MCN Notes Week 1 Prelim

Maternal, Newborn, and Child Health and

Nutrition (MNCHN)
Situation in the Country

The Department of Health (DOH) is committed to

achieve the Millennium Development Goals
(MDGs) of reducing child mortality and improving
maternal health by 2015. Although significant gains
in maternal and child mortality have been realized
in the past four decades, pregnancy and childbirth
still pose the greatest risk to Filipino women of
reproductive age, with 1:120 lifetime risk of dying
from maternal causes.1 Maternal deaths account
for 14percent of deaths among women of
reproductive age. The Maternal Mortality Ratio
(MMR) in the country remains high and decreased In 2000-2003, newborn deaths accounted for 37
very slowly at 162/100,000 live births (LB) in 2006 percent of all Under5 mortalities. Most neonatal
from 209/100,000 LB in 1990. deaths occur within the first week after birth, half of
which occur in the first two days of life. With the
slow decline in MMR for the past two decades and
the loss of momentum in rate of decrease in
newborn, infant, and child deaths, the Philippines is
at risk of not attaining its MDG targets of lowering
maternal deaths to 52/100,000 LB and child deaths
to 20/1,000 LB in the next five years.

Although the Under-Five Mortality Rate (UFMR)

and Infant Mortality Rate (IMR) have considerably
declined (UFMR from 61/1,000 LB in 1990 to
32/1,000 LB in 2008; IMR 42percent in 1990 to
26percent in 2006), the rates of decline have
decelerated over the last ten years. The
deceleration is driven largely by the high neonatal
deaths and slow decline of infant deaths. Neonatal
Mortality Rate (NMR) is still high, with 17 infants
dying per 1,000 LB within the first 28 days of life.
 Factors Contributing to Maternal and Neonatal
Deaths
Majority of maternal deaths directly result from
pregnancy complications occurring during labor,
delivery and the post-partum period. These
complications include hypertension, post-partum
hemorrhage, severe infections, and other medical
problems arising from poor birth spacing, maternal
malnutrition, unsafe abortions and presence of
concurrent infections like TB, malaria and sexually
transmitted infections as well as lifestyle diseases
like diabetes and hypertension.
Neonatal deaths within the first week of life are
often due to asphyxia, prematurity, severe
infections, congenital anomalies, newborn tetanus,
and other causes.
These direct causes of maternal and neonatal
deaths require care by skilled health professionals
in well-equipped facilities. However, 55 percent of
births are delivered at home, of which 36 percent
are attended to by TBAs or hilots.6 This contributes
to the three delays that lead to maternal and
neonatal deaths such as delay in identification of
complications, delay in referral, and delay in the
management of complications. This could explain
why TBAs, even if trained, has had little impact on
reducing maternal and neonatal mortality.
The likelihood of maternal and neonatal
deaths is further magnified with the critical
accumulation of four risks such as (1) mistimed,
unplanned, unwanted and unsupported pregnancy ;
(2) not securing adequate care during the course of
pregnancy; (3) delivering without being attended to
by skilled health professionals (i.e. midwives,
nurses and doctors) and lack of access to
emergency obstetric and newborn services; and (4)
not securing proper postpartum and newborn care
for the mother and her newborn, respectively.
Prevention of maternal and neonatal
morbidity and mortality entails the provision and
use of the MNCHN core package of services. This
will require informed decisions by mothers and their
families and a health system that is responsive to
their needs. However, informed decisions on
utilization are prevented by low awareness and
poor recognition of health risks, lack of information
on available services and providers in the area,
lack of options to finance health services due to
poverty, lack of education, and staying in GIDA. On
the other hand, responsiveness of the health
system is limited by the insufficiency in scope,
scale and quality of delivered health services;
disparity between provided interventions and
allocated budget; lack of harmony and coordination
between public and private service providers; and
financial support that is unresponsive to the needs
of patients and their families.
Strategic Response to the MNCHN Situation
The MOP is anchored on the interrelatedness
of the direct threats to life that necessitate
immediate medical care, including basic and
comprehensive emergency obstetric and newborn
care, managing risks that increase likelihood of
maternal and neonatal deaths, and the underlying
socioeconomic conditions that hinder the provision
and utilization of MNCHN core package of services.
As support, policy and strategic responses
have been geared toward a range of strategies
involving the entire health system – from individuals
and households, communities, frontline health
service providers, local governments, regional
agencies, up to national agencies and other
stakeholders.
The following key strategies employed reflect this
continuum:
 Ensuring universal access to and utilization of an
MNCHN Core Package of services and
interventions directed not only to individual women
of reproductive age and newborns at different
stages of the life cycle, but also to the community.
 Establishment of a Service Delivery Network at all
levels of care to provide the package of services
and interventions.
 Organized use of instruments for health systems
development to bring all localities to create and
sustain their service delivery networks, which are
crucial for the provision of health services to all.
 Rapid build-up of institutional capacities of DOH
and PhilHealth, being the lead national agencies
that will provide support to local planning and
development through appropriate standards,
capacity build-up of implementers, and financing
mechanisms.
Given the limited resources, areas with poor
MNCHN performance in terms of service coverage
indicators such as contraceptive prevalence rate,
antenatal care, skilled-birth attendant / skilled
health professional deliveries and facility-based
deliveries, early initiation of breastfeeding, fully
immunized children, and, and those areas that
have large populations with poor and less educated
mothers, and GIDAs will be prioritized. These areas
are at higher risk from adverse maternal and
neonatal outcomes.
A desired outcome for the integrated
MNCHN Strategy is to make the least progressive
and most vulnerable areas to move more rapidly
and catch-up with the rest of the localities in the
country. It is critical for DOH to always be reminded
and for localities to understand that as the local
conditions differ, the approach, pathway, and pace
towards reaching this goal also vary. However, any
action towards this desired endpoint is a step to the
right direction even if it is short of the ideal and
should be encouraged.
MNCHN Core Package of Services
The MNCHN Core Package of Services
consists of interventions that will be delivered for
each life stage: pre-pregnancy, pregnancy,
delivery, and the postpartum and newborn periods.
Most of these services require minimal cost and
can be delivered by health workers as part of their
routine functions with some that may require
additional training and minimal investments in
facilities.
The intervention in the MNCHN core
package of services that were found effective in
preventing deaths and in improving the health of
mothers and children include the following:
1. Pre-pregnancy: provision of iron and folate
supplementation, advice on family planning and
healthy lifestyle, provision of family planning
services, prevention and management of infection
and lifestyle-related diseases. In particular, modern
family planning reduces unmet need and unwanted
pregnancies that expose mothers to unnecessary
risk from pregnancy and childbirth. Unwanted
pregnancies are also associated with poorer health
outcomes for both mother and her newborn.
Effective provision of FP services can potentially
reduce maternal deaths by around 20 percent. This
also encompass adolescent health services,
deworming of women of reproductive age (to
reduce other causes of iron deficiency anemia),
nutritional counseling, oral health.
2. Pregnancy: first prenatal visit at first trimester, at
least 4 prenatal visits throughout the course of
pregnancy to detect and manage danger signs and
complications of pregnancy, provision of iron and
folate supplementation for 3 months, iodine
supplementation and 2 tetanus toxoid
immunization, counselling on healthy lifestyle and
breastfeeding, prevention and management of
infection, as well as oral health services. While the
contribution of antenatal care in anticipating and
preventing maternal and newborn emergencies is
unclear, components of prenatal care remain
effective in reducing perinatal deaths and serves as
a venue for birth planning and promotion of facility-
based deliveries.
3. Delivery: skilled birth attendance/skilled health
professional-assisted delivery and facility-based
deliveries including the use of partograph, proper
management of pregnancy and delivery
complications and newborn complications, and
access to BEmONC or CEmONC services. The
recent emphasis on the importance of access to
emergency obstetrics and newborn care (EmONC)
services is due to the shift from the risk approach to
pregnancy management to that which considers all
pregnancies to be at risk. Under the risk approach
pregnant women are screened for risk factors and
only those diagnosed with pregnancy complications
are referred to facilities capable of providing
EmONC services. The approach that considers all
pregnancies to be at risk recommends that all
pregnant women should deliver with assistance
from skilled health professionals and have access
to EmONC services since most maternal deaths
occur during labor, delivery or the first 24 hours
post-partum and most complications cannot be
predicted or prevented. “The best intra-partum care
strategy is likely to be one in which women
routinely choose to deliver in health centers with
midwives as the main providers but with other
attendants working with them in a team.
This recommendation is in line with the global
consensus that the best way to address high levels
of MMR and NMR is to “ensure that all women and
newborns have skilled care during pregnancy, child
birth and the immediate post-partum period”.
4. Post-Partum: visit within 72 hours and on the 7th
day postpartum to check for conditions such as
bleeding or infections, Vitamin A supplements to
the mother, and counselling on family planning and
available services. It also includes maternal
nutrition and lactation counseling and postnatal visit
of the newborn together with her visit.
5. Newborn care until the first week of life:
Interventions within the first 90 minutes such as
immediate drying, skin to skin contact between
 mother and newborn, cord clamping after 1 to 3 How Do Genes Pass From Parent to Child?
minutes, non-separation of baby from the mother,
early initiation of breastfeeding, as well as essential To form a fetus, an egg from the mother and sperm
newborn care after 90 minutes to 6 hours, newborn from the father come together. The egg and sperm
care prior to discharge, after discharge as well as each have one half of a set of chromosomes. The
additional care thereafter as provided for in the egg and sperm together give the baby the full set of
“Clinical Practice Pocket Guide, Newborn Care chromosomes. So, half the baby’s DNA comes
Until the First Week of Life.” from the mother and half comes from the father.
6. Child Care: immunization, micronutrient
supplementation (Vitamin A, iron); exclusive
breastfeeding up to 6 months, sustained
breastfeeding up to 24 months with complementary
feeding, integrated management of childhood
illnesses, injury prevention, oral health and
insecticide-treated nets for mothers and children in
malaria endemic areas.

Genetics and Genetic Counseling

What Is Genetics?
Genetics is the study of genes. Our genes carry
information that gets passed from one generation to
the next. For example, genes are why one child has
blonde hair like their mother, while their sibling has
brown hair like their father. Genes also determine
why some illnesses run in families and whether
babies will be male or female.
What Are Genes?
Genes are sections of DNA (deoxyribonucleic acid)
that are found inside every human cell. They’re so
tiny that they can be seen only under a powerful
microscope. DNA is made of four chemicals that
form pairs in different combinations. The
combinations create codes for different genes.
Each person has about 20,000 genes. The genes
code for different traits, such as eye color, body
type, or male or female sex.
What Is a Chromosome?
Inside each cell, DNA is tightly wrapped together in
structures called chromosomes. Every normal cell
has 23 pairs of chromosomes (for a total of 46):
 22 pairs of chromosomes are the same in males
and females. These are called autosomes.
 The 23rd pair — the sex chromosomes —
determines the sex of the baby. Females have two
X chromosomes and males have one X
chromosome and one Y chromosome.
What Is a Genetic Disorder?
A genetic disorder happens when a gene (or
genes) has a problem with its code, and this
causes a health problem. Sometimes a genetic
disorder happens when a child inherits it from one
or both parents. Other times, it happens only in the
child (and the parents do not have the genetic
disorder).
How Do Genetic Disorders Happen?
Different things can cause a genetic disorder, such
as:
 a change (mutation) in one gene on a chromosome
 a missing part of a chromosome (called a deletion)
 genes shifting from one chromosome to another
(called a translocation)
 an extra or missing chromosome
 too few or too many sex chromosomes
Looking Ahead
Scientists are learning more and more about
genetics. A worldwide research project called The
Human Genome Project created a map of all
human genes. It shows where the genes are
located on the chromosomes. Doctors can use this
map to find and treat or cure some kinds of genetic
disorders. There is hope that treatments for many
genetic disorders will be developed in the future.
What is Genetic Counseling?
Genetic counseling gives you information about
how genetic conditions might affect you or your
family. The genetic counselor or other healthcare
professional will collect your personal and family
health history. They can use this information to
determine how likely it is that you or your family
member has a genetic condition. Based on this
information, the genetic counselor can help you
decide whether a genetic test might be right for you
or your relative.
Reasons for Genetic Counseling
Based on your personal and family health history,
your doctor can refer you for genetic counseling.
There are different stages in your life when you
might be referred for genetic counseling:
 Planning for Pregnancy: Genetic
counseling before you become pregnant
can address concerns about factors that
might affect your baby during infancy or
childhood or your ability to become
pregnant, including
o Genetic conditions that run in your
family or your partner’s family
o History of infertility, multiple
miscarriages, or stillbirth
o Previous pregnancy or child affected
by a birth defect or genetic condition
o Assisted Reproductive Technology
(ART) options
 During Pregnancy: Genetic counseling
while you are pregnant can address certain
tests that may be done during your
pregnancy, any detected problems, or
conditions that might affect your baby during
infancy or childhood, including
o History of infertility, multiple
miscarriages, or stillbirth
o Previous pregnancy or child affected
by a birth defect or genetic condition
o Abnormal test results, such as a
blood test, ultrasound, Chorionic
Villus Sampling (CVS),
or amniocentesis
o Maternal infections, such
as Cytomegalovirus (CMV), and
other exposures such as medicines,
drugs, chemicals, and x-rays
o Genetic screening that is
recommended for all pregnant
women, which includes cystic
fibrosisexternal icon, sickle cell
disease, and any conditions that run
in your family or your partner’s family
 Caring for Children: Genetic counseling
can address concerns if your child is
showing signs and symptoms of a disorder
that might be genetic, including
o Abnormal newborn screening results
o Birth defects
o Intellectual
disability or developmental
disabilities
o Autism spectrum disorders (ASD)
o Vision or hearing problems
 Managing Your Health: Genetic counseling
for adults includes specialty areas such as
cardiovascular, psychiatric, and cancer.
Genetic counseling can be helpful if you
have symptoms of a condition or have a
family history of a condition that makes you
more likely to be affected with that condition,
including
o Hereditary breast and ovarian
cancer (HBOC) syndrome
o Lynch syndrome (hereditary
colorectal and other cancers)
o Familial hypercholesterolemia
o Muscular dystrophy and other
muscle diseases
o Inherited movement disorders such
as Huntington’s diseaseexternal icon
o Inherited blood disorders such
as sickle cell disease
Following your genetic counseling session, you
might decide to have genetic testing. Genetic
counseling after testing can help you better
understand your test results and treatment options,
help you deal with emotional concerns, and refer
you to other healthcare providers and advocacy
and support groups.