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Maternal and Newborn Health in Crisis and Post-Crisis Situations

Learning outcomes: by the end of the session, you should be able to:. 1. Identify key issues of maternal and newborn health services needed in crisesAdvocacy for MNH services in crisesThe three delaysBasic and Comprehensive Emergency Obstetrics and Neonatal Care (BEmONC and CEmONC)2. Identify

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Maternal and Newborn Health in Crisis and Post-Crisis Situations

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    1. Maternal and Newborn Health in Crisis and Post-Crisis Situations

    2. Learning outcomes: by the end of the session, you should be able to: 1. Identify key issues of maternal and newborn health services needed in crises Advocacy for MNH services in crises The three delays Basic and Comprehensive Emergency Obstetrics and Neonatal Care (BEmONC and CEmONC) 2. Identify strategies for setting up referral mechanisms (transportation, communication, support of referral hospitals) 3. Plan for comprehensive MNH programme services Antenatal and Postnatal Care Traditional Birth Attendants (TBAs) Monitoring and Evaluation

    3. Maternal and Newborn Health (MNH) in Crisis Situations

    4. Maternal and Newborn Health (MNH) Care during pregnancy (Antenatal Care – ANC)

    5. Why is preventing neonatal and maternal mortality and morbidity a priority? - In displaced population, 4% of the total population will be pregnant at a given time - Leading cause of death among women of reproductive age - 536,000 deaths worldwide - Lifetime risk of maternal death: - Sub-Saharan Africa: 1 in 22 - Developed countries: 1 in 7300 - 15% of women are expected to have life-threatening complications - 5% of all pregnancies will require c-section Maternal Mortality in 2005 – Estimates developed by WHO, UNICEF, UNFPA and the WB

    6. Major Causes of Maternal Death Worldwide

    7. MNH: Mortality Statistics Globally, 9 to 33 babies out of every 1000 born die in the perinatal period 25% birth asphyxia 25% birth injuries prematurity, low-birth weight hypothermia infections (sepsis, tetanus, syphilis)

    8. Can’t predict or prevent complications… … but can prevent deaths by reducing DELAY:

    9. Complications Hemorrhage Postpartum Antepartum Ruptured Uterus Eclampsia Obstructed labor Infection

    10. The 3 Delays: What can be done in your setting? 1) Delay in the decision to seek care: Teach TBAs, women, men about the complications that need emergency treatment NOT PART OF THE MISP 2) Delay in reaching health facility: - Initiate establishment of 24/7 referral system to manage EmONC (Emergency Obstetrics and Neonatal Care) - Communication system (radio, mobile phone, medical record) - Transportation (stretchers, vehicle, security, transport at night) - Clean delivery kits distributed to all visibly pregnant women in case 2nd delay cannot be overcome and women need to deliver outside the health facility 3) Delay in receiving appropriate care at the health facility: - Equip health centers and hospitals - Train health workers in emergency obstetric procedures

    11. Referral mechanisms: challenges and solutions What if ensuring 24/7 referral services may not be possible due to insecurity in the area? Ensure that staff qualified in basic EmONC are available at all times at the primary health care level to stabilize patients with basic EmONC Establish system of communication (radio) to communicate with more qualified personnel for medical guidance and support

    12. Basic Emergency Obstetric and Neonatal Care (BEmONC) At health centers (1 per 30,000 people) Provided by midwives and nurses 1. Administer parenteral antibiotics 2. Administer parenteral uterotonic drugs (oxytocin) 3. Administer parenteral anticonvulsants for pre-eclampsia and eclampsia (magnesium sulfate – MgSO4) 4. Perform manual removal of placenta 5. Perform removal of retained products of conception (MVA - manual vacuum aspiration, D&C dilatation & curetage) 6. Perform assisted vaginal delivery, e.g. vacuum

    13. Comprehensive EmONC (CEmONC) At hospital with operating theater (1 per 150,000 – 200,000 people) Provided by team of doctors, anesthetists, midwives and nurses BEmONC (steps 1-6), plus 7. Perform surgery (Cesarean section, laparotomy for ectopic pregnancy, anesthesia) 8. Perform safe blood transfusion

    14. Summary: MNH Crisis Situations Establish referral system Supply referral level (CEmONC) Midwife delivery kits (health facility, BEmONC) Clean delivery kits (home deliveries in case access to health facility not possible) Plan for antenatal care (ANC) and postnatal care (PNC) integrated into primary health care (PHC) services as soon as possible

    15. Maternal and Newborn Health in Post-Crisis / Stabilized Situations

    16. Postnatal Care (PNC) Postpartum visit within 24 - 48 hours Mother General condition, sepsis Breasts Lochia, state of perineum Discuss nutrition, hygiene, breastfeeding Supply iron, folate, iodine if appropriate Family planning

    17. Postnatal Care (PNC) Baby General condition, warmth Breastfeeding on demand Weight Umbilicus care Discuss well child services: immunisations, growth monitoring

    18. Antenatal Care (ANC): 4 antenatal visits recommended Assess maternal health, including history and clinical signs Detect and manage complications Make a birth plan Give counselling (nutrition, clean delivery, family planning) Reinforce prevention activities (syphilis, tetanus, malaria, anemia, iodine deficiency, STIs, etc.)

    19. Assess maternal risk factors Poor obstetric history Strikingly short stature Maternal age < 15 years Grand multiparous or nulliparous Size - date discrepancy Unwanted pregnancy Extreme social disruption/deprivation Multiple gestation Abnormal lie/presentation

    20. Group Work: Plan for ANC and PNC integrated into PHC services as soon as possible KEY ACTIVITIES: Collect background information Find secure location Ensure access for all potential users Reinforce privacy and confidentiality Ensure access to water and sanitation Put in place supplies and protocols to ensure aseptic conditions Train/retrain staff

    21. Monitoring & Evaluation (M&E)

    22. M&E: MISP

    23. M&E: UN Process Indicators

    24. M&E: UN Process Indicators - At least 15% of pregnant women develop obstetric complications - Between 5 and 15% of all births require a caesarean section

    25. Monitoring Impact MMR: Maternal Mortality Ratio NMR: Newborn Mortality Ratio Incidence of obstetric complications Verbal autopsies Facility-based maternal deaths review Confidential enquiries Review of “near misses” Clinical audit

    26. Maternal and Newborn Health Topics Relevant to Coordination

    28. Breastfeeding HIV negative women: exclusive breastfeeding ? 6 months HIV positive women > Exclusive breastfeeding ? 6 months unless replacement feeding acceptable, feasible, affordable, sustainable and safe –‘AFASS’ depending on individual circumstances, health status of woman, local situation, availability of health services, counseling and support. > Field-based flash heating of breast milk under study Wet nurse: if culturally accepted, needs HIV counselling and testing before wet-nursing and 6–8 weeks after starting. Education on HIV prevention also required.

    29. Prevention of Post-Partum Hemorrhage (PPH) Leading cause of maternal mortality (25%) Impossible to predict PPH ? every woman is at risk AMTSL (Active Management of the Third Stage of Labor) reduces the incidence of PPH, need for blood transfusion and medical intervention: Uterotonic agent within 1 minute of birth of baby (Oxytocin 10 Units IM, Misoprostol 600 mcg PO if no Oxytocin available) Controlled cord traction External massage of the uterus

    30. PPH: stability of Oxytocin Needs cold chain High temperature ? decrease efficacy Do not discard if no other uterotonic available

    31. Traditional Birth Attendants (TBAs) It is not necessary to train TBAs and midwives before providing them with clean delivery kits ? delivery kits to reach pregnant women without delay TBAs should not be encouraged to perform technical midwifery tasks WHO no longer recommends training new TBAs Orientation of existing TBAs on the following tasks should wait until the situation has stabilized: Educating women and families on danger signs, timely referral, nutrition, hygiene, breastfeeding support, family planning, etc. Distribution of iron, folate, vitamin A, intermittent preventive treatment for malaria

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