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Maternal Health Program DOH The Maternal Health Program is a set of actions and services administered by the Department

of Health to aid women before, during and after pregnancy. The Philippines is tasked to reduce the maternal mortality ratio (MMR) by three quarters by 2015 to achieve its millennium development goal. This means a MMR of 112/100,000 live births in 2010 and 80/100,000 live births by 2015. The maternal mortality ratio (MMR) has declined from an estimated 209 per 100,000 live births in 1987-93 (NDHS 1993) to 172 in 1998. The Philippines found it hard to reduce morality. Similarly, perinatal mortality reduction has been minimal. It went down by 11% in 10 years from 27.1 to 24 per thousand live births. The percentage of pregnant woman with at least four prenatal visits decreased from 77% in 1998 to 70.4 in 2003. In addition, pregnant women who received at least two doses of tetanus toxoid also decreased from 38% in 1998 to 37.3% in 2003. Only about 76.8% of pregnant women received iron supplementation during pregnancy. The Philippine Health Statistics revealed that maternal deaths are due to: Complication Hypertension Postpartum Hemorrhage Pregnancy with abortive outcomes Percentage of total maternal deaths 25% 20.3% 9%

However births attended by health professionals increased from 56% in 1998 to 59.8% in 2003. There was also a notable increase to 51% in 2003 from 43% in 1998 in the percentage of women with at least one prenatal visit. Only 44.6% of postpartum women received a dose of Vitamin A. The underlying causes of maternal deaths are 1. delays in taking critical actions: 2.delay in seeking care, 3.delay in making referral and delay in providing of appropriate medical management. Other factors that contribute to maternal deaths includes 1. closely spaced births, 2.frequent pregnancies, 3.poor detection and management of high-risk pregnancies, 4.poor access to health facilities brought about by geographic distance and 5.cost of transportation, 6.and as well as health care and health staff who lack competence in handling obstetrical emergencies.

The overall goal of the Maternal Health Program is to improve the survival, health and well being of mothers and unborn through a package of services all throughout the course of and before pregnancy. The Strategic Thrust for 2005-2010 Basic Emergency Obstetric Care (BEMOC) Launch and implement the Basic Emergency Obstetric Care or BEMOC strategy in coordination with the DOH. The BEMOC strategy entails the establishment of facilities that provide emergency obstetric care for every 125, 000 population and which are located strategically. The strategy calls for families and communities to plan for childbirth and the upgrading of technical capabilities of local health providers. Improve the quality of Prenatal and Postnatal Care Pregnant women should have at least four prenatal visits with time for adequate evaluation and management of diseases and conditions that may put the pregnancy at risk. Post-partum care should extend to more women after childbirth, after a miscarriage or after an unsafe abortion. Reduce womens exposure to health risks Through the institutionalization of responsible parenthood and provision of appropriate health care package to all women of reproductive age especially those who are 1. less than 18 years old and over 35 years of age, 2.women with low educational and financial resources, 3.women with unmanaged chronic illness and 4.women who had just given birth in the last 18 months. Appropriate Allocation of Resources LGUs, NGOs and other stakeholders must advocate for health through resource generation and allocation for health services to be provided and are in place in the health system. To address the problem, packages of health services are provided to the clients. These essential health care packages are available and are in place in the health system. Essential Health Service Package Available in the Health Care Facilities These are the packages of services that every woman has to receive before and after pregnancy and or delivery of a baby. Antenatal Registration Pregnancy poses a risk to the life of every woman. Pregnant women may suffer complication and die. Every woman has to visit the nearest facility for antenatal registration and to avail prenatal care services. This is the only way to guide her in pregnancy care to make her prepare for child birth. The standard prenatal visits that women have to receive during pregnancy are as follows: Prental Visits 1st visit 2nd visit 3rd visit Every 2 weeks Period of Pregnancy As early in pregnancy as possible before four months or during the first trimester During the 2nd trimester During the 3rd trimester After 8th month of pregnancy till delivery.

Tetanus Toxoid Immunization Neonatal Tetanus is one of the public health concerns that we need to address among newborns. To protect them from deadly disease, tetanus toxoid immunization is important for pregnant women and child bearing age women. Both mother and child are protected against tetanus and neonatal tetanus. A series of 2 doses of Tetanus Toxoid vaccination must be received by a woman one month before delivery to protect baby from neonatal tetanus. And the 3 booster dose shots to complete the five doses following the recommended schedule provides full protection for both mother and child. The mother is then called as a fully immunized mother (FIM). Micronutrient Supplementation Micronutrient supplementation is vital for pregnant women. These are necessary to prevent anema, vitamin A deficieny and other nutritional disorders. They are:

Nutrient Vitamin A

Dose 10,000 IU

Schedule Twice a week starting on the 4th month of pregnancy Daily

Remarks Do not give Vitamin A supplementation before the 4th month of pregnancy. It might cause congenital problems in the baby.

Iron

60 mg/400 ug tablet

Treatment of Diseases and Other Conditions There are other conditions that might occur among pregnant women. These conditions may endanger her health and complication could occur. Follow first aid treatment: Conditions/Diseases What to do Do not give Difficulty of -Clear airway breathing/obstruction of -Place in her best position airway -Refer woman to hospital with EmOC capabilities Unconscious -Keep on her back arms at the side -Tilt head backward (unless trauma is suspected) -Lift chin to open airway -Clear secretions from throat - Give IVF to prevent or correct shock -Monitor VS every 15 minutes -Monitor fluid given. If difficulty of breathing and puffiness develops, stop infusion

Post partum bleeding

-Monitor U.O. -Do not give oral rehydration solution to a woman who is unconscious or has convulsions. -Do not give IVF if you are not trained to do so -Massage uterus and expel clots -If bleeding persists: >Place cupped palm on uterine fundus and feel for state of contraction >Massage fundus in a circular motion >Apply bimanual uterine compression if ergometrine treatment done and postpartum bleeding still persists >Give ergometrine 0.2. IM and another dose after 15 minutes. -Do not give ergometrine if woman has eclampsia, preeclampsia or hypertension. Giver mebendazole 500mg tablet single dose anytime from 4-9 months of pregnancy if none was given in the past 6 months Give sulfadoxinpyrimethamine to women from malaria endemic areas who are in 1st or 2nd pregnancy, 500mg-25 mg tab, 3tabs at the beginning of 2nd to 3rd trimesters not less than one month interval. Do not give mebendazole in the first 1-3 months of pregnancy. This might cause congential problems in baby.

ntestinal parasite infection

Malaria

Clean and Safe Delivery The presence of a skilled birth attendance will ensure hygiene during labor and delivery. It may also provide safe and non traumatic care, recognize complications and also manage and refer the

women to a higher level of care when necessary. The necessary steps to follow during labor, childbirth and immediate post partum include the following: Do a quick check upon admission for emergency signs: 1. Unconscious/convulsion 2. Vaginal bleeding 3. Severe abdominal pain 4. Looks very ill 5. Severe headache with visual disturbance 6. Severe breathing difficulty 7. Fever 8. Severe vomiting Make woman comfortable Establish rapport with the client by greeting and interviewing to make her comfortable. Assess the woman in labor Assessing the client is a reference guide for a health worker to determine its status during labor stage. This can be done by taking the history of the ff: 1. Last menstrual period (LMP) 2. Number of pregnancy 3. Start of labor pains 4. Age/height 5. Danger signs of pregnancy Taking the history through interview will help determine the clients condition during delivery of a baby. Determine the stage of labor Labor can be determined when womans response to contraction is observed pushing down and vulva is bulging, with leaking amniotic fluid, and vaginal bleeding. A vaginal examination can be performed to determine the degree of contraction. Decide if the woman can safely deliver By assessing the condition of the client and not finding any indication that could harm the delivery of a baby, a trained health worker can decide a safe delivery of a mother. Give supportive care throughout labor There are many things that a woman needs to do during labor. This will help her deliver clean, safe and free from fatigue. These are: 1. Encourage to take a bath at the onset of labor 2. Encourage to drink but not to eat as this may interfere surgery in case needed. 3. Encourage to empty bladder and bowels to facilitate delivery of the baby. Remind to empty bladder ever 2 hours

4. Encourage to do breathing technique to help energy in pushing baby out the vagina. Panting can be done by breathing with open mouth with 2 short breaths followed by long breath. This prevent pushing at the end of the first stage. Monitor and manage labor These re different stages of labor to watch out any danger signs Stage What to do First Stage Not yet in -Check every hour for emergency ative labor, cervic is signs, frequency and duration of dilated 0-3cm and contractions, fetal heart rate, etc. contractions are weak, -Check every 4 hours for fever, pulse, less than 2 to 10 minutes. BP and cervical dilatation -Record time of rupture of membranes and color of amniotic fluid. -Assess progress of labor >Refer woman immediately to hospital facility with comprehensive emergency obstetrical care capabilities if after 8 hours, contractions are stronger and more frequent but no progress in cervical dilatation, with or without membranes ruptured. First Stage In active -Check every 30 minutes for labor, cervic is dilated 4 emergency signs cm or more -Check every 4 hours for fever, pulse, BP and cervical dilation -Record time of rupture of membranes and color of amniotic fluid -Record findings in partograph/patient record. Second Stage Cervic dilated 10 cm or bulging thin perineum and head visible -Check every 5 minutes for perineum thinning and bulging, visible descend of the head during contraction, emergency signs, fetal heart rate and mood and behavior. -Continued recording in the partograph. -Deliver the placenta -Check the completeness of placenta and membranes

Not to do Do not do vaginal examination more frequently than every 4 hours.

-Do not allow woman to push unless delivery is imminent. It will just exhaust the woman. -Do not give medications to speed up labor. It may endanger and cause trauma to mother and the baby. -Do not apply fundal pressure to help delivery the baby.

Third Stage Between birth of the baby and delivery of the placenta

-Do not squeeze or massage the abdomen to deliver the placenta

Others Monitor closely within one hour after delivery and give supportive care Continue care after one hour postpartum. Keep watch closely for at least 2 hours. Educate and counsel on FP and provide FP method if available and decision was made by a woman. Birth registration Importance of BF Newborn Screening for babies delivered in RHU or at home within 48 hours up to 2 weeks after birth Schedule when to return for consultation for post partum visits Inform, teach and counsel the woman on important MCH messages: 1st Visit 2nd Visit 1st week post partum preferable 3-5 days 6 weeks post partum

Support to Breast Feeding Most mothers do not know the importance of breastfeeding. A support care groups like nurses have critical role to motivate them to practice breastfeeding. Family Planning Counseling Proper counseling of couples on the importance of FP will help them inform on the right choice of FP methods, proper spacing of birth and addressing the right number of children. Birth spacing of three to five years interval will help completely recover the health of a mother from previous pregnancy and childbirth. The risk of complications increases after the second birth. Conclusion The DOH Maternal Health Program has be eager to decrease the maternal mortality rate of the country and this program is a good example to that effort.

REFERENCES:

http://nurseslabs.com/doh-maternal-health-program/ http://nurseslabs.com/doh-maternal-health-program/

Maternal Health Program by the DOH

Submitted to:
Mr. Aurelio Manego RN, MAN (Clinical Instructor)

Submitted by:
TIAMZON, Ericka CABALONA, Cybil MACATIAG, Allysa