SKILLED CARE DURING PREGNANCY

Millennium Development Goal 5 (MDG 5), improve maternal health, set the targets of reducing maternal mortality by 75% and achieving universal access to reproductive health by 2015. But, so far progress in reducing mortality in developing countries and providing family planning services has been too slow to meet the targets. -

- Every pregnancy should be wanted.- All pregnant women and their infants

should be able to access and receive skilled care.

- All women should be able to reach a functioning health facility to obtain appropriate care for themselves or their newborns when complications arise during pregnancy, delivery or the postpartum period.

- Safe pregnancy, childbirth and motherhood are basic human rights.

KEY MESSAGES OF MAKING PREGNANCY SAFER

10 FACTS ON MATERNAL HEALTH

Worldwide, 1000 women die every day due to complications during pregnancy and childbirth - up to 358 000 women per year. In developing countries, conditions related to pregnancy and childbirth constitute the second leading causes (after HIV/AIDS) of death among women of reproductive age.

Four main killers cause around 70% of maternal deaths worldwide: Bleeding after delivery can kill even a healthy wosevere bleeding, infections, unsafe abortion, and hypertensive disorders (pre-eclampsia and eclampsia).man, if unattended, within two hours. Most of these deaths are preventable.

FACT 2

More than 136 million women give birth a year. About 20 million of them experience pregnancy-related illness after childbirth. The list of morbidities is long and diverse, and includes fever, anemia, fistula, incontinence, infertility and depression. Women who suffer from fistula are often stigmatized and ostracized by their husbands, families and communities.

FACT 3

Fact 4About 16 million girls aged between 15 and

19 give birth each year, accounting for more than 10% of all births. In the developing world, about 90% of the births to adolescents occur in marriage. In many countries, the risk of maternal death is twice as high for an adolescent mother as for other pregnant women.

FACT 4

Fact 5The state of maternal health mirrors the gap

between the rich and the poor. Only 1% of maternal deaths occur in high-income countries. A woman's lifetime risk of dying from complications in childbirth or pregnancy is an average of one in 120 in developing countries and compared to one in 44 300 in developed countries. Also, maternal mortality is higher in rural areas and among poorer and less educated communities. Of the 1000 women who die every day, 570 live in sub-Saharan Africa, 300 in South Asia and five in high-income countries.

Fact 6Most maternal deaths can be prevented

through skilled care at childbirth and access to emergency obstetric care. In sub-Saharan Africa, where maternal mortality ratios are the highest, only 46% of women are attended by a trained midwife, nurse or doctor during childbirth.

FACT 6

Fact 7In developing countries, the percentage of

women who have at least four antenatal care visits during pregnancy ranges from 34% for rural women to 67% for urban women. Women who do not receive the necessary check-ups miss the opportunity to detect problems and receive appropriate care and treatment. This also includes immunization and prevention of mother-to-child-transmission of HIV/AIDS.

FACT7

Fact 8About 18 million unsafe abortions are carried

out in developing countries every year, resulting in 46 000 maternal deaths. Many of these deaths could be prevented if information on family planning and contraceptives were available and put into practice.

FACT 8

One target of the Millennium Development Goals (MDGs) is to reduce the maternal mortality ratio by three quarters between 1990 and 2015. So far, progress has been slow. Since 1990 the global maternal mortality ratio has declined by only 2.3% annually instead of the 5.5% needed to achieve MDG 5, aimed at improving maternal health.

FACT 9

The main obstacle to progress towards better health for mothers is the lack of skilled care. This is aggravated by a global shortage of qualified health workers. By 2015 another 330 000 midwives are needed to achieve universal coverage of mothers with skilled birth attendance.

Fact 10

Evidence from the historical record suggests that the

care during childbirth and reducing maternal mortality.

Each can be adapted to local as well as national

settings, and additional interventions (such as

strengthening referral systems) may also be necessary.

following are effective strategies for increasing skilled

> Recognising the magnitude of the problem

of maternal mortality and acknowledging that most

maternal deaths are avoidable;

> Making a political commitment to reducing

maternal mortality, and putting in place legislation that

facilitates skilled care during childbirth for all women;

>

CONT........

Professionalising midwifery practice andensuring that midwives are (and are seen by

the publicas) competent professionals, through adoption of effective systems of supervision and accountability

Incorporating key life-saving medical skillsinto midwives’ scope of practice; and Ensuring availability of funding for skilled careat all births, along with needed supplies and equipment

CONT........

> Recognising the magnitude of the problemof maternal mortality and acknowledging that mostmaternal deaths are avoidable;> Making a political commitment to reducingmaternal mortality, and putting in place legislation thatfacilitates skilled care during childbirth for all women;> Professionalising midwifery practice andensuring that midwives are (and are seen by the publicas) competent professionals, through adoption ofeffective systems of supervision and accountability

CONT.........

> Working with communities to create knowledge

on maternal health issues, and strengthening their

ability to make and act on decisions regarding

their health, including the use of health services;

> Ensuring effective, community-based systems of

transport, communication, and referral; and> Establishing and maintaining a well-

functioning,well-equipped, and extensive health care

system.

holistic approach toreducing maternal mortality

During, pregnancy a skilled attendant should be able to Monitor the health of the woman and fetus

provide preventive and curative care for common illnesses such as anaemia, sexually transmitted diseases,urinary tract infections, and malaria, as well as providetetanus toxoid immunisation;

Educate clients about danger signs and offer guidance in planning for the delivery.

Essential Competencies of Skilled Attendants

financing universal coverage of skilled care, it is critical that governments: > Ensure access to care for all, especially the very poor (e.g., through subsidies for the poor that cover the costs of public or private care they cannot afford); > Identify areas for cost savings based on countryspecific figures, and use cost estimates to select the most cost-effective interventions;

Cont..........

> Ensure regular payment of salaries in the publicsector, since experience has demonstrated that healthworker motivation and incentives are key to ensuringthe quality and sustainability of health care services;

Explore the range of options for more equitableand sustainable financing of skilled care and maternalhealth services, pilot-test new mechanisms (beforeimplementing them nationally), and promote moreeffective implementation of current financing

methods.

Cont.........

Supportive policies, laws, and regulations that make safe motherhood a priority; Authorise healthprofessionals, including midwives, to

carry out all life-saving interventions in which they are

proficient;and counter the range of barriers women face in

accessing care; Effective health system infrastructure, adequate equipment and supplies and systems ofreferral, communication, and transort;

Laws, Policies, and Infrastructure

> Professional associations that promote thevelopmdeent of skilled attendants through

shapingpolicy and protocols, establishing standards of

practiceand core competencies, and facilitating

communicationand information exchange; and> Quality education and supervision systems thatoffer pre-service and continuing (or in-service)

education,and provide a mechanism for support

CONT.............

Incidence of partograph use to measurethe progress of labour, which can be a good indicatorof the quality of care, especially during longand obstructed labours.

Client satisfaction and preferences for care,measured through qualitative approaches like clientinterviews and focus groups.

quantitativemeasurement instruments have been developedand used to assess client satisfaction, no consistentapproach has been developed due to the complexitiesof measurement involved.

INDICATORS OF QUALITY OF SKILLED CARE

> Staff skills and satisfaction, which assessproviders’ clinical skills, experience, training,and communication abilities, along with work

hoursand salaries—all important inputs to qualitycare provision. Measurement of these factors ischallenging: many indicators will be neededto assess the strengths and weaknesses of

services

CONT...............

Two audit approaches currently being tested

In “near-miss audits”,cases of severe, lifethreatening

complications(rather than deaths) arereviewed in hospitals bya team of midwives,doctors, social workers,and administrators.

Audit: A Non-Indicator Approach

2. Criterion-based audits involve the development

of a list of criteria for good quality care. Case notes

Cont.........

Saving Women’s Lives, Improving Newborn Health

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