INSTITUTE OF HEALTH, SCHOOL OF PUBLIC HEALTH

DEPARTMENT OF GENERAL PUBLIC HEALTH

ASSIGNMENT ON MATERNAL HEALTH SERVICES

SUBMITTED BY: GROUP ONE MEMBER

NAME ID NUMBER

1. Asnake Tadesse -----------------------------WP0540/14

2. Ashenafi Lemesa---------------------------- WP0536/14
3. Yosef Tekle------------------------------------WM0010/14
4. Kasahun Tesfaye ----------------------------- WM0010/14
5. Mustafa Aman--------------------------------- WP0534/14

SUBMITTED TO: - DAWIT GALGALO (BSC, MPH , PHD/RH FELLOW)

December, 2022

Adola,Ethiopia

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 ACKNOWLEDGEMENT

We would like to express our special thanks of gratitude to our teacher Mr. Dawit Galagalo (BSC, MPH, and
PHD/RH Fellow) who guides us at every step & every aspect of this assignment , so that’s completed
successfully.

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 Table of contents page number
ACKNOWLEDGEMENT ................................................................................................................................................. ii
LIST OF FIGURES .......................................................................................................................................................... iv
LIST OF TABLES............................................................................................................................................................. v
ACRONYMS .................................................................................................................................................................... vi
1. INTRODUCTION ......................................................................................................................................................... 1
1.1Back ground ...................................................................................................................................................................................... 1
1.2 General Consideration....................................................................................................................................................................... 2
2. ANTENATAL CARE SERVICE .................................................................................................................................. 4
2.1 Introduction ...................................................................................................................................................................................... 4
2.2 Antenatal care coverage and content.................................................................................................................................................. 4
2.3. Basic components of the new Approach ........................................................................................................................................... 6
2.4 Maternal and fetal assessment at first ANC contact ............................................................................................................................ 7
2.5 Maternal and fetal assessment during subsequent contacts ................................................................................................................11
2.6 Health and Nutrition Education during ANC ....................................................................................................................................12
2.7 Weight Gain during Pregnancy ........................................................................................................................................................13
2.8 Risk Screening and Referral .............................................................................................................................................................14
2.9Anemia.............................................................................................................................................................................................14
2.10 Infections during Pregnancy ...........................................................................................................................................................15
2.11 Role of Trained Traditional Birth Attendants (TTBA’s) ..................................................................................................................16
3 DELIVERY CARE SERVICE ......................................................................................................................................17
3.1 Aims of delivery care are to achieve .................................................................................................................................................18
3 .2 TBA and Delivery care ...................................................................................................................................................................18
3.3 Obstetric care categories ..................................................................................................................................................................19
4. POST NATAL CARE SERVICE .................................................................................................................................23
5. FAMILY PLANNING SERVICES ..............................................................................................................................24
5.1 Objectives, Strategies and Service Modalities of FP in Ethiopia ........................................................................................................25
5.2 Eligibility ........................................................................................................................................................................................25
5.3 Justifications for the Provision of FP Services ..................................................................................................................................25
5.4 Types of Family Planning Methods Natural methods ........................................................................................................................25
5.5. Factors for Effective Family Planning Programs ..............................................................................................................................27
6. SAFE ABORTION AND COMPREHENSIVE ABORTION CARE ..........................................................................28
6.1 Complication of unsafe abortion.......................................................................................................................................................30
6.2 Abortion related care........................................................................................................................................................................31
6. SUMMARY ON MAJOR CAUSES OF MATERNAL MORTALITY AND SERVICES TO BE DELIVERED ......34
7.REFERENCES ..............................................................................................................................................................36

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 LIST OF FIGURES

Figure 1 Essential health sector intervention for save motherhood ................................................................................................. 3

Figure 2.Trends in antenatal care coverage .................................................................................................................................... 5
Figure 3.Share of abortion for maternal death in Ethiopia ............................................................................................................ 29

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 LIST OF TABLES

Table 1.ANC contact schedule ....................................................................................................................................................... 6

Table 2.Selected clinical conditions (screening from clinical data) and methods of screening when indicated................................. 9
Table 3.Existing and newly developed high-risk conditions during pregnancy ............................................................................. 10
Table 4. Assessment and interventions in subsequent ANC contacts ............................................................................................ 11
Table 5.Recommended maternal weight gain during pregnancy and dietary diversification .......................................................... 13
Table 6.Difference between Basic EOC (BEOC) and Comprehensive EOC (CEOC) ................................................................... 20
Table 7.components and level of emergency obstetric care .......................................................................................................... 22

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 ACRONYMS

ANC------------------------------ Antenatal care

CHW------------------------------- Community health worker

CMR------------------------------ Child mortality rate

EDHS----------------------------- Ethiopian Demographic & Health Servey

FP--------------------------------- Family Planning

IMR------------------------------- Infant mortality rate

PAC---------------------------------post Abortion care

PNC------------------------------- Postnatal care

MMR------------------------------ Maternal mortality rate

TTBA------------------------------ Trained traditional birth attendant

WHO-------------------------------World Health Organization

FANC-------------------------Focused Antenatal Care

PID -----------------------------Pelvic inflammatory disease

UNICEF-------------------------------united Nations international children’s emergency fund

UNFPA-------------------------------United nationsS population fund

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1. INTRODUCTION
1.1Back ground

Maternal health refers to a woman's health and well-being before, during, and after pregnancy and
encompasses aspects of physical, mental, emotional, and social health. The World Health
Organization defines maternal health as the health of women during pregnancy, childbirth, and the postnatal
period.”

Maternal health also includes the absence of maternal morbidity, severe maternal morbidity, and maternal
mortality. Maternal morbidity refers to health conditions that complicate pregnancy and childbirth or that
has a negative impact on a woman's health and well-being. Severe maternal morbidity (also called acute
maternal morbidity) refers to outcomes of labor and birth that result in significant negative short- or long-
term consequences to a woman's health.

Globally, an estimated 810 women died each day due to complications of pregnancy and childbirth with the
majority of deaths in low- and middle-income countries in 2017. Between 2000 and 2017, the average
annual rate of reduction in global maternal mortality was 2.9%, which is far short of what is needed to
achieve the global Sustainable Development Goals (SDG) targets.

The SDGs prioritize maternal mortality reduction, with a global average maternal mortality target of less
than 70 per 100,000 live births and a supplementary national target that no country should have an MMR
greater than 140 per 100,000 live births by 2030. For every woman who dies of pregnancy-related causes,
many more will suffer from morbidity, disabilities and long-term ill-health. Given the current pace of
progress, it is estimated that we will fall short of the SDG target by more than one million lives as well as a
burden on maternal health and well-being.

Ethiopia made a striding change in maternal death over the last decades, the MMR decreased from 871 per
100,000 in 2000 to 401 per 100,000 in 2017; this is death of about 12,000 mothers every year. Direct
obstetric complications account for 85% of the deaths. The long-term conditions disable women following
delivery-related complications, such as fistula, uterine prolapsed, chronic pelvic pain, depression and
exhaustion. Fistula is especially common in Ethiopia, primarily due to the frequency of adolescent
pregnancy combined with neglected prolonged labor.

High maternal mortality rates are also directly related to high neonatal mortality rate of 29/1,000 live births.
This reflects the difficult state of the mother at the time of birth. The main cause of neonatal deaths includes
prematurity, asphyxia and sepsis.

Among the direct causes of maternal deaths, reports from evidence showed that abortion related deaths are
on decline while bleeding during and after child deaths are causes most of the deaths. Such a decline in
maternal death achieved by collaborative effort of the Ministry of Health, partner organizations, bilateral
organizations and joint effort of the community and other stakeholders.

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 The achievement is a result of increasing uptake of skilled delivery service with an increment from 8% in
2000 to 49% in 2019 as seen in the most recent mini-EDHS. Preventing every unwanted pregnancy by using
modern family planning, using skilled delivery service for every delivery and access to emergency obstetrics
and newborn care for every complication markedly reduces maternal death. The ministry of health expands
the recommended services including quality antenatal care, postnatal care and comprehensive abortion care
that is being delivered through the three tier health system.

1.2 General Consideration

For most women in the developing world the luck of regular access to modern health services greatly contributes to
the increased morbidity and mortality. Most mothers receive insufficient family planning advice and ante natal care
or none at all and deliver without access to skilled obstetrical care when complications develop. Even in countries
with relatively well-developed health systems, preventable maternal illness and death persist because of inadequate
management of the complications of pregnancy.

Based on the above issues the important and major purposes of provision of Maternal Health Services are:

• Prevention of maternal morbidity and mortality

• Recognition and treatment of complications as they arise, and

• The promotion of the health of the mother and the newborn.

Maternal health services include

 Antenatal care

 Delivery care

 Postpartum care

 Family planning

 Post abortion care

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Figure 1 Essential health sector intervention for save motherhood

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2. ANTENATAL CARE SERVICE

2.1 Introduction
Antenatal care (ANC) is a health service provided to pregnant women in the continuum of maternity care.
The WHO defines ANC as the care provided by skilled health care professionals to pregnant women and
adolescent girls to ensure the best health conditions for both mother and baby during pregnancy.

The components of ANC include: risk identification, prevention and management of pregnancy-related or
concurrent diseases, health education and health promotion. Additionally, it provides an opportunity for
reproductive health service integration. Making adequate preparation for birth and emergencies is also an
important ANC intervention to end preventable maternal and perinatal mortality and morbidity.

The ANC also serves as a platform for pregnant women and adolescents to have access to comprehensive
reproductive health (RH) services. Thus, the ANC is not only destined to ensure a healthy mother and a
healthy baby by providing quality ANC, but also to make pregnancy a healthy and positive experience for a
woman and her family. These can be achieved by ensuring the physical, emotional, and mental wellbeing of
pregnant women, and creating an opportunity to link ANC to other health services.

Historically, the ANC service was initiated in the 1900s in the United Kingdom. Traditional ANC was
practiced until focused antenatal care (FANC) was introduced in 2002. Recent evidence noted that when
compared to the previous model, the FANC model was associated with more adverse events, especially
increased perinatal mortality. These findings informed the review of the ANC contact schedule, which was
increased to eight contacts rather than four visits, among other interventions.

The maternal mortality ratio (401/100,000 live births) and neonatal mortality rate (33/1000 live births) in
Ethiopia are among the highest in the world and Ethiopia adopted the 2016 WHO model of eight contacts to
reduce maternal and perinatal mortality and morbidities.

Specific to the current guideline, within the continuum of RH care, ANC provides a platform for important
health care functions, including health promotion and disease prevention, screening, diagnosis, and
management. It has been established that by implementing timely and appropriate evidence-based practices,
ANC can save lives. Crucially, ANC also provides the opportunity to communicate with and support
women, families, and communities at a critical time in the course ofa woman’s life.

2.2 Antenatal care coverage and content

Skilled Providers Antenatal care (ANC) from a skilled provider Pregnancy care received from skilled
providers, such as doctors, nurses/midwives, health officers, and health extension workers
The 2019 EMDHS results show that 74% of women who had a live birth in the 5 years before the survey
received ANC from a skilled provider for their last birth

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 Figure 2.Trends in antenatal care coverage

According data from Mini EDHS 2019 (Figure 2)

Forty-three percent of women in Ethiopia had at least four ANC visits during their last pregnancy, while
26% of women had no ANC visits. Rural women (29%) were more likely than urban women (15%) to have
no ANC visits.

Only 28% of women had their first ANC visit during the first trimester, while 32% had their first visit during
the fourth or fifth month of pregnancy and 12% had their first visit during the sixth or seventh month. Two
percent of women did not receive any ANC until the eight month of pregnancy or later

Forty-three percent of women in urban areas received ANC within their first trimester of pregnancy, as
compared with 22% of those in rural areas

Trends: The proportion of women with the recommended four or more ANC visits increased from 12% in
2005 to 43% in 2019. During this same time period, the proportion of women who received ANC in the first
trimester increased from 6% to 28%

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 2.3. Basic components of the new Approach

As per the 2016 WHO recommendation, Ethiopia is replacing the previous four-visit FANC model with the
new ANC eight-contact model. In order to reduce perinatal mortality and improve the pregnancy experience
of women, a minimum of eight contacts is required. For those pregnant women with identified problems,
additional contacts may be scheduled as necessary.

Accordingly, the first contact is recommended to be a single contact in the first trimester (up to 12 weeks),
two contacts in the second trimester (at 20 and 26 weeks of gestation), and five contacts in the third trimester
(at 30, 34, 36, 38, and 40 weeks)

The appointment schedule is: first appointment during the first trimester, second appointment 8 weeks later;
the third, 6 weeks later; fourth and fifth 4 weeks apart; and then the rest every 2 weeks. The reason for
increasing the number of contacts in the third trimester is considering the increased risk of complications to
the mother and the fetus during this period of gestation.

This schedule enables the ANC provider to early detect and treat potential maternal and fetal complications
before advancing to a severe or irreversible stage. It also gives room for the pregnant woman to share her
symptoms and worries with her care provider before worsening. In the current model, the word “visit” is
replaced with “contact” as the connotation of the latter indicates an active connection between a pregnant
woman and a health care provider

Table 1.ANC contact schedule

Contacts Gestational age of contact in Schedule of next
weeks appointment

First trimester
st
1 Up to 12 After 8 weeks

Second trimester
nd
2 20 After 6 weeks
rd
3 26 After 4 weeks

Third trimester
th
4 30 After 4 weeks
th
5 34 After 4 weeks
th
6 36 After 2 weeks
th
7 38 After 2 weeks
th
8 40

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 2.4 Maternal and fetal assessment at first ANC contact

History and physical examination

Creating a rapport between the ANC provider and the pregnant women with a welcoming environment and
respectful reception is critically important to get full information about her pregnancy history, make her
comfortable for physical examination and investigations, and, above all, to create a comfort zone for the
continuity of the woman in the health service.

Once communication is established, pregnancy-specific assessment can be started. The end goal of the first
contact assessment is identifying clinical evidence to classify the woman as deserving routine or special
care/referral. To reach either conclusion, the summary of a systematic approach is presented in Box 1.

Box 1. ANC history and physical examination during first contact

 Identification: name, age, address, phone number, occupation, and marital status
 Menstrual history: date of first last normal menstrual period and regularity of
the menses; current or previous breastfeeding, use of contraception; determining
the gestational age and EDD
 History of present pregnancy: including pregnancy symptoms, fetal kicks, and
any complication to date
 Intention of the present pregnancy: planned/unplanned;if
unplanned, wanted/unwanted
 Past obstetric history: number of pregnancies and outcome of each; cesarean
sections; problems and complications, including bleeding, preterm births,
stillbirths, and high blood pressure during pregnancy
 Medical history: including cardiovascular disease, renal disease, diabetes
mellitus, convulsion, tuberculosis, and other past and current medical problems
 Current medication: including therapeutic medicines, illicit drugs,
herbal/traditional remedies, drug allergy
 Gynecologic history: including screening for cervical cancer, gynecologic surgery, STI
 Nutritional history: number of food groups and frequency of meals consumed
per day, craving for unusual food type, appetite, emesis
 Social and personal history: including use of alcohol, tobacco, exposure to
second-hand smoke, khat, caffeine in large quantity (>300 mg/day or >3 small
cups of Ethiopian coffee), or other harmful substances, assessing for intimate
partner violence, female genital mutilation (FGM)
 Mental health: ask if pregnant woman felt depressed, sad, hopeless, irritable,
worried a lot, had multiple physical complaints, felt little interest or pleasure in
doing things
 Intimate partner violence: have you been hit, kicked, slapped or insulted,
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 threatened, screamed, cursed at by your husband or somebody close?
Physical examination

 General appearance for pallor, respiratory distress

 Vital signs: blood pressure in left lateral or sitting comfortable position, pulse rate,
respiratory rate, temperature
 Weight and height: height as a baseline and weight measurement for weight gain
monitoring during pregnancy
 Acute malnutrition screening: using MUAC
 Examining the conjunctiva, oral mucosa, and nail beds for pallor
 Auscultating the chest for breathing sounds and heart sounds, any additional sounds
 Obstetric examination: Measuring the symphysis fundal height and doing the
Leopold maneuvers
 Auscultating the fetal heartbeat with Doppler (12+ weeks), Pinard fetoscope (20+
weeks), palpating the abdomen for any mass or organomegaly
 Examining the musculoskeletal system for any gross deformity/swelling, varicose
veins in the lower limb
 Examine for any sign of trauma like bruises that would indicate intimate partner
violence
 Examining the FGM scar after consultation and deciding on the need of
deinfibulation (in high prevalence areas)
Vaginal examination is not a routine practice during ANC. The most common indications are symptoms of
STI, vulvovaginal candidiasis, bacterial vaginosis, history of FGM, screening for precancerous cervical
lesion, vaginal bleeding (speculum after 28 weeks of gestation), suspected leakage of amniotic fluid
(speculum), and suspected preterm labor.

Basic and case-specific ANC screening

The following tests should be done for all pregnant women.

 Hemoglobin (Hb) or hematocrit (Hct), blood group, and Rh

 Urine analysis: dipstick, microscopy and gram stain
 Tests for HIV, HBV, syphilis
 Ultrasound before 24 weeks: One ultrasound scan before 24 weeks of gestation (early ultrasound) is
for all pregnant women to estimate gestational age, improve detection of fetal anomalies and
multiple pregnancies, placentation, reduce induction of labor for post- term pregnancy, and improve
a woman’s pregnancy experience.

 Selective or case-specific screening is recommended for gestational diabetes mellitus, Tb, and group
B streptococcus (GBS).

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Table 2.Selected clinical conditions (screening from clinical data) and methods of screening when indicated

Clinical condition Suggestive evidence Methods of screening

Gestational Personal or family history, 75 gm 2-hour OGTT (oral
diabetes previous macrosomia or glucose tolerance test;
mellitus stillbirth, obese, large-for- details are in the national
date uterus, family history, management protocol)
glycosuria
Tuberculosis Current cough, weight Symptom-based screening
(TB) loss/failure to gain weight, and performance of
night sweats, and fever diagnostic test

Group B Previous perinatal infection Vaginal swab culture

streptococcu with Group B streptococcus
s

Pregnancy risk identification

While all pregnancies are potentially at risk (complications often occur in pregnant women with no known
risk conditions), it is important to do risk identification and stratification at first contact and in subsequent
visits. Multiple assessment methods (past and present obstetric history, medical and surgical history,
systematic physical examination, laboratory, and imaging) are applied to assess the health and wellbeing of
the mother and the fetus.

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Table 3.Existing and newly developed high-risk conditions during pregnancy

Existing conditions Newly developed conditions

 Age <19 and >35 years  Threatened abortion
 Elderly primigravida  History of exposure to
 Short stature teratogenic drugs, chemicals, or
 Overweight/obese (BMI >25 kg/m2) or radiation
underweight (BMI <18.5 kg/m2)  Pregnancy after sexual assault
 Severe physical deformity/disability  Multiple pregnancy
 Multiple pregnancy  Antepartum hemorrhage
 History of three or more abortions or  New onset or superimposed
one or more stillbirths hypertension
 Birth weight of previous baby <2500 or  Oligohydramnios or
>4000 gm polyhydramnios
 Previous manual removal of  Lack of uterine growth or
placenta, malpresentation, confirmed fetal growth
malposition, post-term, pre- restriction
eclampsia/eclampsia, operative  Large for date uterus
delivery  Anemia
 Rh-sensitized mother  Rh-sensitized mother
 Anemia, chronic medical diseases,  Systemic infection
including diabetes mellitus, renal, cardiac  Acute pyelonephritis
disease and chronic hypertension
 Recurrent lower urinary tract
 Psychiatric illness infection
 Unplanned and/or unwanted pregnancy  Bacterial vaginosis
 High HIV viral load, acute viral  Gestational diabetes mellitus
hepatitis, syphilis, TB, malaria, and other
 Preterm labor
systemic infections
 Post-term pregnancy
 Imprisoned pregnant women
 Abnormal presentation or
abnormal lie
Homeless pregnant women  Prelabor rupture of fetal
 On chronic treatment for certain disease membranes
 Chorioamnionitis
 Short cervix

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 2.5 Maternal and fetal assessment during subsequent contacts

In subsequent ANC contacts, the focus of assessment is to reevaluate the changes from the previous status
and to look for new developments. Therefore, gestational age-based assessment in subsequent visits is to
assess maternal wellbeing, fetal growth and wellbeing. When there are doubtful conditions, additional
investigations could be requested.

On top of making a thorough assessment in every subsequent contacts (as described in Table 4), instructing
the woman on how to detect her and the wellbeing of the fetus is critical. Warning about danger symptoms
and signs of pregnancy is included in the counseling section.

Table 4. Assessment and interventions in subsequent ANC contacts

Gestatio
nal age Specific activities
in weeks
20 Review the history, physical findings and laboratory results at first
(2nd contact
contact) Ask about fetal movement
Enquire about any complaint or concern
Determine the gestational age
Observe her general appearance
Measure blood pressure
Measure weight check for weight gain
Look for pallor
Measure arm for acute malnutrition screening using MUAC
Measure the uterine fundal height
Listen for fetal heartbeat
Perform ultrasound scanning
Initiate iron-folate and calcium supplementation and counsel on
adherence
Provide preventive chemotherapy(deworming)
Check for other danger signs and symptoms
Assess feeding practices and counsel on optimal maternal nutrition;
extra meal/feeding frequency, diet diversity, including fruit and
vegetables, animal source feeding
Assess for mental health and intimate partner violence

26 Conduct same activities as week 20 except for ultrasound scanning

(3rd Conduct urinalysis for proteinuria and urine gram stain
contact) Test for gestational diabetes for high-risk pregnant women

Gestatio
nal age Specific activities
in weeks

11
 30 Conduct same activities as week 20 except for ultrasound scanning
Repeat testing for syphilis and HIV if earlier test results are negative
(4th contact) Repeat Hb test
Perform fetal wellbeing assessment if there is a discrepancy between
fundal height and gestational age or if there is a reduction in fetal
movement
Counsel on birth preparedness and complication readiness
Counsel on optimal breastfeeding practices

34 Repeat all activities done at 30 weeks

Determine fetal presentation
(5th contact) Test urine for proteinuria for high-risk women
Repeat testing for syphilis and HIV if not done at 30 weeks
Counsel on breastfeeding and immunization
Counsel on stimulation for early childhood development

36 Conduct all activities done at 34 weeks

Assess mental health
(6th contact)

38 Conduct all activities done at 36 weeks

Inquire any fears, myths, worries about labor and delivery
(7th contact)
Repeat Hb test
Advise the pregnant woman on fetal movement counting

40 Repeat all activities done at 38 weeks

Review fetal movement counting
(8th contact) Ultrasound scanning for fetal wellbeing assessment

2.6 Health and Nutrition Education during ANC

Health and nutrition education during ANC must focus on:
• Pregnancy: fetal movement (especially for primigravida), labor and common problems
• Diet and Nutrition: extra food, weight gains, fasting and rest
• Avoiding alcohol, tobacco, and drugs (especially in the first trimester)
• Personal hygiene • Delivery preparation
• Labor signs
• Breast-feeding
• Newborn care
• Family planning
• Traditional beliefs and practices

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 2.7 Weight Gain during Pregnancy

Pre-pregnancy weight and weight gain in pregnancy are both critical and additive in their effect on
pregnancy outcome. Equal emphasis should be given to assuring that both are normal.

A pregnant mother has to have weight measurement a month apart, anytime during the second or third
trimester. A gain of less than one kg per month is the danger signal, with no weight gain or weight loss
being even more severe and calling for immediate action, such as food supplementation directly for the
woman.

Mothers should be weighed and counseled at the available opportunity present either during prenatal care or
when they bring their children for immunization or growth monitoring.

Arm circumference is the most feasible measurement to implement. The same cut-off point can be used to
identify under nutrition in or out of pregnancy and ranges from 21-23.5cm depending on the country or
region. Because of the simplicity of arm circumference technology, which requires only an inexpensive tape,
women can measure each other in their own homes.

Table 5.Recommended maternal weight gain during pregnancy and dietary diversification

Baseline/ Recommende
pre-pregnancy d weight gain Dietary diversification
BMI in kg/m2 in kg
Underweight 12.5–18 More calorie and protein diet adequate vegetables
(<18.5) and fruits
Normal (18.5 to 11.5–16 Moderate carbohydrate and protein diet adequate
<25) vegetables and fruits
Overweight (25 to 7–11.5 Normal carbohydrate and protein diet, very
<30) low fat, more vegetables and fruits
Obese (≥30) 5–9 Lower carbohydrate and protein diet, more
vegetables and fruits, avoid fat foods

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 2.8 Risk Screening and Referral
The aim of prenatal care is to assess the risk of complications in later pregnancy, labor or delivery and
arrange for a suitable level of care.

Though many systems of risk scoring of varying levels of complexity have been devised, most of the major
problems which can lead to maternal mortality cannot be predicted with sufficient accuracy, except in the
case of obstructed or prolonged labor.

In addition, risk approach for maternity care can only work if all women are screened by adequately trained
personnel, and if appropriate referral services are acceptable and within their reach geographically,
logistically and financially.

Even where the risk approach works, however, the need for emergency care is not eliminated due to the
unpredictability of many complications. A history of prolonged labor in a multigravida with or without
adverse outcomes, and short stature in relation to the local norms, are strong risk factors for obstructed labor.
Cut off points for height and for number of previous births must be selected based on local circumstances to
ensure that the maximum proportion of those who may develop problems are identified without
overwhelming service capacity.

Some health care systems have established the feasibility of providing maternity waiting homes for women
with high-risk pregnancies, where they can wait for the onset of labor close to a health care facility well
prepared to handle obstetric problems, without occupying the limited number of hospital beds.

2.9Anemia

Anemia is very prevalent among women in developing countries, as a result of iron and/or folate deficiency
and of malaria and other parasitic diseases. WHO estimated that around 60 percent of pregnant women in
developing countries (other than China) had nutritional anemia despite efforts in iron supplementation,
fortification and dietary modification Anemia contributes to maternal mortality by making women more
susceptible to infection and less able to withstand infection or the effects of hemorrhage.

Anemia is known to give rise to considerable long- term morbidity in women, and at extreme levels may be
associated with low birth weight. Anemia during pregnancy may be aggravated by malaria, hookworm
infection, and schistosomiasis.

Death from anemia results from heart failure, shock, and infection due to lowered resistance. Effective
prevention depends ultimately on lifelong nutrition of girls and women, and thus on agricultural and
economic factors and food distribution patterns within communities and families. It can, however, be
detected and treated simply and effectively during pregnancy.

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Though the use of routine iron and folate supplementation in pregnancy has been abandoned in industrial
countries where anemia and subclinical deficiency are rare, this approach almost certainly has a place in
areas where they are common; acceptable doses of inexpensive oral supplements can prevent anemia from
developing or treat mild to moderate disease.

Supplements may, however, produce unpleasant side effects, such as nausea and constipation, and
compliance may be poor, especially in the absence of symptoms of anemia, or where symptoms are accepted
as normal in pregnancy.

Iron can be given intra-muscularly or intravenously to ensure compliance and avoid gastro-intestinal side
effects, but hemoglobin does not rise any more rapidly through this form of administration than through
adequate oral therapy. Blood transfusion as a treatment for anemia is discouraged because of the serious
dangers of blood borne infection of, notably, HIV, malaria, syphilis, and hepatitis B.

2.10 Infections during Pregnancy

Pregnant women are sexually active and at risk of sexually transmitted disease, including HIV/AIDS. In
prenatal care screening and treatment for syphilis is routine and is a cost-effective intervention many studies
in developing countries have demonstrated high prevalence levels of both syphilis and gonorrhea in pregnant
women, leading to considerable long-term morbidity in women, and to congenital disease and prenatal
mortality. Researchers estimate that of those women, who are currently pregnant, 10 to 15 percent have
syphilis and two-thirds of all these pregnancies have an adverse outcome.

Reliable screening tests exist for both syphilis and gonorrhea, as do safe, effective treatments. Screening can
be conducted in the clinic while women are attending and treatment started immediately. Unfortunately,
screening and treatment of sexually transmitted diseases are not often regarded as core components of
prenatal care and may only be available in special clinics. Despite the serious logistic obstacles, effective
screening, treatment and contact tracing programs for all pregnant women is rewarding.

Women are at higher risk of AIDS because the two predominant modes of transmission of HIV infection are
sexual and prenatal. A study in Uganda has shown the HIV infection rate for women to be approximately 1.4
times that of men, and the rate of HIV infection is greater at an earlier age among women (15-19 years) than
among men. The rate of transmission from male to female to be 2.5 times higher than from female to male.

The risk of transmission of AIDS is particularly high were high rates of sexually transmitted diseases,
especially those which cause ulcerative lesions such as chancroid and syphilis, are found. In the case of HIV,
curative treatment is not available, and even treatment to delay the onset of symptomatic disease with
antiviral drugs is not readily available or affordable in developing countries. However, some of the most
effective strategies for sexually transmitted diseases are equally important for AIDS prevention. These
include
• Promoting education strategies that modify or eliminate risk behaviors
• Providing adequate diagnostic and treatment facilities for patients
• Limiting complications by early detection and adequate treatment;
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 • Reducing the risk of infection during genital tract procedures through safe delivery
Procedures
• Reducing exposure to infection by offering health education;
• Limiting further transmission through counseling and partner referral and
• Promoting condom use and targeting family planning programs more aggressively toward men.

Treatment of symptomatic urinary tract infections is important, and it has been shown that screening for
asymptomatic bacteriuria, followed by appropriate antibiotic treatment, reduces the incidence of
pyelonephritis in the mother, as well as the incidence of low weight and premature delivery.

Depending on the local prevalence, screening and treatment for other important infectious diseases,
including malaria and tuberculosis, should be included as essential components of prenatal care. Studies
have shown that malaria is more prevalent in pregnant women than in non-pregnant women. Also, anemia
during pregnancy may be aggravated by malaria infection.

The increased risk of low birth weight babies and the risk of neonatal and infant mortality associated with
low birth weight are of major concern in areas of endemic malaria. Chorio-amnionitis and fetal infection and
loss can be prevented through prompt referral of women with pre-term or pre-labor rupture of the
membranes and prophylactic use of antibiotics.

In developed countries where hepatitis B is prevalent, vaccination of the infants of hepatitis B carriers is
effective in preventing early infection and its long-term sequelae. The incidence of viral hep0atitis was twice
as high for pregnant women than for non-pregnant women, in studies for Ethiopia and Iran. It is also more
serious, with case fatality rates up to three and a half times as high. Malnutrition increases the chances of
contracting hepatitis, as well as its severity. Premature labor, liver failure, and sever hemorrhage are
common complications of severe hepatitis.

2.11 Role of Trained Traditional Birth Attendants (TTBA’s)

In general trained traditional birth attendants are important and helpful in advising and referring during
pregnancy & delivery.
Because TTBA’s can easily identify problems such as:
• Young primigravida
• Previous pregnancy problems
• Short stature (depending on local norms of risk)
• Bleeding before or during labor
• Pre mature rupture of membrane

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 3 DELIVERY CARE SERVICE

Normal birth is defined as Spontaneous in onset, low risk at start of labour and remaining so throughout
labour and delivery. The infant is born spontaneously in the vertex position between 37-42 completed weeks
of pregnancies. After birth, mother and baby (child) are in good condition. Describes as the process by
which the fetus, placenta with its membrane is expelled through birth canal.

Increasing institutional deliveries is important for reducing maternal and neonatal mortality. However,
access to health facilities is more difficult in rural areas than in urban areas because of distance, scarce
transport, and a lack of appropriate facilities. Although institutional delivery has been promoted in Ethiopia,
home delivery is still common, primarily in hard-to-reach areas.

Trends: Institutional deliveries increased from 5% in 2005 to 26% in 2016 and 48% in 2019. During the
same period, there was a sharp decline in home deliveries (94% in 2005, 73% in 2016, and 51% in 201

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 3.1 Aims of delivery care are to achieve

o A healthy mother and child with the leas possible level of intervention
o Early detection and management of complications
o Timely referral of obstetric emergencies (if any) to a level where it can be managed appropriately
Prevention of postpartum hemorrhage

One of the leading causes of maternal mortality is postpartum hemorrhage. Active management of the third
stage of labor (AMTSL) reduces the risk of retained placenta and postpartum hemorrhage. Skilled attendants
must offer AMTSL to all women. It consists of:
1. Administration of a uterotonic drug, preferably oxytocin to the woman within one minute of the birth of the
baby;
2. Controlled traction of the umbilical cord;
3. External massage of the uterus following delivery of the placenta.

The most elementary knowledge in delivery care is the 5c’s

 Clean hands
 Clean delivery surface
 Clean perineum
 Clean cord cutting
 Clean environment

3 .2 TBA and Delivery care

One of the primary aims of trained birth attendant training programs throughout the developing world is to
promote clean delivery in the home through deduction and provision of basic supplies such as sterile razor
blades and washable plastic sheets. It is, however, difficult to ensure cleanliness in all deliveries, particularly
where access to clean water is limited.

Educating trained birth attendants, women, their families, and community health workers to recognize the early
signs of delivery problems including sepsis is a very important activity to save the life of the mother and the
new born.

TBAs attend most of deliveries in Ethiopia and other less developed countries. For example Deliveries attended
by TBA is 31% in Ethiopia according to mini DHS, 2019
Globally there is debate on the effectiveness of TBA training and their roles in preventing maternal and infant
morbidity and mortality

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 Advantages of TBA

 Community-based Sought out by women

 Low-tech

 Teaches clean delivery

 Can provide obstetric first aid at home

 Can provide and teach

 families preventive care and obstetric

Disadvantages of TBA

 Limited access to emergency drugs and other resources

 Distance from referral

 Facility may delay

 Emergency treatment Knowledge, skills and training not standardized

3.3 Obstetric care categories

There are three type of obstetric care

 Essential obstetric care (EOC)
 Emergency obstetric care (EmOC)
 Obstetric First Aid (OFA)

3.3.1 Essential Obstetric care (EOC)

Essential Obstetric care (EOC) is the elements of obstetric care for the mother and new-born needed for the
management of normal and complicated pregnancy, delivery and the postpartum period.

There are two types of EOC

 Basic EOC (BEOC)
 Comprehensive EOC (CEOC)

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Table 6.Difference between Basic EOC (BEOC) and Comprehensive EOC (CEOC)

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2.2.4.2. Emergency obstetric care (EmOC)

Refers a series of crucial lifesaving functions which can prevent the death of women experiencing the start of
complications during pregnancy, delivery or the postpartum period. Is a medical response to a life threatening
conditions, It is not a standard for all deliveries

3.3.2 Obstetric First Aid (OFA)

Obstetric first aid is that part of EmOC that is performed at the more peripheral levels of the health system

 Early recognition of obstetric emergencies

 Administration of parenteral antibiotics

 Administration of parenteral oxytocic drugs

 Administration of parenteral anticonvulsants

 Referral and transport arrangements

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Table 7.components and level of emergency obstetric care

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 4. POST NATAL CARE SERVICE

Postpartum period is a period one hour following the delivery of placenta through the first six weeks of an
infant’s life. During the postpartum period, physical, social, and mental problems can emerge, indicating a need
for both preventive and curative intervention packages

Post Natal Care(PNC): Is Care given after delivery for mother and new born

IN Ethiopia, 34% of women age 15-49 who gave birth in had a postnatal check during the first 2 days after birth,
while 64% did not receive a postnatal check (EDHS 2019)

Post Natal Care (PNC) a care up to six weeks in the postpartum period. Incorrectly given least attention and
usually neglected.
During postnatal care always give equal attention and care for both the mother and the new born Objectives of
Postnatal Clinic:
• Observe physical status
• Advice, and support on breast-feeding
• Advise on Family Planning
• Provide emotional support
• Health education on weaning and food preparation.
• Discuss about menstruation (when it will restart) and when to start sexual relation (this point is usually
overlooked in post natal clinics) Support of the mother and her family in the transition to a new family
constellation, and response to their needs prevention, early diagnosis and treatment of complications of mother
and infant, including PMTCT
 Referral of mother and infant for specialist care when necessary
 Counselling on baby care
 Counselling on maternal nutrition, and supplementation if necessary
 Immunization of the infant
The main life threatening complications of the postnatal period include
 Haemorrhage,
 Anaemia
 Genital trauma
 Sepsis
 UTI and mastitis.
WHO recommends, with limited resources, contact with the health care system at least during the first 24 hrs
and before the end of the first week would be the most effective strategy

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5. FAMILY PLANNING SERVICES

Family Planning-refers to the use of various methods of fertility control that will help individuals (men and
women) or couples to have the number of children they want and when they want them in order to assure the
wellbeing of children and the parents.

Family planning simply means preventing unwanted pregnancies by safe methods of prevention
Family Planning is a means of promoting the health of women and families and part of a strategy to reduce the
high MMR, IMR, and CMR.

Preventing maternal mortality by reducing exposure to pregnancy and therefore to risks associated with
pregnancy and childbirth in the event of wanted births Preventing pregnancy and abortion when pregnancy is
unwanted. Based on the above factors family planning programmers can be taken as the means to offer the
service, to all who desire it, the opportunity to determine when to have children, the number of their children
and spacing of births.

Accordingly Information about FP should be made available in order to promote access to FP services to all
individuals desiring them. Many reports indicate that contraceptive prevalence often rises among older, higher
parity women, or those at greatest risk of abortion. There is also a high prevalence in contraceptive use among
more educated, urban women with better access to services.

Even though family planning programs have raised awareness and contraceptive use throughout the developing
world, there is considerable unmet need for contraception.

According to Mini EDHS 2019

Contraceptive knowledge: Knowledge of family planning is nearly universal in Ethiopia, with 96% of currently
married women having heard of at least one modern method.
Modern contraceptive use: Modern contraceptive use among currently married women has increased steadily
since 2005, from 14% to 41%.
Methods used: Injectables are the most commonly used method among currently married women (27%), followed
by implants (9%).
Sources of modern methods: The most common source of modern contraception is the public sector (87%);
only 12% of women obtain their method from private sector sources.

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5.1 Objectives, Strategies and Service Modalities of FP in Ethiopia

The objectives are to limit the size of a family, adequately space children, Decrease maternal and child
morbidity and mortality due to unwanted pregnancies

Help infertile couples to have children In Ethiopia, as part of family planning service strategies, all health
institutions (rural, urban, government and, private) are expected to provide family planning services. The
delivery modalities which the Ministry of Health is using are Community Based Distribution Services (CBD)
Facility Based ,Work based services ,Outreach Services ,Social marketing

5.2 Eligibility

Family planning services for whom?

Any person male or female who can conceive or cause conception regardless of age or marital status is eligible
for family planning services including family planning counseling and advice.

5.3 Justifications for the Provision of FP Services

The Justifications for the Provision of FP Services is to Decrease fertility rate and population growth, Reduce
maternal deaths by spacing or preventing pregnancy. It is reported to bring 20% reduction in maternal deaths,
Reduce too early, too late, too close too many pregnancies ,Reducing risk of unwanted pregnancies and illicit
abortion, brings immense benefits to children.

It helps to avoid closely spaced, frequently ill children, LBW newborns, and, slow growth of children, Improve
family welfare, Increase sustainable growth and decrease dependency ratio & help infertile couple

5.4 Types of Family Planning Methods Natural methods

 Breast feeding as a contraceptive

 Abstinence
 Withdrawal (Coitus interrupts)
 Periodic abstinence methods or safe days Technical methods
 Hormonal methods
 Mechanical and chemical methods
 Post coital contraception
 Permanent contraception
 Female sterilization and Male sterilization

25
Family planning choices are often the first element of primary health care that can be made available in a resource poor
setting. Provision of basic non-clinical contraceptives requires minimal skill and can be handled by community-based
providers with appropriate training.

The risk/benefit ratio of using methods such as oral contraceptives is in favor of nearly all women in such a setting, and
a variety of cost-effective, distribution systems can be set up, from social marketing to community-based distribution
programs focused on vulnerable groups.

Methods vary in their clinical effectiveness, and couples vary in the degree to which they make proper use of them.
There has been a gradual shift toward more effective and more long-term methods, especially sterilization. Worldwide,
female sterilization is the leading method and now accounts for about half of all contraceptive use, but regional
comparisons show substantial variations in method acceptance. The most popular method in China is the IUD; in
Northern Africa, the pill; and in Latin America, female sterilization. Traditional methods account for over 10 percent of
users.

Although contraceptive methods are not without risk, the risks tend to be small, balanced by some health benefits,
considerably outweighed by the risks of pregnancy and childbirth, and dwarfed by the risks of unsafe abortion. The
health benefits and risks of each method vary by the individual circumstances and the medical condition of the user;
careful counseling of users by family planning providers can further reduce the risks. The IUD, for example, is
associated with pelvic inflammatory disease, mainly in women who are at risk of developing sexually transmitted
diseases.

Barrier methods are not as effective as some other methods in preventing pregnancy, but they have an important no
contraceptive benefit by protecting against HIV infection and sexually transmitted diseases. Factors important when
discussing and selecting contraceptive method include:

o Effectiveness - success if used regularly

o Acceptability - easy to use
o Interference with sexual activity
o Availability - easy to get for continual use
o Side effects- problems and significance
o Reversibility - How easy to conceive again

N,B :-Couples have to select the method that is best for them!! Success depends on all the factors and always, if
possible, discuss with both couples.

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 5.5. Factors for Effective Family Planning Programs

• There must be access to services.

• Services must be provided in both public and private health facilities and through community-based distribution
networks.

• There must be contraceptive diversity to meet varying family planning needs throughout the life cycle and for both
women and men

• Counseling must be offered by health care providers trained to respect clients concerns and sensibilities.

• Strategic management must take into account contraceptive demand, public and political support, the service delivery
infrastructure and the logistical supply system.

• Collaboration with the private sector can be an effective means of reaching many more people. And,

• Effective information, education and communication is essential. Always rember that

• Contraceptive use has no direct effect on the risk of death once pregnant; therefore, if all women were equally likely
to adopt effective methods of contraception, irrespective of age, parity, and other determinants of obstetric risk,
increasing contraceptive prevalence would not change the risk of death once pregnant.

• A decline in fertility also means that first births, which are riskier, will increase as a proportion of all births. This
means that increasing contraceptive prevalence could, in theory, actually lead to an increase in the maternal mortality
ratio, even though the maternal mortality rate and lifetime risk of maternal mortality decline. Abortion is the major
cause of death among reproductive age women in many developing countries.

• The fact that women do resort to primitive abortion, even knowing it to be unsafe, is evidence of their strong desire to
prevent unwanted, unplanned births. Women known to have had abortions are therefore likely to accept contraception,
and should be targeted in family planning efforts. On-site delivery of post-abortion family planning, including the
provision of initial counseling and contraceptive methods following abortion, is essential.

In General Family planning increases the standard of Health and Quality of Life!
It is cost effective more than many other health and social interventions!

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6. SAFE ABORTION AND COMPREHENSIVE ABORTION CARE

Abortion is the termination of pregnancy before fetal viability before 28 weeks of GA or birth weight of <1000gm.

Type of abortion

 Spontaneous:-termination is not provoked deliberately (threatened, inevitable, incomplete, complete or missed

abortion).

 Induced: deliberate interference with the pregnancy for the sake of terminating it.

 Induce abortion may be either safe or unsafe

Safe abortion is performed by qualified persons using correct techniques and in sanitary conditions.

Unsafe abortion:- Terminating an unintended pregnancy either by person without the necessary skills or in an
environment that does not conform to minimum medical standards, or both (WHO ).

Abortion is more than a medical issue, or an ethical issue, or a legal issue. Unsafe abortion- is a critical public health
concern in many developing countries, causing the deaths of 10,000 of women worldwide each year. In Ethiopia,
unsafe abortions account for approximately 25-50% of maternal deaths. Abortion complications are a leading cause of
hospitalization for Ethiopian women

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Figure 3.Share of abortion for maternal death in Ethiopia

Reasons for Induced Abortion

 To stop childbearing

 To postpone childbearing

 Socioeconomic conditions

 Relationship problems

 Age

 Health (including mental)

 Coercion (e.g., rape, incest

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 6.1 Complication of unsafe abortion

Complications can limit women’s productivity inside and outside the home, constrain their ability to care for
children and adversely affect sexual life
Acute Complications
 Incomplete abortion
 Sepsis
 Hemorrhage
 Uterine Perforation
 Bowel injury
 Long-term Complications
 Chronic pelvic pain, PID
 Tubal blockage and secondary infertility
 Ectopic pregnancy
 Increased risk of spontaneous abortion

Consequences of unsafe abortion on health

 Hemorrhage
 Sepsis
 Generalized peritonitis
 Uterine perforation
 Gangrenous uterus
 Shock
 Tetanus…
 Death
 Psychological problems
 Long term- infertility
Consequences of unsafe abortion on Economy
 Loss of productivity due to illness
 Treatment cost health system
 Individuals cost for treating moderate complications estimated to be 3X mild cases
 Severe cases cost 8X mild cases
 Treating abortion complication is over 10X costly than normal delivery

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6.2 Abortion related care

There are two type of abortion care

 Women centred comprehensive abortion care.

 Post abortion care (PAC)

woman-centered comprehensive abortion care is an approach to providing abortion services that takes into
account the various factors which influence a woman’s individual health needs-both physical and mental as well
as her personal circumstances and her ability to access services

It comprises three key elements:

Choice – the right & opportunity to select b/n options (concerning RH)
Access – having access to the needed service quality- having respectful and confidential service

Post abortion care (PAC) is a comprehensive service for treating women that present to health facilities after
abortion has occurred.
PAC is an approach for Reducing morbidity and mortality from complications of unsafe and spontaneous
abortion, Improving women’s SRH and lives
WHY PAC important
PAC protects women’s health
1 in 8 pregnancy-related deaths worldwide is caused by unsafe abortion
13% of all maternal deaths – could be prevented by implementing appropriate PAC and helping couples obtain
FP information and services
PAC reduces women’s suffering
Most women suffer of physical pain and emotional trauma from unsafe abortion and miscarriage
Their suffering could be reduced by provision of compassionate, high-quality medical care
PAC reduces health care costs
Complications from unsafe abortions are significant cost to health care systems (personnel time, supplies like
drugs, blood transfusions, hospital beds, operating rooms)

PAC offers opportunities to meet the multiple health needs of underserved women
For some women, the 1st contact with the formal health care system occurs during emergency Rx of abortion
complications Offers an opportunity to inform women about available FP choices, Connect Patients with other
types of RH care and improve women’s overall health
PAC can prevent repeat abortions
Studies in several countries found that 11 to 48% of the women seeking emergency Rx for abortion
complications have already had a previous abortion.Most women who have had one or more induced abortions
are likely to be motivated to prevent future pregnancies
Essential elements of post abortion care

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Community and service providers partnership
Counseling
Treatment
Contraceptive and family planning services
Link to Reproductive and other health services

Strategies for improving the quality of PAC

1. Upgrade clinical care

Use of appropriate technology for the setting and the patient Making resource available (Adequate supplies of
essential medications and surgical equipment
Improved client-provider interactions

2. Provide family planning information and services

Offer FP counseling and services to post abortion patients

2. Expand access to PAC

 Train CHWs to provide FP and make referrals

 Make PAC services available at the community level
 Train mid-level practitioners to perform MVA
 Improve referral systems for RH services
4. Plan comprehensive PAC services
 Plan PAC services to improve quality of care, cut health care costs & Offer outpatient PAC services

5. Involve male partners

 Inform male partners about PAC treatment

6. Policy makers role

 Develop national norms & standards regarding PAC

 Decentralize services to extend access
 Develop local training capability
 Provide supportive supervision system
 The legal provisions of abortion services
Article 551: TOP by a recognized medical institution within the period permitted by the profession is not
punishable where:
A. Pregnancy results from rape or incest

32
B. Continuation of the pregnancy endangers the life of the mother or the child or the health of the mother or
where the birth of the child is a risk to the life or health of the mother
C. The fetus has an incurable and serious deformity
D. The pregnant woman, owing to physical or mental deficiency she suffers from or her minority is physically
as well as mentally unfits to bring up the child

Interpretation & eligibility

Art. 551-1-A (Rape or incest)
 On disclosure of the woman
 Not required to submit evidence
 Not required to identify the offender
Art 551-1-B
 Follow the knowledge of standard medical indications that necessitate TOP to save the life or health of
the mother, in good faith
 Woman shall not necessarily be in state of ill health
 Determine in good faith that the continuation of the pregnancy or the birth of the fetus poses a threat to
her health or life

Art 551-1-C (fetal deformity)Necessary tests

Art 551-1-D (physical or mental deficiency, or minority)
 Stated age on the medical records
 Disability definition-physical or mental
 Determine in good faith that the woman is disabled

Art 551-2 (grave & imminent danger)Providers authorized to perform TOP on women whose medical condition
warrant immediate action

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6. SUMMARY ON MAJOR CAUSES OF MATERNAL MORTALITY AND
SERVICES TO BE DELIVERED

An effective program to prevent maternal deaths will include services at the community, health center and referral
level, all of which must be coordinated to ensure their effective functioning.

Preventing the main causes of maternal death will require a spectrum of services including prenatal and delivery care,
family planning, and treatment for the complications of unsafe abortion (with provision of safe abortion depending on
the law). Provision of comprehensive and integrated care increases the chance of achievement of the objectives of
maternal health care.

The major types of services and activities to be conducted to prevent and decrease maternal mortality from the major
causes are listed below.

Family planning can reduce maternal deaths from all causes, by reducing the fertility rate, and especially, unwanted
pregnancies, and thus unsafe abortion. Further reductions in deaths from unsafe abortions can be achieved through
provision of emergency treatment for complications.

Antenatal care during the prenatal period can improve the health of women and their infants through routine screening
and treatment for sexually transmitted diseases, urinary tract infections, and locally prevalent infectious and parasitic
diseases, particularly malaria. It also help to manage hypertensive disorders of pregnancy, and assessing the risk of
complications at delivery (particularly obstructed labor),

Prophylactic iron and folate supplements are recommended where anemia is common and identified, with screening.

Tetanus toxoid immunization is highly effective in reducing neonatal deaths and the 30,000 estimated maternal tetanus
deaths yearly.

Health education during the ante natal period may increase awareness of danger signs (such as bleeding, pre-labor
rupture of the membranes, and generalized edema (swelling), offer information about appropriate treatment, including
where, how and when to obtain it, and encourage community planning for routine and emergency care, including
communication and transport. The most important component of antenatal care, however, is likely to be referral
services for women, in case they are needed.

A proportion of the cases of obstructed labor can be predicted, well before labor, form previous obstetric history and
height, so that arrangements can be made for adequately supervised labor with access to operative delivery if required.
The use of the partograph in labor leads to earlier diagnosis of prolonged labor and more timely intervention or transfer,
which can improve the survival chances of mother and infant.

Hemorrhage is largely unpredictable, but can be prevented by routine active management of the third stage of labor by
skilled birth attendants using oxytocic drugs. Effective treatment includes rapid manual removal of retained placenta,
oxytocic drugs, intravenous fluids, blood transfusion, and surgery.
34
Minimizing vaginal examinations and ensuring clean delivery practices can prevent sepsis at delivery. The latter can be
promoted through education of women, training of trained birth attendants and other health care staff and provision of
adequate equipment and supplies. Early detection of puerperal sepsis depends on careful postpartum visit of women at
home.

Deaths from hypertensive diseases of pregnancy are the most difficult to prevent. However, most recommend for
prevention of preeclampsia to give low dose aspirin with calcium supplements. This may become the most effective
intervention to reduce mortality, especially in women at high risk and areas of high prevalence if women are seen early
in pregnancy. Though the choice of treatment for advanced disease is still under investigation, it is clear that care in
referral centers reduces mortality. As such, early detection, education to promote recognition of danger signs, and
referral are necessary.

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7.REFERENCES

1. Federal Democratic Republic of Ethiopia (FDRE). 2016. National Guideline on Adolescent, Maternal, Infant
and Young Child Nutrition. Addis Ababa, Ethiopia: FDRE
2. Ethiopia mini demographic health survey (EDHS ).2019
3. FDRE MOH.National Norms & Guidelines for Safe Abortion Services in Ethiopia second edition,2014
4. FDRE MOH ,National Antenatal Care Guideline | February 2022
5. United Nations, Department of Economic and Social Affairs, Population Division (2015). World Population
Prospects: The 2015 Revision.
6. Ethiopia Demographic and Health Survey 2016 via the DHS Program
7. United Nations Inter-agency Group for Child Mortality Estimation (UNICEF, WHO, United Nations Population
Division and the World Bank).
8. United Nations Maternal Mortality Estimation Inter-agency Group (WHO, UNICEF, UNFPA, United Nations
9. Population Division and the World Bank).
10. Trends in maternal mortality: 1990 to 2015: estimates by WHO, UNICEF, UNFPA, World Bank Group and
the United Nations Population Division.
11. Blencowe H, Cousens S, Oestergaard M, Chou D, Moller AB, Narwal R, Adler A, Garcia CV, Rohde S,
12. Averting Maternal Death and Disability, United Nations Children’s Fund, and United Nations
Population Fund special data compilation, 2015.
13. Global Health Workforce Statistics database, World Health Organization, Geneva.
(http://www.who.int/hrh/statistics/hwfstats/).
14. United Nations, Department of Economic and Social Affairs, Population Division (2015).
15. WHO-MCEE estimates for child causes of death, 2000-2015. (http://www.who.int/healthinfo/global_
16. burden_disease/estimates_child_cod_2015/)
17. WHO. Standards for improving quality of maternal and newborn care in health facilities. Geneva, Switzerland;
2016
18. Ethiopian ministry of health, ETHIOPIAN NATIONAL HEALTH CARE QUALITY STRATEGY,
Transforming the Quality of Health Care in Ethiopia, 2016–2020.
19. Banke-Thomas A, Ameh CA. WHO’s quality of maternal and newborn care framework: is harmonisation of
tools best? Lancet Glob Health. 2019;7(7):e841.
20. Ethiopian ministry of health, HEALTH SECTOR TRANSFORMATION IN QUALITY, A guide to cascade
Quality Improvement activities in Ethiopian health facilities, 2016.

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