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PROGRESS of
MATERNAL
MORTALITY REDUCTION Uv tiUY WESTERN
PACIFIC REGION
World Health Organization Regional Office for the Western Pacific
2003
WHO!WPRO LlBRARY MANILA, PHILIPPINES
WHO Library Cataloguing in Publication Data Progress of maternal mortality reduction in the Western Pacific Region
1. Maternal mortality - trends. ISBN 92 9061 081 6 (NLM Classification: HB 1322.5)
©World Health Organization 2003 All rights reserved. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers' products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. The World Health Organization does not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use. Publications of the World Health Organization can be obtained from Marketing and Dissemination, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel: +41 22 791 2476; fax: +41 22 791 4857; email: bookorders@who.int). Requests for permission to reproduce WHO publications, in part or in whole: or to translate them - whether for sale or for noncommercial distribution - should be addressed to Publications, at the above address (fax: +41 22 791 4806; email: permissions@who.int). For WHO Western Pacific Regional Publications, request for permission to reproduce should be addressed to Publications Office, World Health Organization, Regional Office for the Western Pacific, P.O . Box 2932, 1000, Manila, Philippines, Fax. No. (632) 521-1036, email: publications@wpro.who .int
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~BLE OF CONTENTS Acknowledgements Preface Cambodia China Lao People's Democratic Republic Mongolia Papua New Guinea Philippines VietNam
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vicKNOWLEDGEMENTS This document was prepared in consultation with the Ministries/Department of Health of seven countries. The support of the following is acknowledged: National Maternal and Child Health Center, Ministry of Health, Cambodia Primary Health Care/Maternal and Child Health Department, Ministry of Health, China Mother and Child Health Center, Ministry of Health, Lao People's Democratic Republic Maternal Health Care, Ministry of Health, Mongolia Port Moresby General Hospital, Ministry of Health, Papua New Guinea National Center for Disease Prevention and Control, Department of Health, Philippines Maternal and Child Health/Family Planning Department, Ministry of Health, Viet Nam
. The production of this booklet was made possible through the collaboration of WHO country offices and four units in the Western Pacific Regional Office: Health Information and Evidence for Policy, Public Information, Publications and Reproductive Health. WHO is grateful to all who contributed time and provided information.
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AEFACE Maternal mortality ratio reflects a woman's basic health status, access to health care and the quality of care that has been provided. Recognizing the need and the value of improving maternal and newborn health, the international development community renewed its commitment to reducing maternal mortality, which is reflected in the United Nations Millennium Declaration of 2000 endorsed by 149 heads of states. The UN Millennium Development Goal for improving maternal health is to reduce maternal mortality ratio by three quarters between 1990 and 2015. In May 2000, the Western Pacific Regional Office of the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) co-sponsored a regional workshop on maternal mortality reduction in Manila, where participants from seven countries attended and affirmed that it is the right of every mother and newborn to survive pregnancy and childbirth, and that each family, community, local and national government has the responsibility to prevent their deaths. National plans of action to reduce maternal mortality, which were drafted at the workshop, have subsequently been approved and actively implemented by each government after the workshop. It is true that the maternal mortality ratio is still disappointingly high in some countries and that its reduction is painfully slow. But it is also true that many achievements and progress have been made since the year 2000. Several countries have shown political commitment by the formulation of national policy and service protocols, human resources have been strengthened by the development of curriculum and training courses, and innovative approaches have been sought to meet the needs of the disadvantaged and neglected population. The aim of this booklet, therefore, is to highlight the progress in the work towards maternal mortality reduction since the year 2000. For each of the seven countries, the 10 most important achievements have been listed and an example of good practice has been described. In some countries, an increase in maternal mortality ratio has been observed, but even such an adversity has acted as a catalyst for the governments to further strengthen their endeavour. We hope that this booklet will be useful not only to share experiences and to learn from each other, but also to inspire us all to persist and face the numerous challenges which still need to be overcome.
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Ten most important achievements: • Five-year Implementation Framework for Health Sector Strategic Plan (20032007) has been developed with major targets and outcomes related to maternal and infant mortality reduction. The lifetime risk of dying from pregnancy has been reduced sharply from 1:52 in year 2000 to 1:77 in year 2003. In order to reduce unwanted pregnancy and unsafe abortion, the number of health centres which can provide family planning services has increased in the past three years, and the authorization to implement an abortion law has been delivered by the Ministry of Health. Various midwifery training programmes and curricula have been developed and are being implemented to address the shortage of skilled birth attendants. These include: four-month midwifery training programme; one-year post-graduate training programme; and community-based nurse-midwife assistant training programme. Essential drug and medical equipment lists have been expanded to include all items needed for delivery of Safe Motherhood services. National Protocols for Safe Motherhood Practice now include: Clinical Guidelines on the Management of the Third Stage Labour; Management of Pre-eclampsia and Eclampsia; Management of Complications of Unsafe Abortion; Safe Abortion; and Maternal Death Audit. Contraceptive Technical Working Group has been established and regular meetings are being conducted to discuss and solve problems related to contraceptives. Reproductive Health Management training courses have been provided to managers from all levels to enable them to efficiently perform their duties related to on-the-job supervision of health personnel, monitoring the performance of the programme, and reporting back to provincial and central level. The National Reproductive Health Programme has become an important coordinating structure of provincial plans. It has also restructured its monitoring and supervision framework to support the health sector development decentralization process empowering staff at all levels of health care delivery. Through active information, education and communication (IEC) activities, the information on birth spacing, antenatal/postnatal care, delivery by trained health personnel, identification of danger signs/symptoms during pregnancy, and where to seek care should a. complication occur, have been disseminated widely.
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Midwifery Training ProgrammesA strategy.with short and long term vision The first biennial review of the Health Workforce Development Plan (1996-2000) underscored the current serious shortage of midwives with an expected shortage of over 1 000 midwives by the year 2005. Increasing the number of trained midwives at the referral hospital and health centre level was seen as an urgent training priority. As a response, the Ministry of Health established a technical working group on midwifery under the joint chair of the Human Resources Department and the National Maternal and Child Health Centre that included representation from the training institutions and the major donors involved in reproductive health. A short-term and a long-term strategy were envisioned and later incorporated into the Health Sector Strategic Plan (20032007). The short-term strategy, whose goal was to increase the number of staff trained with midwifery skills, was to introduce a short intensive practical course, creating multi-skilled nurses at the health centre level. In November 1999, the working group proposed the development of a four-month mother and child health course. This course prepared nursing staff in health centres where there was no midwife to conduct a normal delivery and identify risk cases for referral. The long-term strategy involved developing and introducing two courses : 1. A post-basic Diploma in Midwifery for registered nurses which commenced in December 2002; and, A pre-service training aimed at producing staff with midwifery skills to work in remote areas, which is due to commence in December 2003.
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The technical working group on midwifery is still actively meeting and is completing the task of rationalizing the health centre and referral hospital continuing education package for reproductive health related services.
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Ten most important achievements: • The Programme for the Development of Chinese Women (2001-201 0) has been developed, with the reduction of maternal mortality as one of the major objectives. The law of "Maternal and Infant Health" and "Regulation on the Administration of Technical Services for Family Planning" have been promulgated. Twelve western provinces have been identified as priority areas and the government has committed 200 million Chinese yuan for maternal mortality reduction through activities such as promotion of hospital delivery and in-service training at referral level. Maternal and child mortality surveillance system has been strengthened and the quality of data has been improved. The manuals "Managing Complications in Pregnancy and Childbirth: A Guide for Midwives and Doctors", "Improving Access to Quality Care in Family Planning: Medical Eligibility Criteria for Contraceptive Use", and "Selected Practice Recommendations for Contraceptive Use" have been translated into Chinese. Health education courses for maternal and child health practitioners at various levels have been conducted to increase their IEC capability. Local governments have been encouraged to establish county-level first aid centres and the "life expressway" (a referral system with minimal administrative procedures) to ensure pregnant women will have access to emergency obstetric care as quickly as possible. The National Regulation of Midwifery has been developed in order to increase the number of skilled birth attendants. UNICEF and the United Nations Population Fund (UNFPA) projects on Safe Motherhood have been carried out as national pilot projects for improving maternal and child health services. The administrative management of the "floating people" (migrant workers) has been intensified in order to meet their needs and to decrease the mortality in pregnancy and childbirth.
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Improving Maternal and Child Health Monitoring System monitoring tool for Millennium Development Goals Maternal and child health monitoring system has become an important part of the national health information system. It includes annual report and maternal and child mortality surveillance. The information collection/monitoring system allows a cycle of identification of a health problem, development of an intervention, regular monitoring and evaluation of the intervention. Dissemination of information is an important part of this cycle, and a national conference is being held annually together with the publication of newsletters to ensure that not only policymakers but also health workers at lower levels are aware of the situation. In order to ensure the quality of data being collected, the Ministry of Health developed a quality assessment standard of Maternal and Child Mortality Surveillance in 1999, and disseminated it to all provinces. Maternal and child death registration cards have been revised in order to improve the collection of qualitative data, strict quality control procedures have been introduced and the capacity of the national Maternal and Child Health Surveillance Office has been strengthened. Quality assessment is being carried out regularly, with special attention to integrity and completeness of the record; timeliness; accuracy; practice of and finishing time of maternal death review. One of the important aspects of the quality assessment is the under-report survey. This is done quarterly at township level, twice a year at county level, and annually at provincial level. All possible sources of information on maternal and child deaths are checked, including hospitals, police stations, epidemic prevention units and the crematorium. All the underreported cases are then integrated with the regular reports and appropriate adjustments are made on national mortality statistics. This system was found to be not only effective in measuring quality control, but also beneficial in promoting the importance of maternal health care monitoring system, motivating workers, identifying problems and solutions, and enhancing cooperation among stakeholders .
Trend of maternal mortality ratio, 1990-2001 ltiiiJ i - - - -
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Source: Department of PHC/MCH, Ministry of Health, China
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o(;.oPEOPLE's DEMOCRATIC REPUBliC Ten most important achievements : • National Action Plan on Maternal Mortality Reduction for the period of 20012005 has been developed. Reproductive Health Strategic Assessment has been conducted to identify the problems and gaps of reproductive health, and the framework for integrated reproductive health programming has been developed. National Policy on Safe Motherhood has been revised, and maternal care package of different levels of health facility identified. The pilot test of maternity waiting homes in remote areas of the Lao People's Democratic Republic has been initiated with the support of the United Nations Development Programme (UNDP), as a strategy to increase accessibility of women to emergency obstetric care services. Ten master trainers at central level have been trained in order to implement training for provincial health staff at regional hospitals. The manual "Managing Complications in Pregnancy and Childbirth: A Guide for Midwives and Doctors" has been translated. Five hundred copies have been printed and distributed to central and provincial hospitals to be used as reference. "Guide in Managing Obstetric Emergency Complications" for provincial and district health staff and "Guide on Management of Maternal and Child Health Problems" for district hospital and health centre staff have been developed. Mother and Child Health Monitoring Booklet has been developed and pre-tested, to be ready for printing and distribution to the whole country next year. A joint Action Plan on Maternal and Neonatal Tetanus Elimination (MNTE) for the period of 2003-2004 has been developed with the support of UNICEF. Seven districts of two provinces were selected for implementation in 2003. Integrated Safe Motherhood Project and Learning for Children and Community Development Programme have been implemented in 24 districts of six provinces in the period of 2002-2006, with support by UNICEF.
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Maternity Waiting Homes A new approach to reduce maternal mortality in remote areas The maternal mortality ratio of the Lao People's Democratic Republic is one of the highest in the Region, with 530 per 100 000 live births (2000). Moreover, it has been estimated that only about 27% of the population live within a three-kilometre radius of a health facility, and in remote southern provinces, for example, the maternal mortality ratio may be a staggering figure of 1004 per 100 000 live births. Most women and families believe that pregnancy and delivery are normal events not requiring the assistance of skilled medical personnel and health services, making them ill-prepared for complications when they arise. It is estimated that only 21.4% of births are attended by trained personnel. Recognizing that the community plays an important role in improving maternal and newborn health, the Government of the Lao People's Democratic Republic has approved the pilot test of maternity waiting homes in remote, poor areas with financial and technical support from UNDP and WHO. Such facilities will allow pregnant women and family members to consult skilled birth attendants and to receive counselling and health education while they comfortably await the birth of the baby. Through such an initiative, community involvement will also be enhanced in recognizing danger signs and ensuring that the pregnant women will have access to appropriate care when needed. A team of maternal and child health professionals visited Mongolia in 2002 to observe the operation of their maternity waiting homes and Mother Friendly Hospitals.
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ONGOUA
Ten most important achievements: • National Programme on Reproductive Health and Maternal Mortality Reduction Strategy have been approved by the Mongolian Government. Mother Friendly Hospital Initiative has been developed and piloted in two provinces. The indicators for assessment were also developed. Mid-term monitoring and evaluation have been conducted on Maternal Mortality Reduction Strategy and National Programme on Reproductive Health. Maternity waiting homes have been re-established in soums and provinces and in the Maternal and Child Health Research Centre. • More than 30 national obstetrics and midwifery trainers have undergone clinical practice training course on managing complications in pregnancy and childbirth. The manual "Managing Complications in Pregnancy and Childbirth: A Guide for Midwives and Doctors" has been adapted to local situation, translated and distributed to all service providers. On-the-job training on management of complications in pregnancy and childbirth has been organized nationwide. Some orders on antenatal care, maternal mortality registration and maternal death audit systems have been revised by the Ministry of Health. Training on reproductive health/Safe Motherhood has been carried out for local decision-makers. Referral system for high-risk pregnant women from rural areas has been improved.
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Mother Friendly Hospital Initiative An innovation from Mongolia Despite the fact that 96% of deliveries in Mongolia are facility based, the country's maternal mortality ratio was still unacceptably high with 169 per 100,000 live births (2001). In response to this situation, the Ministry of Health issued a Maternal Mortality Reduction Policy in 2001 with an innovative "Mother Friendly Hospital Initiative" as one of the major pillars of the national strategic plan aiming to improve the quality of maternal and neonatal care provided in the health facilities.
Ten Steps to Mother Friendly Hospital 1. 2. Write hospital policy on safe motherhood. Train all staff involved in obstetric care to improve the quality of care provided to pregnant women. Provide all women with the following key health services: antenatal care and counselling; skilled care during labour and delivery; postpartum care and care of the neonate; family planning; nutrition counselling; abortion-related care; diagnosis and treatment of sexually transmitted infections; adolescent reproductive health education and service; and community education. Prioritize pregnant women with complications and provide emergency obstetric care. Stock appropriate equipment, drugs and supplies including blood for emergency obstetric and neonatal care. Provide counselling and support for women on safe motherhood, including safe delivery, family planning, prevention of sexually transmitted infections and domestic violence. Inform and educate pregnant women, their families and the community on the danger signs of pregnancy. Provide communication network, maternity rest homes and transport to improve the referral system between aimag and the soum and between the soum and the community. Create a maternal and perinatal monitoring committee.
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10. Mobilize the community to assist in identifying pregnancy complications, transporting referred women and recruiting blood donors.
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A PuA NEw GuiNEA Ten most important achievements: • A National Health Plan for 2001-2010 has been adopted by the government of Papua New Guinea. The plan recognizes the high maternal mortality ratio of the country. The Government declared 2003 as "Year for Safe Motherhood" in order to introduce stakeholders and potential doctors to the concept of Safe Motherhood to outline the role that they can _ play in its success. The Women's and Children's Health Project, supported by the Australian Agency for International Development (AusAID), has initiated many national and regional workshops for trainers of trainers, nurses and midwives. Basic obstetric instruments, oxytocins and iron supplementations have been supplied by AusAID, enabling continuous provision of best services to pregnant women. Information base has been set up at the labour ward of the Port Moresby General Hospital. Family planning information brochures have been prepared, guided by the Family Health branch of the Department of Health, to be used for educating health workers. Antenatal ten steps have been developed for use by health centres to guide and prompt health workers at all levels to efficiently provide supervision and care for antenatal patients. A flip-chart of "Ten Emergencies in Obstetrics and Gynaecology" has been made to assist attendants in remote areas with diagnosis and management of patients. Labour ward protocols of selected and common problems have been prepared and sent to all registrars and all referral and teaching hospitals. National workshops on improving access to quality family planning services have been conducted to update the knowledge of or medical eligibility criteria for contraceptive use. In addition, the family planning service standard has been revised.
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National Health Plan 2001-2010 The Government of Papua New Guinea is deeply concerned with the high maternal mortality ratio of 370 per 100 000 live births (1996), one of the worst in the Region. Geographical barriers make access to health services especially difficult in some areas. In the highlands, for example, the maternal mortality ratio is 625 per 100 000 live births. Major causes of maternal mortality are heamorrhage and postpartum sepsis. Important contributing factors include poor antenatal care; deliveries unassisted by trained personnel; poor nutrition during pregnancy leading to anaemia; too early, too late or too frequent pregnancies; and the lack of awareness of the availability/benefits of maternal health services. To address the issues of women's health and safe motherhood, the National Health Plan 2001-2010 sets out the following goals: improve and strengthen pre- and post-natal care and supervised delivery; improve community awareness and education; improve supervision and training of clinical staff; improve nutritional programmes for women of child-bearing age and those who are pregnant and breastfeeding; and involve women in the design and implementation of women's health and safe motherhood programmes.
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AruPPINES Ten most important achievements: • Maternity waiting homes, birthing homes and lying-in centres have been established and/or upgraded in 25 provinces through the Women's Health and Safe Motherhood Project Phase 1. Consequently, the national guidelines for maternity waiting homes and birthing homes have been developed. Physicians for the first level referral doctors for emergency obstetric care have been trained through the Women's Health and Safe Motherhood Project Phase 1. Clean and safe delivery has been advocated and clean-and-safe-delivery kits have been distributed through the Women's Health and Safe Motherhood Project Phase 1. The second week of May has been declared as national Safe Motherhood Week, and is now being celebrated annually (Presidential Executive Order No.200). The inclusion of non-hospital delivery of low-risk pregnant women in the maternity health care package of the Philippine National Health Insurance has been strongly advocated. The use of the partograph for facility and non-facility deliveries and its inclusion in the nursing and midwifery curricula have been promoted, and national trainings have been carried out. Safe Motherhood service-quality standards for the Sentrong Sigla have been formulated. Sentrong Sig/a is a certification and recognition programme that develops and promotes good quality standards for health facilities. The manual "Essential Care Practice Guide (Pregnancy, Childbirth and Newborn Care: a guide for essential practice)" has been introduced and pilot-tested at the community level in order to strengthen the capacity in essential and emergency obstetric care. Training guidelines for the manual "Managing Complications in Pregnancy and Childbirth: A Guide for Midwives and Doctors" have been developed and the training-of-trainers course for obstetricians at the regional level has been conducted. A Mother-Baby Book, an integration of the Home Based Maternal Record (HBMR) and Growth Monitoring Chart (GMC), has been developed and pilottested.
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Managing complications in pregnancy and childbirth joining forces among stakeholders
The maternal mortality ratio in the Philippines is 172 per 100 000 live births (1998), even higher than countries like Viet Nam and Mongolia whose income levels are substantially lower than the Philippines. Inadequate capacity for managing complications in pregnancy and childbirth in referral hospitals is one of the reasons why the maternal mortality ratio remains high in the Philippines. For example, the first referral level should provide essential obstetric care and surgical obstetrics, but in reality, most district hospitals in the Philippines lack trained professionals and equipment to carry out procedures such as caesarean section and blood transfusion . The Philippines has recognized the need to improve the quality of care at the referral level in order to reduce maternal mortality and has actively tackled the issue by forming a Technical Working Group on Safe Motherhood. The Technical Working Group, consisting of the Department of Health, UNICEF, WHO and members from referral hospitals, has worked in collaboration to conduct trainers' training courses on "Managing Complications in Pregnancy and Childbirth" for obstetricians at regional level. In addition, a manual has been integrated into the curriculum of medical internship and residency programmes. In parallel, actions have been taken to strengthen the capacity of essential obstetric care at community level by the introduction of the manual "Essential Care Practice Guide". Training courses for facilitators and trainers have been conducted , and local governments are adapting and pilottesting the guide in three areas in Manila.
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){rr NAM Ten most important achievements: Five-year National Safe Motherhood Master Plan has been developed for implementation of the National Strategy on Reproductive Health Care for 20012010. • Maternal mortality survey has been carried out in seven provinces (representative of seven geographical areas) in order to update the national maternal mortality ratio and to provide baseline data for the Five-year National Safe Motherhood Master Plan. Field assessment on Safe Motherhood in seven provinces (representative of seven geographical areas) and a literature review of all 42 international/national Safe Motherhood projects (1995-2001) have been conducted to provide data for the Five-year National Safe Motherhood Master Plan. National Standards and Guidelines for Reproductive Health Care Services with components of safe motherhood, family planning, adolescent reproductive health, reproductive tract infections and sexually transmitted infections have been developed. The Pregnant Women Care Project with multi-micronutrient supplementation tablets was carried out in three pilot districts during 2001-2002 in order to reduce low birth weight, giving good results. Socialized obstetrics has been carried out in commune level in order to train not only midwives but all Community Health Workers on obstetric care. Simultaneously, a training plan "Primary-midwife become secondary-midwife" has been developed. The aim is to have 100% Secondary-Midwife in commune level by 201 0. Guideline of Maternal Mortality Audit has been developed and have been pilot tested in 5 provinces. Monitoring system for maternal & child mortality in public health facilities has been reviewed, indicators agreed, and framework for future steps has been developed. Comprehensive abortion care service delivery model and materials have been developed. The manual "Managing Complications in Pregnancy and Childbirth: A guide for Midwives and Doctors" has been adapted to local situation and has been translated into Vietnamese.
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Maternal Mortality Survey - from data to action! In Viet Nam, the most recent survey of maternal mortality was conducted In 1995 In three provinces. In order to obtain a more accurate, up-to-date picture of maternal mortality, a largescale maternal mortality survey was conducted in 2002 in seven selected provinces representing the seven geographical regions in the country. To everyone's surprise, the survey report revealed that the national estimate of maternal mortality ratio should be 170 per 100 000 live births, a significantly higher estimate than the previous one (90 per 100 000 live births in 2000). The most common direct causes of maternal death were haemorrage (41%), eclampsia (21.3%) and infection (16.6%). Other contributing factors to high maternal mortality were lack of knowledge about pregnancy and childbirth, lack of access to health facilities, late referral due to lack of transportation, and the poor economic status of pregnant women. The Government has taken the findings from this survey seriously, and has made sure that they were fed into the formulation of the Five Year Master Plan. The results also served as the baseline data for the national safe motherhood project funded by the Netherlands, and also led to specific recommendations on health education, training, a basic package of essential obstetric care, and improvements in the information system.
Estimated maternal mortality ratio by parity (Survey results of seven provinces) 2Ji1
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Parity Source: MCH/FP Department, Ministry of Health, Viet Nam
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