the promise of preconception care in prevention of birth defects and preterm births dr neena raina...

WHO-SEARO 1

The Promise of Preconception Care in

Prevention of Birth Defects and Preterm Births

Dr Neena RainaRegional Advisor

Child and Adolescent HealthWHO - SEARO

WHO-SEARO 2

Structure of presentation

1. What is Pre-conception Care2. Do we have evidence based

interventions3. Why is it important in SEAR4. Opportunities for introducing

it in SEAR5. “Healthy Transitions” for

Adolescents6. Way forward

WHO-SEARO 3

1.What is Pre-conception Care

WHO-SEARO 4

Pre-pregnancy health status and health behaviors have direct or indirect implications

for maternal and neonatal outcomes • Intervening after a woman is pregnant has limited impact:

– First few weeks after conception are critical for fetal development

• Week 5: brain, spinal cord, heart begin to form• Week 6: Neural tube closes; the heart is pumping• Week 7: Brain and face are rapidly developing

• Most women do not seek prenatal advice/care before 12 weeks when it is too late to modify many risks

Intervening during pregnancy is too late for many interventions

Many health risk behaviours are initiated during adolescence

WHO-SEARO 5

Modifiable risk factors are common toseveral “congenital conditions”

Risk factor Malformations Preterm Birth

IUGR Developm. disability

Nutrition status X X X

Insufficient folic acid/vitamin X X X X

Smoking X X X

Alcohol use / abuse X X X X

Illicit drugs X X X X

Obesity X X X

Diabetes - getsational X X X

Infectious diseases X X X X

Selected medications X X X X

Psycho-social stressors X

Environment and working activity

X

X

X X

ICBDSR presentation in Regional Meeting 2012

WH

O-SEARO 6

Modifiable risks for birth defects and prematurity that need to be addressed before conception

• Undernutrition and anaemia

• Folic Acid insufficiency• Obesity• Diabetes• Hypertension• Epilepsy• Alcohol use

• Age at pregnancy• Too close and too many

pregnancies• Infections: TORCH• Use of medications

during early pregnancy• Exposure to toxins• Exposure to tobacco

Many risk factors are initiated during adolescence

WHO-SEARO 7

Pre-Conception Care• Preconception care is the provision of biomedical,

behavioral and social health interventions to women and couples before conception occurs.

Aims:• Improving health status and reducing behaviors and

individual and environmental factors to improve maternal and child health outcomes.

Boundary: the period before pregnancy may be divided into a proximal and a distal period:

Proximal period immediately preceding pregnancy Distal adolescence (10-19 years)

Life course – when to intervene?

WHO-SEARO 9

2.Do we have evidence based interventions

Gathering evidence: Global consultation

Global consultation in WHO Headquarters, Geneva - February 2012

Meeting to develop a global consensus on preconception care to reduce maternal and childhood mortality and morbidity

Three questions were answered:

1. What are the health problems, risk behaviours and risk factors contributing to maternal and childhood mortality and morbidity?

2. What are the effective interventions to address them?

3. What are the effective means of delivering these interventions?

Gathering evidence: Existing reviews

Using existing evidence and reviews from:• The Centers for Disease Control and Prevention• Erasmus University• Aga Khan University• Health Council of the Netherlands

WHO-SEARO 13

Recommendations to Improve Preconception Health – United States by the Centers for Disease Control and Prevention (2006)

Systematic Review of Preconception Evidence by the Aga Khan University in Karachi, Pakistan(2011)

Evidence for Pre-Conception Care

Gathering evidence: WHO departments

• Maternal, Newborn, Child and Adolescent Health

• Reproductive Health and Research

• Nutrition for Health and Development

• HIV• Mental Health and Substance

Abuse• Immunization, Vaccine and

Biologicals• Public Health and Environment• Tobacco-Free Initiative• Violence and Injury Prevention• Partnership for Maternal,

Newborn and Child Health

Consultation with various relevant WHO departments:

Strength of evidence

• There is growing experience in implementing preconception care initiatives:

• In high-income countries, such as Italy, the Netherlands and the United States

• In low- and middle-income countries, such as Bangladesh, the Philippines and Sri Lanka

Preconception care has a positive effect on a range of health outcomes

macrosomia

vertical transmission of HIV/STIs

child mortality maternal mortality

preterm birth

birth defects

cretinism

diarrhoea

Improved mental health

childhood cancers

congenital and neonatal infections

Reduced too early pregnancy

Reduced abortion

Improved mother nutritional status

Low birth weight

Underweight and stunting

hypothyroidism

Tobacco use and youth health: a potential for Healthy Transitions

20 y.o.

90% of adult smokers are estimated to have started smoking before age 20 years

5 million deaths in 2005

10 million deaths in 2020

Exposure to environmental toxins in early life and its long term effect

cigarette smoking during

pregnancy

reduced birth weight or

increased risk of lower birth

weight

offspring obesity

eliminating smoking beforeor during pregnancy could avoid 5–7% of preterm relateddeaths and 23–24% of cases of sudden infant death syndrome

WHO-SEARO 19

Areas addressed by preconception care package

WHO-SEARO 20

Evidence-based interventions: Selected examples

Area addressed by the preconception care

package

Evidence-based interventions

• Screening for anemia• Supplementing iron and folic acid• Information, education and counselling• Monitoring nutritional status• Supplementing energy- and nutrient-dense food• Screening for diabetes mellitus• Management of diabetes mellitus• Counselling people with diabetes mellitus• Monitoring blood glucose (also in pregnancy)• Promoting exercise• Salt iodization

Nutritional conditions

WHO-SEARO 21


• Screening for anemia• Taking a thorough family history• Family planning• Genetic counselling• Carrier screening and testing• Appropriate treatment• Providing community-based education• Community-wide or national screening

among populations at high risk• Population-wide screening

Genetic conditions

Areas addressed by the preconception care

package


WHO-SEARO 22


• Keeping girls in school• Influencing cultural norms that support early marriage and

coerced sex• Creating visible, high-level support for pregnancy

prevention programmes• Educating girls and boys about sexuality, reproductive

health and contraceptive use• Building community support for preventing early pregnancy

and for contraceptive provision to adolescents• Enabling adolescents to obtain contraceptive services• Empowering girls to resist coerced sex• Engaging men and boys to critically assess norms and

practices regarding gender-based violence and coerced sex• Educating women and couples about the dangers to the

baby and mother of short birth intervals• Providing contraceptives

Too-early, unwantedand rapid successivepregnancy

Areas addressed by the preconception care

package


WHO-SEARO 23

3.Why Preconception care is important in SEAR

Source: World Health Statistics 2013

MDG 5 Indicators-SEAR Countries

Countries

MMR (per 100 000 live births)

SBA (%)

CPR (%)

Unmet Need

for family

planning (%)

ANC (%) Births by

caesarean

section (%)

Post natal

within 2 days of

child birth (%)1990 2000 2010

At least 1

visitAtleast 4 visits

BAN 800 400 240 31 61 12 50 26 17 27BHU 1000 430 180 58 66 12 74 77 12

KRD 97 120 81 100 100 94 13 IND 600 390 200 58 55 21 75 50 8 48INO 600 340 220 80 61 13 93 82 7 70MAV 830 190 60 95 35 29 99 85 32 67MMR 520 300 200 71 46 83 43 NEP 770 360 170 36 50 27 58 50 5 45SRL 85 58 35 99 68 7 99 93 24 71THA 54 66 48 99 80 3 99 80

TLS 1000 610 300 30 22 32 84 55 2 25

WHO-SEARO

The Region is not likely to reach MDG4

118

81

50

77

3944

27

MDG Target36

0

20

40

60

80

100

120

140

1990 1995 2000 2005 2012 2015

Child Mortality in SEA Region in 2012 (UN-IGME Report 2013)

U5MR IMR NMR MDG Target

25

Decline in NMR has been slower

WHO-SEARO 26

Newborn mortality remains high in SEAR

• Responsible for 54% of under-five deaths• Three congenital conditions: Prematurity,

Birth Asphyxia and Birth Defects account for 35-55% of under-5 mortality

• These causes of mortality share many risk factors

WHO-SEARO

Prematurity, Birth Asphyxia and Birth Defects account for 35% (Myanmar) to 55% (Thailand) of under-5 mortality

Source:World Health Statistics 2011 http://www.who.int/whosis/whostat/2011/en/index.html

Mya

nmar

BhutanIndia

Timor-L

este

BangladeshNepal

Indonesia

DPR Korea

Maldive

s

Sri La

nka

Thailand

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

0%

10%

20%

30%

40%

50%

60%

Birth defects Prematurity Birth asphyxia Under-5 mortality rate

Und

er-5

mor

talit

y ra

te (p

er 1

,000

bir

ths)

Dis

trib

ution

of c

ause

s of

dea

ths

(%)

27

http://www.who.int/whosis/whostat/2011/en/index.html

WHO-SEARO 2828

Estimates of Birth Defects in SEARBirth Defects prevalence / 1000 live births

58.6 58.4

54.1

64.3

59.3

60.8

58.5

59.9

62.2

59.9 60.3

48

50

52

54

56

58

60

62

64

66

Bangl

ades

h

Bhuta

n

DPR Kore

aIn

dia

Indo

nesia

Mal

dive

s

Mya

nmar

Nepal

Sri Lan

ka

Thai

land

Tim

or Les

te

March of Dimes Global Report on Birth Defects (2006)

WHO-SEARO

Birth Defects Situation Analysis:

WHO-SEARO and US-CDC

WHO-SEARO 30

Estimates of Pre Term BirthsBorn Too Soon Report: 2012

WHO-SEARO 31

Eleven countries with PT birth >15% by RankBorn Too Soon Report: 2012

WHO-SEARO 32

4.Preconception Care in SEAR

Twin track:• Pre- and Inter-pregnancy care: Maternal

Health• Healthy Transitions for adolescents:

Adolescent Health

Is there a gap in Continuum of Care?

33

• Healthcare provided across the lifecycle through strong public health programs can ensure that all women and babies are healthy

• There is a gap in the continuum of care for adolescent girls (and boys) and women before pregnancy.

WHO-SEARO 34Pre-pregnancy Pregnancy

Fam

ily/c

omm

unity

Out

reac

h/ou

tpati

ent

Clin

ical

ANTENATAL CARE - 4-visit focused ANC package

- IPTp and bednets for malaria

- PMTCT

POSTNATAL CARE- Promotion of healthy behaviors

- Early detection of and referral for illness

- Extra care of LBW babies

- PMTCT

- Counselling and preparation for newborn care, breastfeeding, birth and emergency preparedness

Healthy home care including: - Newborn care (hygiene, warmth)- Nutrition including exclusive breastfeeding and appropriate complementary feeding- Seeking appropriate preventive care- Danger sign recognition and careseeking for illness- Oral rehydration salts for prevention of diarrhoea- Where referral is not available, consider case management for pneumonia, malaria, neonatal sepsis

- Where skilled care is not available, consider clean delivery and immediate newborn care including hygiene, warmth and early initiation of breastfeeding

• Optimising Adolescent and pre-pregnancy nutrition

• Health education and counseling on risk factors prevention

CHILDBIRTH CARE

– Emergency obstetric care– Skilled obstetric care and immediate newborn care (hygiene, warmth, breastfeeding) and resuscitation– PMTCT

EMERGENCY NEWBORN AND CHILD CARE - Hospital care of newborn and childhood illness including HIV care

- Extra care of preterm babies including kangaroo mother care

- Emergency care of sick newborns

-Post-abortion care

- STI case management

• Multivitamin and folic acid supplementation

• Family planning

• Youth development programs

• Prevention of obesity

INTERSECTORAL Improved living and working conditions – Housing, water and sanitation, and nutrition education and female empowerment

Birth

•Screening and management of chronic diseases especially diabetes

•Genetic counselling

Strengthening pre-conception care in the RMNCAH Continuum

WHO-SEARO 35

Pre-pregnancy care for prevention birth defects Life course Continuum

Infancy U5Neonatal periodPregnancyBirth

10-19 Pre-Pregnancy

PCC

ANC

New

born

Ca

re CH

Imm

uniz

ation

Interventions to address MH risk factors for BD and PT births

Ado

Hea

lth

SBA

WHO-SEARO 36

Sri Lanka

Package for newly married couples

Goal: To have improved reproductive health outcomes by improving the health of the

newly married couples.

WHO-SEARO 37

Package for newly married couples

• RISK SCREENING

• CLINICAL ASSESSMENT

• IMMUNIZATION

• AWARENESS AND COUNSELLING

• PROVISION OF OTHER SERVICES

WHO-SEARO 38

TOOLS IN THE PACKAGE

• INVITATION CARD

• SCREENING TOOL

• GUIDE FOR HEALTH

WORKERS

• BOOK FOR THE NEW

COUPLE

• BMI CALCULATOR

WHO-SEARO 39

SCREENING TOOL

• Screen for risk factors by using the screening tool by PHM/MOH

• Basic investigations• Physical assessment by

PHM• Height, weight and BMI• Clinical examination by MOH• Refer for further diagnosis

/treatment/ for specialized care

• Follow up

WHO-SEARO 40

Book for the New Couple

♣ SEXUALITY AND SEXUAL RELATIONSHIP

♣ SEXUALLY TRANSMITTED DISEASES AND

RESPONSIBLE SEXUAL BEHAVIOUR

♣ A PLANNED FAMILY

♣ GOOD NUTRITION

♣ GOOD HEALTH HABITS/ HEALTHY

BEHAVIOUR/ HEALTHY LIFE STYLE

♣ GOOD MARITAL RELATIONSHIP AND WELL

BEING OF THE FAMILY

♣ BENEFITS OF NON VIOLENCE

♣ BEFORE CONCEPTION

♣ MALE PARTICIPATION AND PARENTHOOD

♣ TOBACCO AND ALCOHOL

WHO-SEARO 41

5.Many health risk behaviours are initiated during adolescence: Need to catch them

young“Healthy Transitions”

Adolescents in SEARProportion of adolescents (10-19)

1.2 billion adolescents (10-19) globally About 350 Millions in

SEAR of which 230 million in India

Source: World population prospects: The 2006 Revision Population Database. 42

Large number of adolescents in SEAR with many health problems

• Sexual and reproductive

health problems

• Nutritional problems

• Substance use: Tobacco,

alcohol

• Injuries, accidents and

violence

• Mental health problemsWHO-SEARO

Health problems start during Adolescent period

• Age parameter: 10-19 years• Confounding factors:

– Biological: Early or late onset of puberty– Social-cultural factors

• Experiencing rapid growth and development:– Physical: Body image and form – Sexual: Reproductive capacity– Mental: Mind– Emotional-psychological– Social

• Formative Phase:– Attitudes– Behaviours

43

Heterogeneous groups and circumstances with variable needs:

– Boys and girls– Urban and rural– In school and out of

school– Unmarried and married:

Pregnant and mothers– At home and homeless

(on streets)– In employment (formal

and informal

Proportion of adolescents who have begun childbearing

Source: Bangladesh DHS 2007; India NFHS-3 2005-06; Indonesia DHS 2007; Nepal DHS 2006; Sri Lanka DHS 2005-06; Timor-Leste DHS 2003

19.7

5.1

9.6

14.4

7.6

11.8

41.5

25.3

5.9

18.2

7.1

17.6

0

5

10

15

20

25

30

35

40

45

Bangladesh India Indones ia Nepal Sri Lanka Timor Leste

Highest Quinti le Lowest Quinti le

Poor women aged 15-19 are more likely to begin child bearing early

Per cent married by Age 18 among adolescents (15-19 yrs)

44

Early Marriage and childbearing

BAN BHU IND INO MAV NEP SRL THA TLS0

10

20

30

40

50

60

70 64.9

25.8

47.4

22

3.9

40.7

11.8

19.6 18.9

WHO-SEARO

WHO-SEARO 47

Adolescent Pregnancy: Higher Child Mortality

BAN IND INO MAV MMR NEP SRL TLS0

10

20

30

40

50

60

45

54

30

25

43

51

22

35

26

34

16 13

3432

14

26

NMR

<20 20-29

2x2x

BAN IND INO MAV MMR NEP SRL TLS0

10

20

30

40

50

60

70

80

90

57

76

56

29

82

69

23

74

34

50

32

20

64 64

19

58

IMR

<20 20-29

1.5x

1.6x 1.8

x

Source: Bangladesh DHS 2011; India NFHS3 2005-06; Indonesia DHS 2007; Maldives DHS 2009; Myanmar FRHS 2007; Nepal DHS 2011; Sri Lanka DHS 2006-07; Timor-Leste DHS 2009-10

WHO-SEARO 48

Large number are under-nourished and anaemic

BAN IND MAV NEP SRL TLS0

10

20

30

40

50

60

70

80

25

47

2426

40

33

64

51 53

71

52

65

11

2

24

38

15

BMI

<18.5 18.5-24.5 ≥25

BAN IND NEP TLS0

10

20

30

40

50

60

70

80

49

56

39

22

Anaemia

Source: Bangladesh DHS 2011; India NFHS3 2005-06; Nepal DHS 2011; Sri Lanka DHS 2006; Maldives DHS 2009; Timor-Leste DHS 2009-10

WHO-SEARO 49

Dietary behaviors, Overweight & Obesity (13-15 years)

IND INO MMR SRL THA0

5

10

15

20

3.5

5.8

2.6

6.5

2.5

10.89.9

5.1 4.5

9

2.1 1.80.7 0.5

4.2

Who went hungry most of the time during the past 30 days because there was not enough food in their home

Who are overweight

Who are obese

Perc

enta

ge

Source: Latest Global school-based student health survey (GSHS)

WHO-SEARO 50

Early Tobacco use among adolescents (13-15 years)

BAN (2007) BHU (2009) IND (2009) INO (2009) MAV (2011) MMR (2011) NEP (2011) SRL (2011) THA (2011) TLS (2009)

-10

10

30

50

70

7

1915

23

1115

20

11

16

57

9

28

19

41

15

2325

16

24

60

5

128

6 7 8

16

58

53Total Male Female

Perc

enta

ge

Source: Latest Global Youth Tobacco Survey (GYTS)

WHO-SEARO 51

Early Alcohol Consumption(13-15 years)

INO MAV MMR THA0

5

10

15

20

25

2.64.9

0.8

15.6

2.74

1.4

19.8

1.94.4

9.9

Who had at least one drink containing alcohol during the past 30 days

who drank so much alcohol that they were really drunk one or more times during their life

who had a hang-over, felt sick, got into trouble with family or friends, missed school, or got into fights one or more times with family or friends, missed school, or got into fights one or more times as a result of drinking alcohol during their life

Perc

enta

ge


WHO-SEARO 52

High Unintentional Injuries and Violence(13-15 Years)

INO MAV MMR SRL THA0

10

20

30

40

50

60

39.8

20.8

48

32.933.730.4

14.6

47.1

34.1

45.9

40

27

37.2

46.850

36.9

19.4

37.9

27.2

Who were physically attacked ≥1x during the past 12 months

Who were in a physically fight ≥1x during the past 12 months

Who were seriously injured ≥1x during the past 12 months

Who were bullied on ≥1 days during the past 30 days

Perc

enta

ge


WHO-SEARO 53

Mental Health Problems ( 13-15 Years)

IND INO MAV MMR SRL THA0

5

10

15

20

25

8.4 8.7

3.8

7.6 8.110.1

1.4

9.6

3.5

5.63.64

17.2

0.7

9.98.5

who felt lonely most of the time or always during the past 12 months

who ever seriously considered attempting suicide during the past 12 months

who have no close friends

Perc

enta

ge


Public Health Issues with Adolescents• Nutrition Issues:

– Undernutrition, Anemia, Overnutrition• Sexual And reproductive health:

– Early sex: unsafe– Coerced sex– Early marriage and child bearing– STI, HIV

• Mental Health: Anxiety, stress, depression, suicide• Tobacco and alcohol use• Injury and accidents• Violence: Victims and perpetrators

WHO-SEARO 54

Health Sector needs to collaborate with other sectors

“Home” for adolescents in health services ?

Newborn and child

health services

Maternal andreproductive

health services

Disease Treatment for

all

Health Sector Response to improve Adolescent Health - - The “4 S framework”

CollectStrategic

Information

Supportive Evidence-

basedPolicies

StrengthenHealth services

For Adolescents

Support to & synergy with other sectors to ensure community support and improve demand

for health services use by adolescents 56

Progress so far• Regional Strategy and National

strategies (9 countries)• Country Fact sheets on AHD and

Adolescent pregnancy• National Standards and

implementation guidelines on AFHS (9 countries)

• Training packages adapted, HWs trained (8 countries)

• Quality and coverage assessments (6 countries)

• Regional Program management capacity building course

• Collaboration with other sectors - education

57

58

• Physical & mental health promotion

• Nutrition and micronutrients

• STI/RTI: Screen and manage• HIV/AIDS prevention,

testing• Contraception, condom

promotion• Pregnancy and childbirth

care• Substance use prevention• Healthy Lifestyles

promotion• Immunization

Package of AH services: Range in SEAR Countries

August 2013 WHO-SEARO 59

Coverage assessment: UtilizationReceived IFA Tabs in Last Six Month

Haryana, India


Adolescent Health Programme in SEAR

Focus has been on Sexual and

Reproductive Health

Opportunity to add elements of Pre-Conception Care

Package –

Healthy Transitions Package

Adolescent Health Programme being scaled up in SEAR Countries

WHO-SEARO 61

Evidence-based preventive and curative health interventions for adolescents

Existing delivery mechanisms that could be used to deliver interventions at scale

Provide age-appropriate sexual health education

Delay pregnancy Provide contraceptive services

including condoms Prevent, screen and manage STIs,

HIV Provide Iron folic acid Immunization Prevention of Substance use Prevent NCD risk behaviours

• School health program• Nutrition program• Youth programs AFHS HIV testing and counselling

clinics NCD programmes Mental Health programmes

We know that specific interventions are effective and can be delivered to Adolescents

“Healthy Transitions for Adolescents” package

WHO-SEARO

‘Healthy Transitions for adolescents’Ensuring health across life-course

• Healthy adolescence• Healthy reproductive health

outcomes – Reduction in prevalence of

prematurity, LBW, Birth Defects– Reduction in maternal, foetal,

neonatal and child mortality

• Healthy adulthood (long term)– NCD prevention– Reduction in Tobacco and harmful use

of alcohol related problems and cost– STIs and HIV prevention

62

WHO-SEARO

63

Where Service type Intervention / package

Health Facilities

•RH Services•AFHS•Immunization programmes

•Add preconception-related interventions•Integrate essential components of Pre-marital counseling and genetic screening•Expanded post-natal care (facility visits)• Healthy Lifestyles: NCD prevention

Schools •School Health Programme•Health Promoting Schools

•Integrate essential components of Pre-marital counseling •Nutrition and micronutrient supplementation•Healthy Lifestyles: NCD prevention

Out Reach •Community support groups & delivery platforms•Mass media campaigns/ Social marketing•Information technology, (mHealth)

•Expanded post-natal care (home visits)•Pre-marital counseling•Healthy Lifestyles: NCD prevention

•Optimizing Adolescent and pre-pregnancy nutrition

Existing Opportunities in Public Health Programmes

WHO-SEARO

64

Where Service type Intervention / package

Health Facilities

•RH Services•AFHS•Immunization programmes

•Add preconception-related interventions•Integrate essential components of Pre-marital counseling and genetic screening•Expanded post-natal care (facility visits)• Healthy Lifestyles: NCD prevention

Schools •School Health Programme•Health Promoting Schools

•Integrate essential components of Pre-marital counseling •Nutrition and micronutrient supplementation•Healthy Lifestyles: NCD prevention

Out Reach •Community support groups & delivery platforms•Mass media campaigns/ Social marketing•Information technology, (mHealth)

•Expanded post-natal care (home visits)•Pre-marital counseling•Healthy Lifestyles: NCD prevention

•Optimizing Adolescent and pre-pregnancy nutrition

Existing Opportunities in Public Health Programmes

Use of modern communication

technology for health assessment

and prevention/promotion

WHO-SEARO 65

Preconception care in SEAR: 2 Tracks

Infancy U5Neonatal periodPregnancyBirth

10-19 Pre-Pregnancy

PCC

ANC

New

born

Car

e

CH

Imm

uniz

ation

Healthy Transitions for

adolescents

AFH

S

SBA

Maternal Health

WHO-SEARO 66

6. Way forward and challenges

WHO-SEARO 67

Regional expert Group Consultation on Pre-

Conception Care: Aug 2013 WHO-SEARO and CDC-US

• PCC package would address maternal mortality, neonatal morality, pregnancy wastage, birth defects, pre term births and intrauterine growth retardation.

• The selected interventions would need to be implemented through integration and convergence within the health system as well as in other sectors.

• Optimize on established programmes such as Maternal, Reproductive ,Newborn and Child Health and adolescent health programmes as well as the programmes like Birth Defects prevention and Non Communicable Diseases.

• Expanding interventions to adolescent boys and girls would ensure better RH outcomes as well as healthy adulthood in the long term.


Opportunities• Global commitments and partnerships for MDG 4 and 5 – Health

agenda beyond 2015• Enhanced commitment of national governments for AH programme

and earmarking of domestic resources• Better understanding of adolescent brain• Newborn and child health plans, RH plans at Global, regional and

national level.• New technology: Information and communication technology

(internet,Mobile phones,Social media) to connect with young people and gatekeepers

• New initiatives: Newborn health, Preterm births, RH ,Birth defects prevention, Pre-conception, HPV, NCD prevention

• Need for demonstration projects

Every Journey begins with a single step, But you will never finish if you don’t start!

miles to go…

13 Dec 2011Regional Meeting on Birth Defects, New

Delhi71

the promise of preconception care in prevention of birth defects and preterm births dr neena raina...

Documents