Millennium Development Goals 4 and 5 Accelerating a Unified Strategy to Save Mothers, Newborns and Children

1. Millennium Development Goals 4 and 5 Accelerating a Unified Strategy to Save Mothers, Newborns and Children Mario C. Villaverde MD, MPH, MPM Undersecretary of Health

2. At current rate of decline, the Philippines is unlikely to reach the MDG target for MMR by 2015 Not so encouraging. Decrease in trend is very slow. We should have halve it by 2000 and another half by 2015. More efforts to be exerted on this. very slow decline of MMR in past 20 years;present rate of decline not enough to reach MDG target of 52/100,000 LB in 2015; maternal deaths account for 14% of deaths among women of reproductive age; maternal death triggers other adverse consequences in families: orphans, loss of family care provider Not so encouraging. Decrease in trend is very slow. We should have halve it by 2000 and another half by 2015. More efforts to be exerted on this. very slow decline of MMR in past 20 years;present rate of decline not enough to reach MDG target of 52/100,000 LB in 2015; maternal deaths account for 14% of deaths among women of reproductive age; maternal death triggers other adverse consequences in families: orphans, loss of family care provider

3. Hypertension, post-partum hemorrhage and severe abortive outcomes are the leading direct causes of maternal deaths Mothers die mainly from pregnancy complications: Hypertension Hemorrhage Abortive outcomesMothers die mainly from pregnancy complications: Hypertension Hemorrhage Abortive outcomes

4. Most maternal deaths occur during labor, delivery and the immediate post-partum period

5. UFMR and IMR targets are likely to be reached by 2015 but pace of reduction has decelerated due to very slow decline of NMR Childhood death rates in the Philippines showed a downward trend from 1993 to 2003 with the decline slowing down in the last 10 years. The underfive mortality rate (U5MR), which significantly decreased from 72 per 1000 live births (LB) in 1983-1987 to 52 per 1000 LB in 1988-1993, decreased to only 42 per 1000 LB after 10 years. The infant mortality and child death rates exhibited similar trend over the same period. The infant and child deaths which lowered respectively to 31 and 12 per 1000 LB in 1993-1997, came almost to a halt in the last decade, with still 30 infant deaths and the same 12 child deaths per 1000 LB in 2003. Neonatal and post-neonatal deaths declined the slowest over the past 20 years with the reduction of only 9 percent and 7 percent, respectively, from 1988 to 2003. The 2006 Family Planning Survey (FPS) though showed a further decline in the underfive death rate at 32/1000 LB and infant death rate at 24/1000 LB.[1] Under five mortality is the probability of dying between birth and exact age five (the number of deaths below age five per 1000 live births [2] Infant mortality is the probability of dying between birth and age one year (the number of infant deaths per 1000 live births during the first 12 months of life) [3] Child mortality is the probability of dying between exact age one and age five (the number of deaths of children age 1-4 years per 1000 children surviving to age 12 months [4] Neonatal mortality is the probability of dying within the first month of life [5] Postneonatal mortality is the probability of dying after the first month of life but before age oneChildhood death rates in the Philippines showed a downward trend from 1993 to 2003 with the decline slowing down in the last 10 years. The underfive mortality rate (U5MR), which significantly decreased from 72 per 1000 live births (LB) in 1983-1987 to 52 per 1000 LB in 1988-1993, decreased to only 42 per 1000 LB after 10 years. The infant mortality and child death rates exhibited similar trend over the same period. The infant and child deaths which lowered respectively to 31 and 12 per 1000 LB in 1993-1997, came almost to a halt in the last decade, with still 30 infant deaths and the same 12 child deaths per 1000 LB in 2003. Neonatal and post-neonatal deaths declined the slowest over the past 20 years with the reduction of only 9 percent and 7 percent, respectively, from 1988 to 2003. The 2006 Family Planning Survey (FPS) though showed a further decline in the underfive death rate at 32/1000 LB and infant death rate at 24/1000 LB.[1] Under five mortality is the probability of dying between birth and exact age five (the number of deaths below age five per 1000 live births [2] Infant mortality is the probability of dying between birth and age one year (the number of infant deaths per 1000 live births during the first 12 months of life) [3] Child mortality is the probability of dying between exact age one and age five (the number of deaths of children age 1-4 years per 1000 children surviving to age 12 months [4] Neonatal mortality is the probability of dying within the first month of life [5] Postneonatal mortality is the probability of dying after the first month of life but before age one

6. Neonatal events account for most of the direct causes of under-five mortalities

7. Majority of newborns die due to stressful events surrounding delivery

8. Undernutrition, high fertility rates and unmet needs for family planning are major underlying factors that worsen morbidity and mortality outcomes for mothers and children Nutritional factors �Obvious� hunger �Hidden� hunger Fertility factors High fertility rate High unmet needs for family planning and reproductive health Incidental illnesses Malaria, HIV/STIs, TB, chronic diseases Further breakdown by day of life shows that neonatal deaths half occur during the first two days upon birth. This emphasizes how crucial the quality of care that must be provided to newborns at this stage of life outside the mother�s womb. 17 infants die per 1000 LB within first 28 days of life (neonatal mortality rate); mostly within first week after birth; half die during the 1st 2 days Further breakdown by day of life shows that neonatal deaths half occur during the first two days upon birth. This emphasizes how crucial the quality of care that must be provided to newborns at this stage of life outside the mother�s womb. 17 infants die per 1000 LB within first 28 days of life (neonatal mortality rate); mostly within first week after birth; half die during the 1st 2 days

9. Maternal and newborn deaths are influenced by the place of delivery and who assists in the process Most mothers prefer to give birth at home with the assistance of TBAs where mothers and newborns are distanced from life-saving interventions provided in health facilities by health professionals during intrapartum period, maternal and neonatal deaths are high Mothers do not routinely choose to deliver in health facilities and avail of professional services due to several barriers hostile hospital system, poor interpersonal skills of staff, financial, physical, social and cultural constraints are deterrents to actual service utilization

10. Policy Issues and Policy Options Separate programmatic strategies for mothers and children do not address the need to congregate or integrate actions around labor, delivery and immediate post-partum where most of the deaths occur DOH needs to institute a unified strategic framework for maternal and newborn care that is linked with child survival strategies and will maximize the delivery of service packages and ensure a continuum of care across the life cycle stages

11. Policy and Strategic Thrusts

12. 4-Tierred Service Delivery Model The 4-tierred service delivery model will target the direct causes of maternal and infant deaths � Integrate maternal and newborn service packages Infrastructure development RHU/BHS, private clinics � birthing facilities for normal spontaneous delivery Selected RHUs and district/ core district hospital � for Basic Emergency Obstetric and Newborn Care (BEmONC) Oxytocin, IVF, emergency drugs + NEWBORN CARE Provincial/ Regional hospital/ medical center � for Comprehensive Emergency Obstetric and Newborn Care (CEmONC) Blood services, surgical services HR development Midwifery scholarship programs � TBAs/ CHWs to midwives (step-ladder approach) DTTB, Medipool Placement Program and RHT (midwives/ nurses/ doctors) Upgrading skills for BEmONC and CEmONC Develop as team of professionals (midwife at basic level; MW/N/D with BEmONC and CEmONC) Information/ health education Database/ surveillance system IEC/ health education and advocacy National/ local policy makers/ decision-makers TBAs/ CHWs Health professionals (MW/N/MD) Pregnant women/ families The 4-tierred service delivery model will target the direct causes of maternal and infant deaths � Integrate maternal and newborn service packages Infrastructure development RHU/BHS, private clinics � birthing facilities for normal spontaneous delivery Selected RHUs and district/ core district hospital � for Basic Emergency Obstetric and Newborn Care (BEmONC) Oxytocin, IVF, emergency drugs + NEWBORN CARE Provincial/ Regional hospital/ medical center � for Comprehensive Emergency Obstetric and Newborn Care (CEmONC) Blood services, surgical services HR development Midwifery scholarship programs � TBAs/ CHWs to midwives (step-ladder approach) DTTB, Medipool Placement Program and RHT (midwives/ nurses/ doctors) Upgrading skills for BEmONC and CEmONC Develop as team of professionals (midwife at basic level; MW/N/D with BEmONC and CEmONC) Information/ health education Database/ surveillance system IEC/ health education and advocacy National/ local policy makers/ decision-makers TBAs/ CHWs Health professionals (MW/N/MD) Pregnant women/ families

13. Infrastructure and Service Package Development First Tier � Community-based teams Women�s Health Teams Second Tier � Basic Essential Obstetric and Newborn Care (BEONC) RHUs/BHSs, birthing facilities, private clinics Third Tier � Basic Emergency Obstetric and Newborn Care (BEmONC) Selected RHUs, district/core district hospitals, private hospitals Fourth Tier � Comprehensive Emergency Obstetric and Newborn Care (CEmONC) Provincial hospitals, regional hospitals, medical centers

14. Human Resource Development TBAs and Community Health Workers Defining roles and incentives in Women�s Health Team Training TBAs as professional midwives Regulating TBA practices Midwives, Nurses and Doctors Upgrade skills of midwives, nurses and doctors for BEONC, BEmONC and CEmONC Mandates for midwives Develop as team of professionals Midwives at basic level Midwives, nurses and doctors at BEmONC and CEmONC

15. Information System, Health Education and Advocacy Database, information and surveillance system Establishing sensitive indicators for performance and outcomes Improving data quality, disaggregation, timeliness Analyzing and acting on data Health Education and Advocacy IEC / health education and advocacy National and local policy makers / decision-makers TBAs / CHWs Health professionals (MW/N/MD) Pregnant women / families

16. Financing Schemes Free access for mothers Minimal or zero co-payment especially for indigents Cash transfer vouchers for transport Incentives for institutional and individual providers PhilHealth reimbursement share Performance-based incentives Incentives for local government participation PhilHealth capitation fund Government grants

17. Implementing and accelerating a unified strategy to save mothers, newborns and children is possible Focusing interventions on the direct causes of deaths Integrating maternal, newborn and child health interventions Shifting from home-based TBA-assisted births to facility-based professionally-assisted births Targeting high-risk and low performing areas to fast track attainment of goals Empowering mothers to utilize life-saving packages Developing incentive and disincentive mechanisms to influence positive behaviors from health providers and consumers