maternal and child healt anh d family planning
TRANSCRIPT
World Health Organization ^йж Organisation mondiale de la Santé
EXECUTIVE BOARD Provisional agenda item 8 EB93/INF.DOC./3 Ninety-third Session 13 January 1994
Maternal and child health and family planning
This document presents a tabular summary o f action in response to priorit ies set and
recommendat ions made at the sixth meet ing of the Expert Comm i t t e e on Ma te rna l and Ch i ld Hea l th , in
1975, as well as the needs which have emerged since 1975, and related fami ly p lann ing policies and
programmes.
The summary was presented to the seventh meet ing of the Expert Comm i t t e e in December 1993.
i
PRIORITIES SET AND RECOMMENDATIONS MADE AT THE SIXTH MEETING OF THE EXPERT COMMITTEE, IN 1975: HIGHLIGHTS OF SUBSEQUENT ACTION, ACHIEVEMENTS, PERSISTENT PROBLEMS AND EMERGING NEEDS
Priority needs or
concerns identified
by the 6th Expert
Committee in 1975
Recommendations of
the 6th EiKpert
Committee in 1975
Policy and programme
response: WHO or
other since 1976
Achievements
(data from HFA
evaluation 1985 and
1991)
1983-
1985
1988-
1990 Remaining problems Emerging needs
Inadequate coverage Extend PHC and
support systems of
care to underserved
WHA32.42 1.(2)-
Promote free services
for periods of high
risk; primary health
care.
WHA31.55 - M C H
coverage:
strengthening PHC.
WHA46.18 - M C H
and FP for health.
Prenatal care (%):
Developing countries: 48 65
of which least
developed: 45 53
Childbirth - trained
attendant:
Developing countries: 41 53
of which least
developed: 36 32
Infant care:
Developing countries: 43 64
of which least
developed: 36 56
Those most in need
(women, children, migrants,
rural and urban poor,
refugees, aged, young)
continue to have limited
access to services. Trends
may be getting worse in
some regions.
Coverage is a more
complex issue than simply
ensuring the availability of
services. Use of services
involves perceptions,
motivation, cultural and
economic accessibility.
Services still suffer lack of
infrastructure,
overstretching and
management deficiencies.
Structural adjustment
and cutbacks in public
services. Placement of
charges may decrease
use of essential care.
Uneven population
growth, distribution,
migration, urbanization,
need to be built into
health planning.
Equity not being
addressed.
Perinatal period and
early childhood
neglected
Give priority - ensure
intersectoral
coordination - M C H
integration with
overall services and
part of
socioeconomic
development
WHA45.22 - Newborn
health as part of safe
motherhood; four
essential needs.
WHA34.22 - Breast-
feeding promotion to
improve infant and
young child health -
promotion of code.
See above
Breast-feeding
protection,
promotion and
support.
Pressing needs include:
strengthening training in
lactation management,
clean delivery, resuscitation
and thermal control.
Maternal nutrition,
infection control and
decrease energy
expenditure to decrease low
birth weight, sustaining
immunization coverage.
Toxic environmental
exposures, substance
abuse, H IV /A IDS
management, child
neglect/abuse,
psychosocial factors
affecting health and
development.
EB93/INF.DOC. 3
Priority needs or
concerns identified
by the 6th Expert
Committee in 1975
Recommendations of
the 6th Expert
Committee in 1975
Policy and programme
response: W H O or
other since 1976
Achievements
(data from HFA 1983- 1988-
evaluation 1985 and 1985 1990
1991)
Remaining problems Emerging needs
Need for integration
of M C H within PHC
Develop a basic
package for delivery
within primary health
care according to
local needs, social
and cultural
characteristics and
resources
WHA32.20 on the
Alma-Ata Declaration
and the HFA strategy.
WHA32.42 - Follow-
up to Alma-Ata
WHA46.18 - MCH/FP
Various component
elements developed:
Immunization - EPI;
infection control -
ORS, sick child case
management;
essential obstetric
care and the
mother/baby
package; FP as an
essential element of
MCH.
Many countries lack an
integrated delivery system
for MCH/FP in PHC.
"Vertical" programmes with
own management,
information and training
strategies supported by
external funding.
Need for further
decentralization and focus
on first referral level.
Risks that aggressively
set targets without an
overall health
development and PHC
strategy will distort
programmes.
Development of district
health systems.
Care for mothers and
children fragmented
and not family
focused
Use of all contacts of
mother and child
with health workers
to provide
simultaneous delivery
of integrated
promotive,
preventive, curative
and rehabilitative
action
WHA46.27 -
International year of
the family
The concept of
"missed
opportunities"
applied EPI in some
countries; Patient
Flow Analysis
techniques applied to
providing integrated
MCH/FP care in
some countries.
Vertical management,
information and training
structures for technology
specific activities persist.
Rehabilitation not
developed or integrated.
Integration of TBA training
supervision support in
MCH/Safe motherhood.
Evaluation of TBA
programmes and their
impact.
Need for supporting
legislation in health.
Coordination of policy.
Coordination with
private sector especially
NGOs.
Identification of high-
risk families and
support systems.
EB93/INF.DOC./3
Priority needs or
concerns identified
by the 6th Expert
Committee in 1975
Recommendations of
the 6th Expert
Committee in 1975
Policy and programme
response: WHO or
other since 1976
Achievements
(data from HFA
evaluation 1985 and
1991)
1983-
1985
1988-
1990 Remaining problems Emerging needs
Health workers are
not aware of factors
influencing health,
nor the actual and
potential of other
sectors
Modify training for
intersectoral
orientation. Draw on
community personnel
and resources,
support from
community leaders.
WHA46.17 - Health
development in a
changing world.
Special attention to
women and
development, children
and young people.
Little progress other than
advocacy in the areas of
MCH/FP not translated
into training and
collaboration; campaign
approach is less effective
than using existing
infrastructure where access
to facilities exists.
Incomplete understanding
of linkages between health
status and developmental
and behavioural activities.
Limited experiences in
community involvement.
No clear mechanism for the
involvement of and
coordination with non-
government sector.
Emphasis on target
setting and technologies
fails to put attention on
(1) the understanding
of the underlying basis
of vulnerability, and
(2) the need for a PHC
and district supported
infrastructure to "carry"
programmes.
Need orientation of
health workers on
prevention of unhealthy
lifestyles and linked
diseases including HIV,
AIDS, STDs, cancer,
stroke, cirrhosis,
accidents.
Need for strategic
alliances with other
sectors, particularly
education and
environment.
EB93/INF.DOC./3
Priority needs or
concerns identified
by the 6th Expert
Committee in 1975
Recommendations of
the 6th Expert
Committee in 1975
Policy and programme
response: WHO or
other since 1976
Achievements
(data from HFA
evaluation 1985 and
1991)
Continued high levels
of malnutrition and
its long-term effects,
particularly as a
result of infections
and close child
spacing
Develop effective and
feasible interventions
during pregnancy,
lactation, childhood
and adolescence and
encouraging and
facilitating BF and
weaning
W H A resolutions on
infant and young child
feeding, International
Code of Marketing of
BM Substitutes, and
micronutrients;
Innocenti Declaration;
Plan of Action of
International
Conference on
Nutrition
WHA45.34 - code.
W H O / U N I C E F
meeting on young
child feeding
WHA46.7 -
International
Conference on
Nutrition.
WHA31.53 -
immunization.
WHA35.31 -
immunization.
Low birth weight
Developing countries:
of which least
developed:
Safe water supply:
Developing countries:
of which least
developed:
Contraceptive use
(%)••
Developing countries:
of which least
developed:
Effective
immunization during
pregnancy and
childhood should be
adapted to local
conditions
Develop
immunization
procedures as
integral part of M C H
care with other
complementary
approaches
Targets set by
WHA44.33 -
Child summit goal.
WHA46.33 -
Poliomyelitis.
WHA46.36-
Tuberculosis.
WHA42.32 - Neonatal
tetanus.
Global coverage:
DTP3:
BCG:
Polio:
Measles:
TT2:
Remaining problems Emerging needs
Emphasis on the role of
men and other family
members in prevention and
management of problems.
Elimination of harmful
traditional practices
affecting women and
children's health.
Addressing attitudinal
change and training of key
health personnel closest to
women and children in
need of care.
Raising status of women
and girls especially by
ending the traditional
discrimination against the
girl child.
Nutritional and care
implications of children
having children;
periconceptual
nutrition; implications
of low birth weight and
childhood nutrition
status for adult disease.
Coverage decreased slightly
1991; vertical programmes.
Sustainability (costs) and
political commitment.
Strengthen management
logistics support, laboratory
services.
Interaction between
H IV infection and
other immunizable
childhood infections
and diseases.
1983- 1988-
1985 1990
13
24
68
49
34
8
22
12
55
30
% % % % %
S390858034
% % % % %
к^
о о 4
4 4 5 5 2
EB93 INF.DOP3
Priority needs or
concerns identified
by the 6th Expert
Recommendations of
the 6th Expert
Committee in 1975
Policy and programme
response: W H O or
other since 1976
Achievements
(data from HFA 1983- 1988-
evaluation 1985 and 1985 1990 Remaining problems Emerging needs
Committee in 1975
Recommendations of
the 6th Expert
Committee in 1975
Policy and programme
response: W H O or
other since 1976 1991)
Need for linking Integrate FP WHA41.9 linking FP Integration FP is not integrated in Build on concept of
M C H and FP education and care in to health and widespread for other areas of health care. reproductive rights and
demonstrated but not M C H and other development - urging MCH/FP FP denied to unmarried choice.
generally applied in health care. FP integration with Coverage = women - need for new Needs for adapting to
policies or Education and MCH. FP integration in legislation. adolescent RH .
programmes legislation requires WHA30.44 - Health M C H generally Links between FP and Need for coordination
multidiscipline legislation in health accepted - often not STD/AIDS prevention not MCH /FP with
approach. services strengthening operational in many operational. STD/AIDS
PHC. countries. Need to address large programmes.
WHA38.22 - unmet need for
Adolescent contraception through
reproductive health. innovative approaches.
WHA32.42 - Alma Look at the effective
Ata: MCH, nutrition, implementation of FP as
family planning and intervention strategy for
immunization essential Safe Motherhood.
PHC aspects. Concept of quality of care
needs to be accepted and
generalized.
EB93/INF.DOC./3
Priority needs or
concerns identified
by the 6th Expert
Committee in 1975
Recommendations of
the 6th Expert
Committee in 1975
Policy and programme
response: W H O or
other since 1976
Achievements
(data from HFA 1983- 1988-
evaluation 1985 and 1985 1990
1991)
Remaining problems Emerging needs
Need to define
essential M C H care
package and provide
suitable training,
including community
Provide integrated
training for all levels
of health workers,
including
undergraduate
medical education
Programme packages
developed: EPI,
diarrhoeal disease,
safe motherhood -
mother/baby package.
Joint UNFPA/
U N I C E F / W H O
statement on TBAs'
safe motherhood
initiative.
WHA30.48 - Health
manpower
development,
midwifery and nursing
training.
WHA36.11 - Nursing,
midwifery: role in
providing health
services for effective
PHC development.
WHA42.27 - Training
nursing, midwifery
personnel, reorient
education, legislation
and regulations.
Training modules for
specific technologies:
EPI, CDD , AR I ,
SMI, sick child.
Training package for
TBAs; master
trainers for TBAs.
Little integrated training,
undergraduate medical
training virtually unchanged.
Territoriality and inertia.
Integration of TBA in
M C H services not
addressed adequately in
many countries.
Effective approaches for
community involvement and
mobilization. Persistent
issues remain unsolved, i.e.
supervisory referral and
logistical backup support
from M C H services.
Need emphasis on IEC
component of services.
Need for alternative
learning methods for
clinical and programme
problem solving.
Need to reorient M C H
training and approach.
Need to define the
minimum
information for all
aspects of M C H for
planning, monitoring
and evaluation for
programme impact
Develop simple,
reliable information
systems for local use
in monitoring
programmes,
channelling to
regional and central
levels with feed-back
WHA42.44 - Public
information and health
education
International driven
targets have raised
awareness of
information needs.
"Bottom-up" methods
developed.
Quality of information
remains poor when used in
one-way flow;
dissemination, adaptation
and application of methods
Risk of overloading of
information systems
and burdening system
through ad hoc systems.
EB93/INF.DOC./3
Priority needs or
concerns identified
by the 6th Expert
Committee in 1975
Recommendations of
the 6th Expert
Committee in 1975
Policy and programme
response: W H O or
other since 1976
Achievements
(data from HFA 1983- 1988-
evaluation 1985 and 1985 1990
1991)
Remaining problems Emerging needs
School health
programmes not
realizing potential.
Not involve students
or teachers in PHC
and community
development.
Teachers to be used
for health education.
Strengthen school
health programmes
with full participation
of students, teachers
and nurses aides
Launching concept of
comprehensive school
health programmes.
Progressive
implementation of
comprehensive school
health programme
including services
health education,
healthful
environment and
other health-related
components.
Develop of school health
policy, legislation and
ñnancial support.
Intersector coordination
between health and
education sectors.
NGOs, teachers unions and
private sector making
fragmented and meagre
efforts.
Missed opportunities for
improving coverage of
information and services for
children and their families.
Empowerment of
families through
school - health.
Reduce cumulative
impact of risk factors.
EB93/ZF.DOC./3
TABLE 2. NEWLY EMERGING NEEDS IN MCH/FP
Newly emerged needs
(1975-1993) - not
identified by the 6th
Expert Committee
meeting,1975
Policy and programmes'
resolutions Achievements Remaining problems
Women's health -WHA38.27 (1985) on women, health 1975- 1985- -Sexual discrimination: violence
and development 1980 1990 against women; son preference;
-WHA38.22 (1985) on maturity before -Increased women's global -Malnutrition and anaemia;
childbearing and promotion of life expectancy at birth: 62.1 65.9 -High-risk fertility patterns;
responsible parenthood -Increasing cancer incidence.
-WHA39.18 (1987) on implementation Regions:
of the Nairobi Forward-looking
Strategies for the Advancement of Africa 49.5 53.6
Women North America 77.3 79.2
-WHA42.42 (1989) on women's health Látin America 65.8 69.5
-WHA42.32 (1989) on neonatal tetanus Asia 58.9 63.9
(EPI) Europe 75.8 77.7
-45th World Health Assembly: technical
discussions on women, health and
development
- U N 34/180 (CEDAW)
-UNFPA Amsterdam Declaration
EB93/INF.D0C./3
Newly emerged needs
(1975-1993) - not
identified by the 6th
Expert Committee
meeting, 1975
Policy and programmes'
resolutions Achievements Remaining problems
Maternal health -WHA39.18 (1987) s.a.
-WHA40.27 (1987) on maternal health
and safe motherhood
-WHA45.5 (1992) on strengthening
nursing and midwifery
-WHA46.17
1983- 1988-
1985 1990
Establishment of health-for-
all global indicators
concerning maternal health:
-Prenatal care: global
coverage by trained
personnel (per 100 live
births) 58 67
-Immunization of pregnant
women: global coverage by
tetanus toxoid vaccination
in % 24 34
-Childbirth attendance:
global coverage by trained
personnel (per 100 live
births)
-Establishment of maternal 53 55
health and safe
motherhood programme
1987:
Guidelines and training
modules for midwives and
ТВ As; mother/baby
package; research on
maternal mortality;
women's health database
1983 1991
-Global maternal mortality rate (per
100 000 live births): 390 370
-Regions:
Africa 640
North America
Latin America 270
Asia 420
Europe 29
-Global annual total of 500 000
maternal deaths.
Women and H I V -Paris Declaration on Women, Children
and AIDS (1989)
-WHA43.10 (1990), adoption of Paris
Declaration
-Establishment of the
Global Programme on
AIDS (1987)
- > 3 million HIV-infected women in
world (1992);
_ cumulative total of > 600 000 AIDS-
cases among women (1992).
EB93/IZF.DOC./3
Newly emerged needs
(1975-1993) - not
identified by the 6th
Expert Committee
meeting, 1975
Policy and programmes'
resolutions Achievements Remaining problems
Women and children in
difficult circumstances
-International Convention
on the Rights of the Child
-Operationalizing policy, coordination
and collaboration in multisectoral
approaches;
-Violence to and abuse of women
and children in situations of war and
displacement.
Quality of care -WHA45.34 -Quality of care recognized
in BFHI - including links to
breast-feeding support
groups
-Discrepancy between coverage arid
impact; lack of community/health
system partnership; social distance of
health providers and community;
need for communication skills.
Traditional practices
affecting women and
children
_ WHA46.18 -Network of NGOs in 26
countries
-Inter-African
Communique
-Accelerating local action,
programme developmeiit linked to
discrimination and their social status.
EB93/INF.DOC./3
-л.
гчз FAMILY PLANNING POLICIES AND PROGRAMMES: A REGIONAL PERSPECTIVE
Regions Policies and programmes Coverage* Demographic evolution
(latest data) Unmet needs Reorientation
Latin
America
and the
Caribbean
High population awareness;
emergence of a regional
"population consciences"
population policies often part
of national development
plans. By and large
governments have
internationalized population
programme; establishment of
national commission;
population issues are part of
development plans;
establishment of sectoral
programme strong health and
women's rights component in
many countries.
1992: Modern
methods
prevalence
10-74%
Latin America:
Crude birth rate 30/1000
Average population
growth rate 2.2%
Caribbean:
Crude birth rate 24/1000
Average population
growth rate 1.4%
43% of married women
who want no more
children are not using
any contraceptive
method.
Estimated 4.6 million
unsafe abortions per year.
-From contraception to reproductive
health of population
-Increasing modern contraceptive use
-Addressing adolescent reproductive
needs
-Building partnership with Government
and NGOs
-Improving management
-Towards sustainability
Africa Highest birth rates in the
world; population issues are
part of political agenda.
32 countries with public
sector FP; 17 with
government support to
private FP programmes;
population distribution high
concern; integration of M C H
and FP as national policy and
major outlet for FP (not
always operationally
supported by some donors in
the past).
1988-89: Any
method range
from 5% to 50%;
Modern methods
from l%-40% but
with only a very
few countries with
> 10%
Highest birth and population
growth rates globally
Crude birth rate 45/1000
Average population
growth rate 3.0%
77% of married women
who want no more
children are not using
any contraceptive
method.
Estimated 3.3 million
unsafe abortions per year.
FP remains
-constrained to M C H services.
Few countries made thrust towards
community-based distribution of
contraceptives and involvement of
private sector.
- N e e d to explore variety of channels
through ^diich FP services can be
delivered safely and effectively.
EB93/INF.DOP/3
Regions Policies and programmes Coverage* Demographic evolution
(latest data) Unmet needs Reorientation
Middle Recognition of health and
East development implications of
population growth;
acceptance of integration of
M C H and FP increasing;
slow progress of FP
programmes even in the few
countries with strong
commitment; still high rate
of population growth but
widening acceptance of the
health rationale for family
planning.
1988: Any
method 10%-
63%; Modern
methods 6%-45%
Crude birth rate 35/1000
Average population
growth rate 2.8%
57% of married women
who want no more
children are not using
any contraceptive
method.
Estimated 380 000 unsafe
abortions per year.
The term FP was not acceptable
officially in several countries. The
population rationale of FP is not
relevant for many E M R countries.
Today, FP as a component of M C H is
the usual norm in most countries.
Reproductive health awareness is an
important target in most M C H
programmes.
The global and national women's health
movements include fertility regulation
as a basic human right.
Asia Nearly all countries have
population policies and
measures implementation of
programme facilities by
strong planning tradition and
experience; FP programmes
in place and successful for at
least 2 decades; status of
women strongly linked to
programme success.
Modern methods
South Asia: 34%
East Asia: 5-74%
South-east
Asia: 4-62%
South Asia:
Crude birth rate 35/1000
Population growth rate 2.3%
South-east Asia:
Crude birth rate 21-43/1000
Average population
growth rate 1.3-3.5%
East Asia Pacific:
Crude birth
rate 10.5 to 31.9/1000
Average population
growth rate 0.64-3.3%
57% of married women
who want no more
children are not using
any contraceptive
method.
Estimated 10.3 million
unsafe abortions per year.
South-east Asia: less
than 50% of women in
child bearing age practice
contraceptives.
In Asia Pacific, family planning will be
better integrated with other health
programmes especially primary health
care; national family planning and
population policies will emphasize
health benefits of family planning more;
health will be more integrated with
other social and economic sectors.
1990 - Bhutan endorsed a population
policy and adopted small family norm.
1989 - Myanmar adopted position of
maintaining the population growth rate
without intervention but included child
spacing in routine health and welfare
activities.
Maldives are making contraceptives
available at the PHC level in spite of
population policy of non-intervention.
EB93/INF.DOP/3
Co
Regions Policies and programmes Coverage* Demographic evolution
(latest data) Unmet needs Réorientation
Europe FP services generally widely
available; abortion still major
means for regulating fertility
in many eastern European
countries and many former
republics of the USSR.
Average in
western Europe:
70%
West Europe:
Crude birth rate 12/1000
Average population
growth rate 0.1%
East Europe:
Crude birth rate 13/1000
Average population
growth rate 0.2%
Migrant groups,
adolescents,and
traditional families
outside FP network.
Estimated 260 000 unsafe
abortions per year (excl.
Republics of the former
USSR which is estimated
at 2.1 million).
FP just starting in Central Asian
Republics, changes in abortion
legislation under review or made in
several countries.
* Contraceptive prevalence among women in fertile age married or m union.
II
II
EB93/SF.DOP/3