·(WP)RPH/TCP/RPH/002-E

Report series number: RS/2000/GE/OS(PHL) English only

REPORT

WORKSHOP ON MATERNAL MORTALITY REDUCTION IN SELECTED COUNTRIES IN THE WESTERN PACIFIC REGION

Convened by:

WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC

and co-sponsored by:

UNITED NATIONS INTERNATIONAL CHILDREN'S FUND

Manila, Philippines 29 May -· 2 June 2000

Not for sale

Printed and distributed by:

World Health Organization Regional Office for the Western Pacific

Manila, Philippines

January 200 I

NOTE

The views expressed in this report are those of the participants in the Workshop on Maternal Mortality Reduction in Selected Countries in the Western Pacific Region.

This report has been prepared by the World Health Organization Regional Office for the Western

Pacific tor governments of Member States in the Region and f(H· those who participated in the

Workshop on Maternal Mortality Reduction in Selected Countries in the Western Pacific Region,

which was held in Manila, Philippines from 29 May to 2 June 2000.

SUMMARY ...... ...... ... ... ..... ... ..... ................ .. .... ...... ...... ...... ....... .. ...... ....... ..... ... ..... ........ .. ............ .. 1

I . INTRODUCTION .. ......... .... .... ........ ............. .... ... .... .. ............... ... .. ............. .... ....... ... ..... .... ..... 2

1.1 . Objectives ofthe workshop .......................... ........... ......................... ........ ............ , .. ...... 2 1.2 Participants and resource persons ................... ..... ... .... .. ............. .............. ....... ........... .. 2 1.3 . Organization ... .......................... ... .... .. ..... ... ... .. ......... .. .......... .. ........................... .... ... .... .. 2 1.4 Opening ceremony ....................... ......... ........... .... .. .. ..... .. .................. ... .... ....... .. ..... ...... . 3

2. PROCEEDINGS ....... .. ............... .. ... ...... .. ...... ............ ..... ... .... ..... .... .... ... .. .. ... ................. ... ...... ]

2.1 Summary of presentations .... .................... .......... .... ....... .. .... ... ....... ..... ............ ..... ... .... .. . 3 2.2 Summary of country repmts .... .. .... ...... ... ...... ... .... ..... .. ......... ........ ..... ... ....... ...... .... .. ... .... 7 2.3 Summary of discussions ............ .................. .. ........ ...... ......... .. ...... .. ......... ... ... .... ..... .. .. .. . 9 2.4 Evaluation of the workshop .............. .. .... .............. ....... .... .. ........... .............................. I 0

3. CONCLUSIONS .... ...... .... .. .. .. ....... .. .... .......... .... ... .. ... ..... ... .... ... .... ... ... ... ... .... ... ... ............ .. ... I 0

ANNEXES:

ANNEX I - LIST OF PARTICIPANTS, CONSULTANT, TEMPORARY ADVISERS, OBSERVERS AND SECRETARIAT ...... ............. ... .... .. ..... 13

ANNEX 2 - AGENDA ............................. .... .. .. ....................................... ..... ... .............. 23

ANNEX 3 - OPENING REMARKS BY THE REGIONAL DIRECTOR rOR WHO REGIONAL DIRECTOR. DR SHIGERU OMI .... .. .............. 25

ANNEX 4 - DRAFT PLANS OF ACTION OF THE COUNTRIES .............. .......... .... _7

Keywords:

Maternal mortality I Maternal welfare I Western Pacitic

SUMMARY

There are approximately 600 000 women who arc estimated to die due to complications in childbirth and about 50 000 of these deaths are in the Western Pacific Region. There is a marked difference in maternalmmtality ratios (MMR) in the countries of the Region. For instance. the Lao People's Democratic Republic has one ofthe highest ratios of650 per 100 000 live births while Singapore has one of the lowest with only 4 per 100 000 live births. The maternal mottality refl ects a woman's basic health status, her access of health care and the quality of care that she receives. To support the countries in reducing maternal mortality, the WHO Regional Office for the Western Pacific held a workshop in Manila from 29 May to 2 June 2000. The countries selected for the workshop had the highest maternal mortality ratios in the Region. They were Cambodia, China. the Lao People's Democratic Republic, Mongolia, Papua New Guinea, the Philippines and VietNam . The goal ofthe workshop is to enable the countries to reduce maternal mortality by 30% by 2003 from the 1998 levels. The meeting was co-sponsored by UNICEF and other agencies like UNFPA, ADB and GTZ had also close working cooperation.

The objectives of the workshop were to:

(1) review the status of maternal health in participating countries;

(2) identify factors, which contribute to high maternal deaths;

(3) analyse their own country situations as regards the activities and interventions to promote safe motherhood:

( 4) update the participants on different strategies and programmes to reduce maternal mortality; and

(5) draft a national plan of action to reduce maternal mortality by year 2005 .

There were 29 participants from the seven countries. Several papers were presented by resource persons to update the participants on new strategies in maternal health. The country representatives then presented their reports as well as described their experiences on cettain issues like political commitments, community patticipation, etc. The major causes of maternal mortality are still PPH, eclampsia, sepsis. obstructed labour. malaria and anaemia. The main problems in most of the countries are budget constraints, inadequate political commitment, lack of drugs and equipment, lack of training, poor infrastructure, poor communications and low community involvement. The countries have several ongoing projects to reduce MMR. Their main aim in the workshop was to find out what needed to be done further to develop a Plan of Action so that representatives from international agencies could work on the programmes in the future. Agencies such as UNICEF, UNFPA, and ADB presented their roles and functions to help the countries. At the end of the workshop, the participants agreed on some major issues. One of the major conclusions is the formation of a network among the countries to exchange ideas and experiences to further reduce the mortality in each of the countries. For the network to function. each of the participating country will have to have a focal point and WHO will assist in this network to update information regularly.

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I. INTRODUCTION

A joint workshop organized by the WHO Regional Office for the Western Pacific Region

and UNICEF was held in Manila from 29 May to 2 June 2000. Seven countries with high

maternal mortality ratios attended the workshop. The countries are Cambodia, China, the Lao

People's Democratic Republic, Mongolia, Papua New Guinea, the Philippines and VietNam.

The workshop also received support and cooperation from UNFPA, ADB and GTZ.

1.1 Objectives:

General objective

The general objective of the workshop was to support priority countries in reducing

maternal mor1ality ratios ofthc 1998 levels by 30% by the year 2003.

Specific objective

After the workshop the participants:

(I) reviewed the status of maternal health in participating countries;

(2) identified factors which contributed to high maternal deaths;

( 3) analysed their own country situations as regards the activities and interventions to

promote safe motherhood;

( 4) were updated on the different strategies and programmes to reduce maternal

mortality; and

( 5) drafted national plans of action to reduce maternal mor1ality.

I .2 Participants and resource persons

The workshop was attended by 29 participants from the seven countries, I short-term

consultant, 2 temporary advisers, 6 representatives from UNICEF and UNFPA, 4 observers from

ADB, 2 resource persons and 9 Secretariat members from WHO, UNICEF and UNFPA. The

Director General of Health from Cambodia, Professor Eng Huot, was elected Chairman,

Professor Tran Thi Phoung Mai, Deputy Director of Maternal and Child Health/Family Planning

li·om VietNam the Vice-Chairperson and Dr Mathias Sapuri, Acting Dean from the Medical

School of Papua New Guinea, was elected Rapporteur. (Annex I)

l.3 Organization

The agenda of the workshop is given in Anne>. 2. The schedule of the workshop included

plenary sessions where several papers were presented and discussed. Dr Richard Guidotti and

Dr Omelia Lincetto from the WHO Headquarters also present~d papers. All countries present~d

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country reports. The country representatives then worked together, with suppott from the consultant and resource persons, to prepare plans of action to reduce maternal mortality for their own countries and this was presented on the last day. On the last day, conclusions vvere presented and they were agreed to by the country representatives. The consultant and temporary advisers assisted countries in drafting national plans while the UNICEF country representatives helped in identifying sources of funding.

1.4 Opening ceremony

Regional Director of WHO for the Western Pacific, Dr Shigeru Omi. opened the workshop. In his message, Dr Omi emphasized that maternal mortality is a major problem in the Western Pacific Region (Annex 3). Maternal mortality is the 'litmus test' ofthe status of women and that it is mutifactorial in origin and that although some factors are difficult to solve, we in the health sector, should do our utmost to further reduce the mortality rates. Dr Omi pointed out the need to 'rethink ' existing programmes to improve maternal health in the Region. The national governments should acknowledge that safe motherhood is a cost-effective, economic and social investment. With the participation of government decision-makers and experts in the workshop, WHO could determine the more urgent needs that required our attention. He also took the opportunity to inform the participants of the changes that have taken place in WHO since he took over. There has been a reduction in bureaucracy and more delegation and this has made the work flow smoother and quicker. He has also taken the initiative to intensify partnership with other UN agencies and nongovernmental organizations to reduce overlap of functions. This workshop was an example of the new partnership as several agencies supported and worked together to make this workshop a success. He said that 51 programmes in this Region were reduced to 14 to enable WHO to achieve concrete and tangible results. He also emphasized that while national governments were concentrating on the highly technical and medical aspects. they should not lose sight of political and health systems issues.

Dr Ray Yip, Senior Project Ofticer for Health and Nutrition, UNICEF Area office for China and Mongolia, thanked WHO for organizing the workshop. On behalf of UNICEF, he welcomed this cooperation and said that such cooperation should continue in the future. Learning and benefiting from each other is a wonderful way to work at the country level.

2. PROCEEDINGS

2.1 Summary of presentations

Summaries of the presentations made during the workshop are given below. Copies of the original papers are available in the Reproductive Health Unit of the WHO Western Pacific Regional office.

2.1.1 Dr Pang Ruyan, Regional Adviser in Reproductive Health ofthe WHO Regional Office for the Western Pacific, presented a paper entitled "Focus -Reproductive Health." ln her paper, she emphasized that there was a wide range of maternal mortality rates (MMR) in the Region and the countries represented in this workshop had the highest MMR in the Region. The overall average MMR in the Western Pacific Region was 120 per 100 000 live births. Although this was lower than the other Regions, we still have to play a proactive role to reduce maternal mortality

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further. She emphasized that Reproductive Health includes many other activities such as family health, safe motherhood, women's health care, infertility, prevention and control of

STI/HIV I A IDS, and abortion and management of its consequences. She discussed the mission

statement of the Reproductive Health focus, objectives and targets, strategies, expected results by

the year 200 I and 2003. She also discussed the external and internal linkages and monitoring and

evaluation of reproductive health and safe motherhood. She emphasized in her mission statement

that the goal of the Reproductive Health focus is to improve the status of women and infants . To

attain this goal, there is a need to mobilize government commitment, provide equitable and

accessible reproductive health care, strengthen capacity building, improve quality of care and promote reproductive health.

2.1 .2 Safe motherhood (UN lCEF perspective)

Dr Ray Yip recounted the UNICEF perspective on safe motherhood. Basically, there was

not much difference between the WHO strategy and the UNICEF strategy and he then presented

the outcome of the UNICEF workshop in Indonesia. The model is an accessibility model where

the strategy is based on an economic model and the three components of the model are supply,

demand and agent. On the supply side, there is the need to increase capacity building, quality and

affordability and it is important that the services are client-friendly. On the demand side, it is important that the women has basic knowledge, tinancial capacity and positive attitude to increase the demand and, finally, the agent is most important because it facilitates the link

between the demand and the supply side. In this case, the model is based on education,

communication and transportation. Each of these areas is linked and interdependent. He also

emphasized that among the major killers of pregnant women, obstructed labour and haemorrhage

need quicker response time as compared to toxaemia and sepsis. Toxaemia should be diagnosed

in antenatal care and appropriate treatment given. Sepsis is preventable.

2. 1.3 Making pregnancy safer

Making Pregnancy Safer (MPS) was presented by Dr Richard Guidotti, Medical Officer

from the Reproductive Health and Research Department of WHO Headquarters, Geneva. MPS is

a health sector strategy tor reducing maternal and perinatal morbidity and mortality by WHO and

pa11ners. Globally MPS falls under the bigger umbrella of Safe Motherhood strategy. The WHO

strate~:,ry of making pregnancy safer will work with other partners and agencies to achieve greater

access to essential maternal and perinatal care in SO priority countries by the end of 2005 . The

basic strategy is to promote partnership, establish norms, improve capacity, monitor and evaluate

the implementation of the strategy. The targets are that skilled attendants should be present at least 80% of births by year 2000 and 75% reduction in pregnancy-related mortality should be

achieved by the year 2015. Other targets include reduction in unwanted pregnancy and unsafe

abortion, and access to well-equipped facilities in complex emergencies. He also discussed the

causes of maternal deaths and their main interventions.

2. 1.4 Integrated management of pregnancy and childbirth (IMPAC)

The IM PAC strategy was discussed by Dr Orne II a Li ncetto, Medical Ofticer from the

Reproductive Health and Research Department of WHO Headquarters. She discussed the essential health sector interventions for safe motherhood. The IMPAC strategies mainly included

standardization of care by setting norms and standards, improving health worker skills, improving

health systems response and improving family and community practice. The first step in IMPAC

is to develop norms and standards. The approach is to provide primary care using Essential Care

Practice Guide (ECPG) and a manual for managing complications in referral hospitals thereby

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'improving the competence of health care providers. Every woman should have antenatal care. 'labour and delivery care, postpartum care, post abortion care, emergency care when needed and treatment at the higher level of care, ifrequired. It also strengthens community and family :support for healthy pregnancy outcome.

2.1.5 Essential care practice guide for pregnancy and child birth (ECPG)

Dr Lincetto talked about ECPG, which are guides for the essential standard care for women and newborn at the primary health care level during pregnancy, labour and delivery, and post partum period. The main objective is to manage routine labour and delivery, avoiding complications both for the mother and newborn, by recognizing the complications and referring them to higher levels of care and to avoid major pregnancy and birth complications. The main :ECPG are a chart booklet of flow charts, mother's counselling booklet, labour form, referral form. maternal and newborn home record, wall chmis, adaptation and training guides. and technical basis papers.

2.1.6 Managing complications in pregnancy and childbirth

Dr Richard Guidotti introduced the manual which WHO has developed for physicians and midwives working in the district hospitals. The manual, using a symptom-based approach to diagnosis, included normal childbirth and only the emergency and serious complications of pregnancy and childbirth which will be very useful for the health staff in referral hospitals. ·r he use of this man11al creates a good linkage with the primary level health care and thus becomes an essential component of IMPAC Aside for the clinical management of cases, it also included sections on emotional support. The recommendations provided were based on available evidence from the review of studies. Dr Guidotti explained that this could be used in setting standards of care or revising current obstetric practice but some countries may need to translate and adapt it prior to nationwide use.

2.1.7 Integrating the safe motherhood in health system reform

Dr Hematram Yadav, the WHO consultant to the workshop, presented the main reforms needed in the health care system of the countries to improve maternal mortality. I le emphasized the need to have clear goals and objectives for reproductive health and more resources tor maternal and child health care. The reforms needed were mainly to improve accessibility and availability of services for maternal and child health, upgrading the health centres for maternal and child health services, doing maternal mortality audit, and integration of maternal and child health/family planning. It is important that the budget allocation for maternal and child health should be proportional to the size of the problem in the respective countries. Although increasing the antenatal coverage is important in some countries, the quality of the antenatal care and postpartum care is equally important and has to be addressed. Finally, it is impmtant that all available resources at the country level are utilized, including community participation.

2.1.8 Safe motherhood and community participation

The Philippine participants presented "Functional two-way community-based referral system: A partnership approach to safe motherhood". In this approach, there is a two-way referral system for obstetric emergencies from the household level up to the highest level of care. Health care is not the responsibility of the midwife but also of the community. The community should get involved in the management of health services. The three levels of care identified are the rural health unit, the community and the hospitals. In this project, the community takes

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responsibility for the health care of the people; however, the project needs to be followed up and sustained.

Another project involving the community was presented by the Papua New Guinea participants and in that project doctors travel to remote villages to see and treat patients. Some of the villages do not have access to medical care, so this approach helps to reduce the burden of disease in the community.

2.1.9 Political commitment to safe motherhood

The participants from the People's Republic of China presented "Political commitment to

Sat~ Motherhood in China". The Ministry of Health in China has been continuously monitoring China's maternal mortality rates since 1990. The national maternal and child health surveillance office is responsible for data collection, analysis, and quality control of this project. It covers a total of 116 surveillance sites across the country including 37 urban districts and 79 counties. The strategy to monitor maternal mortality has shown reduction in the maternal mortality since

1990 although large discrepancies exist between different regions in China. The coastal regions

have the lowest MMR and remote areas have higher MMR. In order to bridge the gap between

the poor regions in western China and the coastal regions, the government of China has formulated a strategy which integrates health development as its major component to develop the western part of the country. The key strategies are to increase hospital deliveries and strengthen the capacity of health faci I ities at the grassroots level to deliver obstetric care.

The participants of VietNam also explained how VietNam was politically committed to safe motherhood. They explained the various decisions and laws made by the Minister of Health and the Prime Minister which were related to sate motherhood. They also showed indirect relationship between facility-based childbirth and maternal mortality ratio.

2.1.1 0 Building partnership and resource mobilization

In this session WHO, UNICEF, UNFPA, and ADB spoke on their roles and how they function at the country level. The WHO representative explained the budget process. The overall

budget for the Region was 788 mi II ion for the 1998/99 bienni Llll1 . The majority of the funds came from governments (459.9 million); other lJN agencies gave 90.8 million. Overall, the funds for

the Region are decreasing.

UNICEF works very closely with a variety of partners at national and local levels. There is less hureaucracy in UNICEF and funds can be requested directly at the country level. UNICEF

officers can monitor projects at even the village level.

UN FPA, on the other hand, is the largest internationally funded source of population assistance to developing countries . Its main objective is to provide developing countries quality reproductive health and family planning services, to advance the strategy of !CPO and ICPD+5

and to promote cooperation among UN agencies. The three main programmes are Reproductive

Health/Family Planning Population and Development Strategies and Advocacy.

The Regional Technical Assistance Project (RET A) is the strengthening sate motherhood programme conducted by ADB/UNICEF. The main objective of RET A is to improve maternal

health and reduce maternal mortality by about half over the next decade. Six countries are covered by the project in Asia and the countries in the Western Pacific Region are Cambodia, Lao

People's Democratic Republic and Papua New Guinea.

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Country perspectives on how international agencies and nongovernmental organizations function at the country level were given by Cambodia and the Lao People's Democratic Republic. Jn their presentations, the speakers focused on the need for better coordination at the country level between various agencies. There are several programmes which are not coordinated and they overlap. The programmes last for only a year or two and then due to lack of funds are stopped. To overcome the problem of overlapping among agencies. most of the countries have now formed a committee at the country level to coordinate the various projects and activities.

2.2 Summary of country reports

All the countries represented presented their country reports and the summary of the country reports is given below. (Also see Annex 4).

Cambodia is one of the poorest countries in the Region and its current population is 1 I .4 million. Eighty five percent of this population is rural and females constitute 52% ofthe population. A total of 42% of the young population is under I 5 years of age. Females aged 15-44 years constitute 24 .9% of the population. Crude birth rate is 3.8% and total fertility rate is 5.2 ( 1997). Only 12~/o of Cambodian women have secondary or higher education, and 14% have primary school education. The low level of female education results in a lack of general knowledge and affects common behaviour. The maternal mortality ratio is 473 per I 00 000 live births ( 1995). infant mortality rate is 80 per I 000 live bit1hs and the contraceptive prevalence rate is I 6%. Only 45% of pregnant women attend antenatal clinic and 30% receive two tetanus toxoid immunizations. Only 5% of births take place in the institutions and 70% of births are not reported to the health care system. The main causes of maternal rnortal ity are postpartum haemorrhage. eclampsia, obstructed labour and sepsis. The factors influencing maternal mortality are poverty. largeness of family. low education, and poor information available on maternal mortality.

The Government of Cambodia gives high priority to the safe motherhood programme. The main focus of the safe motherhood policy is improving maternity care services. child spacing at all levels of health care delivery and reducing the rate of abortions. In this respect several protocols and guidelines have been developed and several ofthe activities of the safe motherhood programme are supported by several international agencies. Further key interventions include among others the use of traditional bitih attendants for normal deliveries in remote areas. The Ministry of Health encourages families to seek appropriate and timely health care and registration of all births and deaths.

The Peoples Republic of China has a population of I 284 million (1998) and the female population constitutes 603 million or 46.9%. The health budget represents 2.27% of the national expenditure. Maternal mortality ratio is 56.2 per lOO 000 live births (1998), infant mortality rate is 33.2 per 1000 live births and under 5 mottality is 42 per 1000 live births. The main causes of maternal mortality are obstetric haemorrhage (54. 16% ), PI H syndrome (12.28% ), puerperal infection (5.16 %) and clinical complications (2 I .22%). The national policy on maternal mortality is to reduce MMR by 50% by 2000 based on the level of 1990. There has been a significant reduction in maternal mortality and infant mortality in China since 1990. However, there is a large disparity between different regions. The coastal regions have a lower mortality rate and remote areas have a higher mortality rate. There is a high illiteracy rate in poor and remote areas, which hinders the improvement of women's health. The incidence ofSTIIHIV and AIDS is increasing and the maternal health of migrant population needs to be addressed.

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The Lao People's Democratic Republic has a population of 4.57 million and over 80% of the population lives in rural areas. The maternal mortality ratio is 650 per 100 000 live births and the infant mortality is 104 per 1000 live births. About 56% ofthe females are enrolled in primary schools and the adult female literacy rate is 47%. The contraceptive prevalence rate is 25%. The main causes of maternal mortality are postpartum haemorrhage, retained placenta, eclampsia, obstructed labour, sepsis, induced abortion, and uterine inertia. About 28% of deaths occur during pregnancy and 72% occur after delivery. More than 73% are due to direct obstetric cause and most of them due to postpartum haemorrhage. Most of the deaths occur at home (90%) and the number of institutional deliveries is low. Most of the contributing factors are early pregnancy, poor nutrition, high fertility rate, low literacy, severe anaemia, malaria, and poor availability and accessibility of health care. The national policy on Maternal and Child Health is addressing these issues, a national workplan on safe motherhood for year 1998-2002 has been developed and the objective is to reduce MMR from 6501100 000 live births to 400/100 000 by year 2002. Similar objectives have been set for infant mortality and under 5 mortality in China. Among other activities to reduce MMR are improving access, community participation, integrating maternal and child health/family planning, coordinating with international agencies and strenb>thening reproductive health.

Mongolia has a population of2.4 million and has a density of 1.4 persons per square kilometre. It is a vast country with a sparse population and poor communications system. The crude birth rate was 21 per 1000 live births in 1999 and life expectancy is 67.9 years. The maternal mortality ratio is 175 per 100 000, the infant mortality is 36 per 1000 live births and the contraceptive prevalence rate is (CPR) is 50.3%. The most common form of contraception is the intra-uterine contraceptive device (IUCD). About 3.8% of the GNP is spent on health. The total fertility rate is 2.3 and it is decreasing. The main causes of MMR are postpartum haemorrhage (I 1.2%), PET/eclampsia (24.4%), sepsis (I 0.1 %), obstructed labour ( 4.4%) haemorrhage during pregnancy (5.5%) and the indirect cause is 44.4%. Mongolia adopted a population policy only in 1996. The government has introduced the National Programme to Improve Women's Status, Reproductive Health National Programme and the National Adolescent programme. The main problems of maternal mortality are poor quality of antenatal care, poor knowledge, lack of essential drugs and equipment. poor referral system and poor communication system in the whole country. The government has taken serious steps to reduce these problems. International agencies also have several programmes to overcome the reproductive health in the country.

Papua New Guinea has a population of 4.7 million and about 700 languages. The crude bi1th rate is 33 per 1000 live births and the crude death rate is I 0 per I 000 live births. The maternal mortality ratio is 370 per 100 000 live births, the infant mortality is 77 per 1000 live bi1ths and the total fertility rate is 4.8. The contraceptive prevalence rate is 26%. The main causes of maternal mortality are postpartum haemorrhage (30%), sepsis (28%), malaria and anaemia (15%) obstructed labour (4%) and PET/eclampsia (3%). The main issues are poor infrastructure, geographical isolation and inaccessibility, shortage of trained manpower, inappropriate use of available funds, inadequate transport facilities, and staff motivation and commitment. To overcome these problems, the government is trying to improve the health of women by trying to increase antenatal coverage for women. It is also increasing the contraceptive rate through a vasectomy programme. The use of radio to educate mothers is another means to improve knowledge among the women.

The Philippines is an archipelago with 7 100 islands and has a population of74 million. The life expectancy is 71 years tor females and 66 years for males. The MMR is 172 per I 00 000 live bi11hs (NDHS 1998). MMR has a wide variation in the country with low in Manila and high in the Autonomous Region of Muslim Mindanao (ARMM) which has an MMR of 320 per

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100 000. The infant mortality is 36 per I 000 I ive births, the perinatalmortality rate is 27 per 1000 live births. About 65% of the deliveries areal home, only 34.2% are in health facilities. Overall, about 41% of the deliveries are still conducted by traditional birth attendants and the rest by doctors and nurses. The main problems of reducing maternal mortality are lack of funds, strong religious beliefs, and poor distribution of resources especially doctors, and delay in seeking health care in the remote areas, unavailability of quality services in the islands and, finally, poor collaboration with the private and professional societies. To overcome these differences, the First National Motherhood Conference was held in Davao City in August 1999 to develop a framework to reduce maternal mortality. The following principles were formulated: promotion of women's rights, access to quality health, focusing on health promotion and advocacy, addressing family planning issues, empowering communities and repmiing all maternal deaths. Other strategies include prevention and treatment of anaemia, and clean and safe deliveries. The country has also several ongoing programmes with international agencies in several provinces and more needs to be done in high priority areas.

VietNam has a population of 76 million and about 38.8 million are females. It is a young population and 33.5% of the population is below 15 years of age. The GOP per capita is US$352 and 3.8% ofthe national budget is spent on health. The MMR is 100 per 100 000 live births the infant mortality is 36.7 per I 000 1 ive births, contraceptive prevalence rate is 62. 1% and the total fertility rate is 2. 5. The major causes of MMR are haemorrhage (70% ), infection ( 14% ), PET/eclampsia (I 0% ), and uterine rupture (2% ). The main problems are lack of trained midwives, (approximately 40% ofthe CHC are without midwives). lack of knowledge and training of the existing staff, inadequate drugs and equipment, poor community involvement. low budget and poor communication. The government has taken serious steps to reduce this problem by making decrees and laws to protect the society. The national policy on sale motherhood is to improve the health of the mother and newborn and to reduce MMR to 70 per I 00 000 live births by 2010 and lMR to 25 per I 000 in the same period. The strategy includes providing essential obstetric care and antenatal care. providing essential drugs, providing clean delivery kit, and home delivery to be attended by a trained health worker. improvement of training of personnel, and transportation. Several international agencies have projects in various provinces throughout the country.

2.3 Summary of discussions

There was active discussion in the workshop and the summary of the discussion and is'iues are as follows:

2.3.1 There is poor registration ofbi1ihs and deaths in many of the participating countries. Efforts should be made to improve the data collection and analysis. The public should be encouraged to register all births and deaths. This will help to improve the health information and statistics.

2.3.2 Although hospital deliveries are being encouraged in some countries to reduce maternal mortality, they may not be applicable to all countries because of limited resources. The increased hospital deliveries will increase utilization rate in hospitals and this will also increase the cost of health care. Countries should review their own situation and make their decisions.

2.3.3 The use of traditional birth attendants is also dependent on individual countries. Efforts should be made to increase safe delivery by trained personnel at home or in institutions. If there are limited resources and transportation is a problem, especially in remote areas, the use of

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available resources like traditional birth attendants or village health workers should be considered.

2.3.4 Some of the countries are in the process of introducing national health care insurance

schemes. This may affect the accessibility of care for maternal and child health services.

Countries should make available resources to make sure that maternal and child health care is not

affected.

2.3.5 There are too many international agencies and nongovernmental organizations in

different provinces in the countries and some of the strategies applied vary in the training and

implementation. There are no resources for sustaining these programmes. Both the country

representatives and the agencies should try to work out the problem of sustaining the strategy.

2.3.6 There are several guidelines available in the countries. Some of them developed by

international agencies and some by the country personnel. An effort should be made to

standardize these guidelines so that the training can be standardized in these countries.

Agreement for use ofiMPAC and manual :

2.3. 7 The programmes discussed in this workshop are not vertical programmes and have to be

coordinated in the existing MCH programme.

2.3.8 Networking to exchange information and experiences should be encouraged between

the countries to help each other to reduce maternal mo1tality.

2 .3.9 The plans of action prepared in this workshop should be tinalized and countries should

work with international partner agencies for strategies planned.

2.4 Evaluation ofthe workshop

Twenty-nine representatives from seven countries attended the workshop and all or them

said that the objectives of the workshop were met. Overall the process and outcome were

well-received. Few participants observed that the discussion period during tile workshop \Vas

sho11 and should have been lengthened so that the participants could exchange ideas during the

discussions. One pa11icipant wanted the reading materials to be available earlier so that we could

have a better discussion. Most of them are willing to take part in the network . There was a

request to have the next meeting in a province so that we can see field experience.

3. CONCLUSIONS

The participants affirmed that it is the right of every mother and infant to survive

pregnancy and childbirth and that each maternal death is both a failure and a tragedy. The

pa11icipants believe that protecting women and mothers is the responsibility and duty of each

family, each community and each local and national government and the participatJts conclude

that:

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1. Maternal mortality ratio (MMR) and neonatal mo11ality rate (NMR) are still unacceptably

high in some countries in the Western Pacific Region and there is an urgent need for

governments to undertake more pro-active steps to reduce these high levels.

2. Seven WHO Member States have developed draft national action plans on safe

motherhood which are intended to guide their respective national programmes to reduce

maternal morbidity and mortality.

3. The draft action plans attempted to identify possible sources of investments to implement

programmes for the years 2000 to 2005. It is recognized that there is a need to further

strengthen partner agencies' collaboration to rationalize use of resources to be able to provide

maximum support to the national plans and programmes for safe motherhood and maternal

mortality reduction.

4. The participants will mobilize political support to implement the national action plans as

soon as possible. In addition, building capacities of countries to plan, manage, implement and

monitor safe motherhood programmes need to be developed and strengthened.

5. Country officials, the donor community, and other stakeholders will continue to

recognize the national action plan as a vital component to make pregnancy safer . The national

action plan is a dynamic instrument that will continue to evolve to become an even more

realistic reflection of a country's thrusts and priorities to reduce maternal morbidity and

mortality.

6. The WHO standards of care guidelines (Essential Care Practice Guides and Managing

Complications of Pregnancy and Childbirth) are available and may be adapted and used by

countries according to their specific needs, priorities and resources.

7. MMR is an impact indicator which reflects a woman's basic heath status, her access to

health care and the quality of care that she receives. However, there are times when MMR

may be difficult to measure and it may not adequately reflect trends in maternal health.

Countries may utilize other process indicators to monitor their safe motherhood programmes

such as proportion of pregnancies and deliveries attended by skilled attendants; health facilities

delivery rate; number of facilities with functioning basic essential obstetric care; proportion of

pregnant women with tetanus toxoid immunization and others, as necessary.

8. A network on maternal and newborn health among the participating countries, the UN

agencies, and other international organizations represented in the workshop has been organized

and will be made operational as soon as possible.

9. The network is established to ensure the continuous coordination and collaboration

among the Member States and ensure opportunities for region-wide dissemination of

information. Specifically, it is expected that the network will promote and facilitate

information sharing; facilitate collaboration and coordination for promoting safe motherhood

and making pregnancy safer; provide support in programme monitoring and evaluation; and

facilitate and assist Member States in mobilizing resources for strengthening safe motherhood

programmes.

- 12-

10. Member States in the Region will continue to collaborate and help one another to reduce

maternal and neonatal deaths and WHO will continue to be the lead agency in technical and

collaborative activities in making pregnancy safer.

CAMBODIA

CHINA

- 13 -

LIST OF PARTICIPANTS, CONSULTANT, TEMPORARY ADVISERS, RESOURCE PERSONS,

REPRESENTATIVES, OBSERVERS AND SECRETARIAT

1. PARTICIPANTS

Professor Eng Huot Director-General of Health Ministry of Health I 5 I ·· I 53 Kampuchea Krom A venue Phnom Penh Telephone no .: Fax no.: E-mail:

(855 023) 880 406/016 813 151 (855 029) 880 407 enghuot@camnet.kh

Dr Tan Vuoch Chheng Deputy Director National Maternal and Child Health Centre P.O. Box I 13, St . France, Sras Chak Phnom Penh Telephone no. : Fax no.:

Dr Chhun Long

(855 23) 015 917 951 (855 23) 023 362 516

National Programme Manager for Reproductive Health National Maternal and Child Health Centre P.O. Box I 13, St . France, Sras Chak Phnom Penh Telephone no.: Fax no.: E-mail:

(855 23) 362516 or (855 23) 427300 (855 23) 430142 chhunlong@bigpond.com.kh

Mr Guo Shenggui Deputy Director General PHC/MCH Department Ministry of Health Beijing, Telephone no .: (8610) 6879 2303 Fax no.: (8610) 6879 2321

Dr Wan Yan Division Chief National Working Committee for Children and Women Beijing, Telephone no. : Fax no.: E-mail:

(861 0) 65 22 5324 (8610)6513 3997 hdha@public3. bta.net.cn

ANNEX I

Annex I

LAO PEOPLE'S DEMOCRATIC REPUBLIC

- 14-

Dr Xing Jun Project Officer PHC/MCH Department Ministry of Health I Xizhimenwai Nanlu Beijing I 00044 Telephone no.: Fax no.: E-mail:

(8610) 6879 2310 (861 0) 6879 2321 phmchmis@public.east.net.cn

Dr Huang Xinghua Professor of Obstetrics and Gynaecology Beijing Obstetrics and Gynaecology Hospital 17 Qihelou Beijing 100006 Telephone no.: (86 10) 6525 0731 Fax no.: (8610) 6595 8095

Dr Zhao Gengli Associate Professor Mother and Infant Health Care Center Beijing Medical University I X ian men Street I 00034 Beijing Telephone no.: Fax no.: E-mail:

(861 0) 6617 4284 (8610) 6616 7629 gengli z@hotmail.com

Dr Douangchanh Keoasa Deputy Director Department of Hygiene and Prevention Ministry of Health Vientiane Telephone no.: ( 856) 21 2140 I 0 Faxno. : (856)21214010

Dr Khanthong Siharath Deputy National Project Director, Reproductive Health/

Family Planning and Chief of Training Division Maternal and Child Health Center Ministry of Health Vientiane Telephone no.: (856) 21 214596 Fax no.: (856) 21 214595

Dr Chansouk Chanthapadith Chief of Technical and Evaluation Section and Coordinator of EPIO; Logistic of Reproductive Health Programme of

Maternal and Child Health Center Maternal and Child Health Center Ministry of Health Vientiane Telephone no.: Fax no.: E-mail:

(856) 21 214596 (856) 212 14595 Lao net_ net _gtzhp@lao net. net

MONGOLIA

PAPUA NEW GUINEA

- 15 -

Dr Darjaa Oyunsuren Director. Public Health Department Dalanzadgad Town South Gobi Aimag Province Telephone no.: (976) 1 053 3719

Dr Seded Khishgee Deputy Director Maternal and Child Health Research Centre Bayangol District 15 Ulaanbaatar-24 Telephone no.: (976) I 362951 Email: khishgee 133@hotmail.com

Dr Ishnayam Davaadorj Senior Officer, Reproductive Health Coordination and Policy Development and National Programme Director Reproductive Health Subprogramme, UNFPA Ministry of Health and Social Welfare Ulaanbaatar-24 Telephone no.: Fax no.: E-mail:

(976) 1 322878 (976) I 311601 mon97p03@magicnet.mn

Dr Genden Purevsuren Logistics and Training Consultant Reproductive Health UNFPA Sub-Programme P.O. Box 29/645 Ulaanbaatar Telephone and Fax no.: E-mail:

(976) 1 3 II 60 I mon97p03@magicnet.mn

Dr Mathias Sapuri Acting Dean Medical School University of Papua New Guinea Box 1774 Boroko, N.C.D. Telephone no.: Fax no.: E-mail:

Dr Ligo Augerea Obstetrician

(675) 3112626 or 3112504 (675) 3230066 sapuri@daltron.com .pg

Alotau Hospital Milne Bay Province Telephone no.: (675) 6411200 Fax no.: (675) 6410040 E-mail: ligosa@daltron.com.pg

Annex I

Annex 1

PHILIPPINES

VIETNAM

- 16-

Dr Shirley Heywood Obstetrician/Lecturer Division of Obstetrics and Gynaecology University of Papua New Guinea Boroko, N .C.D. Telephone no.: Fax no. : E-mail:

(675) 323 2411 (675) 323 2411 s.heywood@upng.ac.pg

Dr Paulyn Jean Rosell-Ubial Officer-in Charge Maternal and Child Health Service/Family Planning Service 2"d floor, Building 13 Department of Health Compound Sta. Cruz, Manila Telephone no.: (63 2) 658 5386 Fax no.: (632) 752 9961 E-mail: mchs@doh.gov.ph

Dr Carmen C . Gervacio Medical Officer VII Maternal and Child Health Service/Family Planning Service 2"d floor, Building 13 Department of Health Compound Sta. Cruz, Manila Telephone no.: (63 2) 931 4979 Fax no .: (63 2) 732 9961 E-mail : mchs@doh.gov.ph

Ms Vicenta E. Borja Nurse VI Maternal and Child Health Service/Family Planning Service 2"d floor, Building 13 Department of Health Compound Sta. Cruz, Manila Telephone no.: (63 2) 446 2563 Fax no.: (632) 732 9961 E-mail : mchs@doh.gov.ph

Professor Tran Thi Phuong Mai Deputy Director Department of Maternal and Child Health/Family Planning

Ministry of Health 138 A Giang Vo Street HaNoi Telephone no.: Fax no.:

Dr Vu Thi Thanh

(84 4) 8329119 (84 4) 8236926

Senior Programme Officer Department of Maternal and Child Health/Family Planning

Ministry of Health 138 A Giang Vo Street HaNoi Telephone no.: Fax no. :

( 84 4) 8464060 (84 4) 8430487

- 17 -

Dr Truong Thi Thu Van Department of Obstetrics and Gynaecology Bach Mai Hospital No. 20, 81 A Klmuen Quarter HaNoi Telephone no.: (84 4) 8522401

Dr Nguyen Due Vy Director National Institute for Protection of Mothers and Newborn c/o UNICEF !VietNam 72 Ly Thuong Kiet Street HaNoi Fax no.: (84 4) 826 2641

Ms Mai Thi Cong Danh Researcher, Management System and Scientific Researcher on Obstetrics/Gynaecology Tu Du Obstetric Hospital 24 An Duong Vuong Street Ho Chi Minh City Telephone no.: (84 08) 320 391

2. CONSULTANT

Dr Hematram Yadav Associate Professor Department of Social and Preventive Medicine University of Malaya Kuala Lumpur Malaysia Telephone no.: Fax no.: E-mail:

(60 3) 736 8081 (60 3) 252 5579 dryadav@hotmail.com

3. TEMPORARY ADVISERS

Dr Glen Mola Associate Professor and Head Obstetrics and Gynaecology University of Papua New Guinea Box 1421 Boroko NCO Papua New Guinea Telephone no.: (675) 324-83 I 0 Fax no.: (675) 375 82 I 2 E-mail: glenmola@dg.com.pg

Annex 1

Annex 1

UNFPA

- 18-

Dr Loreto Mendoza Independent Consultant Primary Health Care/Maternal and Child Health

No. 23 Charming Street BF Homes, Almanza Las Pinas Philippines Telephone no. : (63 2) 806 1760

E-mail: loret.m@mail.com

4. RESOURCE PERSONS

Mr WuGuogao External Relations Officer

World Health Organization

Regional Office for the Western Pacific

Manila Philippines Telephone no. : Fax no.: E-mail :

(63 2) 528 9930 (direct) (632) 521-1 036; 526-0362; 526-0279

guogaow@who.org.ph

Mr D. Bayarsaikhan Technical Officer, Health Care Financing

World Health Organization

Regional Office for the Western Pacific

Manila Philippines Telephone no.: Fax no.: E-mail :

(63 2) 528 9808(direct) (632) 521-1036; 526-0362; 526-0279

bayarsaikhand@who.org.ph

5. REPRESENTATIVES

Ms Florence Tayson Assistant Representative

United Nations Population Fund

NEDA sa Makati Building I 06 Amorsolo Street, Legaspi Village

1229 Makati City Philippines Telephone no. : Fax no.: E-mail :

(63 2) 892 06 11 to 25 (63 2) 8178616 officemail@unfpa.org.ph

UNICEF

- 19-

Dr Liu Bing Project Officer for Maternal and Child Health UNICEF Area Office for China and Mongolia 12 Sanlitun Lu Beijing 100600 China Telephone no.: (861 0) 6532 3131 Fax no.: (8610) 6532 3107 E-mail: bliu@unicef.org

Dr Martha B. Cayad-an Maternal Health and Nutrition Officer UNICEF/Manila 61

h Floor, NEDA sa Makati Building I 06 Amorsolo Street, Legaspi Village 1229 Makati City Philippines Telephone no.: Fax no.: E-mail:

(63 2) 892 7653 (632) 810 1453/810 0272 mcayad-an@unicef.org

Dr Onevanh Phiahouaphanh Programme Officer, Community Health UNICEF Vientiane Telephone no.: Fax no.: E-mail:

(856) 21 315 200 (856) 21 314 852 ophiahouapha@unicef.org

Dr Ketsamay Rajphangthong

Annex 1

Assistant Programme Officer, Maternal Health/I-Iealth Promotion UNICEF Vientiane Telephone no.: Fax no.: E-mail:

(856-21) 315 200 (856) 21 314 852 krajphangtho@unicef.org

Ms Tytti Karppinen Assistant Programme Officer, Health Education/Health Information UNICEF Vientiane

· Telephone. no.: Fax no.: E-mail:

(856) 21 315 200 (856) 21 314 852 tkarppinen@unicef.org

Annex 1

ASIAN DEVELOPMENT BANK

- 20-

6. OBSERVERS

Dr Kus Hardianti Health Specialist, Education Health and Population Division (East) Asian Development Bank 6, ADB A venue Mandaluyong City Philippines Telephone no.: (63 2) 632 444 Fax no.: (632) 636 444 E-mail: information@adb.org Dr Vincent de Wit Health Specialist Regional Technical Assistant Project for Safe Motherhood

Asian Development Bank 6, ADB A venue Mandaluyong City Philippines Telephone no. : Fax no. : E-mail:

Mr Jeffrey Sine

(63 2) 632 5732 (632) 636 2310 information@adb.org

Consultant, Strengthening Safe Motherhood Programmes The Futures Group International 1050 17'" Street, N.W. Suite 1000 Washington, D.C. 20036 United States of America Telephone no.: 1-202) 775 9680 Fax no.: (I 202) 775 9694 E-mail: j.sine@tfgi.com

Ms Nancy Piet-Pelon Consultant, Strengthening Safe Motherhood Programmes The Futures Group International 1050 17'" Street, N.W. Suite 1000 Washington, D.C. 20036 United States of America Telephoneno. : 1703)3712621 Fax no.: (1703) 575 9650 E-mail: pietshome@aol.com

- 21 -

7. SECRETARIAT

Dr Pang Ruyan (Responsible Officer) Regional Adviser in Reproductive Health World Health Organization Regional Office for the Western Pacific Manila Philippines Telephone no.: Fax no.: E-mail:

(63 2) 528-800 I; 528-9876 (direct) (632)5211036 pangr@who.org.ph

Dr Rebecca Ramos Short-term Professional in Reproductive Health World Health Organization Regional Office for the Western Pacific Manila Philippines Telephone no.: Fax no.: E-mail:

(63 2) 528-8001; 528-9878 (direct) (63 2) 521 1036 ramosr@who.org.ph

Dr Richard Guidotti Medical Officer, Reproductive Health and Research World Health Organization CH-1211 Geneva 27 Switzerland Telephone no.: Fax no.: E-mail:

( 41 22) 791 2111 (41 22)791 4189 guidottir@who.ch

Dr Omelia Lincetto Medical Officer, Reproductive Health and Research World Health Organization CH-1211 Geneva 27 Switzerland Telephone no.: Fax no.: E-mail:

(41 22)791 2111 (41 22)791 4189 lincettoo@who.ch

Dr Jaime Galvez Tan President FriendlyCare Foundation, Inc. (Regional Technical Assistance, Safe Motherhood Programs UNICEF East Asia and Pacific Regional Office) Ortigas Centre Pasig City 1605 Philippines Telephone no. Fax no.: E-mail:

(632) 637 0470 (632) 637 3064 jzgt@friendlycare.com.ph galveztan@pacific.net.ph

Annex 1

Annex 1

-22-

Dr Nikki R. Lambo Affiliation Director FriendlyCare Foundation, Inc. (Regional Technical Assistance, Safe Motherhood Programs UNICEF East Asia and Pacific Regional Office) Ortigas Centre Pasig City 1605 Philippines Telephone no.: Fax no.: E-mail:

Dr Ray Y.iQ

(632) 636 2790 (632) 635 4719 nikki.Iambo@friendlycare.com.ph nikki@pworld.net.ph

Senior Project Officer for Health and Nutrition UNICEF Area Office for China and Mongolia 12 Sanlitun Lu Beijing I 00600 China Telephone no.: Fax no.: E-mail:

Ms Agnes Jacobs Nurse Educator

(8610) 6532 3131 ext 133 (8610) 6532 3107 ryip@unicef.org

Word Health Organization House 120, Street 228 Sankat Chadomuk Khan Daun Penh Phnom Penh Cambodia Telephone no.: Fax no.: E-mail:

(855) 23 216211 (855) 23216942 jacobsa@who.org.kh

Dr Jayanti Man Tuladhar Adviser, Reproductive Health/Family Planning/MIS/Logistics UNFPA Country Support Team Office for East and South-East Asia GPO Box 618 Bangkok 10501 Thailand Telephone no.: Fax no.: E-mail:

(662) 288 2450 (662) 280 2715 tuladhar@un.org jayantit@yahoo.com

- 23-

ANNEX 2

WORKSHOP ON MATERNAL MORTALITY REDUCTION IN SELECTED COUNTRIES IN THE WESTERN PACIFIC REGION

29 May- 2 June 2000, Manila, Philippines

PROVISIONAL AGENDA

I. Opening ceremony

2. Orientation to the workshop

3. Introduction ofthe regional strategic plan on maternal mortality reduction

4. Introduction of the global movement on Making Pregnancy Safer Initiative

5. Implementing IMPAC and adapting the Emergency Obstetric Case Management Manual

6. Integrating safe motherhood programme into health systems reform and human resource development

7. Political commitments on Safe Motherhood programme and community participation

8. Building partnerships

9. Country reports

I 0. Group discussions (e.g. establish a regional network on maternal mortality reduction)

II. Presentation of draft national working plans by country teams

12. Closing ceremony

-24-

-25-

ANNEX 3

OPENING REMARKS BY DR SHIGERU OMI, REGIONAL DIRECTOR, AT THE WORKSHOP ON MATERNAL MORTALITY REDUCTION IN

SELECTED COUNTRIES IN THE WESTERN PACIFIC REGION, MANILA, 29 MAY - 2 JUNE 2000

DISTINGUISHED PARTICIPANTS, COLLEAGUES, LADIES AND GENTLEMEN:

1 am very pleased to welcome you to Manila and to the WHO/WPRO for this important consultative workshop on maternal mortality reduction. It is significant that UNICEF has decided to join us and be a co-sponsor of the meeting. I am pleased to note that UNFPA and the Asian Development Bank are also very well represented.

We have called this consultation to determine what we can do together to address the global issue of unacceptably high maternal mortality especially in our Region where about 50 000 maternal deaths occur yearly. This is an old problem. But what we need to do now is to determine why progress in the reduction in maternal mortality ratio is slow in some countries and how this can be remedied.

Maternal mortality ratio is an impact indicator which reflects a woman's basic health status, her access to health care and the quality of care that she receives. WHO and UNICEF have referred to the indicator as "a litmus test ofthe status of women". It cuts across different sectors and is affected by multiple factors including socio-economic considerations. While some aspects are difficult to resolve, we, in the health sector, should do our utmost to plan and implement programmes in a most effective and efficient way.

For the past ten years, programmes to improve maternal health have been implemented. Experience has shown what works and what does not in safe motherhood programmes. For example, training of traditional birth attendants and community-based health workers alone will not significantly contribute to reduction of maternal deaths. These workers can be trained to handle normal aseptic delivery only and not emergency obstetrics. Therefore, we may have to rethink the projects that we have been developing along this line. In the past, more resources were earmarked for antenatal care than for delivery, immediate postpartum care and emergency obstetric care. But now we know that the vast majority of complications occur during and after delivery and in the first hours and days after delivery. These and other important lessons learned should be the basis of our current and future planning.

While we have been concentrating on the highly technical and medical aspects, the economic, political and health systems issues should not be lost sight of. National governments must acknowledge that safe motherhood is a cost-effective economic and social investment. We, therefore, urge them to allocate resources and invest an appropriate intervention for implementation. Political commitment needs to be translated into action. This is the reason why we have requested that government decision makers attend this consultation.

Now, I understand that during this consultation, you will be sharing your experiences in implementing safe motherhood programmes. You will also discuss strategies to reduce maternal mortality, and prepare work plans.

-26-

Annex 3

I propose that you take stock of the strengths and comparative advantages of certain

country programmes and identify the contributions or role of each key player, from the

government to the international partner agencies.

With the participation of government decision makers and experts who are familiar with

the country situations, we can determine the more urgent needs that require our attention. The

involvement of key partner agencies will greatly enhance this planning process. Programme or

resource gaps can be identified together and therefore areas of collaboration can be clearly

defined thus lessening expensive duplications and overlaps.

We all share the same goal of having healthier mothers and children. This common goal

should guide us in looking at ways by which we could complement each other's efforts.

For the next five days I expect a lot of intense discussions among country participants as

well as with partner agencies. With your commitment and perseverance I have no doubt this will

be a productive consultation.

Thank you and good day.

WORKSHOP ON MATERNAL MORTALITY REDUCTION ACTION PLAN FOR SAFE MOTHERHOOD 2000- 2005

CAMBODIA

Overall Goals: To make pregnancy safer and to improve pregnancy outcomes for women in Cambodia, by:

1. Reducing the number of women suffering pregnancy-related morbidity and mortality in Cambodia by reducing maternal mortality ratio by 20% from

the baseline level (DHS 2000) by 2005. 2. Reducing the infant mortality rate from 80 per 1000 live births to 70 by 2005 .

3. Reducing the total fertility rate from 5.3 to 4.3 by 2005.

Issues/ Expected Time Responsible Performance Resource

Problems Objective Activities Results Frame Person Indicator Required Source

Reduce the number • Expand birth spacing services . I. CPR increases I. 2005 Birth Spacing

of unwanted - Expand availability of long-term to 30%. MOH

pregnancies. methods (IUD & sterilization). UNFPA

- Expand birth spacing service delivery 2. CPR for male RACHA

sites. sterilization 2. 2005 NGOs

• Inform families through mass education increases to 2%. Etc ....

campaign and inter-personnel communication for increasing demand. 3. Selected HCs IEC- MOH

providing IUD JICA insertions

3. 2005 4. IEC ..... ?

4.

Workshop on Maternal Mortality Reduction Action Plan for Safe Motherhood 2000 - 2005 Cambodia

Issues/ Problems Objective Activities

Reduce the • Expanded birth spacing services number of at risk • Increase coverage of ANC visits . pregnancies. • Increase the number of ANC visits per

pregnant woman.

Increase chances • Distribute iron/folic acid to all pregnant of surviving women. hemorrhage. • Add iron/folic acid tablet distribution to role

of TBA and/or to the role of other health workers.

• Train MWs and nurses in Life Saving Skills (LSS, or basic EmOC).

• Increase involvement oftrained birth attendants (MWs and nurses) in home deliveries. - Expand use of LSS, 3'd stage delivery

management.

• Develop mechanisms for linkages between midwives and TBAs.

• Distribute Mother's Health Records package to all health centers for use all pregnant women.

Reduce the delay • Increase attendance at births by more skilled in recognizing midwives and by more informed TBAs. delivery - Train TBAs to recognize delivery complications. complications and to direct complicated

cases to suitable facilities.

- Increase midwife's skills and involvement in home deliveries, through better TBA-midwife partnerships, increased demand for delivery by a midwife at local level.

Expected Time Responsible Results Frame Person

Performance Resource Indicator Required Source

N co

Workshop on Maternal Mortality Reduction Action Plan for Safe Motherhood 2000-2005 Cambodia

Issues/ Problems Objective Activities

• Phase in use of maternal deaths audits . And - Sustain audits where they are now conducted

(2 pilot areas). - Expand use in all referral hospitals - Institute use at community level where

feasible.

Reduce the delay • Conduct community IEC campaigns & in decision- advocacy campaign on early recognition of making to take delivery complications and importance of action in case of quick transportation of woman to a health delivery facility. complication. - Train HC midwives & TBAs in community

IEC. - Conduct mass education campaigns of

community through mass media and existing community structures.

- Conduct advocacy campaign with community/national leaders on MM issues.

Provide all • Train TBA in selected areas for nonnal women with delivery. access to clean • Expand use of3'd stage delivery using and safe oxytocin as a preventive intervention by delivery. trained attendants (MWs and nurses) .

• Increase the number of midwives trained and available for deployment to new facilities through regular midwifery training.

Expected Time Responsible Performance Resource Results Frame Person Indicator Required Source

Workshop on Maternal Mortality Reduction Action Plan for Safe Motherhood, 2000-2005 Cambodia

Issues/ Problems Objective Activities

Improve financial • Within the MOH's new user fee system,

and geographic implement fee exemption policies for poor

access to health care women needing EmOC. facilities for women • In selected areas, phase-in development of experiencing transportation arrangements for women in need pregnancy-related of referral to a HC or hospital for EmOC. complications. • In selected areas, phase-in establishment of LSS

(basic EmOC) for treating abortion complications and delivery complications at the peripheral (HC and home) level. - Expand use of oxytocins and anticonvulsants

in HCs and in the home by MWs and nurses. -Expand use of other life saving interventions at

HCs, including antibiotics, resusitation of neonates, and expansion of the MP A.

• Increase the number of midwives trained and available for deployment to new facilities through regular midwifery tra ining.

Improve quality of • Provide basic EmOC at selected HCs and

care for women improve quality of EmOC, including quality of

experiencing service providers, at all referral hospitals:

pregnancy-related -At HCs, management of hemorrhage,

complications. convulsions, administration of antibiotics, and

placenta removal. -At referral hospitals, all EmOC services

• In sequence: -Train existing midwives at existing health

centers in life saving skills. - Train other existing medical staff at existing

HC in life saving skills. Train staff at new health centers and referral hospitals as new facilities are established.

Expected Time Responsible Performance Resource

Results Frame Person Indicator Required Source

Workshop on Maternal Mortality Reduction Action Plan for Safe Motherhood 2000-2005 Cambodia

Issues/ Problems Objective Activities

-Increase the number of midwives trained and available for deployment to new facilities

Integrate basic • Establish a coordination mechanism with all EmOC into the related MOH departments and national MPA programmes. documentation and • Expand and modify MP A documents to include practice. prevention of complications and LSS (basic

EmOC) interventions.

• Phase in implement basic EmOC interventions from the MPA into practice.

• Get the Essential Drug Bureau and the Central Medical Store to supply equipment and drugs necessary for the added activities.

• Get the health information system to report details about pregnancy complications and maternal deaths.

Ensure integration • Map safe motherhood programs and services and of safe motherhood develop National Action Plan. components within - Make inventory of Safe Motherhood inputs existing MCH and into various MCH programs related programs -Conduct national workshops for review of the between the draft SM plan and dissemination of the final ministry of health plan. and other • Develop monitoring and evaluation plan for SM ministries, activities. international • Organize 3-monthly meetings with district organizations, management teams to monitor progress of SM bilateral agencies activities. and NGO's. • Publish annual statistics relative to indicators of

maternal health, BS, and newborn care.

Expected Time Responsible Performance Resource Results Frame Person Indicator Required Source

• Map • 2000 MOH, with • Short-term To be WHO

• Final support from consultant calculated RETA national WHO and develops map UNFPA plan RETA • National . Detailed workshop to imple- review draft mentation plan plans conducted

• National dissemination workshop conducted

Workshop on Maternal Mortality Reduction

Action Plan for Safe Motherhood 2000-2005

Cambodia

Issues/ Problems O bjective Activities

Develop • Develop and review nationally relevant

appropriate protocols for SM interventions using

policies and WHO and other guidelines.

regulations for - Translate and adapt WHO SM

specific, new areas guidelines. of safe motherhood • Using maternal death audit guidelines strategies. developed for the two pilot projects,

develop and implement national guidelines.

• Develop perinatal and neonatal death audit guidelines.

Conduct research • Develop a national research agenda for

that will be used to safe motherhood. create a better empirical base for policy making and program planning.

Expected Results

• All WHOSM guidelines translated.

• All existing SM guidelines reviewed.

• Final, revised national SM guidelines produced.

• National guidelines for MDAandNDA produced.

Time Responsible Frame Person

2000-2001 MOH; • CST/WHO

•

•

•

Performance Indicator

WHO guideline translation performed

CST advisor mission conducted National SM guideline document. National MDA andNDA guideline documents

Resource Required To be calculated

Source WHO

w N

Agency Programme/ Assisting Project Title

Government Reduction of of China MMR&NNTin

12 provinces

Support, WHO protection and

promotion of spontaneous delivery (research)

Safe Motherhood UNICEF Initiative

UNFPA Strengthening MCH/Family Planning Services at the Grassroots Levels

World Bank Health VI

WORKSHOP ON MATERNAL MORTALITY REDUCTION COUNTRY SITUATIONAL ANALYSIS

PEOPLE'S REPUBLIC OF CHINA

Activity Geographical Area Duration Funding Source

Training 12 provinces Jan. 2000-Dec. Central Government

Health education 378 counties 2001 Local Government

Equipment UNCEF

Monitoring & Supervision Poverty Alleviation Training 5 provinces Jan. 2000-Dec. WHO

Health education 2001

Control study

Training 3 1 provinces 1990-2000 UNCEF

Health education 468 counties GOC

Monitoring and Supervision Community Participation Training 23 provinces 1995-2000 UNFPA

Equipment 32 counties GOC

Surveillance Health Education Monitoring & Supervision Training 8 provinces 1995-2001 WB

Health Education 250 counties GOC

Equipment

Govt. Commitment

90%

Manpower

Matching fund Manpower

Matching fund Manpower

Matching fund Manpower

Issues/ Objectives Problems

Higher Reducing MMR in poor MMR areas

Poor Strengthening Ob/gyn ob/gyn service emergency capacity at treatment county &

skills of township county and levels township hospitals

WORKSHOP ON MATERNAL MORTALITY REDUCTION SUMMARY ACTION PLAN

PEOPLE'S REPUBLIC OF CHINA

Activities Expected results Time frame Responsible Performance person indicator

Training MMR in poor areas 2000-2005 PHC/MCH Hospital

Poverty reduced by 20% of the Dept., MOH Delivery Rate

Alleviation 2000 level and ratio of

Health Education deliveries

Monitoring & attended by

Supervision skilled village

Equipment birth attendants

Training and Preventable deaths at 2000-2005 PHC/MCH Project counties

hands-on practice; the county and township Dept, MOH equipped with

Specially assigned levels reduced essential

experts; equipment for

Establishment of a emergency

referral system; treatment;

Provision of County and

essential township

equipment for hospital doctors

emergency trained

treatment

Resource Source required

US$ 300mil GOC, intemati onal agencies (UN and others)

US$ 200mil GOC ( 1.2/person) UN

& other intemati onal agencies

Issues/ Objectives Problems

Low utilization of health facilities

ANC 35%Delv To increase assisted by ANC cov to

HWI9% 60% by 2005

PCNJI%

Cpr 18%

A. Low To increase awareness of delv assisted communities in byHWto health 50% by2005

B. Low quality of MCHcare

WORKSHOP ON MATERNAL MORTALITY REDUCTION SUMMARY ACTION PLAN 2000-2005

LAO PEOPLE'S DEMOCRATIC REPUBLIC

Strategies/Activities Expected results Time frame Responsible Performance person/ Indicator agency

I 2 3 4 5

I. Strenthening IEC on X X X X X MOHIMCH, # Health education

08 andECPG LWU,LYU session

I . Raising awareness Health education through health provider, sessions conducted mass media, community members, L WU, L YU

2. Organize Mother and Improve knowledge of X X X X X MOH/MCHI MCH examination

Child Health communities in health LWU,LYU days organized in all

Examination day (model care prov yearly

mothers and children)

3. Review/develop IEC Adequate IEC materials * MOHIMCH. IEC materials

materials and distribution and reach to people LWU.LYU available at health

to health facilities and facilities and villages

villages

4. Community Facilitate and stimulate * * * * * involvement through programme CMC implementation

II. Improvement health services at all levels in pilot area

I. National orientation Increased awareness on X MOH National orientation

workshop on MMR MMR reduction workshops conducted

reduction workplan.

Organize planning workshop in pilot area.

2. Develop of existing Improve the Qtl of Care X X WHO,MOH Manuals finalized.

manuals guideline on (especially EMOC) translated, pretested, IMPAC print and used

Resource required (US$) est

500 000

I 000 000

Source

UNICEF

UNICEF

WHO/UNC

EF/UNFPA

WHO/RET A

w U1

Workshop on Maternal Mortality Reduction

Summary of Action Plan 2000-2005 Lao People's Democratic Republic

Issues/ Objectives Strategies/ Activities

Problems

3. Operation manual of OB and ECPG for health facilities and village levels

3.1 Translation and discussion and finalize on OB and ECPG.

3.2 Printed manuals

4. Strengthening capacity of training centre in pilot area (TOT), training of care providers at provincial district health centre and VHW.

5. Provision of supplies/medical equipment to health service units

6. Improvement and expansion referral system in pilot area

7. Accurate health information system

Expected results Time frame

I 2 3 4

Knowledge and skill of X X X X HW improved and applied.

Adequate med sup! and X Qtl of service be improved

EOC be improved X X X X

Health data be improved X X X X in pilot areas

Responsible Performance Resource Source

person/ Indicator required

a2ency (US$) est

5

MCH

X MOHIMCH Training course conducted in two regional training

MOHIMCHC WHOIUNC WHO,

procured UNICEF. UNFPA

X MOHIMCHC Provide transportation, loan supported

X MOHIMCHC - Standardized WHO/

record forms UNICEF available and used

- Monitoring/supv/

mid-term review and evaluation conducted

Workshop on Maternal Mortality Reduction Summary of Action Plan 2000-2005 Lao People's Democratic Republic

Issues/ Objectives Strategies/ Activities

Problems

8. Monitoring/

supervision/evaluation

9. Annual review and planning workshop pilot areas in northern and southern parts of the country

REMARK: The project implementation, first pilot areas are 2 province, l 0 districts, 40 health centres and 80 villages in year 2001- 2002

the next, when success continue in 5 province, 30 district and 200 health centres and 120 villages in year 2003-2005

Expected results

Understanding and participation in implementation of MMr reduction programme

Time frame Responsible Performance Resource Source

person/ Indicator required a2ency (US$} est

I 2 3 4 5

X X X X X MOHIMCHC UNFPA/

UNICEF

X X MOHIMCH Conducted WHO/RET A

workshops

TOTAL I 500 000

Agency Programme/projec assisting t

Government Reproductive health

WHO MOG/RH-001

UNICEF Safe motherhood

UNFPA RH/sub-programme

WORKSHOP ON MATERNAL MORTALITY REDUCTION COUNTRY SITUATIONAL ANALYSIS

MONGOLIA

Major activities Geographical Amount and area Duration

- Management support through national All provinces 1997-2001 and provincial task forces established of Mongolia

- Delivery services to mother and child free of charge

- Provision of maternity leave (120 days before and after delivery)

- Re-establishment of maternity rest homes throughout the country

- Free delivery of emergency obstetrics and gynaecological aid

-Various technical support All provinces $145 000/

- Training of doctors on safe mother hood of Mongolia 2000-2001

and reproductive health services

- Supply of equipment

- Translation, printing and distribution of guidelines and manuals

- Local training on mobilization of National level $55 000-75 000 per community participation in safe year/ motherhood programme 2000-2001

- Translation and distribution of guidelines and training modules

- Management of sub-programme National level $2.3 million

- IEC and advocacy activities 1997-2001

- Supply of contraceptives and essential obstetric drugs

- RH survey

- Local training for health workers on RH services

Government commitment

- Provision of free services related to pregnancy and child birth

- Provision of manpower

- Support programme implementation and logistics

- Support programme implementation and logistics

- Support programme implementation and logistics

WORKSHOP ON MATERNAL MORTALITY REDUCTION SUMMARY ACTION PLAN 2000-2003

MONGOLIA

Problems:

I. Poor quality of maternal care 2. Poor knowledge of men and women on danger signs and complications of pregnancy 3. Poor communication and long distance of service delivery 4. Poor use of information system 5. Medical school is focused on curative care 6. Poor advocacy of safe motherhood/reproductive health among policy makers, decision makers

Objectives Activities Expected result Time Responsible Performance frame person/agency indicator

1. Improve quality Develop training - Knowledge and skills of 2000-2001 WHO Training materials of care materials on safe medical staff improved MHSW developed

motherhood - Midwives trained

Train 30 trainers Reduce MMR 2000-2003 30 trainers trained, from provinces, 400 midwives trained districts

Evaluate and Review existing situation; 2001 WHO Evaluation report monitor quality of make recommendations MHSW care on improvement

Recruit STC to Have a recommendations 2000 WHO Mission report review curriculum on improvement of 2001 MHSW Undergraduate and of medical existing curriculum postgraduate training college/medical cirr university

Required Source funds (USD)

1 500 WHO

7 400 WHO 49000 UNICEF, UN

FPA, ADB, MHSW

3 500 WHO

8 000 WHO

Workshop on Maternal Mortality Reduction

Summary Action Plan 2000-2003

Mongolia

Objectives Activities

Train obs/abroad (study tour)

Printing and distribution of standards

Train senior OB/GYN on safe motherhood standards

Supply of essential equipment

2. To improved Train heads and community directors of health

participation facilities

Train NGO activists and VHWs on danger signs of pregnancy

To establish funds for IEC awareness

Improve use of Review and improve

information MMcard

Expected result Time frame

Improve 2000-2002

knowledge/skill, attitude of doctors

Save with above 2000-2002

Introduced standards same into practice

Improved supply and 2000-2002

availability of equipment

Take support and 2001 increase knowledge 2003

Increased access to 2001 information

Increased IEC 2000 activities 2001

2002

Improve quality of 2000 care

Responsible Performance Required Source

person/agency indicator funds (USD)

WHO Developed 9 key 45 000 WHO

MHSW specialists and managers trained

WHO Nat. RH standards 5 000 WHO

MHSW delivered to SDPs

WHO Total 30 OB/GYNs 4000 WHO

MHSW trained

WHO Quality of care 200 000 WHO

UNICEF improved UNICEF

UNFPA 80 peoples trained 10 000 UNFPA

UNICEF UNICEF

UNICEF Change attitude 12 000 UNICEF

I 00 NGO activists trained

WHO Have operational fund 15 000 Local

UNFPA government

UNICEF

WHO % of card users MHSW

MHSW increased (properly) MCHRC

Workshop on Maternal Mortality Reduction Summary Action Plan 2000-2003 Mongolia

Objectives Activities

Support and introduce MMR case review in health facilities

Develop indicators to measure quality of services

Improve referral of Review and improve high risk women referral guidelines and complicated cases

Support maternity waiting homes in provincial centre

Expected result Time frame

Improve quality care 2000 2001

Same 2000 2001

Improved access to 2000 essential and 2001 specialized obstetrics care

Improved access to 2000-2001 specialized obstetrics care

Responsible Performance Required Source person/agency indicator funds

(USD)

WHO Increase number of WHO MHSW centers used properly MCHRC

WHO Successful use of WHO MHSW indicators MCHRC

WHO Developed and Local WHO MHSW distributed and government MCHRC MCHRC implemented organization

guidelines on referral will be maternity care responsible

for the budget required

WHO Increased % of MHSW number of mother with MCHRC high risk and obs.

Complications referred to the provincial and state maternity hospitals

Agency Program!Project Assistin2 Title

Government of MCH PNG

WHO RH

VBA RETA

CH & nutrition UNICEF UNFPA Strengthening RH

Population

ADB RETA

HSDP

AU SAID WCHP

STD/HIV

HSSD

WORKSHOP ON MATERNAL MORTALITY REDUCTION COUNTRY SITUATIONAL ANALYSIS

PAPUA NEW GUINEA

Major Activities Geographical area Duration

ANC, PNC, Delivery, FP, Management PNG 6 years

of gyn problems, Reproductive health education

Technical support 4 provinces 4 years

Increase health centre delivery Milne bay and EHP 2 years

Reduce maternal mortality in PNG by Country wide 6 months

- country analysis

- policy agreement

- increase immunization coverage, Milne bay and Madang 2 years

- reduce malnutrition

IEC (radio, pamphlets, community 4 provinces 4 years

awareness, adolescent RH information, and peer group training) Stafftraining, midwifery, special skills (vasectomy & TL) Equipment for RH Policy document & advocacy problems country wide 2 years

ditto above country wide 6 months

Hospital technical equipment country wide 4 years

Strengthening maternal & child health country wide 4 years

Reduce HIV epidemic country wide 3 years

Strengthening rural health infrastructure country wide 4 years

Fund Source in Government kina commitment

2. 7million

1.2 million

1.2 million

ADB

170 million Usd LOAN

70 million

15 million

110 million

Issues/Problems Objectives

AUSAID WCHP

STDIHIV

HSSD

55% unsupervised Increase% rural deliveries deliveries at MMR574 rural health resulting in 79.7% centres maternal deaths

WORKSHOP ON MATERNAL MORTALITY REDUCTION SUMMARY ACTION PLAN

PAPUA NEW GUINEA

Activities Expected Time frame Responsible Performance results person indicator

Strengthening country wide 4 years 70 million maternal & child health country wide 3 years 15 million

Reduce HIV country wide 4 years 110 million epidemic

Strengthening rural health infrastructure

Survey of Increased 10 years Family health % supervised

health centres supervised of DOH deliveries

with delivery rate to -HC community 85% -hospital survey. Introduce idea ofVHC and birthing at HC

Renovation of health centres as required.

Resource required

Finance AU SAid (HSSP)

Workshop on Maternal Mortality Reduction Summary Action Plan Papua New Guinea

Issues/Problems Objectives Activities

Midwife in Increase every health midwifery centre (50 training places church, 136 from 50 to gov't.) 150/year (2

new schools)

Increase Training VHC community involvement

Increase Strengthen community outreach in FP involvement and ANC

-risk identification (picture cards) - AN decision re TL or temp FP method - birth plan

Expected Time frame results

Increase supervised deliveries

Responsible Performance Resource person indicator required

Human I midwives Finance UNICEF resource dept. trained DOH 2. midwives

employed in HC

Guidelines Number of from training VHCin division DOH, villages PNGO&G Vaccination society and coverage university, Nutrition status supervised at <5yrs FP provincial level acceptance by provincial ANC advisor attendance

Provincial Finance AUDAid obstetrician

Picture cards SCF

Workshop on Maternal Mortality Reduction Summary Action Plan Papua New Guinea

Issues/Problems Objectives Activities

Education Emphasize 3 cleans, nutrition, FP, pregnancy and birth planning, STD prevention

Training and supervision -Clinical supervisory visit and in-service training -Nursing standards labour monitoring cleanliness drug storage and use (oxytocin, misoprostol, vaccine) - Management supplies, power, water, transport communications

Expected Time frame Responsible Performance Resource results nerson indicator required

Health AUSAid promotion division DOH

All HC functional for all aspects of HC deliveries Finance AUSAid/ ANC delivery Provincial WCHP service, obstetrician postnatal care and meeting FP needs

Provincial health

VI 0

Agency assisting Programme/project

1. Government

2. WHO Operational research on the use of partograph

3. UNICEF CPC V maternal health and nutrition programme

WORKSHOP ON MATERNAL MORTALITY REDUCTION COUNTRY SITUATIONAL ANALYSIS

PHILIPPINES

Major activities Geographical Duration Fund source area

- Development of safe motherhood Nationwide 2000 GOP policy

- Development of adolescent and youth health policy

- Monitoring and evaluation

- PMAC prevention and management of abortion and its complication

- Identification of suitable area Laguna 1996-1997 WHO/DOH/UNICEF/ AusAID

- Orientation of health worker

- Evaluation of training programme

- Implementation

- Data collection

-Dissemination of result and discussion of implication

Provision of supplies and training 20 provinces, 1993-2003 UNICEF fund 5 cities

Government commitment

Technical assistance in the development of policy/standard guidelines

Travelling expenses and per diem

LGU -TEVs

LGU and DOH- TEVs and per diem

Workshop on Maternal Mortality Reduction

Country Situational Analysis Philippines

Agency assisting Programme/project

4. UNFPA Reproductive health project

5. ADB ICHSP

Major activities

Pilot RH element implementation with facility and capability upgrading

Improve the efficiency and effectiveness of the health care delivery system through a comprehensive approach to health system development at the local level

Geographical area Duration

9 provinces, 2000-2004 4 cities

Kalinga, Apayao 1998-2002 Pal a wan Guimaras South Cotabato, and Surigao del Norte

Fund source

UNFPA

ADB

Government commitment

LGU and DOH- TEVs and per diem

LGU and DOH- TEVs and per diem

U1 N

Issues/problems Objectives

1. High maternal Reduce maternal mortality rate mortality ratio to

86 deaths per 2. Low Birth 100,000 Weight of babies livebirths by

year 2004. 3. Mortality rate (Baseline 172 of neonates deaths per

100,000 livebirths in 1998, NDHS)

WORKSHOP ON MATERNAL MORTALITY REDUCTION SUMMARY ACTION PLAN

PHILIPPINES, 2000-2005

Activties Expected Time frame Responsible Performance Results persons/agencies indicator

l. Development Copies dissemi- Jun - Aug MCHS/SM Approved and and approval of nated to all Coordinator signed by the National Policy regions and Secretary of Health onSM,RH, interested AYHandPMAC institutions/

agencies

2. Orientation & MMRTeam July-Sep Regional and Orientation, organization of organized in provincial organization of theMMR Team Regions. V, VIII, MMRteam in 3 priority CAR conducted regions w/ high MMR (Regions V, VIII, CAR)

3. Conduct of On-going review Oct-Dec MCHS/WHSMP All 1999 maternal MMR for every deaths reviewed

maternal death

Resource Source required

Reams of DOH-MCHS bond paper

Training fund DOH, UNICEF, LGU {TEVs, per diem

MMRtool , LGUs TEVs

Workshop on Maternal Mortality Reduction Summary Action Plan Philippines, 2000-2005

Issues/problems Objectives Activties

Reduce the 4. Training of proportion of the first level LBW to 12% of referral doctors total livebirth in the priority (Baseline 16.6% areas (Regions in I 998 NDHS, V, VIII, CAR) 1997 FHSIS)

Reduce mortality 5. Adaptation of rate to 3.0 OB emergency neonates per manual 1 ,000 livebirths. (Baseline 7.8/1,000 livebirths in PHS 1994)

6. TOT on the use ofthe partograph

7. SM-GIS

Expected Results

Trained doctors able to manage OB emergency cases

Adaptation of WHO generic manual to Philippine use

Trained regional coordinator on the use of partograph

Equitable resource allocation

Time frame Responsible Performance Resource Source

persons/agencies indicator required

June-Dec MCHS All district Training funds, WHSMP hospitals in 3 TEVs, per diems regions with at least I trained FLRD

July-Dec MCHS Manual adapted Funds, UNICEF writeshop supplies

Oct-Dec MCHS All regional Training funds, GOP coordinators TEV s, per diem trained

June-Dec MCHS Data collected/ Travelling GOP installed expenses, per

diem of data collection, GPS, camera, computer forms

Workshop on Maternal Mortality Reduction Summary Action Plan Philippines, 2000-2005

Issues/problems Objectives Activties

8. Procurement, distribution of micronutrient supplementation (Vit. A, iron, multiple vitamins)

9. FFL training

10. Monitoring and evaluation

Expected Time frame Responsible Results persons/agencies

Women of June-Dec MCHS reproductive age receiving

Regions

Trainees able to Aug-Nov MCHS train illiterate women

SM programmes June-Nov MCHS implementation monitored

Performance indicator

Micronutrient supplementation available in health facilities

Training conducted in CPC V areas

Monitoring and evaluation of regional and provincial implementation of SM programme

Resource required

Micronutrient, freight

Training fund, supplies, traveling expenses, per diem

Travelling expenses, integrated monitoring checklist

Source

WHSMP

UNICEF/DOH/ HSMP

UNICEF/DOH

GOP

U1 U1

Issues/problems Objectives Activties

I. Orientation and organization of MMR team on the rest of the 13 regions

2. Conduct of MMRin all regions

3. Training of FLRD

4. TOT on the use ofEOC manual to complement the training of FLRD

5. Training of implementation on the use of partograph

SUMMARY OF ACTION PLAN 2001

Philippines

Expected Results Time frame Responsible persons/agencies

MMRteam Jan-Dec MCHS organized in 13 regions

On-going review 2001-2005 MCHS for every maternal death. Results analyzed and recommendations dessiminated

District hospitals in 2001-2002 617 regions able to perform OB emergency management

Doctors, nurses 2001-2002 MCHS able to perform OB emergency management

Nurses, midwives, 2001-2002 Regions monitor labor using the partograph in the periphery

Performance Resource Source indicator required

Orientation, Orientation, UNICEFIUNFPA organization of fund, TEVs, MMRteam per diem conducted

Every cases of MMR tools, LGUs maternal deaths TEVs reviewed

All district Training fund, WHSMP,LGUs hospitals in 6/7 per diem, regions with at TEVs least 1 trained on FLRD

All district Training fund, UNICEFIUNFPA hospital with TEVs per diem trained doctors, nurses on EOC manual

Number of Training fund, UNICEFIUNFPA/ nurses, TEVs, per MCHS midwives diem trained on partograph

Summary of Action Plan 2001 Philippines

Issues/problems Objectives Activties

6. Upgrading of facilities

7. Zonal meetings

8. Multisectoral consultative/plan ning workshop to encourage political commitment

9. Civil works

10. Revision of the maternal care manual for midwives

Expected Results Time frame

Accessible 2001-2004

functional facilities

Agreements, Jan-Dec commitment

Strengthened partnership/support 5% budget utilized - communication support (e.g. transportation)

Functional 2001-2002

Copies used as Jan-March reference guide

Responsible Performance

personsla2encies indicator

MCHS/WHSMP Number of facilities upgraded

MCHSIUNICEF 4 zonal meetings conducted

Agreements/plan of action

WHSMP - I 0 lying-in - 15 maternity waiting homes - 10 halfway nurses

MCHS Revised edition

Resource required

Construction budget, fund for supplies and equipment

Meetings fund, TEVs

Fund, TEVs, per diem

Construction budget

Budget for revision/ production

Source

WHSMP, UNFPA

MCHSIUNICEF

MCHS

WHSMPIUNFPA

UNFPA/WHO

U1 00

Issues/problems Objectives Activties

1. Training of H.C. doctors, nurses, midwives on OEC in CPC V areas

2. Integration of OEC in the midwives, nursing and medical curriculum

3. Expansion of FFL training to non-CPC V areas

4. Integration of functional two way referral system in the health district system

SUMMARY ACTION PLAN 2002

Philippines

Expected Time frame Responsible Results persons/a!!encies

Doctors, 2002-2004 Regions/provincial nurses, midwives in H.C., lying-in, maternity waiting homes, halfway homes able to respond to OEC before referral to higher level

Doctors, nurses March Regional/provincial and midwives able to perform OEC after graduation.

Trainees able May WHSMP/MCHS to train women to become literate functional Functional Jan-March two-way referral

Performance Resource Source indicator required

Number of Training fund, UNICEF doctors, nurses, TEVs, per diem midwives trained

OECand Management UNICEF/UNFPA

integrated in the funds, workshop curriculum funds, curriculum

development

Number of trained Training fund, UNFPAIMCHS

FFL TEVs, per diem

Organized two- Orientation/mana MCHS

way functional gement funds, referral system in logistics funds district health system

Summary Action Plan 2002 Philippines

Issues/problems Objectives Activties

5. Regional meeting with TBAs, "Strengthening support" redirecting roles in the community participation for safe motherhood

6. Translation/product ion/distribution of IEC prototype to local dialect

7. Updating ofSM website

8. Development of IEC materials on postpartum and early pregnancy

Expected Results

TBAs participation in various activities (e.g. health promotion)

- Copies read by the community -Copies used in health promotion campaign

Interested parties able to access SM programme-Philippines

Distributed to Regional offices for adaptation/ reproduction/ distribution

Time Responsible Performance

frame persons/agencies indicator

April Regional MCH Registration of

coordinator active TBAs

2002-2005 Regions Number of copies available

2000-2005 PIRES Continued updates

June MCHS/PIHES Prototype developed

Resource required

Meeting funds (16 regions), TEVs, DSA

Logistical supplies

Logistical supplies

Source

UNlCEF/MCHS

MCHS/PIHES

MCHS/PIHES

MCHS/PIHES

0\ 0

Issues/problems Objectives Activties

I. Training of health center doctors, nurses and midwives on OEC in non-CPC V areas

2. Follow-up meeting with TBAs by regions

3. Programme review on safe motherhood RH

SUMMARY ACTION PLAN 2003

Philippines

Expected Results Time frame Responsible persons/agencies

Doctors, nurses, 2003-2005 Regions/provincial midwives in health offices health center, lying-in, maternity waiting homes, able to respond to OEC before referral

Documentation of May Region the past year Trained Birth Attendant (TBA) community participation

Documented March MCHS status of programme performance by regions

Performance Resource Source indicator required

Number of Training fund, UNFPA doctors, nurses, TEVs, per diem midwives trained

Attendance to Meetings fund, UNICEF/ meetings TEVs, DSA MCHS

Programme Workshop fund, UNICEF/ review conducted per diem, TEVs MCHS

Issues/problems Objectives Activties

I. Documentation and expansion of best practices (e.g. health & financing

2. Advocate for legislation

- Increasing maternity leave from 2 months to four months for the 1st & 2nd child w/ birth space of 2 years & above

-Training of nurse anesthetist

- BF room for every establishments

SUMMARY ACTION PLAN 2004-2005 Philippines

Expected Results Time frame Responsible

2004 2005 persons/agencies

communities/ X Regional Offices facilities implementing health care financing

Approved bill X MCHS

Performance Resource Source indicator required

Document, list of TEVs MCHS/ communities/ DSA Region facilities Logistics

Copy of bill MCHS proposal

Nurse anesthetist trained

Agency Programme/project assisting

UNFPA Strengthening RH Services

UNFPA/ RH Initiative EU

UNICEF District Action Plan on Safe Motherhood

WORKSHOP ON MATERNAL MORTALITY REDUCTION COUNTRY SITUATIONAL ANALYSIS

VIETNAM

Activity Geographic area

Integration Delivery care with FP and RH components. 8 Provinces

SM components: - Policy level: clinical guidelines, Procedures and Responsibilities for every level of care. - Improving services and capacity in 8 provinces. - Counselling and IEC for community.

Adolescent RH through local NGOs and local people Hanoi and Hue

committees cities

Focus on promoting Home-based Pregnancy Record, and EOC 18 districts of 16

in commune and district levels. provinces.

Reduction MMR by: Capacity building for health personnel at all levels, for Nutrition program

-Community (TBAs), strengthen midwifery training at school. covers the whole

- Upgrading Health services: provision basic supply and country.

equipment, set up a functioning referral system, use of

delivery kit in all home delivery. - Community empowerment. -Nutrition, vitamin A, iron, iodine, and training.

Funding/ Government Duration

1997-2000 Yes (30%?) (US$4 million)

1999-2001 Yes

1996-2000 Yes (20%)

PHC- Safe Mother hood (US$400,000/ year) -Nutrition (US$800,000/ year)

Workshop on Maternal Mortality Reduction

Country Situational Analysis VietNam

Agency Programme/project Activity

assisting Buffet, Training for Safe Capacity building for maternal care technical provider, especially in

Netherlands Motherhood and care their areas of knowledge and skills of infection prevention, ANC,

Government of the Newborn management of normaJ deliveries/newborn care.

andAUSAJD Initiative (SMCN) -Training -Equipment and supplies -Infrastructure

SCFIUS Safe Motherhood Life-skills Training for midwives, ANC, cJean and safe delivery,

training on AN skills for mother and community through regular

group meeting by the pregnant women. Mother to mother group. Support to family for revolving fund. Su_pport mother-mother group.

JICA Safe Motherhood ANC and pregnancy management through promoting community

involvement by Mother-Mother groups and share experiences

among groups within villages and communes.

Training of midwives and community workers.

World Bank Clean delivery Provide clean environment and clean water supply for clean and

safe delivery, promoting the use ofPartograph.

Infrastructure and equipment Ambulance. Training Midwives, Nurses, TBAs and community workers.

ADB Support for Rural Primary Health Care:

Health -equipment and supplies for District hospital

- Infrastructure for District Hospital. - Training for doctors, midwives and village health workers for all

levels.

Geographic area Funding/ Govern Duration ment

8 provinces: MCH 1999-2000- Yes

centers 2004 US$6 million

Thanh Hoa 1995-2000 Yes

province, 1 0 districts

3 districts ofNghe 1997-2000- Yes

an province 2005

16 provinces, 1 0 1998-2003 Yes

district per province

13 provinces 2001-2005 Yes US$100 Govt. million 30%

Workshop on Maternal Mortality Reduction Country Situational Analysis VietNam

Agency Programme/projec Activity

assistin2 t

AU SAID Strengthen the Strengthen the capacity of provincial MCHIFP centers

capacity of provincial MCHIFP centers

GOVT Kangaroo mother Comprehensive Care for low birth weight infant

care •

Marie Stopes Improve quality of -Set up clinic

International EOC -contraceptive methods/sterilization -safe abortion -EOC

UNICEF/WHO Breastfeeding -Promotion of breastfeeding program -Training and education materials development for secondary

medical school -Baby-friendly hospital with international standard -Implementation of international code

GOVT Safe Motherhood Training Project Supplies, equipment

Infrastructure, clean water supply Monitoring and supervision Management information system

Geographic area Funding/ Govern Duration ment

5 provinces ? Yes 5 y (1998-2003)

1 central hospital Ongoing 100% and 1 provincial hospital

6 provinces/one 2000-2003 Yes clinic each mobile clinic

20 provinces + 13 1995 -2005 Yes provinces (2000)+28 provinces by 2005

76 central/provinces hospital ( 46 already covered) by 2005 Pilot in 5 l00%GVT 100% provinces, 5 districts each, 5 2 y (1997-99) communes each: total 125 CHCs

Issue/problem ObjectivesS

HR.: Lack of 100% CHCs with Midwives midwives by 2005

(about 2000 midwives)

Lack of updated Re-training of all knowledge existing midwives

by 2005

Lack of doctors with 40% CHCs have obstetric emergency doctor with obst. knowledge at CHC emergency

training by 2000 (about 4000 doctors)

Lack of health To cover the workers with needs with HWs training in basic trained on basic obst.care in CHCs obst. Care (about

5000)

WORKSHOP ON MATERNAL MORTALITY REDUCTION SUMMARY ACTION PLAN

VIETNAM

Activities Expected Results Time Responsible frame person

Training of new At least 1 trained Provincial

midwives midwife in each 36M secondary/medica

Redeployment CHC providing SM I school: training

DIC and C/C services* Commune: identify midwives

Re-training of At least I trained 5Y Provincial MCH

about 5000 midwife or HW with center: re-training

existing midwives basic obst.care in Commune: each CHC providing identify midwives

TOT SM services* Central level

Training 1500 At least 1 doctor going Central medical

Redeployment with obst. schools

500 centrai/P/D/C Emergency training in 40% of CHCs**

Training of 5000 At least I trained 6M Provincial MCH

HWs on basic midwife or HW with centers/ hospitals

obst.care basic obst.care in each CHC providing

TOT SM services* Central level

Indicator Resources Sources

%ofCHCs Yes GVT with at least (1000) I trained Gap: 300 UNFPA midwife WHO? (700)

% ofre- Yes GVT trained (3000) midwives Gap: UNICEF

I500 (500) ?

%of doctors Yes GVT in the CHCs

%of trained Yes GVT HWsin UNFPA CHCs Gap: 40% WB

CHCs ?

Workshop on Maternal Mortality Reduction

Summary Action Plan VietNam

Issue/problem ObjectivesS

Lack of doctors with 40% CHCs have

obstetric emergency doctor with obst.

knowledge at CHC emergency training by 2000 (about 4000 doctors)

Lack of health To cover the workers with needs with HWs training in basic trained on basic obst.care in CHCs obst. Care (about

5000)

There are too many Uniform curricula different curricula and training and training materials by 2001 materials

Need of improve To strengthen capacity MOH management management, capacity at monitoring and MOH!RHto supervision of RH provide assistance

to provinces

Activities Expected Results

Training 1500 At least l doctor Redeployment with obst. 500 central/P/D/C Emergency training

in 40% ofCHCs**

Training of 5000 At least 1 trained HWs on basic midwife or HW with obst.care basic obst.care in

each CHC providing TOT SM services*

Revise curricula Coordination and all and training agencies to use the materials same curriculum and WorkshopRH training materials Selection of curriculum and training materials Training Quality service Development of clinical/ monitoring/ training guidelines

Time Responsible Indicator Resources Sources

frame person going Central medical %of doctors Yes GVT

schools in the CHCs

6M Provincial MCH %of trained Yes GVT

centers/ hospitals HWsin UNFPA CHCs Gap: 40% WB

CHCs

Central level ?

1-2 y MOH:MCHand Same curr. Gap: GVT

training And training WHO WHO

departments materials UNFPA UNFPA

will be used GTZ Pathfinder

by all Other? GTZ agencies

5Y MOH Standardized UNFPA GVT

Provincial people documents UNFPA

committees available

Workshop on Maternal Mortality Reduction Summary Action Plan VietNam

Issue/problem ObjectivesS

Low access to 100% communes service/ referral have SM Difficult committees communication Low community involvement

Lack of standard To have 100% delivery room in CHCswith about 5000 CHCs standard delivery

room by 2005

Activities

Organize commune committees Arrange transportation To provide phone in each CHC to call ambulance Support to poor people

Identify CHCs Provide standards for improvement Upgrade CHCs

SM services CHC provided by trained midwife: ANC care at least 3 times per pregnancy Normal delivery Referral of high risk pregnancies Post-partum 2 visits per pregnancy

Expected Results

Early detection of early pregnancy and ofhigh risk pregnancies Improve CHCs referral capacity Reduce delay

To have improved CHCs for clean delivery

Immediate newborn care (resuscitation and thermal protection)

Post-natal visits 2 Immunization Breast feeding counselling FP

EOC services provided by the doctor: -Manual removal ofplacenta - Removal incomplete abortion - IV treatment

Time Responsible Indicator Resources Sources

frame person 5Y Director DHC % of high risk GVT GVT

Leader of pregnancies Gap People

commune identified on ambulance: UNICEF

committees total 150 DHs (phones) WB

pregnancies Gap phone: (ambulance) 8000 CHCs

5Y Director PHS %ofCHCs GVT

Leader of upgraded ADB

commune WB

committees