Bi-Regional Workshop on the Progress of Maternal Mortality Reduction, Manila, Philippines, 27-30 October 2003 : report

(WP)IRPHlICPfRPHl3.3fOO iIRPH( i )f2003-E

Report series number: RSf2003fGEf24(PHL)

English only

REPORT BI-REGIONAL WORKSHOP ON THE PROGRESS OF MATERNAL MORTALITY REDUCTION

Convened by: WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR SOUTH-EAST ASIA REGIONAL OFFICE FOR THE WESTERN PACIFIC

Manila, Philippines 27-30 October 2003

Not for sale Printed and distributed by: World Health Organization Regional Office for the Western Pacific Manila, Philippines June 2004 WHO/WPRO LIBRARY

MANILA, PHILIPPINES

2 '2. JUL 2004

NOTE

The views expressed in this report are those of the participants in the Bi-regional workshop on the progress of maternal mortality reduction.

This report has been prepared by the World Health Organization Regional Office for the Western Pacific for governments of Member States in the Region and for those who participated in the Biregional Workshop on the Progress of Maternal Mortality Reduction, which was held in Manila, Philippines from 27 to 30 October 2003.

CONTENTS

SUMMARY .................................................................................................................................. 1 I. INTRODUCTION ................ ,................................................................................................... 3

1.1 Objectives ...................................................................................................................... 4 1.2 Participants and resource persons ................................................................................. 4 1.3 Organization .................................................................................................................. 5 1.4 Opening ceremony ........................................................................................................ 6 2. PROCEEDINGS ....................................................................................................................... 6 2.1 2.2 2.3 2.4 2.5 2.6

Poster presentations and awards .................................................................................... 6 Global and regional overviews ...................................................................................... 7 Group discussions ......................................................................................................... 9 Problem solving sessions ............................................................................................ 10 Country plans of action ............................................................................................... 12 Closing ........................................................................................................................ 17

3. CONCLUSIONS .......................................................... ,..................................................... 18 ANNEXES: ANNEX I LIST OF PARTICIPANTS, CONSULTANT, TEMPORARY ADVISERS, REPRESENTATIVES, OBSERVERS, AND SECRETARIAT ........................................................................................ 21 AGENDA .................................................................................................. 31 COUNTRIES' ACTION PLANS .............................................................. 33

ANNEX 2 ANNEX 3

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SUMMARY

During the past few years, several workshops have been held in the WHO Western Pacific Region: the Workshop on Maternal Mortality Reduction in Selected Countries in the Western Pacific Region, held in Manila, Philippines, in June 2000; the Workshop on Monitoring Systems for Maternal and Child Mortality in Public Health Care Facilities, held in Kunming, China in September 2001; and the Second Workshop on the Monitoring Systems for Maternal and Child Mortality in Public Health Care Facilities held in Beijing, China, in December 2002. All were aimed at improving maternal and child health, especially in developing countries with high maternal and child mortality. These workshops tackled various aspects of maternal and child health and examined the situation with a view to developing national plans and programmes to further reduce maternal and child mortality. The national programmes have started, and some are more successful than others. It is necessary to review the trends in maternal and child health in countries of the Region to identifY the reasons for successes and failures and find solutions to the problems. Some characteristics and problems in the Western Pacific Region and the South-East Asia Region of WHO are similar, and it was, therefore, decided to hold a workshop for countries in the two Regions, providing an excellent forum for discussing important issues and sharing experiences. As the United Nations Children' Fund (UNICEF) and the United Nations Population Fund (UNFPA) are also very active in the two Regions and suppoli successful projects in the maternal and child health area, they joined WHO by co-sponsoring the workshop. The objectives of the workshop were: (I) to review the progress of maternal mortality reduction and lessons learned during the past four years; (2) to draft a national plan of action (2005-2010) for making pregnancy safer, with particular emphasis on increasing deliveries by skilled birth attendants, strengthening health services to improve accessibility and quality of health services, and increasing participation of individuals, families and communities to improve maternal and neonatal health; and (3) to propose the way forward and the actions necessary to improve maternal and neonatal care. A total of 46 participants from 19 countries of the two WHO Regions attended the workshop, and countries with low, medium and high maternal mortality were reprcsented. There were 13 observers from various nongovernmental organizations and donor agencies. To support the workshop proceedings, several UNICEF and UNFPA country staff joined their country's team of participants. Several staff of the three organizations' regional offices and from WHO Headquarters were present as secretariat. One WHO consultant and two temporary advisers also supported the meeting. During the workshop countries presented their situation and the progress they had made in the previous few years and identified reasons for successes and failures. Expelis from the supporting staff gave global and regional overviews and proposed ways forward. Participants, together with the support staff, then identified solutions that could be introduced for further reduction of maternal mortality. Based on the discussions and the wealth of information shared during the meeting, each country developed a plan of action for implementation at home after review and approval by the appropriate authorities.

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Participants developed a set of conclusions that will be useful for national authorities and international supporting organizations and agencies in fostering collaborative efforts to reduce maternal mortality. The objectives of the workshop were met. Participants found the information presented, and the interaction with officers from countries with different mortality levels, very valuable and useful. It is expected that, as an outcome ofthe workshop, maternal mortality reduction will be accelerated, especially in countries with high mortality.

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1. INTRODUCTION

Recognizing the need and the value of improving maternal and neonatal health, in 2000 the intemational community renewed its commitment to reducing maternal and perinatal mortality. The Millennium Summit Declaration includes the Millennium Development Goals (MDG), endorsed by 149 Heads of State. Millennium Development Goals 1. Eradicate extreme poverty and hunger 2. Achieve universal primary education 3. Promote gender equality and empower women 4. Reduce child mortality 5. Improve matemal health 6. Combat HIV/AIDS, malaria and other diseases 7. Ensure environmental sustainability 8. Develop a global partnership for ci".l-lopment In order to take appropriate measures to attain the Millennium Development Goals target of reducing matemal mortality by three quarters between 1990 and 20 IS, there is a need to regularly review progress, identify influencing factors and find remedies. The WHO Regional Office for the Western Pacific and the United Nations Children's Fund (UNICEF) co-sponsored a regional workshop, held in Manila, Philippines, in May 2000, where participants from seven priority countries attended. The participants affirmed that it is the right of every mother and newborn infant to survive pregnancy and childbirth, and that each maternal death is a failure and tragedy, not only for the family, but for the whole community. Therefore, families, communities, local and national governments have the responsibility to prevent this tragedy. In the WHO Regional Office for the Western Pacific, the first and second workshops on monitoring systems for maternal and child mortality in public health care facilities were convened in 200 I and 2002 in Kunming, China, and Beijing, China, respectively. The general objective of these workshops was to improve information collection and utilization for the management of maternal and child health programmes in priority countries of the Region. For the last decade, despite the efforts, maternal mortality has still been very high or has not been decreasing in many countries of the South-East Asia and the Western Pacific regions of WHO. There is also a very wide range of mortality levels within countries. Maternal mortality is an impact indicator, which reflects a woman's basic health status, access to health care and the quality of health care that is provided. It cuts across different sectors and is affected by multiple factors, including women's overall status and socioeconomic development in the country. Past experiences have shown that high maternal and perinatal mortality is associated with a lack of skilled attendants at birth; poor or inadequate health services for mothers and newborn infants; a lack of quality care at all levels, especially at the referral levels; inappropriate family practices; and inadequate community involvement. The most important factor of all is the

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absence of political commitment and insufficient financial support to plan and implement the right strategy at the right time.

Skilled birth attendant refers exclusively to people with midwifery skills (for example midwives, doctors and nurses) who have been trained to proficiency in the skills necessary to manage normal deliveries and diagnose, manage or refer obstetric complications.

To attain the goal of reducing maternal mortality, there is an urgent need to mobilize government commitment, provide equitable and accessible good quality health services, promote more partnerships and community involvement, and improve health systems response. I. I Objectives

As the two WHO regions (South-East Asia and the Western Pacific) are facing similar problems and challenges, a biregional workshop was convened in Manila, the Philippines, from 27 to 30 October 2003. UNICEF and the United Nations Population Fund (UNFPA)joined WHO as co-sponsors in supporting the workshop. The objectives of the workshop were: (I) to review the progress of maternal mortality reduction and lessons learned during the past four years; (2) to draft a national plan of action (2005-20 I 0) for making pregnancy safer, with particular emphasis on: • • • increasing deliveries by skilled birth attendants; strengthening health services to improve acctssibility and quality of health services; increasing participation of individuals, families and communities to improve maternal and neonatal health; and

(3) to propose the way forward and necessary actions for improving maternal and neonatal care. 1.2 Participants and resource persons

Participants came from 19 countries of the WHO South-East Asia Region and Western Pacific Region. Participating countries were: Bangladesh, India, Indonesia, Myanmar, Nepal, Sri Lanka, Timor Leste and Thailand from the South-East Asia Region; and Cambodia, China, the Lao People's Democratic Republic, Kiribati, Malaysia, Mongolia, Papua New Guinea, the Philippines, Micronesia, Solomon Islands and Viet Nam from the Western Pacific Region. Altogether, 46 participants attended the workshop. There were 13 observers present from various agencies and donor organizations. Several UNICEF and UNFPA country staff joined their country's team of participants. The secretariat of the workshop consisted of the responsible officers from WHO Headquarters and respective regional offices of UNICEF, UNFPA and WHO. One WHO consultant and two temporary advisers supported the meeting.

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A full list of persons who attended the workshop is in Annex I. The participants elected Dr T. Sodnompil from Mongolia as chairperson, Dr V.K. Machanda from India, as Co-chairperson, and Dr D. Danila from the Philippines and Dr Tin Tin Win from Nepal as rapporteurs. 1.3 Organization

A pre-workshop meeting of members of the secretariat and resource persons was held at the venue of the workshop on 26 October 2003. The agenda and the timetable were finalized several issues relating to the conduct of the workshop and definitions used were clarified and'the role of each person decided. Participants were requested in advance to prepare post-cr presentations on their situation and trends in maternal and neonatal health. The posters wer~ .J .,;played at the venue of the meeting. A team of judges agreed upon by participants evaluated the posters and awarded prizes to the five best posters. The first day of the workshop was devoted to two major tasks. During the first session, global and regional overviews on the situation, trends and activities relating to maternal and neonatal health were presented by the representatives of the participating agencies. This was supplemented by the country situations presented through the country posters. The second session of the first day and the morning of the second day were organized using group discussions. Countries were divided into three groups according to the level of their maternal mortality (low, medium, and high). During the group discussions, participants, secretariat and resource persons shared their experiences and tried to find out why maternal and neonatal health programmes had succeeded or failed and what factors helped or hindered progress. After the group discussions, each group presented a summary of their deliberations to the plenary meeting, which was followed by discussions. During the next session, held during the afternoon of the second day and the morning of the third day, presentations by speakers from the secretariat and representatives of the participating organizations summarized and promoted various solutions to problems that prevented progress in maternal and neonatal health. Six presentations were delivered in two parallel sessions. Participants were free to decide which session to attend. Each presentation was followed by comments from two invited countries and discussion by participants. The summaries of the "problem-solving" session were presented to the plenary, followed by comments and discussions. The last major activity of the workshop was the preparation of a country action plan by each participating country. Resource persons, secretariat and the country staff of the co-sponsoring organizations were encouraged to work together with participants. Each country plan was presented and discussed at the plenary session. Before the closing of the meeting, participants summarized their conclusions derived from the presentations and discussions. The conclusions are intended to be used by country programme managers in order to foster firm and sustained political commitment, better financial resources, improvement of health services, community participation and partnerships of all interested parties.

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1.4

Opening ceremony

Dr Richard Nesbit, Director, Programme Management, WHO Regional Office for the Western Pacific, on behalf of the Regional Director, Dr Shigeru Omi, welcomed pal1icipants, secretariat and observers, and emphasized the importance of achieving the Millelmium Development Goals. The target is to reduce maternal mortality by three quarters between 1990 and 2015. However, in many countries, maternal mortality is still unacceptably high, and worldwide about 529 000 women die each year, more than 200 000 of them in the South-East Asia and the Western Pacific regions. These deaths could be prevented if all women, regardless of income, had access to skilled health workers during pregnancy and childbirth, and emergency obstetric care when complications arose. He expressed hope that the workshop would provide a good opportunity to find solutions to the problem of high maternal mortality. Dr Nesbit also welcomed the co-sponsoring agencies and other organizations who had sent their representatives to the workshop, emphasizing that solutions could be found and programmes implemented only if true partnership existed among all interested parties. Finally he wished those present a successful meeting. On behalf ofthe Regional Director of the WHO Regional Office for South-East Asia, Dr Monir Islam, Director, Family and Community Health Department greeted participants. He also referred to the Millennium Development Goals. He listed several solutions important to progress, among them, access to skilled care during pregnancy, delivery and postpartum. Examples of successes in several countries were also mentioned. He also wished the participants a successful workshop and said he looked forward to working with them. Dr Stephen Atwood, on behalf of UNICEF, and Dr Vincent Fauveau, on behalf of UNFPA, welcomed participants to the important workshop. They stated that, as both organizations were very actively supporting programmes am'·l ,.1 developed strategies aimed at reducing maternal mortality and improving maternal and child health, they were glad to join the workshop as co-sponsors. Personally, both representatives said they were looking forward to a successful meeting in which they were happy to participate actively.

2. PROCEEDINGS

/I

A summary of the presentations and discussions is given in this section. Detailed presentation outlines can be requested from the Reproductive Health Focus of tile WHO Western Pacific Regional Office. Participants of the workshop were all given a CD-ROM containing all presentations and relevant documents. 2.1 Poster presentations and awards

All 19 participating countries displayed a poster on their maternal and neonatal health situation. All the posters were very attractive and informative, providing a lot of statistical data and information on country programmes and activities to reduce maternal and perinatal morbidity and mortality. The team of judges, based on voting by all participants, found the posters from the following countries to be the best five: I. Mongolia; 2. Indonesia; 3. Cambodia; 4. Sri Lanka; and 5. the Lao People's Democratic RepUblic.

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2.2

Global and regional overviews

Mrs Joy Phumaphi, Assistant Director General, Family" ;.J Community Health, WHO Headquarters, explained the importance of the health of the mother and children from the viewpoint of the development and progress of the country. She gave examples of the life of families from developing countries, highlighting the significance of the availability and equal access to good quality health services and the consequences of poverty. She stressed that our work should focus on the groups of the population that are most in need. Dr Bocar Diallo, Manager, Making Pregnancy Safer, WHO Headquarters, presented the linkages between the safe motherhood initiative (SMI) and the Making Pregnancy Safer programme. The latter supports the SMI through health systems, partners and other interested parties and sectors, women's empowerment and human rights, which are all necessary to socioeconomic development. One of the most important elements essential to success is the continuum of skilled care for each woman during pregnancy, delivery and postpartum. To provide this, there is a need to formulate, adopt and implement evidence-based policies, strategies and programmes, a skilled workforce, appropriate tools and guidelines, a culture of good management and mainstreaming of maternal and neonatal health into the overall development framework of the country. Communities have to be fully involved and partnerships built with all interested parties. Evidence-based advocacy at all levels, including the policy-making level, is a must. The conclusion was that "women and newborns are not dying because of diseases we cannot treat. They are dying because societies have yet to make the decision that their lives are worth saving." Dr Pang Ruyan, Regional Advisor, Reproductive Health, WHO Regional Office for the Western Pacific, spoke about the situation in the Western Pacific Region, in her presentation entitled on accelerating progress in maternal mortality reduction. The regional reproductive health focus is working very actively on helping countries to improve their maternal health situation. As a result, all countries with high maternal mortality have developed National Safe Motherhood Action Plans for 2001-2005. The regional programme supports countries to increase skilled birth attendance, reduce unwanted pregnancies, improve their information systems and strengthen partnerships .. The lessons learned during this work include that political commitment needs to be translated into action, and that the presence of ski lied birth attendants at birth and timely referrals are crucial. The regional objectives are: (I) to support governments to develop evidence-based strategies and policies on maternal and neonatal mortality reduction, particularly in priority countries; (2) to support government efforts to reduce unwanted pregnancies and increase contraceptive use; and (3) to support countries and areas to improve the health and nutrition status of women of all ages, especially pregnant and nursing women. Dr Pang concluded by saying that reducing maternal and infant mortality required national legislation and policy, coordinated long-term efforts within Itlt: health system, and action from ,. within families and communities. Speaking on behalf of the UNICEF South Asia Regional Office, Dr I. J. Uhaa, in his presentation, entitled A regional movement for maternal mortality reduction in South Asia, started by demonstrating that women's low status hindered their health and their chance of survival when pregnant or in childbirth. He presented a vision for South Asia, saying: "The selfdetermination and dignity of all women is universally valued, and this value is reflected in each woman's realization of her right to a safe, life-enhancing pregnancy and birth." Focus was placed on providing 24-hour emergency obstetric care services, with good management, as part of women's rights to health care. Dr Uhaa then explained the need to build partnerships, develop capacity and share information and experiences. Practical examples of successful programmes to provide 24-hour emergency obstetric care services in Bangladesh and Nepal were also given. The following lessons learned are important to mention: committed leadership and long-term

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financial and human resource investment is necessary, competency and quality service is achievable, 24-hour readiness is possible with improved accountability and management, and community participation in EmOC makes a difference. In order to continue successful programmes, there is a need to continue advocacy for commitment to and investment in maternal mortality reduction, facilitate partnerships, and build on success factors regarding technology, management and human rights; and all this should be done within the broader national development framework. Dr Stephen Atwood from the UNICEF East Asia and Pacific Regional Office presented regional strategies to reduce maternal deaths and maternal and child undernutrition. After giving detailed information on the present situation and trends in the region, he suggested approaches to reduce maternal mortality. For mothers with unpredictable, non-preventable causes it is necessary that deliveries be conducted by skilled birth attendants and that the mothers have easy access to emergency obstetric care. When complications are preventable and/or predictable, the approach should be prevention, early diagnosis and treatment. He emphasized that there were several causes of complications responsible for high numbers of deaths that could be diagnosed and cured, or taken into account as risk factors. Such conditions include anaemia, malaria, high fertility and undernutrition. Nutrition is being considered as a serious problem in the region, and UNICEF have, therefore, developed conceptual frameworks to tackle the problem. The most important aspect is that intrauterine undernutrition should be prevented in order to save the life of both the mother and child. UNICEF works in close partnership with the World Food Programme (WFP), WHO, the United Nations Joint Programme on HIV / AIDS (UNAIDS), nongovernmental organizations and other organizations to help employ the best approaches in each country. He urged participants to critically evaluate their situation and take into account all kinds of possible approaches and strategies. Strategies that are not successful in one country, or in one setting, may be effective in other situations. Dr Monir Islam, Director, Family and Community Health Departmen~ WHO South-East Asia Region, presented an overview on maternal and neonatal health in the South-East Asia Region. With various data sets that included global as well as regional information, he clearly showed that the presence of skilled birth attendants is the most important factor in lowering maternal and perinatal mortality. Increasing the proportion of deliveries carried out by skilled attendants, with referral for complications when they arise, will significantly reduce the number of maternal and perinatal deaths. It was also shown that high fertility and a high rate of unwanted pregnancies contribute to high maternal mortality. The regional strategy promotes partnerships, advocates political support for MCH programmes, helps strengthen national capacity for implementing national programmes, develops evidence-based standards and tools, and promotes monitoring and evaluation. The UNFPA vision and strategy for making safe motherhood a reality was presented by Dr Vincent Faveau. A brief overview of the present situation and the reasons for past failures were summarized as follows: a lack of national commitment, coordination and partnership; inadequate financial support and increasing poverty; and the low status of women. The application of inappropriate strategies, including too much emphasis on prenatal care, was also mentioned. The new way of thinking takes into account that all pregnancies are at risk, shifts the focus from pregnancy to delivery, and considers good quality care as the key element. The UNFPA strategy is based on three pillars: (I) family planning, (2) skilled attendance at (all) births, and (3) emergency obstetric care. After giving details of the three pillars Dr Faveau stressed the importance of using process indicators for situation analysis. UNFPA supports countries to integrate emergency obstetric care into their naticlilal MMR programmes. UNFPA

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also supports countries to develop appropriate human resource strategies and integrate gender and human rights issues into their national strategies. 2.3 Group discussions

Before the group discussions, the consultant gave some suggestions and guidelines on the objectives and most important points, and the expected outcome of the discussions. This was in addition to the distributed written guidelines. He explained the process of reducing maternal mortality by analysing the present situation and recognizing the lessons learned in order to propose effective ways forward. It is also necessary to take appropriate actions and implement programmes. He expected that participants would explore how the maternal health situation in their countries had changed and find the reasons for the trends. It is necessary to identify problems, bottlenecks, weaknesses, strengths and successes and to share information. Only honest and critical evaluation will show the real picture. He explained the danger of identifYing solutions that would be good for everyone and the importance of trying to find solutions that suit specific country situations. The group of countries with low maternal mortality ratios (China, Kiribati, Malaysia, Sri Lanka and Thailand) identified several commonalities of their sllccessful programmes, such as high-level government commitment, a high rate of hospital deliveries, and free or low-cost services. Several factors had helped in decreasing their maternal mortality ratios significantly, including: the availability of infrastructure, the affordability of services, deliveries by skilled birth attendants and an increasing rate of hospital deliveries, planned deliveries through antenatal clinics, the decentralization of blood-transfusion services, and a good survei lIance and information system. The group identified the following promoting/inhibiting factors: cost of health service, over-medicalization, serving the underserved, quality of care, sustained political commitment, and partnerships with all interested parties. The group of countries with moderate levels of matern;J Inortality ratio (Indonesia, Micronesia, Mongolia, Myanmar, the Philippines, Solomon ISlands and Viet Nam) found that quality of care, intersectoral partnerships and the empowerment of individuals, families and communities were key ingredient for successful maternal health programmes. They also agreed that underlying causes of maternal deaths should be dealt with in addition to implementing key strategies. The most important aspects of the countries' approacht,s were also presented. The countries with high maternal mortality ratios found that, in addition to the high level of MMR, it was also characteristic that the MMR was either stagnating or the rate of decline was very slow. The issues common to these countries are: for various reasons skilled health personnel are not available, the health service delivery system is rather weak, the quality of care is low, long-term sustainable financial support is not available, there are harmful cultural beliefs and practices, and the status of women is very low, and maternal deaths are considered as part of life. Factors that would help better maternal care services include: high-level political commitment, true partnership and cooperation with all development partners, decentralization of health services, clear delineation ofroles and responsibilities at various levels, public-private partnership and community involvement. The group found that the following factor~ hinder the progress in maternal health services: high fertility rate, weak health systems, costly health care which families cannot afford, lack of sustainable financial support, inadequate political support, and weak implementation of good plans and strategies. Good governance, decentralization and accountability were found to be key element for success.

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2.4

Problem-solving sessions

Participants had two days of discussions on problems and how to solve them in order to improve maternal and neonatal health. All the groups worked very hard in trying to find solutions to a very difficult, complex and complicated probler.,"..,,at has been referred to as the shame of the century. Before each group discussion on problem-solving, an introductory presentation was given by one of the facilitators/secretariat members. The following were the presentations: • • • • • • Mainstreaming safe motherhood: Ms Maryse Dugue Lack of skilled attendants: Dr M. Islam Referrals: Dr V. Faveau Providing emergency obstetric care: Dr I. Uhaa The problem of increasing accountability at all levels: Dr R. Guidotti Preventable causes of maternal deaths: nutritional causes, diseases and complications of unwanted pregnancies: Dr S. Atwood

The group on mainstreaming maternal and neonatal health, tackled two very important issues relating to the topic: the health sector reform and, related to that, the sectorwide approach. In the area of health sector reform, mention was made of goals that include efficiency, quality, equity, client responsiveness and sustainability. The components of health sector reform were also discussed, including financing reforms, structural reforms and policy changes. In the area of sectorwide approaches, there is a need to improve the effectiveness of aids and to allocate resources rationally. The main principles should focus on developing countries' interests and priorities to be placed at the centre, donor-funded programmes should be within the framework of locally-owned strategies, planning and implementation should involve a range of stakeholders, and development initiatives should seek to build on and strengthen local capacity. One of the main conclusions from the deliberations is that health sector reform, and as part of it the sectorwide approach, can be a very useful tool for this purpose and that government has to be in the driving seat and must take leadership in the process. Furthermore the possible conflict between local and central government should be taken into account and resolved. During the plenary discussion ofthis topic, several issues came up, among them that mainstreaming maternal and neonatal health is much wider than the topics discussed during the group meeting. It was strongly felt that health sector reform and sectorwide approaches are not equal to mainstreaming, and there are many other ways, depending on the local situation. Among them, the evaluation and planning exercises of country cooperation agreement (CCA), the United Nations Development Framework (UNDAF), and Poverty Reduction Strategy Papers (PRSPs) and others were mentioned. It is recommended that countries to take all these possible ways into account when they plan their next step for the reduction of maternal mortality. The session on lack of skilled attendants came up with inany issues on which a lot of work done has already been done, guidelines and evidence published, and definitions and functions agreed upon. In spite of the fact that new roles have been suggested for traditional birth attendants, there are still some countries that cannot discontinue the practice for several reasons and constraints. It seems to be clear that every country where this issue is an existing problem should try to re-examine the situation and find strategies and ways to achieve the goal of all deliveries being attended by skilled health workers. Competency and skills are required for skilled birth attendants. There was also a discussion on the strategies needed where there are no skilled birth attendants, and how to replace traditional birth attendants with skilled birth

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attendants. At this moment, some countries need to redefine the roles of traditional birth attendants, depending on each local situation. However, skilled birth attendants alone cannot reduce the maternal mortality ratio if referral facilities are not available, and this should be taken into account when planning further actions. The session on referrals tackled several aspects of avoiding the three delays held responsible for many maternal deaths. TI::: role of families and communities in guaranteeing the safe and timely referral of pregnant mothers is very important. Problems with referrals are mainly due to most women believing in traditional healers for their deliveries; most women having very limited knowledge of and concern about obstetric danger signs, and very little information and low use of clinical services during pregnancy and delivery; cultural factors regarding husbands; mother-in-Iaws' involvement; and poor access to appropriate facilities. The participants discussed how to overcome these problems. Some of the major problems and possible solutions include transportation-related matters, various aspects of maternity waiting homes/houses, health insurance, community involvement, communication, skilled birth attendants, cultural aspects, etc. From the group's deliberations it transpired that there is ~1 uniform solution, but every country has to adjust their strategies according to their situation, resources and needs in order to come up with the best possible solutions to avoid the three delays. Possible strategies include: empowering women by promoting their social development; establishing insurance schemes to cover, not only medical services, but also for transportation costs; community mobilization; promoting a positive attitude among health providers with development of birth preparedness plans mainly focusing on the poor; and avoiding late referrals. The use of maternity waiting homes, as described by Mongolia, is a good concept that can be adapted to local circumstances should the need arise to improve timely access to health facilities. Improving transportation needs financial support and strong community responsibility and involvement. Nepal has also awareness on safe motherhood issues, and developed local/community transp0l1ation services for emergencies and early referrals from traditional birth attendants. The topic of providing emergency obstetric care stimulated a lot of discussion both in the group and the plenary sessions. It seems that every country has been working on providing a certain kind and degree of emergency obstetric care. However, the situation needs to be improved in the peripheral areas. Peripheral/rural areas should havt; emergency obstetric care, which can provide the basic functions. There should be respect for human rights. Emergency obstetric care should not only pay attention to the mother, but also should include neonatal emergency care. Improving technical management skills is a key component for further progress and success. There were several points recommended for the emergency obstetric care: adherence to the global standard; 24-hour quality service; equity of services with regard to geographic access; maternity waiting wards; caring for carers, such as providing minimum basic facilities for service providers and their career paths and postings; legislation, training and delegation of emergency obstetric care; investment in preservice as well as in service training; regular meetings to maintain standards; and using maternal and perinatal death audits. There were also some additional suggestions that the community should co-manage and contribute to some extent; facilities should be fully staffed; and the health authorities should make sure that the facilities for emergency obstetric care are being used: The session on increasing accountability recommended that the causes of maternal death need to be identified and corrective action taken. The group dealt with the maternal death audit in details, discussing its advantages and emphasizing confidentiality and the importance of avoiding punitive measures. They also mentioned problems in implementation, such as quality

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of data, non-cooperation of doctors and double diagnosis. The audit system should start modestly and expand gradually. It is of utmost importance that evaluation is followed by corrective measures. The discussion raised the point that there are various ways of evaluating the quality of maternal/neonatal care and finding the causes of death. This could be done, not only through clinical records, but using many other ways, such as community survey and from the registration system. If the have not yet done so, countries, in their work plan, should initiate monitoring and evaluation ofthe quality of services and should try to find the causes of maternal and neonatal deaths and make provision for corrective measures. The session on preventable causes of maternal deaths stated that all maternal deaths are preventable. Preventing pregnancy through family planning definitely prevents maternal death. The suggested interventions, when the health systems are in place, will lead to a considerable reduction in maternal mortality. All kinds of preventive measures have to be employed, including supplementation and treatment of concomitant conditions in an integrated ways. There is a need to use all opportunities for advocacy and health education. The discussion revealed that, in addition to medical causes, the social causes also have to be tackled. In addition, the imp0l1ance of bringing the issues to the policy-making level was emphasized. As an overall summary, it can be said that in the countries present at the workshop there is a wealth of experience, good examples, and lessons learned and there is much room for countries to learn from each other. Some strategies have been successful for some, but may not be as good for others. There is no uniform solution good for everyone. Many participants voiced the opinion that there is no "either/or" in finding solutions. OnL 13 to think of all possible ways, and try to tackle all aspects of improving maternal health. 2.5 Country plans of action

All countries had drafted their national plans of action individually, except for Papua New Guinea and the Federated States of Micronesia who had drafted a joint plan since the two countries share the same problems and have similar solutions to tackle those problems. Below are the national plans of action of countries. 2.5.1 Bangladesh The main strategies for 2005-20 I 0 focus on: (I) (2) (3) (4) emergency obstetric care; skilled birth attendants; improving nutritional status; and behavioural change and communication. steps will be: developing a national strategy to cover all aspects; working together with stakeholders' groups; including activities in relevant annual operational plans; and

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- monitoring and evaluation of interventions. 2.5.2 Cambodia The main strategies for 2005-20 I 0 focus on: (I) improving standards and guidelines to ensure qlu. .j and consistency in implementation of safe motherhood (SM) activities; (2) strengthening capacity of health staff and expand provisions of SM services; (3 ) increasing quality SM services at community level; (4) improving coordination and management ofSM activities; (5) overseas training and workshops; and (6) research review and evaluation.

2.5.3 China The core strategies focus on: (I) continuing to enlist government commitment; (2) promoting facility-based delivery in the western part through the "three cycle model"; and (3 ) promoting quality emergency obstetric care. The main activities include: - implementing and scaling up the national SMI project in the western provinces. - establishing sistership among provinces and organizations (east/west, higher/lower levels) to assist manpower development; - developing, implementing and monitoring service protocols; and - improving surveillance and conducting evidence-based operational research on quality of care. 2.5.4 India The main strategies focus on: (I) providing skilled attendants at birth; (2) providing essential obstetric care to all; (3 ) operationalizing emergency obstetric care; (4) improving infrastructure, physical and manpower at community level, subcentres and primary health centres; (5) providing neonatal care; (6) expanding safe abortion services; (7) reducing unwanted pregnancies; (8) improving male participation; and (9) introducing sector reforms. . . 2.5.5 Malaysia The core strategies focus on: (I)

reaching the unseen:

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- increasing the number of health care providers in maternal health and updating their skills and knowledge; - improving the referral system; - improving the quality of services; - increasing community participation; and - improving knowledge of mothers in SM; and (2) improving quality of care: - increasing the number oftrained health care providers in maternal health at peripheral levels; - improving the quality of service delivery; - increasing awareness on reproductive health and usage of contraceptives, and improving accessibility; and - upgrading HMIS through computerization. 2.S.6 Mongolia The main strategies focus on: (I) (2) (3 ) (4) (S) strengthening political commitment; increasing access to skilled birth attendants; providing equitable and accessible services; improving the quality of maternal and neonatal care; and promoting partnerships and improving health systems response.

The immediate actions to include: - organizing a press conference or briefing on the bi-regional workshop on progress of maternal mortal ity reduction; - finalizing a draft plan of action on maternal mortality reduction for 2006-2010 by organizing a national workshop for local health authorities and sharing with donor agencies; - seeking approval of the national plan of action for maternal mortality reduction for 2005-2010 by the ministers' committee meeting on September 200S; and - introducing the national plan of action for 2005-2010 to all stakeholders. 2.5.7 Union of Myanmar The main strategies focus on: (I) improving the skills of nurses and midwives by providing emergency obstetric care services; (2) strengthening service delivery at community level; (3 ) strengthening service provision through upgrading of facilities and ensuring the regular flow of adequate supplies/equipment; (4) strengthening the referral system; (S) raising awareness of SM issues through information, education and communication; (6) improving the quality of data collection and the effective use of data; and (7) improving management and coordination of SM activities within the health system.

- 15 -

2.5.8 Nepal

The core strategies focus on: (1) maternal/neonatal health as a priority in the health sector reform implementation plan, sectorwide approaches (SWAPS) and district health plan; (2) developing and operationalizing a human resource development strategy; (3 ) expanding comprehensive and basic emergency obstetric care facilities at district hospital and primary health care centres, considering geographic equity; (4) activating coordination and collaboration for a (RHCC, SMSC, SM network); (5) operationalizing the revised national lEC/BCC strategy for SM; (6) strengthening skilled attendants at community and facility levels to ensure safe delivery, management of complications and timely referrals; (7) annual review and planning meetings at central, regional and district level; (8) updating/strengthening neonatal intervention based on the national strategy; (9) providing access to safe abortion services; and (10) strengthening the referral system. 2.5.9 Pacific island countries and areas

The major strategies for the Pacific Island countries and areas focus on: increasing supervised delivery (to 70% for Papua New Guinea); providing basic obstetric care (Kiribati): training midwives in existing health facilities (more cost effective); providing an essential package of drugs and office supplies; upgrading facilities as needed (Papua New Guinea); balancing preventive and curative aspects (Federated States of Micronesia); and restoring clinics to the pre-crisis health facility delivery level of 86% (Solomon Islands) that are now at 70%.; (3 ) capacity building of staff and facilities; (4) upgrading facilities (equip referral facilities, in~/~se supervision from centres); (5) providing incentives to health facilities with a high delivery rate; (6) training of additional workers like midwives or similar, traditional birth attendants or VHVs (Federated States of Micronesia, Papua New Guinea, Solomon Islands), developing policy on legalization and remuneration which is underway; (7) ensuring access to care - decreasing distance between woman and health providers: providing maternity waiting homes; building additional facilities; and referral and transportation/communication; and (8) creating awareness on safe motherhood issues - innovative mobilization of community. (I) (2)

2.5.10 The Philippines The core strategies focus on: (I) (2) (3 ) (4) (5)

updating policy/standards/guidelines development; capacity building; advocacy to local government units and other stakeholders; resource mobilization; improving family and community support systems on SM and women's health;

- 16 -

(6) (7) (8)

strengthening the information system and service delivery; quality assurance; and monitoring, evaluation and research.

2.5.11 Solomon Islands The core strategies focus on: (I) (2) (3) (4) (5) (6) strengthening pol itical commitment; increasing access to skilled birth attendants; increasing contraceptive prevalence rate and family planning; providing equitable and accessible services; improving the quality of maternal and neonatal care; and promoting partnerships and improving health systems response.

2.5.l2Sri Lanka The core strategies focus on: (l) (2) (3) (4) (5) (6) needs; (7) (8) (9) (10) (11)

focusing on interventions to reduce maternal deaths due to preventable causes; further reduction of maternal death by focusing on indirect causes; strengthening the quality of neonatal services; developing MIS to collect key maternal and perinatal morbidity statistics; improving the quality of maternal and neonatal care; improving family planning service delivery by addressing unmet family planning focusing interventions to reduce intra- and inter-district disparities; mobilization of resource; improving untrained provincial- and district-level management capacity; improving the monitoring and supervision of MNH activities; and ensuring the sustainability of achievements and further improvements.

2.5.13 Thailand The core strategies focus on: (I) improving and maintaining the quality of services for safe motherhood and the health of newborn infants: human resources; logistics and supplies; management/supervision; coverage; and research and development; (2) improving and maintaining the participation of individuals, families and communities: empowerment of women; husband involvement; family participation; and community support; (3) improving the health management information system: national database; maternal death audit; and severe morbidity report and conference at provincial and national levels;

- 17 -

(4)

providing an enabling environment: public policy formulation.

2.5.14 Republica Democratica de Timor-Leste The major components are to: (I) develop and implement a national reproductive health strategy with four key elements; (2) make safer pregnancy a priority activity; (3) promote family planning; (4) implement the essential reproductive health package; (5) develop healthy lifestyle education for adolescents; (6) improve the skills of health providers through training; (7) improve the quality of services and monitor effective matemal and neonatal care; and (8) develop IEC materials for community health.

2.5.ISVietNam The core strategies include: (I) strengthening the reproductive health services delivery system; (2) reinforcing the data collection system for maternal and perinatal death audit; (3) integrating safe motherhood with other health programmes; and (4) raising awareness of women, families and communities on maternal mortality and emergency obstetric care. The detailed country plans of action are attached in Annex 3. 2.6 Closing

Before the closing ceremony, participants completed the workshop evaluation questionnaire. Most of the participants (92%) mentioned that the workshop experience had been very good and helpful, and that the objectives of the workshop had been met. Some of the participants (6%) mentioned that the time given to draft the national plan of action was limited. Some of the participants (12%) also mentioned that there should have been more time for sharing country experiences. Almost all of the participants (98%) mentioned that the workshop had been well organized, had strengthened collaboration among donors, as well as countries, and had provided a good opportunity to exchange ideas, express problems and discuss how to solve them. Most of the participants (91 %) had appreciated the sessions on levels of maternal mortality reduction, problem-solving and the poster exhibition and competition. Concerning the follow-up activities by national governments, countries would like governments to implement their work plans, to have stronger policies toward maternal and neonatal health and to keep maternal and neonatal health high on the agenda. Countries would like WHO to provide more technical support and to avoid implementing projects in an ad hoc manner. It was suggested that the next MMR workshop (in two years time) should be held in Mongolia.

- 18 -

Dr Richard Nesbit, Director, Programme Management, closed the workshop on behalf of the Regional Director.

3. CONCLUSIONS

Participants at the Biregional Workshop on the Progress of Maternal Mortality Reduction reviewed past trends and the present situation of maternal and neonatal health in their respective countries and noted that progress in maternal and neonatal mortality reduction had been very slow. In some countries mortality is still unacceptably high. A wide range of possible solutions, examples of successful programmes, strategies and interventions were also discussed and experiences shared. Based on the discussions participants concluded the following: (1) Experiences in countries where maternal and neonatal health programmes have been successful in reducing maternal and neonatal mortality have demonstrated that access to and utilization of skilled care, including emergency obstetric care, has played the most important role. (2) Strong political commitment and appropriate action, including sufficient financial support, is a prerequisite for a successful maternal and neonatal health programme. (3) There is a need to ensure equitable access to quality care. Programmes, strategies and mechanisms need to be devised and implemented in such a way that the special needs of disadvantaged groups of the population are adequately addressed. (4) Skilled birth attendants need to be politically and technically empowered by the government and professional circles, with strong support from the community, in order to provide effective services. (5) Successful maternal and neonatal health programmes, depending on local conditions, should employ other strategies and interventions, which art' ~upportive of or essential to the success of the programme. These may include: • preventing unwanted and adolescent pregnancy; • reducing the three delays (Examples: preparing a birth preparedness plan at all levels, motivating health workers to refer when needed, educating women and their families, providing maternity waiting facilities, arranging for transportation, improving the status of women, encouraging community support, removing the economic and social barriers to utilizing the services); • developing and implementing an information system for monitoring progress and taking necessary action when needed; • preventing and/or treating common morbidities and conditions before and during pregnancy.(These include: improving nutritional status, iron and vitamin supplementation, malaria, HlV / AIDS, TB, de-worming.); and • improving the quality of care by analysing the causes of death and taking appropriate actions.

- 19 -

(6) In the context of the national and subnational government framework, health sector reform and related approaches (CCA, UNDAF, SWAP and others) offer ways of mainstreaming maternal health programmes. (7) As there are many successful experiences, strategies and interventions, participants strongly felt that immediate and sustained action needs to be taken at country level. Unless maternal and neonatal health is improved dramatically, especially in high mortality countries, the Millennium Development Goals cannot be achieved. (8) Participants expressed their appreciation for the support provided by the international community, particularly UNICEF, UNFPA and WHO, and the need for continued coordinated technical and financial support.

- 21 ANNEXl LIST OF P ARTIClPANTS, CONSULTANT, TEMPORARY ADVISERS, REPRESENTATIVES, OBSERVERS, AND SECRETARIAT

1. P ARTIClPANTS

SOUTH-EAST ASIA REGION BANGLADESH Dr Mohammad Mahbubur Rahman, Director (PHC) and Line Director (ESP) Directorate of Health Services, Mohakhali. Dhaka Telephone no.: (880-2)881 1741; (880-2)862 0362 (res.) Facsimile: (880-2) 881 7232 E-mail address:aamahbub@bttb.net.bd Dr V.K. Manchanda, DDG (Maternal Health), Ministry of Health and Family Welfare, New Delhi

INDIA

INDONESIA

Dr Sri Hermiyanti, Director of Family Health, Directorate-General of Community Health, Ministry of Health, Jakarta . Dr Lukman Hendro Laksmono, Ministry of Health, Republic of Indonesia

MYANMAR

Dr Tin Tin Win, Assistant Director, Depan/.Kmt of Health, Yangon

NEPAL

Dr Ganga Shakya, Senior Medical Officer, Family Health Division Department of Health Services, Kathmandu

SRI LANKA

Dr C. Anoma layathilaka, Consultant, Community Physician, Family Health Bureau, 231 De Saram Place, Colombo-I 0 Telephone no.: (00941) 696677; 699332; (00941) 763012 E-mail address:jayathilakaca@yahoo.com Dr Vineeta Karunaratne, Director (MCH), Family Health Bureau, Ministry of Health, Nutrition and Welfare, 231 De Saram Place, Colombo-l 0 Telephone no.: (00941) 696677; 699332; (00941) 763012 E-mail address:fhbdir@slt.lk Mrs Malsiri Seneviratne, Secretary. Ministry of Health, Western Province Sri Lanka

THAILAND

Dr Nipunporn Voramongkol, Chief, Maternal and Child Health Group Bureau of Health Promotion, Department of Health, Ministry of Public Health Bangkok E-mail address:nvoramongkol@hotmail.com

TIMORLESTE

Mr Carlos Tilman, Director, Division of Health Services Delivery Ministry of Health, Dili

- 22 Annex I

WESTERN PACIFIC REGION CAMBODIA Dr Tung Rathavy , Deputy National Program Manager for Reproductive Health National Maternal and Child Health Centre, P.O. Box 113, Phnom Penh Telephone no.: (855) 23427300; (855) 16834700; Facsimile: (855) 23430142 E-mail address:rathavy@online.com.kh Mrs Loun Mondul, Policy and Planning Officer, Planning and Health Information Department, Ministry of Health No. 151-153 Kampuchea Krom St., Phnom Penh Telephone no.: (855) 012 891 290; E-mail address: 01 289 I 290(a)mobitel.com.kh Dr Ket Ly Sotha, Chief of Training Unit, JICA MCH Project, Phnom Penh Telephone no.: (+855) 23 430 136 I~acsimile: (+855) 23722805

CHINA

Dr Wang Bin, Chief, Women's Health Division, Department ofPHC and Maternal and Child Health, Ministry of Health, No. I Nanlu Xishimen Wai Beijing 100044 Telephone no.: (8610) 68792310; Facsimile: (8610) 68792321 E-mail address:wangbin!@moh.gov.cn Dr Cao Bin, Consultant, Department of PHC and MCH, Ministry of Health No. I Nanlu Xishimen Wai, Beijing 100044 Telephone no.: (86\0) 68792305; Facsimile: (86\0) 68792321 E-mail address:caobin2305@163.com Dr Gao Yanqiu, Lecturer, Department of Maternal and Child Health Peking University Dr Kang Chuyun, Lecturer, Department of Matemal and Child Health Peking University

KIRIBATI

Dr Airambiata Metai, Director of Public Health Services, P.O. Box 268 Bikenibeu, Tarawa Telephone no.: (686)28396; Facsimile: (686)28152 E-mail address:moh@tskl.net.ki Ms Maere Anterea, Medical Assistant, Family Planning Centre Betio Hospital

LAO PEOPLES DEMOCRATIC REPUBLIC

Dr Soumthana Doungmala, Deputy Director of Maternal and Child Health Center, Ministry of Health, Central EPI, KM3 Thadeua Road, Vientiane Te\ephone no.: (85621) 350027; Facsimile: (85621) 350067 E-mail address:somthdml@laotel.com Dr Sayavone Khounnorath, Assistant Manager, Safe Motherhood Project MCH Centre, Nongbone Road, Vientiane Telephone no.: (85621) 452520; Facsimile: (85621) 452520

- 23 -

Annex I Dr Kaseumsouk Vongsouthy, Deputy Director, Saravane Provincial He.alth Department Dr Khantong Sihalath, Deputy Project Manager of RH Project MALAYSIA

Dr Mohd. YusofIbrahim, Deputy Director of Health, 1st Floor, Federal House P.O. Box 11290,88814 Kota Kinabalu, Sabah Telephone no.: (6)088-456544/456573; Facsimile: (6)088-217740 Dr Tserendorj Sodnompil, State Secretar~, .Jinistry of Health Government Building-MoHI7, U1aanbaatar Telephone no.: (976-1 I) 323541; Facsimile: (976-11) 323541 E-mail address:moh@magicnet.mn Dr Yadamsuren Buyanjargal, Head, Quality Assurance Department Officer-in-charge of Maternal Health Care, Directorate of Medical Services and National Project Manager, MOG/RPH, Ministry of Health U1aanbaatar-48 Telephone no.: (976-11) 320738; Facsimile: (976-11) 311601 E-mail address:buyanjargal@yahoo.com Dr Sukhbaatar Altantuya, Obstetrician and Gynaecologist, Maternity Hospital No. I, Sykhbaatar District, Ulaanbaatar Telephone: (976) 99169761 (mobile); E-mail address: sIt b2@yahoo.com Dr Ishnayam Davaadorj, RH National Program Director, Ministry of Health and Social Welfare, Ulaanbaatar-24 Telephone: (976) I 322878; Facsimile no: (976) I 311601 E-mail address:moh@magicnet.mn Professor Mr B. Jav, Head of Obstetric and Gynaecological Department National Medical University of Mongolia, Ulaanbaatar Telephone no.: (976-11) 322928; cell: 976 9929 78928 Dr Tsevelmaa

MONGOLIA

PAPUA NEW GUINEA Dr Amoa Apeawusu Bediako, Deputy Chief Obstetrician/Consultant Obstetrician, Division of Obstetrics and Gynaecology, Port Moresby General Hospital, Free Mail Bag, Boroko NCD Telephone no: 324 83 \0; 1320; E-mail address: apeawusll.amoa@llpng.ac.pg Dr Naomi Pomat, Paediatrician, UPNG School of Medicine of Health Sciences P.O. Box 5623, Boroko NCO, Waigani, National Capital District Telephone no.: (675) 3248200 or (675) 3253340 Ms Ruth Iangalio, Technical Officer, Women's Health and Reproductive Health Ministry of Health

- 24 Annex 1

PHILIPPINES

Dr Diego Danila, Program Manager-Safe Motherhood, Family Health Service 2nd Floor, Bldg. 13, Department of Health, San Lazaro Compound Sta. Cruz, Manila Telephone no.: 7329956 Dr Juanita A. Basilio, Medical Officer VII, National Center for Disease nd Prevention and Control, Department of Health, 2 Floor, Bldg. 13 San Lazaro Compound, Sta. Cruz, Manila Telephone no.: 7499006 Dr Rosalinda U. Majarais, National RHlHealth Systems Development Project Coordinator, DOH-UNFPA-PMU, Bldg. 3, Ground Floor Sta. Cruz, Manila Dr Jocelyn I. Hagan, National RD Adviser, DOH-UNFPA-PMU Bldg. 3, Ground Floor, Sta. Cruz, Manila

MICRONESIA, FEDERATED STATES OF

Ms Andita Meyshine, Maternal and Child Health Coordinator Department of Health Services, P.O. Box 577 Weno, Chuuk Telephone no.: (691) 3302 577; Facsimile: (69\) 330 2320

SOLOMON ISLANDS

Dr Junilyn Pikacha, Director ofRPH UI)." .vlinistry of Healthand Medical Services, Honiara Telephone no.: (677) 24260; Facsimile: (677) 24260 E-mail address:repro@solomon.com.sb Dr Leeanne Panisi, Senior Medical Officer, Registrar, Obstetric & Gynaecology Department, National Referral Hospital, P.O. Box 349, Honiara Telephone no.: (677) 23600; 70186; E-mail address: vatumanivo@yahoo.com

VIETNAM

Dr Nguyen Dinh Loan, Director, Reproductive Health Department Ministry of Health, 138A Giang Vo Street, Ha Noi Mrs Nguyen Thi Ngoc Phuong, Director of Hospital, Tu du Hospital 284 Cong Quy Street, Ho Chi Minh Telephone no.: (848) 8390306; (84 8) 9250431; Facsimile: (84 8) 8396832 E-mail address:bvtudu@vnn.vn Dr To Minh Huong, Deputy Director, Ha Noi Gynaecology and Obstetrics Hospital, 73 Group 13B, Lang Thuong, Ha Noi Telephone no.: (00844) 354459; E-mail address: huongtominil@yailoo.com Mr Truong Hong Son, National Institute of Nutrition, Ministry of Health HaNoi

2. CONSULTANT Dr Janos Annus, Szeged, Memestakacs u.6, H-67222, Hungary

- 25 -

Annex I

3. TEMPORARY ADVISERS

Dr Rebecca Ramos, Institute of Community and Family Health, II Banawe A venue Quezon City ~il~~ , Dr Richard John Guidotti, STP-RHR, World Health House, IP Estate, Mahatma Gandhi Marg, New Delhi 110002 Telephone no.: (91-11) 23370804; Facsimile: (91-11) 23378510; E-mail address:gllidottir@whosea.org

4. REPRESENTATIVES

UNICEF

Dr Marilen Danguilan, Senior Adviser, Women's Health, UNICEF House, 3 UN Plaza, New York, New York 10017 Telephone no.: 212-326-7606; Facsimile: 212-824-6460 E-mail address: mdanguilan@unicef.org Ms Dale Davis, Project Officer, UNICEF ROSA, P.O. Box 5815 Lekhnath Marg, Kathmandu Dr Liu Bing, Area Office for China and Mongolia, UNICEF 12 Sanlitun Lu, Beijing 100600, China Telephone no.: (86-10)65323131; Facsimile: (86-10)65323107 Dr Romanus Mkerenga, Health and Nutrition Officer, 106 Amorsolo St., Legaspi Village, Makati City Telephone no.: (00-632) 840 0731 Dr Martha Cayad-an, Maternal Health and Nutrition, 106 Amorsolo St., Legaspi Village, Makati City Mr Colin Davis, Senior Programme Coordinator, 106 Amorsolo St., Legaspi Village, Makati City Mr Budi Subianto, Project Officer, Health, UNICEF Jakarta P.O. Box 83 I 8/JKSMP, Jakarta 12083, TnrJ.lIle5ia Telephone no.: (6221) 570 5816; Facsimile: (6221) 571 1326 E-mail address: bsubianto@unicef.org Dr Eblin Ekunwe, Project Officer, Health and Nutrition, UNICEF Papua New Guinea, P.O. Box 472, Port Moresby, NCD, Papua New Guinea Telephone no.: (675) 321 3000; Facsimile: (675) 321 1372 E-mail address: eekunwe@unicef.org Dr Tuya Mungun, National Officer HIN, United Nations House-I 2 Sukhbaatar District, Mongolia Telephone no.: (976-11 )312 185 107; Facsimile: (976-11) 327313 E-mail address: tmungun@unicef.org Dr Yasmin Ali Haque, UNICEF, Dhaka, BSL Complex, 3rd Floor I, Minto Road Ramma, Dhaka E-mail address: Yhague@unicef.org

- 26Annex 1 Dr Myo Zin Nyunt, Project Officer (Health), UNICEF-Myanmar Telephone no.: (95-1) 212086, 2087,2090,2091 Facsimile: (95-1) 212063 E-mail address: mnyunt@unicef.org Dr Cao Tran Viet Hoa, National Project Officer, Health and Nutrition UNICEF Ha Noi

UNITED NATIONS POPULATION FUND

Dr Chaiyos Kunanusont, HIV 1 AIDS/STI Adviser . . .. UNFPAICST for East and South-East Asia, Floor 14, UlJlted NatIOns BUlldmg Bangkok 10200, Thailand Telephone no.: (+662) 2881476; Facsimile: (+662) 2802715 E-mail address: kunallusont.unescap@ull.org Dr Saramma Thomas Mathai, UNFPA Country Technical Services Team P.O. Box 5940, Kathmandu, Nepal Telephone no.: (977-1)5523880; Facsimile: (977-1) 5527 257 Dr Peden Pradhan, Assistant Representative, UNFPA-Nepal, The UN House Nepal Telephone no.: (971-1) 523637; 527 682/83; Facsimile: (977-1) 583 965 E-mail address: peden.pradhan@undQ.,Q!:g Mr Daniel Baker, Chief of Mission, UN House, Caicoli Street Dili, East Timor Telephone no.: (670) 723 0588; E-mail address: dbaker.unfpa@undp.org Dr Estrella Serrano, RHlFP Specialist, UNFPA-Beijing Telephone no.: (8610)65323731 ext 203; Facsimile: (8610)65322510 E-mail address:eserrano@public.un.org.cn Mr G. Purevsuren, RH Senior Adviser, Programme Support Unit UNFPA Mongolia, Post Office-46, Ulaanbaatar Telephone no.: (976-11) 329363; Facsimile: (976-11) 353501; cell: 97699187566; E-mail address:psunit-unfpa@mongol.net

5. OBSERVERS ASIAN Ms Maryse Dugue, Project Specialist (Health), Pacific Operations Division Pacific Department, 6 ADB Avenue, Mandaluyong City, Philippines Telephone: (632) 632-5155; E-mail address: mdugue@adb.org

DEVELOPMENT BANK (ADB)

AUSTRALIAN AGENCY FOR INTERNATIONAL

DEVELOPMENT (AusAID)

Ms Virgie Ongkiko, Australian Embassy, Philippines Level 23-Tower 2, RCBC Plaza, 6819 Ay~la Avenue, Makati City, Philippines Telephone: (632) 7578 100; Telephone: (632) 7578 100

FIJI SCHOOL OF MEDICINE

Dr Warne Baravilala, Fiji School of Medicine Hoodless House, Brown St., Suva, Fiji E-mail address:w.baravilala@fsm.ac.fi

- 27-

Annex 1 HEALTH UNLIMITEDATTAPEU OFFICE Ms Irma Saligumba, Provincial Health Trainer Health Unlimited PHC Project, Attapeu Province Lao People's Democratic Republic Telephone/Facsimile: (856-36) 036211030 E-mail address:huphclao@laotel.com Ms Susan Claro, Health Unlimited-Attapeu Office, P.O. Box 078 Samakisay District, Lao People's Democratic Republic Telephone/Facsimile: (856-36) 03621 \030 E-mail address:huphclao@laotel.com

INTERNATIONAL MEDICAL CENTER

OF JAPAN (IMCJ)

Dr Noriko Fujita, Expert Service Division, Bureau oflnternational Cooperation, 1-21-1 Toyoma, Shinjuku-ku, Tokyo 162, Japan Telephone no.: (81-3) 3202-7181; Facsimile: (81-3) 3205-1038 Ms Satomi Naito, Expert Service Division, Bureau oflnternational Cooperation 1-21-1 Toyoma, Shinjuku-ku, Tokyo 162, Japan Telephone no.: (81-3) 3202-7181; Facsimile: (81-3) 3205-\038

JICA

Ms Mayumi Hashimoto, JlCA Advisor 011 Midwifery Training P.O. Box 613, Phnom Penh, Cambodia Telephone no.: (+855) 23 430 136; Facs:. ~!e: (+855) 23722805 E-mail address:mayumi-hashimoto@nilty.com Mr Ikuo Takizawa, Assistant Resident Representative, JICA Philippine Office Telephone no.: 893-3081; Facsimile: 816-4222 E-mail address:takizawa@iica.org.ph Ms Takako Shibata, Expert on Maternal and Child Health JlCA Philippine Office Telephone no.: 893-3081; Facsimile: 816-4222 E-mail address:stakako@info.com.ph Dr Eden Divinagracia, Executive Director, #38-A San Luis Street Pasay City Telephone no.: (63-2)8345007; Facsimile: (632)8345008

PHILIPPINE NGO COUNCIL ON PUPULATION, HEALTH AND WELFARE, INC.

USAID

Ms Lily Kak, USAID Asia Near East Bureau 4.09-103 1300 Pennsylvania Avenue, NW, Washington DC 20523 Telephone: 202 712 1784; Facsimile: 202-2163171 E-mail address: ikak@usaid.gov Dr Hen Sokun Charya, Development Assistance Specialist for MCHIRH Office of Public Health, USAlD/Cambodia Telephone no.: (855)23 216436 ext. 316 Facsimile: (855) 23 217 638; E-mail address: shen@usaid.gov

- 28Annex I 6. SECRETARIAT WHO Headquarters Mrs Joy Phumaphi, Assistant Director-General, Family and Child Health, Geneva Dr Bocar Diallo, Programme Manager, Making Pregnancy Safer (MPS), Department of Reproductive Health and Research (RHR), Geneva Dr Jelka Zupan, Medical Officer, New-born Care, Making Pregnancy Safer, Department of Reproductive Health and Research (RHR), Geneva

WHO Regional Office for Soutb-East Asia Dr Monir Islam, Director, Family Health Department, New Delhi, India Telephone: 91-1123370804; Facsimile: 91-1123378510; E-mail address: islamm@whosea.org Dr Ardi Kaptiningsih (Responsible Officer), Regional Adviser, Reproductive Health, New Delhi, India Telephone: 91-11-2337; Facsimile: 91-1123378510; E-mail address: kaptiningsiha@whosea.org Dr Arvind Mathur, National Professional Officer, (Health Systems and Community Health), WR, India Office, New Delhi Telephone no.: 91-1123018955; 23017993 ext. 23102; Facsimile: 23012450 Dr Laura Guarenti, MO-MCHlRH, Indonesia E-mail address:guarentil@who.or.id Dr Domingas da Paixao de Jesus Bernardo, Focal Point for Reproductive Health, UN House, Caicoli Street DiIi, Timor Leste Telephone no.: (670) 33 I 3562; 723 5899; E-mail address: domingas.whodili@east-timor.org domingasServardo@yahoo.com Dr Vijaya Manandhar, National Programme Officer, Kathmandu E-mail address:manandharv@who.org.np

WHO Regional Office for tbe Western Pacific Dr Linda Milan, Director, Building Health Communities and Populations, Manila, Philippines Telephone: (63-2)5289981 ;Facsimile: (73-2)5260279; 526 0362, 521 1036 E-mail address: milanl@wpro.who.int Dr Pang Ruyan (Responsible Officer), Regional Adviser, Reproductive Health, ManU!!, Philippines Telephone: (63-2)5289876; Facsimile: (73-2)5260279; 5260362,521 1036 E-mail address: pangr@wpro.who.int Dr Khine Sabai Latt, Short-term Professional (Medical Officer), Safe Motherhood, Manila, Philippines Telephone: (63-2)5289878; Facsimile: (73-2)5260279;5260362,521 1036 E-mail address: lattk@wpro.who.int Ms Sachie Iiyama, Short-term Professional, Reproductive Health, Manila, Philippines Telephone no.: (63-2)5289862; Facsimile: (73-2)5260279; 5260362,521 1036 E-mail address: iiyamas@wpro.who.int Mr Wu Guogao, External Relations Officer, Programme Management, Manila, Philippines Telephone no.: (63-2)528 9929; Facsimile: (63 2)5260279; E-mail address: wug@wpro.who.int

- 29Annex I

UNICEF

Dr Stephen J. Atwood, M.D., Regional Advisor, Health and Nutrition, Bangkok, Thailand 10200 Telephone: (662) 356 9417; Facsimile: (662) 280 3563-4; E-mail address: satwood@unicef.org Dr Iyorlumun J. Uhaa, Regional Advisor, Health and Nutrition, Kathmandu, Nepal Telephone: (97 7) 417 082; Facsimile: (97 7) 418466; E-mail address: iuhaa@unicef.org

UNITED NATIONS POPULATION FUND

Dr Vincent Fauveau, Maternal Health Adviser, UNFPA Technical Support Division, Geneva, Switzerland Telephone: 31 229178574; Facsimile: 41 2291780 16; E-mail address: fauveau@unfpa.org

ANNEX 2

unicef. UNITED NATIONS CHILDREN'S FUND R£GJONAL OFFICE FOR EAST ASIA AND PACIne

WORLD HEALTII ORGANIZATION REGIONAL OFfiCE FOR SOUTH-EAST ASIA REGIONAL OFFICE FOR TilE WESTERN PACifiC

•••• ••• .._ I, UNITED NATIONS POPULATION FUND

REGIONAL OFFICE FOR SOUTH ASIA

BI-REGIONAL WORKSHOP ON mE PROGRESS OF MATERNAL MORTALITY REDUCTION Manila, Philippines 27-30 October 2003

WPRlICPIRPHl3.3/001IRPH(1)2003.1 21 October 2003

ENGLISH ONLY

AGENDA

(l)

Opening ceremony Adoption of workshop objectives and agenda Overview of global and regional progress on maternal mortality reduction Country reports (poster exhibition and competition) Group discussions and presentation Panel on problem solving Summary of the problems and its solutions Group discussion on country plans of action Presentation of the draft country plans of action Closing ceremony

(2) (3) (4) (5) (6) (7)

(8) (9) (10)

- 33 -

ANNEX 3

COUNTRIES' PLAN OF ACTION

- 35 -

Annex 3

Trend In matemal mortality reduction ••

Bangladash Action ,./an

.

(2005-2010) Reduction of Matemal Mortality

• slow rate of decline In MMR, from 500/100,000 LB In 1990 to 380/100,000 LB In 2000 TFR h.s plateaued at 3.3 since the mid-1990s and CPR for mc~1t.,n methods Is • .,so stagnating between 4145%

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The Bangladesh response to high MMR••• • MCH-FP programme focus in 70s and BOs with focus on ANC, high risk-screening Bnd training of TBAs • GoB signatO<}' to the International conventions CRC, CEOAW, ICPO, Beijing PFA

The Bangladesh response to high MMR •••

• 1998-2003: stage of consolidation and scaling-up through opportunity of SWAP and HSR (Health and Population Sector Programme) 71 National Sirategy for Maternal HeaHh developed » EIIIOC. $BA, autrition. etc.. 71 Efforts have focussed on strengthening systems rather than projects 71 Annual performance reviews focusing on key indicators at impact, process and input levels 71 PRSP affinns obligation obligation to attaining MDGs -- includes maternal mortality reduction

• 1993-1997: stage of advocacy and development of concept and levels of EmOC with professional bodies, women's rights activists, development partners and key policy makers - various inijiatives supported by different OPs

• 2003-2006: implementation of Health. Nutrition and Population Sector Programme

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Action Plan 2005-2010 •• Strategy: Focus on EmOC

Action Plan 2005-2010 .. Strategy: Focus on Skltted Birth Attandanco

Activities: • strengthening systems • Training and deployment of competent teams • cfinical quality assurance and mon~oring • initiatives for inaeasing utilisation • communijy mobilisation and support for referral • addressing equijy - cos~ information,etc.. Indicators: • coverage of functioning Comprehensive & BasIc EmOC facilities • met need for EmOC

Activities: • Training. certification and deployment of competent providers (field workers, nurses) in area where EmOC functioning • clinical quality assurance and monitoring • community mobilisation and support for referTal Indicators: • births con.;:ucted by skilled attendants • births OOIlJucted in faailijy

. . . . . . .10

=:.=.-=:.

- 36 Annex 3

Action Plan 2005-2010 •• Strategy: Improve nutrltlon_l.tatus Activities: • strengthen linkages with nutrition inijjatives • policy on Vit A supplementation for pregnant women and night blindness during pregnancy • strengthen anaemia control activities Indicators:

ActlDn Plan 2005·2010 .• Strategy: Behaviour Change and Communication Activities: • provide information on danger signs, nutrition supplementation • nurture birth planning/preparedness and community support for referral • advocacy and communication for addressing violence against women • promoting maternal mortality reduction as a woman's right Indicators: • service utilisation (EmOC, SSA. supplemenlation,

• n~ht blindness during pregnancy • severe anaemia during pregnancy Strategy: Addressing other medical cause. • Situation analysis and Protocols lor malaria and TB IHnrMdMh pNn 2005-20fl) mfiWnIIl momllty I'YcflKfIon

etc.. ) increased

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NaxtSteps •••

• The national strategy Covers nearly all aspects • Raise issues with stakeholder group - GoB, DPs, NGOs, women's organisations • include activities in relevant annual operational plans • monitor and evaluate interventions

Maximising opportunities ••• Implementation of whatever it takes to save women's lives ... in a sustained manner!

'~...:..

'

Making preg,nancy Safer Draft Action Plan, India

"Making Pregnancy Safer is an integral component of Reproductive and Child Health Programme, which has been under implementation since October 1997. The second phase of this programme will be for the period 2004-2009. The draft action plan indicated below is an outline of what is being proposed. The final action plan will however be ready as part of the Programme Implementation Plan

forReR-IT. Note: 1. Performance Indicators are not indicated as they would form part of PIP and are under the process development 2. Various donor agencies and development partners have been involved in the development of the program. 3. The time line would coh~vide with the RCH-II implementation and hence not indicated in the draft action plan ere. Strategy Activity ,

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Performance Responsible Time Agency Indicator Frame

1. Skilled attendance at' birth

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24 hour delivery services at Primary Health Centres ~ Development of a cadre of

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Community Level Skilled Birth Attendants particularly for 8 weak states; ~ Continue training ofTBAs in safe delivery practices, identification of complications, referral and linking them with the referral facilities a.s a short term measure 2. Provision of Essential Obstetric Care to all • Strengthen outreach services for pre-natal care; • Anemia Prophylaxis • Improving the post natal care • Making First Referral Units functional in a progressive manner;

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3. Operationalise EmOC

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Upgarding Operation Theatres, Equipment • Guide lines for Blood storage at FRUs finallised III • Training MBBS doctors Anesthesia initiated

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4. Improving Infrastructure Pbysi~al & Manpower

• Training of MBBS doctors m caesarian section and Em. Obstetric Care to be initiated in collaboration with FOGSI • Encourage partnership with Private secto r; of Involvement • Enhancing community and panchayats for improving referrals . Community Level - Existing Traditional Birth Attendants being trained in safe delivery practices as short term measure - Introduction of a community level skilled birth attendant with 1 year training in midwifery skills being fmalised. . Sub Centres - Additional Health Workers employed in remote areas;

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5. Provision of New Born Care

- Pilot programme to Improve Competencies of ANMs already initiated; . Primary Health Centres- Up-grading Labor Rooms for 24 hour delivery servIces - Training Medical officers for Safe Abortion Services - Training of Public Health· Nurses in Basic Em. Obst care in selected districts being done • Institutionalize neonatal care; • Hom e base-·~ newborn care; Improve immunisation coverage-strengthen outreach in weak performing districts

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6. Expanding Safe Abortion

• Introduction of Manual Vacuum Aspiration in all PRe s where 24

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hours delivery services shall be operational; • Dissemination of amended MTP Act', • Promotion of medical methods of safe abortion;

7. Reducing unwanted pregnancy

Promotion of spacing methods; }> Increasing the basket of choices for contraceptives; }> Introduction of newer contraceptives; }>

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8. Improving Male Partic!J!ation 9. Introducing sector reforms

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Have well defined state level policies on personnel Itransfersltenure of posting }> Introduce District· based cadres of Doctors & health workers - re deploy existi~staff as~er needs

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Look at the operational feasibility of single Doctor Primary health centres keeping needs of Em. O.C. and contraceptive programme III VIew

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Introduce good Financial Management practices and management of logisitics to avoid delays in programme implementation » Involvement of village communities through the Panchayati Raj system - Health fund with Panchayats? » Involvement of other related social sectorsloke the Integrated J Child Development services and nutrition Programmes

..,.. N

ACTION PLAN YEAR 2004-2010 MOR - INDONESIA STRATEGY ADVOCACY

ACTIVITY Finalise bi-annual MOH/Family Health Division' work plan to lead and support MPS activities Develop or adapt an advocacy package for / Maternal Neonatal Mortality reduction and Emergency Obstetric &Neonatal Care Finalise the National RH policy Develop a strategy for building coordination & p:mnership among the different MPS intervenient . Establish aMPS intersectoral task force Develop a detailed TOR Establish a permanent secretariat with specific TOR.

PERFORMANCE TIME FRAME r-zooS-2006 2007 2008 2009 2010 INDICATORS Work plan finalised • X

.

Advocacy package for I Maternal Neonatal Mortality reduction and Emergency Obst<ltric &Neonatal Care devel~~d Policy finalised

X

.

X X

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PARTNERSIDP DEVELOPMENT

Strategy finalised

Task force established TOR developed Secretariat in loco

X

X X X

X

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STRATEGY MPS strategy IMPLEMENTATION SUPPORT

ACTIVITY Advocate for free Essential Obstetric and neonatal care for the poor Socialize the MPS strategy to Provinces and Districts Support and negotiate with the SPM team the finalization of the MPS Costin!Lspn:ad sheet Coordinate with the responsible departments to ensure constant functionality of the BEON and CEON services (purchase & logistic of drugs, medical equipment etc .. ) Review the country' experiences to easy the access to 0& N Emergency care for the poor (delivery waiting home, coupons, tabulin,etc .. )

PERFORMANCE TIME FRAME INDICATORS 2005! 2006 2007 2008 2009 2010 Number of Districts with free ONC for poorhotal number of districts Number of socialization meetings /number planned Costing spread sheet finalised

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X

X

X

X

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Number of coordination meetings Ti me table of regular distribution % of Health Services with stock-out of essential drugs Stud y real ised and results presented

X

X

X

X

X

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X

X

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--

STRATEGY

ACTIVITY

PERFORMANCE TIME FRAME INDICATORS 2005 2006 2007 2008 2009 2010 Dissemination of the result in the selected districts

Advocate for the implementation of the most effective intervention in specific Districts Support the district Health Offices in the development and integration oftheir MPS plans (DPS IMPROVE QUALITY of Review and update CARE/ACCOUNTABILITY existing MPA guidelines to produce a package to be utilised at District level Socialization of the package Maternal and perinatal audit Guideline' updating Support Districts to introduce MNMAudit

X

X

X

X

X

X

Number of Planning exercise supported by central level

X

X

X

X

X

X

I

Package for the districts ready

X

,

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Number of District u'tilising the package Guidelines up-dated

X

X

X

X

X

X

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X X X

"Maternal mortality Confidential Enquiry" piloted at provo level

Number ofMMPA reports/number of MPdeaths notified in the area No of Provinces with pilot on going/total provinces socialised

X

X

X

X

X

X

X

X

X

X

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'-PERFORMANCE TIME FRAME INDICATORS 2005 2006 2007 2008 2009 2010 ,

STRATEGY

ACTIVITY

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SuppOl1 the District to Supervision system developed develop BEON and CEON supervision system Develop technical Guidel ines produced guidelines for safe abortion Introduction of policy Districts with free for free malaria malaria prophylaxis and anaemia prophylaxis/total of selected districts /year control in pre/pregnancy/pregnancy and PP in selected Districts Establish and strengthen Number of activities the coordination with T8 ofTB and HIV/AIDS and H IV/AIDS program programs adressed to pregnant women f-:-' I ' 111 sc ected provlI1ces % offacility base delivery/ skilled advocate for facility attended delivery based ski \led attended delivery Undergo a fe-mapping of Mapping finalised the villages in need of BDD Number of BOD Advocate the central MOH staff/BDD with level support for poor different contracts Distri cts' staffirlg

X

X

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X

X

X

X

X

X

X

X

X

X

X

X

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X

X

X

X

X

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X

X

X

X

X

X

X

X

X

STRATEGY TRAINING

ACTIVITY PRE SERVICE: Advocate capacity building of Academy teachers Advocate for the adoption orthe latest MPS guidelines and tools in all the Midwifery Academy training IN SERVICE: Monitoring Training centres for their adherence to established standards Improvement / finalization of In-service training modules Adapt and adopt EmON care UN process indicators Socialize the new indicators at appropriate levels Obtain the decree for compulsory notification for all maternal death

PERFORMANCE TIME FRAME INDICATORS 200S 2006 2007 2008 2009 2010 Number of midwifery teachers with high degree in teaching methodology Modules adopted as teaching material

X

X

X

X

X

X

X

X

X

X

X

X

X

X I I I I

No of Modules finalised UN indicators adapted

X

X ,

l>....

:,~ONITORING & EVALUATION

X

Nli:w indicators routinely used Decree released

X

X

X

X

X

X

X

• -------

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• Draft Action PI Strategy l. To improve skills

U'

fM Responsible Timeframe 2005 2006 2007 2008 2009 2010 Agency Department of Health (DOH) UNICEFIWHO

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Activity Pre- andiniservice training of hospital & basic health staff on EmOC (MOs +) Supervision of trained MOs, nurses and midwifes Assessment of standard midwifery practices annually I

Performance Indicator No. of trained MOs, Nurses and MWs

of nurses and midwifes providing EmOC services

No. of supervisory visits DOH by Central, SID, Dist. & SID, Dist. & Tsp.level Tsp. No. of skilled staff providing EmOC servIces

• DOH SID, Dist. & Tsp. DOH UNICEF/WHO ,

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Refresher training of No. of health st'<.o~T " EmOC to basic received refresher health staff every training alternate year

-

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Strate gy 2. To strengthen service delivery at community level

Activity Training of health volunteers 'AMW s) Training of traditional birth attendants (TBAs) Provision of AMWITBA kits and clean delivery kits Supportive supervision at community level by , MWs

Perfo rman ce Indic ator No. of AMWs trained

Respo nsible Agency DOHIUNICEF

Time frame 2005 2006 2007 2008 2009 2010

No. ofTB As trained

DOH

No. of kits distributed

DOHfUNICEF IUNFPAlWHO ~

No. of supervisory visits/colTective actions

DOH

'"

Develop and No. ofIEC s and distribute IEC flipchatt (pictorial materials & guides) distributed flipcharts for AMWs &TB As --

DOHfUNICEF IUNFPAIWHO ,

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.' g. Strategy Activity Performance Indicator Responsible Agency DOHlUNFPA! WHO Time fram e 2005 2006 2007 2008 2009 2010

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3. To strengthen service provision through upgrading facilities and ensuring regular flow of adequate supply/equipment

Renovation of subrural healt~centres

No. of sub-centres

No. of training centres Develop training centres at central, Dist. And Tsp. Level Equipping first refelTal health facilities (Station/Tsp. Hasp.) with standard EOC equipment/supply No. of hospitals fully equipped with standard EOC equipment/s\lpply

DOHlUNFPAJ WHO/UNICEF

DOH/UNICEF IUNFPAJWHO V1

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". Strategy 4, To strengthen refelTal system Activity Perfot'mance Indicator Responsible Timeframe 2005 2006 2007 2008 2009 2010 A2ency DOHIUNFPN WHO/UNICEF

No. of villages with Facilitate transpoli plan developmel1t of No. of refen'al cases transport plan between village, health centre, Tsp. & Dist. Level Community awareness ratsmg on danger signs and high-risk pregnancIes •

No, of community DOWUNFPN education sessions on WHOIUNICEF awareness ratsmg No, of pregnant women, families and communities with improved knowledge No. oftsp. received ceIiification and recognition awards DOHlUNFPA/ WHO/UNICEF ,

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Recogniti on of tsp. and communities for early referral --

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Strategy 5. To raise awareness of safe motherhood issues through Information, Education and Communication

Activity Develop IEC materials fo.~using on pregnancy complications, birth spacing and life saving measures

Pel"formance Indicator Increased number of PW, families and communities aware of pregnancy complication Increased number of pregnant women delivering with skilled personnel at facilities

Responsible Agency DOH/UNFPAI

Timeframe 200S 2006 2007 2008 2009 2010

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WHOIUNICEF

I

Train health staff at all levels for intelpersona,l comn<l.lnication skills and use ofIEC materials

No. of health staff trained No. of education sessions and IECs distributed

DOHlUNFPAI WHO/UNICEF

VI N

.

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Strategy 6. To improve quality data collection and effective use of data

Activity Promote vital registratior~:of births

Performance Indicator No. of villages with improved vital registration

Responsible A2enc~

Timeframe 2005 2006 2007 2008 2009 2010

DOHlUNFPAJ WHOIUNICEF

and deaths through health staff and village authorities Improve health management information system on routine data collection of maternal health

Quality data from routine reporting

DOHlUNFPAJ

WHO/UNICEF

VIIN

DevelopmeQt of Quality data for better guidei;l1es, forms planning of SM and tools of maternal death audit

DOHIUNICEF IUNFPAJWHO

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• /II

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Strategy 7. To improve management and coordination of SM .activities within the health system

Activity Development of coordinati orr committee for SM activities Strengthen collaboration between other health programmes

.Responsible Timeframe 2005 2006 2007 2008 2009 2010 Agency Committee formed and DOH/UNFPAI no.llevel of membership WHO/UNICEF Performance IndicatOl" .

...,

X

Matemal malnutrition, micronutrients, HIV/AIDS, etc. addressed in S M activities No. of study tOUl'S and no. of staff participated

DOHlUNFPAI WHO/UNICEF

Study tours of health staff in-country to places with good practices Strengthen monitoring and supervision

DOHIUNICEF IUNFPAlWHO

U1 ~

Monitoring and DOHIUNICEF supervision plan /UNFPAlWHO developed and followed .'

NEPAL Nepal has developed a 15 years Safe Motherhood Plan of Action, 2002 - 2017 Time Frame: 2004-2010 Strategy 1.MaternaVneonatal health as a priority in the Health Sector Reform .:... Implementation Plan, SWAPs & District health plan. Activity Performance Indicator Advocate for SM mainstreaming at policy level ( for resource allocation ). seek for partnership SM/neonatal health programmes reflected as a priority agenda in HSR-lP, and district annual plans Responsible Agency MOH

-

-

I IJ1 IJ1

2. Human Resource Development Strategy for SM to be developed and operationalised

Form working Group with technical assistance, review existing HR. status and formulate strate~y (addressing cadres, accreditation, emplo~ment/deployment, transfer policies and career ladder) - set up training sites and provide TOTs

HRD strategy developed, Training sites established & functional

FHD,NHTC in coli. with EDPs

-

Competency-based training including training site identification for expansion and supportive supervision process for service providers. Review preservice curriculum of midwifery & incorporate EOC in nurses' & doctors' curriculum.

::;l --~

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3. Expansion of comprehensive and basic EmOC facilities at district hospital and Primary Health Care Centers considering geographical equity.

4. Activate coordination and collaboration forums ( RHCC, SMSC, SM Network). 5. Operationalise revised National IECIBCC Strategy of SM 6. Strengthen Skilled Attendance at community and facility levels to ensure safe delivery, management of complications and timely .referrals

- Strengthening the competency of service providers through in-service CBT for EmOC - Upgrading physical facility: safe blood transfusion services, equipment/supplies, training, etc. - Strengthening management capacity for improved Quality 24- hour MNH services - Regular coordination meetings

2 CEOC & 10 BEOC sites established every year

(!)

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Meeting minutes

- Implement the Birth Preparedness Package at facility and community level - CBT Refresher training - Develop an enabling environment: supplies, equipment, registration with district hospital, continuous leaming package (mentoring, supervision, updates etc) - Delegation of joint responsibility to SHP incharge, HP, and district hospital - Upgrading ofMCHW to ANM level as career opportunity Assess progress ofMNH programme progress by all SM stakeholders including: CBOs. NGOs, civil society & private sector. - Finalise tools and implement process of MDReviews. Expand based on the learning. -

qualitative study reports Number of providers . trained and in place.

U1

'" Annual meeting reports FHD

7. Annual review and planning meet:ngs at central, regional & district level- ali stakeholders. DHS Survey to see the impact of SM program. - Integrate EOC monitoring into HMIS - Introduction of maternal and perinatal death review process at central, regional and selected district hospitals by National maternal death review Committee 8. Update/strengthen neonatal intervention as -'per the national strategy.

-

I I

- Develop guidelines & integrate into pre & inservice SM trainings

Guidelines developed& integrated into curricula

FHD,NHTC

- - -

------

----

--

--_.-

----

---

9. Provide access to safe abortion service

-

10. Strengthen referral system

-

Finalise abortion care guidelines, training manuals & curricula ToT & training of service providers Establish, expand CAC service sites Develop national guidelines for referral based on project experiences and lessons learnt Provide basic communication equipment and emergency transport mechanisms Establish linkage between community and facility

CAC service sites established & functional Referral guidelines

FlID,NHTC

FHD

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5' i::I

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- 58 Annex 3

Maternal and Newborn Care Current Situation •

Maternal, newborn morbidity and mortality reduction in Sri Lanka Draft Plan of action

• •

Pregnallt mothers registered by PIIM 93% Average 5 Oeld visits per mother by PIIM at home Percentage of Dve births in government Institutions 94%

• Prevelence of anaemia • • among pregnant mothers -29.7% InraDt registration by

•

Post natal care by PUM: at home-SO% Average 2.7 visits during first 10 days • Pregnant motbers Immunized with tetanus I~d 100%.9% AJlfHB

• • • •

PUM87 tofant mortality rate 15.9 per 1000 LB Neo natal mortality rate n.9 per l000LB MMR 46.8 per 100000LB- 2001 LDW rate 16.7% Hospital SB rot. 13.4

per lOOOLB

Maternal and Newborn Care Current Situation cont... 'Contraceptive prevalence-70.1 % Modern methods· 49% ·TFR·1.9 'Teenage pregnancies- 10% 'Exclusive breast feeding rate -56.7% 'Female literacy - 90%

Maternal and Newborn Care Current Situation cont MCH service delivery Integrated approach well defined infrastructure for service delivery Health i~ a devolved subject since 1989 Ministry of heath has developed a master plan for 10 yrs

Current Problems in MNH High percentage of preventable maternal deaths Indirect deaths are on the increase Stagnant NNMR Maternal newborn morbidity statistics are not properly monitored Quality issues are not adequately addressed Tendency to dilute the focus (national and inter national leveQ on MOlHER and CHILD with emergence of new programs resulting from demographic transition

Current Problems in MNH Inadequate focus on FP service delivery Inter and intra district disparities !under privileged groups

On going conflict situation Resource constraints Managerial issues

• Sustainability

- 59 -

Annex 3

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DRAFf ACTION PLAN, THAILAND 2005-2010 STRATEGY Improve and maintain quality of services for safe motherhood and newborn health

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(I)

ACTIVITY Human resources - In-service training - pre-service training Logistics and supplies Equip Health Centres with basic EmOC packages Ensure availability of one comprehensive EmOC per 500,000 population - Ensure quality FP services

OUTPUT INDICATORS

RESPONSI BLE AGENCY MOPH Medical college NW'Sing college MOPH

TIME FRAME

2005 90%

2006 100%

2007 100%

2008 100%

2009 100%

2010 100%

...,

><

• % of health centres with skilled personnel

-

-

1

Management Establish provincial supervision mechanisms Coverage - Ensure access to services - Develop and implement comprehensive models for the minorities and hard-to-reach groups Research and development - Establish continuing education programmes for staff Health system research e.g. costeffectiveness, staff replacement

• % of Health Centres with basic EmOC packages • Number of provinces with sufficient Comprehensive EmOC • % of Service Delivery Points (SOP) with quality FP services • % of provinces with Provincial supervision system

90%

100%

\00%

100%

100%

\00%

I

I I

MOPH 50% MOPH 97% 100% 97% 100% 97% \00% 98% 100% 98% 100% 98%

I I

i !

0-

o

• % of ANC and deliveries attended by SBA

• % of staff eligible for continuing education who really continue education • Number of research studies per year - ---

----

.

-_ .. - L _ . _

MOPH Medical college Institute of Health research and develoPlll.ent

50% I

50% I

50% I

50% I

50% I

50% I I

Draft Action Plan for Reduction of Matemal Mortality 2006-2010, WHO Bi-regional Workshop, Manila, 26-30 October 2003,

Improve and maintain participation of individuals, families and communities

-

Empowennent of women Integrate life-skill education in school curricula Strengthen pre-marital counselling services - Increase awareness on early ante natal care Husband involvement - Increase awareness on early ante natal care - Increase awareness on danger signs of pregnancy and delivery to prevent the first and second delays Family participation - Increase awareness on danger signs of pregnancy and delivery to prevent the fIrSt and second delays Community support Involve Village Health Volunteers in motivating women and families to utilize safe motherhood and new born health services

• % of students aware of significance of ANC • % of couples receiving premarital counselling • % ANC in the first trimester • % ANC in the first trimester

MOE, MOPH NGOs

30% 20% 30%

35% 30% 50% 50%

40% 40% 70% 70%

45% 50% 80% 80%

50% 60% 90% 90%

60% 70% 90% 90%

MOE, MOPH NGOs

30%

• % ANC in the first trimester

MOE, MOPH NGOs MOE, MOPH NGOs MOl NESDB, NSO, MOPH MOPH, Royal college of OB-GYN MOPH

30%

50%

70%

80%

90%

90% I

i

-

• % ANC in the ·first trimester

30%

50%

70%

80%

90%

90%

...., '" 1 1 I

Improved health management information system

National database

• National database system

1

1

I

Maternal death audit

• % of maternal deaths with audit

50%

60%

70%

80%

90%

90%

Severe morbidity report and conference at provincial and national levels Enabling environment

I Public policy formulation MOPH, Parliament Paternity leave 12% 10% 10% 10% 10% 11% - Iron and trace elements fortification EmOC = Emergency Obstetric Care, MOE = Ministry of Education, NESDB = National Economic and Social Development Board, NSO = National Statistics Office, MOPH = Ministry of

-

• % of provinces routinely undertaking report and conference • Legislation on paternity leave • % anemia in pregnant women

50%

70%

80%

90%

90% I

90%

Ei D <I>

Public Health, MOl = Ministry of Interior

>< w

Draft Action Plan for Reduction of Maternal Mortality 2006-2010, WHO Bi-regional Workshop, Manila, 26-30 October 2003,

- 62 'Annex 3

, Republica Democratica de Timor-leste Country Plan of Action 2004 - 2013

.JfJ_ ....

Country Situation • Maternal mortality ratio: estimated BOO per 100,000 live births • Infant mortality ratio: 78-149 per 1000 live births • Total fertility rate: 7.6 • Contraceptive prevalence rate: 7 % • Percentage of antenatal care: 43·/. *Source MICS 2002

Country Situation Percentage of delivery assisted by skilled birth attendants: only 24% Shortage of skilled health providers • Absence of health preventive and curative services addressing adolescents • Lack of access to management of high risk and complicated cases • Poor referral system

Components of plan of action Development and implementation of National Reproductive Health Strategy, with four key elements: o All pregnancies are safe through ImplementJng '~Maklng Pregnancy Safer'" o

strategy Essential Reproductive Health package

implemented In phases o All adolescents prepared for a healthy family life o Prevention and management of STIs,

HIV/AIDS

Components of plan of action ~Makln\l

Components of plan of action o Promotion of family planning ,. Implementation of National Family Planning Polley .. Nationwide socialization of health care providers .. Promotion campaign among women and couples .. Training of health care providers on counselling and techniques » Assured supplies of contraceptives.

Pregnancy Safer" priority activities:

• ImplenMntation of family planning program In collaboration with UNFPA Increas. number of dellve"es attended by

'killed h.. lth provklars- recruit,. train, and place mldwlv.. In remote are. .

• p,....AI 11 CHC with b ... for belle

emeraency ob.tetrlc care- e.g., procurament of equipment completed: tralnlno of health staff'to _tart

Improve compreh....lve BmOC at two ext.tlng re'......1 Ito,plbll. (Dm. Baucau hOllpltal) PAl,." four new rem,.1 hOlpltal1 for Cl!moc

- 63 -

Annex 3

Components of plan of action Essential Reproductive Health Package Implemented In phases through 2013 • Build awareness and support for the concept by consultation with stakeholders

Compon,mts of plan of action Develop healthy lifestyles education for adolescents • Improve access to reproductive health

Information • Include familv life skills education In school curriculum In coordination with introduction of school health programme for secondary schools • Provide youUl friendly services In health facilities

• Develop operational guidelines for Implementation • Train staff • Regular monitoring and evaluation

Components of plan of action Improvement of health provider skills through training in : o o o o o a

Components of plan of action Improve the quality of services and monitor for effective Inaternal and newborn care o o

Safe and clean delivery Newborn care Breastfeedlng counselling Family planning services and counselling Life saving skills In obstetric emergencies Management of STIs using the syndromlc approach

Placement of 2 midwives in every

Community Health Center (sub-district) Continued Implementation of Standards for guidelines for: Essential Care Package Guide for Pregnancy, Childhood and Newborn Care Managing Complications In Pregnancy and childbirth

Midwifery Practice o Adaptation and Implementation of

o Skills In community health IEC o Explore possibility of midwifery school,

especially to supply remote areas

Components of plan of action Community Health IEC: o Integration of reproductive health messages In general health promotion strategy and programmes o Train community health motivators In delivery of reproductive health messages o Develop appropriate health IEC materials and approaches

National Safe Motherhood Action Plan 2005-2010 (Draft) - Cambodia Strategy l. To Improve

Activities I. Develop National Comprehensive SM training Plan.

Standards and guidelines to ensure quality and consistency in implementation of safe motherhood (8M) activities.

Performance Indicators National Comprehensive 8M training plan existed

Responsible Agency

Year

2005 X

2006

2007

2008

2009

2010

::1 ::1 (1)

>

~

w

2. Review and revise national guideline for incorporating active management of third stage of labour in standard 8M practice 2.1. Organize technical working group meeting to review national guideline for active management of third stage oflabour. (Oxcytocin and Misoprostol) 2.2. Update National 8M protocols for Referral Hospital, EMOC and Health Center. 2.3. Review and revise training curricula for post basic midwifery training. 2.4. Review and revise community based nurse-midwife assistant training curricula. 2.4.1. Incorporate refresher training plan in to provincial plan and implementation.

National guideline reviewed and revised.

X

Technical working group meeting conducted.

X

National Protocols updated

X

l='"

Ir . ining curricula reviewed and revised Training curricula reviewed and revised.

X

X

,

+ Refresher training plan existed in provincial plan. + # of course + # of participants

X

X

X

X

X I

-

L_

I

Strategy

Activities

Performance Indicators # of Ods implemented maternal death audit.

Responsible Agency 2005 X 2006 X

Year 2007 2008 X X

2009 X

2010 X

5. Maternal Death Audit 5.1. Expand maternal death audit nationwide. 6. Review, revise and inclusion in MPA and CPA essential drug list and equipment list of all items needed for SM. 2. Strengthen capacity 1. Develop refresher-training plan on active management ofthird stage of Health staff and of labour. expand SM services provision. 2. Conduct refresher training of trainer on new active management of third stage oflabour. 3. Conduct refresher training of trainer on new active management of third stage oflabour. 4. Abortion 4.1. Training on comprehensive safe abortion and management of its complkations for RH. 4.2. Conduct training on Pre-Post Abortion cuunselling and refer complicated abortion cases. 5. EmOC: Pre Service Training: 5.1. Incorporate new SM training curricula in to training curricula for medical student at university of Health Science. 5.2. Continue one year post basic midwifery courses at TSMC and 3 RTCs.

X

Refresher training plan existed

X

# of trained provincial trainers # of ToT # of trained provincial trainers # of ToT # of courses # of participants

X

X aU1

X

# of course # ofHC staffs New SM training curricula incorporated.

X .

X

# of courses # of participants -----_._-

X

X

X

X

X

X

:>< w

<Il

:J

~

Strategy

Activities

5.3. Continue Nurse-Midwife Assistant training course for remote area. 6. Continuing Education 6.1. Conduct basic and emergency obstetric care for physicians at RH. 6.2. Conduct basic and emergency obstetric care for RH midwife 6.3. Conduct basic and emergency obstetric care for HC midwifes. 6.4. Conduct basic and emergency obstetric care for Nurse-anaesthetists and operation theatre nurses. 7. Birth Spacing and VSC 7.1 Conduct BS training for new HC staff 7.2. Conduct refresher training for health staff 7.3. Conduct VSC training for RH staff. 8.PMTCT 8.1. Conduct PMTCT training for health Staff 3. To increase quality "1. Conduct Outreach activities by SM services at MW or HC staffs as per outreach community level guideline. 1.1. Conduct village visits for ANC, tetanus toxoid vaccination, birth preparedness, delivery, PNC, breastfeeding, BS, new born vaccination. Iron and folic acid distribution, Vit A distribution, data collection and refer women with risk pregnancy. -

Performance Indicators # of course # of participants # of course # of participants

Responsible Agency 2005 X X 2006 X X

Year 2007 2008 X X X X

2009 X X

2010 X X

g .., ~

# of course # of participants # of course # of participants # of course # of participants

X X X

X X

X

X

X X X

X X X ,

X X

X X

X

# of course # of participants # of course

X

X

X

X X X X

X X

X X X X X I

X X C1> C1>

#of participants # of course # of participants # of course # of participants

X X

X ~{

X X

X X X

X

X X

# of visits per year % of pregnant women received: ANC, IT vaccination, Iron tablet, information and eduction. # of referral cases. -

X

X

X

--

----

----

Strategy 4. Improve management and coordination of Safe motherhood activities.

Activities 1. Conduct monitoring from Central level to Provincial level (RH and HC) 2. Conduct supervision from Provincial and OD level to RH and HC level. 3. NRH to give input on sector wide management group on safe motherhood priority. 4. Monitor progress ofSM activities within the HSSP to gain experiences and lesson learn for future planning and implementation (every 6 months) 5. National meeting to coordinate SM activities: 5.1. Annual symposium on MCH 5.2. Workshop on Safe abortion. 5.3. Annual WS on Maternal Death Audit. SA. Annual WS on EmOC 5.5. Annual WS on Midwifery training. 5.6. Annual meeting on BS and VSC. ~-

Performance Indicators # of vists conducted

Responsible Agency 2005 NMCHC 2006

Year 2007 2008

2009

2010

X

X

X

X

X

X

# of visits conducted

PMCH

X X

X X

X

X

X

X

X

X X

X

X

X

X

X

X

X

X

X

X

X

X

X 0-

"

-

--

--------

-

--

~-

---

'--

5' p !Il

>< w

Strategy

Activities

Performance Indicators

Responsible Agency

Year

I

2005 X X X X X X X

2006 X X X X X

2007 X X X X X

2008 X X X X X

2009 X X X X X

2010 X X X X X

~ ::;! <D

5. Oversee Training and Workshop

6. Research, Review and evaluation.

6. National meeting to coordinate and infonn other ministry on SM activities. 7. Conduct monthly Coordination Committee Meeting. S. Conduct bi-monthly MCR Subcocom meeting. 9. Conduct Technical working (SM, Midwifery training package) group meeting. 10. Conduct monthly Prococom meeting. I. Conduct Specialist training on safe abortion in Vietnam. 2. Attend international workshops and conferences on RH and safe motherhood. 1. Conduct CDHS 2. Conduct National Health Survey. 3. Conduct WS on dissemination of the research finding.

...,

X

X

X X

X

X

X a-

co

i -,

X

X X

- 69 Annex 3

, . Goal of Na~~~~~~ Plan of Action Country Strategy of Safe Motherhood By the year 2010, to have reduced maternal mortality by one-fourths of the year 2000 level .

PHC & MCH Department Ministry of Health

~~

..""...

\

.- . -:

China

, -'-'

• 2000: 53 per 110,000 live births • 2010: 40 per HIO,OOO live births

The Distribution of Maternal Mortality In China, 2002 (1/100,000)

Core Strategy 1. Corti'''Je to enlist government COlLr,. dIlents

• Cover facility-based delivery in rural socr.d health insurance in the west areas • Continue to finance 8MI Project by government

Core Strategy 2. Promote facility-based delivery in the west thro.ugh "Three-Cyde Model"

Family

Community

SUpporter

Health System

- 70 -

Annex 3

Core Strategy

Main Activities 1. Implementing and seoping up National SI\-U Project in the westlpart of middle province. (pha •• II: 2004-2006, 121million USD) 2. Establish sistership among provinces and

O Health system

3. PromotiDg quality of EmOC • Capacity of Facility (motherfrieDdly) • Better performed skilled birth atteDdaDce

organizations (eastlwest, higherllower levels) to assist man-power development National level: OQce 8 year Loeallevel: based on tbe needa

Main Activities 3. Developing, implementing and monitoring service protocol! • Dlwelopinl: 1003-W04

Takincelfective: 1005-1010

4. Improving surveUlance and conducting envidence based operational re..arch .. for quality of care Assess.....' or mlternal1aditiag (1004) MMll. lad family plaaalng•....•(l003-W04)

- 71 -

Annex 3

_In.lan Malemal Mortalllv ledueUID To be implemented in a sustained fashion, with the use of appropriate technology and making all efforts to match plan with resources

BraUcUI. Plan Pacmc Island CIUBbl.1

AcUIQ.lan Ile~I_ldS••

en"se. Blinn RI JI%. '11)

.,.,dlllt•••, Basic OI.llIblc CI"IIJ

- Trllllalllll.IIWI'.1I UIsIIII 11.l1li IIc.... • .In C .. ln.can - Ess..Ullllcbla II 111m .all ........... , - ...... '.1:.0081. IIIHIIInIl - BI•••ce.nVl" ••' C ...... 8$1l1li1111 - 1.lllnU.. II c,-.cs 11118II1II'._ IIIfInrJ '.n.1I 111% In crlslslS.L ... IIM - . . . . . .II ...IIWIVIS.I.,........... 'IIJ

CI"lcIty l1li1.... SIIII & FaclOUas Flclhlnradl - hili nflmllllCl1lll81 - .........nIII..... CIIIlIr

I.

'. lIe....... II ........ flClIIlJWllllIII,1I IItllltnnll • Trllll., 11II1IIl1li1.1 Wlltl,. - . . . . . . sbIIIIr - JIII.,_II, P"IIJ IIUn .. IIIlIIIzIIIIa

... ,....,..,.. II ...11WU

- . . . . . . .~~~Cl

·

7)

................................... • .................'7 II r•

"_IIII~fII_'" • ............. 111IIIIIIII....,

72 -

Annex 3

DRAFT ACTION PLAN OF MMR IN LAO.PDR 2006 -2010

Goal: Improve the quality of life among women and children by reducing the maternal and neonatal mortality. Objectives:

Reduce maternal mortality from 390 to 250 per 100.000 LB by the year 2010 Reduce neonatal mortality from25 to18 per 1000LB by the year 2010 Reduce fertility rate from 4 to 3.5 by the year 2010

STRATEGIES: Advocacy for increased awareness. political commitment and leadership for policy formutaUon and implementation Social mobilization and Community Parucipation Functional Referral Structure and System . (Evaluation of Maternity Waiting Home for possible further expansion and continuous human resources development) Information Managemant System and logistical

..

_ --'" --'" -"-'

~

.....

oen......... -Uhop for hIth rlnklnl ~~.IJYIIIII.IIoo

........ c:....- .....

... d

.... II~I

......... pfOr

_ _ lkIndlll ......... l6on

... w.......... .........

........ pleMMtaCloro

-."- ...

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L ......

"-

-~"

.rr.InIItQ otmau oraMlu1kln1 (VMCMCl on MMR 4 .... ~ study on pDUtW. rwoI ....... fII .... Io~NfwnloI_ ........

.. of viii.... tr.InH

P-*dlNltlOn

.

Pf-anUlcKI

management Interpagency coordination and inter-sectoral conabOration

ofItlDl ~ f1and

s.-.. tor

, . . , . - ." CompI..t8d Pngnancl"

............ .,..Il00••

........

<fIofpftotllll.....

-.................. ............... _ . --_ .. ---. -_ .... . -----", .......... _ _ n...aEMOC .............. oIE111OC

.• 01-'* NVtIwed .... ,....,...,........ .. I!II ... .. OfHC;. . . . . . . . .,.".....

...-

. . . . . . . "' ........ 01

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..................... _

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.......... • reg.... repott . . - . . - - . of MIIlA

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b.~ • ~

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73 Anne?, 3

I.......... MCY

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-- ---• RIIIIM ...... __ ", • ......... EmDe ..

-

........ 1IIIIOC1IDr

.", ....... ...-. ........

-.-

...

-

74 -

Annex 3

Statistics of delivery pattern :

• 80% HOSPITAL DELIVERY 83% SAFE DELIVERY ,70% ATIENDED ANTE NATAL CLINIC ANC VISIT = 7.7 68% ATIENDED POSTNATAL CLINIC • PN VISIT = 2.3 32% USE FAMILY PLANNING

DRAFT ACTION PLAN 2006 -2010, MALAYSIA

........ _ . _. --L_. --_. - -----L_ --_. -. -...... ._. - ...... --._. -L_ ..... -L_ -..... - --.... - ,PIAno,

~-

,

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1.'.... _

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t- i""'"

75 -

Annex 3

-- ._, _. - -.... -_ ..... --'" --- - .... '"_ ...... _. --.-,-- .-_.- _. . --- --- ---_ ...... -. - -....-."..".., .."..,

-..-

on-..

1. ~ClUlUl'Vc.CAAI!~

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Draft

National Plan of action for reduction of MMR for 2005-2010 - Mongolia Strategy Activity I.

g ..., 2009 2010

Performance indicator

Responsible agency 2005 2006 MoLSW, MoH, MoH,DMS

Time frame 2007 2008

~

1. Strengthening the political committment

2. 3. 4.

5. 6.

7.

Review national policy on population (birth, fert rate, registration) Develop and approve ill national RH program for 2007-2011 Organise national RH conference Advocacy and Consultative meetings on RH subnationaI level for all stakeholders Motivation of health service providers Advocacy for improving infrastructure at subnationallevel through regional development strategy Approve national plan of action on prevention of iron deficiency anemia

1. Revised policy papers according to MDGs 2. Approved RH national prog

+ MoH,Local governors office and Provincial health Department Local governors MoH and other sectors, local government

+

3.Consensus & recommendation 4.Developed Plan of action at the sub national level 5. Resolution on improving social welfare issues for health service providers (incentives, Mol and salary) provincial 6. Improved road authority condition & communication in remote provinces MoH,MoAgF 7. approved plan of action 19 intersoum hospitals 5 mobile clinics are functioned

Ir

Lo.

+

+

'" a+

r

2. Increllsing access to skilled birth attendants

2.1. Re-establshment of intersourns hospitals at subprovincial level for Comprehensive EmOC 2.2. Establish mobile clinic on SMH & provide service for nomadic Imobile popUlation in western region 3. Improvement of Registration system for migrated population to urban

MoH,Local + government & health department MoH, local + health department MoLSW,MoH

+

+

Resolution is made --

MoH,DMS

+

. -

-

-

I

4. Survey on cost effectiveness of Maternity waiting home 3. Providing equtable and accessible service

Survey findings MoH,DMS

+ + + MoH,DMS WHO,

3.1. Baseline survey to assess Survey findings out and in patient maternity hospi tals and wards at I, II, III levels 3.2. Develop operational plan Plan of actions of action on streng/improvement of facility capacity building 3.3. Provide necessary equipment partilcularly basic neonatal care and Necess equipment is drugs/contraceptives in available at the service accordance to national standard to all levels Operational plan 3. Improve maintenance services of the RH equipment Incraesed Utilization time and training for specialists 4. Provision of transport at I, II, III levels (horse, motocycIe, Improved transport ambulance car)

MoH,DMS

MoH, implementing agency Local authority MOH donors

.

.. -J -J

~

.';:--<~

4. Improving tho; quality of matertnal and newborn care

4.1.Develop and adapt guidelines on EmOC, MVA, RH Counselling & Mgt of Gynecologic diseases into practice 4.2. Reflect guideline into pre and postgraduate training curriculum 4.3. Improve knowledge and skills of OB-Gyn through: - MCPC training for doctors in 7 provinces, -ECPG for midwives at natiowide - MYA for OB-gyn in nationwide; Managementofpregnacy -

Adaptation of guideline

MoH,DMS, MCRC

1+

Reflected into training curriculum for undergraduate students and servo providers

MoH,MCHRC, MMU

Improved skills ofOBgyn, midwives and others doctors

S' ::l MoH,DMS, MCRe <b

,

.. ~

...,

><

.

and extragenital for senior OB-gyn and senior doctors of internal medicine - Training on counselling methodology 4.4. Develop postraining evaluation guidelines & check lists for follow- up 4.5.Conduct follow-up actions after training 4.6. Regular visit consultative team (OB-gyn, DIM, Laboratory people) at provincial level to soum hospital 4.7. Improve Water I Sanitation and heating system of the hospital at soum level 4.8. Supplementation ofViT A for postnatal mothers at nationwide 4.9. Improve women in reproductive age nutrition through IEC on use of fortified food (Iron, iodine, Vit C) 4.10. Improve newborn care through provision of incubator, warm table, (matrass) and ambu bags 4.12. Introduce Client oriented Providers Efficiency exercise (COPE) in planing, evaluation 4.13. Training for dec makers on supportive supervision and mgt 4.14. Improving heating of maternity wards in cooperation with local authority and private sector 4. 15.Introduction of evidence based Audit to HS '--------

!

!

::J

~

Developed guideline and check lists Number of follow-up actions Number of visits and Protocol

MoH, MoH,DMS, MCHRC

.'>C

(1)

""

Provincial health department

NI % ofhosptitals with improved water and santitation and heating system % of postnatal mothers received ViT A developed IEC and Num of health facilities distributing of IEC materials Provided essential equipment Number of skilled participants

MoH, local authority, Community Public Health Institute, Local health department 11'1, DMS and Pill, local health departments

• .

(»

.....

MoH, DMS

Numl"l0 of trained decision makers and their skills Num/% of maternity wards with improved heating system

MoH,COPE Facilitator's team

-

S. Promoting partnerships and improving health systems response

4.16. Improve Blood banking service ataimag and intersoum level 4.17. Conduct routine screening for health status of women in Rep age at nationwide and treat them 4.1B. Intensify HIV test for blood donor at the province level lB. Implementation of Mother and child friendly initiatives 5.1. Scale-up a model of Adolescence friendly-service in natiowide S.2.Undertake IEC activities for target groups (poor families, dropout children, unemplyomeer, under servent lunpreveliget population) 5.3. Train private sector's prarctioners on FP/STI counselling 5.4. Extend a model for counselling hotline services for adolescences at nationwide in cooperation with local NGOsS.S.Re-training for school teachers on RH issues

NurnJ% of provincial and intersoum hospitals with blood bank service Survey findings % of recovered women

Local health authority MoH, NPIAgency MoH,Blood Center, local authority Local health departments MoH, OMS, PHI MoH, local health departments

Num/% of Motherand Child Friendly Hospitals

•

Number of Adolescence friendly-service increased

•

. ...

Developed IEC materials and list of dissemination N of trained people Number of counselling hotline service increased in provinces

DMS, PHI and mass media

~

o-J

Local authority and local NGOs

!

N/umber of teachers improved skills

MoH,MoSTEC ----

Rapid actions: I. Organize Press Conference on Briefing of the Bi-regional workshop on Progress ofMM reduction 5 Nov, 03 :t-

2. Finalise a Draft plan of action on MM reduction for 2006-2010 through organising national workshop for local health authorities and sharing with donor agencies, by 2004-2005 3. Approval of National Plan of action for reduction of MMR for 2005-2010 by Minister's Committee Meeting by Sep, 2005. 4. Introduce National Plan of action for reduction ofMMR for 2005-2010 to all stakeholders

~

o o

v.>

- 80 Annex 3

Plan of Action for Reducing Maternal and Perinatal Mortality

Goal • Reduce maternal mortality by ¥. by year 2015

.t~_t~~~~ Philippines 2004-2010

development goal) • National Health Objectives

F

~enium

Capacity Building • Revised policy on traditional birth attendants • Alignment of existing manual on maternal care with ECPG • Development of Guidelines for PhilHealth Circular no. 15 and 16 • Dissemination of updated policies and guidelines • Adaptation ofECPG into Philippine setting • Training of core trainers at regional, provincial and city level for ECPG and MCPC • Training of implementers • Preservice training (integrating IMPAC into the medical, nursing, midwifery curriculum) • Follow up after training (supervision, mentoring) I

Resource Mobilization • Development of advocacy tools/materials • Orientation of LGUs on safe motherhood, women's health, reproductive health that wouJd InDsIate into local resolutions, budset aUocation and oIher supput to the program • Celebration ofSare Molherhood Week,Women's

HeaItb Month, Family Planning Month, Breaslfeeding Week,.etc

• Donors' Meetings • Procurement and distribution ofVil A, iron supplements, multivitamins, TT v'L-,,<';nes • Str<:ngthen counterparting mechanisms through interagency meetings and workshops

- 81 -

Annex 3

Community Support Mechanisms • Development of communication plan 011 safe motherhood, women's health • IEC materials to focus on: • •

Community Support Systems • Nationwide expansion of Female functional literacy courses, parent effectiveness skills • Dissemination and utilization of mother and child book • Replication of models on community health care financing • Development of a community-based EmOC (prereferral, in transit)

Timely care seeking Delivery by professional birth attendants

•

Prevention of unwanted/unplanned pregnancy

• •

Male involvement on safe motherhood Healthy mothers for healthy babies (Healthy lifestyles)

ji';'~~i;;i§lt~il~~r~~~!r~~~'ti~;~,,~$;JI;~Ai Strengthening Service Delivery • Mainstreaming the essential package of services for pre-pregnancy, prenatal, natal, postnatal • Local capacity building through technical and financial support.assistance

system • Reactivate/update the safe motherhood website to include perinatal/neonatal data • Utilization of GIS and inclusion of maternal/perinatal/neonatal data • Inclusion of maternal, perinatal, neonatal data intl! existing CBMIS I',

~';l:"i~'~m!6~~!!~:~!e.~~~~;~r~~ Quality Assurance • Mainstreaming "Sentrong Sigla' ("center of vitality") • Mother-Baby Friendly Hospital Initiatives (+) certification

" ,

.

research • Follow up status of birthing homes • Desk review/needs assessment • Comprehensive program review every 3 years • Analysis of maternal death review results at all levels

.

~,! ,

- 82 Annex 3

Monitoring, Evaluation, Research • Documentation of best practices • Assessment of training on ECPG and MCPC • Regular team monitoring (interagency)

DRAFT ACTION PLAN (Solomon Islands) STRATEGY ACTIVITIES PERFORMANCE INDICATOR • Provincial politicians and senior officers aware of safe motherhood issues, problems and situations and to commit support. RESPONSIBLE AGENCIES MOH - National - Provincal (RH Division) AusAID funding MOH SICHE World Bank funding UNFPA? MOH NGOs Women's Groups Civil Society Village Health Community MOH - Province - National World Bank UNFPA MOH - Province - National NGOs Churchl Women's Group Other stakeholders MOH - Province - National AusAID ROC

Drafted : 29 October 2003 TIME FRAME '041 '051 '061 '071 '081 '091 '10

1. Strengthening political commitment

1. Raise awareness on safe motherhood for Provincial politicians and senior officers at Provincial Assembly meetings

2. Increasing access to skilled birth attendants

1. Training of midwives -In country - Overseas (PNG)

• Trained midwives available to be posted to provincal hospitals, AHC and RHC in remote and difficult to reach areas. • Waiting homes improved and new ones built in appropriate locations.

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2. Work with churches, Chiefs, women's groups to imprOVe/strengthen and establish waiting homes at AHC/RHC for pregnant women.

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3. Targeting areas of High MMR in provinces - Training midwives and posting to areas with high MMR - Improve communication and transport arran ements 4. Encourage health facility based deliveries in areas of high home births. - GP, MP, and CIP

• Midwives available in high MMR areas of the provinces

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• Increase facility deliveries from present % in GP, MP, CIP

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5. Rotation of RlN's ?NA's from AHC and RHCs for specific identified skills e.g. manual removal of placenta, active management of 3rd stage of labour at Provincial Hospitals and NRH labour wards. 3. Increase FP/CPR 1. Improve local DEP FP Module, pilot practical component. 2. Consolitation of FHC in xxxxxx. 3. Expansion of FHC to Malaita Province.

• R/Ns more competent in life saving skills

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DRAFT ACTION PLAN (Solomon Islands) STRATEGY ACTIVITIES 4. Introduction ofFHC in CIP, GP, WP, MP PERFORMANCE INDICATOR RESPONSIBLE AGENCIES

Drafted : 29 October 2003 TIME FRAME '04 '05 '06 '07 '08 'Olt

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'!;¥;:< If·"";~ • Basic obstetric care and EOC equipments, drugs and supplies available at NAP, RHC and AHC according to supervisory checklist. MOH - Province - National

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4. Providing equitable and accessible services

1. Basic obstetric care services and EOC equipments, drugs and supplies be made available at all NA posts, RHC and AHC according to expected functions and services to be rendered at each cateQorv of facilities. 2. Two-way radio in 80% of each provincial rural health facilities.

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• Two-way radios available and functioning in 80% of rural health facilities.

MOH - Province - National AusAID ROC? EU? Provincial government MOH - Province - National

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3. Strengthened supervision and on-the-job training at provincial and zone areas using supervisory checklist.

• Provincial supervisors visit each facility and its staff at leastlwice a year and provide on-the-job training and support. • Feedback findings to provincial healt monitoring and evaluation committee.

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4.1 Order Haemoglobin colour sca~e ,. r all rural health facilities (AHC, RHC, NA;-is)

• Haemoglobin colour scale available in all rural health facilities.

MOH - National WHO MOH UNFPA

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4.2 Training of community staff on use of Hb colour scale

• Rural health staff (90%) trained on use of Hb colour scale, and are using it. • FHC introduced xxxxx

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5. Expand introduction of FHC to xxxxxx

MOH UNFPA World Bank ??

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5. Improving quality of maternal and newborn care.

1. National in-service training of nurses on safe motherhood according to Integrated Management of Pregnancy, Childbirth and Newborn strategy.

* 80% of nurses (R/N, N/As) having trained on safe motherhood accordin to IMPCN strategy.

MOH - Province - National

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DRAFT ACTION PLAN (Solomon Islands) STRATEGY ACTIVITIES PERFORMANCE INDICATOR • 90% of National, Provincial and arealzone supervisors having attended the National RH conference on SMH. RESPONSIBLE AGENCIES MOH - Province - National UNFPA WHO AusAID? MOH - Province - National ROC UNFPA AusAlD RHD-MOH DEP -MOH MOH - Province - National UNFPA AusAID ROC DEP RHD MOH Province UNFPA fundina MOH - Province - National RHO World Bank MOH - Province - National WHO UNFPA MOH RHD

Drafted: 29 October 2003 . TIME FRAME '04 '05 '06 '07 'DB '09 '10

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2. National RH conference on safe motherhood

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3. Provincial RH mangement training of zone/area supervisors.

100% coverage of provincial zone/area supervisors management training.

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4. Strengthened and improved FP training.

• Complete FP manual review and print manual. • Complete improvement of FP pilot site clinics Buola, Gizo, Kira 1/2 HCC - Equipments, drugs and supplies - Improve physical standards

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5. Pilot FP practical skills. Attachment in pilot sites. Buala, Zizo, Kira, Rove clinics.

• FP DEP students complete FP practical skills al; .:lment and are competent to perform required specific skills • RlNs sent to Manila complete FP training and returned to workplace.

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6. Send students for FP training in Manila Philippines

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7. Continue review and improving and expanding the SIRHSS (coding sheet) in all provinces.

• SIRHSS improved and expanded in all provinces.

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B. Finalize safe motherhood and RH protocols and policy guidelines, including

• Final copy of protocols and policy guidelines completed, printed and

.••••

1

I

DRAFT ACTION PLAN (Solomon Islands) STRATEGY ACTIVITIES - Malaria in Pregnancy - Anemia in Pregnancy - STI in Pregnancy - Breastfeeding etc PERFORMANCE INDICATOR distributed to all health workers. RESPONSIBLE AGENCIES OBS/GYN department Stakeholders AusAlD IM-IO RH National Committee MOH RHD Obstetric NR H Provinces

Drafted : 29 October 2003 TIME FRAME '04 '05 '06 '07 '08 'Og '10 ,

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g. Establish maternal mortality and perinatal neonatal death audit in NRH, Gizo, Kiluufi Hospital Makira Hospital and others

* Audit system established in hospitals

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6. Promoting partnerships and improving health syslems response

1. Safe motherhood awareness raising for civil society and stakeholders, community leaders, NGOs, churches, at provincial level. 2. Develop advocacy tools! information for stakeholders and partners.

* Stakeholders in provinces are aware of SMH issues and commit support

MOH World Bank AusAlD MOH RHD HPED (RH committee) MOH - Province - National World Bank AusAID ROC

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* Advocacy tools completed and available.

3. Worldng with village health committees, NGOs, church women's groups to establish transport and referral system for obstetric emergencies. Also for referring pregnant women to weiting homes.

• Some communities establish transport and referral system for pregnant women.

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4. Increase men's awareness of SM issues and other RH issues Sistership idea. S.Monitoring and Evaluation

-

87 -

Annex 3

Situation of Maternal . -

------

Mo~iitY-1

-~------~------.----

.. Situation of Maternal Mortality in Viet nam

MMR per 100 000 live births in Vietnam Population

= more than 80 millions

~---------------------------

.. +---~------------------------

-

---=.-. MMR in different regions

-------------------------' Challenges I @ ---_._--_. __ .__ -.._.", ".. ---_. __ _ _ _

10 _ _

H..-

10_. . .

10........

_

..

____

_

.........

_

_

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I

- 88 Annex 3

~

28% of pregnant women not received ANC.

' " 11 % of deliveries without skilled attendance. ' " Perinatal Mortality. 06 complications still high. ' " Malnutrition of children under 5 is 37%. ' " Gaps among regions (range 45- 411). ' " Anemia among pregnant women about 45 % ' " Data collection s slem

= weak

RH care system • Management capacity • Facility and equipment • Management of data • Manpower: lack of secondary midwives . • Technical capacity • Policies

-~~

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-

SltuaUon of Maternal Mortality rate ... ~-~

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Action Plan Strategy 1. Conttnue to shngthen the RH _dollvary .....

Action Plan TIme 2. _

Activities

Strategy

Activities

Time 2004

TraiWlg. RHlIining - - . . 2004-2008 _ MO .• NIssa at ••dI _ _ about midwiVes and emOC (technics, lMnegernenl)

...

TllIinng minOrtties in remote

Prooidng 2004-2010 drugl to health facility at commune and district lewis

-_ for

and Portnetal Develop guidllines and lools IINth Auclt U ntfnforceIMnt of data collection aptem 9veryyaar

Pilot (7 provi0c8s), review meeting 2005 -2008

2004-2008

........ ..-

areal

to I8fW

R<wiew. _g""Implementing

20GI

for

counby

"'.

whole 2008·2010

-

89 -

Annex 3

Action Plan Strategy 3. Integration of Safe Motherhood with other

Action Plan Time 2004

Activities Develop minimum package of health care for different target groups

Strategy 4. Ralstog awareness

Activities OeveloP'T'lent of lEe materials 10 increase communty awareness on high risk pregnarcy

Time 2004

health programs

of women, famity and community about MM

andEmOC Developnsnt of lEe to increase anten.-al care and childbirtl in heath facilities QevelOl=JTlent of lEe materials on family planning

Collaboration among different 2004-2010 programs· Immunization program Nutrition program Malaria control program

2004-

2005 20042010

MTCT program Adolescent RH prOl;jram

.........

eevelopnent of IEC materials on prevertion Printing and dissemination of materials

sro

2004 2004

........

I ~::~n!A~:an delivery !dIS

In

2004-2010

I ~velopnent

of training materials

on

~~

THANK YOU FOR YOUR ATTENTION