Safe childbirth and Effective Perinatal Care: Are Changes Necessary?

1. Safe childbirth and Effective Perinatal Care: Are Changes Necessary?

2. Safe Childbirth

3. What Are the Eight Millennium Development Goals (MDGs)? • Goal 1: Eradicate extreme poverty and hunger • Goal 2: Achieve universal primary education • Goal 3: Promote gender equality and empower women • Goal 4: Reduce child mortality • Goal 5: Improve maternal health • Goal 6: Combat HIV/AIDS, malaria and other diseases • Goal 7: Ensure environmental sustainability • Goal 8: Develop a global partnership for development Note that health is given a lot of attention!

4. It Is Impossible to Accept High Numbers of Maternal Mortality Because… • … evidence-based data demonstrate that 80% of all death can be prevented with help of simple, effective and low-cost interventions …

5. It Is Impossible to Accept High Numbers of Neonatal Mortality Because… • Many cases of infant and neonatal mortality can be prevented by known, available and low-cost technologies if they are accessible to all WHO, 2005

6. Safe Mother Initiative (SM) – 1987 to 2000 Goal: decrease maternal mortality (MM) by 50% by 2000 Strengthened international efforts though MM unchanged Lessons learned from achievements & ineffective strategies Making Pregnancy Safer Initiative (MPS) 2000-today Goal: Ensuring skilled care at every birth within the context of a continuum of care Global strategies and health sector focus Provide technical support and building national capacity Safe Motherhood Initiative Making Pregnancy Safer Initiative

7. Definition: A ‘skilled attendant’ is an accredited health professional – such as a midwife, doctor or nurse – who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth, and the immediate postnatal period, and in the identification, management and referral of complications in women and newborns Skilled Attendant

8. Correlation between Skilled Attendant Care and Neonatal Mortality Rate 100 50 Skilled Attendant Care Neonatal deaths 80 40 60 30 Skilled Attendant Care (%) Number of neonatal deaths per 1000 live births 40 20 20 10 0 0 Latin America and the Caribbean More developed countries Africa Asia WHO, 2005

9. The “components of skilled attendant care”. Emphasize that core midwifery skills are essential for all providers. Skilled Attendant

10. All skilled attendants must have the core midwifery skills Skilled attendant prototype is the licensed midwife. First-level maternal and newborn care should preferably be organized in midwife-led birthing centres Even within the walls of a hospital, however, first-level care should maintain the demedicalized and close-to-client characteristics of midwifery-led birthing homes First-level care requires strong links for back-up referral care (emergencies and non-emergency interventions) as a continuum of care Skilled Attendant Care WHO, 2004 WHO, 2005

11. Main Objectives Perinatal Care Improvement • To reduce maternal mortality 75% by 2015 compared with the rate in 1990 • To reach a level of infant mortality that is less than 35 per 1,000 live births • To provide access to reproductive health services for all in need • To provide all mothers and newbornsskilled care at every birth within the context of a continuum of care WHO, 2005 WHO, 2006

12. Making Pregnancy Safer Fundamentals • Care for pregnancy and childbirth calls for a holistic approach • Pregnancy and childbirth is an important personal, familial, and  social experience • In pregnancy and childbirth there should be a valid reason to  interfere with the natural process • Medical interventions for pregnant women, mothers and newborns, if indicated, need to be available, accessible, appropriate and safe WHO EURO, 1998 WHO EURO, 2003 WHO EURO, 2007

13. Making Pregnancy Safer Principles Care should: be based on scientific evidence and cost/effective be family centered, respecting confidentiality, privacy, culture, belief and emotional needs of women, families and communities ensure involvement of women in decision-making for options of care, as well as for health policies ensure a continuum of care from communities to the highest level of care, including efficient regionalization, and multidisciplinary approach WHO EURO, 1998 WHO EURO, 2003 WHO EURO, 2007

14. Two Models of Perinatal Care Mother and infant are treated as patients Different steps of labour happen in different rooms Infant care is provided in a separate room Father is informed to visit about the progress of labour No relatives are allowed Respect for woman’s right to participate in care and decisions Labour/birth in one room Mother and infant care in same room Social support/companion in labour and birth Relatives are involved in mother and infant care Traditional Midwifery-led/First-level care WHO EURO, 2002 WHO, 2005

15. Appropriate Technologies • Technology is a set of activities that includes methods, procedures, interventions, equipment, etc. applied systematically to solve a specific problem • Technology is considered appropriate if it is effective, safe, affordable, good for both the patients and the doctors, and is feasible in its implementation Beverley Chalmers et al, 2001 WHO EURO, 2002

16. Appropriate Technologies in Perinatal Care Woman has role in making decisions Partograph use in labour Social support for labour/birth is beneficial and encouraged Unrestricted/upright labour/birth positions Exclusion of unjustified procedures Early and unrestricted skin-to-skin contact Prevention of neonatal hypothermia Effective neonatal resuscitation Breastfeeding on demand and rooming-in Correct hand washing as best infection prevention Rational use of medicine WHO EURO, 2002

17. Safe Childbirth

18. Childbirth is a major life event and it is therefore extremely important to manage the care of pregnant women in an effective and safe manner.

19. Midwife led care (MLC) has been defined as care where "the midwife is the lead professional in the planning, organization and delivery of care given to a woman from initial booking to the postnatal period" (Royal College of Obstetricians and Gynecologists, RCOG 2001).

20. MLC is a new model started in Gaza Strip on 2011. This model is a shared program between MOH and WHO, started primarily at Al-Tahreer hospital in Khanyounis on April 2011, January 2012 at Al-Emaraty hospital in Rafah, Tal Al Sultan,April 2013, EL Harazin, Gaza, and May 2013, Al-Aqsa hospital, Midzone. (WHO, 2012).

21. Objectives • To use Labour surveillance (Partogram) • To provide Non pharmaceutical pain relief • To provide Psychological support • To initiate Mother and baby contact soon after birth (skin to skin) • To initiate Attachment to the breast in the first hour • To Keep the baby warm • Counseling and health education in post natal room • To ensure Newborn examination by a pediatrician before discharge

22. Mechanism of work • Step 1 :Risk assessment • Step 2 :Natural birth • Step 3: Post natal check of the mother • Step 4: Post natal check up of the newborn

23. Step 1 : risk assessment Standard: All women at labour are examined by a doctor who, accordingly to the risk assessment criteria , assign the women either to the care of the midwife ( low risk pregnancy ) or to a doctor ( high risk pregnancy ) 23

25. Step 2: natural birth Standard • The women at low risk will receive natural childbirth care by a midwife during all phases of her labour and delivery ,Good communications , privacy ,support, caring environment, careful clinical monitoring and evidence based procedures will be ensuredto her

27. Step 3: post natal check for the mother Standard Mother and new born are transferred to the post partum area where they will ideally remain for at least 6 hours. During the stay she will receive the standard post partum examination ; she will be advised on essential care for baby, on breast feeding and on danger signs indicating the need to seek health care for her or her baby 27

29. Step 4: post natal check up for the new born Standard The new born will be completely examined by a pediatrician before being discharged . The pediatrician will advice the mother on the need of any special care and will plan a follow up visit in case of any risk factor

30. Recommendation • Most women should be offered midwife-led models of care and women should be encouraged to ask for this option although caution should be exercised in applying this advice to women with substantial medical or obstetric complications.

31. Key Areas for Action • Safe motherhood can be advanced through respecting existing human rights, through empowering women to make choices in their reproductive lives with the support of their families and communities. • The access to and quality of maternal health services needs to be improved. All deliveries should be overseen by skilled attendants and essential care should be available when obstetric complications arise.