1. Orientation on
Quality Maternal Health Care
Service Package
Dr Theingi Myint
Deputy Director (MCH)
Department of Health
1|

2. Pregnancy and Childbirth
Global Situation
Becoming a mother can be dangerous
and life-threatening.
More than 350,000 women die annually
in pregnancy and childbirth, most
from preventable causes:
Every day 1,000 women die giving life,
One every 90 seconds.
This year an estimated 5.8 million
newborns will die before their first
birthday.
The risk is greatest for women in poor
countries and for poor women in all
2|

3. Pregnancy and Childbirth
Myanmar Situation (Estimation)
1 million pregnancies every year
325,000 unwanted pregnancies
246,000 unsafe abortions
 2,000 women die from complications
(Average – 7 death in one township)
24,600 newborns die within the first week
of life
15,000 babies are born dead
3|

4. MDG Goal 5: Improve maternal health
Target
Improve maternal health
Indicators
Maternal mortality ratio
Proportion of births attended by skilled
health personnel
Achieve, by 2015,
universal access to
reproductive health
Contraceptive prevalence rate
Adolescent birth rate
Antenatal care coverage (at least one
visit and at least four visits)
Unmet need for family planning
4|

5. MDG 5 related RH Indicator
N
o
Indicators
1.
Maternal mortality ratio
(/100,000 LB)
Source: UN I
Estimation
2.
1990
1995
2000
520
380
2001
300
Proportion of births
attended by skilled
health personnel (%)
Source: HMIS
MICS
IHLCA
2005
2006
57.9
2010
2011
63.5
64.1
67.
0
2015
130
64.4 64.8 67.1
80
70.6
77.9
4.
Adolescent birth rate
(%)
Source: FRHS
17.4
5.
Antenatal care
coverage (%)
Source: HMIS
MICS
IHLCA
Unmet need for family
planning (%)
5|
Source: FRHS
2009
200
37
6.
200
8
230
Contraceptive
Prevalence rate (%)
Source: FRHS
MICS
IHLCA
3.
2007
41
(all)
38
50
46
(modern)
39.5
16.9
63.1
63.9
64.6
15
68.
2
70.6
73
74.3
80
83.1
83.3
19.1
17.7
10

6. nm
ar
M
ya
Source: UN-Inter Agency Estimates, 2012
6|

7. Source: UN-Inter Agency Estimates, 2012
7|

8. Maternal Mortality Ratio in Myanmar
8|
Source: UN

9. MMR (per 1000 LBs)
9|

10. Causes of maternal mortality (Global)
Hypertensive
disorders
12%
Other direct
causes
8%
Indirect
causes
20%
10 |
Unsafe
abortion
13%
Sepsis
15%
Obstructed
labour
8%
Haemorrhage
24%

11. Causes of Maternal Mortality in Myanmar
Source| : Nationwide Cause Specific Maternal Mortality Survey 2004-2005,
11
DOH/UNICEF

12. Progress is possible and it is happening
% increase in the SBA coverage
% increase in the institutional delivery
41
39.4
36.7
30
SBA and institutional
coverage over 90%
27.1
25.2
25.2
18.5
15
9.6
7
5.1
9.9 10.1
13.1
14
12.8
10.6
7
2.7
2.3
1.6
Armenia
(2001-2005)
12 |
Dominican
Republic
(1991-2007)
Phillippines
(1993-2003)
Nepal (2001- Senegal (1986Namibia
Ghana (19882006)
2005)
(1992-2006/7)
2008)
Nicaragua
Rwanda (1992- Indonesia
(1998-2001)
2007)
(1987-2007)
Egypt (19952005)

13. Institutional Delivery
13 |

14. Institutional Delivery & Skill Birth
Attendance
14 |

15. Abortion Rate (%)
15 |

16. MCH Vs Reproductive Health
16 |

17. MCH Versus Reproductive Health
Main activities of MCH Essential RH care
Antenatal care
Safe and aseptic delivery
Postnatal care
Neonatal care
Under 5 care
Nutritional development
for mothers and children
Immunization
MCH care including Antenatal
care, Safe and aseptic delivery,
Postnatal care, Neonatal care
( Safe Motherhood)
Post – Abortion Care
Birth Spacing
RTI/ STI including HIV/AIDS
Adolescent Reproductive Health
Comprehensive RH care
Infertility
Violence against Women
Osteoporosis, Ca Cervix etc
17 |

18. Essential RH care
Safe Motherhood
Post – Abortion Care
Birth Spacing
RTI/ STI including HIV/AIDS
Adolescent Reproductive
Health and Male Involvement
18 |

19. Essential RH care
Safe Motherhood
19 |

20. Our Goal for Safe Motherhood
Reduction of maternal and newborn mortality
and morbidity
- the silent tragedies
20 |

21. But WHY Do These Women Die?
( Three delays Model)
 Delay in decision to seek care
–
–
–
–
Lack of understanding of complications
Acceptance of maternal death
Low status of women
Socio-cultural barriers to seeking care
 Delay in reaching care
– Mountains, islands, rivers — poor organization
 Delay in receiving care
– Supplies, personnel
– Poorly trained personnel with punitive attitude
– Finances
21 |

22. Recognition
22 |

23. Recognition
23 |
Referral

24. Recognition
24 |
Referral
Responsiveness

25. The Six Pillars of Safe Motherhood
STD-HIV Control
Post-Abortion Care
Post-Natal Care
Obstetric Care
Ante-Natal Care
Birth Spacing
Safe Motherhood
Communication for Behavior Change
Primary Health Care
Equity and Education for Women
25 |

26. Essential RH care
Post – Abortion Care
26 |

27. Elements of Post abortion Care
Emergency
Treatment
BS Counseling
& Services
Other
Reproductive
Health Services
27 |

28. Essential RH care
Birth Spacing
28 |

29. Family Planning Vs Birth Spacing
Population Ground
Health Ground
Permanent Method and
Temporary Method
Temporary Method
Eg. Sterilization
29 |
Eg. Contraceptive Pills

30. Essential RH care
RTI/ STI including HIV/AIDS
30 |

31. Different types of RTIs
RTI
EXOGENOUS
ENDOGENOUS
IATROGENIC
Through Sexual Activity
Eg. Syphillis
AIDS
Overgrowth of Normal Flora
Eg. Bacterial Vaginosis
Candidiasis
Through Medical Procedure
Eg. IUD Insertion
31 |

32. Essential RH care
Adolescent Reproductive Health
32 |

33. 33 |

34. Saving mothers and newborn lives
No more about technology but it
is about quality, access and
coverage
34 |

35. We know what needs to be done:
Technology is available for very long time
Skilled care during pregnancy, childbirth and
post partum/post natal period
Access to emergency obstetric and newborn
care
Access to family planning/ Birth Spacing
35 |

36. We know what didn’t work
 Traditional
Birth Attendants as skilled birth
attendants
 Risk
approach
 Focusing
36 |
efforts on antenatal care alone

37. The new paradigm in reducing
Maternal Mortality and Peri-natal Mortality
All pregnancies are at risk: Most
obstetrical complications are neither
predictable, nor avoidable, but can be
treated
Shift of focus from pregnancy to delivery,
and from home to facility
Therefore, readiness is key, accompanied
by quality of obstetric care
37 |

38. What we need
Skilled Birth Attendants for 100% of
deliveries
Emergency obstetric care for the 15% of
deliveries where it is needed (at least 7%
mothers and 9-15% newborns)
Basic Emergency Obstetric Care (6)
Comprehensive Emergency Obstetric Care
Referral from community to facilities
38 |

39. Why Skilled Care at Every Birth?
Most complications and deaths occur
during childbirth and immediately after birth
Rights of all women and newborns –
government’s responsibility
Many countries have a low proportion of
births attended by skilled attendants
Commitment towards achieving MDGs 5
and 4
39 |

40. Reason for not going to health facility
( countries in South, South East Asia (N= 82022 women 5
100
80
60
%
46.5
42.0
40
$33.4
30.1
23.4
29.9
23.2
31.9
26.8
26.2
22.1
$17.1
20
5.4 5.6 $5.1
9.5 11.2
$10.7
$6.4
$10.5
$14.3
0
Knowing
where to go
for treatment
Getting
permission
to go for
treatment
Getting
money for
treatment
Total
40 |
Distance to
health facility
Rural
Having to
take
transport
Urban
Not wanting
to go alone
Concern
there may
not be a
female
provider

41. 41 |

42. Maternal deaths per 1000000 live births
The higher the proportion of deliveries attended by skilled
attendant in a country, the lower the country’s maternal mortality
ratio
% skilled attendant at delivery
42 |

43. Child Deaths per 1,000 Live Births
What Happens to the Children
When a Parent Dies?
No Parent Dies
43 |
Father Dies
Mother Dies

44. FOCUSED ANTENATAL CARE
FIRST VISIT (as soon as ,
within 3 month)










Take history
Perform physical examination, including vaginal
exam
Look for clinical signs of anaemia
Test urine for bacteriuria, protein
Screen for syphilis
Give tetanus toxoid, iron folate
Advise on individual birth plan, healthy lifestyle
Tell her about danger signs
Refer if necessary
Complete clinic & home based records





Perform physical examination. Check for twins
Listen to foetal heart sounds
Test urine for bacteriuria, protein
Check haemoglobin
Give iron folate
Give tetanus toxoid (if 4 weeks from first dose)
Review individual birth plan, advise on healthy
lifestyle
Refer if necessary

THIRD VISIT (8 month)







SECOND VISIT (6-7 months)

 44 |


Perform physical examination
Listen for foetal heart sounds
Test urine for bacteriuria, protein
Give iron folate and mebendazole
Review individual birth plan, advise on healthy
lifestyle
Refer if necessary
Complete clinic & home based records
FOURTH VISIT ( 9 month)







Perform physical examination. Check fetal lie
and presentation
Listen to foetal heart sounds
Test urine for bacteriuria, protein
Give iron folate
Tell her about signs of labour
Review individual birth plan, what to do if not
delivered by end of week 41
Refer if necessary

45. AN Care Vinyl
45 |

46. ta=ccHta7;ay:
om;zGm;=yKpkapmifha&Smuf=cif;
Basic Emergency Obstetric Care
(1) yÃdZD0aq;udk xdk;ay;=cif;
Administer parenteral antibiotics
(2) om;tdrfusHKhaq;xdk;ay;=cif;
Administer parenteral oxytocic drugs
(3) udk,f0efqdyfwuf a7m*gajumifh wufaeaom vlemtm;
twufusaq;xdk;ay;=cif;
Administer parenteral anticonvulsants for eclmpsia
(4) tcsif;rusaom vlemtm; vufESifhcGmxkwfay;=cif;
Perform manual removal of placenta
(5) uav;ysufaom vlemwGif usefaeaom tcsif;ESifh oaE<om; tptersm;tm;
z,fxkwfay;=cif;
Perform manual removal of retained products
(6) uav;tarG; jumaeaom vlemtm; ulI nSyfqGJarG;ay;=cif;/
46 |

47. =yD;=ynfhpHkaomta7;ay:
om;zGm;=yKpkapmifha&Smuf=cif;
Comprehensive Emergency Obstetric Care
aq;&HkwGifuko7ef
ta=ccHta7;ay: om;zGm;=yKpkapmifha&Smuf=cif; vkyfief;
(6) 7yf
(7) cGJpdwfukoay;=cif; Perform surgery
(8) aoG;oGif;ukoay;=cif; Perform blood transfusion
(9) arhaq;ay;=cif; Perform anaesthesia
47 |

48. Basic Emergency Care
Ante Partum and Post Partum Hemorrhage
Prolonged labour and Uterine rupture
Severe Pre Eclampsia and Eclampsia
Puerperial Sepsis
Abortion related Complications
48 |

49. 49 |

50. THANK YOU
50 |