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Appendix 6 - Maternal and perinatal health assessment

Maternal and Perinatal Health Status

· What is the estimated fertility rate, contraceptive prevalence rate, maternal mortality rate or ratio, infant mortality rate, neonatal mortality rate, and perinatal mortality rate for urban and rural areas?

· What is the prevalence of the following morbidities: Anemia Malaria Hepatitis Tuberculosis Reproductive tract infections (HIV, syphilis, gonorrhea) Hypertension

· Diabetes

· What are the principal causes of death in hospital/in the community of women, stillbirths, neonates?

· What is the relative importance of each of the following as an immediate cause of death:

Maternal mortality:
- Abortion complication
- Eclampsia
- Hemorrhage
- Puerperal infection
- Obstructed labor
- Other pre-existing conditions and infectious processes
- Anemia as a factor
- Maternal undernutrition and workload as a factor

Perinatal/neonatal mortality:
- Birth injury
- Asphyxia
- Prematurity/low birth weight (rate in hospital)
- Sepsis (general, acute lower respiratory infection, other)
- Neonatal tetanus
- Complicated labors (prolonged, obstructed, breech, transverse)
- Mismanagement of labor

· Why do women and infants die of these causes? What are the factors surrounding pregnancy, management of labor and delivery, and care of the newborn that contribute to high mortality rates?

· What is the cesarean section rate?

· What are the fresh stillborn levels (died during delivery) and macerated levels (intrauterine deaths)?

· What is the ratio of emergency deliveries to scheduled registered deliveries in hospitals?

Utilization

· What are the patterns of service utilization for Family planning Prenatal care Assisted delivery (home, clinic or hospital)
· Postpartum care for mother and newborn

· Why don't women use modern medical services?

· When do they use them?

· Which danger signs are recognized? For what and from whom do women and their families seek care?

Access

· How physically accessible are services to the population (e.g., distance, transport, etc.)?

· How are resources allocated and family planning, maternity and neonatal care organized?

· What are the physical constraints to use of family planning, prenatal/postnatal services?

· What are the sociocultural constraints to service use?

· What are the costs to clients of care?

Pregnancy/Birth/Neonatal Home Care

· What is the role of the traditional birth attendant, members of the family?

· What are the common practices that contribute to poor outcome? (prenatal, birth, postpartum)

· What are the common home birth practices?

· Management of labor

· Use of oxytocics and other methods for speeding labor

· Perceptions of duration of labor

· Cord care are there safe birth kits available for families?

· Neonatal care (warming, feeding, swaddling, and the like)

· What are the pregnancy and postpartum taboos and prescriptions for behavior that affect outcome?

· What are the beliefs and conditions that dictate these practices?

· What are the breastfeeding patterns? Immediate Exclusive When are other liquids and solids introduced? What are they? Why?

Content and Quality of Clinical Care (Ministry of Health, nongovernmental organizations)

· What government regulations and practices govern which level of worker has responsibility for types of relevant work (e.g., cesarean sections, manual removal of placenta)?

· What does prenatal care consist of?

What information and services are provided?

· Are women screened for risk using a standard tool? (get copy)

· When found to be high risk, are there high risk clinics?

· Are food supplementation programs targeted to pregnant women? And if so by what criteria?

· What is the national goal for prenatal care (# of visits)?

· What is the average number of visits per woman prior to delivery? On average, when do they initiate visits?

· What are the roles of the different health providers?

· Is there a functioning referral system?

Are there norms, protocols, forms available? If non-functional, why?

· Is there a means of communication between levels, of transport?

· Who handles obstetrical emergencies (urban/rural)? Have they had training for this? Are there norms, protocols, forms available?

· Does postnatal care routinely include:

· Advice on breastfeeding/family planning/neonatal care?

· Physical exam of mother and infant?

· Food/iron supplementation?

· What are the attitude and practices of health providers on:

Abortion?

· Adolescent fertility?

· What is the relationship between the Ministry of Health, the hospitals, the public health facilities (health posts, health centers, hospitals), the private sector providers, and the community health agents?

Community Outreach/Promotion/Education

· Is there any outreach into the community to find and monitor pregnant and postpartum women? Who conducts it? How often?

· What is the role of the traditional birth attendant, community health worker or clinicbased staff?

· What educational materials exist on (get copies and analyze):

Pregnancy/prenatal care
Safe birth . Postpartum care
Care of newborn
TT immunization
Prevention and treatment of sexually transmitted disease (STD)
Maternal nutrition
Anemia
Breastfeeding

· Family planning

Human Resources Development

· What are health providers taught about family planning, maternal and perinatal health?

· What materials are used for training? Assess the adequacy of those materials.

· How do traditional birth attendants and other health providers rate their own knowledge and skills? How do their superiors rate their skills?

· What types of additional training do they ask for?

· What organizations and training entities have on-going training in family planning and maternal health? Get copies of curricula and manuals, if possible.

Women's Status

· What are the school enrolment and literacy rates for women?
· What is their rate of participation in the formal labor force?
· What is their level of isolation from information and health services (e.g., religious, cultural)?

Nongovernmental Organizations, Women's Groups, and Other Channels for Education and Services

· Are there women's groups at the community level?

· What is their principal function?

· Are they or have they been used for health education? or as community support for maternal or other health interventions?

· What role are nongovernmental organizations playing in education and services? What is their relationship with the Ministry of Health?

· Do they have the capacity to take on additional maternal health activities?

Other Programs in this Field

Describe the on-going and planned programs of the Ministry of Health, other national organizations, and those of the international agencies that are relevant to family planning and maternal and perinatal health.

For each include:

· Location
· Time frame
· Implementing organization as well as funding organization(s)
· Purpose
· Goals
· Current status

For All of the Above

· Identify existing research and information that has been collected and try to obtain copies of reports for review.

· Identify local experts and resource persons who could be used in training/ programming in maternal health.

· Identify materials (management information system, health education) that have been developed that could be duplicated and used.

· Identify innovative programs and techniques that have been tried with apparent success in the country; these make good case studies and presentations in workshops, and may be replicable.

· Identify programs that could be tapped to strengthen on-going family planning and maternal health activities.