Addressing MDG 4 & 5 Through the MNCHN Strategy

Presented by:

Juanita A. Basilio, MD, MPH

DOH-NCDPC-FHO

The Millennium Development Goals (Our Commitments by 2015)

The health of women and children plays a role in all MDGs

Major Causes of Under Five Deaths

Western Pacific Region - 2010

Source: WHO. Global Health Observatory (http://www.who.int/gho/child_health/en/index.html)

Philippine Progress Report on MDG 4: Reduce child mortality

Philippines has been doing well in reducing under-five mortality and infant mortality rates but needs to address neonatal mortality rates.

Infant and Under-five Mortality (2003 2011)

MDG Targets for 2015 (26.7 and 19) are ACHIEVABLE

FHS 2011: NSO, DOH, USAID

<5 year old and Neonatal Mortality

# of deaths per 1000 live births

Under Five MR Neonatal MR

1988-1998: 40% 1998-2008: 20% Neonatal mortality hasnt improved

DHS 88, 93, 98, 03, 08

Majority of newborns die due to stressful events or conditions during labor, delivery and the immediate postpartum period
# of deaths per 1000 live births

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

Day of Life
NDHS 2003, special tabulations

Philippine Progress Report on MDG 5:

Improve maternal health

On reducing the MMR by 75 percent:

Remains a difficult challenge

On universal access to RH services: CPR-modern method= 34 percent (married women) and 22 percent (all women of reproductive age)

At current rate of decline, the Philippines is unlikely to reach the MDG target for MMR by 2015
250
209

200 150 100 50 0 1993

NDHS 1993, 1998; FPS 2006

172
Most Death are Preventable Hemorrhage Hypertension

162 140

Obstructed Labor/Ruptured Uterus

Sepsis Related Unsafe Abortion

52

1998

2006

2015

Achieve MDG 5 Targets

Target B: Ensure Universal Access to Reproductive Health Services

Target A: Reduce Maternal and Newborn Mortality

Manual of Operations to Implement Health Reforms to Rapidly Reduce Maternal and Newborn Mortality

Policy Developments
Administrative Order 2008-0029 (Sept. 9, 2008) Implementing Health Reforms for Rapid Reduction of Maternal and Neonatal Mortality

Administrative Order 2009-0025 (Dec. 01, 2009) Adopting New Policies and Protocol on Essential Newborn Care

Policy Developments

Administrative order no. 2012 -0009 (June 27, 2012) National Strategy towards Reducing Unmet Need for Modern Family Planning as a Means to Achieving MDGs for Maternal Health

What is MNCHN?

Maternal, Newborn, Child Health and Nutrition

Guiding Principles
Every pregnancy is wanted, planned and supported Every pregnancy is adequately managed throughout its course

Every delivery is facility-based and managed by skilled health professionals

MNCHN STRATEG Y

Every mother and newborn pair secures proper post-partum care

Integrated MNCHN Service Package

Pre-Pregnancy Services
Financing Health Facilities and Service Packages Human Resource Health Products and Pharmaceuticals Other Support Systems

Antenatal care

Postpartum and Postnatal Care

Care during Delivery

Core Service Package (Life Cycle Approach)

Pre-pregnancy package of services Complete pre-natal package Complete care during delivery Immediate postpartum and neonatal Emergency maternal and newborn service package

Pre-pregnancy package

Micro-nutrients (Iron w/ folic acid) Tetanus-toxoid immunization Fertility awareness, birth spacing and FP counselling Nutrition and healthy lifestyle Oral health Counselling and services on STD/HIV/AIDS Management of lifestyle related diseases

Pre-Natal package

Monitoring of height and weight Blood pressure determination and monitoring Pregnancy test, urinalysis, CBC, blood typing, STI screening Pap smear and acetic acid wash, blood sugar determination Micro-nutrient supplementation Tetanus toxoid Malaria prophylaxis Birth planning

Pre-Natal package

Counselling on FP methods ( LAM, BMF contraceptives) Counselling on healthy lifestyle Prevention and management of bleeding in early pregnancy Early detection and management of danger signs and complications of pregnancy Assessment of fetal growth and well being Prevention and management of other diseases Provision of other support services

Childbirth Service Package

Monitoring progress of labor using the partograph Identification of early signs/symptoms and appropriate management The 3 Cs of childbirth No episiotomy and no fundal pressure Active management of the third stage of labor

Essential Newborn Care Package

Post-partum service package

Physical Exam ( BP monitoring, pelvic exam) Identification of early signs and symptoms of postpartum complications like hemorrhage, infection and hypertension Micronutrient supplementation Provision of FP services Counselling on

Nutrition Exclusive breastfeeding up to six months neonatal care

(w/in 24 hours postpartum routine care)

Neonatal Care

Cord care Vitamin K injection Eye prophylaxis Delayed bathing to 6 hours of life BCG and Hepatitis B Immunization Newborn screening Birth registration Counselling on post-partum/post-natal check-up, home care and immunization

MNCHN Service Delivery Network

End-referral facility (Provincial hospitals etc), BEMONC functions + Blood transfusion & Cesarean Section; Operates 24 hrs, with OB/surgeon, pedia, nurse, MW, med tech

CEmONC

Normal vaginal delivery, imminent breech delivery, emergency drugs (antibiotics, MgSO4, oxytocin), Essential newborn District Hospitals, RHUs care, FP services with SHPs

BEmONC FACILITY

Community Level Service Provider:

RHU, BHS, WHT, BHT

Pregnancy tracking, birth planning, home visits and follow-up, nutrition package; IEC on facility delivery and FP; communication activities targeted to mothers and their families

TRANSPORTATION and COMMUNICATION SYSTEM

Basic Emergency Obstetrics and Newborn Care

(BEmONC)

Parenteral administration of oxytocin in the third stage of labor Parenteral administration of loading dose of anti-convulsant Parenteral administration of initial dose of antibiotics Assisted delivery during imminent breech presentation

BEmONC (continuation)

Manual removal of placenta Removal of retained placental products Administration of loading dose of corticosteroids for threatened pre-mature delivery Newborn resuscitation w/ oxygen support Essential Newborn Care

Comprehensive Emergency Obstetrics and Newborn Care (CEmONC)

BEmONC

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

Operative delivery ( C. Section ) Blood transfusion services Advanced life support management for low birth weight, premature and sick newborn like sepsis, asphyxia, severe birth trauma, severe jaundice, etc.

The First Four Years of MNCHN

Promotion of facility-based deliveries Promotion of Essential Intrapartum and Newborn care Promotion of Responsible Parenthood Increasing Philhealth enrollment and benefits

Facility enhancement Capability building for health workers Mobilization of community health teams Provision of essential drugs and commodities Iron with Folic Acid supplementation

Silent mode

Maternal nutrition Mens health and male involvement in RH Addressing low birth weight Disasters and emergency situation

MNCHN Strategic Plan 2013-2017

Vision
Every woman, child and their families utilize quality health services in a continuum of care

Mission
To lead, harmonize, and converge all efforts in delivery of maternal, newborn, child health and nutrition (MNCHN) package of services to ensure equitable, accessible, efficient health services to communities through dynamic partnership and shared advocacy, responsibility and accountability.

Goal
Rapidly reduce maternal and neonatal mortality through local implementation of a MNCHN strategy

Objectives
Implementing the MNCHN Strategic Plan supports the attainment of DOHs Universal Health Care strategy as it aims

To reduce maternal mortality ratio from 162/100,000 live births to 52/100,000 live births and To reduce neonatal mortality rate from 17/1,000 live births to 14/1,000 live births

Specific Objectives

Increase contraceptive prevalence rate from 50.7% to 63% Reduce unmet need from 19% to 16% Increase percentage of pregnant women having at least four antenatal care visits from 78% to 80% Increase facility-based delivery from 55% to 85% Increase skilled birth attendance from 72% to 85% Increase percentage of newborns initiated to breastfeeding within one hour of life from 53.5% to 90% Increase percentage of exclusively breastfed infants for the first 6 months of life from 48% to 70% Increase percentage of fully immunized children from 82% to 95%

Strategy 1

Scale up, promote, implement, evaluate the delivery of comprehensive MNCHN service package in a continuum of care through strengthened local health systems. National government will provide support to local health systems that is guided by the six pillars of UHC strategy.

Strategy 2

Enhance capacity to provide targeted support to province-wide or city-wide health systems and disadvantaged population groups where access to MNCHN services is limited and where mortalities are likely to occur or are most severe

Strategy 3

Engage the, advocate to, and mobilize resources of all province-wide or city-wide health systems to adopt, implement and steward the integrated MNCHN strategy

12 Key Result Areas

KRA 1: Financial risk protection provided to MNCHN clients KRA 2: Provision of quality and evidence-based MNCHN services ensured and continuously provided KRA 3: Improved health-seeking behavior by MNCHN clients KRA 4: National policies supportive of the integrated MNCHN strategy are enacted and implemented KRA 5: Partnerships with relevant MNCHN stakeholders at the national level synchronized and strengthened KRA 6: Monitoring and evaluation of progress in MNCHN operational and institutionalized

12 Key Results Areas

KRA 7: Mechanism to identify priority population for MNCHN services established KRA 8: Tailored MNCHN program activities to address the need of priority population done KRA 9: Resources needed to implement and sustain a local integrated MNCHN service provision secured KRA 10: Local policies supportive of the integrated MNCHN strategy are enacted and implemented KRA 11: Local service delivery network strengthened KRA 12: Partnerships with relevant MNCHN stakeholders at the local level synchronized and strengthened

Strategy to reduce maternal and child undernutrition ( A UNICEF EAPRO Strategy Paper)

Target adolescent girls, pre-pregnant women and pregnant women with interventions to improve maternal and child nutrition Increase the nutrition content of preventative and curative health care and improve the access of adolescent girls, pre-pregnant women and pregnant women to theses and contraceptive services Develop community-based processes aimed at empowering adolescent girls, pre-pregnant women and pregnant women (nutritional and socio-economic status) Increase coverage of effective child nutrition interventions

Major Causes of Low Birth Weight

Vary by region but usually include: Low maternal energy intake (food quantity) Poor diversity of diet (food quality in terms of vitamins &
minerals)

Excessive energy expenditure from heavy physical activity Infections (sexually transmitted, malaria) Becoming pregnant at young age (before mothers
own growth is completed)

Substance abuse Exposure of mother to secondary smoke inhalation and indoor air pollution Domestic violence

Conclusions

Maternal nutrition

Plays a vital underlying role in maternal, neonatal, and child mortality. Because its role is not as obvious and is often not the immediate cause of death, its importance is often overlooked Maternal undernutrition initiates an intergenerational cycle of malnutrition, poor health outcomes, and poverty. This is the place to break the cycle

Nutrition is everyones responsibility and like other cross-cutting issues, too often it falls through the cracks.
Women are not dying because of diseases we cannot treatthey are dying because societies have yet to make the decision that their lives are worth saving -- Mahmoud Fathalla