In countries with existing plans for maternal, newborn and child health interventions, the H4+ agencies are supporting faster implementation and linkages with national health strategies
Trang 2WHO Library Cataloguing-in-Publication Data
Maternal, newborn, child and adolescent health: progress report 2010-2011: highlights
1.Child welfare 2.Child health services 3.Adolescent health services 4.Maternal welfare 4.Infant welfare 4.Program evaluation 5.Program development I.World Health Organization
ISBN 978 92 4 150360 0 (NLM classification: WA 310)
© World Health Organization 2012
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The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters.All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication However, the published material is being distributed without warranty of any kind, either expressed
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Trang 4Message from the WHO
Assistant Director-General
The new decade has been marked by important new initiatives that focus
on the health of women and children and seek to accelerate progress
towards achieving the Millennium Development Goals 4 and 5 In
September 2010, the UN Secretary-General Dr Ban Ki-Moon presented
the Global Strategy for Women’s and Children’s Health The Global
Strategy that was developed by a broad range of constituencies, seeks
to save 16 million lives of women and children by 2015 in the 49 poorest
countries
Efficiency and effectiveness are key words in the Global Strategy We must
invest more, but also direct our investments rightly WHO in collaboration
with the Partnership for Maternal, Newborn and Child Health summarized
and published in 2011 the essential low-cost interventions, commodities
and guidelines for women and children across the continuum of care If
these are implemented at scale, the global community can dramatically
increase access to life-saving interventions for women, children and
adolescents living in the most vulnerable populations
Governments and the global community at large have responded
overwhelmingly positively to the call for commitments and over 40 billion
US$ will be made available for the implementation of the Global Strategy
Commitments range from governments pledging to increase domestic
health expenditure and expand the health work force to partners
increasing access to low-cost technologies and increasing financial
support
Commitments need to translate into action and action has to generate
results The Commission on Information and Accountability for Women’s
and Children’s Health, established by our Director-General Dr Margaret
Chan in January 2011, came out with ten compelling recommendations
for tracking results and resources Moreover, the Commission called for a mechanism of internal oversight and I am delighted that
an independent Expert Review Group was appointed by the UN Secretary General in September 2011, after a transparent and open nomination process The ERG will report
on progress every year and hold stakeholders
to account, in beneficiary as well as donor countries WHO is privileged to host the Secretariat of the ERG and to facilitate access to information through its website at http://www.who.int/woman_child_accountability/en/
It is now a time of unprecedented opportunity Never before has the global community rallied so strongly and uniformly around the cause of reproductive, maternal, child and adolescent health WHO is determined
to play its role and facilitate that indeed, investments will lead to improved access and coverage of essential interventions The Family, Women and Children’s Health Cluster is uniquely positioned to take on the charge Its new structure permits us to act in a more coherent way and respond efficiently to the requirements for building the continuum of care This report highlights achievements of the Department of Maternal, Newborn, Child and Adolescent Health It pays testimony to a range of tools and actions developed and supported by our extensive network of staff in headquarter, regional and country offices WHO cannot do it alone, but with so many committed stakeholders, I would like to convey the message that we can and will deliver on the promises made
Flavia Bustreo, Assistant Director-General, Family, Women's and
Children’s Health Cluster
Trang 5Message from the Director
The Department of Maternal, Newborn, Child and Adolescent Health was established from the 2010 merger of the departments of Making Pregnancy Safer and Child and Adolescent Health and Development The merger represents a consolidation of efforts and a confirmation of WHO’s commitment to investing in Millennium Development Goals 4 and 5 and ensures the application of the continuum of care from pregnancy through infanthood and childhood to adolescence
The Department provides evidence, norms and standards and supports the adoption of evidence-based policies and strategies in line with international standards of human rights, including the universal right of access to health care It also builds capacity for high-quality, integrated health services for pregnant women, newborns, children and adolescents, and monitors and measures progress in implementation and impact To
do this, the Department works closely with other technical units at WHO's headquarters and in regional and country offices and with partners
The process of research and development
of policies, norms, standards and tools, implementation, monitoring and evaluation is not a linear one but a cyclical one WHO has
a unique mandate to play a leadership role in that process This highlights report for 2010-
11 shows examples of key achievements in the period and demonstrates that the Department has continued to be highly productive and effective throughout its reorganisation
Ultimately, it is the action and outcomes at country level measure the success of the work of the Department This report provides a good picture
of the depth and diversity of our work, and can serve as an inspiration for renewed and strengthened action for the health of mothers, newborns, children and adolescents
Elizabeth Mason, Director, Department of Maternal,
Newborn, Child and Adolescent Health
Working along the continuum
of care
Trang 6The UN Global Strategy for Women’s and Children’s Health
In September 2010, the
UN Secretary-General launched the Global Strategy for Women’s and Children’s Health as
a final push towards the attainment of Millennium Development Goals
4 and 5 The Strategy was developed with the involvement of many partners and stakeholders, and generated commit-ments in excess of US$ 40 billion
Measuring results is key to the success of the Global Strategy, and in 2011 the Commission on Information and Accountability for Women’s and Children’s Health, set up by the WHO Director-General, was charged with this task Chaired by President Jakaya Mrisho Kikwete of the United Republic of Tanzania and Canadian Prime Minister Stephen Harper, the Commission made 10 recommendations for tracking resources and measuring results These recommendations form the basis of a common global work plan on accountability that focuses on the 75 countries with the highest burden of maternal and child mortality
The work plan calls for the strengthening of vital registration of births and deaths, national health information systems, and quality-of-care assessments including maternal death surveillance and response It recommends that countries conduct annual reviews of progress combined with advocacy It also promotes national digital health strategies and transparent reporting on resources by both recipient and donor countries An independent expert review group will report on progress
in the implementation of the Commission’s recommendations
The Department is playing an important role in follow-up of the accountability work plan together with the other H4+ agencies (UNICEF, UNFPA, WHO, the World Bank and UNAIDS) and in partnership with development agencies, academic institutions and non-governmental organizations It will lead the working group
on quality-of-care and maternal deaths surveillance and response, and support
From global strategy
to national reality
Efforts to put the UN Global Strategy for Women’s and Children’s Health into action reached an important milestone in 2011
By the end of the year, all 49 of the lowest income countries that are the focus of the Global Strategy had made specific commitments to accelerating action towards the achievement of Millennium Development Goals 4 and 5
WHO together with its partners in the H4+ inter-agency mechanism facilitated the development of national commitments Now WHO is working with its H4+ partners
to support countries to turn these national commitments into action In countries with existing plans for maternal, newborn and child health interventions, the H4+ agencies are supporting faster implementation and linkages with national health strategies and systems strengthening efforts, as well as with monitoring progress
in maternal, newborn, child and adolescent health
In Burkina Faso, the Democratic Republic of the Congo, the Republic of Sierra Leone, the Republic of Zambia and the Republic of Zimbabwe the H4+ agencies have jointly supported the development of country plans with a specific focus
on accelerating progress in maternal and newborn health under the umbrella of
a grant from the Canadian International Development Agency In addition, with support of France, the H4+ agencies work in nine francophone countries in West Africa and in Haiti to improve maternal and child health This joint support will continue over the next five years to further reinforce the national scale-up of integrated reproductive, maternal, newborn and child health interventions, and national health systems strengthening and monitoring
united nations secretary-general ban Ki-moon
Global Strategy for Women,s and Children,s Health
g L O B A L C O N T E X T A N D
S T R A T E G I C D I R E C T I O N S
Trang 7The UN Convention on the Rights of
the Child: more relevant than ever
The 20th anniversary of the UN Convention on the Rights of the Child (CRC),
in 2009 was an ideal opportunity to look at how the CRC can be used
as a practical framework and tool for improving child and adolescent health With that in mind, WHO, UNICEF, Save the Children International, and World Vision International organized a technical consultation in May 2010,
bringing together a diverse group of experts in the fields of child and adolescent
health, human rights and law, including representatives from UN agencies,
international aid organizations, academic institutions, and independent experts
While the Convention had been extensively used to advocate for and raise
awareness of children’s and adolescents’ health, it had not been systematically
applied as a tool for strategic planning and programming The consultation provided
a unique platform to explore and discuss both opportunities and challenges in
applying the Convention as an essential legal and normative framework, as well
as a programmatic tool, for advancing child and adolescent health in countries
A number of recommendations adopted at the consultation are now being
implemented, including providing assistance to the UN Committee on the Rights of
the Child in the development of a General Comment on children’s right to health
The consultation also revealed that raising awareness of the CRC must go
hand-in-hand with demonstrating its practical added value in planning and programming
for child and adolescent health
Planning informed
by evidence
Having a national strategy and plan of action to increase access and coverage
of effective interventions is a pre-requisite for countries to make steady progress towards the attainment of improved health outcomes of the population, including the targets of the health-related MDGS
The Department is providing guidance on strategy development that involves identification of high impact interventions to address the burden of disease according
to context, and costing of the resulting action plan To this effect, a new tool is now available to guide the national dialogue The United Nations OneHealth Costing Tool developed by UN agencies can be used to ensure that national strategies and plans for maternal, newborn and child health are appropriately prioritized and realistically costed The tool covers multiple public health areas (such as immunization, HIV and tuberculosis) as well as health system functions such as human resources and medicines, supplies and equipment It thus has potential to consider the health sector’s absorptive capacity and simplify and harmonise national planning and costing processes under one unified platform
Experts in health systems and maternal and child health programmes from nine countries in the Western Pacific Region attended a training workshop on using the OneHealth tool At the end of the workshop, participants were able to cost health-related interventions in different country contexts and generate basic costing projections for their maternal and child health programmes They could also perform a strategic assessment of a health system’s performance and capacity for key maternal and child health interventions Additionally they could use the tool to compare alternative scenarios for scale-up, examining the financial implications and the expected reduction in disease burden
One key aspect of OneHealth is the Lives Saved Tool (LiST), which is used for estimating intervention impact of different intervention packages and coverage levels for countries In the Region of the Americas, an intercountry training was held on LiST
in the Republic of Peru This brought together government officials and academics
in the fields of health care planning, health economics and health care financing from six countries, together with technical staff from WHO country offices in the Republic of Honduras and Peru The workshop resulted in each country developing
a plan of action to scale-up LiST with the ministries of health and other institutions
Trang 8m A T E R N A L H E A L T H
Reducing maternal mortality
Millennium Development Goal 5, to improve maternal health, is one goal that seems unlikely to be achieved under the current state of affairs At 2.3%, the annual rate of reduction in estimated maternal mortality ratios over the past two decades (1990-2008) remains well below 5.5%, the rate required to reach MDG5 (Figure 1)
Maternal deaths are mostly concentrated in the African and South-East Asia regions (Figure 2) These two regions contribute to more than three-quarters of all maternal deaths worldwide and the African Region continues to have the highest maternal mortality ratio At 620 per 100000 live births, it is more than
44 times the average in more developed regions
In three WHO regions—Western Pacific, South-East Asia and Europe—the estimated maternal mortality ratio has fallen by 50% or more Several factors may have contributed to the decline in estimated maternal mortality rates, ranging from health systems strengthening to increasing female literacy Improved vital registration and notification of maternal deaths are urgently needed for better understanding of and response to improve maternal health
More than 60% of maternal deaths occur in the postpartum period The risk of death is highest close to birth and then decreases over the subsequent days and weeks Delays in recognizing and responding to life-threatening complications
at home are also important non-medical reasons for maternal deaths Globally, the proportion of births attended by skilled health personnel has increased (Figure 3) and many countries are actively encouraging women to give birth in health facilities
Figure 1 Trends in Maternal Mortality
Ratios 1990 - 2008*
0 100 200 300 400 500 600 700 800 900
1990 1995 2000 2005 2010 Africa Eastern
Mediterranean South-East Asia Western Pacific
Americas
Europe World
Figure 2 Maternal Mortality Ratios by country - 2008
Figure 3 Trends in the proportion of births by
skilled health personnel 1990-2008
0 10 20 30 40 50 60 70 80 90 100
Global Africa Americas Eastern
Mediterranean
Europe South-East
Asia
Weatern Pacific
1990 2008
Trang 9Road Map for reduction
of maternal mortality in Africa
By the end of 2011, 44 countries in sub-Saharan Africa had developed national Road Maps for accelerating the attainment of the Millennium Development Goals 4 and 5
As part of the implementation process, countries review their progress towards set objectives and adjust their strategies
to ensure that targets are achieved by 2015
The Road Map review process developed by WHO (AFRO and HQ), together with
other H4+ partners, USAID and others, aims to measure what progress has been
made, identify constraints and bottlenecks, and propose solutions for accelerated
implementation
In 2011, teams of Road Map review facilitators from 15 countries underwent
training, after which the review process was implemented in five countries in the
region Both processes showed that the Road Maps are playing a strategic role in
bringing together all stakeholders and highlighting maternal and neonatal survival
There is still work to be done to improve quality and use of information for identifying
the gaps, setting priorities and allocating resources Sub-national analysis needs
to be strengthened to highlight gaps in equity, access and distribution of maternal
and newborn services, especially to identify differences between rural and urban
areas and to ensure that the interventions are reaching the women and children
that need them most
The Road Map review process will continue to roll out in the remaining countries
in 2012 It will feed into the national health sector review processes related to
monitoring country commitments to the UN Global Strategy for Women’s and
Children’s Health and monitoring of progress towards the Millennium Development
Goals related to maternal and newborn health
Progress in reducing maternal mortality in the Americas: A lot but not enough to reach MDG's
Countries of the Region of the Americas have made great efforts to reduce maternal mortality There has been a 41% reduction
in the maternal mortality rate since 1990, and there have also been considerable improvements in the surveillance and monitoring of maternal mortality, allowing more accurate identification of maternal deaths than in previous years
The majority of maternal deaths are due to avoidable causes and are more frequent among vulnerable groups: poor adolescents, rural residents, indigenous women and those of African descent The gains made so far are insufficient if the region is to reach Millennium Development Goal 5 by 2015
The Plan of Action to Accelerate the Reduction of Maternal Mortality and Severe Maternal Morbidity was developed
by the Latin-American Center for Perinatology/Women and Reproductive Health,
a WHO Regional Office of the Americas technical centre responsible for maternal and perinatal health
The plan focuses on four strategic areas: prevention of unwanted pregnancies and resulting complications; universal access to affordable, high-quality maternity services within a coordinated health care system; increasing the number of skilled personnel in health facilities for preconception, antenatal, childbirth, and postpartum care; and strategic information for action and accountability
IMPLEMENTING
NATIONAL STRA
TEGIES
Trang 10m A T E R N A L H E A L T H
A better system for maternal and neonatal health surveillance in the Eastern Mediterranean Region
The vast majority of maternal and newborn deaths occur around the time of delivery or shortly thereafter, most of which could be avoided by simple preventable measures and referral to emergency services
Effective surveillance, analysis and reporting of maternal and newborn morbidity and mortality are crucial to guide improvements
in service quality
In 2010, the Eastern Mediterranean Regional Office brought together experts from 10 Member States, the American University of Beirut, the US Centers for Disease Control and Prevention, the Aga Khan Foundation and the Royal College
of Obstetricians and Gynaecologists to formulate national plans of action for strengthening maternal and neonatal health surveillance systems in the participating countries The meeting also produced technical recommendations to support the implementation of these plans
The Regional Office also developed generic facility-based maternal and newborn health client record forms These forms are due for field testing in early 2012
They will then be presented to the member states for adaptation and adoption to improve national maternal and newborn health information systems
Maternal mortality and morbidity audit: 'Beyond the Numbers'
in the European Region
The average maternal mortality rate in the WHO European Region dropped from 44 per 100 000 live births in 1990 to 21 per 100 000 in 2008 However, every year many women still suffer pregnancy-related complications and a number of them die as a result There are also large discrepancies both between and within countries Even in countries where resources are limited, most maternal and perinatal complications and deaths can be averted with basic and effective low-cost interventions WHO in the European Region shows how this can be accomplished, using tools such as Beyond the Numbers
The Beyond the Numbers tool was introduced in the European Region in 2004 and since then many countries have implemented it under the leadership of Ministries of Health In June 2010, 90 representatives from 16 countries gathered
in Charvak, the Republic of Uzbekistan to share experiences and lessons learned using the tool, in order to further improve the quality of care for mothers and babies in their countries
There were a number of important lessons learned The principles and practices
of WHO/Europe Effective Perinatal Care as well as national clinical guidelines on major obstetric complications must be implemented for successful introduction
of the Beyond the Numbers tool For appropriate implementation of Beyond the Numbers, the support of ministries of health, together with external support from experts, is crucial Case reviews at the meeting also showed that many of the recommendations were related to organizational issues
STRENGHTENING
THE SUR
VEILLANCE
SY STEM
Trang 11SUCCESS AND CHALLENGES
Documenting lessons learned
Lessons learned from any project can only be effectively shared if they are properly documented This documentation can also be used for advocacy, policy planning and simply for record-keeping When the Japan International Cooperation Agency supported an Indian National Rural Health Mission project in five districts in the Indian state of Madhya Pradesh to improve maternal and newborn health, it invited the WHO’s South-East Asia Regional Office to document the experiences of this project, which ran from 2005 to 2011
The documentation process revealed several significant findings from which
lessons can be learned, such as how successfully the project was aligned with
the National Rural Health Mission It also showed how having a well-designed
project design matrix as part of the organization and management of the project
contributed to its success It demonstrated the usefulness of starting small and
having a scale-up plan, and how commitment and motivation compensated for
manpower shortages It also documented quality improvements as seen from the
increase in institutional childbirths; the enhanced midwifery skills of front-line
health providers; improved conditions in health facilities; better data management;
demand generation for services and community perception
Sound maternal death review processes take time and commitment
Programme managers, maternal health experts and partners from seven countries came together
to take part in an inter-country workshop on maternal death review in the Western Pacific Region At the meeting, hosted by the WHO Western Pacific Regional Office and held in Kuala Lumpur, Malaysia in November 2011, participants from the Kingdom of Cambodia, the Republic of Korea, Lao People’s Democratic Republic, Malaysia, Papua New Guinea, the Republic of the Philippines and the Socialist Republic of Viet Nam shared processes and tools for maternal death reviews and learned from the Malaysian experience Malaysian experts explained the history of reducing maternal mortality and the implementation of the country’s confidential enquiry into maternal death The group also made a field visit to observe a district facility-based maternal death review Country participants then evaluated maternal death review processes and tools from various countries, identified the next steps to strengthen countries’ review processes and developed realistic action plans
Several important messages emerged from the workshop Firstly, maternal death reviews do not need to cover all deaths to be useful The most important step
is to carefully analyse cases to guide local action and stimulate national level policy change Secondly, it took time for Malaysia to have the maternal deaths reported through the health system match the Bureau of Statistics’ data and this was only possible once the country’s vital registration system was well-established Thirdly, Malaysia’s success story can be achieved in an environment with a high commitment, supportive policies, a well-functioning health system and adequate monitoring of processes and outcomes Finally, maternal death review implementation must be tailored to each country’s situation using the most suitable methodology
Trang 12WHO led the development of the Essential Interventions document in collaboration with the Aga Khan University, supported by The Partnership for Maternal, Newborn and Child Health (PMNCH) Consensus was reached through a consultative process
of more than a dozen multilateral, development and donor agencies, health care professional associations, national governments, NGOs and academic institutions
Essential Interventions, Commodities and Guidelines for Reproductive, Maternal, Newborn and Child Health compiles existing evidence on interventions which
can reduce the main causes of maternal, newborn and child deaths Essential
Interventions consists of a list of: (a) 56 key selected reproductive maternal,
newborn and child survival interventions according to their specific delivery levels, (b) types of professional health worker required for their delivery, (c) key commodities required; and (d) corresponding available guidelines
The 56 essential interventions listed were identified based on the evidence of their efficacy, effectiveness and impact on survival; their suitability for implementation
in low- and middle- resource settings; and their likelihood to be delivered through the health sector from the community to the referral levels
The primary aim of this document is to support policy makers and implementers of RMNCH programs in the development of plans and strategies to improve the health
of women and children This set of guidelines can help steer policy reviewing and writing, indicate where existing interventions should be scaled up, and can help guide healthcare professionals at all levels of care in which interventions should
be provided to reduce maternal, newborn, and child deaths It can also guide advocacy to support national efforts to improve women’s and children’s health
An updated approach to prevention and treatment of pre-eclampsia and eclampsia
Hypertensive disorders of pregnancy are a significant cause of severe morbidity, long-term disability and death among both mothers and their babies There are
a number of hypertensive disorders that complicate pregnancy, but pre-eclampsia and eclampsia stand out
as major causes of maternal and perinatal mortality and morbidity The majority of these deaths are avoidable if women who present with these complications are given timely and effective care Thus, optimizing health care
to prevent and treat women with hypertensive disorders
is a necessary step towards achieving the Millennium Development Goals
In 2011, the WHO’s guidelines for the prevention and treatment of eclampsia and eclampsia were updated using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) process In all, 23 recommendations covering various aspects of prevention and treatment
pre-of pre-eclampsia and eclampsia resulted from a technical consultation in Geneva in April The new recommendations [http://whqlibdoc.who.int/
and will be used in updates of the WHO Integrated Management of Pregnancy and Childbirth clinical guidelines
WHO recommendations for
Prevention and treatment of pre-eclampsia and eclampsia
Trang 13Midwifery report: delivering health, saving lives
Increasing women’s access to quality midwifery has become a focus of global efforts to realize the right of every woman to the best possible health care during and after pregnancy and childbirth The first State
of the World’s Midwifery report confirms the critical role that midwives play in improving maternal and newborn health and survival The report, launched
at the Triennial Congress of the International Confederation of Midwives in Durban, Republic of South Africa in June 2011, calls for investment in midwives who can provide such care in communities and primary health care services
Data for the report was derived from surveys conducted in 58 countries, which between them account for 60% of all births worldwide and 91% of all maternal deaths The report highlights the shortage of skilled midwives in many low-income countries, stressing the need for training and deployment Among the 38 countries with the greatest need of midwives, 22 will have to double the workforce by 2015
in order to offer adequate levels of midwifery services In seven countries the number will need to triple or quadruple, while nine will need to dramatically scale
up midwifery by up to 15-fold
The report is the product of collaboration among 29 organizations It builds on prior initiatives to strengthen midwifery worldwide and was closely followed by and the publication of the Strengthening Midwifery Toolkit The State of the World’s Midwifery Report can be found at
A toolkit for stronger midwifery
A clear consensus has emerged that providing skilled attendance for every birth is essential to reduce maternal and perinatal morbidity and mortality WHO recognizes that effective and sustainable reductions in mortality, for both mothers and newborn infants, require the presence
of health care personnel equipped with a full range
of midwifery skills Without competent personnel, international goals for maternal and newborn health cannot be reached
In 2010, WHO published the Strengthening Midwifery Toolkit This toolkit comprises nine modules and focuses on the central role and function of the professional midwife in the provision of quality reproductive and sexual health services Guidelines have been prepared to assist Member States as they consider strategies to strengthen midwifery services
These guidelines have been developed by experts drawing on lessons learned from countries where quality midwifery services have been successfully made accessible to all women The toolkit can be used for establishing or reviewing midwifery programmes according to a country’s needs and priorities
http://www.who.int/maternal_child_adolescent/documents/strenthening_
midwifery_toolkit/en/index.html
Supported by: Coordinated by UNFPA
605 Third Avenue New York, NY 10016 www.stateoftheworldsmidwifery.com
LIVES
ISBN: 978-0-89714-995-2 E/4,000/2011
HEALTH CARE
SERVICE
S
Trang 14m A T E R N A L H E A L T H
Supporting countries to implement maternal and newborn health programmes
In 2010-2011, Member States in the Eastern Mediterranean Region implemented WHO strategies
to make pregnancy safer
The Regional Office supported them with the latest evidence, a range of inter-country activities and field missions to help them identify priority areas, gaps, and constraints of national programmes The Regional Office also developed tools and standards for monitoring, programme evaluation and maternal and newborn health impact assessment
in Member States At the same time, it launched an online reproductive health research directory, an evidence-based tool that supports strategic planning for maternal and newborn health promotion in the Region
An inter-country meeting to promote maternal and neonatal health in the Region held in Dubai, the United Arab Emirates, in April 2011, enabled countries to develop work plans for the implementation of national programmes on maternal and newborn health in 2012-13
Although the region is broadly on track to reach the Millennium Development Goals, some Member States will struggle to meet the targets of Goal 5 They continue
to need support in a number of priority areas, including medical education on maternal and neonatal health; promotion of universal provision of skilled health care for all women and newborns; promotion of good reproductive health practices such as birth spacing and prevention of sexually transmitted infections; and better maternal and neonatal health surveillance systems
Making progress in Albania
For the past three years, the WHO Regional Office for Europe has been providing technical assistance to the Ministry of Health
of the Republic of Albania as it reforms its maternal and child health services under
a project supported by the Spanish Agency for International Development Cooperation The objectives of the project are to improve capacity in regional hospitals; assure equitable access to effective maternal, neonatal and child health care services; and strengthen the Ministry’s stewardship role by increasing its capacity in planning and costing health services, improving transparency and accountability
In 2009, maternity hospital services in Tirana, Shkoder, Korce and Vlora were assessed and 140 health professionals involved in perinatal care received training
in effective perinatal care The Ministry
of Health adapted the WHO/Europe assessment tool for maternity hospitals and developed national clinical protocols for maternal, perinatal and paediatric care Two years on, these actions resulted in substantial and demonstrable improvements in service quality
Work in assuring equitable access to effective maternal, neonatal and child health care services includes applying the WHO principle of involvement of individuals, families and communities, and follow-up activities under the leadership of the Institute of Public Health Another example is the reorganization of school health services In future this will include implementation of the health promotion principles in schools and training of school medical staff Other cases of successful
initiatives can be found in Albania success stories in improving mother and child
health, published in 2011.
www.euro.who.int/ data/assets/pdf_file/0016/154141/e95980.pdf
Albania Success Stories
in improving mother and child health
IMP LEME
NTING
NATIONAL
PROGRAMMES
Trang 15Supporting integrated maternal,
neonatal and child health
4 and 5 in mind, the framework has three strategic objectives:
improving leadership, governance and management capacity for programme implementation; strengthening efficiency and quality of health service
provision; and mobilizing individuals, families and communities for maternal,
newborn and child health
Since 2009, with funding from the Korea Foundation for International Healthcare,
the Ministry of Health supported by WHO (in collaboration with the Asian
Development Bank, UNICEF, UNFPA, the World Bank and other partners) has given
intensive support in selected districts to gain practical experience with delivery of
the integrated maternal, neonatal and child health service package
In these districts, the focus has been on improving maternal, neonatal and child
health programme management, such as strengthening primary health care and
improving the capacity of district hospitals, health centres and village health
volunteers The support has also enhanced coordination among development
partners to ensure that various partners align their activities to the strategy and
its implementation plan
In some districts, coverage of antenatal care went from 16% to 2009 to 35% a
year later, while skilled care at birth went from 9.5% to 21.7% and levels of BCG
vaccination went from 26.6% to 59.2% over the same period The model from
Working in partnership to improve maternal and newborn health in African and Caribbean countries
The programme EC/ACP/
WHO Partnership on Health Millennium Development Goals provided support
to the health sector
in eight African and Caribbean countries (Republic of Angola, Burkina Faso, Republic
of Kenya, Republic of Malawi, Republic of Niger, and United Republic of Tanzania, Co-operative Republic of Guyana and Republic of Haiti), with a total funding of €25 million The programme co-funded by the European Commission and WHO focused on four components (Progress in the achievement of the health related MDGs, Making Pregnancy Safer, Disease Surveillance and Control Programmes and Health Information Systems) It was implemented from March 2006 to December 2010
Strong technical coordination led to effective country implementation As a result there was increased availability and access to qualified and skilled workers providing maternal and newborn care Community mobilization on maternal and newborn health issues was enhanced and referral systems improved In addition, national capacity in planning and management were strengthened
Increased awareness of donors and other stakeholders on women’s and children’s health issues has allowed for more funding secured in most countries
to accelerate progress towards health MDGs The final external evaluation of the project is planned for 2012
GEMENT
Trang 16N E W B O R N H E A L T H
Neonatal mortality declines across all regions
Deaths among newborns declined worldwide from 4.4 million in 1990 to 3.1 million
in 2010 and this decline has occurred in every region of the world.1 This represents
a decline in the rate of neonatal mortality by 28% between 1990 and 2010 with an annual reduction of 1.7% The European Region, the Region of the Americas and the Western Pacific Region experienced the steepest decline, at 50%, followed by the South-East Asia Region at 36% and the Eastern Mediterranean Region at 26%
The slowest reduction, of 19%, was seen in the African Region
Neonatal mortality is an increasingly significant proportion of child mortality Due
to the declining post neonatal mortality, globally the proportion of child deaths that occurred among newborns increased from 37% in 1990 to 40% in 2010 The South-East Asia Region at 27% and the Eastern Mediterranean Region at 23%are the regions with the largest proportional increases In the Western Pacific Region, the region with the largest decline in under-five mortality, neonatal deaths now account for 54% of all under-five deaths
Figure 5 Trends in neonatal mortality rates at global and regional levels 1990-2010
23 25
28 31
32
0 5 10 15 20 25 30 35 40 45 50
1990 1995 2000 2005 2010 Africa Eastern
Mediterranean South-East Asia Western Pacific Europe
Co-operation between countries in the Region of the Americas and beyond has helped promote the Perinatal Information System as an invaluable tool for improving the quality of maternal and newborn care The system can be used to streamline patient record-keeping and also to monitor and evaluate efforts to reduce maternal mortality
The system is in use in hundreds of public and private health institutions, social security and university hospitals across the region To enable countries to share their knowledge and expertise in using the system, in 2010 and 2011 the WHO Regional Office for the Americas together with country offices and ministries of health launched a technical cooperation among countries project, ‘Strengthening Perinatal Information Systems’, in four Latin American countries
Under the project, the Republic of El Salvador, the Republic of Honduras, the Republic of Nicaragua and the Republic of Panama agreed their work plans and reached a consensus on using the Perinatal Information System for analysis and follow-up of eight selected maternal and perinatal health indicators These are: maternal mortality ratio, access to contraception, four or more antenatal visits, skilled birth attendant at delivery, corticosteroids prior to preterm delivery, coverage of screening test for syphilis, timing of umbilical cord clamping and neonatal resuscitation Their experience in using this tool has been shared with other countries in the region, and also beyond the Americas, in the Republic of Equatorial Guinea, the Republic of Mozambique, the Republic of Namibia and
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Trang 17Updated guidelines,
better care for newborns
New and updated guidelines developed
by the Department and published in 2010-11 include:
• recommendations for care of the newborn after birth,
• care of the preterm and birth-weight newborn, and
low-• management of newborn illness and complications
The time around birth is the period of highest risk for the newborn Those who do
not start breathing on their own by one minute after birth should be resuscitated
with room air using a self-inflating bag and mask Updated basic neonatal
resuscitation guidelines will make it even simpler for a skilled birth attendant to
resuscitate asphyxiated newborns
Preterm birth is the most common direct cause of newborn mortality Preterm
birth and the birth of babies who are too small for gestational age,
(lowbirth-weight), are also important indirect causes of neonatal deaths Countries can
reduce their neonatal and infant mortality rates by improving the care of
low-birth-weight infants New WHO guidelines on optimal feeding of low-birth-low-birth-weight infants
contain recommendations on what, when and how to feed a low birth weight
newborn Furthermore, implementation of recommendations on kangaroo care
for preterm infants weighing less than 2 kg will help in improving their survival
Guidelines on hospital care for newborns were also updated Early identification
of infections in newborns and prompt and appropriate antibiotic treatment will
substantially reduce mortality due to sepsis and pneumonia Newborns with
serious infections need intramuscular or intravenous antibiotics and supportive
care in hospitals WHO is working with ministries of health and partners to
implement these guidelines
Progress in assuring essential care for newborns
There has been substantial progress in implementing
a package of essential care for newborns in the African Region Decision-makers from the Republic
of Angola, the Republic of Burundi, the Central African Republic, the Republic of Chad, the Republic of the Congo, the Democratic Republic of the Congo and the Gabonese Republic, underwent training at two inter-country workshops held in Gabon and the Congo
Following these workshops, Gabon went on to organize its own national training sessions for health care professionals in charge of maternity and neonatal services, as well as for midwives, and nurses engaged in newborn care As a result
of this training, in both the Congo and Gabon numerous changes to maternity and neonatal care were recommended
At the community level, the Democratic Republic of the Congo started to train community health workers in case management of the newborn child in three health districts of the country
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Trang 18of implementation is still low and there
is lack of systematically documented and timely data on the current status of IMNCI service coverage
In response, a health facility survey was conducted to determine the current level of IMNCI service coverage at national and regional levels Based largely on telephone interviews as well as some direct observation in public health centres and hospitals, the survey covered more than 2,500 public health facilities
Some 82% of health facilities surveyed had at least one in-service or pre-service IMNCI-trained health worker, while only 23% had two or more IMNCI-trained health workers Most health facilities had the crucial IMNCI job aids, i.e., registration books and chart booklets At facility level, availability of oral medicines was good but parenteral pre-referral medicine supplies were very low except for gentamicin
There was high availability of oral rehydration salts in the facilities but availability
of oral rehydration therapy materials and service provision was markedly low
The relatively low IMNCI coverage in the two most populous regions of Oromiya (45%) and Amhara (49%) as well as the two pastoralist regions of Somali (26%) and Afar (47%) is of serious concern The results of this survey will serve as a baseline for future planning and resource allocation for scaling up IMNCI services and for objective monitoring of the progress of implementation of the strategy in the country
Integrated management of neonatal and childhood illness in India saves lives
Infant mortality dropped by 15% in a district in the Republic of India using the Integrated Management
of Neonatal and Childhood Illness strategy, according to findings from a cluster-randomized trial The strategy combines improved treatment of illness in newborns and children with home visits for newborn care To evaluate its impact on infant mortality, a trial was conducted in a total population
of 1.1 million in Faridabad district, Haryana, India
In clusters where the strategy was implemented, community health workers were trained to conduct postnatal home visits and women’s group meetings, and together with nurses and physicians were also trained to treat or refer sick newborns and children according to the specific guidelines Under the strategy, medical supplies and community health worker supervision were strengthened All births
in the study population were captured via an independent surveillance system and deaths during infancy were documented by visits at 29 days, six, and 12 months Both the intervention and control clusters had a similar number of births, but in the intervention clusters, the adjusted infant mortality was 15% lower compared
to control clusters
Appropriate newborn care practices such as early initiation of breastfeeding and exclusive breastfeeding were more prevalent in the intervention compared to control clusters and the prevalence of severe illness, pneumonia and diarrhoea
in infancy was significantly lower in intervention clusters The study concludes that the IMNCI strategy can be an important component of efforts to reach the Millennium Development Goal 4 on child survival
EXPANDING
IMNCI
Trang 19Newborn HIV and syphilis:
Beyond prevention to elimination
in Asia Pacific Region
The extensive progress in prevention
of mother-to-child transmission
of paediatric HIV and congenital syphilis in the Asia Pacific Region has made elimination a potentially achievable goal All relevant UN agencies work closely together under the Asia-Pacific Task Force
on prevention of mother-to-child transmission, including UNAIDS, the UNFPA, UNICEF, the WHO Regional Office for South-East Asia and the WHO Regional Office for the Western Pacific
The Task Force developed the Asia Pacific Conceptual Framework on elimination of
mother-to-child transmission This is an excellent example of integration between
programmes addressing HIV/sexually transmitted infections and maternal and
neonatal health It received an enthusiastic response when launched at the 10th
International Conference on AIDS in the Asia Pacific in September 2011 and has
highlighted the importance of appropriate maternal health services to prevent
onward transmission of HIV and syphilis
Much work needs to be done to take this ambitious agenda forward, including
profiles of HIV/sexually transmitted infections and maternal and neonatal health
programmes These have already been developed for high-burden countries An
advocacy document to translate the conceptual framework into messages for
garnering support and commitment is being finalized An implementation guide
is underway, to make the framework customized and operational according to the
situation in different countries In addition, a pilot project on stillbirth surveillance
has been initiated in India to address the paucity of information on the congenital
syphilis disease burden
E-learning and telemedicine reach the Maldives
Because newborn health is inextricably linked to maternal health, it is dependent
on universal access to essential services like family planning, skilled care during pregnancy, childbirth and, in the postpartum and postnatal period essential newborn care and emergency obstetric care Ensuring that these measures become the standard of care is a challenge, and requires a minimum level of competence among health providers especially at the primary health care level
In 2010, the Republic of Maldives was given support for essential newborn care training and to develop national guidelines, culminating in a plan of action to strengthen neonatal care at different levels, with emphasis on primary health care The special feature of this activity was use of information technology with the introduction of e-learning through telemedicine For countries like the Maldives facing geographical challenges for service delivery, harnessing IT can increase the accessibility and availability of health and telemedicine services A model has already been developed at the All India Institute of Medical Sciences,
a WHO collaborating centre, and faculty from the Institute facilitated training and plan development They also tested the telemedicine setup in the main referral hospital, including videoconferencing
Subsequently, two online courses enabled regular training of paediatricians and nurses through telemedicine linkage with the Institute Using the platform for continuing professional development, the e-platform is also increasingly being used for expanded purposes including tele-consultation
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Trang 20Getting research priorities right
in Africa and South Asia
Policy-makers and programme managers have a crucial role to play
in setting implementation research priorities that can help countries scale
up maternal, newborn, child and adolescent health care During 2011, national implementation research priority setting exercises were conducted
by the Department in the Republic of Cameroon, the Arab Republic of Egypt, India, the Republic of Kenya, the Islamic Republic of Pakistan and the Republic of Rwanda, and by the Department of Reproductive Heath and Research in the Democratic Republic of Congo, Ethiopia, the Republic
of Guinea, the Republic of Mozambique and the Federal Republic of Nigeria An adapted Child Health and Nutrition Research Initiative methodology was used to identify, score and rank potential research issues
The exercise identified up to 10 research priorities for each country While many
of the priorities were specific to the issues and context within the country, many common themes emerged These included provision of maternal, newborn, child and adolescent health services in remote areas and improving motivation and supervision of health workers Use of telecommunications to improve maternal, newborn, child and adolescent health services was another common priority, as was community-based provision of care and improving quality of care in first level health facilities National institutions in many of these countries have already issued a call for letters of intent to conduct research studies to address the priorities, and those in the remaining countries are in the process of doing so
WHO is working with countries to hold workshops to develop high quality research proposals, the first of which was held in November 2011 in Pakistan
Regional networks help South-East Asian countries boost newborn care
The WHO Regional Office for East Asia initiated strengthening
South-of the South-East Asia Regional Neonatal-Perinatal Database Network Leaders and experts from the Member States in the region came together at a Regional Meeting on Newborn Health Care, Education and Training, held in New Delhi, India, in March 2011 The aim was to collaborate on efforts
to improve newborn health and survival, and boost progress toward Millennium Development Goal 4 The meeting recommendations included developing national networks that would collaborate with the regional network on newborn health The networks could contribute in promoting knowledge management, capacity building (education and training) and research in newborn health
The Regional Office has followed up with WHO country offices to support development of national networks for newborn health The People’s Republic
of Bangladesh, the Republic of the Union of Myanmar, the Federal Democratic Republic of Nepal and the Democratic Socialist Republic of Sri Lanka have already taken appropriate steps
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Trang 21Improved care in the community
for newborns and children
Lay community health workers will be better able
to care for newborns and children thanks to newly published materials from WHO The training materials consist of a community health workers’ manual, facilitator notes, photograph book, chart booklet, and training videos and DVDs
They are part of three-part package that can be used independently or sequentially (see box) Caring for the sick child in the community
was published in 2011 Caring for the newborn at home, and caring for the healthy
child’s growth and development will be published in early 2012.
Evidence that community health workers can play a key role in caring for newborns
and children is leading countries to adopt new policies Preliminary results of
a survey conducted by the Department and partners in 2011 on provision of
postnatal care by community health workers in countries of sub-Saharan Africa
and South-East Asia showed encouraging results Of the 47 countries that
responded, 24 countries reported that they have a policy and are implementing
a community-based maternal and newborn health home visit package Similarly,
the Department has been monitoring the uptake of national policy that authorizes
CHWs to treat children with pneumonia in the community in high burden countries,
and the number has increased from 18 in 2008 to 39 in 2012
The WHO/UNICEF package caring for newborn and children in the community comprises three sets of materials for training and support These materials can be used independently or sequentially
Caring for the newborn at home: Through a series of home visits, the
community health worker:
• Promotes antenatal care, and skilled care at birth;
• Provides care for the newborn in the first week of life;
• Recognizes and refers any newborn with danger signs to a health facility;
• Provides special care for low-birth-weight babies
Caring for the sick child in the community: The community health worker is
able to assess and treat sick children aged 2 to 59 months and:
• Identify and refer children with danger signs;
• Treat (or refer) pneumonia, diarrhoea and fever;
• Identify and refer children with severe malnutrition to a health facility;
• Refer children with other problems that need medical attention;
• Advise on home care for all sick children
Caring for the healthy child’s growth and development: The community
health worker counsels families on practices that they can carry out at home and promotes:
• Care-giving skills
• Child development
• Infant and young child feeding
• Family’s response to a child’s illness
• Prevention of illness
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Trang 22C H I L D H E A L T H
NEW
EVIDENCE
Progress in reducing childhood mortality
Globally, the leading causes of morbidity and mortality in children under the age of five are pneumonia, diarrhoea, prematurity, birth asphyxia and malaria The number of under-five deaths worldwide has declined from more than 12 million
(1990-Of the 7.6 million child deaths, 40% occurred in the neonatal period (0 to 28 days of life), 31% of occurred between one and 11 months, and the remaining 29% occurred in children aged one to four years As under-five mortality declines, the relative contribution
of deaths in the neonatal period increases
Three WHO regions have reduced their under-five mortality rates by 50% or more: the Western Pacific Region, the European Region and the Americas The highest rates of under-five mortality are still seen in the African Region (119 per 1000 live births), where they are more than 17 times higher than the average for developed regions (7 per 1000 live births)
Under-five deaths are increasingly concentrated
in the African Region and in the South-East Asia Region While these two regions endured the burden
of two-thirds of all under-five deaths in 1990, they now hold nearly three-quarters of all deaths among
of them from these two regions: India, Nigeria, Democratic Republic of the Congo, Pakistan and China India and Nigeria together account for a third
of all under-five deaths
Children’s lives can only be saved if the distribution and causes of their deaths are appropriately established and tackled through evidence-based action and positive changes in policies, strategies, health systems, and ultimately in the status of maternal, newborn and child health
Figure 6 Trends in under-five mortality by WHO region
57 65 73 82 88 97 111
0 50 100 150 200 250
1980 1985 1990 1995 2000 2005 2010 Africa Eastern
Mediterranean South-East Asia Western Pacific
Americas
Europe World
Twelve systematic reviews were completed on aspects of clinical management of pneumonia and oxygen use The synthesized evidence was used to revise pneumonia case management guidelines at various levels of the health system Several research studies addressing various aspects of pneumonia in newborns and children are ongoing, including large multi-centre trials in Africa (Democratic Republic of the Congo, Kenya and Nigeria) and Asia (Bangladesh and Pakistan)
In Pakistan, a landmark study evaluating community case management of severe pneumonia by community health workers documented their ability
to safely and effectively treat cases of severe pneumonia at home with oral amoxicillin In Haripur district 28 clusters were randomly assigned to the intervention group or to be controls In the intervention clusters, community health workers who had undergone additional training treated children aged two to 59 months in the community with oral antibiotics for five days The control group was given
an initial dose of oral antibiotic and referred to a health facility Treatment failures occurred 50% less often in the intervention group
Guidelines and training materials for management
of pneumonia were updated in 2010-2011, and introduced to programme staff and partners in multiple events
>10
10 - 49
50 - 99
100 - 199 200 Not applicable