1. Effective Perinatal Care (EPC) Safe childbirth and Effective Perinatal Care: Are Changes Necessary?

2. Safe Childbirth

3. 1C-3 Effective perinatal Care (EPC) What Are the Eight Millennium Development Goals (MDGs)? Goal 1: Eradicate extreme poverty and hunger Goal 1: Eradicate extreme poverty and hunger Goal 2: Achieve universal primary education Goal 2: Achieve universal primary education Goal 3: Promote gender equality and empower women Goal 3: Promote gender equality and empower women Goal 4: Reduce child mortality Goal 4: Reduce child mortality Goal 5: Improve maternal health Goal 5: Improve maternal health Goal 6: Combat HIV/AIDS, malaria and other diseases Goal 6: Combat HIV/AIDS, malaria and other diseases Goal 7: Ensure environmental sustainability Goal 7: Ensure environmental sustainability Goal 8: Develop a global partnership for development Goal 8: Develop a global partnership for development Note that health is given a lot of attention!

4. 1C-4 Effective perinatal Care (EPC) It Is Impossible to Accept High Numbers of Maternal Mortality Because… … evidence-based data demonstrate that 80% of all death can be prevented with help of simple, effective and low-cost interventions … … evidence-based data demonstrate that 80% of all death can be prevented with help of simple, effective and low-cost interventions …

5. 1C-5 Effective perinatal Care (EPC) It Is Impossible to Accept High Numbers of Neonatal Mortality Because… Many cases of infant and neonatal mortality can be prevented by known, available and low-cost technologies if they are accessible to all Many cases of infant and neonatal mortality can be prevented by known, available and low-cost technologies if they are accessible to all WHO, 2005

6. 1C-6 Effective perinatal Care (EPC) Safe Mother Initiative (SM) – 1987 to 2000 Safe Mother Initiative (SM) – 1987 to 2000 –Goal: decrease maternal mortality (MM) by 50% by 2000 –Strengthened international efforts though MM unchanged –Lessons learned from achievements & ineffective strategies Making Pregnancy Safer Initiative (MPS) 2000-today Making Pregnancy Safer Initiative (MPS) 2000-today –Goal: Ensuring skilled care at every birth within the context of a continuum of care –Global strategies and health sector focus –Provide technical support and building national capacity Safe Motherhood Initiative Making Pregnancy Safer Initiative

7. 1C-7 Effective perinatal Care (EPC) Definition: A ‘skilled attendant’ is an accredited health professional – such as a midwife, doctor or nurse – who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth, and the immediate postnatal period, and in the identification, management and referral of complications in women and newborns Definition: A ‘skilled attendant’ is an accredited health professional – such as a midwife, doctor or nurse – who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth, and the immediate postnatal period, and in the identification, management and referral of complications in women and newborns Skilled Attendant

8. 1C-8 Effective perinatal Care (EPC) Correlation between Skilled Attendant Care and Neonatal Mortality Rate 0 20 40 60 80 100 AfricaAsia Latin America and the Caribbean More developed countries Skilled Attendant Care (%) 0 10 20 30 40 50 Number of neonatal deaths per 1000 live births Skilled Attendant Care Neonatal deaths WHO, 2005

9. 1C-9 Effective perinatal Care (EPC) The “components of skilled attendant care”. Emphasize that core midwifery skills are essential for all providers. Skilled Attendant

10. 1C-10 Effective perinatal Care (EPC) All skilled attendants must have the core midwifery skills All skilled attendants must have the core midwifery skills Skilled attendant prototype is the licensed midwife. Skilled attendant prototype is the licensed midwife. First-level maternal and newborn care should preferably be organized in midwife-led birthing centres First-level maternal and newborn care should preferably be organized in midwife-led birthing centres Even within the walls of a hospital, however, first- level care should maintain the demedicalized and close-to-client characteristics of midwifery-led birthing homes Even within the walls of a hospital, however, first- level care should maintain the demedicalized and close-to-client characteristics of midwifery-led birthing homes First-level care requires strong links for back-up referral care (emergencies and non-emergency interventions) as a continuum of care First-level care requires strong links for back-up referral care (emergencies and non-emergency interventions) as a continuum of care Skilled Attendant Care WHO, 2004 WHO, 2005

11. 1C-11 Effective perinatal Care (EPC) Main Objectives Perinatal Care Improvement To reduce maternal mortality 75% by 2015 compared with the rate in 1990 To reduce maternal mortality 75% by 2015 compared with the rate in 1990 To reach a level of infant mortality that is less than 35 per 1,000 live births To reach a level of infant mortality that is less than 35 per 1,000 live births To provide access to reproductive health services for all in need To provide access to reproductive health services for all in need To provide all mothers and newborns skilled care at every birth within the context of a continuum of care To provide all mothers and newborns skilled care at every birth within the context of a continuum of care WHO, 2005 WHO, 2006

12. 1C-12 Effective perinatal Care (EPC) Making Pregnancy Safer Fundamentals Care for pregnancy and childbirth calls for a holistic approach Care for pregnancy and childbirth calls for a holistic approach Pregnancy and childbirth is an important personal, familial, and social experience Pregnancy and childbirth is an important personal, familial, and social experience In pregnancy and childbirth there should be a valid reason to interfere with the natural process In pregnancy and childbirth there should be a valid reason to interfere with the natural process Medical interventions for pregnant women, mothers and newborns, if indicated, need to be available, accessible, appropriate and safe Medical interventions for pregnant women, mothers and newborns, if indicated, need to be available, accessible, appropriate and safe WHO EURO, 1998 WHO EURO, 2003 WHO EURO, 2007

13. 1C-13 Effective perinatal Care (EPC) Making Pregnancy Safer Principles Care should: Care should: –be based on scientific evidence and cost/effective –be family centered, respecting confidentiality, privacy, culture, belief and emotional needs of women, families and communities –ensure involvement of women in decision-making for options of care, as well as for health policies –ensure a continuum of care from communities to the highest level of care, including efficient regionalization, and multidisciplinary approach WHO EURO, 1998 WHO EURO, 2003 WHO EURO, 2007

14. 1C-14 Effective perinatal Care (EPC) Two Models of Perinatal Care Mother and infant are treated as patients Mother and infant are treated as patients Different steps of labour happen in different rooms Different steps of labour happen in different rooms Infant care is provided in a separate room Infant care is provided in a separate room Father is informed to visit about the progress of labour Father is informed to visit about the progress of labour No relatives are allowed No relatives are allowed Respect for woman’s right to participate in care and decisions Respect for woman’s right to participate in care and decisions Labour/birth in one room Labour/birth in one room Mother and infant care in same room Mother and infant care in same room Social support/companion in labour and birth Social support/companion in labour and birth Relatives are involved in mother and infant care Relatives are involved in mother and infant care Traditional Midwifery-led/First-level care WHO EURO, 2002 WHO, 2005

15. 1C-15 Effective perinatal Care (EPC) Appropriate Technologies Technology is a set of activities that includes methods, procedures, interventions, equipment, etc. applied systematically to solve a specific problem Technology is a set of activities that includes methods, procedures, interventions, equipment, etc. applied systematically to solve a specific problem Technology is considered appropriate if it is effective, safe, affordable, good for both the patients and the doctors, and is feasible in its implementation Technology is considered appropriate if it is effective, safe, affordable, good for both the patients and the doctors, and is feasible in its implementation WHO EURO, 2002 Beverley Chalmers et al, 2001

16. 1C-16 Effective perinatal Care (EPC) Appropriate Technologies in Perinatal Care Woman has role in making decisions Woman has role in making decisions Partograph use in labour Partograph use in labour Social support for labour/birth is beneficial and encouraged Social support for labour/birth is beneficial and encouraged Unrestricted/upright labour/birth positions Unrestricted/upright labour/birth positions Exclusion of unjustified procedures Exclusion of unjustified procedures Early and unrestricted skin-to-skin contact Early and unrestricted skin-to-skin contact Prevention of neonatal hypothermia Prevention of neonatal hypothermia Effective neonatal resuscitation Effective neonatal resuscitation Breastfeeding on demand and rooming-in Breastfeeding on demand and rooming-in Correct hand washing as best infection prevention Correct hand washing as best infection prevention Rational use of medicine Rational use of medicine WHO EURO, 2002

17. Safe Childbirth

18. 1C-18 Effective perinatal Care (EPC) Childbirth is a major life event and it is therefore extremely important to manage the care of pregnant women in an effective and safe manner.

19. 1C-19 Effective perinatal Care (EPC) (MLC) has been defined as care where "the midwife is the lead professional in the planning, organization and delivery of care given to a woman from initial booking to the postnatal period" (Royal College of Obstetricians and Gynecologists, RCOG 2001). (MLC) has been defined as care where "the midwife is the lead professional in the planning, organization and delivery of care given to a woman from initial booking to the postnatal period" (Royal College of Obstetricians and Gynecologists, RCOG 2001). Midwife led care

20. 1C-20 Effective perinatal Care (EPC) MLC is a new model started in Gaza Strip on 2011. This model is a shared program between MOH and WHO, started primarily at Al-Tahreer hospital in Khanyounis on April 2011, January 2012 at Al-Emaraty hospital in Rafah, Tal Al Sultan, April 2013, EL Harazin, Gaza, and May 2013, Al-Aqsa hospital, Midzone. (WHO, 2012). MLC is a new model started in Gaza Strip on 2011. This model is a shared program between MOH and WHO, started primarily at Al-Tahreer hospital in Khanyounis on April 2011, January 2012 at Al-Emaraty hospital in Rafah, Tal Al Sultan, April 2013, EL Harazin, Gaza, and May 2013, Al-Aqsa hospital, Midzone. (WHO, 2012).

21. 1C-21 Effective perinatal Care (EPC) Objectives 1.To use Labour surveillance (Partogram) 2.To provide Non pharmaceutical pain relief 3.To provide Psychological support 4.To initiate Mother and baby contact soon after birth (skin to skin) 5.To initiate Attachment to the breast in the first hour 6. To Keep the baby warm 7.Counseling and health education in post natal room 8.To ensure Newborn examination by a pediatrician before discharge

22. 1C-22 Effective perinatal Care (EPC) Mechanism of work Step 1 :Risk assessment Step 2 :Natural birth Step 3: Post natal check of the mother Step 4: Post natal check up of the newborn

23. 1C-23 Effective perinatal Care (EPC) Step 1 : risk assessment Standard: All women at labour are examined by a doctor who, accordingly to the risk assessment criteria, assign the women either to the care of the midwife ( low risk pregnancy ) or to a doctor ( high risk pregnancy ) 23

24. 1C-24 Effective perinatal Care (EPC)

25. 1C-25 Effective perinatal Care (EPC) Step 2: natural birth Standard The women at low risk will receive natural childbirth care by a midwife during all phases of her labour and delivery,Good communications, privacy,support, caring environment, careful clinical monitoring and evidence based procedures will be ensured to her The women at low risk will receive natural childbirth care by a midwife during all phases of her labour and delivery,Good communications, privacy,support, caring environment, careful clinical monitoring and evidence based procedures will be ensured to her

26. 1C-26 Effective perinatal Care (EPC)

27. 1C-27 Effective perinatal Care (EPC) Step 3: post natal check for the mother Standard Mother and new born are transferred to the post partum area where they will ideally remain for at least 6 hours. During the stay she will receive the standard post partum examination ; she will be advised on essential care for baby, on breast feeding and on danger signs indicating the need to seek health care for her or her baby 27

28. 1C-28 Effective perinatal Care (EPC)

29. 1C-29 Effective perinatal Care (EPC) Step 4: post natal check up for the new born Standard The new born will be completely examined by a pediatrician before being discharged. The pediatrician will advice the mother on the need of any special care and will plan a follow up visit in case of any risk factor

30. 1C-30 Effective perinatal Care (EPC) Recommendation Most women should be offered midwife-led models of care and women should be encouraged to ask for this option although caution should be exercised in applying this advice to women with substantial medical or obstetric complications. Most women should be offered midwife-led models of care and women should be encouraged to ask for this option although caution should be exercised in applying this advice to women with substantial medical or obstetric complications.

31. 1C-31 Effective perinatal Care (EPC) Key Areas for Action Safe motherhood can be advanced through respecting existing human rights, through empowering women to make choices in their reproductive lives with the support of their families and communities. Safe motherhood can be advanced through respecting existing human rights, through empowering women to make choices in their reproductive lives with the support of their families and communities. The access to and quality of maternal health services needs to be improved. All deliveries should be overseen by skilled attendants and essential care should be available when obstetric complications arise. The access to and quality of maternal health services needs to be improved. All deliveries should be overseen by skilled attendants and essential care should be available when obstetric complications arise.

32. 1C-32 Effective perinatal Care (EPC)