Chapter Four

Maternal health services

 Objectives
At the end of the lecture the students will be able to:
Describe the maternal health services

Discuss the different approaches to ANC

Describe the current strategic focuses related to

delivery services
State components and importance of post natal care.

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 Contents

Antenatal care

Delivery services

Post Natal care

Family Planning

Post-abortion Care

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 Antenatal care (ANC)

• Antenatal care (ANC) is the care given to pregnant

mothers so that they have safe pregnancy and
healthy baby.

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 ANC…
Aims of ANC
Promote and maintain the physical, mental and social health of
mother and baby by providing education on nutrition, personal
hygiene and birthing process

Detect and manage complications during pregnancy, whether

medical, surgical or obstetrical

Develop birth preparedness and complication readiness plan

Help prepare mother to breastfeed successfully, experience

normal puerperium, and take good care of the child physically,
psychologically and socially.
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 ANC…
• Essential for any safe motherhood interventions
is the understanding that no one intervention can
make a difference for maternal morbidity and
mortality.
 
• Good antenatal care must be provided within a
larger context where equity, emotional and
psychological support, and a commitment to
provide basic health services are priorities.

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 ANC…
• Antenatal Care is still a big pillar of Safe Motherhood.

• It needs to be linked with quality emergency obstetric

services, should the woman experience a complication
at any time during her pregnancy.

• A good safe motherhood services must be part of a

continuum of services in which family planning, post
abortion care, intra-partum and postpartum care are
all provided and support one another.

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Essential Health Sector Interventions for Safe
Motherhood

SAFE
MOTHERHOOD

Essential Obstetric Care

Antenatal Care
Clean/safe Delivery
Post abortion care
Family Planning

Postpartum Care
BASIC HEALTH SERVICES

EQUITY

EMOTIONAL AND PSYCHOLOGICAL

SUPPORT
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 Effective ANC
• Care from a skilled attendant and continuity of care

• Preparation for birth and potential complications

• Promoting health and preventing disease

– Tetanus toxoid, nutritional supplementation, tobacco
and alcohol use, etc.

• Detection of existing diseases and treatment

– HIV, syphilis, TB, other co-existing medical diseases
(e.g., hypertension, diabetes)
• Early detection and management of complications
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The New approach to ANC

Risk Approach
Vs
Goal-Directed approach

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 Goal-directed approach to ANC
• In the past, healthcare services used a risk system to
identify women with “high risk” pregnancies, so that they
could be referred for specialized care.

• More than 10 years of experience has shown that

this system has many limitations 
– “Risk factors” cannot predict complications

– Maternal mortality is a relatively rare event in the

population at risk and the “risk factors” are relatively
common in the same population.
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Goal-directed approach to ANC …
– “Risk factors” do not appear to be good indicators of

which women will experience complications.

– The majority of women who experience a complication

were considered “low risk;” while the vast majority of
women considered to be “high risk” give birth without
complications.
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 Goal-directed approach…
• Because of the limitations of the “risk approach” many
literatures strongly suggested that:

– All pregnancies should be regarded as “at risk” of

developing a complication and be managed with the utmost
care;

– The focus of obstetric care should be shifted from predicting

complications through identification of “risk factors” to
 Detecting signs and symptoms of actual
problems and Educating women, men and
family members about danger signals and
complication readiness.
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 Goal-directed approach…

• “Risk factors,” should be regarded as “factors

associated with complications” rather than as
indicators of complications.

• Their importance for each pregnancy & childbirth

should be considered on an individual basis.

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 Goal-directed approach…
The basic components of the new WHO ANC model
• First Visit
• Second visit
• Third visit
• Fourth visit
• Post-partum visit
• Late enrolment and missed visits
• Special recommendations
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 1. The first visit
• Ideally, should occur in the first trimester, around, or
preferably before week 12 of pregnancy
a) Obtain information on:
– Personal history
– Medical history
– Obstetric history
b) Perform physical examination
c) Perform the following tests:
 Urine tests
 Blood: syphilis
 Blood-group & Rh
 Hemoglobin (Hgb): only if there are signs of severe
anaemia
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 First visit….
d) Assess for referral
– Calculate EDD (Estimated Date of Delivery) based on LNMP
– Assess risk according to the WHO classification
– Decide

e) Implement the interventions based on the assessment

Iron and folate supplements to all women
If rapid test for syphilis is positive: treat
Tetanus toxoid: first injection
In malaria endemic areas – antimalarial drugs
Refer high-risk cases.

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 First visit….
f) Advice, questions and answers, and scheduling the next
appointment
• Give advice
 on safe sex
 to stop the use of tobacco, alcohol and other harmful substances
 on breast-feeding
 on whom to call or where to go in case of emergency
 on birth plan
• Questions & answers: time for free communication.
• Schedule appointment
g) Maintain complete records
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 2. The second visit
Should be scheduled close to week 26.
• Obtain information
• Perform physical examination (B/P, Uterine ht, Wt, FHB)
• Perform the necessary tests (urine & hgb test)
• Assess for referral
• Implement the interventions according to assessment
– Iron: continue or dose
• Advice, questions and answers, and scheduling
the next appointment
• Maintain complete records
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 3. The third visit
Should take place in or around week 32
• Obtain information
• Perform physical examination (B/P, Uterine ht, Wt, FHB)
• Perform the necessary tests (urine & hgb test for all women)
• Assess for referral
• Implement the interventions according to assessment
– Iron: continue, all. If Hgb <70 g/l , refer.
– Tetanus toxoid: second injection.
• Advice, Q & A, and scheduling the next appointment
• Provide recommendations on lactation, contraception and the
importance of the postpartum visit.
• Maintain complete records
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 4. The fourth visit
Should be the final visit of the basic component and should
take place between weeks 36 and 38.
• Obtain information
• Perform physical examination (B/P, Uterine ht, Wt, FHB,
Fetal lie, presentation (head, breech, transverse).
• Perform the necessary tests (urine)
• Assess for referral
• Implement the interventions according to assessment
– Iron: continue, all.
• Advice, Q & A, and scheduling the next appointment
• Provide recommendations on lactation, contraception and the
importance of the postpartum visit.
• Maintain complete records 25
 5. The postpartum visit
The visit should take place within one week of delivery and
include activities aimed at:
– the prevention of future unplanned pregnancies

– reinforcement of breast-feeding

– complete tetanus immunization for late attendants to ANC;

– folate supplementation for women who are anemic, or with

heavy blood loss in labour;
– prevention of infection;
– planning any continued postnatal surveillance
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 6. Late enrolment and missed visits
• All lately enrolled women should have in their first visit
all activities recommended for the previous visit(s), as
well as those which correspond to the present visit.

• It is expected, therefore, that a late first visit will take

more time than a regular first visit.

• A visit after a missed appointment should include all the

activities of the missed visit(s), as well as those that
correspond to the present visit.

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 7. Special recommendations
Twins
 The risk of stillbirth is 10X higher in each twin fetus.
 Neonatal mortality is also higher.
 Women carrying twins more often develop anaemia, pre-
eclampsia, hyperemesis and polyhydramnios, and will
experience more peripartum complications.

Spacing between visits

• The pregnant woman should repeatedly be advised to
seek care in case of unexpected symptoms, and be
guaranteed easy 24-hour access to help and guidance.
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 Delivery services
• Most of the time labor and birth have natural and
good outcome.

• However, there are conditions during labor and child

birth that contributes to maternal morbidity and
mortality.

• Most of these conditions can be avoided by

providing good quality delivery services.

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 Delivery services…
Aims of delivery care
To provide clean and safe (atraumatic) delivery

Recognition, early detection and management of

complications at health center or hospital
• (E.g. haemorrhage, eclampsia,
prolonged/obstructed labour)
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 Delivery services…
Strategies
All women and birth attendants should be
aware of the requirements for a clean delivery
The 5 cleans of delivery
– Clean hands

– Clean delivery surface

– Clean perineum

– Clean cord cutting

– Clean environment 35
 Delivery services…
Strategies…
• All health care providers should be trained in and
practice clean and safe delivery techniques and avoid
unnecessary procedures.

• All women and their birth attendants should be aware of

the need to refer cases of prolonged or obstructed labor to
a higher level of care.

• All institutional deliveries should be monitored using an

appropriately adapted version of a partograph in order to
prevent prolonged labor.
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 Current Strategic focus
Skilled attendant at every birth

Accesses for essential obstetric care

Emergency referral

Progress monitoring using process indicators

Commitment from the government

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 Skilled attendant at every birth
• Skilled care refers to the care provided to a woman
and her newborn during pregnancy, childbirth and
immediately after birth by an accredited and
competent health care provider who has at her/his
disposal the necessary equipment and the support of a
functioning health system, including transport and
referral facilities for emergency obstetric care.
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 Skilled attendant …
• A skilled attendant is an accredited health
professional such as a Midwife, Doctor, Nurse or
Health officer who has been educated and trained to
proficiency in the skills needed to manage normal
(uncomplicated) pregnancies, childbirth and the
immediate postnatal period, and in the
identification, management and referral of
complications in women and newborns. 39
 Skilled attendant …
• Majority (2/3) of maternal deaths occur + 24-48 hours
after delivery
• Skilled attendants can reduce this through:
– Early detection of complication and referral

– Complications amenable for intervention:

– Eclampsia

– Obstructed Labor

– Puerperal Sepsis

– Obstetric Hemorrhage
• With the assumption that emergency referral is in
place and emergency obstetric service is accessible. 40
 Obstetric Cares

Obstetric care categories

– Essential obstetric care (EOC)

– Emergency obstetric care (EmOC)

– Obstetric First Aid (OFA)

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 Essential Obstetric care (EOC)
• It is the elements of obstetric care for the mother and
new born needed for the management of normal and
complicated pregnancy, delivery and the postpartum
period.

• Two types of EOC

– Basic EOC (BEOC)
– Comprehensive EOC (CEOC)
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 EOC…
Type of care CEOC BEOC
Surgical obstetrics X

Anesthesia X

Blood replacement X

Management of problems of pregnancy X X

Medical treatment X X

Manual procedures X X

Monitoring of normal labor X X

Neonatal special care X X

Family planning X X 43
 Emergency obstetric care (EmOC)
Refers a series of crucial life saving functions which
can prevent the death of a women experiencing the start
of complications during pregnancy, delivery or the
postpartum period.
It is a medical response to a life threatening
conditions
Not a standard for all deliveries
Basic EmOC at a health center by nurse, midwife or
physician/health officer
Comprehensive EmOC at district hospital with
operating theater with professional with surgical
skill. 44
 Type of care BEmOC CEmOC

Administer parenteral oxytocic drugs X X

Administer parenteral Antibiotics X X
Administer parenteral anticonvulsants for pre- X X
eclampsia and eclampsia

Perform manual removal of placenta X X

Perform removal of retained products X X
Perform assisted vaginal delivery X X
Perform blood transfusions X
Perform surgery (Caesarean sections & X
laparatomy) 45
 Obstetric First Aid (OFA)
Obstetric first aid is that part of EmOC that is
performed at the more peripheral levels of the health
system
– Early recognition of obstetric emergencies
– Administration of parenteral antibiotics
– Administration of parenteral oxytocic drugs
– Administration of parenteral anticonvulsants
– Referral and transport arrangements
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 Obstetric First Aid…
• Emergency Referral/ transport from basic EmOC to
comprehensive EmOC is crucial component of safe
motherhood because:
– The median time period between the onset of
complication to death of a mother is too short for
some complications
• PPH = 2Hrs
• Ruptured uterus = 1 day
• Eclampsia = 2 days
• Obstructed labor = 3 days
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 Postpartum care (PNC)
• It is care given after delivery for mother and new
born.
• The main life threatening complications of the
postnatal period include:
• Haemorrhage
• Anaemia
• Genital trauma
• Hypertension
• Sepsis
• UTI and mastitis.
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 PNC…
• All women should be assessed within 24 hours after
delivery & within the first week of delivery

Aims of PNC
Maternal care
– Early detection and management of hypertension,
hemorrhage and sepsis etc.
– Promotion and support to breastfeeding and
management of breast complications
– Information and services for family planning
– STD/HIV prevention and management
– Tetanus toxoid immunization
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 PNC…
NEWBORN CARE

• Resuscitation

• Prevention and management of hypothermia

• Early and exclusive breastfeeding

• Prevention and management of infections including

ophthalmia neonatorum and cord infections
• Recording of birth weight and referral of newborn
for immunizations and growth monitoring.
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Thank You!!!

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