WORLD H E A L T H ORGANIZATION
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ORGANISATION MONDIALE DE ^ SANTE
Regional Office for the Western Pacific Bureau regional du Pacifique occidental REGIONAL COMMITTEE Thirty-ninth session Manila 12-16 September 1988 Provisional agenda item 14 WPR/RC39/9 Corn 1 27 July 1988 ORIGINAL: ENGLISH
NATIONAL MATERNAL AND CHILD HEALTH POLICIES AND STRATEGIES
CORRIGENDUM Page 3, second paragraph, line 5 For The disparity is even 100 read The rate is over ten Page 13, ANNEX 4 Replace the chart with the attached revised one.
WPR/RC39/9 page 13 ANNEX4 MATERNAL MORTALITY RATES PER 100 000 LIVE BIRTHS IN DEVELOPED AND DEVELOPING COUNTRIES OF THE REGION*
Developed Countries Australia Japan New Zealand Singapore
MMR 11(1981) 15 (1983) 20 (1983) 11 (1983)
Developing Countries China Fiji Malaysia Papua New Guinea Philippines Republic of Korea Viet Nam
MMR 44(1984) 47 (1982) 59(1981) 700-1000(1982) 80(1984) 34(1985) 110(1983)
'Source: Maternal Mortality Rates - A tabulation of available information. (WHO document FHE/86.3, 2nd ed.), 1986.
WORLD HEALTH ORGANIZATION
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ORGANISATION MONDIALE DE LA SANTE
Regional Oft'ke for the Westena Pacllk Bureau rigional du Padflque oc:ddental
REGIONAL COMMITTEE Thirty-ninth session Manila 12-16 September 1988
WPRIRC39/9 20May 1988
ORIGINAL: ENGLISH
Provisional agenda item 14
NATIONAL MATERNAL AND CHILD HEALTH POLICIES AND STRATEGIES
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·.·. th~> ar¢8 ~fchild health; and.infanfmortatity ra!es have he,en reduced
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> Ninet}t~r &llt or < the cil~>> rir > ffiat~ril~f .ri6rtalit:Y ····>~t~. · ·<· · prevent.able/ J>roVided the qualitY of ·care < and ooverage·is>ensured.} .WHo Is seeking to erioourage Member State:S tO review the•exiSHrig .· situation arid to take urgent ste..- for the reduetiOri or matel"rial and > perinatallllol'bidity and mortality. ... .. . .
< < > ad6pt&lbf th~ ·Fortieth·World Health.AsSembly, which·iS pr&ent&t iii < ADnex:2. < ··· ·· · ··
·.·.· •·•· · ·•·• •·· < the C01Dhlittee's ·llHentioniS drawn ·tB< res<>lutK>Il.·• WHA4o.27 ·.· •·
WPR/RC39/9 page2
1. INTRODUCfiON
Maternal and child health, including family planning (MCH!FP) concerns the health of all mothers and children. 1 The maternal and child health/family planning programme, through its life-saving, life-giving and life-improving health activities, contributes substantially to the amelioration of human development. Like the two sides of a single coin, the programme, on the one hand, responds to the basic maternal health care needs, including family planning, while, on the other hand, it satisfies the need for continuing health supervision and total medical care of all children from birth through childhood and adolescence. 2 Because of the sheer magnitude of its target population, who constitute two thirds of the total population in developing countries, the maternal and child health/family planning programme clearly plays a decisive role in attaining the health-for-all goal in the Region. As considerable progress has been made in child health through various programmes, this paper will focus more on maternal and perinatal morbidity and mortality as these are felt to be the crucial issues of the programme at the present time. 2. POLICIES, OBJECfiVES AND STRATEGIES As with all programmes, the impact of maternal and child health/family planning largely
depends on the volume of the technical and financial resources allocated to it and the strategies adopted; in other words it depends on the priority given to it. The main bases of the policy guidelines and strategies adopted in countries of the Region are provided by the various resolutions of the World Health Assembly, the Executive Board and the Regional Committee. World Health Assembly resolution WHA32.42 on the long-term programme for maternal and child health and the recently adopted resolution WHA40.27 on maternal health and safe motherhood are presented in Annexes 1 and 2, respectively. In addition, a joint WHO/UNICEF statement: Maternal care for the reduction of perinatal and neonatal mortality, issued in 1986, is an important guide to programme policy. 3 The WHO Western Pacific Region has collaborated with countries of the Region in translating maternal and child health- related policies emerging from World Health Assembly, Executive Board and Regional Committee resolutions into concrete activities through the respective national maternal and child health/family planning programmes. 3. REGIONAL SITUATION Significant progress has been made in the maternal and child health/family planning programmes, especially in the area of child health, over the last two decades. Most countries or areas in the Region have achieved infant mortality rates of below fifty per 1000 live births. This may also be due to the large technical and financial resources invested in special programmes such as immunization, diarrhoeal diseases, acute respiratory infections, nutrition and family planning. However, despite the impressive gains in infant mortality reduction, maternal mortality rates are still unacceptably high in some parts of the Region (as high as 900 per 100 000 live births in one country).
1WHO Technical Report Series, No. 600, 1976 (Sixth report of the WHO Expert Committee on Maternal and Child Health).
2WHO Technical Report Series, No. 731, 1986 (Report of a WHO Study Group on Young People and "Health for All by the Year 2000"). 3Maternal care for the reduction of perinatal and neonatal mortality. A joint WHO/UNICEF statement. Geneva, World Health Organization, 1986.
WPR/RC39/9 page3
4. MATERNAL MORTALI1Y AND MORBIDI1Y
As in most other parts of the developing world, maternal health care in the developing countries of the Region has remained a neglected component of the maternal and child health programme. Concern about this tragic issue has been expressed for some years by WHO.
A WHO estimate, based on the available data, reports that 86% of the world's live births and 99% of maternal deaths occur in the developing countries (Annex 3). A comparative analysis of the maternal mortality rates in the Region reveals not only an alarmingly high maternal mortality rate in developing countries but also a high level of disparity between the developing and developed countries. The disparity is even 100 times greater in some developing countries compared with the developed countries of the Region (Annex 4). Clearly, this underlines the continuing neglect of women's health, particularly in the developing countries. To this extent, maternal mortality is an indicator of inequity or neglect on the part of the health services. The principal issues involved are the coverage and utilization of available health care facilities, the training of health care providers (which will determine the quality of care), the accessibility of a first-level referral system and the knowledge, education and motivation of the public. Whether a woman becomes socially and biologically fit at a given age for child bearing depends largely on her access to an equitable share of food, health care and education. Short stature, low body weight, anaemia combined with unwanted pregnancy may set a young girl on the maternal death trail, particularly if she is drawn into the vicious circle of repeated pregnancies. Once these women enter the reproductive cycle, many lack access to good prenatal care, either because there are no health facilities or because they do not know how to use them. This results in the lack of early and efficient detection and referral of complications and of the assistance of a trained person during child birth. It is not uncommon to see such a situation in many developing countries, especially in the rural and remote areas. The most distressing fact about maternal mortality is that most women requiring life-saving care for obstetrical emergencies, such as postpartum and antepartum haemorrhage, obstructed labour, infection and toxaemia, do not get them at the time of need. Of the few who do somehow reach the first referral level, quite a number die through lack of appropriate facilities. The reasons for this are principally related to shortcomings in the health care system, which is not only out of reach of the prospective mother for financial and logistic reasons but is also often technically deficient. Furthermore, health authorities tend to ignore the fact that if maternal care is inadequate, any further reduction in infant and child mortality will not be possible, for it is well established that more than half of the infant deaths that occur do so within the neonatal period. Another important problem, but less related to the maternal and child health services, is that of illegal abortion. This is a significant cause of maternal mortality in early pregnancy and often passes unreported. The problem is twofold - first, absence of liberal legislation regarding abortion, and second, lack of access to the health services, even where abortion is legal. The next step in the maternal mortality issue is to identify the policy strategies that would give the "M" of MCH its technically and socially justifiable priority. The studies carried out on maternal mortality in China, Papua New Guinea and VietNam, as well as risk approach studies in China, have provided much important information which could be used in formulating technically feasible and financially affordable policies and strategies for the prevention of maternal mortality
WPRJRC39/9 page4
and morbidity. For example, puerperal sepsis, haemorrhage, ectopic pre1nancy and ruptured uterus were found to be leading causes of maternal mortality in Viet Nam, while in China also obstetric haemorrhage topped the list followed by pregnancy- induced hypertension, heart disease in pregnancy, amniotic embolism, pregnancy-related hepatic diseases and puerperal sepsis. 2 These observations clearly indicate the need for quality care and the need for adequate first referral services. Ninety per cent of the causes of maternal mortality are preventable with technologies which have a proven record of safety and cost-effectiveness provided there are trained personnel and available services. The question, however, is how to make these health care technologies easily accessible to women according to their health needs, regardless of their socioeconomic status and geographical location. The risk approach is one of the appropriate management methodologies that are being tested in several countries of the Region. The Malaysian study on the risk approach has reported a better rapport between the community and the health care system and a decline in maternal mortality from 190 per 100 000 live births in 1976 to 0 in 1982 during the project period ( 4697 and 4577 deliveries respectively in Krian District. 3 In China, the Government, on the basis of the positive experience gained in Shunyi County as a result of a WHO collaborative risk approach study, has incorporated the risk approach into its overall Seventh Five-Year Plan from 1987. According to the plan, the risk approach will be implemented in all cities with a population of more than 300 000 (159 cities). The use of a home-based maternal record (HBMR) was found to increase the utilization of prenatal care, the diagnosis and referral of at-risk pregnancies and newborns, the practice of family planning, and the continuation of contraceptive use (WHO 18-country study on HBMR). The use of HBMR was found to be effective in the Philippines, where it is being expanded into other provinces. It is also being initiated in several other countries or areas of the Region, notably in the Lao People's Democratic Republic, Papua New Guinea and VietNam. A national conference and workshop on safe motherhood, was held in Manila in September 1987 with strong political support. This can be cited as an important example of promotional activity in terrns of raising multisectoral national awareness. These examples show that it is feasible to affect political will. There are technologies that can be adopted to different situations, but the crux of the problem remains accessibility to and utilization of services. For the latter the reason could be lack of awareness or limited health education efforts. It appears that health education of mothers has not made much progress in many countries and there is an urgent need to have a new look into its deficiencies.
1Survey on institutional maternal mortality in selected areas of Viet Nam. Obstetrics, Hanoi and WHO, 1985.
Institute of Gynaecology and
2Maternal mortality in Shanghai, China, Chen Ru Jun. WHO Interregional Meeting on Prevention of Maternal Mortality, Geneva, 11-15 November 1985. 3Ministry
of Health, Malaysia. WHO country report , Risk approach in maternal and child health care, November
1983.
WPR/RC39/9 page5
5. PERINATAL MORTALI1Y AND MORBIDI1Y Related to the care of pregnancy and the problem of maternal mortality is the risk to the baby during pregnancy. It is obvious that proper antenatal care can have a major impact on perinatal mortality. 1 It has already been noted that neonatal and perinatal mortality may account for up to 50% of the infant mortality rate and this proportion will rise as childhood diseases such as measles, acute diarrhoea and acute respiratory infections are controlled. Stillbirth and low birth weight due to prematurity, two of the four components of perinatal mortality, are very much related to the health of the mother, especially her nutritional status, and to the quality of antenatal care. This again emphasizes the need for maternal and child health and nutrition services .to reach the entire population· Malaria is a major contributing factor in perinatal mortality in some areas of the Region, and this calls for increased attention to mothers in the endemic areas. Congenital abnormalities are a major concern in some countries, notably in China, where other causes of perinatal mortality are being reduced. The commonest obstetrical complications causing death in the perinatal period are obstructed or prolonged labour, prolapsed cord, and placenta preavia. In these cases, only early diagnosis and a rapid referral system with adequate facilities could help improve the situation. Most early neonatal deaths are in low birth weight and premature babies. Other associated causes of neonatal death are respiratory distress syndrome, brain damage due to birth trauma, congenital abnormalities and infections. Hypothermia is also an easily preventable problem. Prevention of neonatal tetanus and pneumonia, and promotion of breast-feeding are issues that should receive much more attention from the health services.
It can be seen from the foregoing paragraphs that, as with maternal mortality, the causes of perinatal and neonatal mortality are largely preventable by proper healih care without sophisticated technology but with quality care by adequately trained workers. 6. CONCLUSIONS ( 1) Maternal mortality and morbidity in the developing countries of the Region continue to remain high and reflect the wide disparity between the developing and developed countries of the Region. Perinatal mortality is also a major concern. (2) Maternal mortality is an indicator not only of maternal health but also of neonatal health. Using maternal mortality as one of the national indicators for health for all will reflect the
1Perinatal mortality is defined as the total number of still births after 28 weeks of pregnancy plus the number of infant deaths under one week per 1000 births. Neonatal mortality is defined as the number of deaths under 28 days per 1000 live births.
WPRIRC39/9 page6
quality and coverage of health care and thus indicate the prospects of survival for both the mother and the child. (3) Use of simple technologies like a home-based maternal record will increase the utilization of prenatal care wherever available resulting in early diagnosis and referral of at-risk pregnancies and newborns, the practice of family planning and the continuation of contraceptive use, as well as the improved recording and reporting of reliable data. This effort will be successful only if increased attention is paid to maternal health education, increased health coverage and the simultaneous development of an adequate first-level referral system. ( 4) Studies on the extent and causes of maternal and perinatal mortality would help in the formulation of technically and financially feasible policies and strategies for the prevention of maternal mortality for child survival. (5) The health sector should involve sectors such as women's organizations, education and social welfare in its efforts to provide for the care of the mother and child, especially in countries whose services have limited coverage. Such sectors can contribute to health education and social awakening for improved health and the socioeconomic advancement of women. (6) More than one half of infant deaths occur within the neonatal period, mostly due to maternal health-related problems. It is impossible to reduce infant mortality rates any further without improving maternal health care. (7) Apart from the monitoring of the foetus during antenatal care and the proper care of the baby during and immediately after delivery, it is also important that mothers receive adequate support in what used to be called mothercraft - specifically, the establishment of breast-feeding and prevention of infection in the neonatal period. In conclusion, the quality of care the mother receives will determine the outcome of the pregnancy. This quality in its turn depends on the coverage of health services, appropriate training of health workers and the availability of the first-level referral system. As far as the mother is concerned, her knowledge or her health education will complement the efforts of the health sector.
WPR!RC39/9 page7
ANNEXl
THIRTY-SECOND
WORLD
HEALTH ASSEMBLY
WHA32.42 25May 1979
WHO LONG-TERM PROGRANME FOR MATERNAL AND CHILD HEAI..TH
The Thirty-second World Health Assembly, Recalling resolutions WHA27.43, WHA3l.47 and WHA3l.55; Referring to the social target of health for all by the year 2000 and to . the principles regarding primary health care adopted in 1978 at the conference in Alma-Ata; L~unization
Recognizing that maternal arid child h'ealth care including nutrition, family planning and are essential aspects of prUnary hea~th ' care;
Convinced that a rapid development and determined strengthening ' cif maternal arid child health sare are of paramount importance for attaining the goal of health. for all by: the. year 2000; Realizing that , more than one-third of the world's population in the, year. 2000 . is . not yet bern; Recognizing also tha.t. mat:ern. a l and child health is the health priority, firmly interrelated with the s~cial and economic deveJnpmPnt of ev_,ery country; Recognizing that definite iJnprovements in the health of mothers and children have been achieved where special efforts and resources have been committed to this area of health development; Convinced thatit is important t? .. ensure cont.inuation of the· emphasis on the welfare of children started · during the International Year of the' Child; Thanking the Director-General for his comprehensive and informative report providing the background for action .now, 1.
URGES Member States: (1) to further develop their .overall health and socioeconomic planning giving . due and exp.lidt attention to meeting ' health and other needs of mothers, children and . the ; 'ta~ily, and to ensure appropriate distribution of national resources to this end; (2) to promote specific governmental regulations and laws to provide free health services at least during periods of high risk: pregnancy, delivery arid the first years of life when breastfeeding, immunization and treatment of infectious and parasitic diseases are crucial for survival; (J) · to proinote the development of primary health care programmes with concrete plans for maternal and child health care as its essential component that includes care during pregnancy and childbirth, family planning, infant and child care with appropriate focus on improvement of nutrition, prev~ntion of infections~ promotion of physicial and psychological development of c:he child, and education for family life; (4) to ensure the development of appropriate supportive, referral and training services in paediatrics, obstetrics and oc:her related subjects in line with principles of primary
WPRJRC39/9 page8
Annex 1 WHA32 .42 page 2 (5) to ensure active participation of individuals, families and communities in the development and utilization of maternal and child heal"th care; (6) to d~velop, as appropriate, health and related social services such as day-care services, school health, adolescent services and relevant sociaL legislation in support of mothers and children; · .
(7) to encourage new approaches for simpler, more direct and massive actions to bring to those famiLies, mothers and children most in need those essential health and educational services which are still unavailable to them and review when appropriate present utilization of all health personnel including traditional health workers in order to ensure a better use of existing resources for maternal and child health; (8) to develop and strengthen the information support necessary for the planning and implementation of maternal and child care at different levels of the health care system;
(9) to include in the planned efforts for maternal and child health specific attempts to reach high-risk and underprivileged groups of mothers and children and their families, and to specifically support all efforts at improving the nutrition of pregnant and lactating mother• and children; (10) to support research and development as well as evaluation in the area of maternal and child health as part of health aervices reaearch;
2.
UQU'ESTS the 1)1rector•Oenna1-&
(1) to aupport, in collaboration with UNICEF and UNFPA, and c~pttant ncnaovarnmental ors•nicatione in otfic~a1 rt1at~ona with the World Haalth oraantattion and with Hambtr Statea forM~lation and impltmtntation of lona•term maternal and child health proarammee ae part of the development ot their atratesiea to reach tha soal of health tor all by the year 20001 (2) to support Member States in setting quantifiable targets and in the utilization of suitable indicators for monitoring the effectiveness of their activities in maternal and child health; (3) to assist Member States in implementing the Expanded Programme on Immunization as an integral part of MCH aervicea;. (4) chemoprophylax~s
to assist Member States in implementing systematic and planned chloroquine of malaria for children and pregnant mothers in highly malarious areas;
(5) to further support Member States in curricular revisions in teaching medical and health sciences to give wider coverage to family health and .maternal and child health and in development o£ training programmes for all categories o£ workers in the health sector as well as other sectors aiming at the increase of their awareness of the relationship between health and socioeconomic factors with particular reference to the development of children; (6) to further develop the Organization's activities for the development of appropriate technology in maternal and cnild health care and promote health services research in this field; (7) to intensify efforts for providing additional support for the Organization's programme in maternal and child health and to mobilize scientific and financial resources in this field; (8) to report progress of this work to a future World Health Assembly. Fourteenth plenary meeting, 25 May 1979 A32/VR/14
WPR/RC39/9 page9
ANNEX2
FORTIETH WORLDHEALTHASSEMBLY Agenda item .. 18.2
WHA40.27 15. May 1987·
MATERNAL HEALTH AND SAFE MOTHERHOOD The ~ortieth
¥orld
H~alth A~~embly~
Recalling resolutions WHA32 .42, wHA38'.22 . and WHA39,18 - <on the WHO lori'g,;.term programme for maternal and child health; maturity before childbearing and pro~otion of responsibl*" parenthood; ~nd implementation requirements of the Nairobi Forward-looking Strategies for the Advancement .of Women in the health sector, respectively; Noting the extremely high levels of maternal mortality and . related ·morbidity prevailing in many developing countries, constituting in some cases more than 50% of all deaths in women of childbearing age; Further considering that the low social status of women, and the poor nutrition of girls, as well as the lack of appropriate care in pregnancy and childbirth, contribute to this problem; Recognizirtg that ml'lternal and child care, inCluding family plartrting; forms the core of primary health dar~; Recalling the recommendations of the World Conference to Review and Appraise the Achievements of the United Nati6ns Decade for Women and the Forward-looking Strategies for the Advancement of Women, which seta speCific target to reduce maternal mortality and morbiditY;' Taking account of the recommendations of the International Conference on Safe Motherhood in Nairobi .in February 1987 cosponsored by WHO, the World Bank and the United Nations Fund for Population Act'iv:l.ties ·, and suppotted by the United Nations Development Programme; 1.
THANKS the Organization for its initiatives in the field of maternal health; URGES Member States: (1) to give high priority to improving the health of women and reducing maternal mortality and morbidity through appropriate primary health care, adequate food and health programmes for girls from infancy to adolescence, and support to family planning programmes in the context of primary health care, making family planning services available to all those who need them in order to avoid unwanted or high-risk pregnancies; (2) to provide appropriate (prenatal) care with efficient and early detection and referral of high-risk pregnancies;
2,
WPRJRC39/9 page 10 Annex2 WHA40.27 page 2 (3) to seek to ensure the attendance of appropriately trained personnel for all women . in childbirth; (4) to strengthen referral facilities and supervision measures in maternal and child health and family planning in order to deal with obstetrical emergencies and provide essential obstetrical care, and take the necessary steps to prepare appropriate staff at all levels; (5) to coordinate action within the health and other sectors to improve women's education and nutrition; and the generation of financial and other resources for appropriate social support during pregnancy, delivery and the first year following childbirth;
3.
REQUESTS the Director-General: (1) to assist countries with high rates of maternal mortality in studies on the dimensions and causes of the problem, and to support national efforts to reorient primary health care action so as to give adequate priority to the reduction of maternal mortality and morbidity; (2) to support collaborative operational research on safe motherhood, with emphasis on preventing the five main causes of maternal mortality and finding local solutions to overcome the obstacles to appropriate maternal care; (3) to intensify technical cooperation in the field of maternal and child health, including family planning, focusing on measures to reduce maternal mortality and morbidity; (4) to increase the Organization's collaboration with appropriate United Nations agencies and nongovernmental organizations, with emphasis on the promotive and preventive aspects of maternal health and family planning and the availability of essential obstetric care at first referral level and in emergencies of pregnancy and childbirth; (5) to intensify efforts to mobilize appropriate human, scientific and financial resources for maternal health programmes, including epidemiological and operational research aspects, and in particular to seek financial support from multilateral and bilateral agencies and foundations to this end. Twelfth plenary meeting, 15 May 1987 A40/VR/12
WPRIRC39/9 page 11
ANNEX3
LIVE BIRTHS AND MATERNAL DEATHS IN DEVELOPED AND DEVELOPING COUNTRIES OF THE WORLD•
LIVE BIRTHS
MATERNAL DEATHS 3% 1%
South Asia Africa IIIMI"w"'H Jo:•,:•:,.~
Latin America East Asia Developed countries
WHO 861663
•Source: Maternal mortality rates. A tabulation of available information. (WHO document FHE/86.3, 2nd ed. ), 1986.
WPR!RC39/9 page 12
WPR/RC39/9 page 13
ANNEX4
MATERNAL MORTALITY RATES PER 100 000 LIVE BIRTHS IN DEVELOPED AND DEVELOPING COUNTRIES OF THE REGION*
Developed Countries
MMR
Developing Countries
MMR
Australia Japan New Zealand Singapore
10 (1980) 18 (1981) 6 (1981) 5 (1981)
China Fiji Malaysia Papua New Guinea Philippines Republic of Korea VietNam
50 (1982) 47 (1982) 59 (1981) 900 (1980) 90 (1983) 41 (1981) 100 (1982)
*Source: Maternal Mortality Rates - A tabulation of available information. (WHO document FHE/86.3, 2nd ed.), 1986.