COPAR PROGRAMS

THE MATERNAL HEALTH PROGRAM

This means a MMR of 112/100,000 live births in 2010 and 80/100,000 live births by 2015.Year Expected MMR2010 112/100,000 live births2015 80/100,000 live birthsThe maternal mortality ratio (MMR) has declined from an estimated 209 per 100,000 live births in 1987-93 (NDHS 1993) to 172 in 1998.  The Philippines found it hard to reduce morality. Similarly, perinatal mortality reduction has been minimal. It went down by 11% in 10 years from 27.1 to 24 per thousand live births.Year Actual MMR1987-1993 209/100,000 live births1998 172/100,000 live birthsThe percentage of pregnant woman with at least four prenatal visits decreased from 77% in 1998 to 70.4 in 2003. In addition, pregnant women who received at least two doses of tetanus toxoid also decreased from 38% in 1998 to 37.3% in 2003. Only about 76.8% of pregnant women received iron supplementation during pregnancy.The Philippine Health Statistics revealed that maternal deaths are due to:Complication Percentage of total maternal

deathsHypertension 25%Postpartum Hemorrhage 20.3%Pregnancy with abortive outcomes

9%

However births attended by health professionals increased from 56% in 1998 to 59.8% in 2003. There was also a notable increase to 51% in 2003 from 43% in 1998 in the percentage of women with at least one prenatal visit. Only 44.6% of postpartum women received a dose of Vitamin A.The underlying causes of maternal deaths are delays in taking critical actions:delay in seeking care,delay in making referral anddelay in providing of appropriate medical management.

Other factors that contribute to maternal deaths includesclosely spaced births,frequent pregnancies,poor detection and management of high-risk pregnancies,poor access to health facilities brought about by geographic distance andcost of transportation, andas well as health care and health staff who lack competence in handling obstetrical emergencies.The overall goal of the program is to improve the survival, health and well being of mothers and unborn through a package of services all throughout the course of and before pregnancy.The Strategic Thrust for 2005-2010Basic Emergency Obstetric Care (BEMOC)Launch and implement the Basic Emergency Obstetric Care or BEMOC strategy in coordination with the DOH. The BEMOC strategy entails the establishment of facilities that provide emergency obstetric care for every 125, 000 population and which are located strategically. The strategy calls for families and communities to plan for childbirth and the upgrading of technical capabilities of local health providers.Improve the quality of Prenatal and Postnatal CarePregnant women should have at least four prenatal visits with time for adequate evaluation and management of diseases and conditions that may put the pregnancy at risk. Post-partum care should extend to more women after childbirth, after a miscarriage or after an unsafe abortion.Reduce women’s exposure to health risksThrough the institutionalization of responsible parenthood and provision of appropriate health care package to all women of reproductive age especially those who are:less than 18 years old and over 35 years of age,women with low educational and financial resources,women with unmanaged chronic illness andwomen who had just given birth in the last 18 months.Appropriate Allocation of ResourcesLGUs, NGOs and other stakeholders must advocate for health through resource generation and allocation for health services to be provided and are in place in the health system.To address the problem, packages of health services are provided to the clients. These essential health care packages are available and are in place in the health system.Essential Health Service Package Available in the Health Care Facilities

These are the packages of services that every woman has to receive before and after pregnancy and or delivery of a baby.Antenatal RegistrationPregnancy poses a risk to the life of every woman. Pregnant women may suffer complication and die. Every woman has to visit the nearest facility for antenatal registration and to avail prenatal care services. This is the only way to guide her in pregnancy care to make her prepare for child birth. The standard prenatal visits that women have to receive during pregnancy are as follows:Prental Visits Period of Pregnancy1st visit As early in pregnancy as possible before four months

or during the first trimester2nd visit During the 2nd trimester3rd visit During the 3rd trimesterEvery 2 weeks After 8th month of pregnancy till delivery.Tetanus Toxoid ImmunizationNeonatal Tetanus is one of the public health concerns that we need to address among newborns. To protect them from deadly disease, tetanus toxoid immunization is important for pregnant women and child bearing age women. Both mother and child are protected against tetanus and neonatal tetanus. A series of 2 doses of Tetanus Toxoid vaccination must be received by a woman one month before delivery to protect baby from neonatal tetanus. And the 3 booster dose shots to complete the five doses following the recommended schedule provides full protection for both mother and child. The mother is then called as a “fully immunized mother” (FIM).Micronutrient SupplmentationMicronutrient supplementation is vital for pregnant women. These are necessary to prevent anema, vitamin A deficieny and other nutritional disorders. They are:Nutrient Dose Schedule RemarksVitamin A

10,000 IU Twice a week starting on the 4th month of pregnancy

Do not give Vitamin A supplementation before the 4th month of pregnancy. It might cause congenital problems in the baby.

Iron 60 mg/400 ug tablet

Daily

Treatment of Diseases and Other Conditions

There are other conditions that might occur among pregnant women. These conditions may endanger her health and complication could occur. Follow first aid treatment:Conditions/Diseases What to do Do not giveDifficulty of breathing/obstruction of airway

Clear airwayPlace in her best positionRefer woman to hospital with EmOC capabilities

Unconscious Keep on her back arms at the sideTilt head backward (unless trauma is suspected)Lift chin to open airwayClear secretions from throatGive IVF to prevent or correct shockMonitor VS every 15 minutesMonitor fluid given. If difficulty of breathing and puffiness develops, stop infusionMonitor U.O.Do not give oral rehydration solution to a woman who is unconscious or has convulsions.Do not give IVF if you are not trained to do so

Post partum bleeding Massage uterus and expel clotsIf bleeding persists:Place cupped palm on uterine fundus and feel for state of contractionMassage fundus in a circular motionApply bimanual uterine compression if ergometrine treatment done and p[ostpartum bleeding still

persistsGive ergometrine 0.2. IM and another dose after 15 minutes.Do not give ergometrine if woman has eclampsia, pre-eclampsia or hypertension.

Intestinal parasite infection

Giver mebendazole 500mg tablet single dose anytime from 4-9 months of pregnancy if  none was given in the past 6 months

Do not give mebendazole in the first 1-3 months of pregnancy. This might cause congential problems in baby.

Malaria Give sulfadoxin-pyrimethamine to women from malaria endemic areas who are in 1st or 2nd pregnancy, 500mg-25 mg tab, 3tabs at the beginning of 2nd to 3rd trimesters not less than one month interval.

Clean and Safe DeliveryThe presence of a skilled birth attendance will ensure hygiene during labor and delivery. It may also provide safe and non traumatic care, recognize complications and also manage and refer the women to a higher level of care when necessary. The necessary steps to follow during labor, childbirth and immediate post partum include the following:Do a quick check upon admission for emergency signs:Unconscious/convulsionVaginal bleedingSevere abdominal painLooks very illSevere headache with visual disturbanceSevere breathing difficultyFeverSevere vomitingMake woman comfortableEstablish rapport with the client by greeting and interviewing to make her comfortable.

Assess the woman in laborAssessing the client is a reference guide for a health worker to determine its status during labor stage. This can be done by taking the history of the ff:Last menstrual period (LMP)Number of pregnancyStart of labor painsAge/heightDanger signs of pregnancyTaking the history through interview will help determine the client’s condition during delivery of a baby.Determine the stage of laborLabor can be determined when woman’s response to contraction is observed pushing down and vulva is bulging, with leaking amniotic fluid, and vaginal bleeding. A vaginal examination can be performed to determine the degree of contraction.Decide if the woman can safely deliverBy assessing the condition of the client and not finding any indication that could harm the delivery of a baby, a trained health worker can decide a safe delivery of a mother.Give supportive care throughout laborThere are many things that a woman needs to do during labor. This will help her deliver clean, safe and free from fatigue. These are:Encourage to take a bath at the onset of laborEncourage to drink but not to eat as this may interfere surgery in case needed.Encourage to empty bladder and bowels to facilitate delivery of the baby. Remind to empty bladder ever 2 hoursEncourage to do breathing technique to help energy in pushing baby out the vagina. Panting can be done by breathing with open mouth with 2 short breaths followed by long breath. This prevent pushing at the end of the first stage.Monitor and manage laborThese re different stages of labor to watch out any danger signsStage What to do Not to doFirst StageNot yet in ative labor, cervic is dilated 0-3cm and

Check every hour for emergency signs, frequency and duration of contractions, fetal heart rate, etc.

Do not do vaginal examination more frequently than every 4 hours.

contractions are weak, less than 2 to 10 minutes.

Check every 4 hours for fever, pulse, BP and cervical dilatationRecord time of rupture of membranes and color of amniotic fluid.Assess progress of laborRefer woman immediately to hospital facility with comprehensive emergency obstetrical care capabilities if after 8 hours, contractions are stronger and more frequent but no progress in cervical dilatation, with or without membranes ruptured.

First StageIn active labor, cervic is dilated 4 cm or more

Check every 30 minutes for emergency signsCheck every 4 hours for fever, pulse, BP and cervical dilationRecord time of rupture of membranes and color of amniotic fluidRecord findings in partograph/patient record.Do not allow woman to push unless delivery is imminent. It will just exhaust the woman.Do not give medications to speed up labor. It may endanger and cause trauma to mother and the baby.

Second StageCervic dilated 10 cm or bulging thin perineum and head visible

Check every 5 minutes for perineum thinning and bulging, visible descend of the head during contraction, emergency signs, fetal heart rate and mood and behavior.Continued recording in the partograph.

Do not apply fundal pressure to help delivery the baby.

Third StageBetween birth of the baby and delivery of the placenta

Deliver the placentaCheck the completeness of placenta and membranesDo not squeeze or massage the abdomen to deliver the placenta

OthersMonitor closely within one hour after delivery and give supportive careContinue care after one hour postpartum. Keep watch closely for at least 2 hours.Educate and counsel on FP and provide FP method if available and decision was made by a woman.Birth registrationImportance of BFNewborn Screening for babies delivered in RHU or at home within 48 hours up to 2 weeks after birthSchedule when to return for consultation for post partum visits

Inform, teach and counsel the woman on important MCH messages:1st Visit 1st week post partum preferable 3-5

days2nd Visit

6 weeks post partum

Support to Breast FeedingMost mothers do not know the importance of breastfeeding. A support care groups like nurses have critical role to motivate them to practice breastfeeding.Family Planning CounselingProper counseling of couples on the importance of FP will help them inform on the right choice of FP methods, proper spacing of birth and addressing the right number of children. Birth spacing of three to five years interval will help completely recover the health of a mother from previous pregnancy and childbirth. The risk of complications increases after the second birth.ConclusionThe DOH has be eager to decrease the maternal mortality rate of the country and this program is a good example to that effort. This was adapted from the DOH book. Image is from here.

The family planning program

Family Planning

Brief Description of ProgramA national mandated priority public health program to attain the country's national health development: a health intervention program and an important tool for the improvement of the health and welfare of mothers, children and other members of the family. It also provides information and services for the couples of reproductive age to plan their family according to their beliefs and circumstances through legally and medically acceptable family planning methods.The program is anchored on the following basic principles.* Responsible Parenthood which means that each family has the right and duty to determine the desired number of children they might have and when they might have them. And beyond responsible parenthood is Responsible Parenting which is the proper ubringing and education of chidren so that they grow up to be upright, productive and civic-minded citizens.* Respect for Life. The 1987 Constitution states that the government protects the sanctity of life. Abortion is NOT a FP method:* Birth Spacing refers to interval between pregnancies (which is ideally 3 years). It enables women to recover their health improves women's potential to be more productive and to realize their personal aspirations and allows more time to care for children and spouse/husband, and;* Informed Choice that is upholding and ensuring the rights of couples to determin the number and spacing of their children according to their life's aspirations and reminding couples that planning size of their families have a direct bearing on the quality of their children's and their own lives.

E. Intended Audience:Men and women of reproductive age (15-49) years old) including adolescents

F. Area of Coverage:Nationwide

G. Mandate:EO 119 and EO 102

H. Vision:Empowered men and women living healthy, productive and fulfilling lives and exercising the right to regulate their own fertility through legally and acceptable family planning services.I. MissionThe DOH in partnership with LGUs, NGOs, the private sectors and communities ensures the availability of FP information and services to men and women who need them.J. Program Goals:To provide universal access to FP information, education and services whenever and wherever these are needed.K. ObjectivesGeneral:To help couples, individuals achieve their desired family size within the context of responsible parenthood and improve their reproductive health.Specifically, by the end of 2004:Reduce* MMR from 172 deaths 100,000 LB in 1998 to less than 100 deaths/100,000 LB* IMR from 35.3 deaths/1000 livebirths in 1998 to less than 30 deaths/1000 live births* TFR from 3.7 children per woman in 1998 to 2.7 chidren per womanIncrease:* Contraceptive Prevalence Rate from 45.6% in 1998 to 57%* Proportion of modern FP methods use from 28>2% to 50.5%L. Key Result Areas1. Policy, guidelines and plans formulation2. Standard setting3. Technical assistance to CHDs/LGUs and other partner agencies4. Advocacy, social mobilization5. Information, education and counselling6. Capability building for trainers of CHDs/LGUs7. Logistics management

8. Monitoring and evaluation9. Research and developmentM. StrategiesI. Frontline participation of DOH-retained hospitalsII. Family Planning for the urban and rural poorIII. Demand Generation through Community-Based Management Information SystemIV. Mainstreaming Natural Family Planning in the public and NGO health facilitiesV. Strengthening FP in the regions with high unmet need for FP: CAR, CHD 5, 8, NCR, ARMMVI. Contraceptive Interdependence InitiativeN. Major ActivitiesI. Frontline participation of DOH-retained hospitals* Establishment of FP Itinerant team by each hospital to respond to the unmet needs for permanent FP methods and to bring the FP services nearer to our urban and rural poor communities* FP services as part of medical and surgical missions of the hospital* Provide budget to support operations of the itenerant teams inclduing the drugs and medical supplies needed for voluntary surgical sterilization (VS) services* Partnership with LGU hospitals which serve as the VS siteII. Family Planning for the urban and rural poor* Expanded role of Volunteer Health Workers (VHWs) in FP provision* Partnership of itenerant team and LGU hospitals* Provision of FP servicesIII. Demand Generation through Community-Based Management Information System* Identification and masterlisting of potential FP clients and users in need of PF services (permanent or temporary methods)* Segmentation of potential clients and users as to what method is preferred or used by clientsIV. Mainstreaming Natural Family Planning in the public and NGO health facilities* Orientation of CHD staff and creation of Regional NFP Management Committee* Diacon with stakeholders* Information, Education and counseling activities* Advocacy and social mobilization efforts

* Production of NFP IEC materials* Monitoring and evaluation activitiesV. Strengthening FP in the regions with high unmet need for FP: CAR, CHD 5, 8, NCR, ARMM* Field of itinerant teams by retained hospitals to provide VS services nearer to the community* Installation of COmmunity Based Management Information System* Provision of augmentation funds for CBMIS activitiesVI. Contraceptive Interdependence Initiative* Expansion of PhilHealth coverage to include health centers providing No Scalpel Vasectomy and FP Itenerant Teams* Expansion of Philhealth benefit package to include pills, injectables and IUD* SOcial Marketing of contraceptives and FP services by the partner NGOs* National Funding/SubsidyVIII. Development /Updating of FP CLinical StandardsIX. Formulation of FP related policies/guidelines. E.g. Creation of VS Outreach team by retained hospitals and its operationalization, GUidelines on the Provision of VS services, etc.X. Production and reproduction of FP advocacy and IEC materialsXI. Provision of logistics support such as FP commodities and VS drugs and medical suppliesO. Other Partners1. Funding Agencies* United States Agency for International Development (USAID)* United Nations Funds for Population Activities (UNFPA)* Management Sciences for Health (MSH)* Engender Health* The Futures Group2. NGOs* Reachout foundation* DKT* Philippine Federation for Natual Family Planning (PFNFP)* John Snow Inc. - Well Family Clinic* Phlippine Legislators Committee on Population Development (PLPCD)* Remedios Foundation* Family Planning Organization of the Philippines (FPOP)* Institute of Maternal and CHild HEalth (IMCH)* Integrated Maternal and CHild Care Services and Development, Inc.

* Friendly Care Foundation, Inc.* Institute of Reproductive Health3. Other GOs* Commission on Population* DILG* DOLE* LGUs

EXPANDED PROGRAM OF IMMUNIZATION

“To Reduce morbidity and Mortality against 7 childhood Immunizable diseases.” (Tuberculosis, Diptheria, Pertusis, Tetanus, Poliomyelitis, Measles, and Hepatitis B.)Established here at Philippines by Pres. Marcos on the month of July, 1976 PRINCIPLES:1. The program is based on epidemiological situation; schedules are drawn on the basis of the occurrences and characteristics features of the said diseases.2.The whole community rather than just an individual is to be protected, thus, mass approach is applied. 3. Immunization is a basic health service and as such, it is integrated into the health services provided for by Rural Health Unit. Immunization – is a process by which vaccines are introduce to the Body, before infectious sets in. ELEMENTS

1.Target Setting – (0 – 12 mos.) 2. Cold chain Management (for vaccine life span and utilization)3. Information, education and communication3 Reasons:a. For parents, to be motivated to submit their child to immunizationb. To provide health teachings on benefits and importance of immunization4. Assessment and evaluation of the programs over all performance5. Surveillance, studies and research.EPI ROUTINE IMMUNIZATION SCHEDULE FOR INFANTS.

Side Effects of BCG:

1. Koch’s Phenomenon – acute inflammatory process starting with in 24 hrs. and may last for 2 – 4 days. Wheal must disappear in about 30 mins – 1hr. 2.Abscess formation – 1st week – soreness and inflammation, 2nd week – 11th week healing of abscess and ulceration. If there is no scar developed, Repeat the procedure3. indolent ulceration – a. wrong technique, b. exposure of infant to Pt. c activeTB.4. Glandular Enlargement – a. unsterile syringe or needle was used, b. too much vaccine was injected. C. the vaccine might be injected under the skin layer, and not instead in its superficial layer. Management: Physician may order, I and D, or Isoniazid.

Side Effects of Hepa B:1. Mild fever 1 -2 days, - a. Teach mother perform TSB b. advice mother that she may give Paracetamol every 4 hours if fever not relapse. Fever more than 4 days, refer to the Physician.2. Mild Pain, swell and redness. – a. Teach mother to do cold compress first before hot compress 1 – 3 times after injection then every 6 hours. Side Effects of DPT:1. Fever within 24 hours2. local soreness pain and swelling3. Abscess appears after a week or more due to wrong technique, 4. Convulsions is very rare, but may occur more in children above 3 months of age. This is due to the Pertussis virus component of the vaccine. – there are now available D and T only vaccines that may avoid convulsions of DPT.

Side effects for OPV: NONE: But be aware of possible risk for aspiration once wrong site is used. Make sure also that the baby was NPO 30 mins. prior administration, for him not to vomit once drops were administered.

Vaccine Minimum Ageat 1st Dose

Numberof Doses

Dose

Minimum Interval Betwee

Route Site Reason

n Doses

Bacillus Calmette-Guérin

Birth or anytime after birth

10.05 mL

-- Intradermal

Right deltoid region of the arm

BCG given at earliest possible age protects the possibility of TB meningitis and other TB infections in which infants are prone

Diphtheria-Pertussis-Tetanus Vaccine

6 weeks

30.5 mL

4 weeks

Intramuscular

Upper outer portion of the thigh

An early start with DPT reduces the chance of severe pertussis.

Oral Polio Vaccine

6 weeks

32-3 drops

4 weeks

OralMouth

The extent of protection against polio is increased the earlier the OPV is given.Keeps the Philippines polio-free.

Hepatitis B Vaccine

At birth 3 0.5 mL

6 weeks interval

Intramuscular

Upper outer portio

An early start of Hepatitis B

from1st dose to 2nd dose,8 weeks interval from2nd dose to third dose.

n of the thigh

vaccine reduces the chance of being infected and becoming a carrier. Prevents liver cirrhosis and liver cancer which are more likely to develop if infected with Hepatitis B early in lifeAbout 9,000 die of complications of Hepatits B. 10% of Filipinos have Hepatitis B infectio

Measles Vaccine(not MMR)

9 months

10.5 mL

--Subcutaneous

Upper outer portion of the arms

At least 85% of measles can be prevented by immunization at this age

Nutrition program

Vitamin A SupplementationPolicy on Vitamin A SupplementationProgram* The Philippine government is committed to virtually eliminate VAD* ECCD Law: DOH role is to ensure Vitamin A supplementation* Administrative Order No. 3-A, s. 2000: Guidelines of Vitamin A and Iron Supplementation * Therapeutic supplementation: all cases of VAD * Preventive supplementation:1. Universal - children 6-59 months2. Regular/routine - Pregnant and Lactating women, High-risk children 3. Supplementation during emergencies Vitamin A Supplementation » 3020 readsFood FortifcationThe Food Fortification program is the government's response to the growing micronutrient malnutrition, which is prevalent in the Philippines for the past several years.Food Fortification is the addition ofSangkap Pinoyor micronutrients such as Vitamin A, Iron and/or Iodine to food, whether or not they are normally contained in the food, for the purpose of preventing or correcting a demonstrated deficiency with one or more nutrients in the population or specific population groups.Sangkap Pinoy or micronutrients are vitamins and minerals required by the body in very small quantities. These are essential in maintaining a strong, healthy and active body; sharp mind; and for women to bear healthy children.

Nutrition surveys since 1993 have been showing increasing prevalence of micronutrient malnutrition, particularly that of Vitamin A Deficiency Disorder (VADD) and Iron Deficiency Anemia (IDA) among children and women of reproductive age, who are the most at-risk groups to micronutrient malnutrition.