Chapter 5
Prevent Excess Maternal and Neonatal Mortality and Morbidity

OBJECTIVE PREVENT EXCESS NEONATAL AND MATERNAL MORTALITY AND MORBIDITY BY:   providing clean delivery kits to visibly pregnant women or birth attendants to promote clean deliveries; providing midwife delivery kits (UNICEF [48] or equivalent) to facilitate clean and safe deliveries at the health facility; initiating the establishment of a referral system to manage obstetric emergencies.

Why is preventing neonatal and maternal morbidity and mortality a priority?

In any displaced population, approximately 4 percent of the total population will be pregnant at a given time.[49] Of these pregnant women, 15 percent will experience an unpredictable obstetric complication, such as obstructed or prolonged labor, pre-eclampsia or eclampsia, sepsis, ruptured uterus, ectopic pregnancy or complications of abortion.[50] In the early phase of an emergency, births will often take place outside the health facility without the assistance of trained health personnel. Without access to emergency obstetric services, many women will die or suffer long-term health consequences that are preventable (for example, obstetric fistula).

What basic materials can help pregnant women have a clean birth in an emergency?

All displaced populations will include women who are in the later stages of pregnancy and who will therefore deliver during the emergency phase; the crude birth rate (CBR) is estimated at 4 percent. Simple, clean delivery packages for home use should be made available to all visibly pregnant women. These are packages that the women themselves or TBAs can use to help women when they are giving birth. The packages contain very basic materials: one sheet of plastic, two pieces of string, one clean (new and wrapped in its original paper) razor blade, one bar of soap, a pair of gloves and a cotton cloth.

What is the best way to get clean delivery kits?

Because these materials are often easily obtained locally, it is possible to assemble these packages on-site. In fact, it may be possible to contract with a local NGO to produce the kits, which could provide an income generation project for local women. However, clean delivery kits can be ordered from UNFPA.[51] Sometimes this may be a quicker alternative, and the sooner the materials are available, the better it is for pregnant women. In addition, contacting UNFPA at the start of a crisis to establish a relationship and to determine the availability of MISP supplies will likely facilitate better emergency preparedness.

Exercise

How can we ensure that delivery complications are dealt with efficiently at the health center level?

Fifteen percent of women will develop a potentially life-threatening complication during pregnancy or at the time of delivery. At the primary health care level, basic EmOC [53] should be available for these women 24 hours per day, seven days per week. Therefore, it is important to provide midwives and other skilled birth attendants at the primary health center level with materials and drugs to safely conduct deliveries, to deal with complications and to stabilize women prior to transport to the referral level. Supplies to address obstetric emergencies are included in the Interagency RH Kits and can be ordered through UNFPA.

How many deliveries require a cesarean section (c-section)?

According to the UN Process Indicators of Emergency Obstetric Services,[54] 5 to 15 percent of all deliveries require a c-section. These women, and other women suffering from obstetric emergencies, such as those requiring blood transfusion and surgery, may need to be referred to a hospital that is capable of performing comprehensive EmOC.[55] Obstetric complications that cannot be managed at the health center should be stabilized and transported to the referral hospital.

The Reality of Implementing the MISP in Indonesia [56] The Women's Commission conducted an assessment of the MISP in tsunami-affected areas of Aceh, Indonesia in February 2005. While slightly more than half of humanitarian workers interviewed had actually heard of the MISP, only one of 25 people could accurately describe its overall goal, objectives and priority activities. Coordination of the MISP was led by UNFPA, which fielded a designated RH focal point in Banda Aceh within one week of the tsunami and initiated working group meetings among the numerous local and international organizations, as well as the Indonesian health authorities. Women and girls in focus groups expressed concern with the lack of privacy and security in some settings and, in some camps, men and women shared latrines. No MOH personnel and few organizations were able to state that they had a sexual violence protocol in place to respond to the clinical needs of rape survivors. MOH and WHO representatives reported that health workers failed to practice universal precautions, such as cleaning, disinfection and sterilization of medical supplies to prevent the spread of infections, including HIV/AIDS. Most supplies to support the MISP, such as clean delivery kits and midwife kits for health centers, were available to international agencies within or shortly after the first month of the emergency. The need to plan for comprehensive RH services as part of the MISP, including ordering RH supplies, was evident in the demand that women affected by the tsunami had for contraceptive supplies. The demand was quickly addressed through collaborative efforts of donors, the National Family Planning Coordinating Board (BKKBN) and UNFPA.

When should a referral system for obstetric emergencies be made available?

As soon as possible, a referral system, including the means of communication and transport, that supports the management of obstetric complications must be available for use by the displaced population 24 hours a day, seven days a week. The referral system should ensure that women with complications of pregnancy or delivery are referred from the community to a primary health care facility where basic EmOC is available and to a facility with comprehensive EmOC services, if necessary.

Is it better to support an already existing referral facility or set up new one?

Where feasible, a local referral facility (e.g., district hospital) should be used and supported with personnel, medical equipment and supplies as needed to meet the needs of the displaced population. If this is not feasible because of the distance or the inability of the host facility to meet the increased demand, then an appropriate emergency referral facility for the displaced population could be established. In either case, it will be necessary to coordinate with local health authorities concerning the policies, procedures and practices to be followed in the referral facility. The protocols of the country should be followed, although some variation may have to be negotiated.

What are the 24/7 requirements of an effective referral system?

A referral system should have transport at all times. For example, if the NGO staff leave the camp and take the vehicle or ambulance with them, a communication system must be established so that if a woman goes into labor and experiences complications, such as obstructed labor, she can get to the health care facility. It may be necessary to negotiate with camp security personnel to allow the transport of emergency patients at night. In addition, a qualified medical person who can address obstetric complications and perform a c-section if necessary must be available at the referral facility at all times. Finally, the referral facility must have qualified staff, medical equipment and supplies to cope with the extra demands put on it by the displaced population.

Which type of activity related to maternal care is not a priority in a crisis?

Most maternal deaths occur from complications during or after delivery. The majority of these complications cannot be predicted earlier in pregnancy. Of all pregnant women in whom a health problem is identified during antenatal care, most will not develop a life-threatening complication during or after delivery. Therefore, although providing antenatal care and training midwives are appropriate activities once all the components of the MISP are implemented and the crisis phase is over, these interventions are not vital and could divert attention from the more urgent need of access to quality EmOC care in the emergency phase. It is not necessary to train TBAs and midwives before providing them with clean delivery kits as these kits should reach pregnant women without delay. Organizing discussions with TBAs and midwives to exchange information and provide supplies to the community can be done early in an emergency. However, training existing TBAs and/or midwives on clean and safe deliveries should wait until a more stable phase has been reached.[57]

Good practices in excess neonatal and maternal mortality and morbidity observed in Darfur [58] At the time of the Women's Commission's field team visit, UNFPA reported that it had recently completed an EmOC assessment of five of the eight referral hospitals (three were not accessible due to insecurity) in North Darfur and recruited national staff to conduct the assessment in order to build local capacity. It reported at the time that EmOC assessments were underway in South Darfur and West Darfur as well. These assessments built on EmOC assessments undertaken by the MOH in November 2005. The MISP Coordinator in North Darfur enlisted AU forces to provide emergency transport for obstetric complications by helicopter if necessary (due to travel insecurity or time constraints). In North Darfur, the sub-granting agency requested 3,000 delivery kits from UNFPA and distributed an average of 1,000 per month (with a flyer on instructions in Arabic) through home visits by village midwives. The MISP Coordinator in North Darfur trained two local NGOs to create locally made delivery kits, which they are distributing to their communities. The sub-grantee in West Darfur was able to quickly establish basic EmOC services at the peripheral level-in part due to a establishing a good relationship with the MOH. In South Darfur, to navigate security restrictions, the sub-grantee's RH unit coordinated with other internal units, e.g., the water and sanitation unit, to provide MISP supplies. In South Darfur, one NGO's midwives followed up on each referral at the hospital to ensure women and girls received the appropriate care. In South Darfur, UNFPA worked with MOH to provide training to humanitarian actors in manual vacuum aspiration.

Neonatal Care Approximately two-thirds of infant deaths occur within the first 28 days.[59] The majority of these deaths are preventable by initiating essential actions that can be taken by health care workers, mothers or other community members:[60] Immediate care after birth Be sure that attendants use gloves or wash hands with soap and water before the delivery and before tying and cutting the cord. Keep delivery room warm and ensure baby is dried and warmly wrapped immediately after birth. Keep the head covered. Delay bathing for at least six hours. Use a clean (preferably sterile) instrument to cut the umbilical cord, and check frequently for bleeding. Keep the baby with the mother to ensure warmth and frequent breastfeeding. Pay attention to frequent hand washing by anyone handling the baby. Clean baby's eyes immediately after birth, and if prophylaxis is country policy, instill drops or ointment. Encourage Kangaroo Mother Care.[61] Help mother with the first (within one hour) breastfeeding.[62] Continuing postnatal care Keep the baby with the mother. Avoid putting two babies in the same cot. Clean the cord with soap and water and keep it dry. Do not cover the cord with any bandage or cloth. Tell the mother what danger signs to look for in the condition of the cord and in her baby. Be sure she knows when and where to go for help. Teach the mother how to keep the baby warm. Take the baby to the health center at six weeks for immunizations. Advise the mother to give her child nothing but breast milk for the first six months and to continue breastfeeding up to two years or longer.[63] Useful resources include Care of the Newborn: Reference Manual, Every Newborn's Health: Recommendations for Care for all Newborns and Managing Newborn Problems: A Guide for Doctors, Nurses and Midwives.[64]

What causes women to die from obstetric complications?

Often women experience delays in accessing life-saving care that cost them their lives. The situations that hinder women from seeking care can be divided into three categories ("the three delays"):

	delay in deciding to seek care;
	delay in reaching care due to transportation difficulties; and
	delay in having appropriate care available at the facility once reached.[65]

Therefore, after EmOC care services are in place, the immediate focus should be on preventing delays in timely access to good quality EmOC care for women suffering from emergency obstetric complications.

Good practice

If the situation permits, assembling clean delivery packages locally may be a good opportunity to identify and organize TBAs and to talk with them about referring women suffering from obstetric complications or requiring medical care for rape. TBAs can be organized to make up the simple packages and then distribute them to visibly pregnant women. Because TBAs are part of the displaced population, they most likely already know which women are close to their delivery times and are in need of the materials, and may also know which women and girls have survived rape.

MISP Safe Motherhood Monitoring

Clean delivery kits available and distributed. Compare the number of clean delivery packages distributed to the estimated number of births in a given period of time. Midwife kits available at the health center. Hospital staff competency and capacity to provide EmOC assessed and support provided. Referral system for obstetric emergencies functioning 24 hours per day, seven days per week. Indicators to monitor safe motherhood coordination: Estimate of coverage of clean delivery kits Number and type of obstetric complications treated at the PHC level and the referral level Number of maternal and neonatal deaths in health facilities Which supplies are needed or which UNFPA RH Kit(s) could be ordered to address this issue?[66] Number Name Color Kit 2: Clean Delivery (Individual) (Part A + B) Dark blue Kit 6: Delivery (Health Facility) Brown Kit 8: Management of Complications of Miscarriage Yellow Kit 9: Suture of Tears (cervical and vaginal) and Vaginal Examination Purple Kit 10: Vacuum Extraction for Delivery (Manual) Grey Kit 12: Blood Transfusion Dark green

Challenges and Solutions

1) What if ensuring 24/7 referral services may not be possible due to insecurity in the area?   Without access to adequate EmOC, women and girls will die unnecessarily. Therefore, it is extremely important to attempt to negotiate women and girls' access to an appropriate referral facility. Where 24/7 referral services are simply impossible to establish, it is particularly essential that qualified staff are available at all times to stabilize patients with basic EmOC. In this situation, establishing a system of communication, such as the use of radios or cell phones, would be helpful to communicate with more qualified personnel for medical guidance and support. 2) What if the displaced population does not have a history of routinely accessing services for assisted delivery?   As many women in developing countries routinely deliver in their homes, an essential activity to undertake is to ensure the community, especially midwives and TBAs, knows where to immediately refer women with dangers signs of pregnancy and delivery including: severe headache, blurry vision, swelling of face/hands, dysuria, heavy bleeding, high fever, convulsions, prolonged labor, retained placenta and loss of fluids before contractions. It is important to plan and implement training and capacity-building for all staff once the emergency is stable and the MISP has been fully implemented.

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NOTES

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