Ministry of Health
Government of the People’s
Republic of Bangladesh
I.
CONTEXT
Since July 1998 the Ministry of Health and Family Welfare (MOHFW), with support of development partners, have been implementing a sector wide Health and Population Sector Program (HPSP). The goal of (HPSP) is to contribute to the improvement of the health and family welfare status of the most vulnerable groups: the women, the children and the poor of Bangladesh.
During the first 2 ½ years program implementation major accomplishments have been achieved. There has been a complete shift from a large number of separate projects to a sector wide program management approach; health and family planning services have been unified at Upazila level and below; support service as monitoring, training, and job-descriptions have been revised to better reflect the action required.
During the second half of HPSP focus will be on improving quality of service delivery and on achievement of the intended health outcomes. Considerable efforts are still required in order to reduce maternal mortality and improve mental health.
1.1 Current situation as a reflection of efforts over the past years
The Bangladesh Health and Family Planning Program has made remarkable progress over the last to decades. The fertility transition is already well underway in the country and the success of the immunization program is most impressive. The contraceptive prevalence rate has already reached more than 50% level and the fertility rate has declined from 6.3 in 1971-75 to 3.3 in 1999-2000; and over the same period infant mortality has also declined from 87 to 57 per 1000 live births.
Despite these, however, Bangladesh still remains one of the few countries where female life expectancy at birth is lower than that of males. While the progress was satisfactory with respect to reduction in fertility and child mortality, progress was inadequate with respect to maternal mortality and morbidity. This is why safe motherhood has been defined and accepted as the first of eight sub-areas reproductive health care element of Essential Service Package (ESP of HPSP). Maternal mortality is a serious concern in Bangladesh. With the current maternal mortality ratio of 3 per 1000 live births (BBS 1999), the estimated life-time risk of dying from pregnancy and child-birth related causes in Bangladesh is about three-fourths of the babies born to these women also die within first year of their life, and the survival of the other siblings is also at stake.
The major causes of maternal death are postpartum hemorrhage, eclampsia, complications of abortion, concomitant, medical causes, obstructed labor, postpartum sepsis and violence/injuries. It is very important to note that 14 percent pregnant women’s deaths are associated with injury and violence. Also while the incidence of maternal mortality is decreasing, the incidence of violence against women is rising. In addition, most population based studies show the abortion complications are responsible for nearly a quarter of deaths of the mothers. The annual number of induced abortions would be 162,130 (BAPSA 1998, study conducted in collaboration with Allan Guttmacher Institute). Also an estimated 730.000 pregnancies are terminated each year in Bangladesh (262,000 induced abortion plus 468.000 M.Rs), at a rate of approximately 28 per 1,000 pregnant women aged 15-44. Although this rate is moderate compared to levels world wide there is no room for complacency because the extent of undocumented and the unsafe abortion is very high which in most cases result in life-threatening consequences.
About 70 percent of women suffer from nutritional deficiency anemia. Less than40 percent of the population has access to basic health care, and 67 percent of pregnant women do not receive antenatal care. The low level of antenatal care coverage in Bangladesh has improved only marginally during the last five years. Close to 87% do not have assistance from a trained attendant (doctors, nurses, midwives and family welfare visitors). The proportion of women seeking postnatal care from a “medically competent person” is very low both in rural and urban areas. On the whole, only 2 percent of women delivered at home sought postnatal care from medically component persons.
Like maternal mortality, the situation of maternal morbidity in Bangladesh is extremely distressing and unacceptable. In Bangladesh, there are about 9 million women who have survived the rigors of pregnancy and childbirth to suffer from lasting complications such as fistulae, uterine prolapse, inability to control urination and painful intercourse (BIRPERHT), with 37 percent during antepartum, 12 percent during intrapartum and 51 percent during postpartum. These reproductive morbidities diminish women’s fertility, productivity and quality of life, as well as the health and survival of the next generation. These also make them social outcasts in some cases, turned out of homes rejected by their husbands and families.
1.2 The need or a national maternal health strategy
Maternal Mortality Rate of a country is globally now considered an indicator of the overall status of women. In Bangladesh, on one hand MMR represents the end point in a lifetime experience of gender discrimination, neglect and deprivation. On the other hand the existence of high MMR represents the failure of the health system to effectively provide services and care for the people. No new discoveries are needed to save the lives of women from death due to pregnancy related cause. The same women who contribute to 42 percent of the labor force of the country face death and disability in the very process that brings forth life. Reducing maternal deaths is not possible solely through a “health” intervention/initiative. Maternal mortality being considered an indicator of the overall situation of women in a nation, the approach hence, needs to be of more comprehensive nature, one of social development. The improvement of Bangladeshi women’s health is not just a social and moral necessity; it is also an economic imperative. It is estimated that iron deficiency anemia among women alone causes losses in agricultural production to the tune of 5 billion dollars over a period of 10 years. The near absence of skills and facilities to cope with obstetric emergencies is matched by a virtual absence of strategic responses and ability of the health system to respond to the dimension of violence. There is however the unique opportunity to build on efforts to improve obstetric services in hospitals, particularly district hospitals and Upazila Health Complex.
Given that most of the problem relevant to maternal health in Bangladesh are a function of the social standing of the girl child and woman, it is also clear that the present health and family planning system is also not meeting the expected level of function. If maternal mortality is to be considered as an indicator to reflect the general health and impact well being of the female population, then there is a need for reappraisal of interventions, which are expected to create impact on this indicator. This is particularly true given that fixed sites in maternal health do not begin with the clinics whether at the community or union. Skilled attendant attends only 13% of the birth, only 2% PNC services are availed and even now more than 90% of the deliveries are conducted in the home, a situation which is unlikely to change significantly in the next 10 years. Thus the household also needs recognition as being the fixed site for delivery, PNC and BBC service.
The maternal health strategy is needed to:
• Outline the essential services that will be established to meet the needs of women during pregnancy, child birth and puerperum.
• State the human resource development and management plan for establishing the services.
• Provide a guideline for quality assurance, management, communication and social mobilization.
• Give an idea of financial investment needed to put the plan in place.
• Provide direction and basis for the preparation of annual operational plans.
1.3 Strategy Development Process
The development process of HPSP has been widely appreciated since it provided opportunity to all the stakeholders to participate in formulation of the program. Any national strategy development under HPSP should follow this norm.
Besides reviewing relevant documents of maternal health services e.g. HPSP programme implementation Plan., the reproductive health strategy, gender equity strategy, population policy, health policy etc.; different program of Emergency Obstetric Care; human resource development options e.g. midwives and nurses training in Bangladesh in comparison with international experience; etc; the participatory strategy development process should consult key informants with broad experience of maternal health services in the country, consult service providers of different levels, stockholders of different origins and regions and most importantly mothers and prospective mothers from different corners of the country. While the task of the extensive review and pursuing participatory process is daunting, it is essential that all stakeholders become owners of the strategy. So, it was decided that the national maternal health strategy would be developed in a participatory and consultative way. Broadly it was upon that both international and national technical assistance would be sought to facilitate the review and consultation process, and consultation workshop at national and divisional level would be organized with different levels of stakeholders and clients. Input will be secured from all these processes and finally a consensus strategy will be facilitated at the national level. Needless to mention that such an extensive review and participatory process would be time consuming.
Time
Events
December 2000
Initiation of the National Maternal Health Strategy Development process
January 24, 2001
Review of Maternal Health initiatives. Organization or Brainstorming workshop on MHS with important stakeholders with external technical assistance.
February-March 2001
Preparatory work for participatory process
April 4, 2001
Follow-up consultation meeting to set up the strategy development process.
April 20, 2001
Formation of 35 members core group with joint secretary (Family welfare and development) as convener, and five working groups (84 members) with relevant line director as focal points by the MOHFW
April-June 2001
Group work of the core group and five working groups
June 27, 2001
Joint retreat of core group and five workings groups
July 2001
Presentations of five working group reports
August 7, 2001
Sharing of the strategy with concerned Line Directors
August 19, 2001
Grass roots levels consultation on the NMHS at Divisional level, at Sylhet.
August 30, 2001
Grass roots levels consultation on the NMHS at Divisional level, at Rangpur.
September 1-12, 2001
Refinement of group works based on inputs from Divisional levels and synthesizing of the strategy.
September 13, 2001
Review of the draft strategy document in the Core group
September 18, 2001
National Consensus Workshop on NMHS
September 19-30
Finalization of the Strategy
October 2001 and onwards
Publication of the strategy and operationalization
Time frame and structure of the document
This National Maternal Health Strategy has a ten-year perspective and defines priorities for the remainder of HPSP. The following is noteworthy about the structure of the strategy document:
• Section I provides the context and process of development.
• Section II lays out the vision and goal and specifies aims and objectives for achievement by the year 2010
• Section III details the services, their delivery mechanism and management
• Section IV provides the human resource development and management plan
• Section V outlines the principles and priorities for quality assurance
• section VI details advocacy, BCC and community participation
• section VII suggests research topics and evalution
• section VIII provides an estimate of the costs that would be required to implement the strategy in it’s entirety
• Annexed are the matrices produced by the working groups
Through the strategy focuses on the MOHFW service delivery system, which is primarily rural based, it provides a framework for functions in the urban services delivery points an wherever possible references and partnerships have been highlighted.
Aims
To strengthen the provision of essential (including emergency) obstetrical care and improve referral and utilization of services.
Objectives(by 2010)
To improve the nutritional status of women and adolescent girls
Increase met need of EmOc to 70% from 27% Increase uptake of ANC (3visits ) to 60% Increase Skilled Attendance at birth to 50% from 13% Increase PNC to 30% from 2% Increase CPR to 72% from 53.8% with larger proportion of clinical (particularly long-term) methods and discontinuation rates reduced Reduce unsafe abortion practices and provide post-abortion care Accredit ate facilities as woman friendly with provision of services for women subject to violence
Ensure the right people with the right skills are trained to provide quality maternal health services (MHS) at all levels of the health system
Ensure skilled human resources to provide midwifery and Comprehensive EmOC services in all district hospitals, district level MCWCs and 40% Upazila Health Complexes; midwifery and Basic EmOC services in remaining 60% UHCs and 50% UH&FWCs and Upazila and union level MCWCs
Provide skilled birth attendants (community midwives) – one for every 18,000 community clinics-with appropriate back-up services
Ensure appropriate personnel in every static centre are able to provide the full package of appropriate MHS
Ensure capacity and quality of training institutes through accreditation
To promote women friendly health services
Aims
To make health service providers more sensitive to women’s needs and concerns
To make women more aware of their rights in the health care system
To establish the policy of zero tolerance of violence against Objectives (by 2010)
women in all facilities providing health services
Quality of services affects women’s access to services as well as achievement of the desired result from the investment in providing services. The strategy includes
Development of a common understanding of quality of care
Involvement of professional bodies
Development of Common Understanding of Quality of Care
Various approaches may be taken to quality of care but the strategy uses the elements of quality of care developed by Judith Bruce.
Involvement of professional bodies
Active participation of the private practitioners and professional bodies has potential for strong influence over professional practice and behavior. The experience of working with this group has been particularly rewarding in the context of setting up EOC. The Obstetrical and Gynecological Society of Bangladesh (OGSB) is the highest professional body in the field of maternal health, both the health and family planning wings have traditionally drawn on their expertise, they have played a pioneering role in the establishment of EOC in Bangladesh and they have developed a system for training and monitoring of EOC activities involving their members working in Medical Colleges, District Hospitals and the private sector. This body remains open to addressing all areas of a woman’s health including issues such as violence.
2.1 Vision and Mission (PIP)
The vision….
All Bangladesh women with their heads held high, smiling in the fulfillment of their right to safe motherhood.
The mission….
To nature a socio-cultural movement that reduces maternal mortality and morbidity as a woman’s right, and also enhances her self-esteem and status.
The experience in Bangladesh shoes that reducing maternal mortality and morbidity is both an output and an entry point for addressing key strategic issues associated with woman’s rights, such as violence (medical and social aspects). Efforts will also reduce morbidity and the long term suffering of the millions women who survive obstetric complications. However, strategies and interventions will require focus on efforts to enhance woman’s status, dignity and self-esteem, if effective are to be obtained.
2.2 Principles / Priorities
The strategies for maternal mortality reduction- communication, social mobilization, caring practices, decision making at home level and service delivery—will be designed in a way that it will also enhance the woman’s self esteem, status and protect her rights. HPSP aims to reduce maternal mortality and morbidity through:
1. Focus on Emergency Obstetric Care for reducing maternal mortality Given the global and Bangladesh experience with reducing maternal deaths the following lessons have been learnt:
All pregnant women are at risk of developing life threatening complications
Most complications can neither be predicted accurately nor prevented
Once a woman develops complications she needs prompt access to emergency obstetric care services (EOC) if death or disability is to be prevented
The “Three Delays” framework of factors, which hinder a woman receiving the service required, provides a basis for strategic interventions. The “three delays model” will be used to design, implement and monitor strategic activities. The elements of the model will not be used in isolation. Rather, it will be addressed as a system.
11. Provision of Essential obstetric Care/ Basic maternity care services for promotion of “good Practices”, early detection and appropriate referral of complications
The availability of Em0C services is ideally backed up with family planning, ante-natal care, skilled birth assistance and post-natal care. The appropriate provision of these services serves to:
Provide women with a skilled birth attendance including community midwives
Provide the opportunity for communication with the woman and her family, among other reasons to help promote the appropriate use of hospital care as over 90% births take place at home
Prevent complications such as septic abortion (by meeting unmet needs of contraception)
Detect complications such as toxemia of pregnancy and prevent development of eclammpsia in such cases
Facilitate a referral system for complications such obstructed labor or hemorrhage
Reduce socio-economic differentials in access and use of essential obstetric care services
Improve access to EMOC and sexual and reproductive health care including MR by adolescents, as the MMR for girls aged 15-19 is twice as high as those 20-34.
111. Promoting Women’s Access to Resources
Services are being provided but the utilization is limited. For the management of violence against women, the hospital is the public institution most likely to be accessed by affected women. Within the family, women are socialized to restrict their use of resources, including food, without realizing the consequences for themselves and their children.
The Strategy
Builds on established initiatives and
Promotes stakeholders participation and specially focuses on the role of men
Emphasizes communication for behavior change and development.
The initiatives include are:
National Nutrition Programme addresses maternal health through a number of initiatives including the formation of various community as well as food and micro-nutrient supplementation and health education
Communication Programme for Reduction of Maternal Mortality and Violence Against Women has already been developed. It complements ongoing efforts to establish life saving emergency obstetric care services, it breaks the silence on violence against women, and, it addresses the structural issues, which influence the status of women in society. The strategy calls for further messages to be added especially in relation to maternal nutrition.
Women Friendly Hospital Initiative is part of the overall strategy aimed at overcoming a situation of high maternal mortality. It has evolved from the reality of 14% maternal deaths being associated with violence. A key area of the initiative is the management of violence against women. Training courses for doctors developed through a process of multi-sectoral consultation. The focus is on effecting a change in perceptions, emotions, attitude, knowledge and skills of providers, nurturing leadership.
Community Clinics are the front line service and the Community Groups are seen to have a vital role in motivation of families to improve maternal health.
Government–NGO/Private Cooperation calls for innovative measures to ensure that vulnerable women (e.g. those from urban slums) can avail emergency obstetric services. Village doctors, homeopathic doctors and other private practitioners have an important role in ensuring appropriate referrals. Previous local initiatives to involve these practitioners have proven effective in increasing referrals and decreasing poor practices. In order to improve access in urban areas, it is particularly important that this collaboration be prioritized.
2.3 Aims and
Objectives
The
goal of the maternal health
strategy is to reduce
maternal mortality and
morbidity. The aims and
Objectives are as follows:
The Essential Service
package (ESP) of the HPSP
comprises elements critical
to the survival and
well-being of women,
particularly the poor, who
are faced, with the rigors
of pregnancy and childbirth.
Reproductive Health Care is
one of the five components
of ESP. The ESP will provide
increasingly sophisticated
services at each level of
the system, with a capacity
to perform caesarian
sections at all levels of
facilities at the district
and Upazila level. Eight
sub-areas have been defined
under reproductive health
care of which the first four
have particular relevance to
maternal health.
Safe Motherhood will focus on creating the conditions necessary for preventing maternal death and disability with emphasis on provision and utilization of quality ANC, safe and birth practices, PNC and EOC services together with prevention of unsafe abortion and services for cases of violence against women. We further have added the dimension of referral.
Family Planning services will focus on provision of services and provisions to increase CPR of modern methods, reduce discontinuation of contraceptive use and to encourage gradual transition to long-term and permanent methods. Emphasis will also be on improved management of side-effects and complications.
Preventing Unsafe Abortion will be addressed through improved MR services and family planning services
Maternal Nutrition improvement will focus on counseling and supplementation of iron-folic acid and vitamin A
Prevention and control of RTI/STD/AIDS
Adolescent care
Infertility
Neonatal care
3.1 Plan for Services at all levels
Over the decades Bangladesh has continued to struggle with attempts to reduce maternal mortality. Intensified efforts in the field of TBA training and focus on increasing ANC have not brought about the desired outcome. Founded on these attempts, increasing the availability of EmOC has been recognized as a key intervention to reduce maternal mortality. The assessment of availability and utilization of EmOC services in Bangladesh has been based on internationally recognized process indicators and according to the Guidelines for Assessment of Availability and Utilization of Obstetric Services to summarize the findings:
The coverage of both basic and comprehensive EOC services has increased from 1 per 3.6 million populations to 1 per 1.9 million populations
The unmet need of EmOC – proportion of women with obstetric complications treated at facilities – has reduced from 95% to 75%.
Private sector facilities are a major source of EmOC services. Of concern is the fact that though 25% of women experiencing obstetric complications avail private sector services, half of the caesarean sections are performed in this sector, raising questions on the indication for caesarians and the access to this service by the poor.
Though coverage has improved, the volume of EmOC services provided in facilities varies greatly. The 59 district hospitals show a wide range in the performance of facilities – Total deliveries (0 – 2,226) Assisted vaginal deliveries (0 – 220) Caesarean deliveries (0 – 598), Cases of obstetric complications (0- 1,758)
The situation of record keeping and reporting is far from adequate and requires urgent action.
Non-availability of services in district hospitals is primarily a function of availability of consultant – either obstetrician or anesthesiologist of GPs trained in these specialties.
In UHCs the non-availability of services is a function of both human resources and equipment/drugs.
The need for ensuring skilled attendance at birth is well recognized. The challenges remain in identifying appropriate cadres, training the required numbers and ensuring back-up services.
While all services needed are mandated within the various policy documentation and frameworks, there are certain issues which require focus if the gap between policy and implementation is to be avoided. These include:
Mode of maternal health service delivery, particularly in urban and rural deprived areas
Addressing violence during pregnancy
Need for improving utilization of services through communication and social mobilization
Transportation (community and facility)
Coordination on required administrative action and focus of effective referral
The adolescent group, particularly married adolescent girls, is especially vulnerable to the risks of pregnancy and childbirth and will need added focus. These and other factors have resulted in the following situation of the services:
Facilities & service providers
Functions
Emergency Obstetric Care
• MCH, DH, MCWC, UHC, NGO/Urban clinics
• Specialist/trained MO in Obs and anesthesia, Trained nurses, Blood transfusion technician
• Potential antibiotics, oxytocics and anti-convulsants.
• Manual removal of placenta
• Post abortion care
• Repair of tears
• Assisted vaginal delivery
• Caesarian section
• Blood transfusion
• Referral
Ante-natal care
• All services points including CC and NGO clinics
• Providers: FWA, HA, FWV, Nurses, NGO paramedics, selected existing TTBA
• Registration, family health card
• Check-up: by protocol
• TT
• Counseling – on birth preparedness
• Diagnosis of complications and referral
• Supplementation for malnourished pregnant women
Skilled attendance at birth
• All GO and NGO service facilities (urban and rural) & 30% home births
• MO, nurses, FWV, FWA and female HA, NGO worker, community mid-wife
• Conduct normal delivery with pantograph, whenever possible
• Identify complications, provide appropriate level of EmOC and refer as necessary
• Counseling on nutrition, postpartum care, new-born care and FP
Post-natal care
• All facilities and 30% home births (Total 50% births)
• History taking and check-up according to protocol
• Vit -A supplementation
• Counseling
Squeal of obstetric complications
• All tertiary level hospitals and district hospitals
• Providers: consultant obstetrics and gynecology
• Medical and surgical management of long-team complications fistulae, prolapsed, infection, etc
• Follow-up and appropriate referral
Family planning
• All GO and NGO service delivery points( urban and rural)
• Providers: FWA,HA, FWV, MO, Nurses, NGO, paramedics/workers
• Motivation and counseling
• Provision of all contraceptive methods-pill, condom, injectables, IUD, Norplant and emergency contraceptive methods
• NSV and tubectomy services
• Management of side effects and complications
• Appropriate referral
Menstrual Regulation
• All GO and NGO service delivery points (urban and rural)
• Providers: FWV, MO, Nurses, NGO Paramedics
• Pre-MR counseling
• Appropriate selection
• MR—syringe and suction methods
• Management of complications
• Referral
• Post-MR family planning counseling, contraceptive method selection
• Follow up
Nutrition
Nutrition intensification (NNP)
• Community Nutrition centers
• Community Nutrition providers , community nutrition organization
Non intensification areas
• Antenatal / Postnatal Clinics at all levels (urban and rural)
• FWV, Nurses, Doctors
• Weight monitoring
• Targeted supplementary feeding of malnourished women and lactating mothers
• Counseling for improved self-care
• Counseling for improved child-care
• Micronutrient supplementation
• Referral to health services
• Registration of newly married couples and initial counseling
• Home based weighing of newly pregnant wives
• Iron& folic Acid supplementation to pregnant women
• Vitamin A supplementation of postpartum women
Service for women and girls subject to violence
• MCH, DH, MCWC, UHC, NGO/Urban clinics
• Trained doctors (Civil surgeon, consultant, RMO, EMO) trained nurses, social welfare officers
• Diagnosis and management of physical and sexual violence according to SOP guidelines
• Linkages with magistracy, social welfare, human rights organization and other relevant stakeholders
• Follow-up and appropriate referral
Priority actions of HPSP (up to 2000)
While the strategy takes a ten-year perspective, the following will be needed to be addressed in a priority basis in the remaining period of HPSP.
Emergency obstetric Care
• Building a pool of trained Mos
• Clarification on technical standers and job responsibilities
• Placement of full team, retention and ensuring residential (in-station)status o providers
• Emergency preparedness of facility
• Quarterly status monitoring
• Ensuring technical support and quality monitoring of trained medical officer at UHC by senior professionals district and tertiary level
• Interaction with pregnant women and their families to ensure timely decision to seek care for obstetric emergencies
ANC
• Clarification on technical standards and job responsibilities
• Supply of BP equipment, scala $ uristix an other necessary equipment
• QoC and monitoring checklist
• Interaction with pregnant women and their families to ensure ANC uptake an popularization and service delivery mechanism
• Use ANC for birth preparedness
Skilled birth attendance
• Build capacity of FWAs and female HAs as community midwives
• Strengthen existing FWV training in midwifery and incorporation of six months midwifery in FWV basic training
• Finalize strategy for accelerating HRD
• Optimize utilization of available trained nurses
• Create awareness on critical need for skilled attendance at birth and SBP
• Develop social marketing o safe birth kits
PNC
• Clarification on technical standards and job responsibilities
• Birth registration
• QoC and monitoring checklist
• Interaction with pregnant women and their families to ensure PNC visits
Family Planning
• Emphasis on increasing up-take of long-acting and permanent methods and meeting unmet need
• Training and motivation of doctors for sterilization/Norplant and other providers on long acting methods
• Improving provider communication with clients and strengthening IEC activities
• Three years rolling plan for uninterrupted supply
• Strengthen male involvement
• Follow-up to reduce drop out / discontinuation rates
• Strengthening training to ensure proper skills
• Quality control
• BCC on appropriate timing for availing service
• Decreasing provider multiple-use of syringes
Services for women and girls subject to violence
• Finalize and approve standard operating procedures (SOP) by relevant ministries (health, Women’s affairs, home)
• Final approval of training curriculum on management of VAW and sexual violence by curriculum committee
• Training of all Civil Surgeons and other concerned district and Upazila officials
• Strengthen inter-sectoral group including magistracy
Involvements of private sector and NGOs:
• Private sector and NGOs are increasingly playing a role in service delivery. The MOHFW will need to take a strong regulatory function. To promote a greater interest in building occupational skills e.g community mid-wife), there is need o set-up a system whereby the govt. offers training and overall regulatory function. Nursing council will provide certification. This may encourage unemployed nurses to take their own “private” service and certified providers will be responsible for reporting performance to appropriate local authority.
• Clear policy will be determined on what should be the roles and means of involving NGOs in ESP service delivery, especially, maternal health programming. This is particularly important in the urban context.
3.2 Management of services
While human resource development is key to ensuring the availability of services, management issues will be addressed adequately for optimal utilization of the human resources.
3.2.1 Referral system
While the desired functioning of all levels of service facilitates have been defined, it needs to be appreciated that the actual functioning status will determine referral linkages. The aim of referral for obstetric emergencies will be to ensure that women reach a suitably functioning facility in time. To ensure this the following systems will be focused on:
• Increasing awareness, preparedness and prompting action when danger signs appear – through birth planning
• Making specials arrangements for transportation – from community and from one facility to a higher level one
• Popularizing the services available in function facilities – among services providers and communities, between facilities, use of logo, etc.
• Upazila and district based review of referrals – time, mechanism, appropriateness, etc.
3.2.2 Placement o skilled services providers and technical/mentoring support
This remains one of the most challenging dimensions of ensuring round the clock availability of critical maternal health services. Facilities where EmOC will be provided have been identified. Ensuring the availability of the requisite human resources will entail appropriate selection, administrative rigor in posting and placement and providing career-building incentives to promote retention. A particular concern remains on retaining female doctors in rural areas and his will be addressed by providing accommodation, making security arrangements and wherever possible encouraging placement of couples. In areas (geographical) where back-up services have been established, development of the whole referral chain will be concentrated upon.
It is essential for the trained medical officers to have access to specialist and advice, particularly in times of unforeseen complications. Steps will be taken to develop a system of technical support and mentoring by Consultants/Seniors of district and Medical Collage Hospitals.
3.2.3 Logistics, supplies, and constructions/renovation
Experience over the years has resulted in the development of detail procurement lists and specifications of equipment and supplies needed for ensuring critical services. On many occasions a lack of synchrony between placement of skilled services providers and the supply of critical drugs and equipment has resulted in absence of critical live saving services. A details procurement and distribution plan will be prepared tailored to match the HRD plan to ensure synchrony. In-facility capacity in management of equipment, drugs and supplies will be strengthened.
3.2.4 Management information system
Proper record keeping and reporting is critical availability of services and provide a basis for in facility and central level/sub-national management review. Under HPSP standards registers and reporting formats have been developed (for facilities and field staff) which will meet the minimum information needs for tracking and reviewing performance. Modalities for obtaining information of private facilities performance on a routine basis will be worked out.
3.2.5 Supervision and Monitoring
Supportive supervision-both technical and managerial – is essential to ensure smooth and uninterrupted delivery of services. Central, divisional, district and upazila level personnel will conduct supervisory visits to critical facilities (at all levels). The use of checklists will be promoted and feed-back will be provided for improvement. In addition, the availability and utilization of services will be monitored during regular monthly meetings at Upazila, District, Division, and Central level.
3.2.6 Financial management
In order to ensure the availability of critical drugs and supplies, to meet transportation costs for poor women to a higher referral level, to mobilize communication and to ensure round the clock services, particularly emergency services, facility managers will be provided with an adequate annual fund based on the local level plan.
3.2.7 Management structure
Because of the cross cutting nature of maternal health, it is incorporated in several operational plans.
• It is core component of output 1 (ESP)-currently split between health and family planning wings at the central and district level.
• In terms of output 3, integrated support system- skill mixes to meet maternal health requirements at all levels (midwifery training, more female health workers etc.), the upgrading of facilities to be used by women, and an MIS which can track maternal health monitoring indicators are all important components. Logistics and procurement of essential drugs and EmOC equipment are also essential. BBC (maternal mortality reduction, warning signs in pregnancy and delivery and post-partum, violence against women, prenatal health etc.) and quality assurance are also fundamental aspects of maternal health.
• In output 4 on hospital services EOC is a key feature, as is a functioning referral system.
• Output 5 on sectors wide management requires the roles of NGOs and civil society as well as stakeholder representation in the implementation process- all of which are important contributors of maternal health programming which cuts across all levels from community to tertiary care facility. Similarly there are many issues of policy and research, which can support maternal health, in addition, the need to develop better links with the Nursing Directorate (also in the sector but marginalized) is necessary to co-ordinate midwifery training.
• Output 7 including nutrition (reduction of low birth weight) requires additional emphasis in view of chronic problems in maternal under nutrition, even though these are also outlined in the ESP.
Which such a deep interconnection between several outputs in HPSP, maternal health is very vulnerable to bottlenecks in HPSP implementation. Particularly when there is need for synchrony in training, placement, procurement, etc. in the interest of establishing and maintaining services. To date, various mechanisms have been tried out, with little success.
The following critical steps will be instituted for ensuring coordination and synchrony:
i. A separate Director be assigned for maternal Health Services
ii. Till a director is assigned for maternal Health Services, one senior level official of the directorate, possibly additional director general(ADG),be assigned responsibility of maternal health services. The ADG will meet with all concerned Line Directors and Programme Managers every other month for an update on the situation and providing necessary support and guidance.
Service
HPSP Target
Factors influencing availability of services
Availability
Utilization(status)
Antenatal Care
At all services
65% (33%)
•not prioritized by women/ family
•poor targeting
Skilled birth attendance
Unclear
30%(13%)
•not universally available for home deliveries
•who to train?
•3 million births a year
Post natal care (incl. Vit A supplementation)
At all service points
80% (2%)
•women do not leave HH for 40 days after delivery
•not prioritized by women/family
Obstetric First Aid
H&FWC
100% (0%)
•training and permission for FWVs to use parenteral drugs
•supplies
•24 hr. availability of FWV
Basic EmOC
UHCs
75% (3%)
•skill and motivation of service providers
•necessary drugs and equipment
•monitoring
Comprehensive EmOC
MCH
DH
MCWC
UHC (25%)
100%(100%)
100%(70%)
100% (50%)
100% (3%)
•posting, motivation and residential status of specialists
•drugs and equipment
•quality of care
•monitoring
Increase met need of EmOc to 70% from 27%