Maternal and Child Health

 

Addressing the Unfinished Agenda

There is arguably no area as central to the work that PAHO does in conjunction with the Ministry of Health as is that of Maternal and Child Health (MCH) in Guyana; MCH is in fact that the largest vertical programme in the Ministry’s work.

The reasoning is simple: healthy mothers bringing forth healthy children constitute the best foundation for a healthy society. In addressing the unfinished agenda in Maternal and Child Health PAHO has been working with the MOH in achieving certain key objectives.

One has been to reduce the Maternal Mortality Ratio (MMR) - that is, the number of mothers who die as a result of childbirth, compared to every 100,000 children born alive. In 2004, Guyana’s MMR stood at 115.9; in real terms, it meant that of the recorded 16,391 live births that year, 19 children would have to grow up without knowing their mothers. Under the Maternal Mortality Reduction Strategic Plan, developed for the period 2006-2010, it is expected that the MMR would be lowered to fewer than 100 deaths for every 100,000 live births.

Another key objective, of course, is also to save the lives of newborns. In 2004, the Neonatal Mortality Rate (NMR) was 20.4. That is an average of 20.4 children who died not long after birth for every 1,000 who were born alive. This means that at least 334 of the children recorded in 16,391 live birth figures for 2004 are not alive today. PAHO – in what is a crucial objective in addressing the unfinished agenda – aims to help the Ministry of Health to halve the NMR over the upcoming five years, 2006-2010.

A recurring problem affecting pregnancy in Guyana is the prevalence of anaemia in pregnant women, something which affected over half of all pregnant mothers at the beginning of the biennium. A situational analysis revealed that the two public maternity facilities, at New Amsterdam and Georgetown, both have the standards to resolve cases of anaemia. They are able to replenish the blood volume of anaemic patients, in accordance with the figures given by the laboratory tests that are carried out in both facilities. The result will be that during the period under review (2006-2010), the prevalence of anaemia in pregnant women will decrease from 54% to 30%.

The inherent capacity of the maternity facilities at the New Amsterdam and Georgetown Public hospitals also played a role in reducing the incidence of postpartum haemorrhage, particularly while uterus tonics and inputs and supplies for the management of the hydration of the patients were also available. In addition, health professionals will continue to be trained in clinical protocols, which will enable them to continue to solve maternal and neonatal health problems adequately. Workshop training for post-partum haemorrhage interventions were also developed and implemented in regions 4, 6, 7 and the Guyana Nurse College.

HIV/AIDS is an issue which impacts virtually every sector of the health care system in Guyana, including MCH; PAHO’s strategy has been to adopt a holistic approach to dealing with the disease in this specific area.

The percentage of schools in which the integration of life skills, HIV/AIDS, gender, information technologies and human rights have been incorporated into their curriculum has increased. The manual on Prevention of Mother To Child Transmission (PMTCT) was reviewed, giving it relevance with the new manual of management of PMTCT as elaborated by the WHO.

PAHO has participated on the PMTCT committee of, giving suggestions and contributions to the expansion of the program in the different sites for implementation; staff have also participated in PMTCT training courses, where they were exposed to the strategies of PAHO/ WHO with respect to the achievement of the millennium development goals (MDGs) with regard to HIV/ AIDS and to the direction of the MCH goals of the MOH.
The overall efforts to reduce the infection rate of HIV and STI in pregnant women and newborn children will have yielded positive results with an almost 50% reduction in such cases.

Protecting the Achievements

PAHO’s programmes geared to protecting the achievements gained in Maternal and Child Health in Guyana has several aspects, the key one being the consolidation of the implementation of clinical and community Integrated Management of Childhood Illness (IMCI) strategy to address the total health and well-being of the child. It addresses the management of childhood illness with preventative health care, such as nutrition, immunization, and maternal health.

IMCI was introduced in Guyana in 2001. By the end of 2005 the country had acquired a critical mass of trained Health Care Workers in regions 1, 2, 8, 3, 4, 5 and 6. At this time there are plans for full expansion to all regions by 2006. However there is no evaluation of the process. Local implementation sites have been visited by Suriname health personnel in order to learn from Guyana’s IMCI experience. The national IMCI committee considers that the time has come to start community IMCI in order to engage the community (through community organizations) for the promotion of key evidence-based practices for child care.
During committee meetings a plan was defined (objectives, strategies, activities, timeframe, budget and indicators) and it was decided to start the C-IMCI implementation process in region 2 and 9. The reasons for this decision are related to the regional medical chief’s commitment, an enthusiastic working group and the experience gained with the implementation of clinical IMCI.

Other countries’ experience will be used and materials developed within the RC and PAHO alliance were translated into English and printed. Also, in Guyana 11 (from the 16) key family practices were prioritized. Working relation and communication between partners are very good. C-IMCI will be implemented within the framework of the regional American Red Cross and PAHO alliance. Funds from different sources should be secured. The MOH, PAHO and Guyana’s Red Cross have been decided that an action plan to start the implementation of C-IMCI at regions #2 and 9.

This included the preparation of materials for use in workshop training for IMCI facilitators as well as arranging supervisory visits to the regions to support Community IMCI in the Country. The first Community IMCI training workshop was held in Region 2 and a work plan was approved. Educational materials are also being developed for further Community IMCI training.

Another area of protecting the achievements gained has been the strengthening the capacity of the MOH to protect the population from vaccine-preventable diseases. The vaccination campaign for vaccine-preventable diseases such as Measles, Mumps, Rubella and Yellow-Fever was very successful with over 88% coverage. Vaccination in previously low-coverage areas in Regions 8 and 9 also increased due to campaign activities to encourage previous defaulters to have their children vaccinated. The ultimate goal is to achieve a success rate of over 95% in the low coverage areas. Region 1 is also a low coverage area and special emphasis was placed on this area in 2004. Meetings were held with the Regional Executive Officer, the Regional Chairman and Regional Health Officer to devise strategies to combat the constraints faced in this Region. The meetings were reinforced by the EPI Situational Analysis and the System Barriers Report.

Training on Events Supposedly Attributable to Vaccination and Immunization (ESAVI) was conducted at the National EPI meeting in October 2004 and in Regions 5 and 6 by the MCH Staff. A Community Health Workers Manual was produced for the first time in January 2004 with the assistance of PAHO/WHO and this was used for Expanded Programme in Immunisation (EPI) training in Regions 4 (East Coast Demerara), 5, 6, 8 and 9. A third edition of the EPI National Reference Manual was produced at the end of 2004. PAHO/WHO devoted tremendous efforts and resources to complete the manual. Guyana's Surveillance system and integration of EPI within the MCH system was reviewed by a visiting team from Suriname. A Guyanese team reciprocated the visit, an Annual technical meetingwas held in accordance with the Technical country Cooperation (TCC) guidelines in February 2005.

The EPI has produced notable successes particularly in the following areas: surveillance of poliomyelitis, tetanus including neonatal and adult, diphtheria, whooping cough (pertussis), tuberculosis and yellow fever. The last reported case of whooping cough was in 2002. Guyana has maintained a polio free status since 1962 and there has been no reported case of yellow fever or measles since 1968 and 1991 respectively. A total of 105 sites in the country are required to report weekly – every Tuesday – to the Ministry of Health (MOH) on all vaccine preventable diseases.

During the period under review, the programme became a beneficiary of the Global Alliance for Vaccination and Immunization (GAVI) for the support of Pentavalent vaccines, AD syringes, safety boxes and infrastructure support for new initiatives. PAHO and the Ministry of Health have produced a Financial Sustainability Plan for EPI and the EPI systems barriers report for GAVI.
Some 14 health care sites are mandated to report on Acute Flaccid Paralysis and other communicable diseases. Specimens of all diseases are sent to CAREC for testing. It should be noted that the country received the surveillance award from CAREC in 2000.

Maintenance coverage in antigens under 1 year remained high - over 90% - over the last two years, despite constraints in the hinterland areas.

PAHO has assisted the MCH in the review and revision of the Health Information System (HIS), the main objective being the strengthening of maternal and neonatal health measures at a national level. This has resulted in an improvement in the quality, timeliness and efficiency of the information routinely generated by the HIS, in the maternity section of the GPHC and New Amsterdam. A report was also developed to measure MCH indicators through a facility based monitoring system.

PAHO has developed situation analysis in the Georgetown Public Hospital, the New Amsterdam Public Hospital, and the West Coast Demerara Hospital and have also devised key indicators to measure the results and effects of the interventions in the health services. The EOC and the EmOC in the maternities have also been defined.

PAHO and the Ministry of Health have established a Maternal Mortality Audit Committee in hospitals to review maternal deaths. The audit committee will review classify and analyse maternal deaths in the GPHC and NAPH over the last five years. It will also develop guidelines for the Maternal Mortality Epidemiological Surveillance and prepare a training programme on the management of maternal deaths in both maternity facilities.

PAHO has been working to establish Perinatal Information System (SIP) in local Hospitals. SIP is currently part of the Guyana Strategic Plan for the Reduction of Maternal and Neonatal Mortality 2006-2010. More specifically, SIP is expected to contribute to standardize and improve the capacity to undertake monitoring and surveillance of maternal, perinatal and neonatal events in 5 hospitals located in regions 2, 3, 4, 5 & 6. Work on this initiative has been completed at a level which would allow the teaching of SIP and the supervision of its implementation in Guyana. The Standard SIP form and Perinatal Passport, with coat of arms, has been prepared and would be handed to the printers shortly. These include a tutorial on specialized workshop including clinical form completion in antenatal and delivery care, data capture and analysis for focal quality assurance, decision making and research.

PAHO /CLAP/WR follow up activities will focus on (i) the progress on the strengthening of MoH surveillance system for maternal mortality, (ii) the strategies to train and ensure improved clinical management of pregnancy-related complications in hospitals and primary care facilities, (iii) support the School of Midwifery and New Amsterdam hospital in developing a plan to improve midwifery competencies at all provider level, including midwives, medex, and nurse assistants, (iv ) the implementation of SIP forms (clinical record and card), and (v) the potential need for using CLAP job aids (perinatal technologies) such as gestogram tapes to measure height of fundus and cephalic perimeter, among others.

Facing the Challenges

One challenge lying ahead is to establish a fully integrated service for sexual and reproductive health. Towards this end, the MoH in collaboration with PAHO has approved and published the Maternal and Neonatal Mortality Reduction Strategic Plan for the period 2006-2010. The Plan – intended as a collaborative effort of the various regional health bodies – includes a SWOT analysis on maternal and neonatal health, a mission statement and the elaboration of strategies. Preliminary workshops are also to be held.

In the area of resource mobilisation, financial resources have been obtained from a number of international donor agencies to promote and support technical work in a number of areas. The American Red Cross had allocated US$80,000 in 2005 and UNF had allocated US$40,000 in 2006 for the implantation of community IMCI. Technical and financial cooperation has been negotiated with the Centre for Perinatology and Human Development (CLAP), based in Uruguay, for the implementation of the SIP in Guyana. US$40,000 has been allocated for the implementation of the SIP.

A project to reduce maternal mortality has obtained technical and financial support. The project would cover the preparation and implementation of the Maternal and Neonatal Strategic Plan and a strategy to expand the situation analysis to other regions in the country. This same project initiated a study on domestic violence and its relation to maternal deaths. Resources have been allocated for the contract of a principal researcher to conduct the study.

Resources have also been allocated to conduct a study on maternal and neonatal legislation. Additionally, efforts are also being made to secure resources to contact a consultant who would work with the Ministry of Health to prepare a Strategic Plan on adolescent health in the country.

Funds totalling US$1,500,000 have been secured under the WHO/EU Strategic Partnership Agreement for a period of four years to promote the study of maternal mortality and morbidity and safe motherhood activities.

Something which needs to be developed in order to strengthen maternal and neonatal health programmes is the political and financial commitment through advocacy and effective partnership A cross-section of organisations has joined efforts to participate in communities involved in workshops on nutrition, safe motherhood and PMTCT.

PAHO is also working to inform, educate and organise communities for them to be able to recognise and take appropriate actions relating to maternal, neonatal and child health problems Several meetings were held in various parts of the country to discuss and promote health and health related issues with regional and local community leaders. At Karasabai in Region 9, and Linden in Region 10, the meetings discussed the maintenance of healthy markets, cleaning of the communities and safe motherhood. These communities have also been involved in working groups of the UN.

Meetings with health workers of the GPHC, NAPH, WCDH, Bartica, Suddie, Berbice, Karasabai and Linden discussed the management of the network of services, the maternal and child programmes, the satisfaction of the users, the confidence level of the health providers with the quality of work, and relations with the community and the level of community involvement.

Support was provided to the health team of the MOH (direction of epidemiology) for the organization and supervision of health teams in the national flood emergency.

The Country Office was involved with the Ministry of Health in advocating and enabling environment for safe motherhood and newborn children in preparation for World Health Day. PAHO also participated in the National Committee for World Health Day which included such activities as the creation of an information base on concepts and safe motherhood interventions, a public gathering and parade organized by the maternal and child health agencies. This latter activity was a great success in New Amsterdam. PAHO is also working to promote involvement of civil society in development of interventions in Family and Community Health (FCH).

A training needs assessment was developed in GPHC, NAPH and WCDH and is part of the situational analysis report. The assessment included measurement of the knowledge of health workers in the management of the obstetric and neonatal complications, defined the level of confided information and observed the clinical skills used by health workers to perform a review of maternal deaths.

Health professionals were trained in clinical protocols and can solve maternal and neonatal health problems adequately in region 4, 6 and 7. Workshop training for post-partum haemorrhage interventions developed and implemented in region 4, 6, 7 and Guyana Nurse College.

PAHO has also worked toward strengthening the Capacity of the MOH to implement cost-effective interventions for reduction of under-5 mortality. The CO developed guidelines for health providers in the management of children in national flood emergencies and the management of children, women and pregnant women in shelters during floods.

The objectives of the expanded immunization programme are to maintain vaccination coverage of over 90% in each sub-district and region and to achieve zero cases of vaccine preventable diseases.

It is also expected to maintain a high surveillance for rash with fever, acute flaccid paralysis and other preventable diseases and to prevent neonatal tetanus by continuous vaccination of prenatal mothers with DT vaccine during pregnancy.
The immunization programme is geared to achieve a measles and rubella free country by 2015. In order to achieve this objective, all risk groups will be targeted for vaccination with DT, MMR, Yellow Fever and Hepatitis B vaccines.