Chapter -9 Maternal, Newborn, RH and

Midwifery Services Management

0
1
 Table of Content
Abbreviations.................................................................................................................................................2
Section 1: Introduction...................................................................................................................................3
Section 2 Operational Standards for Maternal Newborn Reproductive health & midwifery services
Management .............................................................................................................................................5
Section 3. Implementation Guidance.............................................................................................................6
3.1. Maternal, newborn, RH and midwifery services Implementation guideline......................................6
3.1.1. Guiding Principles................................................................................................................................6
3.1.2. Preconception Care:.............................................................................................................................6
3.1.3. ANC.....................................................................................................................................................7
3.1.4. Labor and delivery...............................................................................................................................8
3.1.5. Postnatal Care....................................................................................................................................13
3.1.6. Cesarean section.............................................................................................................................13
3.1.7. Maternity waiting homes...................................................................................................................14
3.1.8. Abortion care (CAC) service.............................................................................................................15
3.1.9. Essential neonatal care.......................................................................................................................17
3.2. Maternal and Perinatal Death Audit and Response..............................................................................18
3.3. Adolescent and youth-friendly health service.......................................................................................19
3.4. Roles and Responsibilities....................................................................................................................20

2
Abbreviations
MMR -Maternal Mortality Ratio
HSTP - Health Sector Transformation Plan
ANC - Antenatal Care
CQI - Continuous Quality Improvement
CCO - Chief Clinical Officer
FMOH - Federal Ministry of Health
UVP (POP) - Utero-vaginal Prolapse (Pelvic Organ Prolapse)
ToR -(Term Of Reference)
KMC - Kangaroo Mother care
WHO - World Health Organization
FANC - focused antenatal care
ICU - Intensive Care Unit
HDU - High Dependency Unit
HGB - Hemoglobin
RH - Rhesus
VDRL - Venereal Disease Research Laboratory
HBsAg - Hepatitis B Surface Antigen
HIV- Human Immunodeficiency Virus
NICU - Neonatal Intensive Care Unit
C/S - Ceasaran Section
IESO - Integrated Emergency Surgery Officer
ENC -Essential newborn care
MPDSR - Maternal and perinatal death surveillance and response
SMT - Senior Management team

3
Section 1: Introduction
The Ethiopian population estimated more than 121 million in 2024, and the country is
characterized by rapid population growth (2.6%). The country also has a high fertility rate of 4.6
births per woman (2.3 in urban and 5.2 in rural areas) and a crude birth rate of 32 per 1000 in
2016. Around 23% of the population is women in the reproductive age group.
During the implementation period of the first phase of HSTP I, it was marked by improvements
in life expectancy after birth. This included notable reductions in maternal mortality (decreased
from 676 deaths per 100,000 live births in 2011 to 401 in 2017). And it is planned to reduce the
MMR to 279 per 100,000 live births in the HSTP II implementation period. To realize such an
ambitious plan requires efforts to reduce the likelihood that a woman will have a high-risk
pregnancy, reduce the likelihood that a pregnant woman will experience a serious complication
of pregnancy, or improve the outcomes for women with complications by starting early
preconception care and enrolling to ANC and follow up to pregnant mothers, quality intrapartum
and postpartum care and counseling service to women in the reproductive age group.
Most of the causes of maternal and neonatal deaths in Ethiopia can be averted by providing
quality service at health setups, and most can be prevented by putting measures, systems, and
maternal and neonatal death audits in place and by designing CQI projects at the hospital level.
To provide such service, the hospital shall have an obstetric and gynecologic department led by a
physician, preferably by an OB-GYN specialist or higher, and provide service to both obstetric
and gynecologic pathologies. The department will be under the hospital's CCO or medical
director and must collaborate with other departments as a continuum of service and good patient
outcomes. The units under this department shall fulfill the minimum standard requirements (4
P's) according to the tier level of the hospital. Additionally, all hospitals shall work towards
reducing maternal mortality and morbidity and newborn deaths by treating a mother according to
the Obstetrics management protocol on Selected Obstetrics Topics (FMOH)
Furthermore, this guide also comprises comprehensive neonatal care, a service provided from the
preconception to the postnatal period, including early childhood development service in the
hospital. The units under this department shall have a newborn corner and mother's waiting
room, and the units must fulfill the minimum standard requirements (4 P's) according to the tier

4
level of the hospital.
Furthermore, the care for gynecologic problems like Fistula, UVP (POP), cervical cancer
screening and management, breast cancer screening, and other management shall not be
neglected and be institutionalized according to the tier level.
This chapter put the provision of maternal and newborn care as a continuum service at its highest
quality on condition that the OB-GYN and pediatric departments work in an integrated manner
to improve maternal and neonatal outcomes. Even though the hospital practices those activities
by default, a great deal of emphasis is still needed, and the departments will have a ToR that
entails roles and responsibilities, modes of communication, and others for smooth
communication and creating accountability in work.
Hospitals need to implement the operational standards contained in this chapter, use the revised
standard management protocols, and meet the minimum standards of the hospital. Hospitals
shall also establish a neonatal triage setting for neonates, institute preconception service, provide
early childhood development service, prepare maternal waiting rooms, establish a well-equipped
neonatal unit, and assign an adequate number of qualified health workers in all neonatal and
obstetric units with training on revised national guidelines to address the challenges of high
perinatal and maternal mortality rates.
The purpose of the Standards for Maternity and Newborn Care RH and midwifery service is to
assist program managers and healthcare providers of a hospital to:
 Introduce standards-setting and a quality improvement process at the facility level as a
means to improve access and quality of maternal and neonatal health services;
 To institute new services and further strengthen the changes registered by the previous
version of ESHTG.
 Provide effective maternal and neonatal health services;
 Use existing resources to achieve optimal healthcare outcomes; and improve individuals,
families, and community's satisfaction and utilization of maternal and neonatal health
services.

5
6
 Section 2 Operational Standards for Maternal Newborn
Reproductive health & midwifery services Management

1. The hospital has established a preconception service per the national protocol for
improving obstetric outcomes.
2. The hospital ANC unit provides individualized, client-centered, and evidence-based care
to clients on all working days, and high-risk mothers should be seen in the referral clinic.
3. The hospital shall establish a separate obstetric triage unit and provide care services per
obstetric management protocols.
4. The hospital should ensure intra-parental care per national obstetric management
protocols.
5. The hospital should ensure the provision of Comprehensive Emergency Maternal and
Newborn Care (CEmONC) services.
6. The hospital has established a postnatal care unit and provides comprehensive postnatal
care for improving obstetric outcomes per national obstetric management protocol.
7. The hospital should ensure women-friendly services at all Maternal and neonatal units;
including pain management materials are available in maternity and neonatal units
according to the tier level.
8. Hospitals have comprehensive Neonatal Care service that includes KMC, mothers'
waiting room, and isolation rooms.
9. The hospital should ensure the provision of family planning (with a focus on long-term
methods) and comprehensive abortion care services following the national guideline and
policies.
10. The hospital maternity and neonatal unit undertakes CQI activities by conducting audit
programs and regularly implementing maternal and perinatal death surveillance and
response activities.
11. Midwives should implement the midwifery process for all admitted patients at all
hospitals.
12. The hospital has established a system for providing maternal and newborn-related
services, cooperation, and support packages with catchment facilities
13. The hospital shall provide adolescent and youth-friendly services.

7
Section 3. Implementation Guidance
3.1. Maternal, newborn, RH and midwifery services Implementation guideline

3.1.1. Guiding Principles

The maternity unit includes the ANC unit, labor and delivery ward, and postnatal ward. The unit
should be placed in an easily accessible location, and mothers should be treated with respect and
dignity. Respectful maternity and newborn care norms should be applied to all clients, and pain
should be managed appropriately.

The maternity unit should do audits regularly. Maternity unit audits should be performed every
month, and a client/mom's satisfaction survey should be performed every 3 months. Data should
be displayed on white board at ANC, labor and delivery, and postnatal ward and updated.
Regular review meetings should be held at least every week to discuss audit findings, ongoing
challenges, weekly ward activity, and other findings. Community involvement in the form of a
pregnant forum or community forum should be held at least every 3 months.

Midwives should implement the midwifery process at all hospitals for all admitted patients. All
midwives should assess, diagnose, plan, implement & evaluate their admitted patients according
to midwifery care practice. (Refer to a book, Standard of Midwifery Care Practice in Ethiopia)

3.1.2. Preconception Care:

Preconception care provides biomedical, behavioral, and social health interventions to women
and couples before conception to increase the chance of having a good obstetric outcome.
Preconception care aims to evaluate clinically, provide basic laboratory and imaging
investigations, treat/correct identified disorders for women (preferably in a couple) planning
pregnancy, and avoid fetotoxic exposures.

The wide range of services rendered related to preconception care in hospitals includes
assessments such as basic laboratory and imaging investigations and different categories of

8
intervention, such as treatment/correcting identified disorders for women (preferably in a couple)
who are planning pregnancy and avoid fetotoxic exposures, supplementation, and immunization.

The hospital should train and make aware healthcare providers of the standard healthcare
provisions during the preconception period as well as the integration of preconception services in
all MCH service outlets such as Family planning, Adolescent youth services, including other
units such as OPD, and all chronic care clinics

3.1.3. ANC
Antenatal care (ANC) is a health service provided to pregnant women in the continuum of
maternity care. The WHO defines ANC as the care skilled healthcare professionals provide to
pregnant women and adolescent girls to ensure the best health conditions for both mother and
baby during pregnancy.

This new national ANC guideline document is aligned with the 2016 World Health
Organization (WHO) released comprehensive recommendations on ANC for a positive
pregnancy experience, replacing focused antenatal care (FANC), which has been used for over a
decade. Recent evidence noted that the FANC model was associated with more adverse events
and significantly increased perinatal mortality compared to the previous model.

Therefore, Ethiopia is replacing the previous four-visit FANC model with the new ANC eight-
contact model. Accordingly, the first contact is recommended to be a single contact in the first
trimester (up to 12 weeks), two contacts in the second trimester (at 20 and 26 weeks of
gestation), and five contacts in the third trimester (at 30, 34, 36, 38, and 40 weeks). In addition,
in the current model, the word “visit” is replaced with “contact” as the connotation of the latter
indicates an active connection between a pregnant woman and a health care provider.

In addition to routinely done tests and procedures for all pregnant women, updates are included
in this guideline. Some of these are one ultrasound scan before 24 weeks of gestation (early
ultrasound) for all pregnant women to estimate gestational age, and selective or case-specific
screening is recommended for gestational diabetes mellitus, Tb, and group B streptococcus
(GBS). In addition, it introduces woman-held case notes, creating a woman-friendly
environment, pregnancy support during public health emergencies, caring for women with

9
special needs, and supporting pregnant women during humanitarian crises.

The section on health promotion, disease prevention, and treatment during pregnancy:
counseling on lifestyle modification, dangerous symptoms and signs, counseling on birth
preparedness, and complication readiness are discussed in detail. Besides, counseling on family
planning, infant and young children nutrition, stimulation for early childhood development, and
child immunization is briefly addressed.

Maintaining good nutrition and a healthy diet during pregnancy is critical for the health of the
mother and fetus. Maternal under nutrition is highly prevalent and is recognized as a critical
determinant of poor perinatal outcomes. In Ethiopia, the dietary intake of vegetables, meat, dairy
products, and fruit is often insufficient for many pregnant women. Therefore, nutritional
counseling primarily focuses on promoting adequate weight gain during pregnancy, Promoting
food and micronutrient supplements during pregnancy, assessing for adherence to iron, folic
acid, and calcium supplementation during each contact, and counseling on food safety and
quality is essential during pregnancy.

Hospitals should provide ANC service open throughout working days by trained professionals.
A midwife will be the head of the ANC unit, and all the service providers should be trained on
new national ANC guidelines (ensuring positive pregnancy); the ANC room should keep privacy
by using curtains/screens, and all ANC services will be free. The referral clinic should be open
throughout working days, with investigation results ready on the same day.

3.1.4. Labor and delivery

Laboring mothers are not supposed to visit the central triage but instead go directly to obstetrics
triage units and should be admitted to the labor-delivery ward without any administrative
procedures after rapid assessment and prioritization in the obstetrics triage unit. There should be
an obstetrics triage unit /reception functional 24/7, adjacent to the labor-delivery ward with
assigned competent health care providers, necessary equipment and supplies, triage assessment
tool/sheet with acuity scale, and clear admission criteria. There should be a log book at the
triaging site or reception for laboring mothers in the false or latent phase of labor. Rapid
assessment tool and client flow in labor and delivery posted at reception and obstetrics triage.

10
Figure 1: Rapid assessment of laboring mothers to advance care

Figure 2: Flow chart for triage and registration of laboring mothers

11
The labor ward rooms are clean, well-ventilated, and suitable temperature (neither hot nor cold).
The labor ward needs to have an emergency drug cabinet that has labeled essential drugs. The
labor-delivery ward should have a functional refrigerator with a temperature monitoring chart. It
should have all essential functional medical equipment. The delivery ward room should have a
functional clock, weighing scale, headlamp, and tape meter.

Privacy must be maintained for the first and second stages of labor by screens or curtains, and
sufficient space should be available for laboring mothers and one companion. Mothers are
allowed oral fluids and light food during labor. A family member/Companion/support person
should be allowed to remain with the woman constantly during labor and delivery. There should
be functional bathrooms and toilets with hand-washing basins and soap accessible to laboring
mothers. The labor ward has running water and soap for hand washing for the staff.

The labor and delivery ward should have at least four beds for the first stage of labor and two
delivery coaches for the second stage of labor. The maternity unit must have an ICU or HDU

12
near the nursing station for seriously ill patients.

Partograph should be consistently used, and the third stage should be managed actively. Date
and time of admission, identification and previous obstetric history, admission findings of BP,
PR, Temperature, lie and presentation, FHB, uterine contraction, cervical status (dilatation and
effacement), membrane status (intact or ruptured), molding and station should be documented.
The Partograph has to be used correctly and consistently. If an intervention has to be made, it
should be from the Partograph findings, and the action must be appropriate and timely when
applicable. All interventions, including instrumental delivery and C/S, should be based on
justified indications and performed timely. Pertinent findings and decision notes should be
entered into the medication record.

HGB, blood GP, RH, VDRL for syphilis, HBsAg, and HIV testing should be done for all, and
FHB and uterine contraction should be monitored every 30 minutes; cervical dilatation should be
assessed every four hours. And/or on indications (non-reassuring FHB, signs of 2 nd stage, or
membrane ruptured). Maternal BP was measured every four hours for mothers with no pre-
eclampsia or eclampsia, and pulse rate every half an hour.

A safe childbirth checklist should be used for all laboring mothers. The delivery coach is
comfortable with all accessories, and mothers can deliver in their preferred position. The third
stage should be managed actively. Well-equipped newborn corner for routine essential newborn
care and neonatal resuscitation should be available in the labor ward; Clamp the cord after 1-3
minutes (unless the neonate is asphyxiated and needs to be moved immediately for resuscitation),
cut the cord with a sterile instrument, put sterile tie, and put identity label on the baby( the
identity label should contain mother's name, card number, gender of the baby and time of
delivery). The newborn corner facility should include a radiant warmer, a newborn-sized Ambu
bag of sizes 0 and 1, and a suction bulb and/or suction machine. All midwives should be trained
in Helping Babies Breath, and NICU should be available for advanced care. Ideally, NICU
should be adjacent to the labor ward. The delivery summary should be filled on the form at the
back of the Partograph and on a separate sheet when necessary.

13
The quality of care the mother and newborn receive in the first 24 hours after delivery is crucial
in ensuring both mother and neonate stay healthy beyond the immediate postnatal period. The
care that is provided should focus on prevention, early detection as well as treatment of any
birth-related complications while putting into consideration the physiological as well as
psychological changes that are common during childbirth.

All postpartum women should have regular assessments (immediately at birth, at one hour after
birth, and every four hours): Vaginal bleeding, uterine contraction, fundal height, temperature
and heart rate (pulse), blood pressure, urine void, breastfeeding status, pain, emotional wellbeing
and bonding with the newborn. In addition, to minimize the major risk of Complications during
the Postpartum Period, such as bleeding, hypertensive disorders of pregnancy, and infection,
healthcare providers should keep these in mind during care provision and patient teaching and
counseling. In addition,

Women who experience perinatal loss have an increased risk of postpartum blues and
depression. Therefore, it is crucial that women receive appropriate care and bereavement
counseling in the immediate postnatal period and beyond. In addition, every effort should also
be made to keep the woman in a non- ‐maternity ward to minimize the woman's distress from
being with mothers and newborns in the maternity ward.

The baby should be assessed immediately at birth, at one hour after birth, and every four hours
after that, as well as at discharge for danger signs of Stopped feeding well, History of
convulsions, fast breathing (breathing rate ≥60 per minute), severe chest in- ‐drawing, movement
only when stimulated or no movement even when stimulated, fever (temperature ≥37.5 °C), low
body temperature (temperature <35.5 °C), any jaundice in first 24 hours of life, or yellow palms
and soles at any age. The newborn should promptly refer to NICU for further evaluation if any
danger signs are present. After an uncomplicated vaginal birth at a health facility, healthy
mothers and newborns should receive care for at least 24 hours after birth. Discharge only if the
mother's bleeding is expected, the mother's and baby's vital signs are stable without any sign of
infection or other diseases, and the baby is breast-‐feeding well.

The hospital should assign a responsible focal person, preferably a Senior Midwife, to coordinate
the implementation of 24-hour PNC, Equip and arrange postnatal rooms to sufficiently

14
accommodate delivered mothers and their neonates for at least 24 hours post- ‐delivery, ensure
availability of adequate supplies and materials required to implement the 24-hour PNC, ensure
the 24-hour PNC service is recorded and reported as per the HMIS, etc. The postnatal ward
should be clean, ventilated, appropriately illuminated, have a suitable temperature, be well
equipped, and be adjacent to the labor ward. The postnatal beds should be clean and comfortable
with accessories and bed sheets.

3.1.5. Postnatal Care

The postnatal ward should be clean, ventilated, appropriately illuminated, have a suitable
temperature, be well equipped, and be adjacent to the labor ward. The postnatal beds should be
clean and comfortable with accessories and bed sheets. The hospital should give comprehensive
postnatal care for at least 24 hours, and maternal BP, PR, temperature, uterine tone (contraction),
and vaginal bleeding should be checked every 15 minutes for the first 2 hours. Neonates are
checked for breathing problems, color, pulse rate, breastfeeding, and cord tie security. Mother
should be counseled for danger signs for both mothers (vaginal bleeding, fever, foul smelling
vaginal discharge, severe abdominal pain, safe sex, abnormal body movement) and neonate
(failure to suck, jaundice, cyanosis, fever, abnormal body movement, difficulty of breathing).

3.1.6. Cesarean section

The hospital needs to have a fully functional operating theatre (one table dedicated to cesarean
section) and be adjacent to the labor and delivery ward. Appropriate and adequate cesarean
section team members should be available 24/7 (OBY/GYN, OBGYN residents or IESO,
anesthetist, scrub nurses) with all essential drugs for cesarean section and functional essential
equipment. Patient consent sheet, safe surgery checklist should be used for all surgeries, and
documentation should be complete for all cesarean sections. An audit to assess the completeness
of documentation (Indication and evidence for C-section, time of decision and incision, operation
note with the outcome and name with the signature of the Surgeon, condition of the mother and
the baby, etc., with legible handwriting) should be done every three month and rate and
indications for C/S should be displayed in whiteboard every month. Spinal anesthesia is used in
the absence of contraindication

15
3.1.7. Maternity waiting homes
According to WHO, Maternity waiting homes are recommended to be established close to a
health facility, where essential childbirth care and/or care for obstetric and newborn
complications is provided to increase skilled care for populations living in remote areas or with
limited access to services. Especially for rural communities where the difficulty of topography,
distance, and unavailability of all-weather roads and transportation, the maternity waiting
significantly increases accessibility and addresses equity compared to home delivery.

Some of the admission criteria to maternity waiting homes are: Inaccessible for ambulance
transportation, residing long distance away from health facilities (hospital and health centers),
greater than 38 weeks of gestation (it is not advisable to stay more than a month), pregnant
women encountered with problems during the previous pregnancy such as premature labor,
cervical tear, stillbirth, etc.

The medical services provided in maternity homes include ANC follow-up, appropriate
treatment for sick mothers, health education about ANC, skilled birth attendance, postnatal, F/P,
danger signs, etc. The room is built from locally available materials and might depend on the
local community's culture. The room should be illuminated, ventilated, and clean and should
accommodate at least six mothers in one room. In addition, it should have a cooking area
(kitchen) with complete equipment. Furthermore, the room should have a bathroom, toilet, and
sink for hand washing.

Some of the implementation strategies that the hospital considers are Community mobilization to
contribute both in kind and financially, early imitation of ANC (12 weeks of gestation), strong
leadership (to collaborate with woreda and Kebele administrators), and ensuring the functionality
of obstetric referral network, etc.

16
3.1.8. Abortion care (CAC) service
Abortion services can be categorized as pre-abortion, abortion, and post-abortion services. Pre-
abortion services span from identification of cases, providing laboratory screening, antibiotic
prophylaxis, planning of management, and pain management to preparing the mother for the
procedure; abortion is the actual process of termination of pregnancy using either medical or
surgical methods, while post-abortion care incorporates follow-up of mother’s after receiving the
service, management of life-threatening and non-threatening complication and post abortion
contraception counseling service (including linkage to other needed services in the community or
beyond) that every hospital is expected to provide.

Abortion service shall be provided by the principles of respectful care in a manner that assures
women's right to have autonomy in decision-making, services expected to the tier level of the
hospital, free of abortion stigma, woman-centered, free of charge, available, accessible of high-
quality care in hospitals and early and clear mechanism referral to a higher facility and linkage.

This service unit will be part of or under the obstetric and gynecologic department. It is led by a
senior midwife/ GP or an OB-GYN specialist/higher, whichever is available. The unit must
collaborate with other departments as a continuum of service and good patient outcomes. The
unit shall also provide, as a minimum, the service according to the tier level put on technical and
procedural guidelines of abortion at the hospital. Additionally, all hospitals shall work towards
reducing maternal mortality and morbidity by treating a mother according to the Obstetrics
management protocol on Selected Obstetrics Topics (FMOH).

The hospital shall ensure that the abortion care services provided to women, as permitted by law,
are safe, affordable, and accessible to
֎ Granting all individuals of accessing relevant, accurate, and evidence-based health information
and counseling if and when desired;
֎ Providing comprehensive abortion care services that support women in exercising their sexual
and reproductive rights;
֎ Reduce morbidity and mortality due to unsafe abortion;
֎ Reduce deaths and disability from abortion complications through effective management and
stabilization, and referral;
֎ Improve women’s broader reproductive health by integrating abortion care services into other
sexual and reproductive health services;
֎ Organizing emergency abortion services to provide lifesaving procedures on a 24-hour basis;

17
֎ Help women make free and informed decisions regarding their pregnancy, be more informed
about health services and follow-up care needed;
֎ Prevent unwanted pregnancies through contraceptive services, including counseling and method
provision;
֎ All working staff shall have received appropriate training and demonstrate competent skills, and
the services shall be evidence-based, including the use of national guidelines and policies;
֎ The hospital shall also ensure the availability of safe abortion services, including medical and
surgical options, as permitted by the law.

18
3.1.9. Essential neonatal care
Essential newborn care (ENC) is care given to all newborn infants at birth to optimize their
chances of survival and well-being. ENC starts before birth (teaching parents about the unborn
child during ANC) and extends to the postnatal period. And this stage is characterized by 10
(ten) standardized procedures, from drying and stimulating the neonate to documenting all the
procedures applied to the neonate.
This service unit will be part of or under the obstetric and gynecologic department. It is led by a
senior midwife/ GP or an OB-GYN specialist/higher, whichever is available.
Neonatal resuscitation means to revive or restore life to a baby. It is a lifesaving intervention for
newborns who fail to initiate and maintain spontaneous and adequate breathing at birth. The
obstetrics unit must collaborate with other departments as a continuum of service and good
patient outcomes. The pediatrics department plays a crucial role, especially in early
identification, initiating communication, preparing, and providing care for high-risk pregnancies
that necessitate neonatal resuscitation and/or admission to the Neonatal Intensive Care Unit
(NICU). Hence, for high-risk pregnancies, the neonates shall be seen preferably by a
neonatologist, pediatrician, NICU care-trained general practitioner, and midwife available at the
facility. The early transfer should be instituted if the neonate indicates NICU admission. All
hospitals shall work towards reducing neonatal mortality and morbidity by treating a newborn
according to the Obstetrics management protocol on Selected Obstetrics Topics (FMOH).
Additionally, the unit must fulfill the minimum standard requirements (4 P’s) according to the
tier level of the hospital.
Furthermore, ECD is a process of continuous maturation in terms of cognitive, linguistic, and
executive functions and mental, emotional, and behavioral development in early childhood.
Early childhood represents the period from conception to six years of age. The early years are
critical because this is the period in life when the brain develops rapidly and has a high capacity
for change; the foundation is laid for health and wellbeing throughout life, which is expected to
be delivered in all hospitals.
Hospitals shall implement nurturing care and practice early detection and management of
developmental disorders. They also shall institute play and stimulation facilities for young
children and establish strong referral linkages within health facilities. This service will be led by

19
a physician, preferably a pediatrician/ higher or neonatal nurse. The unit will be under the NICU
of the hospital. The hospital shall ensure that the ENC services provided to neonates are safe,
affordable, and accessible to

Every delivery should be attended with the anticipation of the need for newborn
resuscitation.
The delivery room is clean & warm and has a newborn corner/ resuscitation area.
The unit meets the minimum requirement standards according to the tier level.
Early initiation (within one hour of delivery) of exclusive breastfeeding
The unit must provide all critical postpartum maternal and newborn health care
interventions according to the revised obstetric management protocol;
ENC standards steps are followed and adhered to by all professionals; and
All working staff shall have received appropriate training and demonstrate
competent skills, and the services shall be evidence-based, including national
guidelines and policies.

3.2. Maternal and Perinatal Death Audit and Response

Ethiopia has a high burden of maternal, perinatal, and neonatal death. A well-defined and
enforced MPDSR system stresses that maternal and perinatal deaths should be incorporated into
the existing fortifiable health events reporting system to ensure timely notification. The hospital
should have an MPDSR Committee led by the clinical director/CCD and consists of the main
stakeholders with transparent written TOR, roles, and responsibilities. The MPDSR Committee
should conduct timely maternal and perinatal death audits, identify gaps, prepare action plans, or
do CQI.

20
 3.3. Adolescent and youth-friendly health service
Adolescent and youth Friendly health services are an evidence-based approach to reducing
barriers to Sexual and Reproductive Health service uptake. Friendly health services are
accessible to and acceptable to adolescents and youth people. It laid the foundation for the
health system to meet the SRH needs and rights of the largely under-served adolescent
population (WHO, 2012). Adolescent and youth-friendly health services should have distinctive
features and, therefore, could attract and meet teenagers' needs and retain adolescents and youth
for sustainable utilization (Health, 2004). Adolescent and Youth Friendly Health Services
provides a safe environment at an accessible location, convenient hours, offers privacy, avoids
stigma, and provides information and education material. Adolescent and youth-friendly health
services have provided technically competent, high interpersonal and communication skills and
non-judgmental & considerate care providers who treat all young people equally, with respect
and support. Adolescent and youth-friendly health services could have a strategy and expected
service quality, Fulfill National/WHO standards and characteristics, and be comfortable to
customers and provided within appropriate settings. Adolescent and youth-friendly health
services could meet the SRH needs of Adolescents & retain them for follow-up and repeat visits.

Adolescent and youth-friendly health service organizational structure

 Adolescent and youth-friendly health services have unique nature. It has its separate unit
and should be led by a master of public health in reproductive health, alternatively by a
psychologist and accountable for the hospital's pediatric and adolescent and youth-
friendly health services director.
 The head of adolescent and youth-friendly health services is responsible for leading and
coordinating friendly health services and confidentiality clinics.
 Adolescent and youth-friendly Health service has developed a strategic and annual plan
with adequate budget allocation for planned activities.

21
 3.4. Roles and Responsibilities
I. The maternity unit will be led by an obstetrician and gynecologist or IESO, and they will have the
following responsibilities:

 The maternity head monitors all the activities of the maternity unit
 They should make sure that all services are provided to all women according to
respectful maternity care (please refer to the revised obstetric management protocol)
 The maternity QI subcommittee will conduct regular audit meetings and draw action
plans depending on the finding.
 They communicate with the hospital SMT, arrange training for all staff, and ensure
proper handover mechanisms and follow-up of day-to-day clinical activity.
 They should ensure that at least 5% of vaginal deliveries should be attended to by an
obstetrician or IESO.
 They should ensure that high-risk pregnancies are attended by the most senior health
care professional (OBGYN specialist) and that early communication has been initiated
with the pediatrics department.
The heads of the maternity units (ANC, delivery ward, and postnatal ward) will have roles and
responsibilities in each respective unit. They prepare and compile monthly, quarterly, and yearly
reports and action plans. They should be members of the maternal death audit committee/QI
committee, prepare schedules for the unit, and ensure that all the necessary materials and
supplies are always available. They communicate with the obstetrician/IESO whenever they
have any challenges in their respective units.

II. Mothers'/caregivers' rights and responsibilities

 Mothers and caregivers of newborns and children admitted to hospitals have the right to
know about the health status of their children, and should be regularly communicated.
 Informative, systematic, and regular communication is essential to engage families in the
care of their children. Mothers and caregivers should be encouraged to be involved in the
care of their children, and health education in the future care of their children should be
given.

22
SUMMARY
Most of the causes of maternal and neonatal deaths in Ethiopia can be averted by providing
quality service at health setups, and most can be prevented by putting measures, systems, and
maternal and neonatal death audits in place and by designing CQI projects at the hospital level.
To provide such service, the hospital shall have an obstetric and gynecologic department that is
led by a physician, preferably by an OB-GYN specialist or IESO, and provide service to both
obstetric and gynecologic pathologies. Reproductive, Maternal, Newborn and Child Health
(RMNCH) covers the health concerns and interventions across the life course involving women
before and during pregnancy; newborns, the first 28 days of life; and children to their fifth
birthday. This chapter contains thirteen Operational Standards and Thirteen indicators.

23
Reference

1. MOH, National Reproductive health strategy (2016-2020)

2. MOH, EHSTG (2016-2022) Vol.1, Chapter 8
3. REPRODUCTIVE AND CHILD HEALTH DEPARTMENT (republic of Uganda,2022)
4. . Federal Democratic Republic of Ethiopia: Ministry of Health, HSDP IV. Addis Ababa,
Ethiopia: Annual Performance Report EFY 2004 (2011/2012); 2013. 2.
5. Federal Ministry of Health, Health Sector Development Program IV 2010/11-2014/15.
Addis Ababa: Federal Ministry of Health; 2011.
6. Federal Ministry of Health of Ethiopia, Health Sector Transformation Plan (HSTP)
2014/15- 2019/20, Addis Ababa, 2015.
7. Windau-Melmer, Tamara. 2013. A Guide for Advocating for Respectful Maternity Care.
Washington, DC: Futures Group, Health Policy Project.
8. Federal Democratic Republic of Ethiopia: Ministry of Health, Standard of Midwifery
Care Practice in Ethiopia, August 2013.
9. Federal Democratic Republic of Ethiopia: Ministry of Health, Management Protocol on
Selected Obstetrics Topics, January 2010
10. Technical and Procedural Guidelines for Safe Abortion Services in Ethiopia, Second
edition, June 2014 8. Federal Democratic Republic of Ethiopia: Ministry of Health,
National Guideline for Family Planning Services in Ethiopia, February – 2011
11. WHO recommendations on postnatal care of the mother and newborn. Geneva
(Switzerland): World Health Organization (WHO); 2013 Oct. 62 (p. 120)
12. Federal Ministry of Health, National Mother and Baby Friendly Service Guideline, 2016
11. Integrated Management of Pregnancy and Childbirth, Standards for Maternal and
Neonatal Care, WHO, 2007.
13. Pocket book of hospital care for children, second edition: WHO, 2013
14. Global Initiatives for Improving Hospital Care for Children: State of the Art and Future
Prospects PEDIATRICS Volume 121, Number 4, April 2008
15. Assessment Tool for Hospital Care for Children, Second Edition: WHO 2015

0
ANNEX

Appendix 1: List of Emergency Drugs and Equipment for Child Health

No Equipment Yes No

1 Nebulizer

2 Spacer

3 Oropharyngeal (Guedel) Airways: at least 3 different sizes

4 Self-inflating bags: adult and children

5 Masks: 3 sizes for children

6 Electric (or foot) suction pump and suction catheters: size 15 FG.

7 Oxygen concentrator or oxygen cylinder with the regulator, pressure

gauge, and flow mete

8 Oxygen tubing, nasal prongs, or catheters

9 High-pressure oxygen source with oxygen adopter and oxygen bag

10 Sandbags

11 Blankets

12 Scissors

13 Iris forceps without teeth

14 Consumables

15 Adhesive tape, at least 2 different sizes

16 Cotton wool

17 Cardboard to make splints

18 IV Infusion sets

19 Scalp vein needles (size 21 or 23 G)

20 IV Cannula (size 22 or 24 G)

21 Needles for intraosseous insertion (size 21G)

1
22 Fluids and drugs

23 Ringer’s lactate or normal saline

24 Normal saline with 5% glucose solution or half-strength Darrow’s with

5% glucose

25 Solution

26 Glucose 10% or 50% glucose

27 ORS

28 ReSoMal (commercially bought or prepared)

29 Diazepam IV or Lorazepam

30 Adrenaline

31 Salbutamol puff

32 Corticosteroids:

- Hydrocortisone IV

- Dexamethasone IV

- Prednisolone PO

2
 Appendix 2: List of NICU equipment and essential drugs for child health

No Equipment’s Yes No

Incubators

Radiant warmers

Phototherapy machines

Cardiac monitors

CPAPs

Pulse oximeter

Perfumer

Oxygen concentrators

Oxygen cylinders with gauge

Nasal prongs

Room heaters

Suction machines

Ambu bags and different sizes of face masks

Neonatal cribs

Neonatal BP apparatus

Bulb syringes

Resuscitation table

Refrigerator

Endotracheal tubes

Oropharyngeal airways

Oropharyngeal airways

Infant weight scales

Umbilical catheterization set

Exchange transfusion set

0
IV stands

Thermometers

Supplies

Sterile and clean gloves

Syringes and needles

IV sets and blood transfusion sets

IV cannulas and butterfly needles

Soap and antiseptic solutions

NG tubes

Drugs

Antibiotics:  Ampicillin injection (250mg, 500mg, 1g)

 Cefotaxime sod (500mg, 1g vials)

 Ceftazidime (500mg, 1g, 2g vials)

 Ceftriaxone (250mg, 500mg, 1g vials)

 Clindamycin (150mg/ml)

 Gentamicin (10mg/ml, 40mg/ml)

 Nafcillin (1g, 2g vials)  Penicillin G (crystalline, 5MIU…)

 Vancomycin (500mg, 1g, 5g vials)

Ringer’s lactate or normal saline

Normal saline with 5% glucose solution

Glucose 10%, 40%, or 50% solution

Anticonvulsants
 Diazepam 5mg/ml ampule
 Phenobarbitoneinj, 60mg/ml, 65mg/ml

1
 Appendix3: List of guidelines and job aids for child health

Unit Unit (department) List of GL and job aids Yes No Yes No

Emergency Unit ETAT guidelines (manuals)

Pocketbook on hospital care for children (National)

ETAT flow sheets (for triage, airway, and breathing,

circulation, convulsion, etc)

Pediatrics OPD Hospital care for children (National)

ART guideline

TB guideline

Nutrition guideline

Neonatal unit Hospital care for children (National)

NICU guideline

Neonatal Resuscitation flow sheet

Standard pediatric textbooks

EPI clinic EPI guideline

Pediatric ART Consolidated HIV care/ART GL (national)

clinic
National TB guideline

National nutrition guideline

National PMTCT guideline

Pediatric wards Pocket Book on Hospital care for children (National)

Consolidated HIV care/ART guideline (national)

National TB guideline

National nutrition guidelines

Standard pediatric textbooks

2
 Appendix 4: List of pediatric ARVs and OI drugs

No ARV Drugs Yes No

1 ARV Drugs Yes No

2  FDC: AZT/3TC/NVP

3  FDC: AZT/3TC

4  FDC: ABC/3TC/NVP

5  FDC: TDF/3TC/EFV

6  FDC: TDF/3TC

7  FDC: AZT/3TC/LPV/r

8  FDC: ABC/3TC/LPV/r

9  FDC: LPV/r sprinkles

10 OI drugs

11  Co-trimoxazole suspension (240mg/5ml)

12  Co-trimoxazole tablet (480mg)

13  INH tab (100mg)

14 Nystatin suspension (100,000 U/ml)

15  Clotrimazole mouth paint, 1%

16  Miconazole tab (250mg), oral gel 25mg/ml

17  Amoxicillin suspension (125mg/5ml, 250mg/5ml)

18  Amoxicillin/clavulanic acid suspension

19  156mg/5ml

3
 Appendix 5: Facility, Supplies, and Equipment for Pediatric OPD and ART Clinic

No Equipment’s Yes No

1 Functional hand washing basins Yes No

2 Examination beds with clean sheets

3 Table and chair for the physician (clinician)

4 Weight and height measuring scales for infants and children.

5 MUAC tapes

6 Thermometers

7 Otoscopes and torches

8 Pediatric BP apparatus (different sizes)

9 Disposable and sterile gloves and alcohol swabs

10 Syringes and needles as required

11 Printed papers such as admission cards, prescription papers, lab request

forms, X. ray

12 and U/S request forms, referral papers

13 HMIS/IMNCI registers

4
Appendix 6 Essential drugs that must be available in the emergency drug cabinet of the L&
D ward

In the emergency drug cabinet on the L&D ward or Yes No

Refrigerator

1 Uterotonic medication (Oxytocin,

2 Misoprostol, Misoprostol Po, and/ or

3 Ergometrine)

4 . Magnesium sulfate

5 Diazepam

6 Antihypertensive medication (Nifedipine and

7 Hydralazine)

8 40% glucose

9 IV Cannula

10 Lidocaine

11 Syringe & needle

12 IV fluids (crystalloids)

13 Tetracycline eye ointment

14 Sterile gloves

15 Atropine

16 Vitamin K

17 Adrenaline

18 Ampicillin IV

19 Ca gluconate

5
Appendix 7 Medical equipment in labor and delivery ward and operation theatre
(equipment must be functional at the time of assessment)

No Item Yes No

1 Functional Sphygmomanometer (BP apparatus)

2 Stethoscope

3 Suction machine portable

4 Pinnardstethetescope(Fetoscope)/Doppler

5 Ultra Sound

6 Thermometer

7 Filled oxygen tank with flow meter

8 Nasal prongs for oxygen administration

9 Catheter for oxygen administration

10 Filled oxygen tank with flow meter

11 Nasal prongs for oxygen administration

12 Catheter for oxygen administration

13 delivery sets, at least two sterile

14 Sterile suture kit

15 Forceps

16 Vacuum extractor

17 Urinary Catheter

18 HIV test kits (KHB, Stat pack)

19 Stand lamp

20 Speculum for vaginal examination

21 Craniotomy set

6
22 Sterilizer (Steam or dry)

23 Ambu bag with sterile mask

24 Bed with accessories

25 IV stand

26 Mask for oxygen administration

27 Cord cutting/clumping set

28 Radiant Warmer

29 Towels for drying and wrapping newborn babies

30 weighing scale for baby

31 Tape to measure the baby's length and head circumference

32 Functioning clock

33 Two Episiotomy set

34 Suction bulb for NB resuscitation

35 Long sleeve glove for removal of retained placenta

36 NASG

37 MVA set (at least two)

38 E & C set (at least two)