Introduction

This standards of practice describes the family planning (FP) and selected reproductive health (RH) and maternal and child health (MCH) performance practices to be provided within the Egyptian Health Program, as prepared by the Population and Family Planning Sector and the Integrated Care Department, Ministry of Health and Population (MOHP). This book is a combination of the FP/RH Standards of Practice and the Basic Essential Obstetric Care: Protocols for Physicians and is a strong step in the direction of integrated services. It is aimed at service providers who contribute directly or indirectly to the provision of FP, RH and MCH services within the MOHP facilities. They must comply with these standards. These standards of care define the minimum, measurable elements from which training, supervision, data collection and quality assurance activities can emanate. The goal in formulating these principles is to provide uniformity to the services delivered in the various clinics and service centers. These guidelines of clinical performance are presented to general practitioners (the majority of MOHP care providers) with procedural directions for any needed referrals to specialists and specialized care facilities. Carefully selected reproductive health issues have been added to the clinical procedures and guidelines. These issues were selected because they are common and can be managed at the health unit level. Some services described in this document are not provided in MOHP clinics, for example, the hormone releasing IUD, vasectomy and spermicides. It is the expectation that this Standards of Practice will also be used in universities, clinics of non-governmental agencies, and in the private sector because the Ministry of Health and Population has a responsibility to all sectors of society. Thus, the range of services included in this Standards of Practice ensures the widest possible information available to all practitioners. This will benefit the men, women and children of Egypt, who deserve up-to-date medical care of the highest quality, irrespective of the place of service. Standards of care have, like drugs and commodities, a shelf life. With the increasing knowledge and understanding worldwide, our definition of high quality of care is continually changing. For this reason, the Standards of Practice must be reviewed by national and international experts on a regular basis to ensure their adherence to the current state of knowledge worldwide and their applicability in Egypt, its culture and its health system. This version of the Standards of Practice dates from July 2005. The Ministry of Health and Population (MOHP) is committed to updating it on a regular basis. The MOHP Family Planning and Population Sector Undersecretary and Integrated Care Undersecretary must approve any additions or changes to these principles. Questions regarding the Standards should be put in writing and addressed to the Undersecretary of Population and Family Planning and the Undersecretary of Integrated Care, Ministry of Health and Population, Cairo, Egypt. These Standards of Practice form Volume 1 of a 2-volume document. Volume 2 will describe the Standards of Management of Primary Health Care facilities, as prepared by the Population and Family Planning Sector and the Integrated Care Department, Ministry of Health and Population (MOHP).

MCH/RH Package of Essential Services

The MOHP has formulated the Basic Benefits package. The MCH/RH Package of Essential Services is a document defined by the MOHP, describing the activities and services that are to be implemented and delivered by clients, communities and health providers, to improve and assure the health of the Egyptian population. These services are delivered at two levels within the health system. Each level is expected to provide good quality services for the men and women they serve.

Level 1: Primary Health Care

Rural health unit MCH centers Mobile clinics Health office Rural health compound unit Family health unit/center (Integrated) Rural hospital Urban health center

Level 2: Secondary Health Care

District hospital General hospital Note: MCH/RH is a set of services that every doctor and nurse, irrespective of his or her work setting, should advocate.

Why is this package needed?

This package is needed to clarify to all concernedclients, communities, providers, and managerswhat they can expect and what is expected of them in the area of FP/RH/MCH. Clients are expected to take responsibility for their own health and welfare and can expect high quality FP/RH/MCH services to help them in this. Community leaders should be active in promoting FP/RH/MCH services. Providers are expected to be up to date in their knowledge and provide high quality services. They can expect certain support from their managers. Managers and supervisors are expected to provide training, supplies, commodities etc. to the providers and can in turn expect not only reports, but improving health in the population they serve.

Community and provider responsibilities

Table Intro. 1 Responsibilities of clients and their families Before marriage After marriage
Promote delaying marriage until the women is 20 years old. Visit clinic for premarital counseling. Discuss desired family size and spacing of children with partner. Make informed decision on this desired family size and spacing of children.

Request a clinic for FP services according to client needs. Seek antenatal care early and regularly. Recognize danger signs. Prepare for birth. Adopt healthy self-care behaviors. Plan for emergencies. If possible, plan to deliver in a health facility. Plan and prepare for breastfeeding. Discuss FP use with a provider during last ANC visit and make an informed decision about FP use after delivery. Utilize trained provider/attendant for delivery. Recognize danger signs. Seek timely appropriate care from trained provider for emergencies and complications. Plan for emergencies. Seek family planning/reproductive health counseling. Initiate breastfeeding immediately. Seek vitamin A supplementation. Postpartum and neonatal care (<28 days) Breast-feed exclusively for six months. If needed, seek counseling for breastfeeding. Use a FP method immediately (e.g., exclusive breastfeeding, or another appropriate method). Seek postpartum care as per schedule. Be able to recognize danger signs in woman. Seek timely appropriate care for woman's emergencies and complications. Plan for emergencies. Seek newborn checkup as per schedule. Ask for tuberculosis immunization and for thyroid testing. Be able to recognize danger signs in the newborn. Seek timely, appropriate care for newborn's emergencies and complications. Adopt healthy newborn care behaviors (drying and warming). Visit the clinic on the 40th day after delivery. Breastfeed exclusively for six months and switch to another FP method after six months. If not breastfeeding exclusively, use another FP method. Be able to recognize danger signs of illness of children. Receive immunization as per schedule. Provide appropriate home-care for diarrhea and fever for children. Provide appropriate nutrition for children. Provide appropriate supplementary food for children. Discourage female genital cutting. Maintain healthy nutrition practices. Provide iron-rich foods. Encourage iron-enhancing foods and practices and avoid iron inhibitors. Discourage smoking. Do regular self-examination of breasts. Discourage female genital cutting. Use iodized salt.

ANC

Labor and delivery

Postpartum and neonatal care (<28 days)

Infant/child (2 days 5 years)

6 18 years

All reproductive age groups

Table Intro. 2 Community responsibilities School age/before marriage

Promote delaying marriage until the woman is 20 years old. Support health education. Promote premarital counseling. Encourage families not to practice female genital cutting. Promote use of family planning services. Promote delaying first pregnancy until the woman is 20 years old. Promote a minimum of three years between pregnancies. Promote a minimum of four ANC visits for pregnant women. Promote immediate and exclusive breastfeeding. Promote delivery in a health facility. Promote recognition of, and early care seeking for danger signs. Promote birth preparedness. Plan for emergencies. Promote use of family planning services. Promote use of trained provider/attendant for delivery. Promote recognition of, and early care-seeking for emergences and complications. Plan for emergencies. Promote early initiation of breastfeeding. Promote exclusive breastfeeding for six months. Promote vitamin A supplementation after delivery. Promote use of an appropriate family planning method directly postpartum. Promote family planning/reproductive health services. Promote early initiation of breastfeeding. Promote exclusive breastfeeding for six months. Encourage postpartum visits and support visiting nurses/raedat rifiat in 40th day program. Promote 40th day program. Promote newborn checkup. Promote screening for congenital hypothyroidism. Promote recognition of, and early care seeking for emergencies and complications. Promote healthy newborn care behaviors (drying and warming). Promote exclusive breastfeeding for six months. Promote immunization as per schedule. Promote appropriate home-care for diarrhea and fever. Promote seeking immediate medical care during illness. Provide appropriate supplementary food and nutrition. Promote healthy nutritional practices. Provide iron rich foods. Encourage iron-enhancing foods and discourage iron inhibitors. Promote seeking immediate medical care during illness. Explain dangers of smoking. Distribute weekly iron/folic acid. Provide health education activities to students. Discourage violence against women. Encourage families not to practice female genital cutting. Support outreach programs. Promote regular self-examination of breasts. Promote routine PAP smears for women over 40 years (if service available). Promote use of iodized salt.

After marriage

ANC

Labor and delivery

Postpartum and neonatal care (< 28 days)

Infant child (28 days 5 years)

6-8 years

All reproductive age groups

Table Intro. 3 Primary Health Care

Promote delaying marriage until the woman is 20 years old. Provide premarital counseling. Encourage families not to practice female genital cutting. Provide health education and services, suitable and appropriate for youth and adolescents. Promote delaying pregnancy until the woman is 20 years old. Provide family planning and reproductive health counseling. Provide all FP methods if available (including removal of uncomplicated IUDs and Norplant and Implanon). Refer complicated family planning cases. Provide counseling and if needed referral for infertile couples. Diagnose and manage mild complications of pregnancies. Screen for high risk pregnancies. Stabilize and refer high risk pregnancies to district hospital. Provide immunization (TT). Provide iron and folic acid supplementation. Provide nutritional status, blood pressure monitoring. Provide urine (glucose, protein) and blood analysis (Hb%, Rh factor). Provide breastfeeding counseling. Provide family planning counseling, including immediate postpartum IUD. Promote delivery in a health facility. Provide normal delivery (if services available). Diagnose (stabilize if needed) and refer high risk labor and deliveries. Manage some complications of delivery according to protocol (except rural health unit). Promote early initiation of breastfeeding. Promote exclusive breastfeeding for six months. Provide iron, folic acid and vitamin A counseling and supplementation. Provide family planning counseling, including immediate postpartum IUD. Refer for or provide immediate postpartum IUD (if available). Administer resuscitation of neonate. Refer neonatal complications. Identify birth injury and refer to hospital. Promote early initiation of breastfeeding. Promote exclusive breastfeeding for six months. Identify neonatal infection and refer to hospital. Refer neonatal tetanus cases to fever hospital. Promote and counsel for immediate and exclusive breastfeeding. Promote neonatal screening for congenital hypothyroidism at 3rd-7th day (at home or in clinic). Provide immunization (BCG), zero dose of polio. Promote and organize postpartum care checkups at home. Provide vitamin A and iron supplementation for all mothers. Provide FP counseling and all available services. Manage and refer all IMCI cases according to protocols. Provide immunization as per schedule. Provide two doses of vitamin A at 9 and 18 months of life for infants. Provide 40th day integrated visit for postpartum checkup and newborn screening. Provide growth and development monitoring AT LEAST at 2, 4, 6, 9, 12, 18, 24, 36, 48 and 60 months.

Before marriage

After marriage

ANC

Labor and delivery

Postpartum and neonatal care (<28 days)

Infant and PreSchool Child (28 days 5 years)

Provide nutritional education. Manage ARI, CDD (IMCI) according to protocols. Refer severe cases of ARI, CDD according to protocols. Provide nutrition education. Provide periodic medical examinations. Provide treatment of sick child. Refer cases with severe illness. Supervise immunization for school children. Provide iron supplementation. Discourage violence against women. Encourage families not to practice female genital cutting. Promote regular self-examination of breasts. Promote routine PAP smears for women over 40 years. Screen, counsel and treat reproductive tract infections. Screen, counsel and refer for suspicion of cervical cancer (with speculum). Screen, counsel and refer for suspicion of breast cancer (clinical examination). Counsel and refer for post-menopausal problems. Provide immediate treatment and referral for postabortion care, according to protocols.

6-18 years

All reproductive age groups

Table Intro. 4 Level 2 Secondary Health Care

Promote delaying marriage until the woman is 20 years old. Provide health education. Provide premarital counseling and, if indicated, examination. Encourage families not to practice female genital cutting. Provide health education and services, suitable and appropriate for youth and adolescents. Promote delaying pregnancy until the woman is 20 years old. Provide all available FP counseling and services, including removal of complicated and uncomplicated IUDs, Norplant and Implanon. Provide suitable FP methods for high risk clients such as tubal ligation, when medically indicated, and if available. Provide counseling and if needed treatment or referral for infertile couples. Promote antenatal care services. Provide screening for high risk pregnancies. Diagnose and manage complications of pregnancies. Manage high risk pregnancies according to protocols. Provide nutritional status, blood pressure monitoring. Provide iron and folic acid supplementation. Provide urine and blood analysis (Hb%, Rh factor). Provide breastfeeding counseling. Provide family planning/reproductive health counseling, including immediate postpartum IUD. Promote delivery in a health facility. Delivery with complications requiring surgery and/or blood transfusion. Promote early initiation of breastfeeding. Promote exclusive breastfeeding for six months. Provide family planning counseling, including immediate postpartum IUD. Provide immediate postpartum IUD (if available). Provide iron, folic acid and vitamin A counseling and supplementation.

Before marriage

After marriage

ANC

Labor and delivery

Postpartum and neonatal care (< 28 days)

Provide resuscitation, if needed. Manage postpartum complications. Treat neonatal infection. Refer neonatal tetanus cases to fever hospital. Manage neonatal cases according to standard levels of care. District hospital: Refer severe neonatal cases to general or university hospital. General hospital: Manage severe neonatal complications (ventilation, blood gas analysis, exchange transfusion, very low birth weight <1500gms). Treat birth injury. Refer very severe neonatal cases to university hospital or special center. Refer to primary health care level for neonatal screening. Promote early initiation of breastfeeding. Promote exclusive breastfeeding for six months. Promote postpartum care visits to mother and child. Provide FP counseling and all available services. Refer to primary health care levels for 40th day integrated visit for postpartum checkup. Treat moderate malnutrition. Provide nutritional education.

Infant (28 days 5 years)

District Hospital:
Manage ARI, CDD (IMCI) according to protocols. Refer severe cases of ARI, CDD according to protocols.

General hospital:
Manage ARI, CDD (IMCI) according to protocols. Manage cases in need of intensive care. Discourage violence against women. Encourage families not to practice female genital cutting. Promote regular self-examination of breasts. Promote and provide routine PAP smears for women over 40 years, if available. Screen and treat reproductive tract infections. Screen, counsel, diagnose and treat or refer for cervical cancer. Screen, counsel, diagnose and treat or refer for breast cancer. Provide counseling and treatment for post-menopausal problems. Provide hormone replacement therapy if and when indicated. Provide postabortion care services.

All reproductive age groups