SALUD

Strategies to improve maternal and child health

Dr José Ángel Córdova Villalobos

Minister of Health of Mexico

NEW DELHI, INDIA

November 14th, 2010

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I. Maternal HealthI. Maternal Health

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Maternal Health Background� Population of 108 million inhabitants

� National Health System is decentralized, with the

participation of several public health institutions as well as

the private sector

Maternal Health Background

the private sector

� 72.5% Contraceptive prevalence (ENADID2009)

� 97.3 % Received antenatal care at least once (ENADID 2009)

SALUD

Maternal Health Background� 1,186 Hospitals with obstetric care provided by the public

sector

� 94.1 % Deliveries by health personnel (ENSANut 2006)

Maternal Health Background

� - 35.7 % Change in Maternal Mortality Ratio (MMR) between

1990 (89.0) and 2008 (57.2)

� Maternal deaths: 86% in hospitals, 60% in urban areas, 82%

associated with quality of care

SALUDTrends of maternal mortality in Mexico

(1980 to 2008)

Mexico is classified as Group A by WHO ( with good maternal death registration and good attribution of cause of death)

Millennium Goal in 2015: MMR 22.3 (567 deaths)

Source: Hogan M y cols. Maternal mortality for 181 countries, 1980–2008: a systematic analysis of progress towards Millennium

Development Goal 5. Lancet, april 2010

SALUDMain Strategies on maternal health

Mexico, 2000-2009

2.“ Equal start

in life”

(APV)

4. Improved and

immediate

epidemiological

surveillance

Task Force Groups

for clinical maternal

audits

6.Strategy based on

delays and obstetric

services

3.Creation of CNEGySR

Gender Perspective

Reproductive health

integration Center

High political

commitment

5. Eliminating

Economic Barriers

“Healthy Pregnancy

Program”

7.Universal

Coverage of

Emergency

Obstetric care

1.Baby and mother friendly

hospitals

2000

2007 2008

2001

2002 2003 2004 2005 2006

57.255.658.6

61.861.0

62.760.0

70.872.6

Maternal Mortality Ratio

2009

SALUD

The Mexican experience was a model for other countriesbecause of the positive impact towards the integral maternaland perinatal care.Cross-institutional coordinationHospital Certification and annual recertification.

More than 600 facilities are Baby and Mother Friendly

1. Baby and mother friendly hospital

100% of the personnel received trainingOperative researchJoint accommodation (elimination of physiological neonatal units)Participation of the communityKangaroo Mother careHuman milk banksLactation clinics for the first level of attentionAn agreement with the producers of infant food and formulas in order toendorse the compliance of the International Code of Commercialization ofalike maternal milk products.

More than 600 facilities are Baby and Mother Friendly Hospital

SALUD2. Equal start in life ( APV)

� Focuses on prevention andprimary care

� Strengthens network ofinstitutional andcommunity services,promoting:� Shelters for pregnant

Home to home brigade

Woman

Fam

ily C

ou

ple

� Shelters for pregnantwomen ( PosadaAME)

� Communitariantransportation(Transporte AME)

� Communitarian homes(Casa AME)

� Association betweencommunity attendantand health institutions

community support services

Health care services

Fam

ily C

ou

ple

Community

Home to home brigade

SALUD3. Creation of the National Center

of Gender Equity and Reproductive HealthIn 1995 the General Direction of Reproductive Health is created with

the mission to verify criteria and follow up to the family planning

programs and maternal and perinatal care. This new unit is

conformed by the following areas:

• Family Planning• Perinatal Care

In 2003 the National

Center of Gender Equity • Perinatal Care• Reproductive health of

adolescents• Prevention, early detection, and

infertility management.• Early detection and management

of cancer related to the femalereproductive system.

• Climaterium and menopause• Prevention and control of

Sexually Transmitted Diseases

Center of Gender Equity

and Reproductive Health

is created. It includes the

gender perspective to the

actions in this field, as

well as a gender- related

violence program

SALUD4. Improved epidemiological surveillance and AI-DeM Groups

Active epidemiologic surveillance of maternal death

• Provided to non-secured population

• In direct obstetric deaths

• In recurrent municipals

Group for the Immediate Attention of Maternal Deaths

(AI-DeM Groups)

• In recurrent municipals

• In “red” networks of attention

Recommendations for the improvement of maternal

care actions

State Care Services

SALUD

• Radio messages of

maternal and

perinatal care

translated in 32

indigenous

languages.

Promotes the

5. Eliminating barriers to reach healthservices

Women incorporated in “Healthy

Pregnancy Program” until September 2010

• Promotes the

elaboration of an

individual security

plan to know What

to do? and Where to

go? when the

delivery is near.

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DECISION TO SEARCH FOR MEDICAL HELP

IN HEALTH SERVICES

IN THE COMMUNITYIN THE FAMILY

First Delay Second Delay Third Delay

6. Strategies based on delays to reduce maternal mortality

PROVIDE PROPER ATTENTION

REACH THE RESOLUTIVE HOSPITAL

� Obstetric godmothers

� Associations between

traditional birth attendant

and health institutions

� Security Plan

� Diffusion of information in

indigenous languages

� Identify Resolutive Hospitals for Obstetric

Emergencies

� Definition of obstetric attention networks

� Permanent training of obstetric

emergencies

� Proper management guidelines

� Surveillance of the compliance of the

regulation (COFEPRIS)

� “Healthy Pregnancy Program”

� Promote communitarian

transportation

� Qualified personnel on

providing care to stabilize

women’s health.

� Shelters close to resolutive

hospitals

� Radio communication system

IN HEALTH SERVICES

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� There are 390 resolutive hospitals available within the threemain health institutions (Ministry of Health, SSA, Institute ofSocial Security for Workers of the State, ISSSTE, MexicanInstitute of Social Security, IMSS)

� Independent of their medical affiliation, 95.2% of the pregnant

7. Universal Coverage of Emergency Obstetric Care

� Independent of their medical affiliation, 95.2% of the pregnantwomen have access to a medical unit (2 hr. distance max.)

� The Cross-institutional Agreement for the Universal Coverageof Obstetric Emergencies was signed on May 28th, 2009 withthe support of the President.

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II. Infant Mortality

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supplementation

monitoring

referralsystem

Resuscitation

. K, etc.)

iu

Screening

Special care for sick and premature babies

program

Oral rehydration therapy and diarrhea prevention

Acute respiratory diseases preventive program

program

Integrated Child Health Program

Program

Early Fetal Late fetal Neonatal Post neonatal

Public Health Policies and Strategies to Improve Children's Health

Family

Planing

Folic

acidsupplementation

Antenatal Care

TetanusToxoid

Labor monitoring

Highrisk

deliveryreferral

Neonatal Resuscitation

Newborn care (vit. K, etc.)

Breastfeeding

VitaminA 50 000 iu

Newborn

Screening

Special care for sick and premature babies

National immunizationprogram

Oral rehydration therapy and diarrhea prevention

Acute respiratory diseases preventive program

Vit. A supplementationprogram

Nutrition

Integrated Child Health Program

AccidentPreventionProgram

SALUDMain strategies and lines of action to decrease infant and child mortality.

� Strengthen the National Immunization Program yearly, as well as the National

Registration System (PROVAC), to detect children who are behind in their

immunization schedule and assure high coverage rates.

� Timely detection, management and referral of perinatal complications and

congenital malformations.

� Prevention, timely treatment and referral of acute respiratory diseases, and� Prevention, timely treatment and referral of acute respiratory diseases, and

acute gastrointestinal diseases.

� Timely detection, referral and treatment of leukemia and other solid cancers

in children under five.

� Prevention and timely treatment of accidents in children under five .

SALUDChild Mortality 1990-2015and Public Health Interventions

30

35

40

45

50

Ra

te x

10

0 0

00

Popular Health Insurance for <5 y.o.

National

Integrated

Child Care Program /

Respiratory Program

Infant

MortalityReductionProgram

Seasonalinfluenza vaccine

AH1N1

“Medical

Insurance

“APV: Equal start

in life”

programUniversal deworming

<5 y.o.

Pneumoccocal

7 vaccine

90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15

Under 5 y.o. 44.2 39.7 38.1 36.4 34.9 33.7 32.6 31.7 30.8 29.7 22.7 21.4 21.1 20.2 20.5 19.6 19.0 18.4 17.9 17.3 15.61 14.42 13.19 11.92 10.6 9.265

Under 1 y.o. 36.2 32.2 30.9 29.6 28.5 27.6 26.7 26 25.3 24.4 19.4 18.3 18.1 17.3 17.6 16.8 16.2 15.7 15.2 14.7 13.38 12.42 11.42 10.4 9.359 8.31

0

5

10

15

20

25

Ra

te x

10

0 0

00

National Immunization

Program

Safe water

program ORT

AH1N1

vaccine

National

Health Weeks

Insurancefor a new

generation”

Rotavirus vaccine

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Birth 2 mo 4 mo 6 mo 7 mo 1 2 mo 1 8 mo 4 y 59 mo 6 y

BCG 1st SRP DPT 2nd SRP

1st Hep B 2nd Hep B 3rd Hep B

1st

Pentavalent

Acellular

2nd

Pentavalent

Acellular

3rd

Pentavalent

Acellular

4th

Pentavalent

Acellular

Children's Immunization Schedule

1st Hep B 2nd Hep B 3rd Hep B

1st Rotavirus 2nd

Rotavirus

1st Pneumo

7V

2nd Pneumo

7V

1st

Antiinf luenza

2nd

Antiinfluenza

VOP (Sabin) at 1st y 2nd National Health Weeks *

(* 2 previous IPV doses necessary)

3rd Pneumo 7V

Annual Antiinf luenza Reinforcement October - January

SALUDHow strategies are implemented

in México:

� Health policies are developed by the Federal Government and the 32

states are responsible for operating them and achieving the goals set..

� The Federal Government is responsible for Training of state liaison health

staff, who then replicate the training within each state. (“cascade courses”)

Sharing responsibilities between Federal and State governments

staff, who then replicate the training within each state. (“cascade courses”)

� Community Health Education is mainly achieved by:

� Mass media campaigns

� “In situ” training of patients and parents in health centers.

� There is Federal Supervision of all infant and child health programs, with

discussion of program evaluations and actions needed ,during our

Ministers of Health regular meetings every three months.

SALUDMortality rates for respiratory diseases

in children <5

The values for the baseline is adjusted based on population projections 2005-2050 CONAPO

Source: Mortality data from INGEGI-SS, 1990; SEDD 2007 and CONAPO Population Projections 2005-2050, Flasks Accountability 2008, SEED 2009* preliminary results

SALUDMortality rates for acute diarrheal diseasesin children <5

The values for the baseline is adjusted based on population projections 2005-2050 CONAPO

Source: Mortality data from INGEGI-SS, 1990; SEDD 2007 and CONAPO Population Projections 2005-2050, Flasks Accountability 2008, SEED 2009 * preliminary results

SALUD

Goals

Target 5: Reduce by two thirds the mortality

rate among children under five between 1990

and 2015

Baseline

Latest figure

available

(2009)

Variation

%

Goal

2015

Mortality of children under five years (deaths

per 1,000 births) ¼47.2 17.3 -63.35 15.7

Goals related to Objective 4. Reduce mortality of children under 5 years

Millennium Goals

per 1,000 births) ¼47.2 17.3 -63.35 15.7

Diarrheal disease mortality in children

under five years (deaths per 100 000)122.6 11.8* -90.3 40.9*

Mortality from acute respiratory

infections in children under five years

(deaths per 100 000)

113 23.8* -78.9 37.7*

Infant mortality (deaths per 1,000 births) 39.2 14.7 -62.50 13.1

1/ It refers to the probability of dying in the age group

Source: Mortality data from INGEGI-SS, 1990; SEDD 2007 and CONAPO Population Projections 2005-2050, Flasks Accountability 2008, SEED 2009

SALUDMain causes of infant mortality (children

0 to 11 months) México 2000-2009