mobilize resources · Manage human, material and financial resources · Manage supervision · Monitor progress and use results Develop a strategic plan (every 5-10 years) · Prepare for planning · Do situation analysis · Prioritize and pacakage interventions · Decide how to deliver interventions (major strategies) · Select indicators and set targets for evaluation · Write and disseminate plan (example: short programme review) Include coverage and health impact, e.g. using DHS, external review, household surveys (every 5-10 years) usually performed at the national level I M P L E M E N T A T I O N C Y C L E Source: WHO Regional Office for South-East Asia draft training modules on managing programmes, 2019 (reference 50) CHAPTER 4 74 for South-East Asia had recently developed a regional training programme for building capacity for programme management at the national and subnational levels in Member States. Figure 17 shows a programme planning and management cycle and illustrates the steps in the strategic planning and implementation cycle for accelerating progress. The strategic plan, usually developed at the national level, sets goals (impact) and coverage targets, specifies evidence-based interventions and strategies for their implementation, includes impact and coverage indicators, and provides guidance on financing and supporting the health system. The strategic plan provides the framework for the implementation plan. When a country develops its strategic plan, it is recommended to use the Regional Strategic Framework as a model to identify strategies and major activities. The implementation plan, usually developed at the subnational level, reflects what interventions selected in the strategic plan will be delivered at which level of health care and the related activities to achieve a high coverage of the interventions, activity-related input and output targets, and activity-related indicators and resources. It also identifies the programme activities for the implementation of the interventions, as identified in Figure 17. The Regional Strategic Framework can also be used to develop the implementation plan at the subnational level. RECOMMEND THE FOLLOWING STEPS FOR IMPLEMENTATION OF THE REGIONAL SRHR FRAMEWORK In order to achieve universal access to SRHR within the framework of UHC and accelerating progress towards reducing maternal mortality and perinatal mortality, eliminating cervical cancer as a public health problem, reducing morbidity and mortality due to abortion and reducing adolescent pregnancy and deaths during pregnancy, it is important to scale up the population-based coverage of evidence-based interventions. It is important for each country to identify gaps in implementation and set the priorities. The Regional Strategic Plan can be adopted by countries as follows: • In countries with an ongoing national SRH or RMNCAH strategy. • And which are at the end of the strategic cycle, a new strategic plan should be developed, by adapting the Regional Strategic Framework for SRHR, as relevant. Before developing the new strategic plan, a programme evaluation/review of the previous plan should be done (refer to Figure17). • In countries where the strategic cycle of SRH or RMNCAH strategy has not ended, countries should enter the planning cycle by doing a mid-term review of the implementation status of the strategy. • In countries where there is no national SRH strategy, quick reviews should be done of the strategies and programmes related to maternal health, FP, cervical cancer, ASRH, etc. The Regional Strategic Framework should be adapted taking into consideration the findings of the reviews. Where there are gaps or missing elements, those should be added from the strategic framework. • Some countries may not develop strategic plans but develop implementation plans at the subnational level. Develop an implementation plan for 1–2 years, which includes strategies for effective implementation of interventions, programme activities and resources. The interventions should be prioritized according to the status of SDG indictors related to SRH (refer to the Regional Office for South-East Asia programme management modules to accelerate reduction in maternal, newborn and child mortality). CHAPTER 4 75 4.3 Example of prioritization of strategies to develop a national SRHR framework in countries with high MMR and SBR Reducing maternal mortality and stillbirths is one of the Flagship Priorities for the Region; hence, the recommendations for implementation have a major focus on maternal and perinatal health. Table 11 gives a summary of maternal and reproductive health indicators (status and coverage) and categorization of countries according to their obstetric transition stage and health system development (Tables 12 and 8) and the mCPR stage on the S-curve provides guidance to countries to select interventions. As shown in Table 11, seven countries have MMR above 140 /100 000 live births, SBR above 10 per 1000 births and are in obstetric transition stage III, and three of the seven countries are in health system category 1. Ta bl e 11 : Su m m ar y of m at er na l a nd r ep ro du ct iv e he al th ( M R H ) si tu at io n in t he S EA R eg io n, 2 01 9 C ou nt ri es in w hi ch a cc el er at io n of A R R is n ee de d ur ge nt ly to a ch ie ve m or ta lit y ta rg et s; h ig h A B R (> 50 ) ; co ve ra ge o f re sp ec tiv e in te rv en tio n is < 50 % o f t he ta rg et p op ul at io n; C S is > 15 % o r < 5 % M od er at e to h ig h M M R > 14 0/ 10 0 00 0 liv e bi rt hs a nd S B R > 12 p er 1 00 0 to ta l b ir th s A B R is 1 0 - 50 pe r (1 5 - 19 ) 10 00 P n C ov er ag e of in te rv en tio ns be tw ee n 50 % - 8 0% (n ee d ac ce le ra tio n) C ou nt ri es w ill a ch ie ve SD G ta rg et if th ey m ai nt ai n th e cu rr en t A R R ; c ov er ag e of in te rv en tio ns is > 80 % , ad ol es ce nt A B R is < 10 ; D SF P > 66 % (G PW 1 3 ta rg et ) Lo w m or ta lit y co un tr ie s M M R < 14 0/ 10 00 00 li ve b ir th s; SB R c ou nt ry ta rg et a ch ie ve d A B R : ad ol es ce nt b irt h ra te ; A N C : an te na ta l c ar e; P N C : po st na ta l c ar e; H S: h ea lth s ys te m So ut h- Ea st A si a R eg io n M em be r St at es M at er na l m or ta lit y 10 0 00 0 liv e bi rt hs SB R R ep ro du ct iv e he al th Es se nt ia l i nt er ve nt io ns St ra te gi c gu id an ce U H C in de x an d R M N C H s ub - in de x (c ou nt ri es ar ra ng ed in de cr ea si ng o rd er of m or ta lit y) M M R 20 17 (p er 1 00 00 0 liv e bi rt hs ) EP M M / SD G Ta rg et 20 30 tw o- th ir d re du ct io n of 2 01 0 SD G Ta rg et 20 30 a t 20 10 - 20 17 A R R SB R / 10 00 bi rt hs (2 01 5) A B R (p er 10 00 15 –1 9 ye ar s) D em an d sa tis fie d by m od er n FP (% ) A N C 4 vi si ts (% ) D el iv er y by S BA (% ) C -S ec tio n In st itu tio na l de liv er ie s (% ) PN C 2 da ys m ot he r (% ) * O bs te tr ic - tr an si tio n st ag e ** m C PR S- cu rv e st ag e ** * H ea lth Sy st em ca te go ry U H C R M N C H Moderate to high mortality M ya nm ar 25 0 99 A cc el er at e 20 36 74 .9 59 60 17 37 71 III 2 1 52 57 N ep al 18 6 95 O n tr ac k 18 .4 88 56 69 58 9 57 57 III 2 1 66 68 B hu ta n 18 3 81 A cc el er at e 16 28 66 85 86 12 74 75 III 3 2 72 78 In do ne si a 17 7 77 A cc el er at e 13 .2 36 77 .1 91 98 17 74 87 III 3 2 61 69 B an gl ad es h 17 3 80 A cc el er at e 25 .4 11 3 72 .6 31 42 23 37 36 III 3 2 54 53 In di a 14 5 63 A cc el er at e 23 51 71 .9 51 81 17 79 62 III 2 2 64 66 Ti m or -L es te 14 2 64 O n tr ac k 17 .8 42 46 .6 77 57 4 49 35 III 2 1 49 52 Low mortality D PR K or ea 89 37 A cc el er at e 13 .5 1 91 .6 94 10 0 13 95 98 III 3 3 78 82 M al di ve s 53 22 A cc el er at e 7. 7 10 29 .8 82 10 0 40 95 80 III 2 3 72 73 Th ai la nd 37 15 A cc el er at e 5 51 92 .7 91 99 32 99 78 IV 3 3 83 86 Sr i L an ka 36 14 A cc el er at e 4. 9 21 74 .2 98 10 0 31 10 0 99 IV 2 3 68 73 SE A R eg io n 15 2 66 A cc el er at e 21 54 73 .1 55 80 18 74 64 63 66 CHAPTER 4 76 Table 12: Obstetric transition: the pathway towards ending preventable maternal deaths Source: Obstetric transition: the pathway towards ending preventable maternal deaths (see reference 3) Indicator Stage I Stage II Stage III Stage IV Stage V (Aspirational) MMR (maternal deaths/ 100 000 live births) MMR >1000 MMR 999–300 MMR 299–50 MMR <50 All avoidable maternal deaths prevented Character Very high maternal mortality • High fertility • Direct causes of death high and with high proportion of deaths due to communicable diseases such as malaria • High MMR • Fertility high • Causes of death similar to Stage 1 • High MMR • Fertility variable • Direct causes still predominant • Moderate/low MMR • Low fertility • Indirect causes with more noncommunicable diseases (NCDs) • MMR very low • Fertility rate low • Causes of death – indirect/NCD Issues to be addressed Poor access to care, significant gaps in basic infrastructure, weak health system, severe shortage of skilled birth attendants (SBAs) and weak capacity to deliver essential interventions. First and second delay in accessing care are important. Stage at which tipping point occurs. Access remains an issue for much of the population. Quality of care, with SBA and appropriate management of complications and disabilities are essential to reduce MMR. Third delay in accessing care becomes important (first and second delays also continue). Quality of care, delay in receiving care in the hospitals and probability of over-medicalization Possible interventions include consolidating against issues such as gender-based violence (GBV), issues related to the provision of care to vulnerable populations such as immigrants and sustaining good quality of care SEA Region No country in the SEA Region Bangladesh, Bhutan, DPR Korea, India, Indonesia, Maldives, Myanmar, Nepal, Timor-Leste Sri Lanka, Thailand No country CHAPTER 4 77 The obstetric transition model proposed by WHO, in collaboration with experts (referred to in earlier chapters and in Table 12), provides justification for customizing strategies for reducing maternal mortality according to a country’s stage in the obstetric transition (see Table12) [7]. Within the same country, different stages could exist due to reasons of equity. This obstetric transition model is also applicable for reducing stillbirths. Cost-effective, evidence-based interventions, most of which can be applied through health systems, are available (see Annexes 4 and 4A for key interventions to reduce maternal mortality and stillbirths). As indicated earlier, the countries with high MMR and SBR are in obstetric transition stage III, which points to issues to be addressed such as poor access to skilled care including access to EmONC, delay in accessing care, either due to factors at the home level (lack of awareness about complications or barriers created by birth attendants) or barriers related to reaching a facility (lack of transport, poor roads, distance, lack of funds, etc.) and poor quality of care (see Table12). In these countries: • Institutional deliveries are low or moderate (vary between 37% and 79%). Evidence shows that skilled care at the time of delivery is a triple investment in reduction of maternal and newborn deaths and stillbirths [71]. The implementation of strategies to improve institutional deliveries (see domain on maternal and perinatal, Strategic Outcome 1) should be accelerated. • Home deliveries are high (ranging from 21% to 63%), with a significant proportion of non-skilled birth attendants (see Figure 3). Strategies to improve institutional deliveries should be a priority. • In general, countries in obstetric transition stage III also have poor health systems (see Tables 8 and 9) – with poor performance across various functions of the health system (especially human resources and financing), poor performance of the institutions of the health system (efficiency, access, inadequate density of human resources, etc.), falling under health system category 1 or 2 (see Table 8). The coverage of evidence- based interventions has not reached the universal access level of 99% or a minimum of 90% (see Table11; the level varies between 50% and 75% or yellow and red zone). The poor state of health system functioning is also evident from the low coverage of UHC and the sub-index of RMNCH (see Figure 14). The UHC index highlights the service delivery capacity of the health system if it is <60% or needs substantial improvement in the health system. These countries need to address health system issues simultaneously with technical improvement. • Countries in obstetric transition stage III are at a tipping point in terms of reducing MMR and SBR and countries in health system category 2 have the scope for improving performance; the countries with both these attributes should be able to easily achieve more than 90% coverage of essential interventions with efficient planning for implementation (see stewardship, Strategic Outcome 2 on health systems). Countries in health system category 1, though at the tipping point (as in obstetric transition stage III), will need to invest on health systems and technical interventions simultaneously to accelerate reduction in MMR and SBR. The above measures are also echoed in the five priority areas listed below, based on the recommendations for eliminating preventable maternal mortality and the Lancet series on maternal health [6,35]. The seven countries with MMR above 140/100 000 live births and SBR above 12 per 1000 births should aim for two-thirds reduction in MMR based on the 2010 levels and an SBR rate of 12 or lower by 2030. CHAPTER 4 78 Five priority areas for ending preventable maternal mortality (supplemented by the recommendations from the Lancet series on maternal health) • Prioritize quality maternal health and reproductive health services, addressing all causes of maternal mortality, reproductive and maternal morbidities and related disabilities, responding to locale-specific needs and emerging challenges. • Address inequities in access to and quality of sexual, reproductive, maternal and newborn health care. • Ensure UHC for comprehensive sexual, reproductive, maternal and newborn health care through guaranteed sustainable financing for maternal and perinatal health. • Strengthen health systems and increase their resilience by optimizing the health workforce and improving the capability of facilities to respond to the needs and priorities of women and girls. • Ensure accountability to improve the quality of care and equity. CHAPTER 4 79 4.4 Reducing the unmet need for contraception Meeting the unmet needs for contraception contributes significantly to reducing maternal deaths (see Table 5). The S-curve (see Figure 6) provides guidance to countries to set programmatic priorities as well as goals. • Four of the countries with high MMRs are in stage 2 of mCPR. These countries need to ensure that there are no barriers to services by ensuring contraceptive availability, high-quality services and continued demand generation. The goal should be to achieve a minimum mCPR of 66% by 2023. These countries should: • provide rights-based, quality FP services focusing on the method of choice of the client and apply MEC for contraceptive use, counselling and follow-up (as described under the section on FP, Strategic Outcome 1); • promote post-pregnancy FP (postpartum and post-abortion). • Three of the countries with high MMRs are in stage 3 of mCPR. These countries need to focus on equity among different subgroups so that no woman is left behind. Programmes should focus on long-term sustainability, quality and expanding the range of methods with the goal of equity and government financing. • The main methods of contraception in these countries are short-acting methods with high discontinuation rates; hence the need to promote long-acting methods using a rights- based approach. • Another important strategy to ensure equity is to improve access of adolescents to contraception. 80 CHAPTER 5 Monitoring system for the Regional Strategic Framework for SRHR A robust monitoring and evaluation system is critical to assess the progress of various activities and outcomes. An annual internal review should be carried out. A mid-term review should be done, as well as an evaluation at the end. Goal, outcomes, domains Proposed indicators Proposed Regional target for 2023 Proposed Regional target for 2030 Source of data Comments (SDG, additional or country-specific) Goal (impact) MMR (per 100 000 live births) Proportion of countries achieving country targets for 2023 30% reduction of MMR from the 2017 value 6/11 Reduction by two- thirds from the 2010 value or <70 per 100 000 live births whichever is lower (modified as TAG) 11/11 UN Inter-agency estimates (UN-MMEIG periodic estimates) MDSR (country report) SDG 3.1.1 SBR (per 1000 births) Proportion of countries achieving SBR <12 Intrapartum SBR 12 9/11 50% reduction from the current value 9 11/11 No target set Inter-agency estimates stillbirths surveillance and response ENAP and GSWCAH indicator Neonatal mortality rate/1000 live births Proportion of countries achieving neonatal mortality rate <12 (per 1000 live births) 30% reduction from the current value 10/11 12 11/11 UN-IGME (periodic estimates) SDG 3.2.2 Cervical cancer incidence among women 30–49 years Not set Reduction 10% from the current value GLOBOCAN estimate Additional linked to SDG 3.4 and elimination target for cervical cancer Proportion of countries with total fertility rate <2 6/11 10/11 DHS Adolescent birth rate (per 1000 girls of same age) 10–14 years 15–19 years Proportion of countries that report adolescent birth rate (per 1000 girls of same age) 15–19 (<30) years Not set Not set Table 13: Monitoring indicators for Regional SRH strategy CHAPTER 5 81 Goal, outcomes, domains Proposed indicators Proposed Regional target for 2023 Proposed Regional target for 2030 Source of data Comments (SDG, additional or country-specific) Strategic Outcome: 1 Maternal care Proportion of countries where deliveries by SBA are >90% 9/11 (95%) 11/11 DHS SDG 3.1.2 Proportion of countries where deliveries in facilities are >90% 8/11 11/11 DHS proposed (GSWCAH) Proportion countries where >90% of women aged 15–49 years had four or more ANC visits 9/11 11 /11 DHS Additional (GSWCAH) Proportion of countries where >60% of women had eight ANC visits 5/11 11/11 DHS Proportion of countries where >80% of women had postpartum contact with a health provider within 2 days of delivery 8/11 11/11 DHS Additional (GSWCAH) Proportion of countries where >80% of newborns had postnatal contact with a health provider within 2 days of delivery 8/11 11/11 DHS Maternal and perinatal health Proportion of countries where >80% of pregnant women are screened for syphilis and HIV 7/11 11/11 DHS/MICS Additional (GSWCAH) Proportion of countries where >90% of pregnant women are protected against tetanus 9/11 11/11 DHS/MICS Additional (GSWCAH) Proportion of countries that have adapted the guidelines on ANC, intrapartum care and postpartum care 11/11 Regional surveys Proportion of countries where population-based C-sections as a proportion of all deliveries is in the range 5–15% (Regional average weighted) 5/11 11/11 DHS/MICS Proportion of countries where the institutional coverage of MDSR is >80% in EmONC facilities 11/11 11/11 Regional surveys Proportion of countries where the institutional coverage of perinatal death surveillance and response is >80% in CEmONC facilities 6/11 11/11 Regional surveys CHAPTER 5 82 Goal, outcomes, domains Proposed indicators Proposed Regional target for 2023 Proposed Regional target for 2030 Source of data Comments (SDG, additional or country-specific) Family planning Proportion of countries where demand satisfied for modern methods of contraception is >66% 6/11 11/11 DHS SDG (3.7.1) and monitoring indicator of the Thirteenth General Programme of Work Proportion of countries where mCPR is >50% 6/11 11/11 DHS/MICS Proportion of countries with unmet needs <5% 7/11 11/11 DHS/MICS Proportion of countries that have (>80% of institutions carry out deliveries) scaled up immediate postpartum family planning 7/11 11/11 Regional surveys Proportion of countries that have incorporated medical eligibility criteria (MEC) for contraceptive use 2015 and selected practice into the national FP guidelines 10/11 11/11 Regional surveys Abortion Proportion of countries that have nationally scaled up post-abortion care 8/11 11/11 Regional surveys Proportion of countries where post-abortion FP is being implemented 5/11 11/11 Regional surveys Proportion of countries where national guidelines have incorporated/adapted WHO’s “Safe abortion: technical and policy guidance for health systems” (2nd edition), “Medical management of abortion” and “Health worker roles in providing safe abortion care and post-abortion contraception” 7/11 11/11 Regional surveys Cervical cancer Proportion of countries where >50% of women of reproductive age (15–49 years) were screened for cervical cancer at 35 and 45 years 5/11 8/11 Regional surveys Additional (GSWCAH) and Global strategy towards eliminating cervical cancer as a public health concern (2020) Proportion of countries that have developed national strategic plan/operation to achieve the 2030 targets 5/11 11/11 Regional surveys SRH services in humanitarian crisis Proportion of countries that have contingency plans incorporated MISP or that have incorporated MISP in the emergency plans 9/11 11/11 Regional surveys CHAPTER 5 83 Goal, outcomes, domains Proposed indicators Proposed Regional target for 2023 Proposed Regional target for 2030 Source of data Comments (SDG, additional or country-specific) Strategic Outcome: 2 Health system Countries that have achieved >60% coverage of essential health services (UHC index based on tracer interventions that include reproductive, maternal, newborn and child health) 7/11 11/11 Regional calculations SDG 3.8.1 Proportion of countries that have met the global standards for density of doctors, midwives and nurses at the national and subnational levels 5/11 9/11 Regional calculations Additional (GSWCAH) linked to SDG 3b Proportion of countries that have established CBHS for SRH (ANC, PNC and FP) services 6/11 11/11 Regional surveys Proportion of countries that release annual MMR, SBR reports from MDSR 5/11 11/11 Regional surveys Proportion of countries that have included the pregnancy box in death declaration forms 3/11 11/11 Regional surveys Stewardship Proportion of countries that hold regular national advisory/TAG meetings on SRHR, report and take follow-up actions 11/11 11/11 Regional surveys Proportion of countries that have institutionalized programme management courses 5/11 11/11 Regional surveys National leadership structure for quality of care in health services strengthened (or established) 5/11 10/11 Regional surveys Human resources Proportion of countries that have reviewed needs for task shifting for SRH/ maternal health services 5/11 11/11 Regional surveys Health service delivery Proportion of countries where UHC service delivery index is > 70 4/11 8/11 Information Proportion of countries that have initiated disaggregated (age, geographical) SRH data analysis/publish at the subnational level 3/11 11/11 Regional surveys Financing Proportion of countries where reproductive health sub-account analysis is available 3/11 8/11 Regional surveys CHAPTER 5 84 Goal, outcomes, domains Proposed indicators Proposed Regional target for 2023 Proposed Regional target for 2030 Source of data Comments (SDG, additional or country-specific) RHCS Proportion of countries with reproductive health logistics management system in place 6/11 11/11 Regional surveys Strategic Outcome: 3 Improving health literacy of women and adolescent girls on SRHR and skills in self-care Proportion of countries where >80% of women are knowledgeable about danger signs of pregnancy and what action to take 5/11 10/11 DHS/MICS Capacity building of individuals Proportion of countries that use digital technology for follow-up of SRH services and to provide services (where feasible) 4/11 10/11 Regional surveys Mobilizing communities Proportion of countries that have developed mechanisms for community emergency transport/ 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Lancet 2014 (https://www.healthynewbornnetwork.org/ resource/the-lancet-every-newborn-series/, accessed 4 June 2020). 91 92 ANNEXES ANNEXES ANNEXES Annex 1: Definitions (reproductive rights, sexuality and sexual rights, Integrated definition of sexual and reproductive health and rights – Lancet) Annex 2: Linkages between the key areas of SRHR and SDGs Annex 3: Regional Flagship Programmes Annex 4: Evidence-based health interventions for reproductive and maternal and perinatal health Annex 4A: Key interventions to reduce maternal mortality and stillbirths Annex 5: Preconception package Annex 6: Recommendations on ANC for a positive pregnancy experience, mapped to eight scheduled ANC contacts Annex 7: Recommendations on intrapartum care for a positive childbirth experience Annex 8: Recommendations on postnatal care for mothers and newborns Annex 9: Recommendations for ensuring human rights in the provision of contraceptive information and services Annex 10: Regional and global strategies/guidelines of relevance to the SRHR Strategic Framework 93 ANNEXES 11 Starrs AM, Ezeh AC, Barker G, Basu A, Bertrand JT, Blum & W, et al. accelerate progress–sexual and reproductive health and rights for all: report of the Guttmacher–Lancet Commission. Lancet. 2018;391(10140):2642–92. doi: 10.1016/S0140-6736(18)30293-9. Reproductive rights Reproductive right rests on the recognition of human rights of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children, to have the information and means to do so, and the right to attain the highest standards of reproductive health. They also include: • the right to make decisions concerning reproduction free of discrimination, coercion and violence • the right to privacy, confidentiality, respect, and informed consent • the right to mutually respectful and equitable gender relations. Sexual health • A state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. • For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled. Sexual health implies that all people have access to: • counselling and care related to sexuality, sexual identify, and sexual relationships. • services for the prevention and management of sexually transmitted infections, including HIV/AIDS and other diseases of the genitourinary system. • psychosexual counselling, and treatment for sexual dysfunction and disorders; and • prevention and management of cancers of the reproductive system. Sexual rights Sexual rights are human rights and include the right of all persons, free of discrimination, coercion, and violence, to: • achieve the highest attainable standard of sexual health, including access to sexual and reproductive health services • seek, receive, and impart information related to sexuality • receive comprehensive, evidence-based, sexuality education • have their bodily integrity respected • choose their sexual partner • decide whether to be sexually active or not • engage in consensual sexual relations • choose whether, when and whom to marry • enter into marriage with fee and full consent and with equality between spouses in and at the dissolution of marriage • pursue a satisfying, safe and pleasurable sexual life, free from stigma and discrimination • make free, informed, and voluntary decisions on their sexuality, sexual orientation and gender identity. ANNEX 1: Definitions 11 94 ANNEXES SDG goals and indicators Maternal and perinatal health Fam ily planning Safe abortion Infertility R eproductive cancers G ender-based violence H IV /A ID S and STIs A dolescent SR H R SDG 1: End poverty in all its form everywhere - - - - - - - - SDG 3: Ensure healthy lives and promote well-being for all at all ages 3.1 By 2030, reduce the global maternal mortality ratio to <70 per 100 000 livebirths stated linked linked - - linked - linked 3.2 By 2030, end preventable deaths of newborns and children aged <5 years, with all countries aiming to reduce neonatal mortality to at least ≤12 per 1000 livebirths and under-5 mortality to at least ≤25 per 1000 livebirths stated linked - - - linked linked linked 3.3 By 2030, end the epidemics of AIDS, tuberculosis, malaria, and neglected tropical diseases, and combat hepatitis, water-borne diseases, and other communicable diseases linked linked - - - linked stated linked 3.4 By 2030, reduce by one-third premature mortality from NCDs through prevention and treatment, and promote mental health and well-being - - - - stated - - - 3.7 By 2030, ensure universal access to sexual and reproductive health-care services, including for family planning, information and education, and the integration of reproductive health into national strategies and programmes stated stated linked linked linked linked stated stated 3.8 Achieve universal health coverage, including financial risk protection, access to quality essential health-care services, and access to safe, effective, quality, and affordable essential medicines and vaccines for all stated stated linked linked linked - stated linked 12 Starrs AM, Ezeh AC, Barker G, Basu A, Bertrand JT, Blum RW, et al. accelerate progress–sexual and reproductive health and rights for all: report of the Guttmacher–Lancet Commission. Lancet. 2018;391(10140):2642–92. doi: 10.1016/S0140-6736(18)30293-9. ANNEX 2: Linkages between the key areas of SRHR and SDGs12 95 ANNEXES SDG 4: Ensure inclusive and equitable quality education and promote lifelong learning opportunities for all 4.7 By 2030, ensure that all learners acquire the knowledge and skills needed to promote sustainable development, including education for sustainable development and sustainable lifestyles, human rights, gender equality, promotion of a culture of peace and non-violence, global citizenship, and appreciation of cultural diversity and of culture’s contri- bution to sustainable development - - - - - linked - linked SDG 5: Achieve gender equality and empower all women and girls 5.1 End all forms of discrimination against all women and girls everywhere linked linked linked - linked linked linked linked 5.2 Eliminate all forms of violence against all women and girls in the public and private spheres, including trafficking, and sexual and other types of exploitation linked linked linked - - stated linked linked 5.3 Eliminate all harmful practices, such as child, early and forced marriage, and female genital mutilation - - - - - stated - linked 5.6 Ensure universal access to SRHR as agreed in accordance with the Pro- gramme of Action of the ICPD and the Beijing Platform for Action, and the outcome documents of their review conferences stated stated linked linked stated stated stated stated 5.c Adopt and strengthen sound poli- cies and enforceable legislation for the promotion of gender equality and the empowerment of all women and girls at all levels - - - - - linked - linked SDG 10: Reduce inequality within and among countries - - - - - - - - SDG 13: Take urgent action to combat climate change and its impacts - - - - - - - - SDG 16: Promote peaceful and inclusive societies for sustainable development, provide access to justice for all, and build effective, accountable, and inclusive institutions at all levels 16.1 Significantly reduce all forms of vio- lence and related death rates everywhere - - - - - linked - linked 96 ANNEXES 16.2 End abuse, exploitation, trafficking, and all forms of violence against and torture of children - - - - - linked - linked Data from United Nations General Assembly, 2015.3 Stated means the area is mentioned in the target or indi- cator language. Linked means the area relates to the SDG target but is not specifically mentioned in the target. *No targets under this SDG explicitly state or link to the key areas of SRHR; however, fulfilling this goal con- tributes to the achievement of the SRHR agenda and vice versa. †Although no targets under this SDG explicitly state or link to key areas of SRHR, fulfilling SRHR contributes to achieving this goal. ANNEX 3: Regional Flagship Programmes 1. Eliminate measles and rubella by 2023 2. Prevent and control noncommunicable diseases through multisectoral policies and plans, with a focus on “best buys” 3. Accelerate reduction of maternal, neonatal and under-five mortality 4. Continue progressing towards universal health coverage with a focus on human resources for health and essential medicines 5. Further strengthen national capacity for preventing and combating antimicrobial resistance 6. Scale up capacity development in emergency risk management in countries 7. Finish the task of eliminating neglected tropical diseases (NTDs) and other diseases on the verge of elimination 8. Accelerate efforts to end TB by 2030 97 ANNEXES PRIORITY INTERVENTIONS LEVEL OF CARE (COMMUNITY, PRIMARY, REFERRAL) COMMUNITY OR PROFESSIONAL HEALTH WORKERS EVIDENCE-BASED INTERVENTIONS FAMILY PLANNING Family planning Community- based health services (CBHS) Community based health workers (CBHW) Professional health workers • Information and counselling on safe sex, all methods of contraception • Services (as appropriate) for barrier methods, oral contraceptives, emergency contraceptives and referrals to appropriate facilities for other methods Primary Professional health workers/ SBA • All of the above plus: • Hormonal injections • Long-acting reversible contraceptives such as implants and intrauterine devices • Referral for surgical contraception (female and male) Referral Professional health workers skilled in surgical contraception • All of the above plus: • Surgical contraception (female and male) PRECONCEPTION/PERICONCEPTUAL INTERVENTIONS Family planning Community ALL (CBHW, professional) • Information and counselling on safe sex, all methods of contraception • Services (as appropriate) for barrier methods, oral contraceptives, emergency contraceptives and referrals to appropriate facilities for other methods Primary Referral • All of the above plus: • Hormonal injections • Long-acting reversible contraceptives such as implants and intrauterine devices Prevention and management of STIs, including HIV for PMTCT of HIV, syphilis and hepatitis B Community ALL • Diagnosis (congruent with the level of the facility) • Counselling • Provision of condoms (male and female as acceptable) and • Treatment (congruent with the level of the facility) Primary Professional health workers • All of the above plus: • Diagnosis (clinical and laboratory) • Treatment as per guidelines 13 Adapted from the following sources: (a) UN. The global strategy for women’s, children’s and adolescents’ health 2016-30. Annex 2. Evidence-based health interventions for women’s, children’s and adolescents’ health. (b) WHO, Agha Khan University, PMNCH. Essential interventions, commodities and guidelines for reproductive, maternal, newborn and child health. A global review of the key interventions related to reproductive, maternal, newborn and child health (RMNCH). 2011 (c) WHO. Packages of interventions for family planning, safe abortion care, maternal, newborn and child health. 2010 ANNEX 4: Evidence-based interventions for reproductive and maternal and perinatal health13 98 ANNEXES PRIORITY INTERVENTIONS LEVEL OF CARE (COMMUNITY, PRIMARY, REFERRAL) COMMUNITY OR PROFESSIONAL HEALTH WORKERS EVIDENCE-BASED INTERVENTIONS Referral Professional health workers • All of the above plus: • Treatment as per guidelines • In case of HIV, antiretroviral medicines Iron and folic acid supplementation to prevent anaemia and neural tube defects Community Primary Referral ALL • Iron and folic acid tablets Immunization • Rubella vaccination • HPV vaccinations in some settings Prevention of and management of cervical and breast cancer Community Primary Referral ALL • Health education on prevention including about HPV vaccination at 9–13 years and about symptoms and signs • Health education about breast cancer SEE INTERVENTION AREA ON CERVICAL CANCER FOR HOV VACCINATION, SCREENING, ETC. Management of unintended pregnancy SEE INTERVENTION AREA ON COMPREHENSIVE ABORTION CARE Response to sexual and other forms of GBV Community ALL • Identification counselling and referral Primary Referral Professional health workers • All of the above plus: • Diagnosis and counselling Pre-pregnancy detection and management (nutrition, obesity, tobacco, alcohol, mental health, environmental toxins), genetic conditions and early identification of NCDs such as heart disease Community ALL • Health education Primary Professional health workers • All of the above plus: • Screening (history, physical examination) and counselling • Treatment and referral Referral Professional health workers • All of the above PREGNANCY Antenatal care information and counselling on prevention ALL Community Professional health workers • Information and counselling on self-care at home, nutrition, safer sex, HIV, breastfeeding, family planning, healthy life styles including harmful effects of smoking and alcohol use, birth and emergency preparedness, compliance with preventive treatments, use of insecticide treated bed nets (country-specific) • Support for women living with HIV/AIDS • Assessment of signs of domestic violence and management congruent with the level of the facility 99 ANNEXES PRIORITY INTERVENTIONS LEVEL OF CARE (COMMUNITY, PRIMARY, REFERRAL) COMMUNITY OR PROFESSIONAL HEALTH WORKERS EVIDENCE-BASED INTERVENTIONS Antenatal care Essential Package (see WHO recommendations for positive pregnancy experience) Primary Referral Professional health workers • All of the above plus: • Confirmation of pregnancy and accurate assessment of gestational age • Monitoring progress of pregnancy and assessment of maternal and fetal well-being including nutritional status • Detection of risk factors for and management of genetic conditions • Identification and management of chronic medical conditions (e.g. hypertension, pre- existing diabetes mellitus), congruent with the level of the facility • Prevention, screening and treatment of gestational diabetes, eclampsia, pre-eclampsia (including timely delivery), congruent with the level of the facility • Pre-referral treatment of severe complications (pre-eclampsia, bleeding, infection and complicated abortion) • Detection of problems complicating pregnancy (e.g. anaemia, bleeding, mal-presentations, multiple pregnancy, preterm premature rupture of membranes, macrosomia) • Respond to other reported needs • Treatment of mild to moderate pregnancy complications (mild-moderate anaemia, urinary tract infection, vaginal infection) • Post-abortion care and family planning • Support for women living with violence and HIV • Recording and reporting (both in home-based and facility -based) Iron and folic acid supplementation Community Primary Referral ALL • Iron and folic acid Tetanus immunization Primary Referral Professional health workers • TT vaccine Screening, prevention and management of syphilis and hepatitis B Primary Referral Professional health workers • Testing and treatment of syphilis (woman and her partner) congruent with the level of the facility • Hepatitis B testing and treatment congruent with the level of facility Prevention and management of HIV PMTCT Primary Referral Professional health workers • HIV testing and counselling • PMTCT (by antiretroviral therapy, infant feeding counselling, mode of delivery advice) 100 ANNEXES PRIORITY INTERVENTIONS LEVEL OF CARE (COMMUNITY, PRIMARY, REFERRAL) COMMUNITY OR PROFESSIONAL HEALTH WORKERS EVIDENCE-BASED INTERVENTIONS Identification and response to intimate partner violence Community Primary Referral ALL • Identification and response congruent with the level of facility Situational interventions for smoking cessation during pregnancy for improving birth outcomes Community Primary Referral ALL • Counselling Prevention and management of hypertension in pregnancy Referral Professional health workers In addition to the above under essential package, preventive interventions, screening and management of selected conditions • Treatment of severe complications (anaemia, severe pre-eclampsia, eclampsia, bleeding, infection and other medical complications) following WHO guidelines on specific conditions (e.g. PPH, eclampsia) Antenatal corticosteroids for women at risk of birth at 24–34 weeks of gestation when appropriate conditions are met Referral Professional health workers (specialists) In addition to the above under essential package, preventive interventions, screening and management of selected conditions • Corticosteroids as per national guidelines • Tocolytics Management of malpresentation at term (>36 weeks), multiple pregnancy Referral Professional health workers (specialists) • Management as per national protocols and guidelines Management of unintended pregnancy • See intervention on comprehensive abortion care SITUATIONAL Prevention and management of malaria in pregnancy a) Prophylactic antimalaria for preventing malaria in pregnancy b) Provision and promotion of use of insecticide treated nets for preventing malaria Primary Referral Professional health workers In addition to the above under essential package, preventive interventions, screening and management of selected conditions • Intermittent preventive treatment for malaria, according to the national standards • Sleeping under insecticide treated bed nets Other situations In addition to the above under essential package, preventive interventions, screening and management of selected conditions • Deworming • Treatment of mild to moderate opportunistic infections 101 ANNEXES PRIORITY INTERVENTIONS LEVEL OF CARE (COMMUNITY, PRIMARY, REFERRAL) COMMUNITY OR PROFESSIONAL HEALTH WORKERS EVIDENCE-BASED INTERVENTIONS CHILDBIRTH Social support during childbirth Community Primary Referral ALL • Companion of choice to support the woman in the facility Childbirth care (see WHO recommendations for positive childbirth experience) Primary Referral Professional health workers/SBA • All of the above plus: • Care during labour and delivery • Diagnosis of labour • Monitoring progress of labour, maternal and fetal well-being with partograph • Infection prevention • Supportive care and pain relief • Detection of problems and treatment of complications (e.g. malpresentations, prolonged and/or obstructed labour, hypertension, bleeding and infection) • Prevention and management of eclampsia (including mag sulphate) • Delivery and immediate care of the newborn including provision of thermal care, hygienic cord care at birth, including use of chlorhexidine where appropriate • Initiation of breastfeeding • Neonatal resuscitation Childbirth care (see WHO recommendations for positive childbirth experience) Primary Referral Professional health workers/SBA • Active management of third stage of labour • Treatment of abnormalities and complications (e.g. prolonged labour, vacuum extraction, breech presentation, episiotomy, repair of genital tears, manual removal of placenta) • Immediate postpartum care of the mother • Monitoring and assessment of maternal well-being, prevention and detection of complications (e.g. hypertension, infections, bleeding, anaemia) • Pre-referral management of serious complications (e.g. obstructed labour, fetal distress, preterm labour, severe peri- and postpartum haemorrhage) • Identification and induction of mothers with ≥41 weeks of gestation • Counselling for the family if maternal or perinatal death • Family planning including insertion of IUDs 102 ANNEXES PRIORITY INTERVENTIONS LEVEL OF CARE (COMMUNITY, PRIMARY, REFERRAL) COMMUNITY OR PROFESSIONAL HEALTH WORKERS EVIDENCE-BASED INTERVENTIONS Prevention of mother- to-child transmission during childbirth and prevention of HIV infection in newborn Primary Referral Professional health workers • Counselling and screening for HIV (if not already tested) • Prevention of mother-to-child transmission of HIV by mode of delivery guidance and support for chosen infant feeding option • Care of HIV positive women/ART Prevention of postpartum haemorrhage Prophylactic Active management of third stage of labour Community/home Primary Referral CBHW Professional health workers Professional health workers • Misoprostol • All components of active management of third stage of labour Management of postpartum haemorrhage Community Primary Referral Professional health workers Preventive measures most important If PPH occurs, manage as per WHO guidelines Management of complications Referral Professional health workers (specialists) • Caesarean section for management of maternal/fetal indications • Induction of labour with appropriate medical indications • Management of other obstetric complications POSTNATAL MOTHER Health promotion and support Community Primary Referral ALL • Information and counselling on self-care at home, nutrition, intake of iron and folic acid, safer sex, breastfeeding, family planning, healthy lifestyle including harmful effects of smoking and alcohol use • Promotion of postnatal care with an appropriately skilled healthcare provider at home or in the facility at around day 3, day 7 and at 6 weeks after birth • Promotion, protection and support of exclusive breastfeeding • Support for complication with prevention measures and treatments • Recognition of danger signs, including/blues and depression • Awareness of signs of domestic and sexual violence and referral • Support for women living with HIV/AIDS including ART • Supporting birth and death registration 103 ANNEXES PRIORITY INTERVENTIONS LEVEL OF CARE (COMMUNITY, PRIMARY, REFERRAL) COMMUNITY OR PROFESSIONAL HEALTH WORKERS EVIDENCE-BASED INTERVENTIONS Assessment of maternal well-being including nutrition(see recommendations for positive post-natal experience) Primary Professional health workers • CARE IN THE FACILITY FOR AT LEAST 24 HOURS after an uncomplicated vaginal birth • POSTNATAL CONTACT WITH AN APPROPRIATE SKILLED PROVIDER AT HOME OR IN THE FACILITY at around day 3, day 7 and at 6 weeks after birth • All of the above plus: • Assessment of maternal well-being including nutrition • Prevention and detection of complications (e.g. infections, bleeding, eclampsia, anaemia) • Treatment of some problems (e.g. mild to moderate anaemia, mastitis) • Pre-referral treatment of some problems (e.g. severe postpartum bleeding, puerperal sepsis, eclampsia) • Identification and response to intimate partner violence congruent with the level of the facility • Screening and management of postpartum depression • Early detection of maternal morbidities (e.g. fistula) • Recording and reporting • Cervical cancer screening Referral Professional health workers • All of the above plus: • Treatment of all complications – severe anaemia, severe postpartum bleeding, severe infections, severe postpartum depression Advice on provision of family planning Community ALL • Information and counselling on all methods of contraception focusing on those that can be used during lactation and lactational amenorrhoea method • Services (as appropriate) for barrier methods, oral contraceptives (progestin only if breastfeeding), emergency contraceptives and referrals to appropriate facilities for other methods Primary Referral Professional health workers • All of the above plus: • Hormonal injections (progestin only) • Long-acting reversible contraceptives such as implants and intrauterine devices • Referral for surgical contraception (female and male) Family planning Professional health workers (skilled in surgical contraception) • All of the above plus: • Surgical contraception (female and male) 104 ANNEXES PRIORITY INTERVENTIONS LEVEL OF CARE (COMMUNITY, PRIMARY, REFERRAL) COMMUNITY OR PROFESSIONAL HEALTH WORKERS EVIDENCE-BASED INTERVENTIONS Prevention and management of anaemia Community Primary Referral ALL • Counsel and provide iron and folic acid (90 tablets) Screening for HIV and initiation/continuation of HIV positive women Referral Professional health workers • Counselling and HIV testing • Initiation or continuation of ART and PMTCT as per national guidelines SITUATIONAL Prevention and management of malaria Community Primary Referral ALL • Malaria prevention and management • Use of insecticide-treated bed nets POSTNATAL NEWBORN Health promotion and support Community/ home Primary Referral ALL • Promotion of exclusive breastfeeding • Thermal protection • Infection prevention: general hygiene, cord care and safe disposal of baby’s faeces • Care of small babies without breathing and feeding problems: frequent breastfeeding, skin- to-skin contact, newborn stimulation and play • Recognition of problems and timely care- seeking • Support for routine care and follow-up visits • Birth registration Essential newborn care Primary Referral ALL • CARE IN THE FACILITY FOR AT LEAST 24 HOURS after an uncomplicated vaginal birth • POSTNATAL CONTACT WITH AN APPROPRIATE SKILLED PROVIDER AT HOME OR IN THE FACILITY at around day 3, day 7 and at 6 weeks after birth • All the above plus immediate newborn care listed under childbirth, and breastfeeding • Eye infection prophylaxis • Prevention of infection: cord care and hygienic skin care • Kangaroo mother care • Treatment of local infections (eye, mouth, skin) • Extra support for feeding small and pre term babies without breathing of feeding problems: with breast feeding/milk, kangaroo mother care • Immunization (polio, BCG) • Presumptive treatment of congenital syphilis • Monitoring and assessment of well-being and response to maternal concerns • Detection and initial management of complications such as birth asphyxia, other respiratory difficulties, jaundice, injury or genetic conditions, premature and low birth weight babies with breathing or feeding problems and referral to appropriate facility • Recording and reporting 105 ANNEXES PRIORITY INTERVENTIONS LEVEL OF CARE (COMMUNITY, PRIMARY, REFERRAL) COMMUNITY OR PROFESSIONAL HEALTH WORKERS EVIDENCE-BASED INTERVENTIONS Management of complications Referral Professional health workers (specialists) • In addition to the above, • Management of complications such as severe birth asphyxia, other respiratory difficulties, jaundice, suspected severe bacterial infections, injury or genetic conditions, pre term and low birth weight babies with breathing or feeding problems • Initiation of prophylactic ART for newborns exposed to HIV COMPREHENSIVE ABORTION CARE Prevention of unwanted pregnancy Community Primary Referral ALL • Counselling on appropriate FP methods • Information on what to do in case of abortions (which provider, which institution) and danger signs • Early initiation of FP (within 3 weeks) after abortion Comprehensive abortion care Primary Referral Professional health workers • Where legal, use of medical abortion and surgical abortion as appropriate for the client, congruent with the level of the facility as per national guidelines • Post-abortion care including medical and surgical methods for evacuation of products of conception (congruent with the level of the facility) and other management as per national guidelines • Counselling prior and after procedure including about FP CERVICAL CANCER PREVENTION AND MANAGEMENT Primary prevention Community Primary Referral ALL • Information on cervical cancer – its prevalence and mortality, signs and symptoms, causes and prevention • HPV vaccination among girls of 9–13 years • Information to women, men and boys about cervical cancer Secondary prevention Primary Referral Profession health workers • Screening of women at 35 and 45 years using VIA/PAP smear/HPV DNA • Diagnosis and early treatment of pre-cancerous lesions as per WHO guidelines Treatment Referral Professional health workers (specialists) • Diagnostic facilities and palliative treatment 106 ANNEXES Sepsis and other maternal infections Tetanus toxoid Clean delivery Antibiotics WASH Other maternal disorders Caesarean section Other emergency obstetric care Haemorrhage Uterotonics Blood transfusion Balloon tamponade Surgery NASG Indirect causes Iron folate supplements Malaria intermittent treatment Insecticide-treated bed nets Antiretrovirals Hypertensive disorders Early identification and timely delivery Magnesium sulphate Calcium Aspirin Antihypertensive Caesarean section Obstructed labour Caesarean section Complications of unsafe abortion Family planning Safe abortion services Post-abortion care 9% 18% 18% 22% 12% 13% 8% Infection screening and treatment Ongoing management of chronic illness Family planning Diet supplementation and fortification Underlying Causes Unintended pregnancy Malnutrition Infections Noncommuni cable diseases ANNEX 4A: Key interventions to reduce maternal mortality and stillbirths Main causes of maternal deaths and key interventions Source: Lancet Maternal health. An executive summary of the Lancet series, 2016 107 ANNEXES Interventions and actions to prevent and respond to stillbirths along the continuum of women’s and children’s health care Interventions with proven effect on stillbirth prevention Interventions with potential effect on stillbirth prevention and care Legislative and policy actions Reproductive health: planning and preparing Family planning information and services, including for adolescents (fewer pregnancies among women who are younger than 16 years and older than 35 years, and birth spacing); folic acid fortification or supplementation;*47 prevention of, testing for, and management of syphilis Maintenance of good health and nutrition, promotion of healthy behaviour such as good nutrition, physical activity, and no tobacco, alcohol, and drugs; pre- pregnancy checks for hypertensive disorders, cardiac disease, anaemia, under-nutrition, and obesity;† prevention of, testing for, and management of sexually transmitted infections (e.g. hepatitis B and HIV); prevention of child and forced marriage; detection and management of hazardous and harmful substance use; pre-pregnancy detection and management of risk factors (nutrition, tobacco, alcohol, and environmental toxins) and genetic disorders Legislative and programmatic interventions to delay marriage; legislative and programmatic interventions to ensure completion of secondary education for girls and boys; provision of comprehensive sexuality education for boys and girls; planning pregnancies with modern contraceptive methods; strategic thinking about quality of care, including availability, equitable access, acceptability Pregnancy: ensuring a healthy start Effective antenatal care and support visits;‡ folic acid supplementation; prevention and management of malaria, including insecticide-treated bed nets or intermittent preventive treatment;* prevention and management of syphilis;* interventions for cessation of smoking; screening for and management of maternal illness and risk factors (obesity, hypertensive disorder,* diabetes); detection and management fetal growth restriction Iron supplementation; calcium supplementation (prevention of hypertension); dietary counselling for healthy weight gain and adequate nutrition; detection and management of risk factors (nutrition, tobacco, alcohol, environmental toxins) and genetic disorders; management of chronic medical conditions (e.g. hypertension and diabetes); low-dose aspirin to prevent pre-eclampsia; antihypertensive drugs; magnesium sulphate for severe pre-eclampsia and eclampsia; external cephalic version; counselling for domestic violence Maintenance of good health and preparation for pregnancy, childbirth, and the early months as a new family; receiving at least four quality antenatal care visits, which include essential clinical components‡ Childbirth: supporting a safe beginning Facility childbirth with a skilled birth attendant: antibiotics for PPROM; induction of labour to manage PROM at term; surveillance of labour (partograph), including fetal monitoring; post-term labour induction;* assisted vaginal delivery and caesarean section for fetal indication (comprehensive emergency obstetric care)* Psychosocial support and companion of choice during labour; appropriate procedures for delivery after stillbirth diagnosis (e.g. induction of labour, embryotomy, and caesarean section) Access to midwifery services with the companion of choice; mothers participate in decisions about how they and their baby are cared for and have the privacy and space to experience birth without unnecessary disturbance and interventions 108 ANNEXES Interventions with proven effect on stillbirth prevention Interventions with potential effect on stillbirth prevention and care Legislative and policy actions When the death of a baby occurs: respectful and supportive care NA Quality postnatal care to the mother, including management of complications (e.g. haemorrhage, eclampsia, sepsis, and anaemia), and prevention, early detection, and management of obstetric fistula; family planning advice and contraceptives; initiation or continuation of antiretroviral therapy for HIV; nutrition counselling; postnatal contact with a skilled health-care provider, at home or in a health facility at about day 3, day 7, and at 6 weeks after birth; screening and management for post partum depression; maternal and perinatal death or near-miss case review or audit; compassionate support and counselling for all family members after a stillbirth, maternal, or neonatal death; provision of emotional support and specific information to assist in decision-making and access to financial support when possible Respectful support to all the family members after death as appropriate in context, which might include accurate information on options (e.g. seeing and holding the baby) and decisions (e.g. funeral arrangements and autopsy); continuing support after a death (e.g. information on where to go for help, counselling support, financial support for lost income and extra expenses, and listening); information and education to reduce the stigma and taboo associated with stillbirth, maternal or newborn death; support to community groups, which can reduce stigma and support bereaved families; education and training of health-care workers in respectful care for bereaved parents; creation of safe spaces to support health- care workers caring for the bereaved; encouragement of autopsy where feasible PPROM=preterm premature rupture of the membranes, PROM=premature rupture of membranes, NA=not applicable. *Interventions proven to reduce stillbirth from the Lancet Stillbirth Series in 2011† We suggest investigations are needed to study the effectiveness of primary health-care pre-pregnancy visits aimed to detect health problems having a potential effection maternal mortality, morbidity, and stillbirth, to adapt treatments (antihypertensive drugs), and discuss postpartum contraception. ‡Quality antenatal care visits should include assessment of gestational age, definition of the estimated date of delivery (first half of the pregnancy), body mass index measurement, blood pressure measurement, urine test (albumin), syphilis and HIV screening, and information provision for birth preparedness (e.g. danger signs, including fetal movements, and decision-making by a health care professional competent in midwifery). Additionally, as needed, visits should include context specific interventions such as intermittent presumptive treatment for malaria and a repeated HIV test in late pregnancy. The effect on stillbirths of use of ultrasounds in poor settings to measure gestational age, monitor fetal growth, and inform the mother of possible complications (e.g. placenta location, fetus number and position, amniotic liquid) should be tested. Source: Lancet series on Ending Preventable Still births, Lancet 2016; 387:703–16 109 ANNEXES Timing S. N. Antepartum stillbirth effect Intrapartum stillbirth effect Before pregnancy and basic antenatal care 1. Peri-conceptional folic acid fortification 41% 41% 2. Insecticide-treated bed nets or intermittent preventive treatment for malaria prevention during pregnancy 22% NA 3. Syphilis screening and treatment 80% NA Advanced antenatal care Detection and management of hypertensive disease of pregnancy 20% 20% 4. Detection and management of diabetes of pregnancy 10% 10% 5. Detection and management of fetal growth restriction 20% 20% 6. Identification and induction of mothers with ≥41 weeks of gestation 69% 69% Obstetric care 7. Skilled care at birth and immediate care for neonates NA 23% 8. Basic emergency obstetric care NA 45% 9. Comprehensive emergency obstetric care NA 75% Intervention ≥25 per 1000 births 15–24.9 per 1000 births 5–14.9 per 1000 births Peri-conceptional folic acid supplementation or fortification No No Yes Insecticide-treated bed nets or intermittent preventive treatment for malaria prevention during pregnancy Yes (situational) Yes Yes Syphilis detection and treatment Yes (situational) Yes Yes Detection and management of hypertensive disease of pregnancy No No Yes Detection and management of diabetes of pregnancy No No Yes Detection and management of fetal growth restriction No No Yes Identification and induction of mothers with ≥41 weeks of gestation No No Yes Skilled care at birth and immediate care for neonates Yes Yes Yes Basic emergency obstetric care Yes Yes Yes Comprehensive emergency obstetric care Yes Yes Yes “Yes” refers to inclusion of that intervention in the combination of interventions for that particular stillbirth rate. “No” refers to non-inclusion. Estimated effects of interventions on antepartum and intrapartum stillbirths 99% coverage with these ten interventions could prevent 45% of stillbirth at a cost of US $ 9.6 billion Estimated effect of interventions at various levels of stillbirth rate Source: Bhutta ZA, Yakoob MY, Lawn JE, Rizvi A, Friberg IK, Weissman E et al.; Lancet’s Stillbirths Series steering committee. Stillbirths: what difference can we make and at what cost? Lancet. 2011;377(9776):1523–38. doi: 10.1016/S0140-6736(10)62269-6. Source: Bhutta ZA, Yakoob MY, Lawn JE, Rizvi A, Friberg IK, Weissman E et al.; Lancet’s Stillbirths Series steering committee. Stillbirths: what difference can we make and at what cost? Lancet. 2011;377(9776):1523–38. doi: 10.1016/S0140-6736(10)62269-6. 110 ANNEXES ANNEX 5: Preconception package A STRATEGY FOR COUNTRY ACTION Assess the strengths and weaknesses of the preconcep- tion care system in place Create vational platforms and partnerships to ensure political commitment Delivering the intervention package Maximizing the gains for maternal and child health Leverage on existing public health programmes Reproductive/maternal health early child development Adolescent health Nutrition Immunization HIV Enviornmental health Violence prevention Mental health Preconception Care implementation strategy Adapt the intervention package Identify target population Strengthen human resources Explore innovative ways and channels in delivering preconception care interventions Schools Workplaces Civil society groups Electronic health technologies Mobilize financial resources Establish a plan for monitoring and evaluation AREAS ADDRESSED BY THE PRECONCEPTION CARE PACKAGE Mental health Psychoactive substance use Human immunodefi- ciency virus (HIV)Too early, unwanted and rapid successive pregnancies Infertility/ subfertility Female genital mutilation Genetic conditions Enviornmental health Nutritional conditions Vaccine- preventable diseases Sexually transmitted infections Interpersonal violence Tobacco use Source: WHO. Preconception care: maximizing the gains for maternal and child health Policy brief, 2013 111 ANNEXES Eight scheduled ANC contacts (weeks of gestation) Antenatal care contact schedules 1 ANC (12 weeks) 2 ANC (20 weeks) 3 ANC (26 weeks) 4 ANC (30 weeks) 5 ANC (34 weeks) 6 ANC (36 weeks) 7 ANC (38 weeks) 8 ANC (40 weeks) A. Nutrition Diet and physical activity A.1.1 √ √ √ √ √ √ √ √ Iron and folic acid A.2.1 √ √ √ √ √ √ √ √ B. Maternal and fetal assessment Gestational diabetes mellitus B. 1.4 √ √ √ √ √ √ √ √ Tobacco use B. 1.5 √ √ √ √ √ √ √ √ Substance use B. 1.6 √ √ √ √ √ √ √ √ HIV and syphilis B.1.7 √ -- -- -- -- -- -- -- Ultrasound scan B.2.4 √ √ -- -- -- -- -- -- C. Preventive measures Asymptomatic bacteriuria (ASB) C.1 √ -- √ -- √ -- -- -- Tetanus toxoid vaccination C.5 √ -- -- -- -- -- -- -- D. Interventions for common physiological symptoms Nausea and vomiting D.1 √ √ √ -- -- -- -- -- Heartburn D.2 √ √ √ √ √ √ √ √ Leg cramps D.3 √ √ √ √ √ √ √ √ Back and pelvic pain D.4 √ √ √ √ √ √ √ √ Constipation D.5 √ √ √ √ √ √ √ √ Varicose veins and oedema D.6 √ √ √ √ √ √ √ √ E. Health systems interventions to improve utilization and quality of antenatal care Woman-held case notes E.1 √ √ √ √ √ √ √ √ Task shifting of antenatal care delivery E.5.1 √ √ √ √ √ √ √ √ ANNEX 6: Recommendations on ANC for a positive pregnancy experience, mapped to eight scheduled ANC contacts R ec om m en de d 112 ANNEXES Eight scheduled ANC contacts (weeks of gestation) Antenatal care contact schedules 1 ANC (12 weeks) 2 ANC (20 weeks) 3 ANC (26 weeks) 4 ANC (30 weeks) 5 ANC (34 weeks) 6 ANC (36 weeks) 7 ANC (38 weeks) 8 ANC (40 weeks) A. Nutrition Diet and physical activity A.1.2 √ √ √ √ √ √ √ √ A.1.3 √ √ √ √ √ √ √ √ Iron and folic acid A.2.2 √ √ √ √ √ √ √ √ Calcium supplements A.3 √ √ √ √ √ √ √ √ Vitamin A supplements A.4 √ √ √ √ √ √ √ √ Restricting caffeine intake A.10.1 √ √ √ √ √ √ √ √ B. Maternal and fetal assessment Anaemia B.1.1 √ -- √ -- -- √ -- -- Asymptomatic bacteriuria (ASB) B.1.2 √ -- √ -- √ -- -- -- Intimate partner violence (IPV) B.1.3 √ √ √ √ √ √ √ √ Tuberculosis (TB) B.1.8 √ -- -- -- -- -- -- -- Daily fetal movement counting (?) B.2.1 Symphysis-fundal height (SFH) measure B.2.2 √ √ √ √ √ √ √ √ C. Preventive measures Antibiotic prophylaxis – recurrent UTI (?) C.2 Antenatal anti-D immunoglobulin (?) C.3 Preventive anthelminthic treatment C.4 -- √ -- -- -- -- -- -- Malaria prevention: (IPTp) C.6 √ √ √ √ -- √ -- √ Exposure prophylaxis for HIV prevention C.7 √ -- -- -- -- -- -- -- E. Health systems interventions to improve utilization and quality of antenatal care Midwife-led continuity of care E.2 √ √ √ √ √ √ √ √ Group antenatal care (?) E.3 Community-based interventions to E.4.1 √ √ √ √ √ √ √ √ Improve communication and support E.4.2 √ √ √ √ √ √ √ √ Recruitment / retention of staff in rural/remote areas E.6 √ √ √ √ √ √ √ √ C on te xt -s pe ci fi c re co m m en da ti on ( m or e re se ar ch ) Source: WHO. Preconception care: maximizing the gains for maternal and child health Policy brief, 2013 113 ANNEXES Area Care option No Recommendation Respectful maternity care 1 Respectful maternity care – which refers to care organized for and provided to all women in a manner that maintains their dignity, privacy and confidentiality, ensures freedom from harm and mistreatment, and enables informed choice and continuous support during labour and childbirth – is recommended. Effective communication 2 Effective communication between maternity care providers and women in labour, using simple and culturally acceptable methods Companionship during labour and childbirth 3 A companion of choice is recommended for all women throughout labour and childbirth. Definitions of the latent and active first stages of labour 5 The use of the following definitions of the latent and active first stages of labour is recommended for practice. • The latent first stage is a period of time characterized by painful uterine contractions and variable changes of the cervix, including some degree of effacement and slower progression of dilatation up to 5 cm for first and subsequent labours. • The active first stage is a period of time characterized by regular painful uterine contractions, a substantial degree of cervical effacement and more rapid cervical dilatation from 5 cm until full dilatation for first and subsequent labours Duration of the first stage of labour 6 Women should be informed that a standard duration of the latent first stage has not been established and can vary widely from one woman to another. However, the duration of active first stage (from 5 cm until full cervical dilatation) usually does not extend beyond 12 hours in first labours, and usually does not extend beyond 10 hours in subsequent labours. Routine assessment of fetal well-being on labour admission 13 Auscultation using a Doppler ultrasound device or Pinard fetal stethoscope is recommended for the assessment of fetal well-being on labour admission. Digital vaginal examination 16 Digital vaginal examination at intervals of four hours is recommended for routine assessment of active first stage of labour in low-risk women. Intermittent fetal heart rate auscultation during labour 18 Intermittent auscultation of the fetal heart rate with either a Doppler ultrasound device or Pinard fetal stethoscope is recommended for healthy pregnant women in labour. Epidural analgesia for pain relief 19 Epidural analgesia is recommended for healthy pregnant women requesting pain relief during labour, depending on a woman’s preferences. Opioid analgesia for pain relief 20 Parenteral opioids, such as fentanyl, diamorphine and pethidine, are recommended options for healthy pregnant women requesting pain relief during labour, depending on a woman’s preferences. ANNEX 7: Recommendations on intrapartum care for a positive childbirth experience (INCLUDES ONLY RECOMMENDATIONS) C ar e th ro ug h- ou t la bo ur a nd b ir th Fi rs t st ag e of la bo ur 114 ANNEXES Area Care option No Recommendation Relaxation techniques for pain management 21 Relaxation techniques, including progressive muscle relaxation, breathing, music, mindfulness and other techniques, are recommended for healthy pregnant women requesting pain relief during labour, depending on a woman’s preferences. Manual techniques for pain management 22 Manual techniques, such as massage or application of warm packs, are recommended for healthy pregnant women requesting pain relief during labour, depending on a woman’s preferences. Oral fluid and food 24 For women at low risk, oral fluid and food intake during labour is recommended. Maternal mobility and position 25 Encouraging the adoption of mobility and an upright position during labour in women at low risk is recommended. Definition and duration of the second stage of labour 33 The use of the following definition and duration of the second stage of labour is recommended for practice. • The second stage is the period of time between full cervical dilatation and birth of the baby, during which the woman has an involuntary urge to bear down, as a result of expulsive uterine contractions. • Women should be informed that the duration of the second stage varies from one woman to another. In first labours, birth is usually completed within 3 hours whereas in subsequent labours, birth is usually completed within 2 hours. Birth position (for women without epidural analgesia) 34 For women without epidural analgesia, encouraging the adoption of a birth position of the individual woman’s choice, including upright positions is recommended. Birth position (for women with epidural analgesia) 35 For women with epidural analgesia, encouraging the adoption of a birth position of the individual woman’s choice, including upright positions, is recommended Method of pushing 36 Women in the expulsive phase of the second stage of labour should be encouraged and supported to follow their own urge to push. Techniques for preventing perineal trauma 38 For women in the second stage of labour, techniques to reduce perineal trauma and facilitate spontaneous birth (including perineal massage, warm compresses and a “hands on” guarding of the perineum) are recommended, based on a woman’s preferences and available options. Prophylactic uterotonics 41 The use of uterotonics for the prevention of postpartum haemorrhage (PPH) during the third stage of labour is recommended for all births. 42 Oxytocin (10 IU, IM/IV) is the recommended uterotonic drug for the prevention of postpartum haemorrhage (PPH). 43 In settings where oxytocin is unavailable, the use of other injectable uterotonics (if appropriate, ergometrine/ methylergometrine, or the fixed drug combination of oxytocin and ergometrine) or oral misoprostol (600 µg) is recommended. Delayed umbilical cord clamping 44 Delayed umbilical cord clamping (not earlier than 1 minute after birth) is recommended for improved maternal and infant health and nutrition outcomes. Controlled cord traction (CCT) 45 In settings where skilled birth attendants are available, controlled cord traction (CCT) is recommended for vaginal births if the care provider and the parturient woman regard a small reduction in blood loss and a small reduction in the duration of the third stage of labour as important. Se co nd s ta ge o f l ab ou r Th ir d st ag e of la bo ur 115 ANNEXES Area Care option No Recommendation Skin-to-skin contact 48 Newborns without complications should be kept in skin-to-skin contact (SSC) with their mothers during the first hour after birth to prevent hypothermia and promote breastfeeding. Breastfeeding 49 All newborns, including low-birth-weight (LBW) babies who are able to breastfeed, should be put to the breast as soon as possible after birth when they are clinically stable, and the mother and baby are ready. Haemorrhagic disease prophylaxis using vitamin K 50 All newborns should be given 1 mg of vitamin K intramuscularly after birth (i.e. after the first hour during which the infant should be in skin-to-skin contact with the mother and breastfeeding should be initiated). Bathing and other immediate postnatal care of the newborn 51 Bathing should be delayed until 24 hours after birth. If this is not possible due to cultural reasons, bathing should be delayed for at least six hours. Appropriate clothing of the baby for ambient temperature is recommended. This means one to two layers of clothes more than adults, and use of hats/caps. The mother and baby should not be separated and should stay in the same room 24 hours a day. Uterine tonus assessment 52 Postpartum abdominal uterine tonus assessment for early identification of uterine atony is recommended for all women. Routine postpartum 55 All postpartum women should have regular assessment of vaginal bleeding, uterine contraction, fundal height, temperature and heart rate (pulse) routinely during the first 24 hours starting from the first hour after birth. Blood pressure should be measured shortly after birth. If normal, the second blood pressure measurement should be taken within six hours. Urine void should be documented within six hours. Postnatal discharge following uncomplicated vaginal birth 56 After an uncomplicated vaginal birth in a health care facility, healthy mothers and newborns should receive care in the facility for at least 24 hours after birth. Source: WHO recommendations on intrapartum care for a positive childbirth experience. Summary list of recommendations on intrapartum care for a positive childbirth experience, 2018 C ar e of t he n ew bo rn C ar e of w om an a ft er b ir th 116 ANNEXES ANNEX 8: Recommendations on postnatal care for mothers and newborns POSTNATAL CARE HIGHLIGHTS PROVISION OF POSTNATAL CARE TO MOTHERS AND NEWBORNS • Provide postnatal care in the first 24 hours for every birth: • Delay facility discharge for at least 24 hours. • Visit women and babies with home births within the first 24 hours. • Provide every mother and baby a total of four postnatal visits on: • First day (24 hours) • Day 3 (48–72 hours) • Between days 7 and 14 • Six weeks • Offer home visits by midwives, other skilled providers or well-trained and supervised community health workers (CHWs). • Use chlorhexidine after home delivery in high newborn mortality settings. • Re-emphasize and support elements of quality postnatal care for mother and newborn, including identification of issues and referrals. WHO RECOMMENDATION 2013 RECOMMENDATION 1: Timing of discharge from a health facility after birth After an uncomplicated vaginal birth in a health facility, healthy mothers and newborns should receive care in the facility for at least 24 hours after birth. For the newborn, this care includes an immediate assessment at birth, a full examination around 1 hour after birth and before discharge. Source: WHO, USAID, MCHIP. Postnatal Care for Mothers and Newborns. Highlights from the World Health Organization 2013 Guidelines. 117 ANNEXES RECOMMENDATION 2: Number and timing of postnatal contacts If birth is in a health facility, mothers and newborns should receive postnatal care in the facility for at least 24 hours after birth. If birth is at home, the first postnatal contact should be as early as possible within 24 hours after birth. At least three additional postnatal contacts are recommended for all mothers and newborns, on day 3 (48–72 hours), between days 7 and 14, and 6 weeks after birth. RECOMMENDATION 3: Home visits for postnatal care Home visits in the first week after birth are recommended for care of the mother and newborn. RECOMMENDATION 4: Assessment of the baby The following should be assessed during each postnatal care contact, and the newborn should be referred for further evaluation if any of the signs is present: Stopped feeling well, history of convulsions, fast breathing (rate of ≥ 60 per minute, severe chest indrawing, no spontaneous movement, fever (temperature ≥37.5 ºC), low body temperature (temperature <35.5 ºC), any jaundice in first 24 hours of life, or yellow palms and soles at any age. The family should be encouraged to seek care early if they identify any of the above danger signs in-between postnatal care visits. RECOMMENDATION 5: Exclusive breastfeeding (EBF) All babies should be exclusively breastfed from birth until 6 months of age. Mothers should be counselled and provided support for EBF at each postnatal contact. RECOMMENDATION 6: Cord care Daily chlorhexidine (7.1% chlorhexidine digluconateaqueous solution or gel, delivering 4% chlorhexidine) application to the umbilical cord stump during the first week of life is recommended for newborns who are born in settings with high neonatal mortality (30 or more neonatal deaths per 1000 live births). Clean, dry cord care is recommended for newborns born in health facilities and at home in low neonatal mortality settings. Use of chlorhexidine in these situations may be considered only to replace application of a harmful traditional substance, such as cow dung to the cord stump. RECOMMENDATION 7: Other postnatal care of the newborn Bathing should be delayed until 24 hours after birth. If this is not possible due to cultural reasons, bathing should be delayed for at least 6 hours. Appropriate clothing of the baby for ambient temperature is recommended. This means one to two layers of clothes more than adults, and use of caps. The mother and the baby should not be separated and should stay in the same room 24 hours a day. 118 ANNEXES Communication and play with the newborn should be encouraged. Immunization should be promoted as per existing WHO guidelines. Preterm and low-birth-weight babies should be identified as soon as possible and should be provided special care as per existing WHO guidelines. RECOMMENDATION 8: Assessment of the mother First 24 hours after birth: All postpartum women should have regular assessment of vaginal bleeding, uterine contraction, fundal height, temperature and heart rate (pulse) routinely during the first 24 hours starting from the first hour after birth. Blood pressure should be measured shortly after birth. If normal, the second blood pressure measurement should be taken within 6 hours. Urine void should be documented within 6 hours. Beyond first 24 hours after birth: At each subsequent postnatal contact, enquiries should continue to be made about general well-being and assessments made regarding the following: urination and urinary incontinence, bowel function, healing of any perineal wound, headache, fatigue, back pain, perineal pain and perineal hygiene, breast pain, uterine tenderness and lochia. Breastfeeding should be assessed at each postnatal contact. At each postnatal contact, women should be asked about their emotional well-being, what family and social support they have and their usual coping strategies for dealing with day-to-day matters. All women and their families/partners should be encouraged to tell their health-care professional about any changes in mood, emotional state and behaviour that are outside of the woman’s normal pattern. At 10–14 days after birth, all women should be asked about resolution of mild, transitory postpartum depression (“maternal blues”). If symptoms have not resolved, the woman’s psychological well-being should continue to be assessed for postpartum depression, and if symptoms persist, evaluated. Women should be observed for any risks, signs and symptoms of domestic abuse. Women should be told whom to contact for advice and management. All women should be asked about resumption of sexual intercourse and possible dyspareunia as part of an assessment of overall well-being 2–6 weeks after birth. If there are any issues of concern at any postnatal contact, the woman should be managed and/or referred to according to other specific WHO guidelines. RECOMMENDATION 9: Counselling All women should be given information about the physiological process of recovery after birth and told that some health problems are common, with advice to report any health concerns to a health-care professional, in particular, signs and symptoms of postpartum haemorrhage, pre-eclampsia/eclampsia, infection and thromboembolism. Women should be counselled on nutrition. Women should be counselled on hygiene, especially hand washing. Women should be counselled on birth spacing and family planning. Contraceptives should be discussed, and contraceptive methods should be provided if requested. Women should be counselled on safer sex including use of condoms. In malaria-endemic areas, mothers and babies should sleep under insecticide-impregnated bed nets. All women should be encouraged to mobilize as soon as appropriate following the birth. They should be encouraged to take gentle exercise and make time to rest during the postnatal period. 119 ANNEXES RECOMMENDATION 10: Iron and folic acid supplementation Iron and folic acid supplementation should be provided for at least 3 months after delivery. RECOMMENDATION 11: Prophylactic antibiotics The use of antibiotics among women with a vaginal delivery and a third or fourth degree perineal tear is recommendation for prevention of wound complications. There is insufficient evidence to recommend the routine use of antibiotics in all low-risk women with a vaginal delivery for prevention of endometritis. RECOMMENDATION 12: Psychosocial support Psychosocial support by a trained person is recommended for the prevention of postpartum depression among women at high risk of developing this condition. There is insufficient evidence to recommend routine formal debriefing to all women to reduce the occurrence/risk of postpartum depression or to recommend routine distribution of, and discussion about, printed educational material for prevention of postpartum depression. Health professionals should provide an opportunity for women to discuss their birth experience during their hospital stay. A woman who has lost her baby should receive additional supportive care. Source: WHO, USAID, MCHIP. Postnatal Care for Mothers and Newborns. Highlights from the World Health Organization 2013 Guidelines. 120 ANNEXES ANNEX 9: Recommendations for ensuring human rights in the provision of contraceptive information and services Human rights standard as set out in WHO Guidelines Rights-related outcomes (examples) Measures 1. Non-discrimination Equal access to contraceptive services and information Contraceptive cost; contraceptive uptake by new users; adolescent contraceptive use 2. Availability of contraceptive information and services Method mix; modern contraceptive prevalence; facilities available; commodity stock-outs; provider capacity; funds budgeted to family planning Method mix; modern contraceptive prevalence; facilities available; commodity stock outs; provider capacity; funds budgeted to family planning 3. Accessibility of contraceptive information and services Contraceptive cost; distance to services; modern contraceptive prevalence; contraceptive uptake by new users; adolescent contraceptive use Contraceptive cost; distance to services; modern contraceptive prevalence; contraceptive uptake by new users; adolescent contraceptive use 4. Acceptability of contraceptive information and services 5. Quality of contraceptive information and services 6. Informed decision-making 7. Privacy and confidentiality Client satisfaction; client retention; direct referrals; new users; provider satisfaction; provider retention; community trust in programme; demand for services Client satisfaction; client retention; direct referrals; new users; provider satisfaction; provider retention; community trust inprogramme; demand for services Meeting the established standard of care; method mix; range of services available; client satisfaction; provider satisfaction; access to follow-up 8. Participation Mechanisms for women’s participation 9. Accountability Redress and remedies Source: WHO, UNFPA. Ensuring human rights within contraceptive service delivery: implementation guide, 2015. 121 ANNEXES Regional and global strategies/guidelines of relevance to the SRHR Strategic Framework ANNEX 10: Relevant document 1. WHO SEARO Improving newborn and child health – A Strategic Framework 2018–2022 https://apps.who.int/iris/handle/10665/274311 2. WHO SEARO Strategic Action Plan to Reduce the Double Burden of Malnutrition in South-East Asia Region 2016–2025 https://apps.who.int/iris/handle/10665/253377 3. WHO SEARO Accelerating actions for adolescent health in South-East Asia 2018–2022 http://origin.searo.who.int/entity/child_adolescent/topics/adolescent_health/978-92-9022-647-5/en/ 4. WHO SEARO Regional Vaccine Action Programme 2016–20 5. WHO SEARO Management of sexually transmitted infections: Regional guidelines 6. Strategic Framework for the comprehensive control of cancer cervix in South-East Asia Region, 2015 7. A Training Package on cervical cancer screening and management of cervical pre-cancers 2017 (SEAR publication) 8. WHO SEARO and UNAIDS. Regional Action Plan for HIV in South-East Asia (2017–2021) 9. WHO SEARO: Decade for health workforce strengthening in the South-East Asia Region 2015–24, Second Review of Progress 10. Improving the Quality of Care for Reproductive, Maternal, Neonatal, Child and Adolescent Health in South-East Asia Region: A Regional Framework 122

126 CHAPTER 1