MOTHERHOOD & CHILDHOOD

MAIN PROBLEMS & STRATEGIES

ELENA A. ABUMUSLIMOVAPH.D., ASSOCIATE PROFESSOR

Department of Public Health and Health Care,Northern-West State Medical University named after I.I. Mechnikov, Saint-Petersburg

The United Nations Millennium Development Goals

The United Nations Millennium Development Goals are eight goals that all 191 UN Member States have agreed to try to achieve by the year 2015.

The United Nations Millennium Declaration, signed in September 2000 commits world leaders to combat poverty, hunger, disease, illiteracy, environmental degradation, and discrimination against women.

UNAIDS/G. Pirozzi

8 Millennium Development Goals Eradicate extreme poverty and hunger (MDG 1) Achieve universal primary education (MDG 2) Promote gender equality and empower women

(MDG 3) Reduce child mortality (MDG 4) Improve maternal health (MDG 5) Combat HIV/AIDS, malaria and other diseases

(MDG6) Ensure environmental sustainability – safe

drinking water and sanitation (MDG 7) Develop a global partnership for development

(MDG 8)

MDG 1: Eradicate extreme poverty and hunger

Poverty contributes to unintended pregnancies and pregnancy-related mortality and morbidity in adolescent girls and women, and under-nutrition and other nutrition-related factors contribute to 35% of deaths of children under five year, while also affecting women’s health.

Charging people less for health services reduces poverty and makes women and children more willing to seek care.

Further efforts at the community level must make nutritional interventions (such as exclusive breastfeeding for six months, use of micronutrient supplements and deworming) a routine part of care

MDG 2: Achieve universal primary education

Gender parity in education is still to be achieved. It is essential because educated girls and women improve prospects for the whole family, helping to break the cycle of poverty. In Africa, for example, children whose mothers have been educated for at least five years are 40% more likely to live beyond the age of five.

Schools can serve as a point of contact for women and children, allowing health-related information to be shared, services offered and health literacy promoted.

MDG 3: Promote gender equality and empower women

Empowerment and gender equality improve the health of women and children by increasing reproductive choices, reducing child marriages and tackling discrimination and gender-based violence.

Partners should look for opportunities to coordinate their advocacy and educational programs (including those for men and boys) with organizations focusing on gender equality.

Shared programs might include family-planning services, health education services, and systems to identify women at risk of domestic violence.

MDG 4: Reduce child mortality

Reaching the MDG on reducing child mortality will require universal coverage with key effective, affordable interventions: care for newborns and their mothers; infant and young child feeding; vaccines; prevention and case management of pneumonia, diarrhoea and sepsis; malaria control; and prevention and care of HIV/AIDS. In countries with high mortality, these interventions could reduce the number of deaths by more than half.

MDG 5: Improve maternal health

Women died during pregnancy and childbirth because they had no access to skilled routine and emergency care.

In developing countries the risk of maternal death is very high at 1 in 39, unlike in the developed world where a woman's life time risk of dying during or following pregnancy is 1 in 3800. Increasing numbers of women are now seeking care during childbirth in health facilities and therefore it is important to ensure that quality of care provided is optimal.

Globally, over 10% of all women do not have access to or are not using an effective method of contraception. It is estimated that satisfying the unmet need for family planning alone could cut the number of maternal deaths by almost a third.

MDG6: Combat HIV/AIDS, malaria and other diseases

Many women and children die needlessly from diseases that we have the tools to prevent and treat. In Africa, reductions in maternal and childhood mortality have been achieved by effectively treating HIV/AIDS, preventing mother-to-child transmission (PMTCT) of HIV and preventing and treating malaria.

We should coordinate efforts on such interventions by, for example, integrating PMTCT into maternal and child health services and ensuring that mothers who bring children for immunization are offered other essential interventions.

MDG 7: Ensure environmental sustainability – safe drinking water and sanitation

Dirty water and inadequate sanitation cause diseases such as diarrhea, typhoid, cholera and dysentery, especially among pregnant women, so sustainable access to safe drinking water and adequate sanitation is critical. Community-based health efforts must educate women and children about sanitation and must improve access to safe drinking water.

MDG 8: Develop a global partnership for development

Global partnership and the sufficient and effective provision of aid and financing are essential. In addition, collaboration with pharmaceutical companies and the private sector must continue to provide access to affordable, essential drugs as well as to bring the benefits of new technologies and knowledge to those who need them most.

EVERY WOMANEVERY CHILD

Key facts (1)

Worldwide, 800 women die every day due to complications during pregnancy and childbirth - about 287 000 women in 2010.

In developing countries, conditions related to pregnancy and childbirth constitute the second leading causes (after HIV/AIDS) of death among women of reproductive age.

Key facts (2)

The four main killers are: severe bleeding, infections, unsafe abortion, and hypertensive disorders (pre-eclampsia

and eclampsia).

Bleeding after delivery can kill even a healthy woman, if unattended, within two hours. Most of these deaths are preventable.

Key facts (3)

More than 136 million women give birth a year.

About 20 million of them experience pregnancy-related illness after childbirth. The list of morbidities is long and diverse, and includes fever, anemia, fistula, incontinence, infertility and depression.

Key facts (4)

About 16 million girls aged between 15 and 19 give birth each year, accounting for more than 10% of all births. In the developing world, about 90% of the births to adolescents occur in marriage. In low- and middle-

income countries, complications from pregnancy and childbirth are the leading cause of death among girls 15-19.

Key facts (5)

The state of maternal health mirrors the gap between the rich and the poor.

Less than 1% of maternal deaths occur in high-income countries.

A woman's lifetime risk of dying from complications in childbirth or pregnancy is an average of one in 150 in developing countries and compared to one in 3800 in developed countries.

Also, maternal mortality is higher in rural areas and among poorer and less educated communities. Of the 800 women who die every day, 440 live in sub-Saharan Africa, 230 in Southern Asia and five in high-income countries.

Key facts (6)

Most maternal deaths can be prevented through skilled care at childbirth and access to emergency obstetric care.

In sub-Saharan Africa, where maternal mortality ratios are the highest, less than 50% of women are attended by a trained midwife, nurse or doctor during childbirth.

Key facts (7)

In developing countries, the percentage of women who have at least four antenatal care visits during pregnancy ranges from 56% for rural women to 72% for urban women.

Women who do not receive the necessary check-ups miss the opportunity to detect problems and receive appropriate care and treatment. This also includes immunization and prevention of mother-to-child-transmission of HIV/AIDS.

Key facts (8) About 21 million unsafe

abortions are carried out, mostly in developing countries every year, resulting in 47 000 maternal deaths.

Many of these deaths could be prevented if information on family planning and contraceptives were available and put into practice.

Key facts (9)

Since 1990 the global maternal mortality ratio has declined by only 3.1 % annually instead of the 5.5% needed to achieve MDG 5, aimed at improving maternal health.

•One target of the Millennium Development Goals (MDGs) is to reduce the maternal mortality ratio by three quarters between 1990 and 2015. So far, progress has been slow.

Key facts (10)

The main obstacle to progress towards better health for mothers is the lack of skilled care. This is aggravated by a global shortage of qualified health workers.

MDG 5: Improve maternal health WHO key working areas

Strengthening health systems and promoting interventions focusing on policies and strategies that work, are pro-poor and cost-effective.

Monitoring and evaluating the burden of maternal and newborn ill-health and its impact on societies and their socio-economic development.

Building effective partnerships in order to make best use of scarce resources and minimize duplication in efforts to improve maternal and newborn health.

Advocating for investment in maternal and newborn health by highlighting the social and economic benefits and by emphasizing maternal mortality as human rights and equity issue.

Coordinating research, with wide-scale application, that focuses on improving maternal health in pregnancy and during and after childbirth.

Stages of rendering of the preventive and medical aid for women (by WHO)

rendering assistance to the woman before pregnant; prenatal protection of foetus and pregnant women; intranatal protection of foetus and rational medical

aid of deliveries; health protection of newborn, the organization of

correct feeding, creation of optimum conditions for physical development;

health protection child health during the preschool period, maintenance of conditions for optimum physical development, creation of the necessary immunologic status;

health protection of school-age-children.

The basic establishments of medical services for women

Maternity hospital, Female consultation, Maternity and gynecologic developments of

the general hospitals, Obstetrics-gynecological clinics of medical

institutes and institutes of improvement of doctors,

Scientific research institute of obstetrics and gynecology,

Centre of protection of mother hood and the childhood.

Dynamic supervision over woman health (1)

During the organization of medical aid to pregnant women it is important to register them on time (till 3 months). During normal pregnancy the woman is recommended:

to visit consultation in 7-10 days after the first visit,

come back to the doctor once a month in first half of pregnancy,

after 20 weeks of pregnancy visit a doctor 2 times a month,

after 32 weeks - 3-4 times a month.

Dynamic supervision over woman health (2)

During the pregnancy each woman has to be examined:

by the therapist - 2 times, by the stomatologist - under indications; the clinical analysis of blood (2 - 3 times), the analysis urine (at each visiting), bacteriological research separated of a vagina,

definition of group of blood, the Rh-factor (if Rhesus factor - negative additional inspection of the husband should be done),

the analysis of blood on Wassermann reaction (2 times),

the analysis of blood on a HIV.

Maternal mortality ratio Proportion of deliveries attended by

skilled health personnel Contraceptive prevalence rate Adolescent birth rate Antenatal care coverage

MDG 5: Improve maternal health Indicators

Maternal death definition

The death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes.

International statistical classification of diseases and related health problems, 10th revision (ICD-10)

Direct or indirect maternal death Direct maternal deathsDirect maternal deaths are those resulting from obstetric

complications of the pregnant state (pregnancy, delivery and postpartum), interventions, omissions, incorrect treatment, or a chain of events resulting from any of the above. Deaths due to, for example, obstetric haemorrhage or hypertensive disorders in pregnancy, or those due to complications of anaesthesia or caesarean section are classified as direct maternal deaths.

Indirect maternal deaths Indirect maternal deaths are those resulting from previously existing diseases, or from diseases that developed during pregnancy and that were not due to direct obstetric causes but aggravated by physiological effects of pregnancy. For example, deaths due to aggravation of an existing cardiac or renal disease are considered indirect maternal deaths.

Pregnancy-related deathPregnancy-related death The death of a woman while pregnant or

within 42 days of termination of pregnancy, irrespective of the cause of death.

Late maternal deathLate maternal death The death of a woman from direct or

indirect obstetric causes, more than 42 days, but less than 1 year after termination of pregnancy.

Statistical measures of maternal mortality Maternal mortality ratio (MMR)Maternal mortality ratio (MMR) Number of maternal deaths during a given time period

per 100 000 live births during the same time period. Maternal mortality rate (MMRate)Maternal mortality rate (MMRate) Number of maternal deaths in a given period per 100

000 women of reproductive age during the same time period.

Adult lifetime risk of maternal deathAdult lifetime risk of maternal death The probability that a 15-year-old women will die

eventually from a maternal cause. The proportion of maternal deaths among deaths of The proportion of maternal deaths among deaths of

women of reproductive age (PM)women of reproductive age (PM) The number of maternal deaths in a given time period

divided by the total deaths among women aged 15–49 years.

Maternal mortality ratio (MMR), by WHO, 2010

(maternal death per 100 000 live birth)Region 2010 1990 % change in

MMR between 1990 & 2010

MMR Number of maternal deaths

MMR Number of maternal deaths

World 210 287 000 400 543 000 - 47

Developed regions (Russia)

16 2200 26 4 000 - 39

Developing regions 240 284 000 440 539 000 - 47

Southern Asia(India)

220 83 000 590 233 000 - 64

Southern Asia excluding India

240 28 000 590 70 000 - 59

Caucasus andCentral Asia(Azerbaijan)

46 750 71 1400 - 35

Western Asia(Saudi Arabia)

71 3500 170 7000 - 57

EVERY WOMANEVERY CHILD

MDG 4: reduce child mortality

6.6 million children under five died in 2012. Almost 75% of all child deaths are

attributable to just six conditions: neonatal causes, pneumonia, diarrhoea, malaria, measles, and HIV/AIDS. The aim is to further cut child mortality by two thirds by 2015 from the 1990 level.

Target:Target: Reduce child mortality by two-thirds, between 1990 and 2015, the under-five mortality rate

A child's risk of dying is highest in the first month of life

In the first month of life safe childbirth and effective neonatal care are essential. Preterm birth, birth asphyxia and infections cause most newborn deaths. Once children have reached one month of age, and up until the age of five years, the main causes of loss of life are pneumonia, diarrhoea, and malaria. Malnutrition contributes to almost one half of all child deaths.

Nearly three million children died in 2011 within a month of their birth

Newborn life is fragile. Health risks to newborns are minimized by:

1) quality care during pregnancy;

2) safe delivery by a skilled birth attendant;

3) essential neonatal care after birth: immediate attention to breathing and warmth, hygienic cord and skin care, and exclusive breastfeeding.

Pneumonia is the largest single cause of death in children under five years of age

In 2011, it killed an estimated 1.2 million children under the age of five years, accounting for 17% of all deaths of children under five years old worldwide. Addressing the major risk factors for pneumonia through immunization, exclusive breastfeeding, reduction in household air pollution and adequate nutrition is essential for prevention. Antibiotics and oxygen are vital treatment tools.

Diarrhoeal diseases are a leading cause of sickness and death among children in developing countries

Exclusive breastfeeding and proper sanitation and hygiene, and immunization help prevent diarrhoea among young children.

Treatment for sick children with Oral Rehydration Salts (ORS) and zinc supplements is safe, cost-effective and saves lives. The lives of more than 50 million children have been saved in the last 25 years as a result of ORS.

Every minute a child dies from malaria It is one of the leading causes of death among

children under-five. Sleeping under insecticide-treated nets prevents transmission and increase child survival. Early testing and treatment with effective anti-malarial medication saves lives.

Over 90% of children with HIV are infected through mother-to-child transmission

This is preventable with the use of antiretrovirals, as well as safer delivery and feeding practices. An estimated two million children under 15 years of age are living with HIV, and every day more than 1000 are newly infected.

Without intervention, more than half of all HIV-infected children die before their second birthday.

Early testing and treatment with antiretroviral therapy for all HIV-infected children greatly improves survival and quality of life.

In 2012, about 17 million children suffered from severe wasting

Almost half of the under-five child deaths are associated malnutrition. Severe acute malnutrition leaves children more vulnerable to serious illness and high probability of dying.

Most children can be successfully treated at home with ready-to-use therapeutic foods (RUTF). Globally, in 2012, an estimated 162 million children below 5 years of age, were stunted and 99 million were underweight.

Some 80% of the world’s under-five deaths in 2012 occurred in only 25 countries, and about half in only five countries

Under-five deaths are increasingly concentrated in sub-Saharan Africa and Southern Asia. Child survival rates differ significantly around the world. Within countries, child mortality is higher in rural areas, and among poorer and less educated families.

About two-thirds of child deaths are preventable

They are preventable through access to practical, low-cost interventions, and effective primary care up to five years of age. Child health is improving, but serious challenges remain to achieve global goals to reduce deaths. Stronger health systems are crucial for improving access to care and prevention.

MDG 4: reduce child mortalityWHO strategies

Appropriate home care and timely treatment of complications for newborns;

Integrated management of childhood illness for all children under five years old;

Expanded programme on immunization; Infant and young child feeding.

These child health strategies are complemented by interventions for maternal health, in particular, skilled care during pregnancy and childbirth.

Typical establishments rendering medical - prophylaxis to children

city and regional pediatric hospitals, the specialized children's hospitals (infectious,

psychiatric, tubercular, orthopedic-surgical, regenerative treatment clinic),

children's city polyclinics, children's stomatological polyclinics, establishments on protection of motherhood and the

childhood (children's homes, maternity hospitals, dairy cuisines),

children's balneal clinics, the sanatorium, the specialized sanatorium establishments for all-the-

year action, children's department in hospitals and polyclinics of the

general structure.

The children's city polyclinic provides:

the organization and carrying out a complex of preventive actions (dynamic medical supervision over healthy children, routine inspections, prophylactic medical examination, preventive vaccination);

medical consultation by home visiting service and in polyclinic (including the specialized medical aid), directing children for treatment in hospitals;

treatment-and-prophylactic work in preschool establishments and schools;

carrying out antiepidemic actions together with territorial establishments sanitary epidemic service.

Work load of the local pediatrician

In an area under specifications there should be 750-800 children up to 17 years old inclusive, including 40-60 children of the first year of life.

Work load of the local pediatrician is: 5 people on 1 reception hour in a polyclinic (7 - at routine inspections) and 2 - under service at-home.

Under-five mortality rate (probability of dying by age 5 per 1000 live births)

Years

Azerbaidjan

India Russia Saudi Arabia

Finland

2012

35 (24-50)

56 (51-62) 10 (10-11)

9 (8-10) 3 (3-3)

2010

39 (29-51)

61 (57-66) 12 (11-12)

10 (9-11) 3 (3-3)

2005

51 (43-60)

75 (72-79) 17 (16-17)

15 (14-17)

4 (4-4)

2000

72 (64-81)

92 (88-95) 23 (23-24)

22 (20-25)

4 (4-4)

1995

90 (81-100)

109 (105-113)

26 (26-27)

31 (27-37)

5 (5-5)

1990

93 (84-103)

126 (122-130)

26 (26-27)

47 (39-56)

7 (7-7)

The 11 indicators of maternal, newborn and child health (by

WHO) 1 maternal mortality ratio (deaths per 100 000 live

births); underfive child mortality, with the proportion of

newborn deaths (deaths per 1000 live births); children under five who are stunted (percentage of

children under five years of age whose height-for-age is below minus two standard deviations from the median of the WHO Child Growth Standards).

These three health status indicators are essential for monitoring MDGs. Stunting, a nutrition indicator, is important for understanding not only outcomes, but also determinants of maternal and child health. Nutrition is also a useful proxy indicator for development more broadly.

The 11 indicators of maternal, newborn and child health (by

WHO) 2 met need for contraception; (proportion of women aged

15-49 years who are married or in union and who have met their need for family planning, i.e. who do not want any more children or want to wait at least two years before having a baby,

and are using contraception); antenatal care coverage (percentage of women aged

15–49 with a live birth who received antenatal care by a skilled health provider at least four times during pregnancy);

antiretroviral prophylaxis among HIV-positive pregnant women to prevent vertical transmission of HIV, and antiretroviral therapy for women who are treatment-eligible;

skilled attendant at birth (percentage of live births attended by skilled health personnel);

postnatal care for mothers and babies (percentage of mothers and babies who received postnatal care visit within two days of childbirth);

exclusive breastfeeding for six months (percentage of infants aged 0–5 months who are exclusively breastfed);

three doses of the combined diphtheria, pertussis and tetanus vaccine (percentage of infants aged 12–23 months who received three doses of diphtheria/pertussis/tetanus vaccine);

antibiotic treatment for pneumonia (percentage of children aged 0–59 months with suspected pneumonia receiving antibiotics).

The 11 indicators of maternal, newborn and child health (by

WHO) 3

These eight coverage indicators have been selected because they are strategic and significant: each one represents a part of the continuum of care and each one is connected with other dimensions of health and health systems.

Indicators of maternal, newborn and child health (by

WHO) 4

The global consensus for Maternal, newborn and child health