REVISED FOCUSED ANTENATAL CARE (FANC).pptx

medical surgical document for nursing students

1. FOCUSED ANTENATAL CARE (FANC). What is FANC? Definition : It is personalised care provided to a pregnant woman which emphasizes on the woman’s overall health, her preparation for childbirth and readiness for complications ( emergency preparedness ). It is timely, friendly, simple and safe service to a pregnant woman.

2. ANC is the care provided by a skilled health care professionals to pregnant women and adolescent girls in order to ensure the best health conditions/outcomes for both mother and baby during pregnancy

3. Components of ANC Risk Identification Prevention And Management Of Pregnancy-related Or Concurrent Diseases Health Education And Health Promotion

4. AIM OF FANC. To achieve a good outcome for the mother and baby and prevent any complications that may occur in pregnancy, labour, delivery and postpartum.

5. FOUR COMPREHENSIVE ANTENATAL VISITS. 1 st visit : < 16 weeks. 2 nd visit : 16 – 28 weeks. 3 rd visit : 28 – 32 weeks. 4 th visit : 32 – 40 weeks. During FANC visits, ensure that the following have been accomplished.

6. CONTENTS OF THE 1 ST VISIT. Obtain information on: Personal history – name, age, address History of present pregnancy. Obstetric history. Medical history. Perform physical examination. Lab test e.g.VDRL , Hb, blood group. Provide iron and folic acid, administer tetanus toxoid as per the Kenya guidelines.

7. Ct on CONTENTS OF THE 1 ST VISIT. Refer woman when complications arise that cannot be managed at that facility, e.g. severe anaemia. If the 1 st visit is after 16wks, give in malaria endemic areas: sulfadoxine/ pyrmethamine ( IPT) 3 tablets once to be taken at the facility under supervision(DOT). Mebendazole 500mg stat.

8. Ct on CONTENTS OF THE 1 ST VISIT. Assess the need for specialised care e.g. diabetes, heart disease, epilepsy. Development of an individual birth plan Advise on complications and danger signs. Health promotion, questions and answers, and scheduling the next appointment. Maintain complete records.

9. CONTENTS OF 2 ND VISIT. Obtain information on: Personal history- note any changes since 1 st visit. Present pregnancy- e.g.abnormal changes in body features, s&s of anaemia. Obstetric history. Medical history.

10. Ct on CONTENTS OF 2 ND VISIT. Perform physical examination e.g. blood pressure and pulse, fundal, height, oedema. Lab tests e.g. urine, repeat Hb if at 1 st visit was below 7.0g/ml. Provide iron if Hb is <7.0g/ml, tetanus toxoid in line with national guidelines, administer mebendazol 500mg stat after 1 st trimester

11. Ct on CONTENTS OF 2 ND VISIT. Re-assess for complications and possible referral. Advice, questions and answers, and scheduling the next appointment. Maintain complete records.

12. CONTENTS OF THE 3 RD VISIT. Obtain information on: Personal history- note changes since 2 nd visit. Present pregnancy- abnormal changes in body features, signs of anaemia. Obstetric history. Medical history. Perform physical examination.

13. Ct on CONTENTS OF THE 3 RD VISIT. Lab test – urine, Hb if Hb at previous visit was below 7.0g/ml. Provide iron continue if Hb is<7.0g/ml, consider further investigations. Tetanus toxoid in line with national guidelines. Administer IPT in malaria endemic areas. Re-assess for complications and possible referral. Advice, questions and answers, and schedule the next appointment. Maintain complete records.

14. CONTENTS OF THE 4 TH VISIT. Obtain information on: Personal history- note changes since 3 rd visit. Present pregnancy- note changes in body features, symptoms and events since 3 rd visit, review individualized birth plan. Obstetric history Medical history

15. Ct on CONTENTS OF THE 4 TH VISIT. Perform physical examination. Perform the following tests: urine, Hb if Hb at previous visit was below 7.0g/ml or signs of anaemia are detected on examination. Provide iron if Hb<7.0g/ml, consider further investigations. Administer IPT in malaria endemic areas.

16. Ct on CONTENTS OF THE 4 TH VISIT. Re-asses for complications and possible referral. Advice, questions and answers, and schedule the next appointment. Maintain complete records.

17. LATE ENROLMENT AND MISSED VISITS. It is very likely that a good number of women will not initiate ANC early enough in pregnancy to follow the focused four antenatal visits. These women, particularly those starting after 32 weeks of gestation, should have in their first visit all activities recommended for the previous visits, as well as those which corresponds to the present visit. It is expected, therefore, that a late first visit will take more time than a regular first visit.

18. Comparison between WHO FANC model and WHO ANC Model WHO FANC model WHO ANC Model First trimester Visit 1: 8-12 weeks Contact 1: up to 12 weeks Second trimester Visit 2: 24 -26 weeks Contact 2: 20 weeks Contact 3: 26 weeks Third trimester Visit 3: 32 weeks Visit 4: 36-38 weeks Contact 4: 20 weeks Contact 5: 26 weeks Contact 6: 20 weeks Contact 7: 26 weeks Contact 8: 20 weeks Return for delivery at 41 weeks if not given birth

19. Key recommendations of the new 2016 WHO ANC Model Nutritional interventions: Healthy eating and keeping physically active to stay healthy and prevent excessive wt gain Undernoursished populations to increase daily energy and protein intake to reduce risk of LBW neonates and also balanced energy and protein dietary supplementation to reduce risk of stillbirths and SGA neonates Daily oral IFAS with 60mg to 65mg elemental iron and 400mcg (0.4mg) folic acid to prevent maternal anaemia , puerperal sepsis, LBW and preterm birth

20. Cont … Key recommendations of the new 2016 WHO ANC Model Maternal assessment: fetal assessment: Preventive measures: antenatal prophylaxis with anti-D immunoglobulin in non-sensitized RH-negative pregnant woman at 28 and 34 weeks of gestation to prevent RhD Isoimmunization Antihelminthic after 1 st trimester TD vaccination In malaria- enemic areas IPT of Sulfadoxine-pyrimethamine , to be started in 2 nd trimester, at least 3 doses 4 weeks apart Oral pre-exposure prophylaxis (prep) containing tenofovir disoproxil fumarate is an additional prevention choice for women at substantial risk of HIV infection

21. Cont …Key recommendations of the new 2016 WHO ANC Model Health systems interventions to improve the utilization and quality of antenatal care: Each pregnant woman should carry her own case notes during pregnancy midwife-led continuity of care models in which a known midwife or small group of known midwives supports a woman throughout antenatal, intrapartum and postnatal continuum Group ANC provided by qualified health care professionals may be offered as an alternative to individual ANC for pregnant women in the context of rigorous research, depending on a woman’s preferences and provided that the infrastructure and resources for delivery of group ANC are available

22. Cont …Key recommendations of the new 2016 WHO ANC Model Packages of interventions that include household and community mobilization and antenatal home visits to improve ANC utilization and perinatal health outcomes Task sharing to promote health-related behaviours for MNH to a broad range of cadres including lay health workers, auxillary nurses, nurses, midwives and doctors is recommended Policy- makers should consider educational, regulatory, financial and personal and professional support interventions to recruit and retain qualified health workers in rural and remote areas ANC models with a minimum of 8 contacts to reduce perinatal mortality and improve women’s experience of care

23. Summary of the 2016 ANC model guidelines Nutritional interventions Maternal and fetal assessment preventive measures Interventions for common physiological symptoms Health systems interventions to improve utilization and quality of ANC ANC Models with a minimum of 8 contacts are recommended to reduce perinatal mortality and improve women’s experience of care The new model recommends first contact during the first 12 weeks’ gestation, with following contacts taking place at 20, 26, 30, 34, 36, 38 and 40 wks of gestation

24. Services offered in each contact visit contacts weeks services 1 st trimester Contact 1 Up to 12 wks Baseline investigations, FBC, blood grouping, UA/midstream urine culture, RBS, HIV, TB screening, VDRL. /RPR, Early US, HX and clinical examination, education on danger signs, nutrition, breastfeeding, hygiene and common symptoms Nutritional supplementation: IFAS, calcium BP AND WT. HB to be taken once in each trimester 2 nd trimester Contact 2 20 wks Early obstetric US at 18-20 wks IPTs-SP from 13 wks , 4 wks apart until delivery in malaria endemic areas Deworming using mebendazole 500 mg Contact 3 26 wks Indirect coombs test for RH-VE mother prior to Anti-D administration Prophylactic anti-D at 28 wks

25. Services offered in each contact visit 3 rd trimester Contact weeks services Contact 4 30 wks Clinical examination, obstetric abdominal exam and risk assessment Birth preparedness advice Contact 5 34 wks Contact 6 36 wks Contact 7 38 wks Contact 8 40 wks

26. Justification of the new 2016 ANC Model Evidence suggesting increased perinatal deaths in 4-visit ANC model Evidence supporting improved safety during pregnancy through increased frequency of maternal and fetal assessment to detect complications Evidence supporting improved health system communication and support around pregnancy for women and families Evidence indicating that more contact between pregnant women and respectful, knowledgeable health care workers is more likely to lead to a positive pregnancy experience no difference in health outcomes between ANC Models with 8 contacts and those of 11 to 15 contacts

27. The new 2016 WHO ANC MODEL Advocates for 8 contacts with the 1 st visit in 1 st trimester

28. Group ANC Is another alternative model It integrates the usual individual preg health assessment with tailored group educational activities and peer support, with the aim of motivating behaviuor change amon women, improving pregnancy outcomes and increasing women’s satisfaction

29. Cont …..Group ANC Interventions involves Self-assessment activities Group education with facilitated discussion Socialization activities

30. Preventive measures IFAS: when anaemia (HB less than 11g/dl), the dose of elemental iron is increased to 120 mg until HB rises to normal or higher Vitamin A: Not recommended unless in areas when vit A is deficient. When indicated, give daily or weekly up to 10,000IU per day or weekly dose of up to 25,000IU to prevent night blindness Tetanus/Diphtheria vaccination IPTp : given in malaria endemic areas. 1 st dose in second trimester at 13 wks , and given one month apart, up to 3 doses. If HIV + and on septrin , do not give SP Deworming: Given in second trimester, either albendazole 400mg or mebendazole 500mg single dose only

31. Tetanus diphtheria vaccination (TD) If a preg woman has not been previously vaccinated or her immunization status is unknown, she should receive 2 doses one month apart with the second dose ggiven at least 2 wks before delivery. 2 doses protect for 1-3 years Third dose is recommended 6 months after second dose, which extends protection to at least 5 years Two further doses in the two subsequent years or during two subsequent pregnancies If a woman has had 1-4 TD injections in the past, she should receive one dose of TT during each subsequent pregnancy to a total of 5 doses (5 doses offer protection throughout the childbearing years)

32. Mandatory ANC profile TB HIV VDRL Blood sugars Full haemogram BS for malaria Blood group and rh factor urinalysis

33. OBJECTIVES OF FANC Early detection and treatment of problems Prevention of complications using safe, simple and cost-effective interventions Birth preparedness and complication readiness Health promotion using health messages and counseling Provision of care by a skilled attendant

34. OBJECTIVES OF FOCUSED ANTENATAL CARE. 1. Early detection and treatment of problems . Service providers should identify existing medical, surgical or obstetric conditions during pregnancy such as: Severe anaemia ( Hb < 7gm/dl ). Vaginal bleeding. Pre- eclampsia ( increased B.p, severe oedema ).

35. STI’s, HIV/AIDS, TB and malaria. Chronic diseases ( diabetes, heart or kidney problems ). Decreased / absent foetal movement. Foetal malpresentation after 36 weeks.

36. Why disease detection and not risk assessment? Risk approach is not an efficient or effective strategy for maternal mortality reduction. Every pregnancy is at risk: risk factors cannot predict complications e.g. young age does not predict eclampsia. Research showed that the majority of women who experienced complications were considered low risk ( 90% of women considered to be high risk, give birth without experiencing a complication ).

37. Risk factors do not predict problems. Most high risk women deliver without problems and most women who develop life- threatening complications belong to the low risk group. Every pregnant delivering or postpartum woman is at risk of serious life- threatening complications.

38. 2. Prevention of complications . The service provider should ensure prevention / protection of complications by providing: Tetanus toxoid to prevent maternal and neonatal tetanus. Iron/ folate supplementation to prevent anaemia. Use of IPT and ITNS to prevent malaria / anaemia.

39. Ensure environmental hygiene to prevent intestinal worms. Presumptive treatment of hookworm infection with mebendazole 500mg STAT anytime after the first trimester. Basic maternal and newborn care.

40. 3.Birth preparedness and complication readiness . Service providers should discuss components of birth plan which include: place of birth, skilled attendant, Transportation, funds, birth companion,

41. Items for clean and safe birth and for newborn. Knowledge of danger signs: what to do if they arise. Choose decision maker. Emergency funds. Emergency transport. Blood donor.

42. Discuss birth partners/companions with your clients . A birth partner/ companion may be the father of the baby, a sister, a mother-in-law, mother or an auntie. A birth partner/ companion should be involved in making the individual birth plan ( IBP ).

43. A birth partner/ companion can provide support to the woman during pregnancy at the antenatal clinic and during delivery. Make sure that clients at your clinic know that you welcome birth partners/ companions.

44. Individual Birth plan (IBP) ensures that the client: Knows when her baby is due. Identifies a skilled birth attendant. Identifies a health facility for delivery/ emergency. Can list danger signs in pregnancy and delivery and knows what to do if they occur. Identifies a decision- maker in case of emergency.

45. Cont ….. IBP Knows how to get money incase of emergency. Has a transport plan incase of emergency. Has a birth partner/ companion for the birth. Has collected the basic supplies for the birth.

46. CONT…..IBP 15% of all pregnant women develop life- threatening complications requiring obstetric care. These women could die if nobody is there to make timely decisions at home and in the health facility, no plans for referral or transport have been made, no plans on how to meet new financial demands are made.

47. Specific transport questions for the client : Where will you deliver? Where will you go incase of an emergency? Where is it located? How will you get there? Have you made this journey before? How much will it cost to arrange for the transport and how will you raise it.

48. Mother – baby package. One pair of sterile rubber gloves or clean plastic bags that can be worn over the hands where gloves are not available. Soap. Cotton wool. Clean, unused razorblades. Thread or string.

49. Clothing for the baby and mother. Money to pay for transport, hospital fees, etc. Sanitary towels, napkins.

50. Danger signs in pregnancy. Any vaginal bleeding in pregnancy (APH, Abortion ). Severe headache or blurred vision ( high blood pressure, eclampsia ). Swelling on the face and hands ( high blood pressure, eclampsia ). Convulsions or fits ( high blood pressure, eclampsia ).

51. High fever ( infection ). Laboured breathing ( pneumonia, heart problems, severe anaemia ). Premature labour pains. Noticed that the baby is moving less or not moving at all ( fetal distress, IUD).

52. Other danger signs in pregnancy. Feeling very weak or tired ( anemia, severe disease, multiple pregnancy ). Vaginal discharge ( STI ). Abdominal pain ( STI, early labour ). Genital ulcers ( STI ). Painful urination ( STI ). Persistent vomiting ( severe malaria etc ).

53. Danger signs during labour and delivery. Severe headache/ visual disturbances. Sever abdominal pain. Convulsions or fits during labour. High fever with or without chills. Foul vaginal discharge. Labour pains for more than 12hours. Ruptured membranes without labour for more than 12 hours.

54. cont …Danger signs during labour and delivery Excessive bleeding during delivery. Cord, arm or leg prolapse .

55. Danger signs after delivery . Placenta not delivered within 30 minutes of baby birth. Excessive bleeding after delivery. Severe abdominal pain. Convulsions or fits.

56. High fever with or without chills. Foul vaginal discharge due to infections. Mood swings ( depressions ).

57. Recognize danger signs and get prompt medical attention! Acting quickly is important because a woman could die in a short period of time: In antepartum hemorrhage she can die in just 12hours. In postpartum hemorrhage she can die in just 2 hours.

58. With complications of eclampsia, she can die in as few as 12hours and with sepsis in about 3 days.

59. 4. Health promotion using health messages and counseling. Encourage dialogue on the following: Nutrition. Rest and hygiene. Safer sex. Care for common discomfort. Use of IPT and ITNS.

60. Cont...Health promotion using health messages and counseling. Drug compliance. Family planning, health timing and spacing of pregnancy. Early and exclusive breastfeeding. Newborn care. PMTCT Also teach them about: Danger signs in pregnancy Prevention of STIs Avoidance of alcohol and tobacco Individual Birth Plan (IBP) To come to postpartum clinic immediately, 48 hours, 2 weeks, at 6 weeks, 6 months and one year I mmunization

61. Maintain the woman’s health and survival through : Health education and counseling on: Danger signs in pregnancy. Adequate nutrition and hydration. Early and exclusive breastfeeding. Individual birth plan.

62. Prevention and treatment of sexually transmitted infections ( STIS ) and worm infestations. Avoidance of alcohol and tobacco. Complication readiness plan. Don’t forget to counsel the mother on: To come to postpartum clinic: immediately, 48hrs,2wks, at 6wks & 1yr.

63. To visit well baby clinic ( MCH/FP clinic ) for immunizations. Follow up for exposed babies to TB and HIV. To chose a postpartum family planning method: LAM ( exclusive breastfeeding ). Progesterone only pills.

64. Condoms. Postpartum IUCD. *Feeding options. Teach mother about importance of immunizations : Inform her about the first-year immunization schedule to protect children from TB, polio, tetanus, diptheria, pertussis, hepatitis B and measles.

65. 5. Provision of skilled care at Birth. Currently, only 41% of pregnant women receives skilled care at birth. By 2015, it is expected that three quarters of pregnant women should receive skilled care at birth. A skilled attendant offers services either at the health facility or within the community ( domiciliary practice ). FANC provides an opportunity to increase skilled care.

66. The Role of men/fathers in antenatal care Support and encourage women throughout pregnancy Ensure mothers do not get STIs or HIV Ensure that they remain faithful (or use condoms consistently and correctly) Encourage mothers to attend antenatal clinic Accompany their wives/partners to the health facility and during childbirth

67. Service provider should educate fathers about antenatal care 1. Fathers should make sure that the woman: Has enough nutritious food to eat and that she has taken iron and folate tablets Is sleeping under a treated net and is able to get enough rest Has 2 doses of SP (if from malaria endemic area) and Tetanus Toxoid 2. Make sure that the couple has an IBP 3. Make sure that the couple know the danger signs in pregnancy and labour

68. Maternal Death " A maternal death is defined as the death of a woman while pregnant or within 42 days of termination of the pregnancy, irrespective of the duration and site of pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes." Causes of maternal mortality maybe direct or indirect Direct Causes of Maternal Death These result from obstetric complications of pregnancy, labour and the puerperium and from interventions or any after effects of these events. The Five major causes of direct maternal deaths in order of frequency are: Haemorrhage , Sepsis, Hypertensive disorders, Complications of abortion and obstructed labour Indirect causes of Maternal Deaths They result from previously existing disease or disease that develops during pregnancy which was not due to direct obstetric causes, but which was aggravated by physiologic effects of pregnancy. The major causes of indirect maternal deaths in our set up include Malaria, HIV/AIDS, and anaemia .

69. Underlying causes of Maternal & Neonatal Mortality The three delays There are three distinct levels of delay which contribute to maternal morbidity and mortality: ( Thadaseus and Maine, 1994): Delay in deciding to seek appropriate care. This could be due to: socio-cultural barriers, Failure to recognize danger signs, failure to perceive severity of illness, and cost considerations Delay in reaching an appropriate health care facility. This is due to: long distance to a facility, poor condition of roads, lack of transportation and cost considerations Delay in receiving adequate emergency care at the facility. This may be due to: Shortage of staff, supplies and basic equipment; unskilled personnel, user fees among others.

70. STRATEGIES TO REDUCE MATERNAL AND PERINATAL DEATHS Safe Motherhood And Child Survival Initiative The Kenya Maternal and Newborn Health model (2009 ) International Conference for Population and Development (ICPD): Millennium Development Goals SDGs National Reproductive Health Policy 2007 National Reproductive Health Strategy (NRHS): 2009- 2015 The National Health Sector Strategic Plan (NHSSP II)-2005-2010: ( i ) The KEPH Life-Cycle Cohorts (ii) Levels of Care in KEPH The Annual Operational Plans (AOPs) translate Kenya Essential Package for Health and the National Health Sector Strategic Plan II 2005-2010 into ‘actionable’ operational plans. The Community Strategy Vision 2030 The National Road Map for accelerating the attainment of MDGs related to Maternal and Newborn Health in Kenya. (2008-2015)

71. SAFE MOTHERHOOD AND CHILD SURVIVAL INITIATIVE Introduction Safe motherhood is neither a simple nor a single concept, and what is encompassed by the term has evolved considerably since 1987. While the focus on maternal mortality has remained, three other outcomes have now been incorporated. • Maternal morbidity • Health of the newborn • Positive health of the mother

72. CONT Thus, the meaning of safe motherhood has broadened , particularly in the early 1990s as has the range of factors regarded as determinants of poor maternal health, with women’s low socioeconomic status seen as one of the root causes. The Safe Motherhood mandate for the reproductive health programme is assumed to span across the continuum of pre-conception care , antenatal care, labour and delivery, postpartum and postnatal care and neonatal care (first month of life).

73. cont The RH policy recognises that in at least 15% of pregnant women serious obstetric complications can occur that usually can not be predicted or prevented in advance, and therefore emphasises the need for all pregnant women to have access to skilled care, throughout pregnancy , delivery, postpartum and postnatal periods. The most critical time for both the mother and her baby is during childbirth and in the first few hours afterwards

74. Definition of Safe Motherhood Safe motherhood is a woman’s ability to have a safe and healthy pregnancy and delivery. Making motherhood safe requires action on three fronts simultaneously: Reduce the number of high risk and unwanted pregnancies • Reduce the number of obstetric complications • Reduce the cases of high fertility rate in women with complications

75. The Key Components of Safe Motherhood • Focused antenatal care which research suggests lowers the rate of maternal morbidity and mortality • Safe and clean delivery so that all women deliver under some type of supervised care, where referral systems are established to provide emergency treatment for life threatening complications of delivery • Postnatal care that contributes to a woman’s ability to enjoy sexual relations without pain and have safe pregnancy and delivery in future • Safe, humane and cost-effective postabortion care

76. Safe Motherhood Initiative The Safe Motherhood Initiative (SMI) is a supportive effort, which was launched in 1987, in Nairobi , by WHO and its partners to focus the world’s attention on problems related to pregnancy and childbirth. Lack of commitment to women’s health problems by the government was seen as the major underlying cause of many maternal deaths. To address this problem, delegates to the Nairobi Conference in 1987 recommended the introduction of a Safe Motherhood Initiative (SMI) to be implementedby all countries.

77. Objectives of the Safe Motherhood Initiative The conference described the Safe Motherhood Initiative as a global strategy aimed at reducing maternal mortality by half by the year 2000 by creating circumstances within which a woman is enabled to: • Choose whether she will become pregnant • Receive care for the prevention and treatment of pregnancy complications • Have access to trained birth attendants • Have access to emergency obstetric complications if necessary • Have care after birth • Avoid death or disability from complications of pregnancy and childbirth In response, the Kenya government endorsed this plan of action to reduce maternal mortality and morbidity.

78. Objectives of the Safe Motherhood Initiative The scope of the Safe Motherhood Initiative has advanced tremendously to encompass many action areas and now includes safe motherhood through human rights for women ( Fathalla , 1997 and 2000 ; WHO 2001). The SMI differs from other health initiatives in that it focuses on the well being of women as an end to itself. Thaddeus and Maine ( 1994) argued that, prevention of a death of a pregnant woman is considered to be the key objective, not because the death adversely affects children and other family members but because women are intrinsically valuable.

79. Summary of SMI Events: Year Event Summary 1987 International Safe Motherhood Conference(Nairobi, Kenya) –Safe motherhood Initiative launched Goal : 50% reduction in 1990 levels of maternal mortality by 2000 (and 75% reduction by 2015) 1987-1997 Safe Motherhood Initiative Involved: Enhanced Advocacy for Safe Motherhood Determine the Magnitude of the problem Institution of Effective interventions, Identify constraints to implementation, Address barriers to access 1997 Safe Motherhood Technical Consultation(Colombo, Sri Lanka) Ten key messages were formulated

80. The Eight Pillars of Safe Motherhood In order to reduce maternal morbidity and mortality , efforts should be focused on the eight pillars of safe motherhood as illustrated in the diagram below.

81. Safe Motherhood + (plus)

82. Family Planning Good family planning ensures that individuals and couples have the information and services to plan the timing, number and spacing of pregnancies .

83. Focused Antenatal Care This serves to prevent complications where possible and ensures that complications of pregnancy are detected early and treated appropriately . Four focused antenatal visits are recommended , which emphasise : • Taking two doses of sulphapyremethane (SP ) during pregnancy for malaria endemic areas • Recognising signs and symptoms of malaria • Recognising danger signs in pregnancy and where to go for help • Drawing up an individual birth plan, which should include a mother/baby package , transport plans and funds/money .

84. Clean and Safe Delivery Always ensure that all birth attendants have the knowledge , skills, positive attitude and equipment to perform a clean and safe delivery and provide postpartum care to the mother and baby . transmission (PMCT) of HIV are also key components of safe motherhood.

85. Post Abortion Care Abortion is one of the major causes of maternal morbidity and mortality. Health care workers and facilities need to be well equipped to prevent and effectively manage complications that arise from the procedure . The patients’ psychological well being need to be handled by an experienced health care worker to cover trauma and suicidal tendencies as well its occurrence in future.

86. Prevention of Mother to Child Transmission of HIV (PMTCT) The government is in support of preventive measures that would ensure little or no transmission of HIV virus by any means. PMTCT is a programme that was initiated in the maternal child health care services to protect the unborn baby from contracting the virus.

87. Targeted Postpartum Care Maternal deaths in many cases happen during the postpartum period. Close follow-up by skilled health care worker would ensure early detection, prevention and treatment of any pregnancy and delivery complications, which may not have been noted during pregnancy and delivery.

88. Neonatal Care The neonatal period is very sensitive, surveys have shown that the majority of neonates in this country do not survive. In Kenya more than half of the women deliver at home and hence the need for closer neonatal follow-up and observation as this would lead to early detection and management of complications that may arise at this tender age.

89. Essential Obstetric Care Ensure that essential care for high-risk pregnancies and complications is available to all women who need it.

90. The Kenya Maternal and Newborn Health model (2009) Maternal and Newborn Health (MNH) Pillars Family planning and pre-pregnancy care– To ensure that individuals and couples have the information and services to plan the timing, number and spacing of pregnancies. Focused Antenatal Care – To prevent complications where possible and ensure that complications of pregnancy are detected early and treated appropriately. Essential Obstetric Care – To ensure that essential care for the high-risk pregnancies and complications is made available to all women who need it. Essential Newborn Care – To ensure that essential care is given to newborns from the time they are born up to 28 days in order to prevent complications that may arise after birth . Targeted Postpartum Care – To prevent any complication occurring after childbirth and ensure that both mother and baby are healthy and there is no transmission of infection from mother to child. Post Abortion Care – to provide clinical treatment to all women and girls seeking care, for complications of incomplete abortion and miscarriage as well as counselling and contraceptives. ( Note that HIV PMTCT services are now integrated into ALL the pillars of MNH and clean and safe delivery is part of Essential Obstetric Care )

91. Foundation Measures These eight strategic interventions must be delivered through primary health care (PHC) and rest on a foundation of greater equity for women. This recognises the fact that the eight pillars of SMI can only prevent immediate causes of maternal death. Underlying causes of maternal death are often as a result of the poor socioeconomic status of women and these issues require other strategies. In strengthening this foundation the Ministry of Health has indicated the need for: • Skilled attendants and enabling environment to provide quality care • Supportive health systems: effective systems of referral, management, procurement , training, supervision and health management information systems • Community action, partnership, and male involvement • Equity for all/reproductive rights

92. Cont Foundation Measures When strategising , countries were encouraged to design other non-health activities which could improve the socioeconomic status of women such as providing formal education for girls, giving women equal employment and business opportunities as well as the empowerment of women to make decisions within their own households . These concepts are also dealt with in the section on gender and reproductive health rights . The health sector, through the concept of PHC (collaboration across ministries and sectors) should , therefore, involve other ministries and organisations in implementing a national and district safe motherhood initiative.Maternal deaths are most likely to occur.

93. Emergency Obstetric Care Emergency Obstetric Care refers to a set of minimal health care elements, which should be availed to all women during pregnancy and delivery. It includes both life saving and emergency measures e.g. Caesarean section, manual removal of placenta, etc , as well as non-emergency measures (e.g. use of the partograph to monitor labour , active management of the third stage of labour , etc.). Emergency Obstetric Care functions are generally categorized as Basic Emergency Obstetric Care ( BEmOC ) and Comprehensive Emergency Obstetric care ( CEmOC ) .

94. The signal functions to identify BEmOC and CEmOC are: Basic Emergency Obstetric Care includes: Administration of IV antibiotics. Administration of magnesium sulphate . Administration of parental oxytocics . Performing manual removal of the placenta. Performing removal of retained products. Performing assisted vaginal delivery (e.g. by vacuum extraction). Performing newborn resuscitation

95. Comprehensive Emergency Obstetric Care includes all the seven above, PLUS: Performing surgery (Caesarean section), including provision of emergency obstetric anaesthesia . Administration of blood transfusion.

96. CLIENT AND PROVIDERS RIGHTS Clients Rights include: Right to Information Right to Access Right of choice Right to safety Right to Privacy Right to Confidentiality Right to Dignity Right to Comfort Right to Continuity of Care Right of Opinion

97. PROVIDERS’ RIGHTS Training Information Infrastructure Supplies Guidance Back up Respect Encouragement Feedback Self–expression

98. END! THANK YOU!