|Mother-Baby Package: Implementing Safe Motherhood in Countries (WHO, 1996, 108 p.)|
Why the Mother-Baby Package?
Of the annual total of more than 500 000 maternal deaths that occur each year, most happen in developing countries. They are the result of the same major complications of pregnancy - haemorrhage, sepsis, hypertensive disorders of pregnancy, obstructed labour and abortion. Millions of women survive such complications but nonetheless suffer acute or chronic ill-health or lifelong disabilities.
The complications that affect women during pregnancy and childbirth affect the fetus as well. Around 8.1 million infants die each year, one half of them within the first month of life and a large proportion within a few days of birth. Many of these neonatal deaths are a direct consequence of poorly managed pregnancies and deliveries. Millions of infants survive but with a degree of damage that renders them physically or mentally disabled throughout their lives. The causes are similar around the world - newborn babies die or are damaged because of birth asphyxia, trauma or infections.
Pregnancy-related deaths and disabilities result not only in human suffering but also in losses to social and economic development. The women who die are in the prime of life, responsible for the health and well-being of their families. They generate income, grow and prepare food, educate the young, care for children, the elderly and the sick. Their deaths represent a drain on all development efforts. Above and beyond the social and economic rationale for preventing this burden of mortality and morbidity is the moral imperative. Pregnancy is not a disease, and pregnancy-related mortality and morbidity are preventable with attainable, simple and cost-effective interventions. Failure to do so is to deny women a fundamental human right - the right to the highest attainable level of health.
Most pregnancy-related complications can be effectively prevented or managed without recourse to sophisticated and expensive technologies or drugs. Experience has shown that maternal and neonatal mortality can be reduced when communities are informed about danger signs and symptoms, and quality health services are available and accessible including a referral system to manage complications at a higher level of the health care system.
The international health community has been working to support countries to reduce maternal and neonatal morbidity for several years. Considerable efforts have been expended to implement activities that would lead to substantial improvements in maternal and newborn health. However, many of these efforts have been hampered by a lack of agreement about the most appropriate and effective interventions. Since the start of the Safe Motherhood Initiative in 1987, much has been learned about the effectiveness of different interventions for maternal health and about the feasibility of implementing them in resource-poor settings.
Furthermore, there is now general agreement that the interventions needed to save the lives and preserve the health of mothers and babies cannot be implemented in a vertical and uncoordinated manner but must form part of a broad strategy to improve reproductive health through primary health care. This implies that safe motherhood interventions should be applied holistically within a general health context that promotes equity in access to and quality of care.
Making motherhood safe requires action on three fronts simultaneously:
· reducing the numbers of high-risk and unwanted pregnancies
· reducing the numbers of obstetric complications
· reducing case fatality rate in women with complications.
Strategies and interventions are available for dealing with each of these aspects of the problem and it is these that form the essence of the interventions described in the Mother-Baby Package.
Increasing the availability and accessibility of family planning information and services will substantially reduce the number of pregnancies - particularly high-risk and unwanted pregnancies and thus result in a reduction in maternal deaths.
The number and severity of obstetric complications may be reduced by ensuring that all women have access to quality antenatal, delivery and postpartum care to provide information, prevention and management of diseases during pregnancy, and early detection and management of complications.
Providing access to essential obstetric care to all women who need it will help to reduce case fatality rates among women experiencing complications.
These interventions, coupled with special attention to the needs of the newborn - resuscitation when necessary, immediate breast-feeding, warmth, clean delivery and cord care - will also help ensure the survival and health of infants.
What is the Mother-Baby Package?
The Mother-Baby Package describes each intervention needed to achieve safe motherhood in the short term. It represents the synthesis of activities at different levels of the health care system and defines a basic set of health system interventions and activities that cannot be further reduced. The Package describes simple interventions needed before and during pregnancy, during delivery, and after delivery for mother and newborn. It outlines what can be done to prevent and manage the major obstetric complications in the community, at the health centre and at the hospital. Throughout, it focuses only on those interventions known to be effective which can be implemented by making the most efficient use of available resources.
Some interventions can be delivered at community level by ensuring that women and their families have the information they need to care for themselves during pregnancy and delivery and seek assistance when appropriate. Much of this information can be channelled through community-based facilities such as health posts, dispensaries and trained traditional birth attendants (TBAs).
Other interventions must be carried out at a higher level of the health care system - through the health centres and hospitals and the auxiliary health care providers, midwives and doctors staffing them. A continuum of care must be available, linking all three levels and ensuring the necessary support and supervision.
The Mother-Baby Package brings together the core cluster of interventions to which all women are entitled. The fourfold approach - comprising family planning, quality antenatal care, clean and safe delivery, and access to essential obstetric care for high-risk pregnancies and complications - recognizes that it is not always possible to predict which women will develop complications and that many complications occur among women who are not considered high risk. Therefore, it is essential to ensure that a chain of effective maternity care is available to all women, wherever they live and whatever the circumstances of their pregnancy and delivery.
Ensuring that women and families have access to information and services for family planning can help reduce the number of high-risk pregnancies. Equally it can help reduce the numbers of unwanted pregnancies associated with a higher risk of poor maternal and newborn outcome. Reducing unwanted pregnancies will also reduce the numbers of unsafe abortions that are a major cause of maternal mortality around the world.
Mother-Baby Package interventions
1. Before and during pregnancy
Information and services for family planning
2. During delivery
Clean and safe (atraumatic) delivery
3. After delivery: mother
Recognition, early detection and management of postpartum
complications at health centre or hospital (for example, haemorrhage, sepsis and
4. After delivery: newborn
All women should have access to basic maternity care during pregnancy and delivery. Basic maternity care comprises quality antenatal care and clean and safe delivery whether the delivery takes place at home or in an institutional setting. It also includes early postpartum care for mother and infant to detect and manage complications, such as secondary postpartum haemorrhage, eclampsia and sepsis and to offer support for breast-feeding.
One of the most important functions of antenatal care is to offer the woman advice and information about the appropriate place of delivery given her own particular circumstances and health status. Antenatal care is also an opportunity to inform women about the danger signs and symptoms for which assistance should be sought from a health care provider without delay.
Antenatal care can help reduce the numbers and severity of pregnancy-related complications by careful monitoring and early treatment of diseases aggravated during pregnancy, such as malaria and anaemia. It also provides the opportunity to offer prophylactic treatments such as iron and folate supplementation and management of conditions such as sexually transmitted diseases. It also facilitates the early detection and management or referral of pregnancy-related complications.
Accurately predicting antenatally which women will develop complications is not possible. Any woman can develop complications at any stage of pregnancy, delivery or the postpartum period. And when complications happen, they are often emergencies. Since obstetric complications are unforeseeable and require rapid intervention, every effort should be made to provide all essential obstetric services as close as possible to where women live. Women and communities need to be informed about danger signs during pregnancy and delivery and be encouraged to seek assistance with the minimum delay.
How to operationalize the Mother-Baby Package
Making motherhood safer requires the establishment of a chain of care linking women, families and communities with the health system. Therefore, interventions will be needed at community level and also within health services. The interventions described in the Mother-Baby Package focus largely on those that are the prime responsibility of the health sector. Many interventions needed to improve maternal and newborn health will require the collaboration of other sectors for their successful application. This is the case with, for example, interventions to improve womens social status and access to resources. As countries carry out safe motherhood interventions, the roles and responsibilities of other sectors should be defined and attention directed to these areas.
The district health system is the basic unit for planning and implementing the interventions outlined in the Mother-Baby Package. The district provides a mechanism for linking families and communities with health centres and hospitals in a functional cost-effective manner. Through district-based implementation of interventions, it is possible to ensure that health services are available as close as possible to peoples homes.
Obstetric procedures should be carried out by the person closest to the community who is competent to perform them safely and effectively. The person best equipped to provide community-based, appropriate technology, safe and cost-effective care to women during their reproductive lives is the person with midwifery skills who lives in the community alongside the women she serves. She can ensure the health system serves women equitably and effectively and that the health services available respond to the needs of clients.
Sometimes pregnancy complications require obstetric procedures/such as surgery and anaesthesia. This type of service should be available at the district hospital, along with effective referral and transfer system. General practitioners have an important role to play in ensuring the availability of such services at the peripheral level, especially when there are insufficient numbers of obstetricians available.
Where TBAs attend most home deliveries, upgrading their skills is a way of bridging the gap until all women and children have access to acceptable, professional and modern health care services. Programmes for TBA training should include ongoing support and supervision.
The goals of the Mother-Baby Package are, by the year 2000, to reduce maternal mortality by half and perinatal and neonatal mortality by 30 to 40% of 1990 levels. Reduction of mortality will substantially reduce maternal and neonatal disabilities. The aim, through partnerships between agencies, national governments and NGOs, is to create a global momentum for support to health services, enabling them to deliver maternal and newborn care more effectively.
The objectives of the interventions are:
· to promote family planning and reduce the incidence of mistimed and unwanted pregnancies
· to reduce maternal deaths due to complications of abortion
· to provide basic maternal care to all pregnant women
· to promote, protect and support early and exclusive breast-feeding
· to reduce anaemia in pregnant women
· to reduce sexually transmitted diseases in pregnant women
· to reduce maternal deaths due to eclampsia
· to reduce maternal deaths due to haemorrhage
· to reduce maternal deaths due to prolonged/obstructed labour
· to reduce maternal deaths due to puerperal or post-abortion sepsis
· to eliminate neonatal tetanus
· to reduce neonatal deaths due to or associated with birth asphyxia
· to reduce neonatal deaths associated with neonatal hypothermia
· to reduce neonatal infections.
The Mother-Baby Package is a technical tool intended to provide guidance to countries as they seek to improve maternal and neonatal health and reduce mortality and morbidity. Implementation within countries will require adaptation of the interventions, definition of nationally relevant goals, objectives and targets and the preparation of national action plans. The district should be the locus of implementation of the detailed activities.
The Package does not provide a detailed breakdown of the activities that national authorities have to undertake to carry out the interventions but provides a general outline of the essential steps. These include:
· definition of national policy and guidelines
· assessment of needs
· estimation of costs
· identification of available and attainable resources
· preparation of national action plans
· implementation of activities as defined in district level plans through strengthening of health services; human resources development and management; assuring equipment, drugs and supplies; ensuring quality of care; organizing information, education and communication; and social mobilization
· monitoring and evaluation.
An important first step in implementing the interventions described in the Mother-Baby Package is the analysis of the policy framework within which maternal health care providers operate. This analysis, coupled with a detailed review of the maternal health situation, provides the basis upon which national action plans can be developed. Once gaps in health care provision and policy, legal and regulatory barriers have been identified, a national action plan can be developed which identifies priority activities and assigns responsibilities for implementation.
A basic level of infrastructure is essential if all women are to have access to maternal health care. Much will depend on the local situation. In some places, where existing infrastructure is very weak and distances great, efforts will have to concentrate on the upgrading of peripheral facilities such as health posts and health centres so that they are able to provide the best level of care given the skills available. In other areas, where existing infrastructure is available, it is often the quality of care provided that needs to be improved. Within each district, a needs assessment is an essential step in determining the most appropriate approach. The objective in all cases is to make the highest attainable level of care available as close as possible to where women live.
Development of human resources for safe motherhood, through in-service, skills-based training as well as through initial training, is a prerequisite for success. Staff should be trained in settings closely resembling those in which they will be working. Priority should be given to the development of midwifery skills to provide routine maternal care and to respond to obstetric emergencies. Training may be needed in obstetric surgery, anaesthesia, newborn care, laboratory support and blood transfusion services.
However, training alone cannot bring about the changes required for developing skills and changing attitudes. Decisions as to the functions to be performed by different members of the health care team (for example, authorization of midwives to carry out certain tasks) are essential for effective delegation of responsibility, training and practice.
Information, education and communication (IEC) strategies are needed to enable women and their families to recognize complications and to encourage health-promoting behaviours before, as well as during and after, pregnancy and delivery. Community-based health posts and dispensaries and community-based health care providers, such as auxiliary health workers and trained TBAs, can be important resources in such efforts. In addition, health centres can serve an important outreach function by bringing needed information, advice and services to outlying populations.
Communities can be mobilized to ensure access to effective transport of women and babies with complications. Nongovernmental organizations and womens groups can be important allies in organizing emergency transport. They can also participate in the development of ways and means so that families are able to pay for the care they need, if necessary.
The performance of the health system must be monitored closely to improve the effectiveness of these interventions. Existing information systems should serve as the basis upon which to establish regular monitoring and feedback in order to ensure that programmes meet their targets and objectives and that the goals of safe motherhood are attained.
The role of WHO
The Mother-Baby Package is one of a series of documents which WHO has developed to provide guidance on the development and implementation of safe motherhood action plans. Many of these guidelines concern clinical and managerial aspects of maternal care. Others, currently in preparation, are primarily concerned with managerial issues such as needs assessment, costing, logistics and management.
The role of international collaboration
WHO and other international agencies, notably UNDP, UNICEF, UNFPA and the World Bank, together with a range of bilateral and multilateral agencies, are committed to supporting national authorities in their efforts to reduce the burden of maternal deaths and disabilities and improve the health of women and children. The Mother-Baby Package is a technical tool designed to assist these efforts.