MAT ERNAL

AND NEWBORN
Maternal, Newborn, and Child health and Nutrition Strategy

• The Maternal Newborn Child Health and Nutrition (MNCHN) Strategy

calls for coordinated actions with the end goal of improving women
and children’s health and consequently effecting a rapid reduction in
the maternal, newborn and child mortalities towards attaining MDGs 4
and 5 within the set time frame.

• With this call to act, the Department of Health commits to assist

LGUs upgrade their proposed health facilities to EmONC (Emergency
Obstetric and Newborn Care) standard, a major MNCHN initiative.

• The package of services provided to mothers, newborn and children

follows an integrated approach to service delivery that seeks to
maximize client visits, avoid missed opportunities, and ensure cost-
effectiveness in the delivery of critical
interventions.
DEFINITION OF TERMS

ANTENATAL CARE COVERAGE

An indicator of access and use of health care during pregnancy. It
constitutes screening for health and socioeconomic conditions likely to
increase the possibility of specific adverse pregnancy outcomes,
providing therapeutic interventions known to be effective; and educating
pregnant women about planning for safe childbirth (facility-based
deliveries), emergencies during pregnancy and how to deal with them.
(WHO; Indicator Definitions and Metadata 2008)
BASIC EMERGENCY OBSTETRICS AND NEWBORN CARE (BEMONC)
- Provider is a capable private health facility or an appropriately
upgraded public health facility that is either a Rural Health Unit
(RHU) and/or its satellite Barangay Health Station (BHS) or Hospital
capable of performing the following emergency obstetric functions:
1. Parenteral administration of oxytocin in the third stage of labor; Parenteral
administration of loading dose of anti-convulsants;
2. Parenteral administration of initial dose of antibiotics;
3. Performance of assisted deliveries in imminent breech;
4. Removal of retained placental products ;
5. Manual removal of retained placenta. It is also capable of providing neonatal
emergency interventions, which include at the minimum, newborn resuscitation,
provision of warmth, and referral.

The hospital BEmONC shall also be capable of providing blood transfusion services. These
facilities can likewise serve as high volume providers for IUD (intra-uterine device) and
VSC(voluntary surgical contraception) services. It can also be a single or stand alone
facility or
part of a network of facilities in an inter-local health zone.
COMPREHENSIVE EMERGENCY OBSTETRICS AND NEWBORN CARE (CEMONC)
PROVIDER
is a tertiary level regional hospital or medical center, provincial hospital or an
appropriately upgraded district hospital. It can also be a capable privately
operated medical center. It is capable of performing emergency obstetric
functions as in BEmONC provider facilities, as well as provides surgical delivery
(caesarean section) and blood bank transfusion services, and other highly
specialized obstetric interventions. It is also able to provide emergency neonatal
care, which include the minimum:

1. Newborn resuscitation;
2. Treatment of neonatal sepsis/infection
3. Oxygen support; and,
4. Antenatal administration of (maternal) steroids for threatened premature
delivery. It can also serve as high volume providers for intra-uterine
device (iud) and voluntary surgical contraception (VSC) services.
CONTRACEPTIVE PREVALENCE RATE (CPR)
-is the proportion of women age 15-49 years
reporting current use of a modern method of family planning, i.e. pill, IUD,
injectables, condom, mucus method, basal body temperature method, standard
days method (SDM), and lactational amenorhea method (LAM).

HIGH VOLUME PROVIDERS FOR IUD AND VSC

-are RHUs (for IUDs) and hospitals (for IUDs and VSCs) and accredited private
clinics having sufficient case load to maintain a certain level of proficiency,
about 1-2 per day or more so that the service is part of a sustainable practice
and receive appropriate support from the LGUs.

INFANT MORTALITY RATE

-refers to the number of infants dying before reaching the age of one year per
1,000 live births in a given year. It represents an important component of under-
five mortality rate.
INTEGRATED MNCHN SERVICE
-is a package of services for women and children covering a
spectrum of known cost-effective public health and clinical management measures capable
of reducing exposure to and the severity of risks for maternal and neonatal deaths, as well
as preventing their direct causes, that are within the capacity of the health system to
routinely provide.

MATERNAL MORTALITY RATIO (MMR)

-refers to the number of women who die from any
cause related to or aggravated by pregnancy or its management (excluding accidental or
incidental causes) during pregnancy and childbirth or within 42 days of termination of
pregnancy, irrespective of the duration and site of the pregnancy, per 100,000 live births.

MATERNAL, NEONATAL AND CHILD HEALTH AND NUTRITION (MNCHN) SERVICE DELIVERY
NETWORK
-refers to the network of facilities and providers within a province and (chartered)
city health system offering integrated MNCHN services in a coordinated manner, including
the supporting financing, communication and transportation systems. Such network
includes the BEmONC-CEmONC network (a network of facilities providing emergency
obstetric and newborn care) and matches the Inter-Local Health Zone (ILHZ) arrangement.

NEONATAL MORTALITY RATE

-refers to the number of deaths within the first 28 days of life
per 1000 live births in a given period. It serves as an indicator of maternal and neonatal
health care.
PROVINCE AND CITY HEALTH SYSTEMS
-refer to an organized scheme for delivering health
services including the integrated MNCHN service package in a contained geographic area
covering an entire province and city. It is divided into small sub-systems consisting of public
and private providers organized into Inter-Local Health Zones (ILHZ).

SERVICE DELIVERY GAP REFERS

-to the “weak links” in the MNCHN service delivery chain
that significantly contribute to the maternal and neonatal mortalities in an identified area.

SERVICE UTILIZATION GAP

-refers to barriers to consumption of health services that
significantly contribute to poor health outcomes.

SKILLED HEALTH PROFESSIONAL

-refers to a doctor, nurse, or midwife with proficiency in
managing pregnancy and childbirth including the appropriate management of complications
that might occur. These professionals have complimentary proficiencies and should work as
a team towards a coordinated effort in the initiative of saving lives of women and
newborns.

TRADITIONAL BIRTH ATTENDANTS (TBAS)

-are independent, non-formally trained
community-based providers of care during pregnancy, childbirth, and postpartum period
using conventional method. Under the MNCHN strategy, they are made part of the formal
health system as members of the community-based Women’s Health Teams and serve as
advocates for skilled professional care.
Four Key Strategies of MNCHN
[Link] universal access to and utilization of MNCHN core
package services and
[Link] directed not only to individual women of
reproductive age and newborns at different stages of the life
cycle.
[Link] of a service delivery network at all levels of care.
[Link] use of instruments for health systems development
[Link] build-up of institutional capacities of DOH and
PhilHealth.
MNCHN aims to achieve the following intermediate results:
1. Every pregnancy is wanted, planned, and supported
2. Every pregnancy is adequately managed throughout its
course.
3. Every delivery is facility-based and managed by skilled birth
attendants or skilled health professionals
4. Every mother-and-newborn pair secures proper postpartum
and newborn care with smooth transition to women’s health
care package for the mother and child survival package for
the newborn.
Goals and Expected Outcomes
1.60% modern contraceptive prevalence rate (CPR) by 2010; 80% by
2015 (baseline, 2006 FPS, : 35.9%).
2.80% of pregnant women with at least 4 antenatal visits by 2010; 100%
by 2015 (baseline, 2003 NDHS: 70%).
3.80% facility-based deliveries by 2012; 90% by 2015 (baseline, 2003
NDHS: 39%).
4.50% of infants 4-5 months old are exclusively breastfed by 2010
(baseline, 2003 NDHS: 16%).
5.85% of newborns are screened for metabolic disorders by 2010 and
100% by 2015.
6.80% postpartum and postnatal visits done within the first week of
delivery by 2015(baseline, 2003 NDHS: 51%).
7.95% fully immunized children by 2010; 100% by 2015 (baseline, 2003
NDHS: 70%).
MNCHN core package of services
• A paradigm shift from the risk approach that focuses on
identifying pregnant women at risk of complications to one that
considers all pregnant women at risk of such complications. This
is mainly in response to findings that reveal the inability of
antenatal protocols to accurately predict the onset of
complications during childbirth (DOH,2009).

To assure the safety of mothers and newborns, the following

standards of care must be delivered in all facilities within the
MNCHN service delivery Network.
A. BASIC EMERGENCY OBSTETRIC AND NEWBORN CARE
(BEmONC) PROVIDER FACILITIES:
These facilities are upgraded or enhanced Barangay Health
Station (BHS), Rural Health Unit (RHU), District and Community
Hospitals that are required to provide the following services:
Prepregnancy package
1. Nutrition
• Nutritional counselling
• Promotion of use of iodized salt
• Micronutrient supplementation consisting of important minerals and vitamins
such as zinc, iodine, calcium, vitamin A capsules and iron tablets-
o Iron and folate: 60 mg elemental iron/400 microgram ; folic acid 1 tablet daily
for 3-6 months.
o Vitamin A at least 5000IU every week ( a daily multivitamin supplement
maybe taken as option when the required vitamin A is not available).
o Promotion of use of iodized salt.
2. Promotion of healthy lifestyle including advice relative to
smoking cessation, healthy diet, regular exercise, and
moderate alcohol drinking
3. Advice on family planning and provision of family planning
services
4. Prevention and management of lifestyle-related diseases
like diabetes and cardiovascular disease
5. Prevention and management of infection, including
deworming of women of reproductive age to reduce other
causes of iron deficiency anemia
6. Counseling on STD/HIV/AIDS, nutrition, personal hygiene,
and consequences of abortion
7. Adolescent health services.
8. Provision of oral health services.
Prenatal Package
The pregnant woman who avails of the prenatal package obtains adequate care.
1. Prenatal visits
• At least four visits throughout the course of pregnancy: at least one visit in the first
and second trimesters and at least two visits in the third trimester.
• Prenatal assessment
o Monitoring of height and weight
oTaking the blood pressure
o Screening and blood testing including Complete Blood Count, blood
o Typing, urinalysis, VDRL or RPR, HbSAg, blood sugar screening, pregnancy test
cervical cancer screening using acetic acid wash and papanicolau smear.
o Micronutrient supplementation (iron, folate and Vitamin A supplementation)
o Malaria prophylaxis where appropriate
o Deworming
o Birth planning
2. Micronutrient supplementation
o Iron and folate ( 60mg/40mcg)once a day for 6 months or 180 tabs;
o Vitamin A 10,000 IU twice a week from the fourth month of pregnancy
o Elemental iodine 200 mg given once during the pregnancy.

3. Tetanus toxoid (TT) immunization

o 0.5ml of TT in injected IM on the deltoid muscle.
o Adequate immunization of women with TT prevents tetanus in both the
mother and the newborn. The newborn develops protection through
passive immunity as maternal antibodies pass through the placenta into
the fetal circulation.`
4. Promotion of exclusive breastfeeding, newborn screening
(NBS) and infant immunization.
5. Counseling on healthy lifestyle with focus on smoking
cessation, healthy diet and nutrition, regular exercise, STI and
HIV prevention and oral health.
6. Early detection and management of complications of
pregnancy.
7. Prevention and management of other conditions where
indicated: hypertension, anemia, diabetes, TB, malaria,
schistisomiasis and STI/HIV/AIDS
8. Birth planning and promotion of facility-based delivery.
In addition to her facility-based record, the Home-Based Mother's Record (HBMR) is used
when rendering care to the pregnant woman.
The HBMR is a simplified record of the history of present and past pregnancies, when
applicable, and the findings and measures of the TBA, BHW, or health professionals.
In the evaluation of the HBMR in eight countries, including the Philippines, Shah et al.
(1993) concluded that the HBMR:

[Link] a means of promoting continuity of care through a woman's

reproductive life;
[Link] early recognition of women who are at risk of developing conditions
like severe anemia, hypertension bleeding, and moderate-to-severe edema;
[Link] self-care where appropriate and referral suited to the needs of the
woman;
[Link] initiation of appropriate care according to the woman's identified
needs;
[Link] as a useful record of care and health information and source of health
statistics;
[Link] the health workers in providing for the health educational needs of the
client about risk and care during pregnancy and the periods in between
pregnancies, and care of the newborn and the postpartum.
Childbirth package
1. Skilled birth attendant/ skilled health professional- assisted
delivery and facility based deliveries including the use of
partograph. Most maternal deaths occur during labor or the first
24 hours postpartum, and most complications cannot be
predicted or prevented (DOH, 2011j). It is logical that the best
strategy to prevent maternal deaths is to promote facility-based
childbirth with a skilled health professional attendance
(Campbell and Graham, 2006).
2. Proper management of pregnancy and delivery complications
and newborn complications (DOH, 2011j). The DOH, PhilHealth,
and WHO recommend essential intrapartum an newborn care
(EINC) practices in hospitals and other birthing facilities in the
country.
EINC is called Unang Yakap. EINC practices during the intrapartum period consist of
measures that, based on scientific evidence, are necessary for safe and quality care of the
woman during childbirth. The recommended evidence-based practices include (DOH,
2011b):
• Continuous maternal support by having a companion of choice during labor and
delivery;
• Freedom of movement during labor;
• Monitoring progress of labor using the partograph; the partograph is a graphic recording
of the progress of labor and significant conditions of the mother and the fetus. It is
useful in detecting deviations from normal and in early decision-making on referral, etc.
(WHO, 1994). Figure 10.4 shows the modified WHO partograph;
• Nondrug pain relief before offering labor anesthesia;
• Position of choice during labor and delivery;
• Spontaneous pushing in a semi upright position;
• Hand hygiene;
• Nonroutine episiotomy; and
• Active management of the third stage of labor (AMTSL).

3. Access to basic emergency obstetric and newborn care ( BEmONC) or comprehensive

emergency obstetric and newborn care (CEmONC) services.
Postpartum package
[Link] visits: within 72hours and on the 7th day
postpartum check for conditions such as bleeding or
infections
[Link] supplementation – Iron, Folate, Vitamin
[Link] on nutrition, child care, family planning and
other available services
Newborn (first week of life) care package
Recommended EINC practices in the care of the newborn are
evidence-based measures that are vital for the survival and the
quality care of the newborn (DOH, 2011b).

1. Interventions within the first 90 minutes include the following

(DOH, 2011b):
a. Immediate and thorough drying, which does not only protect
the newborn from cold stress and hypothermia, but also
stimulates breathing. This is recommended as the immediate first
action for all newborns, regardless of gestational age or birth
weight.
b. Skin-to-skin contact between mother and newborn does not
only provide warmth and an opportunity for bonding. It plays a
part in protection of the newborn against infection and
hypoglycemia. Studies have shown that skin-to-skin contact at
birth helps in stabilizing the baby and promotes successful
breastfeeding by facilitating colostrum feeding.
c. Cord clamping 1-3 minutes after birth is recommended. The
customary cord clamping immediately after birth is not a
recommended practice in EINC because evidence shows that
delaying cord clamping by 1-3 minutes allows placental transfusion
at birth. This increases the newborn's blood volume and iron
reserves, and eventually reduces the likelihood of iron deficiency
anemia in infancy. Studies have also shown that delayed cord
clamping provides significant benefits to preterm infants by
reducing the need forblood transfusions and lowering the
incidence of brain hemorrhages.
d. Early initiation of breastfeeding means breastfeeding within
an hour after birth as recommended by WHO. This practice
brings about gains for both the mother
and the newborn. In developing countries, early initiation of
breastfeeding has been shown to reduceinfant deaths attributed
to diarrhea and lower respiratory tract infections. Benefits to the
mother include stimulation of oxytocin secretion resulting in
uterine contraction.

e. Nonseparation of baby from the mother (DOH, 2011j), also

known as rooming-in if the childbirth is in a hospital or a similar
health facility, promotes bonding and allows the mother to
breastfeed her baby on demand.
2. Essential newborn care after 90 minutes to 6 hours (DOH,
2011j):
a. Vitamin K prophylaxis;
b. Hepatitis B and BCG vaccination;
c. Examination of the baby for birth injuries, malformations, or
defects
d. Additional care for a small baby (a baby with a birth weight
<2,500 g) or twin.
3. Care prior to discharge: after the first 90 minutes (DOH, 2011j):
• Support unrestricted, per demand breastfeeding, day and night;
• Ensure warmth of the baby. The care of a preterm infant carried skin-to skin
with the mother, also known as kangaroo mother care (KMC), is an effective
way to meet the baby's needs for warmth, breastfeeding, protection from
infection, stimulation, safety, and love (WHO, 2003b).
• Washing and bathing (hygiene);
• Look for danger signs and start resuscitation, if necessary, keep warm, give
first 2 doses of IM antibiotics, give oxygen;
• Look for signs of jaundice and local infection;
• Perform newborn screening (blood spot) and newborn hearing screening (if
available);
• Provide instructions on discharge.
Child care package

1. Immunization (DOH, 2011j);

2. Nutrition (DOH, 2011j):
• Exclusive breastfeeding up to 6 months;
• Sustained breastfeeding up to 24 months with complementary feeding;
• Micronutrient supplementation
3. Integrated management of childhood illnesses (DOH, 2011);
4. Injury prevention (DOH, 2011]);
5. Oral health (DOH, 2011d);
6. Insecticide-treated nets for mothers and children in malaria-endemic
areas (DOH, 2011j).
MNCHN SERVICE DELIVERY NETWORK
• No single facility or unit can provide the entire MNCHN core
package of services.
• It is important that different health care providers within the
locality are organized into a well-coordinated MNCHN service
delivery network to meet the varying needs of populations and
ensure the continuum of care.
• The MNCHN network can be a province or city-wide network of
public and private health care facilities and providers capable of
giving MNCHN services, including basic andcomprehensive
emergency obstetric and essential newborn care. It also includes
the communication and transportation system supporting this
network (DOH, 2011j).