Rh presentation day 1
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Transcript of Rh presentation day 1
Objectives of the Day
Have a general overview of Global trend of MMR
Describe the current Millennium Development Goals in relation to reproductive, maternal and child health.
Identify causes and contributing factors of maternal mortality and strategies for prevention
Explain the components of reproductive health, MISP and Comprehensive packages.
Getting to know you
Stand up if you have a RH service in your programmeRemain standing if that service includes:ANCSupport to skilled birth attendantsEmergency obstetric servicesFamily planningPost abortion careIntroduce yourself and why you are at the the
position you are at.
Activity
In pairs define on stick and stick on wall under heading.
Maternal death
Maternal mortality ratio
Maternal mortality rate
Reproductive health
Everything you know about the Milleniumdevelopment goals
Definition of Maternal Death
Maternal death is the death ofa woman while pregnant orwithin 42 days oftermination of pregnancy,irrespective of the durationand the site of thepregnancy, from any causerelated to or aggravated bythe pregnancy or itsmanagement, but not fromaccidental or incidentalcauses
Source WHO
Maternal mortality is defined asthe death of a woman whilepregnant or within 42 daysafter termination ofpregnancy from any causerelated to or aggravated bythe pregnancy or itsmanagement. This includesdeath as a complication ofabortion at any stage ofpregnancy
Source UNFPA
4
Maternal Mortality Ratio
Annual number of deaths of women from pregnancy related causes per 100,000 live births
( MDG ratio)
Maternal Mortality RateNumber of maternal deaths in a given period
per 100 000 women of reproductive age during the same time-period.
Millenium Development Goals
Why Who Where When What ?
Can you list them?
Why?
Millennium Declaration to eliviate poverty
Who?United Nations - 189 Member States
What?
The new international framework for measuring progress towards sustaining development and eliminating poverty.
8 Measurable goals to be reached by 2015 Eradicate extreme poverty and hungerUniversal primary education Promote gender equity and empower women Reduce child mortality by 2/3rds Reduce maternal mortality by 3/4 Combat HIV/AIDS malaria and other diseases Ensure environmental sustainability Global partnership for development
MDG5
Target
Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio
equivalent to an annual decrease of about 5.5 percent; and access to universal reproductive health care by 2015.
Achieve, by 2015, universal access to reproductive health
Indicators
Maternal mortality ratio
Proportion of births attended by skilled health personnel
Contraceptive prevalence rate
Adolescent birth rate
Antenatal care coverage (at least one visit and at least four visits)
Unmet need for family planning
9
MDG additional
the proportion of all births assisted by skilled attendants should
reach 90% globally
at least 60% in countries with high rates of maternal death.
MDG 4
Reduce by two
thirds the mortality rate
among children under five
Indicator
Under-five mortality rate
Infant mortality rate
Neonatal mortality rate
Proportion of births attended by skilled health personnel
Target
11
Definition of Reproductive Health
Reproductive health is a state of complete physical, mental and social well being and not merely the absence of disease and infirmity, in all matters relating to the reproductive system andto its functions and processes.
12
Right?
• In groups of four translate this in to a right
Reproductive Health Right
• Recognition of the basic right of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children and to have the information and means to do so, and the right to attain the highest standard of sexual and reproductive health.
• It also includes their right to make decisions concerning reproduction free of discrimination, coercion and violence”
• To have a satisfying and safe sex life, the capabilityto reproduce and the freedom to decide if when and how often to do so.
In summary
• A healthy, safe sex life
• Every pregnancy wanted and safe
• Every child wanted and healthy
• ( Line up progress against this in the country where you work)
Global Trend in MMR
16
Global Context
• 340,000 maternal deaths occur each year, 1000 maternal deaths per day, one every minute
• 8 million women suffer serious illness or disability ( 2 million obstetric fistulas).
• Decrease of 34% since 1990.
4 million newborns die each year
• Neonatal mortality rate countries has remained unchanged at about 30 deaths per 1000 live births.
• 19 of 68 priority countries on track for MDG 4
Access to modern contraceptives has increased 52 – 62% but is only 22% in SSA.
17
Maternal Mortality Ratio in 2005(per 100,000 live births)
18
Current status
99% of maternal deaths occur in developing countries, 65% in 11 countries 50% in fragile states
Roughly 50% maternal deaths occur in SSA and 30% in Asia
Maternal mortality ratio in developing countries is 450 maternal deaths per 100,000 live births
SSA is 824, Asia 329, Latin America132 9 in developed countries
The lifetime risk of death from maternal causes in sub-Saharan Africa is 1 in 16 South-East Asia 1 in 58 1 in 4000 in industrialized countries
Any thoughts on the 11 countries?
11 countries?
Afghanistan Bangladesh DRC Ethiopia India Indonesia KenyaNigeria Pakistan Sudan Tanzania
Global decline 1990 - 2008
MDG aims for a global decrease per year of 5.5% Currently the decline is 2.3%
90 countries = > 40% (Equatorial Guinea (–73%), Eritrea (–69%), Cape Verde (–58%), Ethiopia (–53%) and Rwanda (–51%)
67 countries = < 40% 5 countries = 0 change (S. Leone, Malawi, Angola, Niger,
Tanzania, Mali) 23 countries increased. (Botswana (133%), Zimbabwe
(102%), South Africa (80%), Swaziland (62%), and Lesotho (44%).
(CAUSES??)
Causes of maternal deaths
22
4 Too s
Too young
Too soon
Too many
Too old
Too Young Too Soon
50% deaths from unsafe abortion in Africa are in adolescents. (2003)
Children 10 – 15 years are x5 more likely to die in childbirth
15 – 19 yrs = x2 more likely.
More than 100 million mostly-curable sexually transmitted infections occur each year in young people aged 15 to 24.
50% new HIV infections occur in young people.
Too Many ( Too old)215 million women who wanted to are not using FP.
25% WCBA in SSA 75 million unintended pregnancies 44 million end in induced abortion.
Contraceptive use has increased in all developing regions,
Remains low in sub-Saharan Africa, 22%
Fertility rates have decreased. Remaining high in East and central Africa and in lowest quintiles in certain countries, Columbia, Philippines.
Abortion
Unsafe abortion = 75,000 deaths each yearHigh proportion of deaths in displaced camps45 million unintended pregnancies are
terminated each year 20 million women sought unsafe abortion. 40% of all unsafe abortions are performed on
young women aged 15 to 24. 1 in 5 women who have an unsafe abortion,
suffers a reproductive tract infection; some leading to infertility.
The Three Delays leading MM
First Delay - delay in deciding to seek care Late recognition, fear
of hospitals, cost, permission from decision maker
Second Delay –reaching care facility Bad infrastructure,
lack of transport, cost
Third Delay – obtaining care at health facility Poor staffing (few & lack of
training), fees, lack of blood, supplies & surgical capacity
27
Underlying causes
Access to ANC. In high MMR countries <30% women access ANC.
ANC 1 increased to 64 - 79%.
absence of skilled health personnel during childbirth,
lack of services able to provide emergency
obstetric care and deal with the complications of unsafe abortion, and
ineffective referral systems.
Skilled birth attendance
0
20
40
60
80
100
120
world N. Africa SSA S.America E. Asia S/. A C.Asia W. Asia D. Regions
1990
2007
Skilled birth attendance
60 million women give birth outside a health facility. 50 million without skilled care.
44% births attended by skilled health personnel in sub-Saharan Africa
42% in Southern Asia in 2007
skilled birth attendance at delivery has increased in all developing regions.
Medical causes
Too young Too soon Too many Too oldDelay to choose
care
Late recognition/ lack of
knowledge
Delay to reach care
Poor infrastructure
Delay to obtain care
Lack of skilled birth attendance
Strengthening Health Systems
Health workforce
Service delivery
Leadership/governance
Financing
Medical products
Information
Improved health
Improved efficiency
Social and financial risk
Responsiveness
Overall goals/outcomesSystem building blocks
Access
Coverage
Quality
Safety
The WHO health system framework (WHO, 2007)
HR
Mainly in Africa, shortages estimated at 2.4 million doctors, nurses and midwives.
WHO countdown to 2015 – 341000 midwives, nurses, doctors are required by 2015.
The shortage is especially acute in countries characterized with high MMR and high TFR, which typically have fewer health personnel
The percentage of births attended by qualified health personnel is also low in these countries relative to other groups of countries
Lack of Investment
Maternal health has not emerged as a political priority.
Unintended loss of focus on family planning services within the broader ICPD agenda
HIV/AIDS-related expenditure prioritized at the expense of RH
Underlying causes
• Trends in female literacy
• Trends in female empowerment
• The five countries with the lowest female literacy rates (Afghanistan, Niger, Chad, and Mali) all have maternal mortality ratios (MMR) over 800 deaths per 100,000 live births.
• Afghanistan
• Only 13% of women can read, compared to 43% of men
Raise study on ODA 2003 - 6
$20.8 billion disbursed to 18 conflict-affected
countries,
2.4%, was allocated to RH. This translates to $1.30 per capita per year.
1.7% was disbursed to support family planning activities
46.7% to support HIV/AIDS control efforts.
Countdown to 2015
MMR high or very high in 56 of 68 countries
Gaps:
1. contraceptive availability & uptake,
2. skilled birth attendance,
3.management of newborn &childhood
illness
4. equity gap
37
Key Initiatives CEDAW Convention on the Elimination of Discrimination Against
Women ( 1981) Save Motherhood Initiative ( 1987) ICPD Programme of Action of the 1994 International Conference for
Population and Dev. Status of Women Bejing Declaration 1995 Millenium declaration (2000) Partnership for Maternal, Newborn, and Child Health (PMNCH)
(2007) UN Joint Statement on Maternal and Neonatal Health (UN-
MNH/H4) ( 2009) UNHRC 2010 Resolution on maternal health. Musoka Alliance G8 summit Canada (2010) Global Alliance (2010)
CEDAW Convention on the Elimination of Discrimination
National policies ensure equality of men and women, of human rights and fundamental freedoms in the political, economic, social, cultural, civil or any other field.
the obligation to eliminate discrimination at all levels of the educational system
Safe Motherhood
All women have access to contraception to avoid unintended pregnancies
All pregnant women have access to skilled care at the time of birth
All those with complications have timely access to quality emergency obstetric care
World Bank, WHO and UNFPA consensus that a majority of maternal deaths and morbidity could have been prevented with access to simple interventions
40
ICPD Programme of Action of the 1994 International Conference for Population & Dev.Status of Women Bejing Declaration 1995
Strong emphasis on womens rights and equity
Female education
Protection for female children
Sexual and reproductive health rights
Family planning and it’s relationship to MMR.
Partnership for Maternal, Newborn, and Child Health (PMNCH)
Evidence based high impact intervention to reduce maternal , child and neonatal mortality
To raise $30 billion to support this over two years
Partnership of governments, NGOs and academic institutes, private and government donors.
UN Joint Statement on Maternal and Neonatal Health (UN-MNH/H4)
WB, UNFPA, UNICEF, and WHO, are working with country governments to ensure that core interventions for addressing maternal and neonatal health are addressed within the national health plans.
World Bank (2009), Implementation of the World Bank’s Strategy for Health, Nutrition and Population (HNP) results: Achievements, Challenges and the Way Forward, Washington DC: World Bank
Manifesto For Motherhood Coalition
2009 UK gov. and global partners signed a global consensus:
Every birth safe, every newborn and child healthy .
Muskoka Initiative
From G8 summit Canada.
Member states commit an additional $5 billion between 2010 and 2015 to accelerate progress toward the achievement of goals 4 and 5.
focussing in the countries with the greatest needs while continuing to support those making progress;
supporting country-led national health policies and plans that are locally supported;
High MMR countries
health system strengthening unmet need for family planning. comprehensive, high impact and integrated interventions at the
community level, across the continuum of care, sexual and reproductive health care and services, including
voluntary family planning; health education; treatment and prevention of diseases including infectious diseases; prevention of mother-to-child transmission of HIV; immunizations; basic nutrition and relevant actions in the field of safe drinking water and sanitation.
Global Alliance
Public Private partnership Gates Foundation, USAID, DFID, AUSAID.
5 year commitment to
Increased family planning
Skilled birth attendance
DFID Framework for Results 2011
save the lives of at least 50,000 women in pregnancy and childbirth and 250,000 newborn babies by 2015 enable at least 10 million more women to use
modern methods of family planning by 2015, contributing to a wider global goal of 100 million prevent more than 5 million unintended
pregnancies support at least 2 million safe deliveries, ensuring
long lasting improvements to maternity services, particularly for the poorest 40%.
Pillar 1 Empower women and girls to make healthy reproductive choices
Pillar 2 Remove barriers that prevent access to services, particularly for the poorest and most at risk.
Pillar 3 Expand the supply of quality services
Pillar 4 Enhance accountability for results at all levels
Political & legal framework
Financial barriers Service coverage Data and information
Girls education Innovative transport & referral
Human resources Accountability between citizens & providers
Economicopportunity
Discrimination.Adolescent friendly
commodities Accountability for quality
Social change Support in emergencies ( conflict natural disaster)
QA International agencies accountable for outcome
Gilrs and womens’ wider action
Diversity of providers
Information
DFID’s Focus
Prioritizing RMNH
Adolescent health focused on pregnancy prev.
EOC services
Family planning
Maternal nutrition
Poverty reduction
What services?
The five core aspects of reproductive and sexual health are:
1. improving antenatal, perinatal, postpartum and newborn care;
2. high-quality services for family planning, including infertility services;
3. eliminating unsafe abortion; 4. combating sexually transmitted infections including
HIV, reproductive tract infections, cervical cancer and other gynaecological morbidities;
5. promoting sexual health.
Services through a Mortality Lens
Antenatal, childbirth and postpartum services attendance at every birth of skilled health personnel and
comprehensive emergency obstetric care to deal with complications effective referral systems PMTCT abortion services at primary health care level. For those women who suffer complications of unsafe
abortion, prompt and humane treatment through post-abortion care
Family planning STI SGBV
A full sexual and reproductive health package
includes:
Family planning/birth spacing services
Antenatal care, skilled attendance at delivery, and postnatal care
Management of obstetric and neonatal complications and emergencies
Prevention of abortion and management of complications resulting from unsafe abortion
Prevention and treatment of reproductive tract infections and sexually transmitted infections including HIV/AIDS
Early diagnosis and treatment for breast and cervical cancer
Promotion, education and support for exclusive breast feeding
Prevention and appropriate treatment of sub-fertility and infertility
Active discouragement of harmful practices such as female genital cutting
Adolescent sexual and reproductive health
Prevention and management of gender-based violence
Source UNPFA
53
CMR
• to reduce by two thirds, between 1990 and 2015, the under-five mortality rate;
• Perinatal mortality
• Neonatal mortality
• Child mortality
Trends
10.8 million deaths worldwide of children under five each year 4 million during the first seven days of the
neonatal period. 2.7 million infants are stillborn. Neonatal mortality rate (death in the first 28
days) in developing countries has remained unchanged since the early 1980s at about 30 deaths per 1000 live births.19 of 68 priority countries on track for MDG 4
Causes of neonatal mortality
Preterm, 25%
Asphyxia, 24%
Tetanus, 6%
Diarrhoea, 4%
Congenital, 6%
Other, 7%
Sepsis/
pneumonia,
28%
Source: Opportunities for Africa’s Newborns, 2006. Based on vital registration for one country and updated modeling using the CHERG neonatal methods for 45 African countries using 2004 birth cohort, deaths and predictor variables.
56
Proven community interventions
Immunization Vit. A + zinc Promotion of breastfeeding and advice on weaning Hygiene promotion Promotion of clean delivery Tx of childhood pneumonia, malaria, diarrhoea Homebased neonatal care IPT malaria for women and infants Iodine supplementation Diagnosis and tx of syphilis PMTCT
DFID MNH interventions
Community based management of neonatal pneumonia Community newborn package TT2 ANC Skilled birth attendance Treatment of pre-eclampsia Emergency neonatal care Steroids for preterm birthManagement of maternal sepsis Antibiotics for premature rupture of membranes PPH management.
Further evidence required
Positive deviance for malnutrition
Prenatal calcium
Neonatal cord care with antiseptic
Neonatal resuscitation
Ice breaker
• Find out who has made the longest journey?
• Who has the best dinner plans?
• Who has the most unusual hobby?
• Find the weirdest thing anyone has eaten?
• Who knows what 'Ephebiphobia ' is a fear of?
12 January 2010
HAITI
Background In 2007 the population of Haiti was 9.7 million. Poorest country in the western hemisphere, Ranks 149/182 on the UNDP Human Development Index
2007. 55% of the population lived in households that were below
the extreme poverty line of US$ 1 per person per day. Annual population growth rate during 1995-2000 was 2.1%. 64% pop. live in the countryside, 21 % in the metropolitan
area of Port-au-Prince , and 15% in other urban areas. Progressive urbanization without corresponding employment and government systems has led to a high level of urban slum, gang culture and management of areas , criminal activity and violence.
The main income in cities is small business, service and manual labour in urban areas and in rural areas agriculture rice and bananas and small business.
A sizable percentage of professionals and qualified technicians contribute to the Haitian diaspora ,
Monthly remittances sent to families in Haiti account for 8.3% of household income.
Water and sanitation are major issues in Haiti, with 45% of the population lacking access to safe water in 2009 and 83% of Haiti’s total population without access to improved sanitation (WHO/CCS).
In 2007, 47% of the population lacked access to basic health care, with the majority of the population seeking care from traditional healers.
An estimated 40% of households experience food insecurity, manifested by low birth weight and nutrient deficiencies.
Adolescents
Adolescents 40% pop is < 15 years old, and only 5% is over 65. Adolescents and youth accounted for 8% of the deaths in the country. HIV/AIDS was the leading cause of death in this age group (5.8% of all certified deaths). Among the 10 leading specific causes of death on this population group were:• assault and homicide, • tuberculosis, • typhoid, • causes related to maternity (35/ 100,000 maternal deaths in the age group 10-24 years in 1999).
The fertility rate in girls aged 15-19 years was 80 per 1,000 in 2000. The prevalence of sexually transmitted infections in adolescent males 15-19 years old was 9.9%. In one survey, 18% of the females and 33% of males stated that they had used a condom in their
last sexual encounter. Violence and sexual abuse are very frequent in this population group (70% of adolescent girls and
women have been exposed to violence of some sort).
Maternal Health The maternal mortality rate in 2000 was 523 per 100,000 live
births, a 15% increase relative to 1995.
Maternal causes of death included problems related to arterial hypertension and eclampsia , as well as complications of labor.
78% pregnant women had prenatal checkups with a health professional in the cities but 40% in rural areas.
Adults (20-59 years): The fertility rate is in decline, estimated at 4.4 children per woman in 2009.
The crude birth rate 33 per 1,000 population
Of all women with a regular partner in 2000, 22% were using a modern method of contraception and 5.8% a traditional method.
HIV AIDS
An estimated 120 000 people in Haiti are living with the virus
47 health centres (7%) providing antiretroviral treatment in Haiti, with over 19 000 undergoing treatment with antiretroviral treatment (ART).
HIV/AIDS infection affects 4.5% of the Haitian population.
Every year there are some 13,000 pregnant women who are HIV-positive,
NUTRITION
Recent surveys found an acute malnutrition rate of 12% and severe malnutrition of 2.5% No studies on PLW.
Prevalence of anaemia is reported high, 30 – 50% in studies in pregnant women and 30% in school age children.
A 1997 study of household and maternal determinants of vitamin A and iron status showed severe stunting in 31% of the sample, and wasting in 4%.
In 2000, the prevalence of exclusive breast-feeding for 0-5 months was 49%.
Health Services
The Ministry of Public Health and Population encompasses 10 national bureaux
4 coordinating units, addressing infectious and communicable diseases, EPI, nutrition, and hospital safety.
49 hospitals 371 health posts, 217 health centres coverage of health services was estimated at only about
40% nationally In 2009, there were >250 additional implementing partners
in the health sector, further challenging health coordination (WHO/CCS).
Hospital and clinical facilities in Port-au-Prince have long been compromised by infrastructural deficiencies, electrical blackouts, water problems, and general impoverishment.
HRH
Haiti, before the earthquake, had the lowest number of health workers per population (2.5/1000 population) and the lowest ratio of nurses to physicians (1 to 1.4) of any country of the Americas. 5.9 doctors/nurses , 6.5 health professionals per 10,000 people.
There are considerable rich-poor discrepancies (especially regarding deliveries in safe settings)
The lack of access in rural as opposed to urban areas is high, including the lack of motorised transport
Community participation in health care is limited
Earthquake!
Stats
230,000 deaths
Population displacement, 3 million
1.6 million in 250 camps in Port au Prince
Grand Goave & Petit Goave
4000 amputees
Destroyed 8 hospital 200 health centres, school of nursing and midwifery.
60% health centres and health posts in affected areas.
One of the three midwifery schools
One nursing school were destroyed.
14% of the health workforce died,
4000 health workers were homeless.
Transport very difficult roads are blocked,
fuel prices high ambulance services are operational but limited and arrival times are long
300 camps in urban areas, not all are covered for basic services.
Communities are managed by urban gangs community involvement is ad hoc.
Rural areas difficult to reach
Humanitarian response
• Strong health and nutrition cluster coordination
• 400+ members mean that coordination is very difficult. Not all members are aware of humanitarian reform.
• 20 field hospitals for surgical and general care
• A number of agencies are providing mobile clinic services but mainly in Port au Prince and no-one knows for how long
The Main PMC Diagram
88
In groups
Goal
Specific objectives
Results
The Minimum Initial Service Package
(MISP)
“All migrants, refugees, asylum
seekers and displaced persons
should receive basic education and
health services”
Impact of conflict on women’s health
Increase maternal deaths– DRC mortality survey (2005) showed maternal
mortality ratio 1,174 per 100,000 live births in eastern Congo vs 811 in western Congo1
Increase in abortionUNFPA estimates that unsafe abortion
contributes between 25 and 50% of maternal deaths in conflict affected settings
Increase in levels of Gender Based Violence, including intimate partner violence
Family planning needs not met
–Unmet need for family planning in IDP camps in northern Uganda is 58%, compared to national average of 40.6%
Data on effect of conflict on HIV are equivocal
–No clear effect of conflict or displacement on HIV prevalence5
MISP
Minimum
Initial
Service
Package
Basic, limited RH
for use in emergency, without site-specific needs assessment
services to be delivered to the population
supplies and activities, coordination and planning
93
Minimum Initial Service Package
Prevent sexual violence and assist
survivors
GOALDecrease mortality,
morbidity and disabilityin crisis affected
populations
Reduce transmission of HIV
Prevent excess maternal and newborn morbidity and
mortality
Plan for integrated comprehensive
RH services
Ensure health cluster/sector
identifies lead RH agency
Service Package
Outreach system for SGBV and obstetric care Clinical care of survivors of SGBV or referral. Standard precautions Safe blood transfusion Condoms Clean delivery kits, skilled delivery. Access to BMONC & EONC services. ANC PNC STI + ARV + PMTCT FP Post abortion care Safe abortion care
IFM RH Principles
CoordinationQuality of careCommunicationCommunity participationTech. and managerial capacityAccountability Human RightsAdvocacy
Coordination
Health Cluster system
RH lead agency
RH Officer.
RH working group
Gender working group
HIV working group
Quality of Care
Service coverage ( facilities, HR, Drugs and Equipment)
Adherence to protocols
Quality info to beneficiaries.
HIS + ANALYSIS
Beneficiary feedback
Communication and Community Participation
• Info on service provision
• Key messages on prevention
• Campaigns
• Client counseling
Technical and Managerial capacity Building Accountability Advocacy
Train
Supervise
Monitor
Evaluate
HIS
HAP
Back to Haiti – Aceh Camp
Urban camps
50,000 people in urban area
Poor housing conditions, crowded, managed by
urban gangs
Exposed areas
Mobile clinic urban areas
Rural villages Petit Goave
Six mobile clinics 12 sites.
Priorities for MISP services.
Urban
Rural areas.
• Community Participation
• Male and female community health workers
• TBAs.
• Womens’ groups
• Youth groups
• Communtiy elders.
• Local NGOs.
Key intervention/s per cause
Bleeding
Infection
Eclampsia
Obstructed labour
Unsafe abortion
Indirect Causes
Oxytocin /misoprostol,mannual compression
Antibiotics Tetanus toxoid
Mag. Sulphate
Partograph CEOMC
Family planning
Iron, ITNs IPTp
113