NOTE REPRODUCTIVE HEALTH

HEALTHTOOLBOXACF.FR.2015BF.REPRODUCTIVEHEALTH 1/22

BRIEFING NOTE REPRODUCTIVE HEALTH

This note gives the reader an overall perspective on reproductive health, explaining the context of the issue and the strategies that have proven effective. These are not necessarily the same as the list of interventions presented in the ACF position paper on health. The objective here is to understand the issue ACF is faced with in a more comprehensive manner so that we may desgin interventions that make sense. In addition, for educational purposes, reproductive health and children's health have been treated in two separate documents; however, these two themes should be considered together when interventions are designed.

Educational objectives:- Understand the contextual analysis: key problems and main challenges- Be able to contextualize this theme within the ACF mandate- Identify intervention strategies that have proven effective- Aid in designing a reproductive and children's health intervention proposal

1. Introduction

Definition of the theme

Different terms are often used interchangeably; the concepts are close in meaning, but nuances do exist. Maternal health includes all aspects of a mother's health, from pregnancy to childbirth to the postpartum period. Sexual health is a state of physical, mental and social well-being in the area of sexuality. Reproductive health concerns not only maternal health; it is "a state of physical, mental and social well-being in all things related to reproductive processes and the functioning of the reproductive system at every stage of life. It implies the possibility of having a responsible, satisfying and safe sex life as well as the personal freedom of choosing to have children if and when one wishes to." The definition of reproductive health therefore includes sexual health, maternal health, parenthood and family planning.


In 2013, 289,000 women died during or following pregnancy or childbirth, representing a decline of 45% since 1990. Almost all maternal deaths (99%) take place in developing countries; sub-Saharan Africa alone accounts for 62% of all deaths, followed by Asia at 24%.1 Figure1:Maternalmortalityrateper100,000livebirthsin2013(source:WHOMapProduction)

a) Contextua l izat ion with in the ACF mandate

Nutrition is an essential component of maternal and child health. The pregnancy and maternity monitoring period is also a time during which the mother and child are most exposed to undernutrition. A satisfactory nutritional status is an important factor in child survival. Undernourished women give birth to smaller children, who in turn will have a heightened risk of mortality due to infections and asphyxia. The mother's survival is also affected by her nutritional status. More specifically, stunted growth and/or iron deficiencies are factors associated with women who have a higher risk of mortality during childbirth, representing at least 20% of all maternal deaths. Addressing undernutrition issues within the continuum of care is

1

WHO.Maternalmortality,FactSheetNo.348.May2014.Seehttp://www.who.int/mediacentre/factsheets/fs348/en/


therefore essential for speeding up progress towards meeting the objectives of reducing infant and maternal mortality.

In 2013, The Lancet 2 published a list of 13 interventions proven to reduce rates of undernutrition. A large majority of these practices relate specifically to pregnant and lactating women and young children during the first 1,000 days: "strengthening nutrition-specific, sensitive services within the scope of basic activity packages, such as family planning and pre- and postnatal care, is essential for breaking the vicious intergenerational cycle of undernutrition."

It is within this framework that ACF International decided to review its operating procedure presented in the internal position paper "Harmonizing health and nutrition". ACF is revising its approach and wishes, "aided by the promotion and support of nutritional interventions in the area of health care, to reduce the siloed approach to addressing malnutrition and work more closely with health care partners or directly in support of health care services or other groups within the health care system […]. It is important to ensure that nutritional interventions, as an integral part of basic health care services, be available to adolescents and women within the scope of ACF's multi-sector approach to combating malnutrition." ACF has also drafted a document advocating the integration of nutritional interventions into the sexual and reproductive health funding policy of France, which contributes one-third of ACF's total health care aid in this area.

2. Analysis of the situation a) Analys is of the globa l context

i ) Key problems: causes and ana lys is of cha l lenges

Within the framework of the fifth Millennium Development Goal (MDG), the countries of the world have committed to reduce maternal mortality by three-quarters and achieve universal access to reproductive medicine by 2015. Since 1990, maternal deaths have decreased by 45% globally.

§ Where do maternal deaths occur?

The high number of maternal deaths in some areas of the world reflects unequal access to health care services and highlights the gap between rich and poor. The maternal mortality ratio in developing countries is 230 per 100,000 live births, compared to 16 per 100,000 live births in developed countries. There are also large disparities within countries between high-

2 “Whatworks?Interventionsformaternalandchildundernutritionandsurvival”,TheLancet,Volume371,No.9610(February2008),p.417-440.


and low-income women and between women living in rural and urban areas. Women in the lowest quintile have two to three times less access to maternity services.3The risk of maternal mortality is highest for adolescent girls under 15 years old. Complications in pregnancy and childbirth are the leading cause of death among adolescent girls in most developing countries.

§ Leading causes of death (WHO, 2014)

Maternal deaths fall into two categories:- death due to direct obstetric cause: deaths resulting from obstetric complications

directly linked to pregnancy, labor and the postpartum period.- death due to indirect obstetric cause: deaths resulting from preexisting illnesses or

ailments presenting themselves during pregnancy which are not attributable to direct obstetric causes but were aggravated by the physiological effects of pregnancy.

Most maternal deaths occur during childbirth and the immediate postpartum period (24 hours).

The major complications, which account for 80% of all maternal deaths, have direct causes; they are:4

- severe bleeding (mostly bleeding after childbirth);- infections (usually after childbirth);- high blood pressure during pregnancy (preeclampsia and eclampsia);- unsafe abortion.

Indirect causes are associated with diseases such as malaria and AIDS during pregnancy.

§ Main challenges in reducing maternal mortality

Most of these deaths are preventable through simple and effective interventions which should be integrated into a care continuum extending throughout the life of the woman as well as between the different levels of the health care system. Today, our major challenge is the access of disadvantaged groups to these essential interventions. All women need access to prenatal care in pregnancy, skilled care during childbirth, and care and support in the weeks after childbirth.

In view of the intrinsic link between health and nutrition on the one hand and the significant burden that undernutrition in women and children represents on the other hand, nutritional interventions should be considered an integral part of the maternal and child health care continuum.

3 WHO.Maternalmortality,FactSheetNo.348.May2014.Seehttp://www.who.int/mediacentre/factsheets/fs348/en/

4 SayLetal.GlobalCausesofMaternalDeath:AWHOSystematicAnalysis.Lancet.2014


Poor women in remote areas are the least likely to receive adequate health care. In the 75 countries with the highest prevalence rates of maternal and infant mortality, the main coverage gaps of essential interventions are (Countdown 2015):5

- Before pregnancy: a low prevalence of contraception, which demonstrates unsatisfied demands for family planning.

- During pregnancy: the low coverage rate of preventive treatment of malaria for pregnant women and prevention of mother-to-child transmission of HIV - both indicative of low coverage of quality prenatal care.

- During childbirth and the postnatal period: lack of access to skilled health personnel during childbirth and to emergency obstetric and neonatal care; the low percentage of early initiation of breastfeeding.

The main factors preventing women from receiving these essential interventions are:

- a shortage of health personnel associated with limited delegation of tasks. Only 28 countries out of the 75 reached the minimum ratio of qualified health workers per 10,000 people.

- low quality of care which is associated with a shortage of qualified professionals, a lack of infrastructure and an inadequate supply of commodities and medical materials.

- low demand for care due to high costs, distance, lack of knowledge and local cultural beliefs and practices.

- an inefficient referral system and the weak connections between health care personnel and community workers.

ii) Poss ib le opportunit ies and const ra ints

Opportunities

Growing public awareness and unprecedented investments in women's and children's health have emerged in the last few years, with many initiatives taking place, including:

- The Every Woman Every Child6 program intensifies international action to address health challenges facing women and children, especially its Commission on Life-Saving Commodities

5 Countdownto2015Maternal,Newborn&ChildSurvival.Seehttp://www.countdown2015mnch.org/

6 UnitedNationsSecretary-General.Globalstrategyforwomen'sandchildren'shealth.September2010.Seehttp://www.everywomaneverychild.org/images/content/files/global_strategy/full/20100914_gswch_en.pdf


for Women and Children (UNCoLSC), which works to increase access to and appropriate use of 13 essential commodities which avert preventable deaths of mothers and children7

- the Partnership for Maternal, Newborn and Child Health8 is a platform for organizations that allows them to harmonize their objectives, strategies and resources while agreeing on interventions to improve maternal, neonatal, child and adolescent health

Constraints

- The weakness of health care systems which have difficulty implementing an integrated approach to reproductive, neonatal and child health (RNCH) including nutrition as part of primary health care.

- The deep and persistent inequalities encountered by women and girls in many parts of the world.

b) Analys is of the hea lth s i tuat ion in an intervent ion area : key e lements

RNCH interventions should be planned and implemented at the district level by way of primary health care. To do this, the strengths and weaknesses of the health care system must be assessed at this level.9 The diagnostic methodology developed by ACF to strengthen health care systems10 is well suited for this purpose and subsequently allows for the planning of programming.

However, depending on the context and emergency phase of the situation, other methodologies may be used. Here are a few guides and manuals:

- Centers for Disease Control and Prevention (2007). Reproductive Health Assessment Toolkit for Conflict-Affected Women. Atlanta: CDC.

- Inter-agency field manual on reproductive health in humanitarian settings (2010)11

7 Seehttp://www.lifesavingcommodities.org/about/lifesaving-commodities/

8 ThePartnershipforMaternal,NewbornandChildHealth.Seehttp://www.who.int/pmnch/en/

9 BjörnEkman,IndraPathmanathan,JerkerLiljestrand.Integratinghealthinterventionsforwomen,newbornbabies,andchildren:aframeworkforaction.Lancet2008;372:990–1000

10 ACFInternationalNetwork.HealthSystemStrengthening.Fromdiagnosistoprogramming.Version2.1.2015

11 Inter-agencyWorkingGrouponReproductiveHealthinCrises.Inter-agencyfieldmanual


- MSF (2006). Rapid health assessment of refugee or displaced populations. Paris: MSF.12

- Inter-Agency Standing Committee Global Health Cluster (2009). Health Cluster Guide13

- IASC Global Nutrition Cluster Harmonized Training Package. Health assessment and the link with nutrition14

Summary of key elements to assess (see primary health care program sheet)

-> Obtain a general picture of the status of maternal and child health in the country and area of intervention: maternal mortality ratio, main causes of morbidity and mortality in children under 5, percentage of children with low birth weight, etc.

-> Availability and capacity of health care services: map out the offering of care, highlighting health facilities providing emergency obstetric and neonatal care (EONC), treatment of malnutrition in pregnant and lactating women, the percentage of health care personnel trained in EONC, the availability of medicines essential for mother and child survival, the possibility of receiving care 24 hours a day at health care centers by nighttime care personnel.

-> Make an assessment of the level of coverage of health care services and essential interventions:

- Coverage of family planning, rate of antenatal care consultations (ANC 1 and 4), percentage of deliveries performed by qualified personnel, coverage of postnatal care (1 visit during the two days after the birth), percentage of exclusive breastfeeding during the first 6 months.

-> Existence and level of functionality of the referral system between the community, health care center and district hospital

-> Identify the gaps and analyze the barriers to health care access as well as the most vulnerable populations and groups. An analysis of gender-based discrimination is necessary (understand and recognize the relations unique to each social group)onreproductivehealthinhumanitariansettings(2010).Seehttp://www.who.int/reproductivehealth/publications/emergencies/field_manual/en/

12 MédecinsSansFrontières(2006).Rapidhealthassessmentofrefugeeordisplacedpopulations.Paris:MSF.Seewww.refbooks.msf

13 Inter-AgencyStandingCommitteeGlobalHealthCluster(2009).HealthClusterGuide.Seehttp://www.who.int/hac/global_health_cluster/guide/en/

14 IASCGlobalNutritionClusterHarmonizedTrainingPackage(HTP).Healthassessmentandthelinkwithnutrition.http://www.unscn.org/en/gnc_htp/howto-htp.php#howtousehtp


-> Assess the response capacities of current stakeholders: the ministry of health, associations, etc. What is their capacity and level of involvement? Become acquainted with the national directives and roadmaps for reducing maternal mortality, the list of essential medicines, antenatal and postnatal consultation protocols.

c) Response ana lys is : main intervent ion st rateg ies

The strategies presented below are the recommendations for reducing maternal mortality for which there is currently a consensus. Since obstetric activities (childbirth) are beyond the scope of our organization's internal position paper, when possible, a partnership may be arranged with other players with expertise in obstetrics. However, it is important to ensure that access to essential services is available throughout the continuum of care (time and level of care), especially access to basic and referral obstetric and neonatal care.

The impact of RNCH programs depends on 1) high coverage of essential interventions throughout the care continuum (including nutrition), 2) their quality, and 3) functioning links between the interventions and the health care system.

The approaches taken should follow these main lines:

⇒ Identifying and understanding the barriers that act as obstacles to the use of maternity care services--financial, geographical and socio-cultural determinants--so as to better address them. Addressing the inequities of access to care by targeting the most excluded and vulnerable groups and hard-to-reach populations is seen as the most effective and efficient way of preventing maternal and child deaths.15

⇒ Offering care integrated into the reproductive, neonatal and child health care continuum. There is now an established consensus that the RNCH care continuum includes the delivery of ongoing and integrated health care and nutrition services for

15 UNICEF.ProgressforChildren.AchievingtheMDGswithEquity.2010


women and children throughout the life cycle--from pre-pregnancy through childbirth, the immediate postnatal period and childhood--and in all care settings, including families and communities, outpatient services, clinics and other health care establishments (these are the two dimensions of the care continuum).

Figure 2: Two dimensions of the care continuum (source: Partnership forMaternal and Child Health

2009)

All of these stages are interdependent, and the links between maternal and neonatal health are particularly strong. For these reasons, it is imperative that health care and nutrition interventions be seen as part of a continuum over time so that they may mutually reinforce each other.

⇒ An offering of quality care throughout the continuum should be proposed, consisting of: - Family planning: services allowing the time of birth to be chosen through the use of

contraceptive methods. If all births were spaced at least 2 years apart, infant mortality would decrease by approximately 10%. Furthermore, addressing unsatisfied demands for contraception in developing countries would decrease mortality by at least 30% by reducing unintended pregnancies and related complications (unsafe abortions).16 This is also an opportunity to begin nutritional education well before the birth of the first child as part of a general goal of health promotion.

- Prenatal care: health care provided during pregnancy consisting of 4 prenatal consultations (WHO recommendation). This is a time that can be used to detect malnourished women and ensure that they are cared for.

- Immediate obstetric and postnatal care is preventive and curative care provided during labor, childbirth and the immediate postpartum period. Its goal is to reduce maternal and neonatal mortality through early screening and timely management of obstetric and neonatal complications.

o BONC: basic obstetric and neonatal care available at the primary health care level (health care center) which includes 7 key interventions: administration of parenteral antibiotics, administration of uterotonics, administration of

16

ClelandJ.etal.ContraceptionandHealth.Lancet2012;380:149-156.


parenteral anticonvulsants to treat preeclampsia, manual removal of the placenta, uterine evacuation (manual vacuum aspiration, dilation and curettage), vaginal delivery with instrumental assistance (vacuum, forceps), basic neonatal resuscitation (manual ventilation with bag valve mask).

o CONC: comprehensive obstetric and neonatal care available at the secondary (hospital) level which includes BONC services + the performance of Caesarean sections and blood transfusion.

o During the immediate postpartum period, it is advisable to keep the mother under supervision for 24 hours, as this is a high-risk period for both the mother and the newborn. In fact, 50% of maternal deaths and 40% of neonatal deaths occur in the 24 hours following childbirth.

- Postnatal care is provided during the period lasting until the 42nd day after childbirth.17 If delivery did not take place in a health care center, the first visit should be made during the two days after the birth; afterwards, all women should have a second visit at seven days after delivery and a third at 42 days. These consultations are often underattended; nevertheless, they are essential for detecting medical complications and promoting breastfeeding and family planning.

⇒ Community participation as a cornerstone: mobilizing the community to boost demand for health care. Active participation is an essential element in ensuring accessible projects and meeting needs. It strengthens women's individual skills so that they have better control over their health. Community interventions should be designed in a way that integrates health and nutrition rather than using a siloed approach. Community participation also involves other local players, such as women's associations which promote a better understanding of the context and act as anchors for the project. Traditional midwives are indispensable community leaders; however, an in-depth analysis of the local context, i.e. the nature of their involvement, should be conducted because the strategy deemed most effective in reducing mortality remains delivery by qualified medical personnel.

A gender-based approach is also important because gender inequities are an obstacle to reproductive rights and access to health care. In many contexts, social norms and the way in which they are applied translate into inequities in power relations.

⇒ Support for health care authorities, especially at the health district level; on the one hand, so that they are able to monitor the quality of the activities carried out, and on the other, to improve the collection and analysis of data to have a better overview of the problems in the area.

17

Immediatepostpartumperiod(first24hours),earlypostpartumperiod(2ndto7thdayafterdelivery),latepostpartumperiod(8thto42nddayafterdelivery)


3. Planning an intervention

a) Object ives to meet

General objective: Contribute to the reduction of maternal mortality and morbidity in the intervention area.

Specific objectives: Increase access to quality reproductive and child health care services throughout the care continuum.

To meet these objectives:

- Improve access to maternal care services via different levels of the health care system: community, primary and secondary.

- Increase quality of maternity services.- Support the health district to allow for integration of essential interventions into

primary and secondary health care.

o Types of act ions to cons ider

Depending on the level and resources of the health district, it is conceivable to integrate the essential intervention package gradually, and in principle within the framework of the ministry of health's national RNCH policies. It is important to support the implementation of national roadmaps at the health district level.

The table below summarizes the essential interventions proven to be effective at the different health care system levels, taken from the documents "Essential Interventions for Reproductive, Maternal, Newborn and Child Health", PMNCH 201118, and The Lancet's "Every

18

ThePartnershipforMaternal,NewbornandChildHealth,2011.Aglobalreviewofthekeyinterventionsrelatedtoreproductive,maternal,newbornandchildhealth.Geneva,Switzerland:PMNCH.


Newborn Series", July 2014. It is essential that these interventions target the specific gaps related to the intervention context.

When the intervention is implemented in the field, it is important to refer to the policies of each country because the care package varies according to the health care system level. Interventions associated with childbirth and the management of unintended pregnancies are not included in the ACF position paper.

Table1:Classificationofinterventionsaccordingtothelevelofhealthcare

Interventions Community

Healthcarecenter

Hospital

Adolescentandpre-pregnancy

FamilyplanningPreventionandmanagementofSTIs,HIVandmalariaFolicacidsupplementationtopreventneuraltubedefectsNutritioncounselingandnutritionalsupplements

ê

P

P

P

P

P

P

P

P

P

P

P

Pregnancy

Managementofunintendedpregnancies:- Availabilityandprovisionofsafeabortioncare- Provisionofpost-abortioncare

Appropriateantenatalcarepackage:- Screeningformaternalillnesses- Screeningforhypertensivedisordersduringpregnancy- Screeningforanemiaand‚ironandfolicacidtopreventmaternalanemia- Tetanusimmunization- Counselingonnutrition,childbirthandemergencypreparedness*- PreventionandmanagementofHIV,includingwithantiretrovirals- Preventionandmanagementofmalariawithinsecticidetreatednetsand

antimalarialmedicine- Smokingcessation

Reducemalpresentationattermwithexternalcephalicversion

Preventionofpreeclampsia- Calciumtopreventhypertension- Low-doseaspirintopreventhypertension

MagnesiumsulfateforeclampsiaInductionoflabortomanageprelaborruptureofmembranesattermAntibioticsforpretermprelaborruptureofmembranesCorticosteroidstopreventrespiratorydistresssyndromeinnewborns

--

-

P

-------

- P

P

P

-P -

P - P -

P P

P

P

P P

P

P

P

P P

Childbirth


InductionoflaborforprolongedpregnancyProphylacticuterotonicstopreventpostpartumhemorrhageActivemanagementofthirdstageoflabor(deliveryoftheplacenta)topreventpostpartumhemorrhageCaesareansectionformaternal/fetalindicationManagementofpostpartumhemorrhage(e.g.uterotonics,uterinemassage)ProphylacticantibioticsforCaesareansection

- P -

- P

-

- P

P

- P

-

P

P

P

P

P

P

Postnatalcare(mother)

InitiationofearlybreastfeedingandpromotionofexclusivebreastfeedingHomevisits:promotionofneonatalcare,breastfeeding,examinationforsignsofinfectionandreferralifnecessary.FamilyplanningPreventionandtreatmentofmaternalanemiaDetectionandmanagementofpostpartumsepsisScreenandinitiateorcontinueantiretroviraltherapyforHIV

P

P

P ---

P -

P

P

P

P

P -

P

P

P

P

Methods of intervention

⇒ Encouraging access to and use of integrated maternity services

§ Analyze the problem of inequity by identifying the most vulnerable groups towards whom more specific activities should be targeted and understand the barriers that act as obstacles to the use of maternity health services. Endeavoring to reduce these barriers is absolutely necessary because often the demand for care is low, and these services are underutilized (delivery and postnatal care in particular).

-> To lift socio-cultural barriers and promote the demand for health care : 4. Collaborate with influential persons (traditional midwives, traditional medical

practitioners, religious figures) to understand and act on the levers that promote the lifting of barriers.

5. Use mobile telephones to send personalized messages for antenatal and postnatal consultation to promote demand for care.

6. It may become necessary to organize specific activities based on gender: an analysis of discrimination that differentiates the results by sex, support for women in strengthening their decision-making skills (financial support), awareness-raising among men.

-> To lift financial barriers:

2) exemption of payment for care for pregnant women, introducing cash transfers to poor households to cover transportation costs, etc.

3) At the same time as local intervention, if the cost recovery policy applies to pregnant women, advocacy should be developed in partnership with other players, targeting political decision-makers. This may be accompanied by


messages promoting an increase of the proportion of the national budget allocated to health (if in an African country, refer to Abuja's declaration to allocate 15%). To strengthen the case, the risk of maternal death throughout the life of a woman, for example 1/17, may be used as an indicator ("One women in 17 is at risk of dying as a result of childbirth in this country"); this has the benefit of making statistics more meaningful;

-> To lift geographical barriers: o Set up advanced strategies for antenatal care in remote areas, o Organize home visits for post-natal care by community-based health workers

trained to detect complications and provide the care and guidance necessary (a strategy strongly recommended by UNICEF and WHO).

o Organize transportation between the community, health care centers and hospitals.

With specific regard to access to obstetric care (i.e. delivery), researchers have created a theory on these obstacles in a model called the "3 Delays Model", which serves as a reference for analyzing the situation in an intervention area.

Table2:3DelaysModelandkeyinterventions

Threedelays Commoncauses Keyinterventions Delay1(communitylevel)

Failuretorecognizetheneedforemergencyobstetriccare

Improvewomen's,men'sandfamilies'awarenessofthesignsofobstetricdangers.

Havetraditionalmidwivesparticipateinearlyscreeningandearlyreferralofwomenwithobstetricemergencies.

Delay2(reachingahealthcenter)

Delayinreachingthehealthfacility

Improvethereferralsystem,includingcommunicationcapacityandmeansoftransportation.

Implementfinancingsystemsforthepoorestgroupsandliftthefinancialbarrieratthepointofaccess.

Delay3(intheadministrationofappropriatetreatment)

Thefacilitydoesnothavethepersonnelorequipmenttoprovideemergencyobstetricservices,orthewomancannothaveaccesstotheservicesuponarrival.

Improveemergencyobstetricservicecoveragetomeetminimumrequirements

Improveusageofemergencyobstetricservicesbyreducing

obstaclesandensuringequitableaccess.

Adaptedfrom:TheDesignandEvaluationofMaternalMortalityPrograms,CenterforPopulationandFamilyHealth,SchoolofPublicHealth,ColumbiaUniversity,1997.

A fourth delay can be identified as access to secondary care facilities (district hospitals). The distance between the health care center and the hospital as well as the lack of means of transportation are possible causes of this delay. Furthermore, cultural factors can add to the fear of giving birth by Caesarean section, which is sometimes perceived negatively and diminishes the woman's status. There are various interventions which can be implemented: referral system for emergencies (ambulance), means of communication, maternity waiting areas.- Promote community participation in health education, detection of complications and

the implementation of some basic services.


Home visits paid by community-based health workers are an opportunity to share messages about signs of complications, adequate care practices and healthy diets for pregnant women, young children, and newborns. With regard to health promotion, it is also possible to use existing connections between women or education by peers and women's groups, called the "Women Care Group Model", which has given good results.19

⇒ Increase quality of maternal care services.

- Support the supply of medicine and consumables for essential maternity services, family planning and malnutrition management for pregnant and lactating women.

- Set up a favorable environment: rehabilitation of sanitation facilities, delivery rooms and adequate materials which allow hygiene standards to be met.

- Train qualified personnel on: how to hold an antenatal care consultation, performing deliveries and basic emergency care (BONC), postnatal consultations, family planning and caring for malnourished pregnant and lactating women. It is important to use the national protocols in force as a foundation. An indispensable guide on essential practices in pregnancy, childbirth, postpartum and newborn care is available (published by WHO, UNFPA, UNICEF, World Bank).20

- Train community-based health workers on raising awareness on proper diets for newborns and young children, signs of complications during pregnancy and the neonatal period, care needed during the postnatal period and family planning. Whether it is within the health facility or the community, it is important to work on the quality of counseling given to women and their partners, going beyond simply providing information and giving them the keys to put it into practice. The aim of health promotion is to contribute to strengthening the empowerment of individuals, families and communities with a view to improving maternal and neonatal health. There are several WHO publications on this subject: "Counselling for maternal and newborn health

19 Laughlin,M.TheCareGroupDifference,2004.Seehttp://www.coregroup.org/storage/documents/Resources/Tools/Care_Group_Manual_Final__Oct_2010.pdf

20 WHO,UNFPA,UNICEF,WorldBank.Pregnancy,childbirth,postpartumandnewborncare.Aguideforessentialpractice-2nded.2009.Seehttp://www.who.int/maternal_child_adolescent/documents/924159084x/en/


care"21 and "Working with individuals, families and communities to improve maternal and newborn health".22

- Carry out supervisions in collaboration with agents from the health district's management team.

- Ensure that the referral hospital is able to offer essential interventions, including complicated Caesarean section deliveries, blood transfusion and resuscitation of newborns. If it is not, identify a player who can strengthen this aspect.

- Support the health district to allow for effective integration of the essential

intervention package at the different levels of the health care system- Carry out a diagnosis of the health care system at the district level to identify strengths

and weaknesses, allowing for the implementation of essential interventions in health and nutrition, then draw up an action plan. This should be integrated into the annual action plan of the district.

- Integrate the guidelines recommended by the ministry of health at the national level to reduce maternal, neonatal and infant mortality into the district action plan.

- Strengthen, together with the district's management team, the referral system and the coordination between community, primary and secondary care:

b) Support the referral system: ambulances, etc.c) Coordination meeting between health care centers and community-based health

workers.d) Coordination meeting with health care center teams and chief physician of the

hospital during monthly meetings on the activity report, for example.

2) Strengthen health authorities' capacity for collecting and analyzing data on the use and coverage of health services. In a guide entitled "Beyond the Numbers"23, the WHO describes the methods to use for recording the circumstances of women's deaths, trying

21 WHO.Counsellingformaternalandnewbornhealthcare.Ahandbookforbuildingskills.2013.Seehttp://www.who.int/maternal_child_adolescent/documents/9789241547628/en/

22 WHODepartmentofMakingPregnancySafer.Workingwithindividuals,familiesandcommunitiestoimprovematernalandnewbornhealth.2010.Seehttp://www.who.int/maternal_child_adolescent/documents/who_fch_rhr_0311/en/

23 WHODepartmentofReproductiveHealth.Beyondthenumbers:Reviewingmaternaldeathsandcomplicationstomakepregnancysafer.2004.Seehttp://www.who.int/maternal_child_adolescent/documents/9241591838/en/


to understand why these deaths occurred, and how they can be prevented (mortality audit or review).

3) According to the RSS diagnosis and the weaknesses identified, develop advocacy by concentrating on one of the pillars, for example human resources (improving them in a qualitative or quantitative manner) or equipment and commodities (advocating for the addition of RUTF to the list of essential medicines, for example), when changes to health policy documents or protocols (integrating treatment for undernutrition of pregnant women during an antenatal care consultation) are needed. Please refer to the advocacy sheets for this purpose.

By itself, maternal health mobilizes fewer advocacy players than infant and juvenile health, and the key partners of this advocacy are UNFPA, WHO, Marie Stopes, gynecologist and midwife associations, etc.

4. Monitoring and Evaluation a) Monitor ing the pro ject : cho ice and ana lys is of ind icators

The setup of a monitoring and evaluation system requires: - Making available the resources necessary for allowing the setting of a baseline, final

surveys and sometimes mid-term evaluations.- Standardized report formats, using the national health information system formats- A selection of SMART indicators (specific, measurable, appropriate, realistic and time-

bound)--it is important to become acquainted with the indicators used by the ministry of health within the scope of the national policy on maternal and child health. These indicators must permit measurement of the results at all levels of program theory--inputs, outputs, results--so that not only knowledge improvement is measured, but also practices, and when possible, the change in health.

This table is not exhaustive; it is advisable to refer to the indicators set out in the national roadmap sheets. For more information on calculation methods, source and periodicity, please refer to the appended document on indicators.


Table3:Sampleindicatorsforamaternalandreproductivehealthproject24

Indicator Question Sampleindicators Recommended level(WHO)

Offering(inputs)

Are servicesavailable andaccessible?

• Proportion of health facilities withemergencyobstetricservices• Proportion of health facilities wherescreeningandtreatment forsevereacutemalnutrition is integrated into theantenatalcareconsultation

⇒ Minimum:1fullemergencyobstetricserviceestablishmentand5basicemergencyobstetricserviceestablishmentsper500,000persons.

⇒ Tobesetbytheproject

Quality(outputs)

Is the qualitysufficient?

• % of medical personnel with the basicknowledge (prenatal, obstetric andpostnatalcare)•Proportionofwomenhavinghada2ndantenatal care consultation and havingreceived2tetanusvaccinations• Fatality rate linked to direct obstetriccausesinanestablishment• Intrapartum mortality and very early(24hour)neonatalmortalityrate

⇒ To be set by theproject

⇒ >90%*

⇒ <1%⇒ No currentstandard

Access andUse(outputs)

Are healthservicesused?

•RateofANC1•%ofmotherswhoreceivedapostnatalvisitwithin2days• Proportion of births attended byqualifiedpersonnel•Proportionofbirthsoccurring inhealthfacilities with emergency obstetricservicesasa%ofallbirths•Proportion of women referred to thehospitalwhoaccessit

•100%•80%or increase to90%iflessthan70%*•>90%*•Setbythecountry•>90%*

24 WHO,UNFPA,UNICEF,MailmanSchoolofPublicHealth.AvertingMaternalDeathandDisability(AMDD).Monitoringemergencyobstetriccare.Ahandbook.2011.Seehttp://www.who.int/reproductivehealth/publications/monitoring/9789241547734/en/

* *However,thetargetshouldbesetdependingonthebaselineaswellastheobjectivesofthedistrict.


Coverageofinterventions(result)

Does the targetpopulationreceive essentialinterventionsthat are provento reducemortality?

• Proportion of women withcomplications treated at facilities withemergencyobstetricservices•Demandforfamilyplanningsatisfied• % of pregnant women having receivedintermittentmalariatreatment• % of pregnant women having receivedatleasttwodosesoftetanustoxoid(TT)•%ofdeliveriesbyCaesareansection• % of pregnant women having had atleastfourconsultationsduringpregnancy

•90% (anestimated15%ofexpectedbirths).•Setbythecountry•Tobesetbytheprojectaccording to baseline(min.>75%)•Sameasabove•Min.:5%/Max.:15%•Tobesetbytheprojectaccording to baseline(min.>75%)

Impact Are thereimprovementsin morbidity ormortality?

• Proportion of births with severemorbidity•Maternalmortalityratio

•Tobesetbythecountry

b) Analys is of expected resu lts

An evaluation of the offering and quality of services as well as their coverage is recommended. Table 3 presents, in a logical order, the types of necessary information to be collected relating to essential interventions along the care continuum. Above all, services must be available and accessible to the target population and be of adequate quality. Secondly, the population should find the services acceptable and make use of them. Thirdly, if the provision of care and its quality and use are high, an impact on health or behavior may result.25 Because none of these indicators is perfect, and because none of them can indicate actions needed for improving access to and use of obstetric care, an evaluation of maternity services should be based on several indicators.

The measurement of the maternal mortality ratio is not recommended as a measurement of the results evaluating the success of a project. There are many reasons for this, relating mainly to the process of measurement, including underestimation, failure to classify

25 VincentDeBrouwereandWimVanLerberghe,ed.RéduirelesRisquesdelaMaternité:StratégiesetEvidenceScientifique.Commentmesurerlesprogrèsversuneaméliorationdelasantématernelle?p.337.2001


pregnancies as causes of death, and the relatively small number of maternal deaths (in statistical terms).26

Trendsinestimatesofmaternalmortalityratio(per100000livebirths)incountrieswithACFintervention27

Categorisationofprogressforcountrieswithamaternalmortalityratio≥100in1990

- Ontarget:whereaverageannualreductioninmortalityratioisatleast5.5%- Progressmade:whereaverageannualreductionisbetween2%and5.5%- Insufficientprogress:whereaverageannualreductionislessthan2%

Countrieswithamaternalmortalityratio<100in1990arenotcategorised.

Country

Maternalmortalityratioper100000livebirths

%changebetween1990and2013

Progresstowardsanimprovementinmaternal

health1990 2000 2013

Afghanistan 1200 1100 400 -67 Progressmade

Azerbaijan 60 57 26 -57 N/A

Bangladesh 550 340 170 -70 Progressmade

Bolivia 510 330 200 -61 Progressmade

BurkinaFaso 770 580 400 -49 Progressmade

Cameroon 720 740 590 -18 Insufficientprogress

CentralAfricanRepublic

1200 1200 880 -27 Insufficientprogress

Chad 1700 1500 950 -41 Progressmade

Colombia 100 130 83 -17 Insufficientprogress

DemocraticRepublicoftheCongo

1100 1100 730 -29 Insufficientprogress

Djibouti 400 360 230 -43 Progressmade

26 VincentDeBrouwereandWimVanLerberghe,ed.RéduirelesRisquesdelaMaternité:StratégiesetEvidenceScientifique.Commentmesurerlesprogrèsversuneaméliorationdelasantématernelle?p.337.2001

27WHO.TrendsinMaternalMortality:1990to2013.EstimatesbyWHO,UNICEF,UNFPA,theWorldBankandtheUnitedNationsPopulationDivision.2014


Ecuador 160 120 87 -44 Progressmade

Ethiopia 1400 990 420 -69 Progressmade

Georgia 50 60 41 -18 N/A

Guatemala 270 160 140 -49 Progressmade

GuineaConakry 1100 950 650 -40 Progressmade

Haiti 670 510 380 -43 Progressmade

India 560 370 190 -65 Progressmade

Indonesia 430 310 190 -56 Progressmade

Iraq 110 71 67 -37 Progressmade

IvoryCoast 740 670 720 -3 Insufficientprogress

Jordan 86 65 50 -42 N/A

Kenya 490 570 400 -17 Insufficientprogress

Lebanon 64 37 16 -76 N/A

Liberia 1200 1100 640 -48 Progressmade

Madagascar 740 550 440 -41 Progressmade

Mali 1100 860 550 -51 Progressmade

Mauritania 630 480 320 -49 Progressmade

Mongolia 100 120 68 -34 Insufficientprogress

Mozambique 1300 870 480 -64 Progressmade

Myanmar 580 360 200 -65 Progressmade

Nepal 790 430 190 -76 Ontarget

Nicaragua 170 10 100 -38 Progressmade

Niger 1000 850 630 -37 Progressmade

Nigeria 1200 950 560 -52 Progressmade

OccupiedPalestinianTerritory

96 59 47 -51 N/A

Pakistan 400 280 170 -57 Progressmade

Paraguay 130 120 110 -19 Insufficientprogress

Peru 250 160 89 -64 Progressmade

Philippines 110 120 120 +15 Noprogress

Senegal 530 480 320 -40 Progressmade

SierraLeone 2300 2200 1100 -54 Progressmade

Somalia 1300 1200 850 -34 Insufficientprogress

SouthSudan 1800 1200 730 -59 Progressmade


Swaziland 550 520 310 -44 Progressmade

Syria 130 75 49 -64 Progressmade

Uganda 179 66 60

Ukraine 49 35 23 -54 Progressmade

Yemen 460 370 270 -41 Progressmade

Zambia 580 610 280 -51 Progressmade

Zimbabwe 520 680 470 -10 Insufficientprogress

NOTE REPRODUCTIVE HEALTH

Documents