IMPAC: A tool for making pregnancy safer Dr Jitendra Introduction: The integrated management of pregnancy and childbirth (IMPAC)

is the technical component of the global strategy, Making Pregnancy Safer (MPS). It is based on the latest a ailable scientific e idence. It is a lo!"cost strategy based on #$%&s Mother"'aby Pac(age designed to pre ent maternal and infant deaths and the lifelong disability d)e to complications of pregnancy and childbirth. IMPAC relates to basic essential care at the primary le el and also management of complications !here more ad anced facilities are a ailable. Its g)idelines are intended for physicians, n)rses, mid!i es, comm)nity o)treach !or(ers, and others in ol ed in the pro ision of basic and emergency care and ad ice at ario)s le els of ser ice deli ery. IMPAC strategy ens)res access to* antenatal care normal deli ery care assisted by a s(illed birth attendant treatment for complications of pregnancy (incl)ding hemorrhage, obstr)cted labo)r, eclampsia, sepsis, abortion complications) neonatal care family planning ad ice management of se+)ally transmitted infections. Need of IMPAC: In modern times, impro ements in (no!ledge and technological ad ances ha e greatly impro ed the health of mother and children. $o!e er, the past decade !as mar(ed by limited progress in red)cing maternal mortality. There !as also a slo!"do!n in the steady decline of childhood mortality obser ed since the mid ,-./s in many co)ntries, largely d)e to a fail)re in red)cing neonatal mortality. 0 ery year abo)t eight million !omen s)ffer pregnancy"related complications. % er half a million die mainly d1t se ere bleeding, infections, )nsafe abortions, hypertension, and obstr)cted labo)r. More than -/2 of these deaths occ)r in Asia and s)b"3aharan Africa (In de eloping co)ntries, , in ,4 !omen die of pregnancy"related complications compared to , in 56// in de eloped co)ntries). In addition, o er ./ million !omen s)ffer from ac)te pregnancy"related conditions "" o er a third of them !ith long"term, painf)l, and often distressing conditions that !ill affect them for the rest of their li es. They incl)de permanent incontinence, chronic pain, ner e and m)scle damage, and infertility.

0 ery year, o er fo)r million neonates die, mostly d)ring the critical first !ee( of life7 and for e ery ne!born !ho dies, another is stillborn. Most deaths are d1t poor maternal health and n)trition, inade8)ate care d)ring pregnancy and deli ery, lac( of essential care of ne!born baby, infections, birth in9)ry, asphy+ia, and premat)re births. Despite being so common these problems remain least recogni:ed in many societies. Altho)gh these problems can be pre ented at lo! cost !ith limited reso)rces, the right (ind of information for action is needed. Impro ements in mother ; ne!born health do not re8)ire sophisticated and e+pensi e technologies and highly speciali:ed staff. It re8)ires an essential care d)ring pregnancy, assistance of a person !ith mid!ifery s(ills d)ring childbirth and immediate postpart)m care. A fe! critical inter entions for the ne!born d)ring the first fe! days of life is also essential. $ence, an approach for integrated management of pregnancy ; childbirth is most essentially re8)ired and this generated need for IMPAC. Aim of IMPAC: IMPAC aims at impro ing maternal and ne!born health. It addresses different factors cr)cial to the access of s(illed care before, d)ring and after pregnancy and childbirth. IMPAC targets health systems, health !or(ers, as !ell as families and comm)nities and also establishes coordination among them. Health systems IMPAC aims at impro ing the access to health system and the impro ement of 8)ality of essential and emergency care. This ob9ecti e in ol es national health policy and district le el management of infrastr)ct)re, s)pplies and financing. <)rther it incl)des the assessment of local needs and s)r eillance of health system performance. Health workers Impro ement of the s(ills and competence of health care !or(ers is the second strategy of the IMPAC approach !hereby clinical g)idelines for care before, d)ring and after birth are pro ided. It also cooperates !ith other health programs to integrate f)rther ser ices into antenatal care, for e+ample the pre ention of $I= mother"to"child transmission (PMTCT) or malaria treatment. Family and community Deep"rooted c)lt)ral beliefs in families and comm)nities greatly infl)ence !omen&s decision !hether she see(s s(illed care d)ring pregnancy and childbirth. To increase the )tili:ation of a ailable health ser ices, comm)nities can offer health ed)cation as !ell as logistic or financial s)pport. Figure sho!ing different targets of IMPAC* health systems, health !or(ers s(ills, and family ; comm)nity

Development of Standards for Maternal and Neonatal Care: A Steering Committee and a Standards Development dvisory !roup !ere established. Drafts standards !ere de eloped internally by the technical staff in MP3 in cons)ltation !ith additional e+perts from the Department of >eprod)cti e $ealth and >esearch (>$>) and e+perts e+ternal to #$%. These drafts !ere then shared !ith other rele ant departments, incl)ding Child and Adolescent $ealth and De elopment (CA$)7 3top T'7 ?lobal Malaria Program (?MP)7 $I=1AID37 @)trition for $ealth and De elopment (@$D)7 Imm)ni:ation, =accines and 'iologicals (I=')7 Technical Cooperation for 0ssential Dr)gs and Traditional Medicine ($TP1TCM)7 0ssential $ealth Technologies7 $ealth Policy, de elopment and 3er ices ($D3)7 and $)man >eso)rces for $ealth ($>$) for ens)ring technical acc)racy and consistency !ith other #$% programs. 3tarting from their early de elopment stage the drafts !ere also shared !ith #$% >egional offices and MP3 co)ntry focal points, to gather inp)t on their applicability in different conte+ts. Additional inp)ts ha e been re8)ested from e+ternal e+perts and instit)tions thro)gho)t the entire de elopment process. The Clinical 3tandards and the $ealth ser ice Deli ery !ere re ie!ed in a technical cons)ltation in ?ene a in 5//5 and 5//A respecti ely. Three guiding principles !ere )sed in the selection of the topics* ,. P)blic health rele ance, as ma9or ca)ses of maternal, fetal or neonatal mortality and1or morbidity7 5. <easibility of implementation at first le el facilities in settings !ith limited reso)rces, both from the health ser ice deli ery and comm)nity perspecti e7 B. Cost implications, s)ch as cost"effecti eness. To de elop the standards, a systematic process and methodology for gathering and s)mmari:ing the e idence !as de eloped. <or the Clinical 3tandards the follo!ing so)rces !ere )sed*

Medline, 0mbase, and Cinhal, the Cochrane Cibrary, Medline and the #$% >eprod)cti e $ealth Cibrary, #$% p)blications based on technical !or(ing gro)ps and e+pert re ie!s, and a n)mber of articles and !ebsites based on reference lists re ie! and #$% g)idelines. <or the $ealth 3er ice Deli ery 3tandards the search incl)ded* P)bMed, 3ciencedirect, 0conCit, Interscience, Popline, ID0A, and 0C%@base, as !ell as the databases of rele ant organi:ations, departments, and instit)tions, s)ch as the #orld $ealth %rgani:ation, #orld 'an(, 3a e the children and others as identified by the standards de elopment s)bgro)p. WH !ecommended Interventions for Improving Maternal and Ne"#orn Healt$ Maternal and ne!born health care programs sho)ld incl)de (ey inter entions to impro e maternal and ne!born health and s)r i al. The follo!ing fi e tables incl)de these (ey inter entions to be deli ered thro)gh health ser ices, family and the comm)nity. %a#le & lists inter entions deli ered to the mother d)ring pregnancy, childbirth and in the postpart)m period, and to the ne!born soon after birth. These incl)de important pre enti e, c)rati e and health promotional acti ities for the present as !ell as the f)t)re. "outine essential care# Care to all !omen and babies Situational care# Care dependent on disease patterns in the comm)nity. Additional care# Care to !omen and babies !ith moderately se ere diseases or complications Speciali$ed care# Care to !omen and babies !ith se ere diseases or complications. %a#le &' Care in pregnancy( c$ild#irt$ and postpartum period for mot$er and ne"#orn infant
!outine care (offered to all !omen and babies) Additional care (for !omen and babies !ith moderately se ere diseases and complications) Speciali)ed * o#stetrical and neonatal care (for !omen and babies !ith se ere diseases and complications)

Pregnancy care * A isits %ssential

D Confirmation of pregnancy D Monitoring of progress of pregnancy and assessment of maternal and fetal !ell"being D Detection of problems complicating

D Treatment of mild to moderate pregnancy complications* " mild to moderate anaemia " )rinary tract infection " aginal infection D Post abortion care and family planning D Pre"referral treatment of

D Treatment of se ere pregnancy complications* " anaemia " se ere pre"eclampsia " eclampsia " bleeding

pregnancy (e.g., anaemia, hypertensi e disorders, bleeding, malpresentations, m)ltiple pregnancy D >espond to other reported complaints. DTetan)s imm)ni:ation, anaemia pre ention and control (iron and folic acid s)pplementation) D Information and co)nselling on self care at home, n)trition, safer se+, breastfeeding, family planning, healthy lifestyle D 'irth and emergency planning, ad ice on danger signs and emergency preparedness D >ecording and reporting D 3yphilis testing

se ere complications " pre"eclampsia " eclampsia " bleeding " infection " complicated abortion D 3)pport for !omen !ith special needs e.g. adolescents, !omen li ing !ith iolence D Treatment of syphilis (!oman and her partner)

" infection " other medical complications D Treatment of abortion complications

Situational

D $I= testing and co)nselling D Antimalarial Intermittent pre enti e treatment (IPT) and promotion of insecticide treated nets (IT@) D De!orming

D Pre ention of mother to child transmission of $I= (PMTCT) by antiretro iral treatment (A>T), infant feeding co)nselling, mode of deli ery

D Treatment of se ere $I= infection D Treatment of complicated malaria

D Assessment of female genital m)tilation (<?M)

ad ice D Treatment of mild to moderate opport)nistic infections D Treatment of )ncomplicated malaria

C$ild#irt$ Care (labo)r, deli ery, and immediate postpart)m) %ssential

D Care d)ring labo)r and deli ery " Diagnosis of labo)r " Monitoring progress of labo)r, maternal and fetal !ell"being !ith partograph " Pro iding s)pporti e care and pain relief " Detection of problems and complications (e.g. malpresentations, prolonged and1or obstr)cted labo)r, hypertension, bleeding, and infection) " Deli ery and immediate care of the ne!born baby, initiation of breastfeeding " @e!born res)scitation " Acti e management of third stage of labo)r D Immediate postpart)m care of

D Treatment of abnormalities and complications (e.g. prolonged labo)r, ac))m e+traction7 breech presentation, episiotomy, repair of genital tears, man)al remo al of placenta) D Pre"referral management of serio)s complications (e.g. obstr)cted labo)r, fetal distress, preterm labo)r, se ere peri" and postpart)m haemorrhage) D 0mergency management of complications if birth imminent D 3)pport for the family if maternal death

D Treatment of se ere complications in childbirth and in the immediate postpart)m period, incl)ding caesarean section, blood transf)sion and hysterectomy)* " obstr)cted labo)r " malpresentations " eclampsia " se ere infection " bleeding D Ind)ction and a)gmentation of labo)r

mother " Monitoring and assessment of maternal !ell being, pre ention and detection of complications (e.g. hypertension, infections, bleeding, anaemia) " Treatment of moderate posthaemorrhagic anaemia " Information and co)nselling on home self care, n)trition, safe se+, breast care and family planning " Ad ice on danger signs, emergency preparedness and follo!")p D >ecording and reporting

Situational

D =itamin A administration

D Pre ention of mother"to"child transmission of $I= by mode of deli ery, g)idance and s)pport for chosen infant feeding option

D Management of complications related to <?M

Postpartum maternal care ()p to 4 !ee(s)

D Assessment of maternal !ellbeing D Pre ention and detection of complications (e.g. infections, bleeding,

D Treatment of some problems (e.g. mild to moderate anaemia, mild p)erperal

D Treatment of all complications " se ere anaemia " se ere postpart)m bleeding

%ssential

anaemia) D Anaemia pre ention and control (iron and folic acid s)pplementation) D Information and co)nselling on n)trition, safe se+, family planning and pro ision of some contracepti e methods D Ad ice on danger signs, emergency preparedness and follo!")p D Pro ision of contracepti e methods

depression) D Pre"referral treatment of some problems (e.g. se ere postpart)m bleeding, p)erperal sepsis)

" se ere postpart)m infections " se ere postpart)m depression D <emale sterili:ation

Situational

D Promotion of IT@ )se

D Treatment of )ncomplicated malaria

D Treatment of complicated malaria

Ne"#orn care (birth and immediate postnatal) %ssential

D Promotion, protection and s)pport for breastfeeding D Monitoring and assessment of !ellbeing, detection of complications (breathing, infections, premat)rity, lo! birth!eight, in9)ry, malformation) D Infection pre ention and control, rooming"in

D Care if moderately preterm, lo! birth !eight or t!in* s)pport for breastfeeding, !armth, fre8)ent assessment of !ellbeing and detection of complications e.g. feeding diffic)lty, 9a)ndice, other perinatal problems D Eangaroo Mother Care follo!")p D Treatment of mild to moderate

D Management of se ere ne!born problems " general care for the sic( ne!born and management of specific problems* " preterm birth " breathing diffic)lty " sepsis " se ere birth tra)ma and asphy+ia " se ere 9a)ndice

D 0ye care D Information and co)nselling on home care, breastfeeding, hygiene D Ad ice on danger signs, emergency preparedness and follo!")p D Imm)ni:ation according to the national g)idelines ('C?, $ep', %P="/)

" local infections (cord, s(in, eye, thr)sh) " birth in9)ries D Pre"referral management of infants !ith se ere problems* " ery preterm babies and1or birth !eight ery lo! " se ere complications " malformations D 3)pporting mother if perinatal death.

" Eangaroo Mother Care (EMC) D Management of correctable malformations

Situational

D Promotion of sleeping )nder IT@

D Pres)mpti e treatment of congenital syphilis D Pre ention of mother"to"child transmission of $I= by A>T D 3)pport for infant feeding of maternal choice

D Treatment of* " congenital syphilis " neonatal tetan)s

Postnatal ne"#orn care ( isit from1at home) %ssential

D Assessment of infantFs !ellbeing and breastfeeding D Detection of complications and responding to maternal concerns D Information and co)nselling on home

D Management of* " minor to moderate problems and " feeding diffic)lties D Pre"referral management of se ere problems*

D Management of se ere ne!born problems* " sepsis " other infections " 9a)ndice " fail)re to thri e

care D Additional follo!")p isits for high ris( babies (e.g. preterm, after se ere problems, on replacement feeding)

" con )lsions " inability to feed D 3)pporting the family if perinatal death

%a#le + lists the places !here care sho)ld be pro ided thro)gh health ser ices, the type of pro iders re8)ired and the recommended inter entions and commodities at each le el. %a#le +' Place of care( providers( interventions and commodities
Healt$ care ,evel of $ealt$ care -enue . place Provider Interventions and commodities

Pregnancy /antenatal0 care

!outine

Primary

D $ealth centre in the comm)nity D %)tpatient clinic of a hospital D %)treach home isit

D $ealth !or(er !ith mid!ifery s(illsG

D %n site tests ($b, syphilis) D Maternal health record D =accine D 'asic oral medicines

Situational

Primary

D $ealth centre in the comm)nity D %)tpatient clinic of a hospital D %)treach home isits

D $ealth !or(er !ith mid!ifery s(illsG

D %n site tests ($I=) D Insecticide treated nets (IT@)

Additional

Primary

D $ealth centre in the comm)nity

D $ealth !or(er !ith

D I= fl)ids

D %)tpatient clinic of a hospital

mid!ifery and selected obstetric and neonatal s(illsG

D Parenteral dr)gs (antibiotics, Mg3%A, antimalarial) D Man)al =ac))m Aspiration (M=A) D Anti"retro iral therapy (A>T)

Speciali)ed

Secondary

D $ospital

D Team of doctors, mid!i es and n)rses

All of the abo e pl)s* D 'lood transf)sion D 3)rgery D Caboratory tests D %bstetric care

C$ild#irt$ /mot$er and #a#y0

!outine

Primary

D $ealth centre in the comm)nity D Maternity !ard of a hospital D %)treach home care

D $ealth !or(er !ith mid!ifery s(illsG

D Deli ery set D %+ytocin D Partograph

Situational

Primary

D $ealth centre in the comm)nity D Maternity !ard of a hospital D %)treach home care

D $ealth !or(er !ith mid!ifery s(illsG

D A>T

Additional

Primary

D $ealth centre in the comm)nity D Maternity !ard of a

D $ealth !or(er !ith mid!ifery and selected obstetric and

D =ac))m e+traction D Man)al remo al of placenta

hospital

neonatal s(illsG

D >epair of genital tears D I= fl)ids D Mg3%A, parenteral )terotonics, and antibiotics D @e!born res)scitation

Speciali)ed Mot$er

Secondary

D $ospital

D Team of doctors, mid!i es and n)rses !ith neonatal care s(ills

All of the abo e pl)s* D 3)rgery D 'lood transf)sion

Speciali)ed Ne"#orn

Secondary

D $ospital

D Team of doctors and n)rses !ith obstetric and n)rsing s(ills

D %+ygen D I= fl)ids D Parenteral antebiotics D 'lood transf)sion D Caboratory " biochemical and microbiology (small blood samples)

Postpartum /mot$er0( postnatal /ne"#orn infant0

!outine

Primary

D $ealth centre in the comm)nity D %)tpatient clinic of a hospital D %)treach home isit

D $ealth !or(er !ith mid!ifery s(illsG

D %n site tests ($b, syphilis) D =accines D 'asic oral medicines

Situational

Primary

D $ealth centre in the comm)nity D %)tpatient clinic of a hospital

D $ealth !or(er !ith mid!ifery s(illsG

D %n site tests ($I=) D A>T

Additional

Primary

D $ealth centre in the comm)nity D %)tpatient clinic of a hospital

D $ealth !or(er !ith mid!ifery and selected obstetric and neonatal s(illsG

D I= fl)ids D Parenteral dr)gs (antibiotics, Mg3%A, antimalarial) D Man)al remo al of placenta

Speciali)ed Mot$er

Secondary

D $ospital

D Team of doctors, mid!i es and n)rses

All of the abo e pl)s* D 'lood transf)sion D 3)rgery D Caboratory tests D %bstetric care

Speciali)ed Ne"#orn

Secondary

D $ospital

D Team of doctors, mid!i es and n)rses !ith neonatal s(ills

D %+ygen D I= fl)ids D Parenteral antebiotics D 'lood transf)sion D Caboratory " biochemical and microbiology (small samples)

G $ealth !or(er pro iding maternity care only or a health !or(er pro iding other ser ices in addition to maternity care %a#le 1 lists practices, acti ities and s)pport needed d)ring pregnancy and childbirth by the family, comm)nity and !or(place.

%a#le 1' Home care( family( community and "orkplace support for t$e "oman during pregnancy and c$ild#irt$ and for t$e ne"#orn infant
Home.family Community and "orkplace

Pregnancy

D 3afe and n)triti e diet D 3afe se+)al practices D 3)pport for 8)itting smo(ing D Protection from passi e tobacco smo(ing D 3)pport for a oiding hard !or( D Planning for birth, and emergencies "mother and baby D Eno!ledge and s)pport for the birth and emergency plan D >ecognition of labo)r and danger signs D 3)pport for compliance !ith pre enti e treatments D 3)pport 1 accompaniment for pregnancy care isits D Adolescent girls enco)raged to contin)e going to school D Participation in impro ing 8)ality of ser ices D Participation in transport and financing scheme

D Maternity protection D Time off for antenatal care isits D 3afe and clean !or(place D Tobacco free !or(ing en ironment D Pregnant adolescents (ept at school

Situational

D 3)pport for ta(ing A>T and for coping !ith its side effects

D 3)pport for $I= positi e !omen

C$ild#irt$

D Accompanying and s)pporting the !oman in childbirth D 3)pport and care for the rest of the family D %rgani:e transport and financial s)pport

D 3)pport for the family d)ring childbirth and immediate postpart)m

Postpartum and #eyond

D 3)pport for e+cl)si e breastfeeding1replacement feeding D Personal hygiene D 3afe disposal 1 !ashing of pads D 3)pport for rest and less !or( load D 3afe and n)triti e diet D 3afe se+)al practices D Moti ation for prescribed treatments D >ecognition of dangers signs, incl)ding bl)es 1 depression D %ptimal pregnancy spacing D >eporting birth and death ( ital registration) D Participation in impro ing 8)ality of ser ices D Participation in transport and financing scheme

D Maternity lea e D 'reastfeeding brea(s D Time off for postpart)m and baby care isits D If mother referred to hospital, s)pport that she is accompanied !ith the baby

Ne"#orn and young infant

D 0+cl)si e breastfeeding D $ygiene (cord care, !ashing, clothes) D A oiding contacts !ith sic( family members D Clean, !arm and 8)iet place, tobacco and fire smo(e free D 0+tra care for small babies (preterm, lo! birth !eight) incl)ding EMC D 3)pport for ro)tine and follo! )p isits D Moti ation for home treatment of minor problems D >ecognition of danger signs D 3afe disposal of baby stool D Care see(ing at health facility or hospital

D Promotion, protection and s)pport for breast feeding. D Eeeping mother !ith the baby in hospital for breastfeeding D 3)pporting the family d)ring maternal absence D 3)pport for referral care for sic( ne!born.

Situational

D 3leeping )nder IT@

%a#le 2 lists (ey inter entions pro ided to !omen before conception and bet!een pregnancies. %a#le 2' Care for t$e "oman #efore and #et"een pregnancies
Care #y $ealt$ services Home.family Community and "orkplace D 0d)cation D Information on pre ention of $I= and 3TI infections

Adolescence

D Imm)ni:ation according to national policy (tetan)s and r)bella) D <amily planning D $I= pre ention incl)ding =CT

D Delayed childbearing D $ealthy lifestyle D 'alanced diet, incl)ding iodi:ed salt

All "omen of reproductive age

D <amily planning D Assessment and management of 3TIs D $I= pre ention incl)ding testing and co)nselling

D %ptimal pregnancy timing

%a#le 3 addresses )n!anted pregnancies. %a#le 3' Pregnant "omen not "anting c$ild
Care #y $ealt$ services Home.family Community and "orkplace

Pregnant "oman not "anting c$ild

D 3afe abortion (!here legal) D Post"abortion care and family planning

D Care for )n!anted pregnancy

Principles of good care: Principles to be follo!ed thro)gho)t ser ice deli ery" Communication" Comm)nicating !ith the !oman (and her companion), pri acy and confidentiality, prescribing and recommending treatments and pre enti e meas)res for the !oman and1or her baby. Workplace and administrative procedures3er ice ho)rs sho)ld be clearly displayed, be p)nct)al of time, chec( e8)ipment, cleanliness maintenance, proper !aste disposal, hand o er essential information to the colleag)e !ho follo!s on d)ty, maintain records, smo(e free en ironment, no ad ertisement of form)la feed. Standard precautions and cleanliness" #ash hands, !ear glo es, protect yo)rself from blood and other body fl)ids d)ring deli eries, practice safe sharps ; !aste disposal, deal !ith contaminated la)ndry, sterili:e and clean contaminated e8)ipment, glo es.
Organizing a visit" >ecei e e ery !oman and ne!born baby see(ing care immediately after arri al, perform H)ic( Chec( on all incoming !omen and babies, begin each emergency1ro)tine care isit, introd)ce self, as( name, as( problems, e+plain all proced)res, as( permission before )nderta(ing an e+amination or test or any emergency proced)re, (eep the !oman1 relati e informed thro)gho)t, disc)ss findings !ith her (and her partner), ens)re pri acy d)ring the e+amination and disc)ssion.

t the end of the visit "As( the !oman if she has any 8)estions. "3)mmari:e the most important messages !ith her. "0nco)rage her to ret)rn for a ro)tine isit (tell her !hen) and if she has any concerns. "<ill the $ome"'ased Maternal >ecord ($'M>) and gi e her the appropriate information sheet. "As( her if there are any points !hich need to be disc)ssed and !o)ld she li(e s)pport for this. 4lo"*c$art to #e follo"ed during services: A person responsible for initial reception of !omen of childbearing age and ne!borns see(ing care sho)ld* assess the general condition of the caresee(er(s) immediately on arri al periodically repeat this proced)re if the line is long. If a !oman is ery sic(, tal( to her companion.

A3E, C$0CE >0C%>D

C%%E, CI3T0@, 3I?@3 <00C

CCA33I<I

T>0AT

J #hy did yo) comeK L for yo)rselfK L for the babyK J $o! old is the babyK J #hat is the concernK

Is the !oman If the !oman is or being !heeled or has* carried in or* J bleeding aginally J con )lsing J loo(ing ery ill J )nconscio)s J in se ere pain J in labo)r J deli ery is imminent J )nconscio)s (does not ans!er) J con )lsing J bleeding J se ere abdominal pain or loo(s ery ill J headache and is)al dist)rbance J se ere diffic)lty breathing J fe er J se ere omiting.

0mergency <%> #%MA@

J Transfer !oman to a treatment room for >apid assessment and management 'B"'M . J Call for help if needed. J >eass)re the !oman that she !ill be ta(en care of immediately. J As( her companion to stay.

J Imminent deli ery or J Cabo)r

Cabo)r

J Transfer the !oman to the labo)r !ard. J Call for immediate assessment.

If the baby is or has* J ery small J con )lsions Chec( if baby is or has* J ery small J con )lsing J breathing diffic)lty J diffic)lt breathing J 9)st born J any maternal concern.

0mergency for baby

J Transfer the baby to the treatment room for immediate @e!born care J,"J,, . J As( the mother to stay.

J Pregnant !oman, or after deli ery, !ith no danger signs J A ne!born !ith no danger signs or maternal complaints.

>o)tine care J Eeep the !oman and baby in the !aiting room for ro)tine care.

I< emergency for !oman or baby or labo)r1 no emergency, go to rele ant section

Making pregnancy safer in India

%$e Maternal Healt$ situation in India 0ach year in India, ro)ghly B/ million !omen e+perience pregnancy and 54 million ha e a li e birth (M%$<#, 5//4). #ith an estimated MM,/// deaths per ann)m, India contrib)tes to a ma9ority of maternal mortality b)rden in the region. Maternal mortality ratio, an important indicator of maternal health in India is estimated to be B/,1,//,/// li e births. Ma9or ca)ses of maternal mortality in India remain hemorrhage (B62), sepsis (,,2), Abortions (62), hypertensi e disorders (.2), obstr)cted labo)r (.2) and other

conditions incl)ding anemia, medical disorders d)ring pregnancy contrib)ting to BA2 of all maternal deaths (>?I"3>3 5//4). >egional disparities in maternal and neonatal mortality are !ide !ith states li(e Eerala ha ing an MM> of ,,/1,//,/// li e births )nli(e Nttar Pradesh !ith .,M1,//,///. It is also recogni:ed that delays in accessing speciali:ed maternal care happen at all le els leading to maternal mortality and se ere morbidity. The healthcare indicator )sed to monitor the process of red)cing maternal mortality is the proportion of deli eries attended by a s(illed birth attendant. At present, only A62 of all births are attended by s(illed health professionals !ith only A,2 instit)tional deli eries (@<$3 B). It is recogni:ed that in order to f)rther impro e maternal and ne!born health by red)cing mortality and morbidity related to pregnancy and child birth, it is essential to b)ild continuum of care that increases access to and )se of s(illed care d)ring pregnancy, birth and the post part)m period.

Specific Areas of %ec$nical Assistance provided #y WH : ,.Ad ocacy and Policy De elopment 5.De elopment of technical and operational g)idelines 3. Technical contrib)tions for de elopment of training and reading material for A@Ms1C$=s, 3taff @)rses, Medical %fficers, A3$A A.Dissemination of g)idelines and facilitating planning at state le el Partners: ?o ernment, N@ Agencies, #$% Collaborating Centre and Centres for 0+cellence, Professional Associations, @?%s &' Advocacy and Policy Development

#$% contin)ed ad ocacy for e idence based strategy of Os(illed attendance at birth. This contrib)ted to identification of s(illed birth attendance both at instit)tion and comm)nity, one of the (ey strategies of >C$"II. To empo!er the peripheral health f)nctionaries, especially A@Ms, certain life sa ing s(ills and )se of dr)gs as emergency obstetric first aid has been permitted to A@Ms, e.g. Nse of tablet misoprostol for pre ention of PP$ and In9ection o+ytocin for treatment of PP$, In9ection Magnesi)m 3)lphate for treatment of 0clampsia. #$% !as identified as lead De elopment Partner )nder >C$"5 to s)pport the de elopment of technical g)idelines especially on 3(illed Attendance at birth and 0mergency %bstetrics Care . 0+tensi e contrib)tions !ere made by the technical team at N@<PA, India thro)gho)t the process. In addition, this e+ercise !as f)rther facilitated and s)pported by #hite >ibbon Alliance of India.

Another significant contrib)tion !as the introd)ction of maternal death re ie!s !hich !ere en isaged as a tool for in"depth analysis in the factors (a oidable1 remediable) responsible for maternal mortality. Thro)gh a m)lti site demonstration of )se of safe techni8)es for abortion (Man)al =ac))m Aspiration, M=A) at Primary $ealth Centres, #$% assisted the go ernment !ith the e+pansion of safe abortion ser ices at P$C and mainstreaming the same in >C$"5. Technical assistance !as pro ided in carrying the amendments in the MTP Act.

+'

Development of tec$nical and operational guidelines:

#$%, India, s)pported the Maternal $ealth Di ision of Department of <# in establishing the 0+pert ?ro)ps. The ser ices of cons)ltants !ere hired to coordinate the de elopment of ser ice g)idelines and treatment protocols. It is note!orthy that #$% IMPAC series has been e+tensi ely referenced and )sed for adaptation and de elopment of these g)idelines. In close partnership !ith N@<PA, N@IC0< and #>AI, the de elopment of follo!ing g)idelines !as facilitated Antenatal Care (A@C) and s(illed birth attendance at birth for A@M1C$=s @ormal deli ery and management of obstetric complications at P$Cs1C$C by M% Cife sa ing anaesthetic s(ills for 0m%C by M''3 doctors

?)idelines for operationalising <irst >eferral )nits (<>N)

?)idelines for operationalising 5A ho)rs f)nctioning P$Cs ?)idelines for establishing blood storage at <>N Ma(ing Pregnancy 3afer strategy )nder >C$"II De elopment of @ational ?)idelines for pre ention and management of >TI13TI* In collaboration !ith #$%CC, @ational Instit)te of >esearch in >eprod)cti e $ealth, #$%, India s)pported the de elopment of g)idelines !hich are e+pected to be follo!ed both )nder >C$"5 and @ACP"B. 1' %ec$nical contri#utions to"ards development of training and reading material for ASHA #$% in partnership !ith N@<PA s)pported and contrib)ted technically in the re ie! and de elopment of training and reading material for A3$A. 2' Dissemination of guidelines and facilitating planning at state level

#$% pro ided the s)pport for disseminating the g)idelines to ario)s states and also in de eloping their plans for implementation for maternal health inter entions. The state planning

meetings ha e been facilitated especially !ith the p)rpose of ta(ing the s(illed birth attendant training, emergency obstetric care training and also training for life sa ing anaesthetic s(ills for M''3 doctors.

!eferences: 1. Integrated Management of Pregnancy and Childbirth (IMPAC) ?)idelines. Pregnancy, childbirth, postpart)m and ne!born care* a g)ide for essential practice. #$% ?ene a 5//4. 5. Integrated Management of Pregnancy and Childbirth. #$% >ecommended Inter entions for Impro ing Maternal and @e!born $ealth. #$% ?ene a 5//M.

B. Integrated Management of Pregnancy and Childbirth. 3tandards for maternal and neonatal care. #$% ?ene a 5//M. 4. Integrated Management of Pregnancy and Childbirth. 'eyond the @)mbers* >e ie!ing maternal deaths and complications to ma(e pregnancy safer. #$% ?ene a 5//M.