FAMILY AND COMMUNITY MEDICINE III

Saint Louis University School of Medicine MMXXII

M.01 MNCHN Part 1 (Maternal) • Lifetime risk of dying from maternal causes to Filipino
Dr. Nelson Hora | March 04, 2021 women of reproductive age is 1:120
• 14% of death among women of reproductive age is due to
OUTLINE maternal causes
I. MNCHN • Slow decline of Maternal Mortality Rate (MMR)
II. Epidemiology o 209/100,000 live births (1990)
III. MNCHN Core Package Services o 162/100,000 live births (2006)
IV. Maternal Care • Decline in UFMR and IMR but not in NMR
V. DOH Maternal Package o Under-Five Mortality Rate (UFMR)
VI. Delivery ▪ 61/1000 live births in 1990
VII. Postpartum Period ▪ 32/1000 live births in 2008
o Infant Mortality Rate (IMR)
I. Maternal, Newborn, Child Health and Nutrition (MNCHN) ▪ 42% in 1990
• DOH Administrative Order (A.O.) 2008-0029 ▪ 26% in 2006
o “Implementing Health Reforms for Rapid Reduction of o Neonatal Mortality Rate (NMR)
Maternal and Neonatal Mortality” ▪ 17/1000 live births in 2006
o Provides the strategy for rapidly reducing maternal and ▪ In 2000-2003, newborn death accounted for 37% of all
neonatal deaths through the provision of a package of UFMR. Most neonatal deaths occur within the first 2
maternal, newborn, child health, and nutrition (MNCHN) weeks after birth, half of which occur in the first 2 days
services. of life.
o To assess the health status of the community, look at the
vulnerable population mortality rates. B. FACTORS CONTRIBUTING TO MATERNAL AND NEONATAL
o Part of the Sustainable Developmental Goals (SDG) DEATHS
• The strategy aims to achieve the following intermediate results: 1. Mistimed, unplanned, unwanted, and unsupported
1. Every pregnancy is wanted, planned, and supported. pregnancy
2. Every pregnancy is adequately managed throughout its • Reason why family planning methods are promoted.
course. • Rape victims should be given a choice if they would want to take a
o Womb-to-womb: Conception until Delivery ‘morning-after-pill’.
o But ideally, pre-pregnant mothers should be given 2. Not securing adequate care during the course of pregnancy
supplements of iron and folate • Pregnant patients should be advised to seek Prenatal care at the
3. Every delivery is facility-based and managed by skilled time they become cognizant of their pregnancy.
birth attendants or skilled health professionals. • Most pregnant patients come only for consultation when they are
4. Every mother and newborn pair secures proper post- already in labor and preventable complications of pregnancy are
partum and newborn care with smooth transitions to the not addressed.
women’s health care package for the mother and child 3. Delivering without being attended to by skilled health
survival package for the newborn. professionals, and lack of access to emergency obstetric
o First 1000 days Program and newborn services
• ‘Hilots’, despite having the experience in assisting mothers, they
II. EPIDEMIOLOGY should still be regarded as the last choice because they are not
• Pregnancy-related death worldwide: 500,000/year using improved and scientifically proven techniques.
o 99% from developing countries 4. Not securing proper postpartum and newborn care for the
▪ Maternal mortality rate (WHO): 400/100,000pop mother and her newborn, respectively
▪ Developing countries are more burdened by diseases • Inappropriate postpartum care used by ‘hilots’ include applying ash
that contributes to these mortalities, however, majority and chewed guava leaves on the umbilical stump and immediately
of the world’s resources are concentrated to Developed giving the babies a bath.
countries
o Compounded by: III. MNCHN CORE PACKAGE OF SERVICES
▪ High fertility • Cuts across the following stages:
▪ Poor nutritional status 1. Pre-pregnancy
▪ Lack of basic health services 2. Pregnancy
• Infant mortality: 7.1 million/year 3. Delivery
o 50% die in the first 28 days after birth (neonatal period) 4. Post-partum
o 75% die in the first week after birth 5. Newborn care
o Neonatal and perinatal death are related to maternal 6. Child care
causes.
• Majority of these maternal and newborn deaths are preventable IV. MATERNAL CARE
with currently available technologies. • Focuses on the child-bearing function of the woman
• Goals:
A. PHILIPPINE SITUATION o Promotion of safe motherhood and women’s health
• 14 million Filipino women are in the reproductive age group (15-49 o Ensure healthy newborn
years old)
o 9 million are married or have partners PRIMARY CAUSES OF MATERNAL MORTALITY
o 6 million are considered to be at risk if they become Direct Causes Indirect Causes
pregnant because they: • Severe bleeding • Anemia
▪ are either too young (<20 years old) • Infection • Malaria
▪ or too old (>35 years old) • Consequences of unsafe • Poverty
▪ have >4 pregnancies abortions • Race, ethnic, or tribal
▪ have too close or unspaced pregnancies (<15 months) • Hypertensive disorders affiliation
▪ too sick (mostly anemic or underweight) such as pre-eclampsia and • Lack of education
• Average fertility rate: 3.7 (3-4 number of children per woman) eclampsia
• 2.3 million women are expected to get pregnant every year • Obstructed labor
o 2 million of those who become pregnant will deliver

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 FAMILY AND COMMUNITY MEDICINE III
Saint Louis University School of Medicine MMXXII
WHO. 1999 “Reduction of maternal mortality. A joint WHO/ UNFPA/
UNICEF/ World Bank Statement” PRENATAL CARE UPDATES
• Most direct causes can be addressed and prevented by skilled Before Now
Health Practitioners during the prenatal period. Risk scoring and prediction Recognizes that every
• Indirect causes are related to social (poverty) and environmental pregnancy is at risk
problems. PARADIGM SHIFT
• Every pregnancy faces risks
MAJOR DISABILITIES FROM PREGNANCY AND CHILDBIRTH • Therefore, at every AP visit we must be very careful in doing the
COMPLICATIONS history and physical exam of all pregnant women.
• These complications can be addressed appropriately if patients
deliver in a facility/hospital. Remember: Once a woman is pregnant, most serious complications
Severe bleeding Infection CANNOT be predicted or prevented, but they CAN be treated.
Pelvic inflammatory disease • That is why home deliveries or deliveries by traditional birth
Anemia
Chronic pelvic pain attendants are not advocated anymore.
Infertility
Reproductive organ damage
Hormonal damage
Infertility 2. TETANUS TOXOID
Obstructed or prolonged • Today, Tetanus toxoid is no longer available. Tdap combination
Unsafe abortion
labor is given instead and are given at government institutions
Incontinence Pelvic inflammatory disease because diphtheria protection is also needed for the mother.
Fistula Chronic pelvic pain • During first pregnancy, the woman is recommend
Genital prolapse Reproductive organ damage • ed to have at least 2 doses of TT.
Uterine rupture Reproductive tract infection • Ideally, the 1st dose should be given pre-pregnancy. If not, the
Nerve damage Infertility 1st dose will be given at the 2nd trimester.
Pregnancy-induced hypertension
Precursor to chronic hypertension TETANUS TOXOID IMMUNIZATION SCHEDULES
Kidney failure Infant’s
Protection
Nervous system problems Duration of
Vaccine Minimum Interval from
Lori Ashford. 2002. Hidden Suffering: Disabilities from Pregnancy and Protection Neonatal
Childbirth in Less Developed Countries. PRB. Tetanus
At first contact
NIL – No
V. DOH MATERNAL CARE PACKAGE with woman 15-49
protection
1. ANTENATAL REGISTRATION years (even if the
TT1 (Hence, 2nd dose is None
Antepartum Visits (Minimum Requirement) woman is not yet
really needed to
1st trimester 1 visit pregnant) or at first
acquire protection)
2nd trimester 1 visit AP visit.
3rd trimester 2 visits 3 years of
At least 4 weeks
But ideally: TT2 protection for the ✓
after TT1
• Monthly until the 30th week mother
• Every 2 weeks until the 36th week 5 years of
At least 6 months
• Weekly until Delivery TT3 protection for the ✓
after TT2
• Women can have as much consultation as needed mother
At least 1 year 10 years of
Purpose of prenatal check-ups: after TT3 or any protection for the
TT4 ✓
• Prepare and cope with the pregnancy time within the 10-yr mother
o The mother or couple should be counselled on what to do, period from TT3
not only medically, but also financially. Lifetime
At least 1 year
• Early detection and treatment of illnesses TT5 protection for the ✓
after TT4
• Know the estimate schedule of delivery or the expected date of mother
confinement.
o Use the Naegele’s Rule 3. NUTRITION
• Includes Vitamin A, Iron, Folate, and calcium supplementation
Danger signs of pregnancy: (Should be noted every AP visit) • 50.3% anemic pregnant women
• Vaginal bleeding – it can be a sign of abortion or problems in • 46% anemic lactating women
placental implantation • Supplements:
• Severe abdominal pain – symptom of impending abortion or o Vitamin A
infection ▪ Teratogenic in high doses
• Looks very ill and/or has fever – especially if patient is from o Iron
malarious areas ▪ Not tolerated during the 1st trimester due to morning
• Severe headache with visual disturbance – symptom of pre- sickness
eclampsia or pregnancy-induced hypertension ▪ Given preferably during the 2nd trimester
• Severe breathing difficulty o Folate
• Severe vomiting – may lead to dehydration of both mother and ▪ Given during the 1st trimester
child ▪ To prevent Neural Tube Defects
• Unconscious and/or has convulsions – manifestation of pre-
eclampsia 4. TREATMENT OF EXISTING DISEASES
• Diabetes
Risk factors: • Anemia
• Too young/old • Heart disease
• Too many (multigravida) • Refer to a specialist if needed.
• Too soon (early labor)
• Too sick

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 FAMILY AND COMMUNITY MEDICINE III
Saint Louis University School of Medicine
5. RECOGNITION, EARLY DETECTION, AND MANAGEMENT OF
COMPLICATIONS BEFORE, DURING AND AFTER DELIVERY
Prenatal tests: (Minimum laboratory examinations to be done)
• Urinalysis
• Complete Blood Count, Hemoglobin
• Blood typing
• VDRL/RPR test for syphilis
• Hepatitis B screening
• HIV Screening
• FBS/ 2-hr Oral Glucose Tolerance Test (Standard to all pregnant
women)
o Pregnant patients should not be required to fast, unless
Gestational Diabetes Mellitus is suspected
• Fecalysis
o Since parasitism is prevalent in the country, standard
deworming is done in the 2nd trimester.
BIRTH PLAN
• A document prepared during the prenatal care which states:
o The woman’s conditions during pregnancy
o Her preferences for her place of delivery
o Her choice of birth attendant (midwife, physician)
o Her available resources for her childbirth and newborn baby
o Preparations needed should an emergency situation arise
during pregnancy, childbirth, and postpartum (includes:
transportation, who will take care of the children when mother
is in labor/give birth)
MMXXII
• Fear of ill treatment at the facility
o Home Delivery is preferred mostly by patients because they
are personally cared by ‘hilots’. Care provided by ‘hilots’
include washing soiled blankets and cooking home-cooked
meals for the mother
• Culture
• Poor decision making
• No person to take care of children and/or livestock
• No companion when going to the facility
• Address these problems during the prenatal period or
when doing the birth plan.
2. Delay in identifying and reaching the appropriate health
facility
• Patient intends to go to a health facility but there is no available
transportation
• Distance: woman’s home to the facility
• Lack of roads or poor condition of roads
• No emergency transport
• Unawareness regarding existing services
• No referral system
• Lack of communication with referral facility
• Lack of moral, financial, and logistic support from neighbors and
barangay officials
o These officials are also involved because maternal health is
not just a personal problem, it is a problem of the community.
It reflects the overall health community system. Maternal
mortality rate is one of the indicators if the health system is
working or not.

3. Delay in receiving appropriate and adequate care at the

health facility
• Patient is able to reach the facility, but it is not fully equipped.
• Lack of health care worker
• Non-professional attitudes of health workers
• Shortage of supplies (medicines, blood, etc.)
• Poor skills of healthcare providers
• Health is not a priority for officials in the LGU
• Lack of budget from the LGU

Gone are the days that women deliver at home because environment at
home is not that conducive especially in rural areas.
Skilled Birth Attendants include doctors, nurses, midwives who are
trained to respond to emergencies and complications that might arise
during delivery.
6. CLEAN AND SAFE DELIVERY
• 3% of the 3.5% expected antepartum women will progress to term
V. POSTPARTUM PERIOD
7. PROMOTION AND SUPPORT TO BREASTFEEDING AND Key Events
MANAGEMENT OF BREAST COMPLICATIONS 24 hours after delivery 1st postpartum visit
• We have to be advocates of breastfeeding because of the benefits 1 week after delivery 2nd postpartum visit
attached to it. Counselled to start their Family
Planning methods, whether artificial
Within 6 weeks after
8. HEALTH EDUCATION, COUNSELING, AND FAMILY or natural, since at this time, the
delivery
PLANNING SERVICES Mother’s menstrual cycle may come
back
9. STD/HIV PREVENTION AND MANAGEMENT Within a month after Vitamin A
delivery (200,000 IU supplementation)
10. DENTAL CARE For at least 3 months FeSO4 supplement

V. DELIVERY
• 14 % of deaths among women aged 15-49 are due to maternal
deaths.

3 DELAYS THAT CAUSE MATERNAL DEATH (WHO)

1. Delay in deciding to seek medical care
• Failure to recognize danger signs
• No skilled birth attendants in the area (assisted by whoever is
around)
• No money
• Unwanted pregnancy
• Poor services

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