Obstetric complications cannot be predicted or prevented but can be managed by timely provision of life saving services. Emergency Obstetric Care is defined as a set of critical life saving functions commonly called signal functions provided by a health facility, 24 hours a day, 7 days a week. Among the obstetric complications, many can be dealt by basic EmONC services and few will need comprehensive EmONC facilities, while a majority of the newborn emergencies may also be dealt with at the basic EmONC level.
Definition of Emergency Obstetric and Newborn Care Services:
The provision of Basic EmONC services includes but is not limited to: intravenous and intra-muscular administration of drugs such as antibiotics, oxytocin and anticonvulsants; assisted vaginal delivery; manual removal of placenta; manual removal of retained products of an abortion or miscarriage; and stabilization and referral of obstetric emergencies not managed at the basic level. In terms of newborn emergencies, the required services at the basic EmONC level include management of neonatal infection, very low birth weight infants, complications of asphyxia and severe neonatal jaundice, (skills and supplies for intravenous fluid therapy, thermal care including radiant warmers, Kangaroo Mother Care, oxygen, parenteral antibiotics, intragastric feeding, oral feeding using alternative methods to breast feeding and breast feeding support.
The provision of Comprehensive EmONC services includes all of the services provided at the basic level, plus cesarean section, blood transfusion services, and newborn special care at the advanced level, such as intensive care neonatology units.
The current status of under-five child mortality is 105 per 1,000 live births. It has shown a steady albeit not rapid improvement over the years. The major causes of death in children under 5 are perinatal causes (18%), Diarrhea (18%), ARI (18%), Measles (7%), Malaria (6%) and others (32 %). Thus capacity building of health care workers in management of above conditions is planned in this activity. Ministry of Health has approved and adopted National Child Survival Strategy which clearly defines all interventions required at home, referral and facility level for promoting growth and development of a healthy child and optimal care of sick child. The recommendations of National Survival Strategy for purpose of this PC-1 have been incorporated in different components (EmONC, essential newborn care, Immunization plus, nutrition counseling and IMNCI).
New Born Care:
A recent compilation of available information on the pattern of newborn deaths and IMR in Pakistan indicate that while there has been steady decline in IMR over the last 20 years corresponding with the implementation of the “child survival” programs there has not been a proportional decline in newborn mortality.
Infections, birth asphyxia, and preterm/low birth weight account for 86 percent of newborn deaths, and most occur during the first hours and days of life. Researchers estimate that approximately 70 percent of newborn deaths could be averted through the use of proven, cost-effective interventions. These interventions are surprisingly simple, ranging from ensuring clean delivery, to treating infections with antibiotics, to promoting immediate and exclusive breastfeeding. As outlined in The Lancet Series on Newborn Survival, just strengthening family community and outreach services, including health education to improve home care practices and preventive services such as tetanus vaccination coverage, can reduce newborn deaths by up to 40 percent.
As a result of various studies it is shown that in our communities across the nation the main risk factors identified being responsible for a high mortality and morbidity during newborn/perinatal age are:
There is sufficient evidence available that introducing integrated newborn packages at clinical, outreach and community level brings down newborn mortality by 40%, 25% and 30% respectively.
Emergency newborn care:
Improved care of ill babies especially infections, complications of preterm birth and of birth asphyxia could be provided as a part of Comprehensive EmONC services in selected facilities identified in the National MNCH Program. In addition, newborn resuscitation and immediate newborn care protocols already developed under Women’s Health Project will be provided to 7000 labor rooms in public sector and 3000 maternity homes in the private sector.
Community based low cost and low tech interventions will be scaled up through LHWs and CMWs. This would include Community IMNCI, Community Case Management and Behavior Change Communication.
Integrated Management of Newborn & Childhood Illnesses (IMNCI):
The Government of Pakistan is fully committed to implementation of the IMNCI strategy in Pakistan and a pilot project is implemented since 1998. This is approach is also present in National Child Survival Strategy with emphasis on diseases causing most of the child mortality i.e. Diarrhea and ARI. Now with the experience gained from implementation of the pilot IMNCI program the decision is to increase coverage to the entire country. Out of the three components of IMNCI: the first component of improving the skills of the health workers at the facilities and the second component of improving access and referral will be covered under this PC1. The third component of community IMNCI will be covered by the National Program for Family Planning and Primary Health Care as it has the necessary workers available in the field to support implementation of the strategy.
Creation of IMNCI Task Force
The commitment to implement IMNCI will be formalized and strengthened through the Technical Advisory Group. Strategic guidelines for advocacy and program implementation will be prepared and be part of district social sector plans. The activities will be coordinated by the DPC program under supervision of Program Manager MNCH.
The steering committees of MNCH will review implementation and achievements annually.
The infrastructure at the DHQ hospitals has sufficient capacity to enable provision of EmONC services, however the state of repair of the buildings is open to question. Therefore under this program a systemic effort to repair all the labor rooms, newborn care units, Maternity and Child wards will be undertaken. All the DHQ hospitals will be provided with funds for repair and maintenance. The amount has been estimated at an average cost of Rs. 1.2 million per DHQ Rs. 1.0 million per THQ providing Comprehensive EmONC services, Rs 0.6 million per THQ, Rs. 0.4 million per RHC providing Basic EmONC services. In addition Rs 0.3 million per RHC and 0.1 million per BHU for repair of residential accommodations for female staff. This amount can be reallocated within the district by the provincial MNCH cell based on a proposal having a detailed needs assessment presented by the EDO Health in consultation with the district government. On the other hand it would not be feasible or practical to start construction of new hospitals / health facilities with these funds and as such they will only be used for strengthening the existing health infrastructure. Funds for repair of RHC are already available with Punjab under the Health sector reform program and therefore these are not duplicated.
The hospitals in Punjab, Sindh and NWFP have a majority of equipment available for MNCH and therefore only some additional equipment will be provided to these hospitals. On the other hand, Balochistan has very limited capacity at the DHQ hospitals and thus the nine hospitals will be targeted for strengthening at the regional level. The THQs hospitals will be dealt with on a case by case basis. It is also proposed to provide these hospitals with incinerators to dispose of hospital waste through the Hepatitis B program. However for chemical disposal of hospital waste the recurrent costs shall be met from the regular budget of the hospital. All hospitals will need to be equipped with laboratory support, X-ray, Blood Bank, Operation Theatre and Anesthesia. The equipment package proposed for these hospitals is given on page117. The attached list covers all the essential equipement for DHQ/THQ hospitals for comprehensive EmONC services. Similarly, it is assumed that majority of the districts and tehsils hospitals would not require a complete set of equipment as it is available from the regular provincial budget and other sources. However, a lupsum amount for equipment for comprehensive EmONC services is allocated in this PC-1 for the provinces. Moreover, Piaman project is providing comprehensive EmONC equipment in 10 DHQ’s, 10 THQ’s and 10 RHC’s in their designated districts. UNFPA is also providing all the essential equipment to DHQ, THQ and RHC’s in their own designated districts, equipment for these health facilities for comprehensive EmONC services is not costed in the MNCH PC-1..
Similarly, the hospitals will conduct a review of available equipment in comparison with the list of equipment proposed and categorize it into three parts, available, repairable and new required. This exercise should take maximally six months to complete and the detailed compilation of this information should be available at the Provincial MNCH Cell directorate within 9 months of launch of the program.
The Federal MNCH PIU will conduct a standardization exercise and finalize the specifications of the equipment and issue a call for tenders. The procurement committee will conduct the tendering process and issue rate contracts for the equipment. The supply orders will be issued by the provinces/ districts as per requirement.
The equipment will be provided under warranty and service contract will be made with the supplier to perform at least one maintenance visit every four-six months. Provision has been made for service contracts for electrical equipment.
Newborn Care units at health facilities providing Comprehensive EmONC:
Newborn care units would be added to all facilities providing comprehensive and basic emergency obstetric care services, preferably near to the labour room and maternity ward. This will be done simultaneously with the renovation/ construction under establishing 24/7 comprehensive emergency obstetric care services in the first year of the project. All the facility staff handling deliveries would be trained in essential newborn care. However, for emergency newborn care specialized units would be established with adequate staff and equipment. Staff would be given specialized training for the purpose and will be permanently deployed in the unit rather than on rotation (especially the nursing staff).All facilities providing comprehensive EmONC services will have functional newborn units. Once the district has conducted a situation analysis of availability of staff, equipment and space at the health facility, a proposal to establish the newborn units shall be sent to the provincial MNCH Directorate/Cell.
The newborn unit will require minimally the presence of a pediatrician, one MO/WMO specifically for the unit in addition to at least two staff nurses to run the unit (included in the minimum staff requirement for 24/7 EmONC services).
Establishment of newborn care units would require necessary renovation and construction work. Standard designs and specifications would be developed by an experts committee and followed in all districts and facilities. The proposed equipment and supplies for these units would be procured as required. A list of equipment is provided on page 122.
- Strengthening the THQ Hospital
The provision of comprehensive EmONC services in the hospital requires a functioning MNCH wing comprising minimally of a labor room, operation theater, labour ward, gynecology ward, and intensive care unit; in addition to a newborn intensive care unit, child intensive care unit and children ward. The THQ hospitals shall be provided with a package of equipment based on the need.
Human Resource needs:
The DHQ/THQ hospitals already have an existing structure that can be utilized to improve service provision including availability of posts, operation theaters and indoor facilities; however these are sub optimally staffed. The minimum staffing requirement for comprehensive emergency obstetric and newborn care is outlined below. This number is essential to ensure 24hours a day 7days a week services.
The package of basic EmONC services is designed for facilities with less human resource and infrastructure available but is serviced by an ambulance service and has the provision of transferring the patient to a higher level facility providing comprehensive EmONC services if required.
The provision of basic EmONC services in the hospital requires a functioning MNCH wing comprising minimally of a labor room, operation theater, labour ward, and gynecology ward. In addition at the THQs a newborn intensive care unit, child intensive care unit and children ward will be provided. The hospitals THQ/RHC shall be provided with funds for repair/ renovation of the health facility and not for new construction. The allocation will be decided along side the allocation for comprehensive EmONC facilities. Most of the RHCs have provision for 20 beds for inpatients and have an Operation Theater and X-ray. The provision of services will not require new civil works and there will be a need for some renovation at these RHCs.
Provision of equipment and supplies to meet requirement for basic EmONC package including Laboratory support and functioning of minor OT, Supplies (contraceptives, medicines, IMNCI package of medicines, Basic newborn care kit, clean delivery kits, and basic equipment)
Human Resource needs:
There is a complement of staff posts sanctioned at the THQ and RHC. The provision of Basic EmONC services at these facilities will not entail deployment of additional staff and the existing posts can be utilized with the provision of an incentive from the program.
All the RHCs shall be strengthened to provide 24/7 Basic EmONC services, for this purpose there is already a complement of staff available at the RHC and this will be supplemented to enable service provision for 24 hours through existing posts in the health system. The proposal is to place an additional WMO and LHV at these health facilities to improve the availability of staff and allow for 24 hours coverage for Basic EmONC.
It is Assumed that the BHU’S are being strenghtned under respective Health Sector Reforms in the provinces, which are already scaling up MNCH activities. BHUs are expected to be equipped through the regular health budget of the province to provide preventive obstetric care services and for this the primary ingredient is availability of LHV at the BHUs, while incentive for the LHV aready posted will be provided from the MNCH program as well as renovation of the residence of the LHV at the BHUs. These BHUs can be linked with the CMWs and LHWs to promote institution based delivery. There will be a provision of providing performance based incentives at these BHUs; the performance measures shall include the number of patients seen for Antenatal care, ANC visits per pregnant woman, Post natal visits, number of normal deliveries assisted, number of cases of complicated pregnancy referred to higher level, proportion of children immunized in the catchment area, ORS distribution, FP clients in catchments area.
Medicines, IMNCI package of medicines, Basic newborn care kit, clean delivery kits, and basic equipment) will be provided to identified BHUs.