The New Nation - Internet Edition

The continuum of care framework aims to transcend the traditional emphasis on single, disease-specific interventions. Its central premise can be summarised as follows: Essential services for mothers, newborns and children are most effective when they are delivered in integrated packages at critical points during the life cycle of mothers and children, in dynamic health systems that span key locations, underpinned by an environment supportive of the rights of women and children.

The essential services required to support a continuum of maternal and newborn care include enhanced nutrition; safe water, sanitation and hygiene facilities and practices; disease prevention and treatment; quality reproductive health services; adequate antenatal care; skilled assistance at delivery; basic and comprehensive emergency obstetric and newborn care; post-natal care; neonatal care; and Integrated Management of Neonatal and Childhood Illnesses.

Quality reproductive health services: A growing consensus is emerging on the importance of improving reproductive health services for young people in particular, and curbing the growing incidence of HIV and other sexually transmitted diseases among them. Building reproductive health capacity at the national level will necessitate identifying problems, setting priorities and formulating strategies with the participation of all stakeholders.

Enhanced nutrition: Adequate nutrition for adolescent girls and pregnant women is critical for the health and survival prospects of both mothers and newborns. The undernutrition of young women, which is particularly prevalent in South Asia from an early age, increases the health risks for both them and their babies. Programmes targeted towards improving maternal health are increasingly focused on enhancing the nutrition of girls and women. Increased food intake and supplementation with folic acid and iron are being encouraged during pre-pregnancy and pregnancy. Dietary diversification,

the use of iodised salt and deworming also support the health of pregnant women and mothers. Vitamin A supplementation is recommended for postpartum women. Improved feeding practices for newborns, especially early and exclusive breastfeeding, helps protect them against disease.

Safe water, sanitation, and hygiene facilities and practices: Clean delivery practices are vital to safeguard the health of mothers and newborns from infections. Severe infections, which are often associated with unhygienic delivery practices and unsafe water and poor sanitation, accounted for 36 per cent of neonatal deaths in 2000. Promoting hygienic delivery practices and immunisation has contributed to a significant reduction in the incidence of maternal and neonatal tetanus since 1980.

Disease prevention and treatment: Interventions to prevent and treat infectious diseases in pregnant women are essential complements to maternity services. Two key areas of prevention and treatment relate to HIV and malaria, particularly in sub-Saharan Africa. The fight against H IV shows signs of progress: Prevalence rates among women aged 15-24 attending antenatal clinics have declined in 14 of 17 countries with sufficient data since 2000/2001 and antiretroviral therapy to prevent mother-to-child transmission of HIV worldwide has increased from 10 per cent in 2004 to 33 per cent in 2007. Distribution of insecticide-treated mosquito nets to pregnant women and intermittent preventive treatment of malaria - which consists of a single dose of antimalarial drugs at least twice during pregnancy whether the pregnant woman has malaria or not - are two measures that are helping to contain malaria. Although efforts to prevent and treat HIV and malaria have achieved some successes in recent years, much more needs to be done to address the toll of these diseases.

Adequate antenatal care: Much ill health among pregnant women is preventable, detectable or treatable through antenatal visits. UNICEF and WHO recommend a minimum of four antenatal visits. These visits enable women to receive key interventions, such as tetanus immunisation, screening and treatment for infections, and vital information on complications during pregnancy and delivery. Most of the data relate to women who have received at least one antenatal visit. In the developing world as a whole, three quarters of pregnant women received antenatal care from a skilled health provider at least once, though many do not receive the recommended four visits.

Skilled assistance at delivery: No substitute exists for the assistance of skilled health personnel at delivery. There has been a marked increase in skilled attendance in all regions of the developing world over the past decade, except in sub-Saharan Africa. During the 2000-2007 period, skilled health workers attended 61 per cent of the total number of births in the developing world. The two regions with lowest coverage, South Asia (41 per cent) and sub-Saharan Africa (45 per cent) also have the highest incidence of maternal mortality. For the developing world as a whole, deliveries of women from the poorest fifth of households are around half as likely to be attended by skilled health workers as those from the richest households. WHO recommends that skilled birth attendants administer active management of the third stage of labour (which follows completed delivery of the newborn and lasts until the completed delivery of the placenta) for all mothers - a procedure that is the most widely accepted method to reduce post-partum hemorrhage, a leading cause of maternal death.

Basic and comprehensive emergency obstetric and newborn care: Timely care in a medical facility is sometimes necessary to save the life of a woman experiencing complications during childbirth. Trained health personnel should not only be able to assist with a normal delivery or a delivery with moderate complications, they should also be able to recognise serious complications that require referral for more specialised emergency care. Studies have shown that around 15 per cent of live births are likely to need emergency obstetric care and Caesarean sections may be required in 5-15 per cent of births. It is evident that there are many important gaps in coverage, especially in rural areas of sub-Saharan Africa, where rates of Caesarean section are around 2 per cent. The quality of care delivered is critical: To provide adequate assistances, facilities must have sufficient medicines, supplies, equipment and trained personnel. Factors hindering the provision of and access to emergency obstetric care include cost, distance, lack of personnel, and cultural barriers.

Post-natal care for mothers and newborns: Post-natal care is an area that needs urgent attention. Women seek post-natal care less often than antenatal or delivery care, and even mothers who benefit from immediate post-partum care are often neglected during the days and weeks that follow. Even when a delivery is professionally supervised, post-partum care may be limited to a single check six weeks later. Post-natal care can improve neonatal health, too, especially in promotion of hygienic child care and early and exclusive breastfeeding. Given the multiple impediments to facility-based care following childbirth, including the costs or difficulties in arranging transportation and accommodation for family members, outreach visits can have a vital part in post-natal care, irrespective of where the birth took place.

It is now recognised that delivering interventions in packages can also increase their efficiency and cost-effectiveness. In addition, when services are integrated, there is both more incentive for people to use them and greater opportunity to extend and enhance coverage. The goal is to develop a comprehensive primary-health-care system that provides women and children with essential services and strengthens links between households and health facilities. Health in the home: In the developing world as a whole, 54 per cent of births take place in clinics or hospitals, but in South Asia and sub-Saharan Africa - the regions bearing the brunt of maternal and neonatal mortality more than 60 per cent of women give birth at home. Direct user charges, travel and accommodation costs, together with other indirect costs such as the income foregone by accompanying family members, may prove prohibitive to seeking medical care in facilities. The main burden of post-partum and neonatal care often falls on the family of the mother and newborn.

Better health can begin at home. Nutrition and hygiene practices in the household are prime determinants of the health risks faced by mothers and newborns. Inadequate nutrition, inattention to basic hygiene practices, such as hand washing with soap or ashes after using latrines and before preparing and eating meals, and indoor air pollution can accentuate the spread of infections and diarrhoeal diseases. Exclusive breastfeeding of infants up to six months has considerable potential to improve child health and well-being. Improving household knowledge of elementary health, nutrition and environmental health interventions, along with increased empowerment of women to make decisions about their own and their child's health, could have a strong positive impact on health outcomes for both newborns and new and expectant mothers.

Community partnerships: Communities have a vital role in health care, not merely in the absence of more expensive alternatives but as a path to greater empowerment and human rights. Partnerships in health often involve training people as community health workers who make home visits or staff established health centres. Exclusive breastfeeding, hand washing with soap and the use of insecticide-treated mosquito nets for malaria prevention are three of the most common interventions advocated by community health workers. In addition, many community partnerships in health include workers who are able to advise on measures to prevent mother-to-child transmission of HIV and contribute to the management of childhood illnesses such as malaria, pneumonia and neonatal sepsis. In rural Nepal, for example, trained community health workers have collaborated with skilled health personnel to help reduce neonatal mortality by 30 per cent.

Outreach/outpatient services: Just as community partnerships in health can help expand coverage of essential services while inspiring greater inclusion within health systems, outreach and outpatient services can create bridges between home and community care and facility-based care. They are vital mechanisms for delivering antenatal and post-natal care, as well as sexual and reproductive health programmes. Antenatal and post-natal check-ups for both newborns and mothers can effectively be conducted as outreach or outpatient services. Key services include recognising and checking the danger signs for mothers and newborns, guidance on feeding - particularly early and exclusive breastfeeding - and caring for the newborn, referral for treatment of mother or baby if appropriate, and support and counselling on healthy practices.

Facility-based care: Health facilities generally provide the broadest range of preventive and curative treatments for maternal and newborn care and potentially the Most skilled pool of health-care workers. Medical facilities fall into two main categories: clinics and hospitals. Staff in the clinic, the facility closest to the community, can often cope with uncomplicated births and some of the key complications - for example, manual removal of the placenta or neonatal resuscitation. Given the potential risks associated with labour and childbirth, staff in clinics, as well as those engaged in outreach, need the knowledge to recognise delivery complications or neonatal conditions that are beyond their competence and require referral to a higher level. That next level is likely to be a district hospital where doctors can offer medical diagnosis, treatment, care, counselling and rehabilitation services. In some health systems there may be a referral hospital providing complex clinical care, but in most developing countries the facility-based health needs of mothers and infants are met by clinics or the district hospital, if at all.

-Unicef