MESOAMERICAN HEALTH INITIATIVE
MASTER PLAN
MATERNAL, NEONATAL AND REPRODUCTIVE
HEALTH WORKING GROUP
Submitted to:
Public Health Institute
Bill and Melinda Gates Foundation
The final conformation of this document was carried out by Juan Díaz, Bernardo
Hernández, Edgar Kestler, Sarah Lewis and Elvia de la Vara. The elaboration of the
document received input and incorporated elements from discussion with the members
of the core group of maternal, neonatal and reproductive health, integrated by Bernardo
Hernández (chair, INSP-MEXICO), Edgar Kestler (co-chair, CIESAR, Guatemala), Ana
Langer (Engender Health), Dilys Walker (INSP, Mexico), Emma Iriarte (GTZ-PRAIM
Honduras), Isabela Danel (CDC-CAP), France Donnay (Gates Foundation) and Denis
Alemán (PROFAMILIA, Nicaragua), and from the focal groups of all the countries of the
region: Rosely Serrano and Evelyn Morales (Costa Rica), Natalia Largaespada (Belize),
Douglas Jarquín (El Salvador), Ma. Del Carmen Hernández (Guatemala), Claudia Quiroz
(Honduras), Geneva González and Yadira Carrera (Panama), Clelia Valverde (Nicaragua)
and Rufino Luna (Mexico). We also appreciate the comments and contributions of
Rebecca Aced-Molina (PHI, USA).
October 2009
MASTER PLAN: MATERNAL, NEONATAL AND REPRODUCTIVE HEALTH GROUP
TABLE OF CONTENTS
Acronyms
Executive summary
1. Theory of change
1.1. Problem
1.2. Target population
1.3. Vision
1.4. Levers
1.5. Outcomes
2. Literature-based evidence for effective practices
2.1. Summary of relevant effective practices
2.2. Outcomes, impacts and cost effectiveness of relevant effective practices
3. Possible solutions: selection of effective practices for regional implementation
3.1. Maternal health
3.2. Neonatal health
3.3. Reproductive health and family planning
3.4. Implementation and timing of effective practices
3.5. Rationale for effective practices
4. Integration
4.1. Integration within the maternal, neonatal and reproductive health pillar
4.2. Integration across the vaccine, nutrition, and vector pillars
5. Human and systems capacity building
5.1. Maternal health
5.2. Neonatal health
5.3. Reproductive health and family planning
5.4. Needs
5.5. Available resources
6. Feasibility
6.1. Barriers and challenges
6.2. Unintended consequences
6.3. Protecting other programs
7. Newly emerging issues
8. Policy landscape
9. Indicators for monitoring and evaluation
10. In-text references
11. Appendices
11.1. Selected demographic and health indicators for the Mesoamerican region, 2009
11.2. Examples of interventions selected by countries
11.3. Neonatal health interventions: extensive listings
MASTER PLAN: MATERNAL, NEONATAL AND REPRODUCTIVE HEALTH GROUP
ACRONYMS
BCG
Bacillus Calmette-Guérin
BEmOC
Basic Emergency Obstetric Care
CEmOC
Comprehensive Emergency Obstetric Care
CHW
Community Health Worker
COMISCA Council of Central American Ministries of Health
EmOC
Emergency Obstetric Care
FP
Family Planning
HBV
Hepatitis B Virus
KMC
Kangaroo Mother Care
LBW
Low Birth Weight
MHI
Mesoamerican Health Initiative
MMR
Maternal Mortality Rate
MNRH
Maternal, Neonatal and Reproductive Health
MTC/HIV Mother to child transmission/HIV
NMR
Neonatal Mortality Rate
PMR
Perinatal Mortality Rate
PAHO
Pan-American Health Organization
RH
Reproductive Health
SRH
Sexual and Reproductive Health
SRR
Sexual and Reproductive Rights
STI
Sexually Transmitted Infection
TBA
Traditional Birth Attendant
TFR
Total Fertility Rate
WHO
World Health Organization
MASTER PLAN: MATERNAL, NEONATAL AND REPRODUCTIVE HEALTH GROUP
EXECUTIVE SUMMARY
The Mesoamerican Health Initiative (MHI) constitutes an effort to improve health conditions in this
region (Central America and nine states of the southern part of Mexico), as a way to respond to
the common health challenges and needs faced by the region. So far, the MHI has conformed
four working groups: nutrition, immunizations, vector-borne diseases and maternal, neonatal and
reproductive health. In this document, we present the Master Plan for maternal, neonatal and
reproductive health (MNRH). This plan has been prepared with the participation of a group of
international experts, as well as representatives of the countries of the region.
Goals and objectives
The most important goals in this area are to reduce maternal mortality by 75%, reduce neonatal
mortality by 50%, and achieve universal access to reproductive health services including family
planning by the year 2015, in line with the United Nations 2009 Millennium Development Goals
(MDG) report.
The main objectives are as follows:
 To increase access to childbirth care provided by qualified and competent personnel,
especially in rural and marginalized urban areas.
 To increase access to basic emergency obstetric care, especially in rural and
marginalized urban areas.
 To reduce the gap between the poorest and richest income quintiles in the proportion of
women giving birth with skilled personnel, in all countries in the region.
 To reduce neonatal mortality by improving obstetric care and implementing actions to
improve the quality of immediate care provided to the newborn, especially in communities
removed from large metropolitan areas.
 To increase access to and improve the quality of services that offer permanent and
reversible contraceptive methods for both men and women, and to implement actions to
reduce common barriers to contraceptive access in the region, especially in rural areas
and for adolescents and youth.
Theory of change
Although there have been improvements in basic maternal, neonatal and sexual and reproductive
health indicators in the Mesoamerican region during the past 10 years, on average unacceptably
high maternal mortality ratios and neonatal mortality rates persist. All national governments have
designed policies and programs to reduce maternal and neonatal mortality and to improve
reproductive health services with an emphasis on family planning. However, these programs
have not been fully implemented and the limited available evaluations indicate that most
programs have not achieved the desired impact. The lack of effective implementation of programs
and interventions is due, fundamentally, to deficiencies within the systems of service and
resource provision which fail to make interventions fully accessible to the whole population. This
Plan’s main objective is to increase access to high quality services and promote the equitable
utilization of those services in order to reduce maternal and neonatal mortality, thus contributing
to the achievement of Goals 3, 4 and 5 of the MDGs. However, interventions should not focus
solely on service provision; in addition to identifying and implementing evidence-based
interventions, the Plan addresses ways to promote empowerment and greater community
participation, strategies which have proven essential for the effective implementation of
sustainable interventions.
The Plan’s main targets are women of reproductive age (10-49 years old), and newborns, also
addressing men’s participation and promoting community participation. Proposed actions will be
directed mainly to the poorest populations, indigenous groups, adolescents and young adults,
MASTER PLAN: MATERNAL, NEONATAL AND REPRODUCTIVE HEALTH GROUP
and the rapidly growing marginalized urban populations. The plan recognizes the high importance
of addressing adolescent health as a high priority..
Our vision is that by 2015 the region’s entire population will enjoy equitable access to high quality
services and that all people will be able to exercise their sexual and reproductive rights, including
the right to decide freely and responsibly the number, spacing and timing of their children; to have
the information and means to do so, and the right to attain the highest standard of sexual and
reproductive health. It also includes their right to make decisions concerning reproduction free of
discrimination, coercion and violence, as expressed in human rights documents.
For this plan we have identified the following main levers:
 Political will. Several key actors, like the Mesoamerican Public Health System (SMSP in
Spanish), the Central American Council of Ministries of Health (COMISCA in Spanish)
and the Pan-American Health Organization (PAHO) are supporting this initiative.
 Health policy. Most of the countries of the region have already developed progressive
national policies and programs and put into action projects that incorporate the most
current concepts of reproductive health care.
 Financial and technical support. All national governments have committed to supporting
this initiative. Additionally, the Bill and Melinda Gates Foundation (BMGF) has provided
funds for the planning stage, and the Carso Health Institute has already begun to support
various SMSP activities. These two organizations and the Spanish government have
shown a clear interest in supporting activities for at least five years. Technical support
has been essential for the development of the Strategic Assessment and for defining the
programs to be implemented in the countries. The continuation of this support will be very
important for the establishment of sustainable Mesoamerican-based coordination
mechanisms capable of supporting the scaling up of interventions.
 Existing regional technical capacity for research and training.
 Political support from the Group of Twenty (G-20).
Identification of effective practices
An extensive literature review was conducted to identify evidence-based effective practices, and
to document their outcomes, impacts and cost effectiveness. The next step was the selection of
the most promising ones which compose the proposals for resolving the problems identified in the
Strategic Assessment. These interventions were discussed extensively within the working group
and with the country representatives.
The group has focused on interventions aimed principally at the community and primary care
level, targeting mainly poor and indigenous population. The document discusses the
implementation of each practice and the factors necessary to achieve sustainability of these
practices after the MHI ends. The main interventions proposed in each area are:
a) Maternal health: implementation of basic Emergency Obstetric Care (EmOC), and
interventions aimed at improving care of obstetric emergencies related to infections,
eclampsia, hemorrhage and abortion; and community awareness, education and training to
improve these outcomes.
b) Neonatal health: essential newborn care, care for the low birth weight newborn and
emergency care for newborns with complications.
c) Reproductive health and family planning: implement quality family planning services for
adolescents, ensure access to counseling and services for at least six contraceptive methods,
ensure access to vasectomy, and post-partum and post-abortion contraceptive counseling and
services.
MASTER PLAN: MATERNAL, NEONATAL AND REPRODUCTIVE HEALTH GROUP
Implementation and timing of effective practices
Although the implementation of a given intervention should take into account its specific
characteristics, the following factors were identified as relevant for the implementation of effective
practices. This Master Plan applies to the first five years of the MHI.
 Capacity building is a crucial aspect of most of the interventions proposed, and it should
be considered as an initial step of the implementation of all interventions.
 Definition of implementation sites in each country, focusing interventions on the poorest
areas, and giving emphasis to the community and primary health care level.
 Although the proposed interventions have demonstrated effectiveness in various settings,
it is advisable to undertake operations research in some locations to define which
interventions are best for the country and the components that should be scaled up.
 Interventions should build upon existing structures and organizations in each country.
 Governance mechanisms should be clearly defined to facilitate coordination of actions.
Rationale for effective practices
Some of the reasons why we expect the proposed interventions to have the most potential to
solve the problems identified in the Strategic Assessment are:
 While constituting a regional strategy, the effective practices will constitute a public good
that may generate economies of scale for all countries.
 A capacity building component is considered a crucial part of the implementation process
of these interventions, but monitoring and supervision is equally important to incorporate
into the intervention packages.
 The implementation of effective family planning interventions is crucial for MNRH
because, as stated in the last High-Level Meeting on Maternal Health for MDG5, family
planning is one of the most cost-effective development investments because ensuring
access to modern contraception can prevent up to 40% of maternal deaths.
Integration
A number of interventions in MNRH impact other indicators within this focus area. Therefore the
implementation of interventions, especially personnel training, should keep this integration in
mind both within MNRH and to some degree with the other pillars of this initiative, in order to reap
the most benefit across programs.
Human and systems capacity building
The Master Plan assesses human and systems capacity existing in the region, and identifies
areas where capacity building is needed for successful implementation of the proposed
interventions. In general, the health systems have great limitations in their infrastructure, though
this varies considerably across countries. Moreover, training systems are generally quite weak,
thus strengthening local training capacity is a high priority of this plan.
Feasibility, barriers and challenges, and other issues related to the implementation of the
interventions
The proposed interventions are in accordance with those proposed and tested in other regions by
international organizations, including the BMGF. There is a clear need for strengthening human
resources for the implementation of interventions. The feasibility and sustainability of the
proposed interventions rely heavily on the political commitment of governments of the region,
both to invest in personnel training and to support the implementation of actions. Feasibility and
sustainability will also depend on the ability of the programs to integrate interventions and
strengthen health systems to respond to sexual and reproductive health needs and respect
sexual and reproductive rights.
MASTER PLAN: MATERNAL, NEONATAL AND REPRODUCTIVE HEALTH GROUP
The key MNRH problem identified in the region is the unsuccessful implementation of programs,
standards and projects. Besides the financial factor, aspects such as managerial deficiencies,
lack of trained personnel, lack of effective commitment, poor quality of health personnel and
managerial systems, and political and ideological opposition to family planning are the main
barriers to effective implementation in Mesoamerica, and as such should be carefully addressed.
The implementation of interventions proposed in this Master Plan may lead to unintended
consequences. One is that the successful implementation of interventions, as well as promotion
of community participation may increase the demand for health services.
The proposed interventions have a low potential to negatively influence the performance of other
programs. However, it is important to maintain communication between maternal, neonatal and
family planning programs with other ongoing programs to minimize potential negative effects and
promote synergies among programs. At the same time, some emerging issues may affect the
implementation and sustainability of the proposed interventions: political instability, epidemics and
other health threats (especially if they lead to migration), political opposition to family planning,
natural disasters and economic and financial crisis.
The Master Plan also discusses the policy landscape in consideration of the issues that may
affect the implementation of interventions. Aspects addressed include the commitment of
countries to improve health, and the support and participation of international organizations such
as COMISCA and PAHO.
Indicators for monitoring and evaluation
In the final section of the Master Plan we propose specific indicators for the monitoring and
evaluation of the proposed interventions, at the level of impact, outcomes and outputs. Evaluation
is key for improving health systems and this plan aims to help improve evaluation systems in all
of the countries. Therefore these indicators are an important initial input for the design of
evaluation plans and represent an important first step in this initiative’s goal of improving MNRH
in Mesoamerica.
MASTER PLAN: MATERNAL, NEONATAL AND REPRODUCTIVE HEALTH GROUP
1.
THEORY OF CHANGE
Regional goals
The most important goals in this area are to reduce maternal mortality by 75% by the year 2015,
to reduce neonatal mortality and to achieve universal access to reproductive health services,
including family planning, following the United Nations 2009 Millennium Development Goals
report.
Achieving these goals may require different activities, since countries have at present different
situations. General demographic and health indicators are shown in appendix 1.
This proposal includes the development of interventions to improve obstetric and neonatal
emergencies care, as well as to increase access to family planning methods, strengthening
health services and promoting community empowerment and participation in the Mesoamerican
region (Central America and the States in Southern Mexico).
Objectives

To increase the access to childbirth care provided by qualified and competent personnel,
especially in rural and marginalized urban areas.

To increase the access to basic emergency obstetric care, especially in rural and
marginalized urban areas.

To reduce the gap in the proportion of women giving birth with skilled personnel between
women in the poorest and richest income quintiles in all countries in the region.

To reduce neonatal mortality by improving obstetric care and by implementing actions to
improve the quality of immediate care provided to the newborn, especially in communities
removed from large metropolitan areas.

To increase access to and quality of services that offer permanent and reversible
methods for both men and women, and to implement actions that promote the reduction
of the barriers to contraceptive access common in rural areas and among indigenous
women, adolescents and youth.
1.1 Problem
Despite significant improvements in basic maternal, neonatal, and sexual and reproductive health
indicators in the Mesoamerican region during the past 10 years, on average unacceptably high
maternal mortality ratios and neonatal mortality rates persist. If reductions in maternal and
neonatal mortality continue at the same pace observed in recent years, it is likely that most
countries in the region will fail to meet the Millennium Development Goals, especially goals 4 and
5. All national governments in the region have recognized the great importance of improving the
quality of reproductive health care and have designed policies and programs to reduce maternal
and neonatal mortality, and to improve reproductive health services with an emphasis on family
planning. However, these programs have not been fully implemented and the limited evaluations
that do exist indicate that in many cases, programs have not achieved the desired impact.
The lack of effective implementation of programs and interventions is due, fundamentally, to
deficiencies within the systems of service and resource provision which fail to make interventions
fully accessible to the whole population. The main reasons for unsuccessful implementation are
MASTER PLAN: MATERNAL, NEONATAL AND REPRODUCTIVE HEALTH GROUP
the endemic lack of funding for health prevalent in all countries in the region and the lack of
competent and skilled personnel, especially in those areas removed from large urban
metropolitan areas. Although all countries have implemented training programs for health
personnel, these programs have limited resources, are of questionable quality, and demand for
training far exceeds systems capacity. This is further aggravated by the high staff turnover
common in all Mesoamerican countries.
Furthermore, the global economic crisis continues to threaten efforts to achieve the Millennium
Development Goals. Pressures on donor countries to cut aid budgets may limit resources
available to developing countries, which in turn will face further difficulties in tackling the crisis
and providing for the needs of their populations.
This Plan’s main objective is to increase access to high quality services and promote the
equitable utilization of those services in order to reduce maternal and neonatal mortality, thus
contributing to the achievement of Goals 3, 4 and 5 of the Millennium Development Goals.
However, interventions should not focus solely on service provision; in addition to identifying and
implementing evidence-based interventions, the Plan addresses ways to promote empowerment
and greater community participation, strategies which have proven essential for the effective
implementation of sustainable interventions.
1.2 Target population
The Plan’s objectives are the improvement of health care services for pregnant women and
newborns and increased access to high quality family planning services that result in increased
use of effective contraceptives and a decrease in unwanted and high-risk pregnancies. Thus the
Plan’s main targets are women of reproductive age (10-49 years old) and newborns.
Furthermore, the Plan will include actions aimed at increasing men’s participation and promoting
community participation at large. Proposed actions will be directed mainly to the poorest
populations, indigenous women and communities, and adolescents and young adults. A
reinforcement of health information systems, including geographic information systems, may
help to identify the location of target groups with lower access to obstetric, neonatal or family
planning services.
The main target groups — poor and indigenous populations — are mainly concentrated in rural
localities, so these areas necessarily compose the Plan’s most important focal point.
Nevertheless, since the region’s countries are all undergoing more or less rapid processes of
urbanization, we must also consider actions geared toward the rapidly growing marginalized
urban populations, as they also concentrate vulnerable groups of people. This is important when
considering interventions aimed at improving emergency obstetric care, primarily focused on the
referral hospital setting.
1.3 Vision
The main objectives are to significantly reduce the maternal mortality ratio and the neonatal
mortality rate, and to increase the prevalence of effective contraceptive use as a means to reduce
unmet need and unwanted pregnancies — an important factor responsible for the higher than
expected maternal mortality ratios in the region. The conditions necessary to achieve these goals
are: a) improve access to high quality reproductive health services including family planning,
prenatal care, labor and delivery, and postpartum and newborn care; 1 b) promote the use of
these services among the entire population, ensuring access by the poor and marginalized
1
Improving quality and access to obstetric care are crucial processes, and each one deserves full
attention on its own. However, we recognize in this plan that an increase in access without improving quality
of obstetric care may not give the expected results.
MASTER PLAN: MATERNAL, NEONATAL AND REPRODUCTIVE HEALTH GROUP
including indigenous communities and people living in rural and marginalized urban areas; and c)
promote community education programs as a means to empower the community through
acquiring healthy behaviors, becoming actively involved in health care, and exercising social
control over health services. Greater emphasis on bridging the gap between “knowing” and
“doing” is also a necessary precondition. The region has already reached the point at which it
becomes necessary to concentrate the efforts of “thinkers” or planners, governments and donors
to stimulate and provide the “doers” with the conditions required to implement and evaluate
sustainable interventions; and as a consequence shift from service delivery models of wealth
transference to empowerment models of wealth creation. The evidence shows that community
empowerment and participation via education is imperative in order to make significant and
sustainable changes.
We hope that by 2015 the region’s entire population will enjoy equitable access to high quality
services and that all people will be able to exercise their sexual and reproductive rights, including
the right to decide freely and responsibly the number, spacing and timing of their children and to
have the information and means to do so, and the right to attain the highest standard of sexual
and reproductive health. It also includes their right to make decisions concerning reproduction
free of discrimination, coercion and violence, as expressed in human rights documents..
Consequently, significant improvements in maternal and neonatal morbidity and mortality indexes
will reflect these developments.
1.4 Levers
Political will. The Mesoamerican Public Health System (SMSP in Spanish), which has been
incorporated into the Mesoamerican Development Project, has the explicit support of all countries
in the region. In addition, the Central American Council of Ministries of Health (COMISCA in
Spanish) is supporting activities in collaboration with the Pan-American Health Organization
(PAHO) and other regional institutions. This international collaboration, including the creation of
the Mesoamerican Institute of Public Health (IMSP in Spanish), is the cornerstone that will
facilitate and sustain the implementation of the Plan.
Health policy. The countries of the region have for the most part already developed progressive
national policies and programs and put into action projects that incorporate the most current
concepts of reproductive health care. This includes the concept that reproductive health is a right
of the people and that the organized community must actively participate in programs from the
planning stages onward.
Financial and technical support. All national governments have committed to supporting this
initiative. Additionally, the Bill and Melinda Gates Foundation has provided funds for the planning
stage, and the Carso Health Institute has already begun to support various IMSP activities. These
two organizations and the Spanish government have shown a clear interest in supporting
activities for at least five years. Grant funds are not sufficient to ensure the implementation of all
initiatives (thus making sustainability a key issue), but these funds are an essential resource for
intervention design and implementation. Technical support has been essential for the
development of the Situation Analysis and for defining the programs to be implemented in the
countries. We are hopeful that this support will continue during the first five years of
implementation and evaluation until the establishment of sustainable Mesoamerican-based
coordination mechanisms capable of supporting the scaling up of interventions.
Existing regional technical capacity for research and training. Several countries in the region
have research and training centers that can play an essential role in implementing initiatives.
Additionally, the IMSP may take on a very important role in coordinating activities in the region
thereby increasing the cost-effectiveness of actions.
MASTER PLAN: MATERNAL, NEONATAL AND REPRODUCTIVE HEALTH GROUP
Political support from the Group of Twenty (G-20). According to the Millennium Development
Goals Report (United Nations, 2009) the leaders of the G-20 have agreed to make available large
additional amounts of international liquidity to countries in crisis in order to fight protectionism and
reform the international financial system. They have also reasserted existing commitments to
provide more aid and debt relief to the poorest countries to safeguard development in low-income
countries.
1.5 Outcomes
All countries in the region have committed to achieving the Millennium Development Goals. Our
proposal can significantly advance progress in meeting three of those goals.
With support from PAHO and other international agencies, all of the countries have developed
strategies and programs to improve the quality of prenatal, childbirth and postpartum care with
the goal of reducing maternal morbidity and mortality (Goal 5) and to collaborate in achieving
Goal 4 through reducing neonatal mortality. PAHO’s Regional Initiative for Maternal Mortality
Reduction has been used by some countries to design strategies for reducing maternal mortality.
Commitments have also been made to meet the goal of achieving universal access to
reproductive health services as part of Goal 5, especially universal access to family planning and
labor and delivery care by qualified and competent personnel.
Increased community participation in reproductive health has been acknowledged as an essential
success factor for improving reproductive health services. Several countries are already
implementing initiatives in this regard, some of which are part of the PAHO Healthy Communities
initiative. These initiatives can have a positive impact on health while also contributing to the
achievement of Goal 3 (promoting gender equality and empowerment of women).
All of the countries have put into practice programs and interventions to achieve these regional
objectives, but so far implementation efforts have been either inadequate to achieve the results
required to meet established goals or have not been evaluated to assess effectiveness.
1.5.1
Regional goals
The most important regional goal is to reduce maternal mortality by 75% by the year 2015.
According to the United Nations 2009 Millennium Development Goals report, the commitment
also includes universal access to reproductive health services including family planning, by 2015.
The region has experienced some progress in reducing maternal mortality but results are
inadequate; in particular the coverage of births attended by skilled service delivery personnel and
access to basic emergency obstetric care are lacking, especially in rural and marginalized urban
areas. Figures for this indicator also have an important variability between countries, ranging from
31.4% (Guatemala) to 98.7% (Costa Rica). To get nearer to the universal coverage objective,
greater efforts must be made to increase access to childbirth care provided by qualified and
competent personnel and reduce the abysmal gap in access between the poorest and richest
segments of the population. The percentage of women giving birth with a skilled provider is 50 or
more percentage points lower among the poorest women (quintile 1) than the richest (quintile 5)
in all countries of the region. Improvements in delivery and postpartum care also necessarily
affect neonatal mortality. The second major objective of the Plan is to reduce neonatal mortality
and improvements in obstetric care should decrease neonatal mortality rates. However, only
improving obstetric care is not enough to reduce neonatal mortality; actions to improve the quality
of immediate care provided to the newborn are also crucial, especially in communities removed
from large metropolitan areas.
Reducing unwanted pregnancies is an important regional goal that would also affect the reduction
of maternal morbidity and mortality, especially through the reduction of unsafe abortions.
Although contraceptive prevalence has increased in all countries, significant unmet demand
MASTER PLAN: MATERNAL, NEONATAL AND REPRODUCTIVE HEALTH GROUP
persists, particularly because access to contraceptive service delivery points that offer at least six
methods remains highly insufficient. Additionally, significant proportions of the population identify
themselves as users of natural or traditional contraceptive methods but do not seek any type of
health services-based counseling or consultation. The objective then is to increase access to and
quality of services that offer permanent and reversible methods for both men and women, and to
implement actions that promote the reduction of the barriers to contraceptive access, common
among indigenous women, adolescents and youth. An increase in the prevalence of the use of
highly effective contraceptives alongside a reduced use of less effective natural and traditional
methods is expected. To reach this objective it will be important to create a regional system for
purchasing contraceptive supplies and methods to ensure quality and lower costs. A purchasing
system including a distribution route and administrative procedures is a necessary pre-condition
for ensuring regional self-sustainability. If this type of agreement were reached by regional bodies
such as the Presidential Summit or COMISCA, the following actions would take place: i) finance
and health ministers will earmark the budget for this system, ii) the system will be made a part of
national budget cycles, and iii) the necessary amount of contraceptive methods will be purchased
every year.
1.5.2
Country-specific objectives
Increase access to and use of modern contraceptive methods among indigenous
populations, the poorest wealth quintiles, and otherwise vulnerable populations in the
region. It is important that countries like Guatemala and Honduras continue efforts to deliver a
guaranteed set of benefits (including family planning) to rural and indigenous populations via
decentralized services which make use of third party providers. El Salvador should continue its
rural community services delivery model which uses basic health systems teams that include
actions in the areas of education, promotion and delivery of family planning services. One of the
main actions to achieve this goal is to train family planning service providers who understand the
cultures of different indigenous and ethnic communities and are capable of working in the local
language.
Ensuring the availability of contraceptive methods is key. The increasing decline in international
collaboration to obtain contraceptive methods has forced countries to implement programs to
ensure method availability. With initial support from USAID, some countries have managed to
sustain these efforts, but others are facing great difficulties in maintaining contraceptive
availability. The main challenge to ensuring contraceptive supply is not only securing funding for
the acquisition of methods and supplies, but also developing capacities such that the distribution
of supplies is efficient and methods are available in all family planning service sites.
Thus, one type of intervention would strengthen and consolidate the work that national
contraceptive supply committees are already carrying out in individual countries. By 2015 it is
expected that all countries in the region will have legally secured a protected budget to ensure
acquisition and will have implemented efficient distribution systems.
Expand family planning services, with at least six modern methods available in countries’
health network units or facilities. Although family planning services are generally available in
all countries and their respective health care networks, in reality challenges remain with respect
to ensuring the permanent availability of at least the following methods: an oral method, an
injectable method, a barrier method, IUD, VSC (or in its absence the ability to refer to a center
that does offer it) and guidance on the proper use of fertility awareness based methods,
especially the Standard Days Method (SDM) used with and without Cycle beads. The related
intervention would consist of ensuring that all health system units offer this minimum range of
services, as well as require clinical and counseling capacity development planning and implement
a logistics cycle subsystem to reduce the problem of shortages or stock outs commonly occurring
in the region.
MASTER PLAN: MATERNAL, NEONATAL AND REPRODUCTIVE HEALTH GROUP
Scale up post-partum and post-abortion family planning programs. The provision of
guidance and contraceptive services in the post-partum and post-abortion periods is a proven
effective strategy to decrease the rate of unwanted pregnancies and to increase birth intervals.
The plans of several countries in the region include the implementation of this strategy and
capacity for personnel training already exists.
Operational research to test strategies for implementing emergency obstetric care in all
health centers. An examination of the most appropriate strategies to ensure that there are
competent personnel and resources for the provision of emergency obstetric care in all
(secondary level) health centers providing labor and delivery care is imperative, as is an efficient
transport system to transfer serious cases to tertiary level hospitals.
Provide universal access to treatment for obstetric emergencies in health centers in rural
areas. Acute and unexpected complications during labor, delivery, and puerperium are
responsible for most maternal deaths, principally hemorrhage, eclampsia, infections, and
complications of abortion. The complications responsible for maternal deaths are quite serious in
and of themselves, but in most cases death can be avoided by taking relatively simple therapeutic
measures in a timely manner or by transferring the patients to better equipped facilities.
Furthermore, a large proportion of complications are preventable: taking precautions to prevent
infections, putting into practice active management of the third stage of labor, and avoiding
lacerations. The most basic intervention comprises training the health professionals attending
deliveries, treating the most common complications, and detecting complications that must be
referred urgently to a better equipped hospital. Training should be theoretical as well as practical
and newly trained providers must be supervised periodically, especially during the first months
after training. It is also crucial to implement a system for transferring complicated cases without
delays.
Improve the quality of basic care, detection of danger signs, and treatment of neonatal
emergencies in primary health centers. All physicians, nurses, and auxiliary nurses working in
health centers where deliveries are attended should be trained to give basic care to newborns,
including appropriate cord clamping, prevention of infections, warming, and treatment of
asphyxia. In addition, all personnel should be trained to detect danger signs or complications
such as intense jaundice, hypothermia, intense paleness, or severe indrawing of breath. Any
newborn experiencing these symptoms should be rapidly transferred to a center with more
resources including at least one pediatrician, ideally a neonatologist. Training of personnel cannot
be done as a one-time course, but it is necessary to have a theoretical and practical training
using models and a period of supervised practice.
MASTER PLAN: MATERNAL, NEONATAL AND REPRODUCTIVE HEALTH GROUP
2.
LITERATURE-BASED EVIDENCE FOR EFFECTIVE PRACTICES
2.1
Summary of relevant effective practices
As part of the process of developing this Master Plan, we conducted a literature review to identify
effective practices in the areas of maternal, neonatal and reproductive health (MNRH). In the
following tables we present the main effective practices or packages identified in this review,
including the type of activities involved, the geographical context in which they have been applied,
their target populations, scale of implementation and countries where they have been
implemented. This review includes the main practices identified, from which some of them have
been selected as a core for this master plan, to be detailed in Section 3. Effective practices are
first presented for maternal health, then neonatal health, followed by reproductive health and
family planning (RHFP).
The categories of effective practices (EP) identified to reduce the main causes of maternal
mortality and morbidity at the community and primary care levels were basic Emergency
Obstetric Care (EmOC), active management of the third stage of labor (AMSTL), and various
practices to prevent and manage eclampsia, postpartum hemorrhage and infection, and
complications arising from abortion (Table 2.1.1). We also identified several practices which
address issues through community education and involvement. All practices depend on referral to
secondary and tertiary care when necessary.
Similarly, packages of EPs focused on eliminating or reducing the main causes of neonatal
morbidity and mortality, particularly asphyxia, hypothermia and infection (Table 2.1.2). Appendix 3
presents a comprehensive and detailed listing of EPs, which for reasons of space have been
grouped into the following packages: essential newborn care, care of the low birth weight (LBW)
newborn and care of the newborn with complications. These packages consist of a number of
facility-based or clinical interventions and community based actions which, like the maternal EPs
depend on coordination with high-level facilities.
Finally, effective RHFP interventions for our target population are presented in Table 2.1.3. These
consist of implementing quality family planning services for adolescents, ensuring access to
counseling and services for at least six different contraceptive methods in health centers,
ensuring access to vasectomy and implementing postpartum and post-abortion contraceptive
counseling and services. As with maternal and neonatal health EPs, these intervention packages
can be designed for community and clinical settings.
MASTER PLAN: MATERNAL, NEONATAL AND REPRODUCTIVE HEALTH GROUP
.
2.1.1
Maternal health
Name of EP or
Package of EPs
Basic Emergency
Obstetric Care
(EmOC)
Active
management of
the third stage of
labor to prevent
postpartum
hemorrhage
Type of Activity(ies)
(e.g., training, service delivery,
outreach materials, media campaigns)
1. Train personnel to treat emergencies
and to refer more complex problems to
secondary and tertiary facilities. Ensure
that trained personnel are retained in
rural areas and that all new members of
health teams are trained.
2. Attend normal vaginal delivery, manual
removal of placenta, manual aspiration
of placental remains, Tx of severe preeclampsia and eclampsia, administration
of oxytocin and antibiotics.
3. All health center and hospital personnel
should be trained.in EmOC. This
includes doctors (usually interns or
general practitioners) nurses, midwives
and auxiliary nurses. Improving the skills
of personnel attending deliveries has
shown to reduce maternal mortality
ratios (MMR) in various countries.
4. Training and supervision is crucial
because the current quality of services
delivered is very low in almost all
countries, mainly in rural areas.
Training of all personnel attending
vaginal deliveries, including doctors,
nurses, auxiliary nurses, and
midwives.Training TBA’s would be
challenging.
Geographical
Context
(e.g., urban,
rural)
Target
Population(s)
(e.g., indigenous,
poor, other
vulnerable)
-General
-Rural areas are
of special
concern due to
difficulties in
access
General population
with emphasis on
primary level
services for poor,
indigenous and
rural populations.
-General
-Rural areas are
of special
concern due to
difficulties in
access
Emphasis on public
hospitals and clinics
that treat the poor.
Scale of
Implementation
(e.g., community,
national, regional
levels)
-National
-Methods included
in the package may
be different in
different areas (e.g.,
urban, rural)
-Community
(training for
emergencies and
timely referral)
-Hospital
-Health center
-Community
MASTER PLAN: MATERNAL, NEONATAL AND REPRODUCTIVE HEALTH GROUP
Country(ies)
where
Implemented
Sources
Some
experiences in
developing
countries.
1-7
Almost all
countries have
had some
experience,
albeit limited.
8-15
Best practices
(interventions) to
reduce maternal
mortality from
acute postpartum
vaginal
hemorrhage
Best practices
(interventions) to
reduce maternal
mortality from
eclampsia
Best practices
(interventions) to
reduce maternal
mortality from
postpartum
infection
Best practices
(interventions) to
reduce maternal
mortality from
septic abortion
Community
awareness,
education and
training
Ensure the availability of safe blood
supply and medications such as
Oxytocin and other uterine retractors.
Training of all personnel attending
vaginal deliveries, including doctors,
nurses and midwives, in management
and referral.
Training of all personnel attending
deliveries as well as those providing
prenatal care since prevention is so
important. Availability of drugs
(magnesium sulfate and others).
Training of all labor and delivery
personnel. Prevention of intrahospital
infection.
Training of health care providers for
management of complications from
abortion. Community education for
referral of cases.
Educating families and community
members about danger signs (e.g., preeclampsia) and when/where to refer.
Birth preparedness. Training community
midwives and traditional birth assistants
in the above interventions (e.g., AMTSL,
prenatal counseling).
-General
-Rural areas are
of special
concern due to
difficulties in
access
Emphasis on public
hospitals and clinics
that treat the poor.
-Isolated studies
-Hospital
-Health center
-Community
component poorly
evaluated
Almost all
countries have
had some
limited
experience,
8-10,
16-18
-General
-Rural areas are
of special
concern due to
difficulties in
access
Of the few existing
studies, the focus
has been on
hospitals that treat
the poor.
Small-scale
implementation
without systematic
expansion.
Some
experiences in
all countries.
8-9,
19-26
-General
-Rural areas are
of special
concern (birth
center\s)
-Women giving birth
at home
-Rural populations
-Community
-Health centers
Some isolated
experiences in
all countries.
8-10,
26-31
Some
improvement
attempts in
metropolitan
areas.
Focus on the poor,
who are affected
the most by unsafe
abortion.
Some isolated
experiences in
all countries.
32-33
Rural
-Women giving birth
at home
-Rural populations
-Community
-Household
-Household/
hospital continuum
of care
MASTER PLAN: MATERNAL, NEONATAL AND REPRODUCTIVE HEALTH GROUP
General
8, 34-36
1.
UNICEF, Guidelines for monitoring the availability and use of obstetric services. New Cork. UNICEF;
1997.
2.
Koblinsky M, editor. Reducing maternal mortality: learning from Bolivia, China, Egypt, Honduras,
Indonesia, Jamaica, and Zimbabwe. Health, nutrition and population series, Washington (DC): World
Bank, 2003.
3.
Pathmanathan I, Liljestrand J, Martins J, Rajapaksa L, Lissner C, de Silva A, et al. Investing in
maternal health: learning from Malaysia and Sri-Lanka. Health, nutrition and population series.
Washington (DC): World Bank; 2003.
4.
Ronsmans C, Etard J-F, Walraven G, Hoj L, Dumont A, de Bernis L, Maternal mortality and access to
obstetric services in West Africa. Trop Med Int Health 2003;8:940-8.
5.
Miller S, Cordero M, Coleman A, Figueroa J, Brito-Anderson R, Dabagh R, et al. Quality of care in
institutional deliveries: the paradox of the Dominican Republic. Int J Gynecol Obstet 2003;82:89-103.
6.
Ronsmans C, Vanneste A, Chakraborty J, van Ginneken J, Decline in maternal mortality in Matlab,
Bangladesh: a cautionary tale. Lancet 1997;350:1810-4.
7.
Campbell OM, Graham WJ. Strategies for reducing maternal mortality: getting on with what works.
The Lancet Maternal Survival Series steering group. Lancet 2006;368:1284-99.
8.
Graham WJ, Cairns J, Bhattacharya S, Bullough CHW, Quayyum Z, Rogo K. Maternal and Perinatal
Conditions. 2006. Disease Control Priorities in Developing Countries (2nd Edition) Eds. Jamison DT
et al, 499-530. New York: Oxford University Press.
9.
Adam T, Lim SS, Mehta S, et al. Cost effectiveness analysis of strategies for maternal and neonatal
health in developing countries. BMJ 2005;331:1107.
10.
Kestler E., Valencia L., Del Valle V., and Silva A. Scaling Up Post-Abortion Care in Guatemala: Initial
Successes at National Level. Reproductive Health Matters 2006;14(27):1-10.
11.
Prendiville WJ, Elbourne D, McDonal S. Active versus expectant management in the third stage of
labour (Cochrane Review). In: The Cochrane Library, Issue 4, 2002. Oxford: Uptade Software Ltd.
12.
Gülmezoglu AM, Villar J, Ngoc NN, Piaggio G, Carroli G, Adetoro L, Abdel-Aleem H, Cheng L,
Hofmeyr GJ, Lumbiganon P, Unger C, Prendiville W, Pinol A, Elbourne D, El-Refaey H, Schulz KF,
for the WHO Collaborative Group To Evaluate Misoprostol in the Management of the Third Stage of
Labour. WHO multicentre double-blind randomized controlled trial to evaluate the use of misoprostol
in the management of the third stage of labour. Lancet, 2001;358:689-695.
13.
Managing complications in pregnancy and childbirth: A guide for midwives and doctors. World Health
Organization, Geneva, 2000 (WHO/RHR/00.7).
14.
Biblioteca de Salud Reproductiva N° 10. Información sobre las mejores prácticas en salud
reproductiva. Organización Mundial de la Salud 2007. ISSN 1745-9923. Publicado por UPDATE
Software. Summertown Pavilon, Middle Way, Oxford OX27LG, United Kingdom.
15.
Instituto Biológico Argentino, Buenos Aires, Argentina.
16.
Mousa, HA, Alfirevic, Z. Treatment for primary postpartum haemorrhage (Cochrane Review).
Cohchrane Database Syst Rev 2003;CD003249.
17.
Lu, MC, Fridman, M, Korst, LM, et al. Variation in the incidence of postpartum hemorrhage across
hospitals in California. Maternal Child Health J 2005; 9:297.
18.
Munn, MB. Owen, J. Vicent R. et al Comparison of two oxytocin regimens to prevent uterine atony at
cesarean delivery: a randomized controlled trial. Obstet Gynecol 2001;98:386.
19.
Douglas, KA., Redman, CW. Eclampsia in the United Kingdom. BMJ 1994;309:1395
20.
Tuffnell, Dj., Jankowicz, D., Lindow, SW, et al. Outcomes of severe pre-eclampsia/eclampsia in
Yorkshire 1999/2003. BJOG 2005;112:875
21.
Zwart, JJ., Richters, A, Ory, F, et al. Eclampsia in the Netherlands. Obstet Gynecol 2008;112:820.
22.
Geographic variation in the incidence of hypertension in pregnancy. World Health Organization
International Collaborative Study of Hypertensive Disorders of Pregnancy. Am J Obstet Gynecol
1988;158:80.
MASTER PLAN: MATERNAL, NEONATAL AND REPRODUCTIVE HEALTH GROUP
23.
Which anticonvulsant for women with eclampsia? Evidence from the Collaborative Eclampsia Trial.
Lancet 1995;345:1455.
24.
American College of Obetetricians and Gynecologist. Diagnosis and management of preeclampsia
and eclampsia. ACOG practice Bulletin #33. American College of Obstetricians and Gynecologists,
2002.
25.
Sibai, BM. Magnesium sulfate prophylaxis in preeclampsia: Lessons learned from recent trials. Am J
Obstet Gynecol 2004; 190:1520.
26.
Darstadt DL, Bhutta ZA, Cousens S, Adam T, Walker N, de Bernis L, for the Lancet Neonatal Survival
Team. Evidence-based, cost-effective interventions: how many newborn babies can we save? Lancet
2005;365:977-88.
27.
Adair, FL. The American Comité of Maternal Welfare, Inc: Chairman’s Ardes. Am J Obstet Gynecol
1935;30:868.
28.
Filker, R., Monif, G. The significance of temperature during the first 24 hours postpartum. Obstet
Gynecol 1979;53:358.
29.
diZerega , G, Yonekura, L, Roy, S, et al. A comparison of clindamycin-getamicin and penicillingentamicin in the treatment of post cesarean section endomyometritis. Am J Obstet Gynecol
1979;134:238
30.
Gibbs, RS, Blanco, JD, Castaneda, YS, St Clair, PJ. A double-blind randomized comparison of
clindamycin-gentmicin versus cefamandole for treatment of post-cesarean section endomyometritis.
Am J Obstet Gynecol 1982;144:261
31.
Frenc, LM, Samill, FM Antibiotics regimens for endometritis after delivery. Cochrane Database Syst
Rev 2004; CD001067.
32.
Forma, F. Gulmezoglu, AM. Surgical procedures to evacuate incomplete abortion. Cochrane
Database Syst Rev 2001;CD001993
33.
Grimes, DA. Unsafe abortion: the silent scourge. Br Med Bull 2003;67:99.
34.
Household-to-Hospital Continuum of Maternal and Newborn Care, ACCESS, October 2005.
35.
Home and Community-Based Health Care for Mothers and Newborns, ACCESS, September 2006.
36. Koblinsky, Marge. Essential Obstetric Care and Subsets. Basic and Emergency Obstetric Care: What's
the Difference. MotherCare Policy Brief #1. Arlington, VA: John Snow, Inc., 1999.
MASTER PLAN: MATERNAL, NEONATAL AND REPRODUCTIVE HEALTH GROUP
2.1.2
Neonatal health
Name of EP or
Package of EPs
Type of Activity(ies)
(e.g., training, service delivery,
outreach materials, media
campaigns)
Guidelines for home births
and for the continuum of
care between home and
hospital to prevent and
manage birth asphyxia,
infections, and
hypothermia.
Essential activities under:
-Immediate newborn care
-Helping newborn breathe
-Helping LBW newborn
-Helping sick newborn
-Stabilizing on way to referral site
Recommended essential
skills for birth asphyxia,
infections, and
hypothermia at peripheral
facilities.
Management of birth
asphyxia via community
midwife and community
health worker (CHW)
training.
-Essential steps for newborn care
antenatal, delivery and postpartum.
-Linking the community to facilities and
creating an enabling environment.
Training of community midwives, village
health workers and traditional birth
attendants in various resuscitation methods
for babies born at home.
Tetanus immunization
campaign using female
vaccinators combined with
community and partner
support.
Door-to-door campaign with female
vaccinators and support from fathers,
husbands, community leaders and
influential community members. Formative
research results were used to inform
strategies for behavior change
communication and social mobilization to
help generate demand among at-risk
women.
Home-based model in which
CHWs monitor, identify, treat
and refer newborns with
sepsis.
One intervention provides neonatal care in
the home and includes intensive training
and supervision with key surveillance,
home visit, diagnosis, referral, and sepsis
Tx activities performed by CHWs and
TBAs. Another trained female community
health volunteers to counsel mothers on
Target Population(s)
(e.g., indigenous,
poor, other
vulnerable)
Scale of
Implementation
(e.g., community,
national, regional
levels)
Home birth, with family,
TBA/CHW or skilled
attendant
General
Geographical
Context
(e.g., urban,
rural)
Country(ies)
where
Implemented
Sources
-Household
-Community
-Household/ hospital
continuum of care
General guidelines
1,2
All
-Household within the
community
-Type I and II level
facilities
-District hospital
General guidelines
1, 3-5
Rural areas.
Poor population.
Community
-Indonesia
-Mali
6, 7
2 randomly selected
districts
At-risk women
Community
Pakistan
8, 9
Rural (India)
Communities where births
take place in the home.
-Household
-Community
-India
-Nepal
General
MASTER PLAN: MATERNAL, NEONATAL AND REPRODUCTIVE HEALTH GROUP
10, 11
Traditional birth attendants
(TBAs) trained and issued
safe delivery kits to reduce
perinatal mortality from all
causes including sepsis.
newborn danger signs, use pictorial
algorithms to identify probable serious
bacterial infections, provide Tx, and refer to
peripheral health workers for Tx.
TBAs trained and issued delivery kits; Lady
Health Workers linked TBAs with
established services and documented
processes and outcomes; and obstetrical
teams provided outreach clinics for
antenatal care.
Seven sub-districts
(3 intervention, 4
control) of a rural
district
Population with poor access
to health services.
-Community
-Household/ health
center continuum of
care
Pakistan
12
Community-based and
primary care management of
neonatal infections.
Community-based management of
infections: Tx of infections with antibiotics
in the home and first level facilities.
All types of
communities/
homes, but several
studies in rural
areas.
Families with newborns
affected by sepsis,
meningitis, or pneumonia in
low-resource settings.
-Household
-Community
-1st level facility
-Bangladesh
-India
-Guatemala
-Nepal
-Pakistan
13–15
CHWs trained in communitybased universal skin-to-skin
care to reduce neonatal
mortality from causes
including infections and
hypothermia.
Promotion of community-based universal
skin-to-skin care which reaches all
newborns regardless of their birth weight.
One study combined a set of ideal
practices, with the intervention carried out
by CHWs after seven days of training
followed by supportive supervision. A
randomized control trial promoted universal
community KMC as part of essential
newborn care taught to pregnant and
postpartum mothers by community nutrition
workers.
Rural areas with
high neonatal
mortality.
-Community stakeholders
-Newborns
-Pregnant and postpartum
mothers
-Households with potentially
harmful practices
Community
-India
-Bangladesh
16–18
Apply facility-based
Kangaroo Mother Care for
LBW/ preterm babies to
reduce neonatal mortality
from complications including
infections and
hypothermia.
What is the evidence that facility-based
skin-to-skin care (SSC) (+ breastfeeding)
works for LBW newborns? Six studies
evaluated the effects of SSC in five
areas—mortality, temperature,
breastfeeding, weight gain, and infections.
n/a
n/a
Facility
n/a
MASTER PLAN: MATERNAL, NEONATAL AND REPRODUCTIVE HEALTH GROUP
16
Treatment of neonatal
infections in developing
countries with oral
antibiotics.
A review of the evidence for treatment of
neonatal infections in developing countries
with oral antibiotics, and an evaluation
properties of oral agents that could be
considered.
Simple, culturally relevant messages were
developed to reinforce healthy birth
preparedness and clean delivery, hygienic
umbilical cord care, skin-to-skin care,
breastfeeding and keeping the baby warm.
CHWs and community volunteers
incorporated behavior change messages
into traditional folk songs and worked with
stakeholders through a home visits and
community meetings.
The intervention consisted of a package of
home-based newborn care (HBNC)
activities carried out by project-paid CHWs.
One of the activities was to identify
pregnant women and make antenatal visits
to counsel on healthy behaviors during
pregnancy and birth preparedness.
Door-to-door campaign with support from
fathers, husbands, community leaders and
influential community members.
Developing country
settings with limited
health systems
capacity.
Resource-poor populations.
-Facility
-Community
Developing
countries
19
Uttar Pradesh state,
where 25% of India’s
1 million annual
neonate deaths
occur.
-Communities where more
than 80% of infant deliveries
take place in the home and
away from the formal health
care system.
-Pregnant women
-Families
-Key community members
Community
India
20
Rural
Communities where births
take place in the home.
-Household
-Community
India
10, 15
2 randomly selected
districts
-Fathers
-Husbands
Community
Pakistan
Referral system
Within a package of essential activities,
stabilizing the newborn on way to referral
site.
General
Home birth, with family,
TBA/CHW or skilled
attendant
-Household
-Community
-Household/ hospital
continuum of care
Training of mothers, families
and CHWs to identify early
neonatal warning signs and
community referral and/or
management
The intervention consisted of a package of
home-based newborn care (HBNC)
activities carried out by project-paid CHWs.
One of the activities was to teach families
to recognize and seek care for newborn
danger signs. Another program trained
FCHVs to counsel families on essential
newborn care and newborn danger signs.
Rural
Communities where births
take place in the home.
-Household
-Community
Community-based behavior
change management
through a campaign in which
CHWs incorporate
messages about healthy and
safe delivery practices
including hypothermia
prevention techniques.
Birth preparation
Male involvement
MASTER PLAN: MATERNAL, NEONATAL AND REPRODUCTIVE HEALTH GROUP
8, 9
1, 2
-India
-Nepal
10, 11, 15,
20
1) Household-to-Hospital Continuum of Maternal and Newborn Care, ACCESS, October 2005.
2) Home and Community-Based Health Care for Mothers and Newborns, ACCESS, September 2006.
3) Bringing Care Closer to Mothers and Newborns: Using the GAP to Develop HH Continuum of Care,
ACCESS, February 2006.
4) Koblinsky, Marge. Essential Obstetric Care and Subsets. Basic and Emergency Obstetric Care:What's the
Difference. MotherCare Policy Brief #1. Arlington, VA: John Snow, Inc., 1999.
5) Beck D., Ganges F, Goldman S, Long P. Care of the Newborn Reference Manual. Saving Newborn
Lives/Save the Children Federation. 2004.
6) Reducing Birth Asphyxia through the Bidan di Desa Program in Indonesia, Final Report to Save the
Children 2006, PATH.
7) Pilot study of a community-based intervention to reduce neonatal death due to birth asphyxia in the health
district of Ouelessebougou, Mali, Proposal to Save the Children, 2007, CREDOS.
8) Rasmussen B, Ali N. Mobilizing demand for maternal and neonatal tetanus immunization: reaching
women in Pakistan, S Crump ed. Shaping policy for maternal and newborn health: a compendium of case
studies. JHPIEGO Corporation, 2003: 23-28.
9) Krift L, et al. Final program evaluation, Pakistan program. Save the Children Saving Newborn Lives
Program, 2005.
10) Bang A, Bang R, Reddy H. Home-based neonatal care: summary and applications of the field trial in
rural Gadchiroli, India (1993 to 2003). J Perinatol 2005; 25: S108-S122.
11) Sharma J. Community based management of neonatal infections in Nepal: establishing a model in one
district. Morang innovative neonatal intervention program (MINI) final report. Submitted to Save the Children
US. John Snow International, 2006.
12) Abdul Hakeem Jokhio, Heather R. Winter, and Kar Keung Cheng. Intervention involving traditional birth
attendants and perinatal and maternal mortality in Pakistan. N Engl J Med 2005;352(20):2091-9.
13) Bhutta ZA, Zaidi AK, Thaver D, Humayun Q, Ali S, Darmstadt GL. Management of newborn infections in
primary care settings: a review of the evidence and implications for policy? Pediatr Infect Dis J. 2009
Jan;28(1 Suppl):S22-30.
14) Darmstadt GL, Batra M, Zaidi AK. Parenteral antibiotics for the treatment of serious neonatal bacterial
infections in developing country settings. Pediatr Infect Dis J. 2009 Jan;28(1 Suppl):S37-42.
15) Community-based management of newborn infections MotherNewborNews Volume 3 No. 1 - 2 July
2007 – December 2008.
16) Community-Based Care for Low Birth Weight Newborns: The Role of Community Skin-to-Skin Care
Meeting Report. May 27, 2008 Washington, DC.
17) Darmstadt, GL, et al. Introduction of community-based skin-to-skin care in rural Uttar Pradesh, India. J
Perinatol. 2006 Oct;26(10):597-604. Epub 2006 Aug 17.
18) Sloan, L. Nancy et al. Community-based Kangaroo Mother Care to prevent neonatal and infant mortality:
a randomized controlled trial. Pediatrics, Volume 121, Number 5, May 2008.
19) Darmstadt GL, Batra M, Zaidi AK. Oral Antibiotics in the Management of Serious Neonatal Bacterial
Infections in Developing Country Communities. Pediatr Infect Dis J. 2009 Jan;28(1 Suppl):S31-6.
20) Kumar V, et al. Effect of community-based behaviour change management on neonatal mortality in
Shivgarh, Uttar Pradesh, India: a cluster-randomised controlled trial. Lancet. 2008 Sep 27; 372(9644): 115162.
MASTER PLAN: MATERNAL, NEONATAL AND REPRODUCTIVE HEALTH GROUP
2.1.3
Reproductive health and family planning
Name of EP or
Package of EPs
Type of Activity(ies)
(e.g., training, service delivery,
outreach materials, media
campaigns)
Geographical
Context
(e.g., urban,
rural)
Target Population(s)
(e.g., indigenous,
poor, other
vulnerable)
Scale of
Implementation
(e.g., community,
national, regional
levels)
Exclusive services for adolescents
are better accepted and used
more frequently
Implement quality
family planning
services for
adolescents
Training providers in sexuality and
family planning counseling is
essential
Wide range of contraceptive
options is critical
-General
-Initially urban
Entire adolescent
population
Services should be oriented to
adolescents’ sexual and
reproductive rights and needs and
should be easy accessible and
user friendly.
Ensure access to
counseling and
services for at least
six contraceptive
methods in health
posts
Health systems should offer free
choice of several methods. Each
method added to the available
options increases prevalence 12%
Training personnel for counseling
and delivering at least six methods
and referral to surgical methods.
Ensure availability of methods
(contraceptive security).
General
General population
with emphasis on
primary level services
for the poor
population, adolescent
and youths
Services for
adolescents are
recognized as
very important but
programs have not
been expanded.
Several models
have been tested.
National. Methods
included in the
package may be
different in
different areas
(e.g., urban, rural).
Referral to
surgical methods
should be ensured
MASTER PLAN: MATERNAL, NEONATAL AND REPRODUCTIVE HEALTH GROUP
Country(ies)
where
Implemented
Sources
Many partially
evaluated
experiences in
several
countries.
Most
evaluations
refer to how to
implement and
access.
1-8
No impact
results
available
except from
USA, UK,
Europe, LAC.
All countries
have partially
implemented
programs to
offer FP to the
entire
population.
Access to
services is very
limited in the
region
9-12
Ensure access to
vasectomy in
hospitals and health
centers
Implement postpartum and postabortion
contraceptive
counseling and
services in all
hospitals attending
deliveries and
abortions
Vasectomy has shown to be very
effective and well accepted.
It is by far the most cost effective
method because it is inexpensive,
highly effective and long lasting.
Contraceptive counseling and
services in the post-partum and
post-abortion period have shown
to be effective in several studies in
developing countries, increasing
acceptance of effective
contraceptive methods.
Offered mainly
in urban
hospitals and
health centers
Should be
implemented in
all hospitals and
health centers
attending
deliveries and
abortion
complications.
Several studies,
some expanded
(Guatemala and
Honduras)
No national
coverage.
General. Acceptance
has shown to be
higher in urban
educated men. No
reliable data on
indigenous population.
Entire population with
an emphasis on
adolescents and
youth.
Officially approved
and included in
most FP
programs. Access
is limited and
promotion of use
of the method is
low in LAC.
Acceptance
seems to be
higher in the postpartum period.
Several countries
have implemented
programs.
Population Council
has promoted
projects in several
countries in LAC,
Europe and Africa.
Guatemala has a
structured
program covering
two thirds of the
hospitals, with
continual
monitoring by a
research team.
MASTER PLAN: MATERNAL, NEONATAL AND REPRODUCTIVE HEALTH GROUP
Partially
implemented in
most western
countries.
13-14
Several
countries in all
regions
including
Guatemala
have
implemented
post-partum
and postabortion
contraceptive
services.
15-16
1. Contraception (Issues in adolescent health and development). WHO Discussion Papers on Adolescence.
World Health Organization, 2004.
2. Sabonge K; Wulf D; Remez L; Prada E; Drescher J. Early childbearing in Honduras: a continuing
challenge. Issues Brief (Alan Guttmacher Inst). 2006 Sep; (4):1-23.
3. Figueroa W, Lopez F, Remez L, Prada E, Drescher J. Early childbearing in Guatemala: a continuing
challenge. Issues Brief (Alan Guttmacher Inst). 2006 Sep; (5):1-20.
4. Blandón L, Carballo Palma L, Wulf D, Remez L, Prada E, Drescher J. Early childbearing in Nicaragua: a
continuing challenge. Issues Brief (Alan Guttmacher Inst). 2006 Sep; (3):1-24.
5. Kirby D (2001). Emerging Answers – Research findings on programs to reduce teen pregnancy.
Washington, DC: The National Campaign to Prevent Teen Pregnancy. 2001.
6. Kirby D (2001). Understanding What Works and What Doesn’t in Reducing Adolescent Sexual RiskTaking. Fam Plann Perspect, 33(6):276–281. 2001.
7. Kilbourne-Brook M (1998) Adolescent Reproductive Health: Making a Difference. Outlook, 16(3):1–8.
8. Family Health International Network (2000). Adolescent Reproductive Health, 20(3):1–36.
9. Sullivan TM, Bertrand JT, Rice J, Shelton JD. Skewed contraceptive method mix: why it happens, why it
matters. J Biosoc Sci. 2006 Jul;38(4):501-21.
10. Kayembe PK, Fatuma AB, Mapatano MA, Mambu T. Prevalence and determinants of the use of modern
contraceptive methods in Kinshasa, Democratic Republic of Congo. Contraception 2006 Nov;74(5):400-6.
11. Lapham RJ and Mauldin WP. Contraceptive prevalence: the influence of organized family planning
programs. Studies in Family Planning, 1985 May-Jun;16(3):117-37.
12. Jain AK. Fertility reduction and the quality of family planning services. Studies in Family Planning, 1989
Jan-Feb;20(1):1-16.
13. Frontiers in Reproductive Health (FRONTIERS), Population Council, Washington, DC. Available at:
http://www.popcouncil.org/frontiers/
14. De Rodriguez B, Vernon R, Solorzano J. Expanding Access to Vasectomy Services in the Ministry of
Health of Guatemala. Final Report. Population Council/FRONTIERS, November 2005.
15. Kestler E, Valencia L, Del Valle V, Silva A. Scaling up post-abortion care in Guatemala: initial successes
at national level. Reproductive Health Matters 2006;14(27):138–147.
16.
Postabortion
Care.
Population
http://www.popcouncil.org/rh/pac.html.
2.2
Council,
Washington,
DC.
Available
at:
Outcomes, impacts, and cost effectiveness of relevant effective practices
After conducting the literature review presented in the previous section, we identified the main
outcomes (short or intermediate term) and long term impacts of each effective practice identified.
We also identified information on the cost effectiveness of those practices; the most pertinent
information is presented in the following tables.
High coverage of the most cost-effective interventions depending on a country’s level of
resources is the preferred approach (Adam et al 2005). However, cost-effectiveness data for
interventions specifically carried out in Central America or the Latin American and Caribbean
region is severely lacking. Thus when cost-effectiveness evidence was unavailable for the
proposed EPs we refer to the WHO-CHOICE estimates for Mesoamerican countries. The first
group known as AMRO-D (defined as having high child and adult mortality) includes Guatemala
and Nicaragua. The rest of the Mesoamerican countries form part of the second group classified
as AMRO-B (low child and adult mortality). WHO-CHOICE has carried out the exercise of
estimating the cost-effectiveness of hundreds of maternal and neonatal packages for all regions
including AMRO-B and AMRO-D, which should prove a useful tool for Mesoamerican countries
when setting priorities and choosing intervention packages. The Disease Control Priorities project
MASTER PLAN: MATERNAL, NEONATAL AND REPRODUCTIVE HEALTH GROUP
is also a good source for cost-effectiveness estimates in MNRH in developing countries (see
Graham et al. 2006, Lawn et al. 2006, Levine et al. 2006, and Lule et al. 2006). Some main
findings are highlighted below.
For maternal health (Table 2.2.1), increasing the number of births attended by skilled personnel
will have an immediate impact on maternal mortality, especially in those countries with higher
MMR. The implementation of a good referral system, backed by adequate transportation,
reducing the delays in transporting patients to centers with more resources will have a great
impact on MM for direct causes. Long term impact on indicators will depend upon the
sustainability of the interventions, mainly in rural areas.
Clearly many maternal and neonatal health interventions can be grouped together, thus resulting
in even higher cost-effectiveness. An analysis of hundreds of maternal-newborn packages in high
child/high mortality countries in sub-Saharan Africa and Southeast Asia found that the most costeffective packages were the following: interventions for newborn care at the community level
(e.g., promotion of breast feeding), followed by selected antenatal care interventions (e.g.,
tetanus toxoid), interventions deliverable by a skilled attendant at birth in a health facility (e.g.,
normal delivery care by a skilled attendant), then by more complex interventions that require
referral to a higher level health facility (Adam et al 2005).
Infant mortality has decreased significantly in the entire region but neonatal mortality has
decreased at a slower pace. Improving access to emergency care to newborns, especially in rural
areas, will have an immediate impact on neonatal mortality if proper attendance to asphyxia and
warming is implemented in birth attendance at the primary level, including home deliveries (Table
2.2.2, refer to Appendix 3 for a detailed listing of intervention package outcomes and impacts).
Although cost-effectiveness data is mainly reported in studies from developed countries, in some
cases interventions in other low-and-middle-income countries provide information for neonatal
health programs. A recent examination of evidence-based interventions to reduce neonatal
mortality in developing countries shows that compared with single interventions, packages of
interventions are always more cost-effective, and much of the benefit is derived from communitylevel actions (Darmstadt et al 2005). Furthermore, settings with very high neonatal mortality see
the greatest benefits from implementing these types of intervention packages.
The improvement of access and quality of family planning services will have important short and
long term impact on women’s and children’s health by reducing unwanted pregnancies and
unsafe abortions. The impacts are still greater in adolescents because delaying the first
pregnancy has positive effects on women, reducing high risk pregnancies, increasing access to
education and improving their livelihoods. The expansion of the use of vasectomy in the region
may greatly contribute to decrease fertility rates (Table 2.2.3).
Contraception cost savings and cost-effectiveness estimates are often based on studies from the
United States and Europe (Trussell 2007; Armstrong and Donaldson 2005; McGuire and Hughes
1995). However, the data consistently show that contraception is always cost-effective compared
to no contraception (Mavranezouli 2009). Even the most conservative studies show an average of
four dollars saved for each dollar spent on contraception (Foster et al 2009). Furthermore, long
acting methods are the most cost-effective since the cost of delivering the contraceptive is almost
negligible compared to the savings from avoiding a pregnancy. More effective methods (i.e.,
implants, long-acting injectables, IUD) are by far the more cost-effective (Trussell et al 1995).
Thus, despite the lack of regional data, based on the literature all family planning interventions
proposed are highly cost-effective.
MASTER PLAN: MATERNAL, NEONATAL AND REPRODUCTIVE HEALTH GROUP
2.2.1
Maternal health
Name of EP or
Package of EPs
Short-Term or Intermediate Outcomes
Long-Term Impacts
Cost Effectiveness
Expensive and highly cost effective.
Basic Emergency
Obstetric Care
(EmOC)
-Increased number of basic EmOC services.
-Increased number of deliveries attended by
trained personnel.
-Reduction in maternal morbidity.
-Better referral systems to resolve highcomplexity cases.
.
Effectiveness widely demonstrated. The
greatest cost is associated with
personnel training and a factor that
increases this cost in the region is the
high turnover of medical personnel. All
new members of health teams have to
be trained and old ones should be
supervised periodically. Costs will also
increase with the implementation of
supervision, monitoring and evaluation
systems.
-Reduced maternal mortality ratios.
-Reduction in morbidity and direct
causes of mortality.
Evidence from South Asia and Sub-Reduce secondary mortality caused by Saharan Africa: Improvements in the
obstetric complications by 50%.6
overall quality of care, especially at the
primary level through the provision of
BEmOC together with increased overall
coverage are the most cost-effective
intervention packages—and both include
nutritional supplements. They are
followed by increased coverage at the
primary level. Improved quality of
comprehensive EmOC is the least costeffective option (8).
South Asia
-Improved BEmOC
ICER (Int$ per DALY averted 142)
MASTER PLAN: MATERNAL, NEONATAL AND REPRODUCTIVE HEALTH GROUP
-Improved BEmOC + coverage
ICER (Int$ per DALY averted 144)
Active management
of the third stage of
labor to prevent
postpartum
hemorrhage
Best practices
(interventions) to
reduce maternal
mortality from acute
immediate
postpartum vaginal
hemorrhage
-Increased number of personnel trained in the
active management of the third stage of labor.
-Increased number of deliveries with active
management of the third stage of labor, as a
percentage of all vaginal deliveries.
-Fewer cases of moderate postpartum
hemorrhage (> 500 ml.)
-Fewer cases of severe postpartum hemorrhage
(> 1000 ml.)
.
-Reduction in morbidity and direct
causes of mortality. -Reduce the
number of maternal deaths due to
postpartum hemorrhage. -Reduced risk
of postpartum hemorrhage > 500 ml of
0.38 (95% C.I. 0.32 – 0.46).11
Sub-Saharan Africa
-Improved BEmOC
ICER (Int$ per DALY averted 83)
-Improved BEmOC + coverage
ICER (Int$ per DALY averted 86)
Complements above packages. Training
of personnel is the most expensive
component. The drugs are inexpensive
but the guaranteed availability of
Oxytocin requires a logistics system.
The following package in most of
Mesoamerica with 95% coverage, has
ACER (Int$ per DALY averted 149.4):
Community newborn care package
(support for breastfeeding, support for
low birth weight) + ANC+SMNC (skilled
maternal and newborn care)+treatment
of severe PEE+PPH (post partum
-Increased number of personnel trained to
hemorrhage) referral+community based
manage hemorrhage complications and who
pneumonia+maternal sepsis+ENC
know when to refer patients to better-equipped
(essential preventive care and
facilities.
-Reduction in morbidity and direct
recognition of danger signs and referral).
-Fewer cases of moderate postpartum
causes of mortality.
In Guatemala and Nicaragua, the same
hemorrhage (> 500 ml.)
-Reduce the risk of acute postpartum
package is even more cost-effective:
-Fewer cases of severe postpartum hemorrhage
hemorrhage by 80%.
(> 1000 ml.)
-Reduce the number of maternal deaths ACER (Int$ per DALY averted 38):
-Increased number of cases transferred to higher- due to postpartum hemorrhage.
Management of hemorrhage as part of a
level facilities opportunely. Women should be
package, with 80% coverage in Bolivia,
transferred opportunely and receiving
Ecuador, Guatemala, Haití, Nicaragua y
endovenous volume reposition.
Perú: Community Newborn Care
-Increased number of blood transfusions.
Package (promotion of extra warmth for
low birthweight babies and support to
breastfeeding) + ANC (Primery level
MASTER PLAN: MATERNAL, NEONATAL AND REPRODUCTIVE HEALTH GROUP
Best practices
(interventions) to
reduce maternal
mortality from
eclampsia
-Increased number of personnel trained to detect
cases of pre-eclampsia early.
-Increased availability of drugs.
-Increased availability and use of protocols.
-Increased number of cases treated for
eclampsia.
-Increased number of cases referred to higherlevel facilities and to ICU.
-Reduce the number of convulsions through
treatment with magnesium sulfate by half (RR
0.44, 95% CI 0.32-0.51)25
care, Skilled maternal care, initial
management of post-partum
hemorrhage)
ACER (Int$ per DALY averted) $11
Prenatal care is an important component
of this set of interventions as early
detection of high-risk cases is crucial in
order to have an impact. The same
considerations regarding personnel
training and turnover apply.
-Reduction in morbidity and direct
causes of mortality.
-Reduce the maternal mortality rate by
one third (RR 0.62, 95% CI 0.39-0.99)25
Two very similar MCH packages (MNH268 and MNH-277) that include
prevention and management of
eclampsia in Mesoamerica, with 95%
coverage, in terms of ACERs were
Int$76 per DALY averted and Int$65.4
per DALY averted
In Guatemala and Nicaragua, the same
packages are Int$27 per DALY averted
and Int$31 per DALY averted).
The cost of these interventions comes
from the use of highly effective but
expensive antibiotics. Training-related
considerations apply as well.
Best practices
(interventions) to
reduce maternal
mortality from
postpartum
infection
-Greater number of hospitals with personnel
trained to prevent and treat postpartum infections.
-Increased availability of highly effective
antibiotics.- Increased number of cases treated
for postpartum infection. -Increased number of
cases of postpartum infection referred to a higherlevel facility.
-Reduction in morbidity and direct
causes of mortality.
-Reduce postpartum infection morbidity
by 75%.
MASTER PLAN: MATERNAL, NEONATAL AND REPRODUCTIVE HEALTH GROUP
Management of postpartum infection
included in the following package:
Management of maternal sepsis
(including treatment with intravenous or
intramuscular antibiotics) (95%
coverage)
Africa East: Int$34 per DALY averted
Southeast region: Int$21 per DALY
averted
-Antibiotics for preterm premature
rupture of membranes (95%)
ACER(Int$ per DALY averted 35)
-Higher level of education among the general
population to avoid dangerous operations
resulting in fewer unsafe abortions.
-Increased number of personnel trained to treat
Best practices
unsafe abortion complications, especially
(interventions) to
infections.
reduce maternal
-Increased availability of antibiotics and medical
mortality from septic
teams prepared to carry out intensive treatments.
abortion
-Increased number of cases treated for septic
abortion.
-Increased number of cases of septic abortion
referred to higher-level facilities.
-Increased number of women referred to primary
level health facilities.
-Increased number of women referred to higherCommunity
level facilities.
awareness, education -Higher level of education among the general
and training
population to avoid dangerous operations
resulting in fewer unsafe abortions.
-Traditional birth attendants better equipped to to
prevent and manage complications.
-Reduction in morbidity and direct
causes of mortality.
-Decrease the number of cases of
septic abortion by 80%.
Training personnel to treat abortion
complications can be expensive.
Training for all referral-related actions
must also be taken into account.
There is no cost-effectiveness evidence.
-Reduction in morbidity and mortality
from eclampsia, septic abortion,
hemorrhage and infection.
MASTER PLAN: MATERNAL, NEONATAL AND REPRODUCTIVE HEALTH GROUP
Low complexity, community level
interventions are the most cost-effective.
2.2.2
Neonatal health
Name of EP or Package
of EPs
Short-Term or Intermediate Outcomes
Increased number of trained TBAs and
medical personnel.
Essential Newborn Care
Package
Reduction of the risk of infections, asphyxia
and hypothermia.
Neonatal Resuscitation
Reduction of the incidence of other conditions
and complications from these conditions, such
as: coagulation defects, acidosis, delayed
fetal-to-newborn circulation adjustment,
hyaline membrane disease and brain
hemorrhage due to hypothermia,
hypoglycemia, necrotizing enterocolitis,
omphalitis, acute respiratory infections,
diarrhea, septicemia, and neonatal
conjunctivitis.
The Clean Chain
The Warm Chain
Breastfeeding
Cord, Eye and Skin Care
Immunization
Vitamin K
Prevention of perinatal and early horizontal
transmission of HBV.
Long-Term Impacts
Reduction in asphyxia-related deaths
and mortality.
Reduction in infection-related deaths
and mortality.
Reduction in hypothermia-related deaths
and mortality.
Reduction in intensive care
hospitalization, disability, rehabilitation
and physical therapy costs.
Polio immunization costs US
$20 per disability-adjusted lifeyear averted.
Benefits in infant and child health and
development.
The estimated cost of routine
hepatitis B vaccination was US
$28 per disability-adjusted life
year averted.
Benefits adult health (decreased risk of
liver disease due to Hep B vaccine,
avoid disability).
Reduce neonatal deaths among LBW
babies.
Identification of the LBW
Baby
Increase in referral of babies weighing less
than 1,800 g to more specialized health care
units.
Reduction in NMR as a result of
prevention of neonatal cold injury.
Improvement in weight gain and growth
Reduce disability due to preterm
asphyxia, hemorrhagic disease and
other neonatal complications among
LBW newborns.
Extra support for Warmth
More efficient treatment of life threatening
preterm-related diseases (respiratory distress
syndrome, hemodinamically significant patent
The bag-and-mask was $13 per
averted death.
Reductions in NMR and PMR.
Increased number of TBAs/CHWs/ health
providers trained in LBW baby identification.
Extra Support for Feeding
$0.25 per birth covered, $42 per
asphyxia death averted.
Eye prophylaxis costs US $ 1.40
per case averted when the rate
of gonococcal infection is
greater than ten percent.
Reduction in hemorrhage-related
neonatal mortality.
Low Birth Weight Baby
Package
Extra Clinical Care of the
LBW Baby
Cost Effectiveness
Reduction in hemorrhage-related NMR.
Vitamin K injection costs US $52
per disability-adjusted life-year
averted in areas of high
incidence of LBW (more than 72
per 100,000 births). Oral Vitamin
K is widely used in Europe and
is considerably less expensive,
but the efficacy of oral
administration needs additional
investigation.
MASTER PLAN: MATERNAL, NEONATAL AND REPRODUCTIVE HEALTH GROUP
Vitamin K
duct arterious and necrotizing enterocolitis).
Reduction in hypothermia damage, respiratory
distress syndrome, hypoglycemia, diarrhea
jaundice, sepsis, feeding-related asphyxia,
and other morbidities.
Reduction in the risk of acute otitis, severe
lower respiratory tract infections and atopic
dermatitis, sudden death syndrome and
necrotizing enterocolitis, nosocomial
infection, severe illness and lower respiratory
tract disease.
Emergency Care of
Newborns with
Complications
Identification of Neonatal
Danger Signs
Quality Emergency Care
of the Sick Newborn
Interventions to treat:
 Severe Neonatal
Infection
 Neonatal Tetanus
 Neonatal Asphyxia
 Neonatal Jaundice
 Birth Defects
 Severe Bleeding
Uptake of antenatal and delivery services,
home care practices, and health-care seeking.
Improve key newborn care practices.
Reduction in neonatal morbidity: sepsis,
meningitis, pneumonia, asphyxia.
hyperbilirubinemia
Reduced neonatal bilirubin levels.
Decrease in the risk of hypovolemic/hypoxic
shock.
Reduction in oxygen requirements due to
acute anemia, restitution of intravascular
volume, improvements in hemodynamics,
decrease heart rate and cardiac output,
improve growth parameters, decrease lactate
levels, or decrease apneic episodes in stable
premature infants.
Reduction in time of hospital stay, intensive
care hospitalization, and treatment costs.
Reduction in costs from hospital stays,
treatment, disability, rehabilitation and
physical therapy.
Reduction in the risk of asthma (young
children), obesity, type 1 and 2 diabetes,
and childhood leukemia.
Reduce neonatal mortality.
Reduce neonatal mortality due to
sepsis, pneumonia, tetanus.
Reduce disability, rehabilitation and
physical therapy costs.
Reduction in aesthetic and functional
problems such as difficulties originated
by cleft lip and palate (i.e., swallowing).
Improvement in neurological outcomes
of asphyxiated infants.
Reduction in disability rehabilitation and
physical therapy needs.13
See WHO-CHOICE maternal
and neonatal intervention
packages for regions AMRO-B
and AMRO-D.
Reduction in the risk of sensory neural
hypoacusia prevalence.
Reduction in choroathetoid cerebral
palsy prevalence.
Improved long term survival from
Myelomeningocele.
MASTER PLAN: MATERNAL, NEONATAL AND REPRODUCTIVE HEALTH GROUP
2.2.3
Reproductive health and family planning
Name of EP or
Package of EPs
Implement quality
family planning
services for
adolescents
Ensure access to
counseling and
services for at least
six contraceptive
methods in health
posts
Short-Term or Intermediate Outcomes
Greater use of reproductive health services.
Increased number of new acceptors of contraceptives.
Greater male participation in contraception.
Reduction of gender imbalance.
Increase the number of new acceptors of contraceptive
methods.
Increase user satisfaction and continuation rates.
Change in method mix.
Ensure access to
vasectomy in
hospitals and health
centers
Increased number of acceptors of vasectomy.
Greater participation of men in FP.
Implement postpartum and postabortion
contraceptive
counseling and
services in all
hospitals attending
deliveries and
abortions
Increase prevalence of contraceptive use after deliveries and
abortions.
Long-Term Impacts
Increased contraceptive use in
adolescents.
Reduced number of adolescent
pregnancies.
Reduction of unsafe abortions.
Increased prevalence of modern
contraceptive methods and decrease
in traditional methods.
Decrease in contraceptive unmet
need.
Improved contraceptive mix.
Decreased number of unwanted
pregnancies.
Decreased abortion rates.
Reduction of neonatal and maternal
mortality.
Increased intergestational intervals.
Increased prevalence of IUD use.
Reduction of maternal and neonatal
mortality.
MASTER PLAN: MATERNAL, NEONATAL AND REPRODUCTIVE HEALTH GROUP
Cost Effectiveness
Expensive and
highly cost effective
Highly cost effective
Very inexpensive, the
most cost effective
program.
Inexpensive and highly
cost effective.
3.
POSSIBLE SOLUTIONS: SELECTION OF EFFECTIVE PRACTICES FOR REGIONAL
IMPLEMENTATION
The next step in the development of this Master Plan was the identification of a group of the most
effective practices, which in turn compose the proposals for solutions of identified problems.
These interventions have been discussed at length with the working groups and country
representatives. We are aware of the importance of aligning the proposed interventions with the
ones proposed by other foundations or organizations that do substantive work in this area,
specifically the Bill and Melinda Gates Foundation. The following tables present the main
packages of interventions proposed for each area, describing the process of implementation of
each practice or package and the factors necessary to achieve sustainability after the MHI ends.
3.1 Maternal health
Effective
Practices (EP) or
Package of EPs
Implementation Process
To implement this intervention, it is necessary to train
personnel to treat emergencies and to refer more complex
problems to secondary and tertiary level facilities. The
intervention has emphasis on primary level services for
poor, indigenous and rural populations. It aims that all
health centers and hospitals should have all personnel
trained.in EmOC, including doctors (usually interns or
general practitioners) nurses, midwives and auxiliary
nurses. Training and supervision is crucial.
Basic Emergency
Obstetric Care
(EmOC)
Drugs
Oxytocin
Antibiotics
Magnesium sulfate
Misoprostol
Procedures
Attendance of normal vaginal delivery,
Manual removal of placenta,
Manual aspiration of placental remains,
Treatment of severe pre-eclampsia and eclampsia
Administration of oxytocin and antibiotics.
Sustainability
Political commitment.
Supervision and
monitoring processes with
weekly evaluations of sets
of indicators.
Dissemination plans for
EmOC guidelines and
protocols.
More ob-gyn specialists.
Appropriate infrastructure
for medication storage.
Regional cooperation and
economic support from
donors.
Human resources
In the community: physicians, nurses, midwives
In hospital: physicians, nurses
Active
management of
the third stage of
labor to prevent
postpartum
hemorrhage
The implementation of this intervention includes an initial
phase of training of all personnel attending vaginal
deliveries, including doctors, nurses, auxiliary nurses, and
midwives.
Drugs
Oxytocin
Political commitment.
Supervision and
monitoring processes with
weekly evaluations of sets
of indicators.
Trained personnel.
MASTER PLAN: MATERNAL, NEONATAL AND REPRODUCTIVE HEALTH GROUP
Procedures
-Training of personnel
-Use of uterotonics (oxytocin)
-Immediate cord clamping
-Assistance delivering the placenta with controlled cord
traction
Human resources
In the community: physicians, nurses, midwives
In hospital: physicians, nurses
Other requirements
In hospital: Update and disseminate guidelines
The implementation of this intervention includes training of
all personnel attending vaginal deliveries, including
doctors, nurses and midwives, in management and
referral. For its operation, it is necessary to ensure the
availability of safe blood supply and medications such as
Oxytocin and other uterine retractors.
Drugs
Oxytocin
Best practices
(interventions) to
reduce maternal
mortality from
acute immediate
postpartum
vaginal
hemorrhage
Procedures
Primary intervention components:
-Coordination with others
-Uterine massage
-Administration of uterotonics (including misoprostol)
-IV and blood transfusion
-Catheter
Secondary intervention components:
-Examination of birth canal
-Hysterectomy
Human resources
In hospital: physicians, nurses
In the community: physicians, nurses, midwives
Political commitment.
Supervision and
monitoring processes with
weekly evaluations of sets
of indicators.
Better monitoring of
neonatal and maternal
mortality
Installation and
accreditation of blood
banks to ensure the supply
of safe blood.
Strengthening training,
monitoring and supervision
of TBA’s, midwives and
general practitioners.
Legal advocacy.
Other requirements
In hospital: Update and disseminate guidelines.
In the community: Necessity of reliable blood banks.
Best practices
(interventions) to
reduce maternal
mortality from
eclampsia
This intervention requires training of all personnel
attending deliveries as well as those providing prenatal
care since prevention is so important, and availability of
drugs (magnesium sulfate and others).
Drugs
- Labetalol
-Hidralazina
Improved prenatal care.
Improved quality of care.
Procedures
-Prevention of maternal hypoxy (oxygen mask)
-Drug-based management of severe arterial hypertension
MASTER PLAN: MATERNAL, NEONATAL AND REPRODUCTIVE HEALTH GROUP
-Drug-based prevention of recurring convulsions
-Evaluate uterus evacuation
Human resources
In hospital: physicians, nurses
In the community: physicians, nurses, midwives
Other requirements
In hospital: Ongoing training of medical and nursing
personnel.
Its implementation requires training of all labor and
delivery personnel.
Drugs
-Clindamycin
-Getamicin
Best practices
(interventions) to
reduce maternal
mortality from
postpartum
infection
Procedures
-Administration of drugs including Clindamycin, Getamicin
-Clinical observation
-Evaluation of endouterine aspiration of placenta remains
Ongoing training of health
personnel in the proper
management and
importance of clean
deliveries.
Human resources
In hospital: physicians, nurses
In the community: physicians, nurses, midwives
Other requirements
In hospital: Update and disseminate postpartum
guidelines and norms.
The implementation of this intervention involves 2 main
activities: training of health care providers for
management of complications from abortion, and
community education for referral of cases.
Drugs
Clindamycin
Getamicin
Best practices
(interventions) to
reduce maternal
mortality from
septic abortion
Procedures
-Patient stabilization
-Blood and/or placenta analysis
-Administration of antibiotics
- Evaluation of endouterine aspiration of placenta remains
-Post abortion counseling and contraception
Develop a post-abortion
care plan.
Technical assistance from
international organizations
DAIA, political will.
Application of laws and
guidelines
Human resources
In the community: physicians, nurses, midwives
In hospital: physicians, nurses
Other requirements
In the community: Systematic promotion of contraceptive
methods, investigate clandestine abortions In hospital:
.
MASTER PLAN: MATERNAL, NEONATAL AND REPRODUCTIVE HEALTH GROUP
This intervention consists in educating families and
community members about danger signs (e.g., preeclampsia) and when/where to refer. Includes also training
community midwives and traditional birth assistants in the
above interventions (e.g., active management of the third
stage of labor, prenatal counseling).
Community
awareness,
education and
training
Procedures
Training of TBA’s and community midwives in essential
obstetric care.
Components of preventing delays: ANC counseling,
community mobilization activities on birth planning,
recognition of danger signs, emergency first aid,
emergency planning for referral (money, transportation,
etc).
Community awareness of
the problem
Involvement of rural and
indigenous communities
Components of preventing infection: clean delivery place,
hands, cord cutting, etc.
MASTER PLAN: MATERNAL, NEONATAL AND REPRODUCTIVE HEALTH GROUP
3.2 Neonatal health
Effective
Practices (EP)
or packages
of EPs
Essential
Newborn Care
Intervention
Package
Implementation Process
Drugs
Vitamin K (1mg)
Tetracycline solution (1%) or
Erythromycin (0.5%)
BCG vaccine
Polio vaccine
HBV vaccine
Procedures
Neonatal Resuscitation (Advanced if needed)
Clean and warm chain application
Promote breastfeeding/Mother training
Eye prophylaxis care
After delivery vaccination
Vitamin K administration
Human resources
In hospital: Enough physicians and nurses addressed
to newborn care exclusively
In the community: One trained TBA/CHW/health
provider/physician/nurse per delivery to achieve good
outcomes even if are facing up a multiple delivery.
TBA’s/CHW/health provider should seek for help in
these case if possible
Sustainability
Political commitment.
Supervision and monitoring
processes with weekly evaluations
of sets of indicators.
Dissemination plans for essential
newborn care guidelines and
protocols.
Guarantee TBA’s/ CHW’s/health
providers training al newborn care
interventions above all neonatal
resuscitation
Establish a Perinatal Epidemiology
Surveillance System locally to
address Fetal and Neonatal
Mortality based on BABIES Matrix
(birth weight and age at death
boxes for intervention and
evaluation system) (1).
More pediatrics and neonatology
specialists.
Appropriate infrastructure for
medication storage and distribution
and to keep drugs availability
Regional cooperation and economic
support from donors.
Other requirements
Basic equipment:
Dry clean cloth
Bag and mask
Suction apparatus
Gloves
Shelf to put the baby on
Method to keep the baby warm (overhead light bulbs)
Oxygen supply if possible
Extra Care for
LBW babies
Drugs
Oxygen
Vitamin K (0.5mg)
Tetracycline solution (1%) or
Erythromycin (0.5%)
10% Dextrose solution
BCG vaccine
Polio vaccine
Political commitment.
Supervision and monitoring
processes with weekly evaluations
of sets of indicators.
Dissemination plans for extra care
for LBW babies and emergency
newborn care guidelines and
protocols.
Establish a Perinatal Epidemiology
MASTER PLAN: MATERNAL, NEONATAL AND REPRODUCTIVE HEALTH GROUP
HBV vaccine
Procedures
Identification of the LBW baby
After that basic procedures plus the following:
Extra Clinical Care of the LBW baby
(breastfeeding/danger signs)
Extra support for Feeding
Extra support for warmth
Vitamin K administration.
Human resources
In hospital: Enough physicians and nurses addressed
to newborn care exclusively
In the community: One trained TBA/CHW/health
provider/physician/nurse per delivery to achieve good
outcomes even if are facing up a multiple delivery.
TBA´s/CHW/health provider should seek for help in
these case if possible
Surveillance System locally to
address Fetal and Neonatal
Mortality based on BABIES Matrix
(birth weight and age at death
boxes for intervention and
evaluation system) (1).
Strengthening training, monitoring
and supervision of TBA’s, midwives
and general practitioners about
LBW babies accurate
management.
-Guarantee
neonatologist/pediatricians/physicia
ns/
nurses training for healthy and ill
LBW babies
More pediatrics and neonatology
specialists.
Other requirements
Basic equipment plus:
Method to identify LBW baby (baby balance scale,
color-coded tape to measure foot, chest, mid-arm or
head circumference or/and assessment of gestational
age)
Feeding tubes
Oxygen tubes
Head oxygen box
IV solution sets
Thermometer.
Method to keep baby warmth (kangaroo care,
overhead radiant heater, hot cots or incubator)
Compressed air source (if possible)
Oxygen blender to mix oxygen and compressed air
Pulse oximeter and oximeter probe (if possible)
Re-closable food-grade plastic bags (1-gallon size) or
plastic wrap.
Emergency
Newborn Care
Package
Drugs
Oxygen
10% dextrose for intravenous use
Injection cephalosporin such as cefotaxime,
depending on local policy for treatment of neonatal
sepsis
Vitamin K injection (1mg)
Epinephrine 1:10,000 (0.1 mg/mL) — 3-mL or 10-mL
ampules
Isotonic crystalloid (normal saline or Ringer’s lactate)
for volume expansion — 100 or 250 mL
Naloxone hydrochloride 0.4 mg/mL — 1-mL ampules,
or 1.0 mg/mL — 2-mL ampules
-Political commitment.
-Supervision and monitoring
processes with weekly evaluations
of sets of indicators.
-Dissemination plans for emergency
newborn care guidelines and
protocols.
Establish a Perinatal Epidemiology
Surveillance System locally to
address Fetal and Neonatal
Mortality based on BABIES Matrix
(birth weight and age at death
boxes for intervention and
MASTER PLAN: MATERNAL, NEONATAL AND REPRODUCTIVE HEALTH GROUP
Normal saline for flushes
Anticonvulsants (i.e. phenobarbital) depending on
local policy
Vasoactive drugs (dopamine)
Surfactant factor
Indometacine/ibuprofen for PDA
Tetanus antitoxin
Procedures
After basic procedures:
Identification of the neonatal danger signs
Provide quality services for the sick newborn
Treat efficiently severe neonatal infection
Treat neonatal tetanus
Manage neonatal asphyxia
Provide jaundice treatment
Provide family centered care for babies with birth
defects
Provide adequate severe bleeding treatment
Human resources
In hospital: Enough physicians and nurses addressed
to newborn care exclusively
In the community: TBA’s/CHW’s/health providers and
mothers trained in the identification of neonatal
danger signs.
evaluation system) (1).
Strengthening training, monitoring
and supervision of TBAs, midwives
and general practitioners about
neonatal danger signs identification.
Guarantee
neonatologist/pediatricians/physicia
ns/
nurses training
More pediatrics and neonatology
specialists.
Appropriate infrastructure for
medication storage and distribution
Keep drug availability
Installation and accreditation of
blood banks to ensure the supply of
safe blood.
Legal advocacy
Reorganize human resources
infrastructure by skills
To develop health resources
education systems (i.e.
Pediatrics/Neonatology
specialization programs at regional
hospitals)
Other requirements
Drip IV sets/Feeding tubes
Oxygen tubes/head oxygen box/nasal
CPAP/neonatal mechanical ventilators
Stetoscope
Method to keep baby warmth (overhead radiant
heater beds, hot cots or incubators)
Laryngoscope with straight blades,
-No. 0 (preterm)
-No. 1 (term)
Endotracheal tubes, 2.5-, 3.0-, 3.5-, 4.0-mm internal
diameter (ID)
Blood sugar sticks for detecting low blood sugar
Bilirubinometer for “bedside” measurement of bilirubin
Sterilizer to clean containers for expressed
breastmilk.
Umbilical vessel catheterization supplies
Blood giving sets, ideally with micro-dropper system
Blood transfusion sets
Cardiac monitor and electrodes or pulse oximeter if
possible
MASTER PLAN: MATERNAL, NEONATAL AND REPRODUCTIVE HEALTH GROUP
3.3 Reproductive health and family planning
Effective Practices
(EP) or Package of
EPs
Implement quality
family planning
services for
adolescents
Implementation Process
Sustainability
Implement exclusive services for adolescents
or reserve periods of time in RH facilities for
adolescents when exclusive services are not
feasible.
Political will is very important. Although
there is consensus on the importance of
the issue, it is not a high priority for
decision makers and managers (e.g.,
politically sensitive topic, adolescents not
seen as an important priority group).
Train personnel to attend adolescents
including counseling and service provision.
Information dissemination and community
participation.
Continuous advocacy.
Ensure access to
counseling and
services for at
least six
contraceptive
methods in health
posts
Availability of skilled personnel in primary
and secondary health services.
Continuous training.
Ensure availability of methods.
Advocacy for maintaining availability of
controversial methods (i.e., emergency
contraception, vasectomy).
A system of continuous training is crucial
for sustainability.
Promotion of community participation
through education is critical.
A procurement and delivery system is
critical for maintaining the availability of
commodities (DAIA).
Training of providers in counseling and
service provision.
Implementation of a continuous
supervision system.
Information dissemination to the community.
Internal advocacy in the system.
Information dissemination on the availability
of the method.
Ensure access to
vasectomy in
hospitals and
health centers
Training of providers on non scalpel
technique (gynecologists, urologists and
general practitioners)
Training health providers on promotion of the
method and counseling.
Continuous training.
Appropriate instruments should be
purchased and delivered to hospitals and
health posts.
Continuous monitoring and supervision.
Unbiased information dissemination.
Increase access in primary health care.
Post-partum and
post-abortion
contraceptive
counseling and
services
Trained personnel already exist.
Educational materials.
Implement counseling in antenatal care.
Training of providers, provision of
supplies.
Continuous monitoring.
Intensive information dissemination.
MASTER PLAN: MATERNAL, NEONATAL AND REPRODUCTIVE HEALTH GROUP
3.4 Implementation and timing of effective practices
Discussions were held with the working group and country representatives in order to help define
the core set of MNRH interventions presented in the previous section. As part of this exercise, we
requested the country representatives to prioritize and select interventions that may be more
relevant for their particular context, and to identify specific factors related to implementation of
interventions and their sustainability. Results from the feedback of three countries are presented
in Appendix 2. They all indicate that, based on a core set of interventions, countries can find
themselves in a good position to identify areas of opportunity to implement interventions within
their specific contexts.
Although the implementation of a given intervention should take into account its specific
characteristics, there are several guidelines common to the implementation of EPs in the area of
maternal, neonatal and reproductive health. This Master Plan is for a first phase of five years, so
this time-span should be taken into consideration for the implementation and evaluation of
interventions.
Application of the interventions proposed in this area requires personnel skilled in the treatment of
different maternal and neonatal complications, as well as in counseling and administration of
family planning methods. Given the limited capacity currently existing in the countries of the
region, training activities constitute one of the first activities in the sequence of implementation of
interventions. Some of the interventions will be partially or completely performed by the same
personnel. Therefore, training activities usually will positive influence several interventions,
especially the maternal and neonatal intervention packages which are based heavily on the
training of medical personnel, midwives and TBAs, and lay people in the community. It is also
critical to train not only physicians and nurses but to train all the personnel, mainly those in
charge of the poorest communities. Training should be essentially practical and should be
followed by continuous monitoring and supervision
A crucial step in the implementation of interventions will be the country-specific definition of
implementation sites. Focalization of interventions is an important requisite for their success and
must consider the general guidelines on target populations as described in this Master Plan.
Interventions should be mainly geared toward the community and primary health care levels,
emphasizing activities among poor and indigenous populations. Expansion to less vulnerable
urban communities should be considered after the programs are fully implemented in the poorest
areas.
Despite of the fact that interventions proposed have demonstrated to be effective in several
settings, it is highly recommendable to initiate the activities undertaking operations research in
some locations. Operations research will determine which are the interventions really adequate
for the country and will allow refining the intervention or package of interventions that will be
scaled up thereafter.
The implementation of interventions should also carefully consider the evaluation component. A
finding from the Situational Analysis in maternal, neonatal and reproductive health in
Mesoamerica was the limited information available on the impact of interventions, and by no
means should we miss the opportunity to rigorously evaluate the interventions proposed in this
Master Plan. Thus impact evaluation design also constitutes one of the first major steps in the
implementation process.
Two additional aspects should be considered in the early phases of implementation. First, the
interventions should build upon existing structures in the region. One example is to take
advantage of the presence and structure of international organizations like the Pan American
Health Organization to achieve an effective implementation. Another example is to build upon
existing health or social programs, which may already have actions related to maternal, neonatal
and reproductive health. This may be the case for countries like Guatemala, Honduras or Mexico,
MASTER PLAN: MATERNAL, NEONATAL AND REPRODUCTIVE HEALTH GROUP
where the existence of nationwide social programs with a health component may constitute a
good platform for the implementation of evaluations.
The final aspect to be considered in this part of the implementation and evaluation design
process is to clearly define a governance mechanism which allows the coordination of actions
between and among countries. Strong coordination between countries may give a regional
perspective to the interventions, generating economies of scale and a more rational use of
resources. Therefore it is important to think about a regional coordination mechanism, perhaps in
the form of a regional technical advisory group.
3.5 Rationale for effective practices
The main problem identified in the Theory of Change was that while all national governments in
the region have recognized the great importance of improving the quality of reproductive health
care and have designed policies and programs to reduce maternal and neonatal mortality and to
improve reproductive health services with an emphasis on family planning, there is a lack of
effective implementation of programs and interventions. This is due mainly to managerial
deficiencies within the systems of service and resource provision which fail to make interventions
fully accessible to the whole population.
We believe the implementation of these particular interventions have the most potential to solve
the problem stated above via an analysis of the different reasons that often lead to an
unsuccessful implementation:
a) While constituting a regional strategy, at the same time the EPs will constitute a public
good that may generate economies of scale for all countries. This will help address the
lack of funding in the region that has limited the implementation of interventions thus far.
b) Given the limited resources in the region, the packages of practices and interventions
presented yield great impact for the least amount of money.
c) Adapting high level health system-focused interventions to community and primary-level
strategies was an important consideration in the exploration and selection of intervention
packages in MNRH which tend to be clinical in nature.
d) A capacity building component is considered a crucial part of the implementation process
of these interventions. This will also increase the number of competent and skilled
personnel, the lack of which has been another reason for poor implementation of
interventions.
e) Issues of sustainability of each intervention have been considered in its selection and
implementation. This may also reduce the effect of the high staff turnover existing in
Mesoamerican countries, which adversely affects the successful implementation of
interventions.
f) The implementation of effective family planning interventions is crucial for MNRH
because, as stated in the last High-Level Meeting on Maternal Health -- Millennium
Development Goal 5 (MDG5), to prioritize family planning, is one of the most costeffective development investments because “ensuring access to modern contraception
can prevent up to 40 per cent of maternal deaths.”
The interventions proposed in this Master Plan have been selected after an extensive literature
review, in which the effectiveness and when available, the costs, of these practices have been
documented. In this sense, all the interventions proposed have sound evidence of their
effectiveness, mainly in developing countries. They also take advantage of the windows of
opportunity for reduction of maternal and neonatal mortality (i.e., the period right before and after
birth), and of the windows of opportunity for family planning promotion (i.e., the period after
abortion or birth). The targeting of these interventions to the most underserved segments of the
population (the poor and indigenous groups) also increases their potential impact.
MASTER PLAN: MATERNAL, NEONATAL AND REPRODUCTIVE HEALTH GROUP
4.
INTEGRATION
Since packages of interventions are more cost-effective than any single action, and given the
opportunity to join forces with other program areas based on community and primary care-level
platforms, we have identified several potential areas of integration.
4.1 Integration within the maternal, neonatal and reproductive health pillar
A number of interventions in MNRH have impact on other indicators within this focus area. A
clear example is that increasing family planning availability and provision may not only affect
fertility indicators, but may also reduce maternal mortality rates through the prevention of
unwanted pregnancies. It has been proposed that achieving wide accessibility to family planning
methods may reduce maternal mortality by up to 40% (UNFPA 2009).
In the same way, interventions directed at improving the quality of obstetric care due to infections,
hypertensive disorders or abortions contribute to the overall reduction of maternal mortality.
Likewise, for practical reasons many intervention packages addressing maternal mortality include
actions geared toward reducing neonatal mortality. Therefore, all of the practices proposed for
this focus area effectively integrate packages that could in turn, be directed to the poorest
segments of population.
Finally, increased access and utilization of maternal and reproductive health services will
probably increase the access and utilization of procedures to detect or prevent diseases, such as
cervical cancer, breast cancer, STIs, and even men would have access to screening for prostate
cancer and chronic diseases.
4.2 Integration across the vaccines, nutrition, and vectors pillars
Nutrition Group. The integration of MNRH interventions with nutrition activities should be
carefully examined to avoid duplication and create positive synergies. Breastfeeding is an
excellent example of an intervention that is also addressed within the nutrition group, as its
impact on neonatal and child health is well-documented. Among the effective practices that could
benefit both groups are the provision and availability of contraceptives, as well as pre and
postnatal household visits by health workers. The nutrition group can also benefit MNRH with
norms and guidelines on food and other nutrients supplementation during pregnancy to prevent
nutritional diseases such as anemia
Vaccines Group. The MNRH group shares with the vaccine group its interest in reducing child
mortality, which includes our group’s health focus of neonatal mortality. While our group is
focusing on neonatal emergency care and community preparedness to prevent neonatal
mortality, vaccination also plays an important role in reducing newborn deaths. Synergies
between both groups can also be identified in the improvement of birth records, which may
enhance neonatal care and the implementation of vaccination campaigns. Wide access to
vaccine against rubella should be ensured and clear guidelines on its use by women should be
disseminated to all services attending women in reproductive age.
Vectors Group. Education during antenatal care should include basic measures about
prevention of malaria and dengue, two prevalent infections in some areas of our region. The
vectors group should collaborate with the MNRH group in devising practical measures and
educational materials to reduce the spread of the infections during pregnancy and prevent child
infections.
MASTER PLAN: MATERNAL, NEONATAL AND REPRODUCTIVE HEALTH GROUP
5.
HUMAN AND SYSTEMS CAPACITY BUILDING
5.1 Maternal health
Inputs Required
Capacity
Components of Basic Emergency
Obstetric Care (EmOC)
Weak. Policies and policies to strengthen capacity exists but
systems do not provide enough resources for adequate training
in EmOC. Implementation of programs is insufficient and the
problem is aggravated by the rapid turn over of personnel.
Managerial systems are unable to retain trained personnel
working in rural areas
Blood banks/safe blood supply
Weak
Availability of medications
Weak
Appropriate infrastructure
Training of primary health facility
personnel
Training of community health
personnel
Coordination processes between
community and health facility
Political will
Weak. However, there is an important variability by country in
the existing infrastructure for delivery attendance
Weak
Weak
Weak
Medium
5.2 Neonatal health
Inputs Required
Training of primary health
facility personnel
Training of community health
personnel
Coordination between
community and health facilities
Availability of medications
LBW warm chain equipment
Material and human resources
equipped NICU’s
Implementation and monitoring
evaluation

Capacity
Weak. The capacity exists but the systems do not provide
resources for adequate training.
Weak. The capacity exists but the systems do not provide
resources for adequate training.
Very weak. Facilities are often too overcrowded to receive new
high risk mothers/babies. Cases from the community are often
stigmatized as worst outcomes cases, thus TBAs don’t seek help.
Weak. Basic drugs are available at community level but
specialized drugs for emergency newborn care such as surfactant
factor are expensive and in some places not longer available; even
in more specialized facilities.
Weak. Incubators and heat radiation beds are not available at
community level. Other kind of methods should be implemented at
that level. Availability in facilities is limited.
Very weak. Not enough beds for all sick babies. Concentration of
NICU’s, pediatricians and neonatologist at metropolitan areas.
Very weak. Managers are not used to using data for decisions. No
well-functioning perinatal surveillance systems in the region.
Heterogenity of resources distribution is evident, there are countries with stronger material and
human capacities at least in larger cities. Disparity seems to be a great conflict.
MASTER PLAN: MATERNAL, NEONATAL AND REPRODUCTIVE HEALTH GROUP
5.3 Reproductive health and family planning
Inputs Required
Training of providers and
managers for improving service
delivery
Training social workers to train
the community for improving
community participation
Implementation of monitoring
and evaluation systems
Improvement of managerial
systems
Capacity
Weak. The capacity exists but the systems do not provide
resources for adequate training.
Weak. Some work has been initiated in some countries but the
capacity for training the community is very weak.
Very weak. Managers are not used to using data for decisions.
Weak. People are not well trained and there is excessive
personnel turnover.
5.4 Needs
As previously described, there are huge material resource and human resource needs in the
region. While there is no doubt that every country has economic restrictions which severely limit
health budgets, it is equally important to strengthen political commitment to allocate more
resources to health sector, especially for women's health and family planning. Family planning
programs in particular historically have been funded in large part through international assistance
— and when this financial assistance is reduced or eliminated, governments have not been able
to respond adequately to the reality of shrinking resources. This situation may also be influenced
by the activities of conservative groups who regularly take action against family planning.
With the advent of AIDS as an important public health problem in recent years, the flow of funds
from international agencies has become polarized towards AIDS prevention and treatment
programs. For example, the Global Fund to Fight AIDS, Malaria and Tuberculosis is an important
source of funding for countries in the region, but the largest proportion of the organization’s funds
goes to Africa. Furthermore, these funds do not contribute to the improvement of sexual and
reproductive health care.
Qualified and properly trained service providers and managers are greatly needed throughout the
region, with the situation being far more serious in rural areas and indigenous communities. While
countries have the potential to meet demand for health provider training, the programs that are
implemented are insufficient for the ever- increasing demand, which is even more important in
rural areas. The need for adequate training systems cannot be understated and is further
aggravated by the lack of managerial capacity of systems that fail to get trained personnel to work
in rural areas. Making decisions about training traditional birth attendants or otherwise
incorporating them into the health system are also imperative.
In terms of management, there is a lack of capacity and willingness to adopt continuous
supervision, monitoring and evaluation policies and programs, such that an insufficient number of
skilled health personnel neither maintain adequate levels of training nor remain working in rural
areas, where needs are most pressing. Moreover, systems of monitoring the distribution of
supplies are inadequate, leading to a lack of equipment and essential drugs in rural areas. In
most of the countries in the region health systems have no mechanisms to encourage quality of
care. Due to the lack of a culture of accountability there are few mechanisms to promote
improvement in performance among staff not satisfactorily fulfilling their duties.
MASTER PLAN: MATERNAL, NEONATAL AND REPRODUCTIVE HEALTH GROUP
Last but not least, community participation is quite scarce despite being recognized as an
important component of quality improvement. In recent years significant efforts have been made
to increase and improve the quality of community involvement, but these attempts have largely
been isolated efforts without potential for scaling up.
In the area of family planning, there is still a great need for improvement in supply and distribution
of contraceptives. Although the introduction of systems to ensure availability of contraceptive
supplies (contraceptive security, or CS) in several countries has somewhat improved the
situation, in reality there are still very few health centers offering an adequate range of methods
(reversible and permanent methods, and at least six different methods). This lack of a sufficient
variety of methods in health centers is one of the most important factors limiting access to
services because put simply, it prevents a woman from obtaining her desired method. Besides
being one of the fundamental sexual and reproductive rights of women, choice of method is a
factor that positively influences quality of care. On the other hand, lack of free and informed
choice of methods limits acceptance of methods in health facilities and also has a negative effect
on the continuation of use and effectiveness. A number of studies have shown that when a
woman receives the method she chooses freely, the chances of failure and early discontinuation
of use is significantly reduced (Pariani et al 1991).
Whether provided as part of labor and delivery or abortion services, obstetric care always carries
a risk of complications requiring rapid transportation to a higher-level facility. The need for skilled
personnel and the role of community involvement in the early detection of complications has been
addressed already, but it is also crucial to have in place effective strategies means to transport
patients before cases become irresolvable. Unfortunately, women die relatively frequently
because they are not transported in a timely manner even when the problem has been diagnosed
and transportation has been requested. Implementing comprehensive and efficient transportation
services for these cases is urgently needed, as is the involvement of community members and
various stakeholders, above all in rural areas.
5.5 Available resources
This issue is quite complex: there is a significant shortage of resources, namely equipment and
basic supplies, but the most important deficiency is the lack of qualified and adequately trained
personnel, especially in rural areas. Several countries in the region have reasonable educational
and training structures with university support. There are several high-level institutions renowned
for their research and education activities MNRH, such as the Centro de Población de la
Universidad de Costa Rica, or the Instituto Conmemorativo Gorgas in Panama, just to name a
few. Universities graduate large numbers of health professionals (physicians, nurses,
psychologists, etc.) every year who are well versed in theoretical knowledge, but unfortunately
these professionals lack adequate practical proficiency. Most recently graduated physicians are
able to unequivocally diagnose lupus erythematosus and other pathologies frequently seen in
hospitals, but wouldn’t know or would at least be seriously challenged by an eclamptic patient,
and would likely have difficulties resuscitating an asphyxiatic newborn.
Although the lack of human resources is an important problem in and of itself, it is exacerbated by
inadequate distribution. In-service health professional training is geared toward higher level
professionals (i.e., physicians and nurses), who many times remain working in urban areas where
there is already a reasonable amount of skilled personnel. Health systems are lacking in
mechanisms to effectively incentivize health professionals to stay in small cities or rural areas,
nor are there legal or administrative mechanisms to keep them working in the most underserved
areas.
It is fundamental to strengthen the training of support personnel, as well as monitoring and
supervision mechanisms. Training should be understood as a continuous and integral process.
MASTER PLAN: MATERNAL, NEONATAL AND REPRODUCTIVE HEALTH GROUP
Training courses may not be adequate for professionals, especially support personnel, because
sometimes they are taught by other professionals with limited teaching competence and technical
knowledge. It is necessary to review the actual training processes, based on sporadic courses, to
move to a more continuous in-service training through supervisors. Supervisors should also be
properly trained to be able to train and provide support for their field staff. This implies the
allocation of more resources to support supervisors to conduct training and supervision activities
that can have a real impact on the quality of care.
It is also necessary to strengthen the training of health administrators. Otherwise the
implementation of interventions will be seriously affected due to the lack of achievement of
program objectives and compliance with norms, lack of organization, and problems with
maintaining physical and human resources in the areas where they are most needed. The
administrators must also have some incentive to improve the quality of care, and not to limit the
administrative tasks that they often face. This gap may not be difficult to resolve since countries
and international agencies offer a variety of courses in health administration, but it is necessary to
make serious efforts to improve the quality of administrators’ work.
As highlighted in previous sections, the resources for transportation to higher-level facilities for
resolution of emergency cases, especially obstetric cases, are quite limited. This is also the case
for non-emergency cases, in which transportation or economic problems may affect access to
medical care.
Although availability of informational resources is increasing, program evaluation and control of
supplies and stocks are limited. The lack of reliable information may affect the planning of
activities, especially when decision makers are aware of the poor quality of data. This situation is
not generalized in the entire region, since some countries such as Costa Rica have developed
good information systems that allow the planning of activities based on national evidence.
6.
FEASIBILITY
All the interventions proposed have a relatively low cost because they are oriented towards
primary health care and/or communities. The interventions proposed in this plan have been
aligned with those of other organizations and foundations, specifically the Bill and Melinda Gates
Foundation, which carried out a substantial amount of work in developing countries
demonstrating the feasibility of proposed interventions. Despite some technical limitations, the
necessary facilities and human resources for undertaking the interventions in most cases already
exist in the countries.
However, feasibility also relies on the political commitment of countries in the region. It is
imperative to allocate resources for training personnel to provide basic needs and care, and to
promote administrative measures to keep skilled personnel in the areas where the most
vulnerable populations live. In addition, it is extremely important to have a minimum of equipment
and basic supplies and medications for obstetric and neonatal care, as well as family planning.
This plan offers several options of interventions in the area of MNRH and FP. The countries will
have the opportunity to choose the ones they consider the most relevant for their specific
situation, or even for specific sub-regions or municipalities within each country, given the costs
and available budgets. In order to achieve sustainability after the Mesoamerican Health Initiative
financial support ends, countries must exercise caution when designing the programs with the
initial donor funding.
Most of the proposed interventions require the implementation of strong training, supervision and
evaluation components. The feasibility and sustainability of the interventions will heavily depend
MASTER PLAN: MATERNAL, NEONATAL AND REPRODUCTIVE HEALTH GROUP
on the proper use of the initial funds from this initiative in order to create sustainable mechanisms
for training and administration that ensure the availability of equipment, medications and family
planning methods. The importance of the capacity building element to the implementation and
sustainability of interventions cannot be understated.
The implementation of interventions to increase access to and quality of family planning services
is fundamental for the feasibility of the maternal and neonatal interventions. Providing access to
high quality family planning and reducing the unmet need for family planning may consequently
reduce the number of unwanted and high-risk pregnancies, reducing maternal mortality by an
estimated 40% (UNFPA 2009).
Technical assistance for at least the first five years is also a crucial element for the design,
implementation, monitoring and evaluation of activities. A technical committee, working with the
BMGF and with support from COMISCA, should ensure that the interventions implemented are
those with the greatest potential impact on poor and rural populations, and that they remain
focused on primary health care and the promotion of community participation.
Operative research, or participatory action research, also plays a role in estimating the feasibility
of the proposed interventions. Although we have included in this plan interventions with proven
effectiveness in different settings, it is highly advisable to start the implementation of each
intervention in each country with operative or participatory action research prior to scaling up the
programs. This type of research allows for the refinement of methods and tailored
implementation. Additionally, advance planning of the timeline and speed of expansion and
scaling up of activities greatly helps budget planning, another key feasibility element.
6.1 Barriers and challenges
As stated in the Strategic Assessment, the key problem identified in the region relating to
maternal, neonatal and reproductive health is the actual implementation of programs, standards
and projects, despite usually being well written and approved by the necessary authorities. The
countries of the region have very good reproductive health programs — i.e., up-to-date and
scientifically sound — but in reality the level of implementation in most areas is much lower than
planned. Furthermore, very few programs are thoroughly evaluated and some never even get
beyond the planning stage.
Besides the financial factor which is undeniably important, there are several other factors
contributing to the lack of effective implementation in the region:

Managerial deficiencies, including shortcomings in monitoring and supervision, resource
management and equipment maintenance, among others. Managerial limitations are strongly
linked to the political organization of the countries in the region. Political issues excessively
influence health systems because policies are designed by whatever group is currently in
charge, and as a result most managers at the central level as well as in the provinces lack
autonomy. As a consequence, every time there is an election or even just the replacement of
a minister there are changes in key personnel which threatens program continuity. Political
changes may constitute a barrier to the implementation and sustainability of effective
practices, and it is necessary to consider specific strategies to reduce the risks related to
changes in government positions. This staff turnover has traditionally been a very important
factor negatively influencing project implementation, as it is necessary to reinitiate
negotiations to maintain even successful projects active.

Lack of trained personnel which in some areas is a real problem, but in others only reflects
problems in managerial systems unable to adequately distribute the available personnel. The
concentration of skilled personnel in large urban areas in detriment to small cities or rural
MASTER PLAN: MATERNAL, NEONATAL AND REPRODUCTIVE HEALTH GROUP
areas is characteristic of the region. The need for a continuous training in this area has been
identified as a very important factor to solve the problems of quality in family planning.

Lack of effective commitment to maternal, neonatal and sexual and reproductive health.
Despite the tremendous importance of this health area, financing for family planning is always
very low because governments still do not effectively assume the commitment of providing
contraception. Traditionally, contraceptive methods have been provided by international
agencies and now that donors have halted contraceptive provision, governments have not
completely covered the gap. A similar situation occurs with maternal health in rural areas
where access to skilled birth attendance is very limited.

Political and ideological opposition to family planning. Despite great advances in the
recent years, family planning can still be a political and/or ideological problem in the region.
Countries have included family planning in their health systems but access is still quite limited
in most of them and the political forces against family planning are always alert and active.
Abortion and emergency contraception are the prime examples of this barrier. Most countries
of the region have very restrictive laws on abortion, including countries where abortion is
prohibited in any circumstances. On the other hand, emergency contraception has been
registered in all countries but several groups are advocating for its prohibition. COMISCA and
other international bodies involved in the initiative should actively advocate for the
maintenance of family planning programs and to ensure access to abortion in cases that
almost all countries in the world accept: rape and severe health risk to the mother.

Last but not least, the endemic lack of quality of health personnel and managerial systems
reflects both the lack of commitment to quality and insufficient supervision. The concept of
accountability is still only a concept in the region but systems have no mechanisms to ensure
that norms or guidelines are properly used. This is one of the main challenges for carrying out
training, which should not only be oriented towards technical issues but also should change
the way health personnel treat women. This concept relates to respecting human rights,
including sexual and reproductive rights.
A general challenge that must be addressed in the implementation of interventions described in
this Master Plan is the strengthening of health information systems which must follow from
this initiative. The strategic assessment has identified severe limitations in information as it
currently exists in the region. The availability of reliable information on the existence and
performance of maternal, neonatal and reproductive health services will be of great help for the
planning of specific interventions in each country.
6.2 Unintended consequences
It is possible that the implementation of interventions, especially of family planning, may increase
the demand for health services, which are sometimes already right at their capacity limit. Periodic
control in family planning necessarily includes early detection and prevention of other diseases,
e.g., detection or treatment of sexually transmitted infections or prostate cancer in the male,
which may also increase the demand for services. The increase in demand may be especially
important for the detection of cervical cancer through Pap smears which is a routine procedure for
women consulting for or using family planning methods. Health services must be ready to
respond to this additional demand, including the treatment of cancer in initial stages.
Health education and promotion of community participation may also increase the demand for
health care in all areas such as immunization, diabetes and hypertension screening, etc. The
implementation of services for adolescents may also increase the demand for services other than
SRH, which should be considered in the integral planning of health systems.
MASTER PLAN: MATERNAL, NEONATAL AND REPRODUCTIVE HEALTH GROUP
6.3 Protecting other programs
We consider the proposed interventions to have a very low potential to negatively influence other
programs. However, it is important that different programs maintain good communication
practices to avoid any possible negative interference of MNRH actions with other programs, and
to avoid duplication of efforts and coordinate the use of resources. After all, good coordination
among programs may benefit all of them.
7.
NEWLY EMERGING ISSUES
Political instability: Perhaps is not fair to include this issue in the section “Newly Emerging
Issues” but it is a very important issue that should be always taken into consideration. For this
reason it would be very important to reinforce the international commitments and agreements
among the countries of the region. A big effort should be made to reinforce the influence of
COMISCA in order to ensure the sustainability of programs, independently of changes of
authorities in the countries.
Epidemics and other health threats. The great increase in international mobility of populations
increases the risk of transmission of infectious diseases including STIs.
Political and ideological opposition to family planning. Despite great advances in recent
years, family planning is still problematic in the region. All countries include family planning in
their health systems but access remains very limited in some countries of the region and the
political forces against family planning are always alert and active. Abortion and emergency
contraception are the best examples. Most countries of the region have very restrictive laws on
abortion, and there are even countries where abortion is prohibited under any circumstance.
Emergency contraception has been registered in all the countries but several groups are
advocating for its prohibition and have actually obtained transient prohibition of its delivery in the
public sector. COMISCA and other international supporters of the initiative should actively
advocate for the maintenance of family planning programs and to ensure access to abortion in
cases that almost the entire world accepts: rape and severe health risk to the mother.
There is a great imbalance between the funds allocated to AIDS programs and to
reproductive health programs. Despite the fact that the epidemic in the region is quite
concentrated, with a general prevalence of less than 1%, the programs for AIDS prevention and
treatment have larger budgets compared to maternal, neonatal and family planning programs. It
would not make sense to promote a decrease in funding for AIDS prevention, but it would be
important to coordinate efforts and implement advocacy campaigns to reposition maternal and
neonatal health and family planning as an important priority area, with the objective of increasing
the funds available for the implementation of MNRH interventions.
Natural disasters caused by global warming. While we can’t accurately predict the future, the
changes in climate during the past few years most likely caused by global warming, will
undoubtedly result in more frequent natural disasters such as floods, hurricanes and droughts.
Responding to these disasters will be an extra burden on already limited national health budgets.
Economic and financial crisis. We have already experienced the worst of the economic crisis
but recovery is not yet complete. Furthermore, its impact on wealthy countries makes it quite
likely that resources for international assistance will shrink. On the other hand, in reaction to the
crisis the G-20 made a decision to make an important effort to maintain and even increase levels
of assistance for the poorest countries.
MASTER PLAN: MATERNAL, NEONATAL AND REPRODUCTIVE HEALTH GROUP
8. POLICY LANDSCAPE
The countries of the region have made a strong commitment of improving health actions through
the development of an integrated health program initially acting in four areas: nutrition, diseases
transmitted by vectors, immunizations, and maternal, neonatal and reproductive health. The
initiative has the explicit support of all the countries of the region and COMISCA is taking the lead
in promoting its full implementation. The participation of COMISCA is especially important in
those countries undergoing political instability that may interfere with the implementation of
interventions in the context of the MHI. Support from other international organizations like PAHO
may also provide a platform for the implementation and sustainability of interventions.
Furthermore, all the countries of the region adopted the Millennium Declaration and committed to
achieving the MDGs. However, in general, the countries of the Mesoamerican region have had
slower progress than expected. In addition the global financial situation may compromise funding
for programs to improve maternal health, the goal towards which there has been least progress
so far. Since the mid-1990s, most developing countries have experienced a major reduction in
donor funding for family planning on a per woman basis, despite the undeniable contribution of
such programs to maternal and child health. On the other hand, the leaders of the G-20 have
declared that the efforts to maintain official assistance for development will be intensified to
protect at least the programs having impact on maternal and infant mortality in poor countries.
The Mesoamerican health program recognizes the great importance of maternal and infant health
and will give support to initiatives aimed at reducing maternal and neonatal mortality.
All the countries of the region contributed towards the definition of the main needs that informed
this Master Plan and are committed to increasing efforts to implement effective actions for
improvement of maternal and neonatal health. Although Latin America is not a priority region for
most major donors, the Bill and Melinda Gates Foundation, Carso and others have earmarked
funds for implementation of some of the activities defined in this Master Plan, and will provide
assistance to the region for better utilization of the available funds and in fundraising activities.
MASTER PLAN: MATERNAL, NEONATAL AND REPRODUCTIVE HEALTH GROUP
9.
INDICATORS FOR MONITORING AND EVALUATION
MATERNAL HEALTH
IMPACTS
OUTCOMES
OUTPUTS
Basic Emergency Obstetric
Care (EmOC)
Reduction of maternal mortality
Reduction in gap between
income quintiles in the proportion
of births attended by skilled
personnel
Indicator
Definition
Maternal Mortality ratio
(Number of maternal deaths) / (100,00 live births)
Ratio of births with EmOC in
lowest and upper income
quintiles of population
Proportion of births with EmOC in lowest income quintile
over proportion of births with EmOC in the upper income
quintile
Increase in the number of health
centers/posts that offer basic
EmOC
Number of health centers and
health posts that offer basic
EmOC per 500,000 inhabitants
(Number of health centers and health posts that offer
basic EmOC / (Total number of health centers and
health posts) *500,000 inhabitants
Reduction in the number of
women with obstetric
complications who do not receive
EmOC services
Proportion of women with
obstetric complications who do
not receive EmOC services
(Number of women with obstetric complications who do
not receive EmOC services) / (Total number of woman
who experience obstetric complications) * 100
Increase in the number of skilled
personnel who can provide
EmOC at the community and
hospital levels
Number of skilled personnel
who can provide EmOC at the
community and hospital levels
(Number of skilled personnel who can provide EmOC at
the community and hospital levels) / (Number of health
personnel in the community and in the hospital)
MASTER PLAN: MATERNAL, NEONATAL AND REPRODUCTIVE HEALTH GROUP
Active management of the third
stage of labor (AMTSL) to prevent
postpartum hemorrhage
OUTCOME
OUTPUTS
Definition
Annual Number of maternal
deaths from postpartum
vaginal hemorrhage (%)
(Number of maternal deaths from postpartum vaginal
hemorrhage per year) / (Number of live births per year)
*100,000
Reduction in the number of cases
with severe vaginal hemorrhage
Cases of moderate
postpartum vaginal
hemorrhage (>500 ml)
(Number of cases of moderate and severe postpartum
vaginal hemorrhage (>500 ml) per month) / (Number of
vaginal deliveries per month)
Increase in the number of deliveries
with AMTSL
Vaginal deliveries with
AMTSL
(Number of vaginal deliveries with AMTSL per month) /
(Number of vaginal deliveries per month)
Decrease in the number of cases of
moderate and severe post-partum
vaginal hemorrhage
Percentage of vaginal
deliveries with moderate an
severe post-partum vaginal
hemorrhage
(Number of cases of moderate and severe post-partum
vaginal hemorrhage) / (Number of vaginal deliveries in
hospital with AMTS per month)
Increase in the use of oxytocin or
unijet
Number of units of oxytocin
or unijet used per month
(Number of units of oxytocin or unijet used per month) /
(Number of vaginal deliveries per month)
Decrease in the application of blood
transfusions in post-partum
Number of post-partum blood
transfusions per month
(Number of blood transfusions per month) / (Number of
vaginal deliveries in hospital per month)
Increase in the number of personnel
trained to provide AMTSL to prevent
postpartum hemorrhage
Skilled personnel who are
trained to provide AMTSL
(Number of skilled personnel who are trained to provide
AMTSL)
Reduction of maternal mortality due
to postpartum hemorrhage
IMPACTS
Indicator
MASTER PLAN: MATERNAL, NEONATAL AND REPRODUCTIVE HEALTH GROUP
IMPACTS
OUTCOMES
Interventions to reduce
maternal mortality from
eclampsia
Reduce maternal mortality due
to eclampsia or pre-eclampsia
Definition
Maternal mortality ratio for
eclampsia or pre-eclampsia
(Number of maternal deaths caused by eclampsia per
year) / (Number of live births per year) *100,000
Increase the number of cases
of pre-eclampsia or eclampsia
treated with the proposed
intervention
Cases of eclampsia that are
treated
(Number of cases of eclampsia that are treated
according to proposed intervention) / (Number of cases
of pre-eclampsia o eclampsia)
Increase the number of cases
of pre-eclampsia or eclampsia
successfully transferred to
higher-level institution (when
required)
Cases of eclampsia referred to
higher-level institution
(Number of cases of eclampsia referred to higher-level
institution) / (Number of cases of pre-eclampsia o
eclampsia)
Improvement in the
management of cases of preeclampsia or eclampsia
OUTPUTS
Indicator
Increase in the number of
personnel trained in the
treatment of emergencies due
to pre-eclampsia or eclampsia
Ratio of discharges from severe
pre-eclampsia or eclampsia to
discharges from mild or
moderate pre-eclampsia
Personnel trained in the
treatment of emergencies due
to pre-eclampsia or eclampsia
(Number of cases of severe pre-eclampsia or
eclampsia) / (Number of cases of mild or moderate preeclampsia)
Number of people trained in the treatment of
emergencies due to pre-eclampsia or eclampsia
MASTER PLAN: MATERNAL, NEONATAL AND REPRODUCTIVE HEALTH GROUP
IMPACTS
OUTCOMES
OUTPUTS
Interventions to reduce
maternal mortality from
postpartum infection
Reduction of maternal deaths
due to post-partum infection
Indicator
Definition
Maternal mortality ratio for
post-partum infection
(Number of maternal deaths from post-partum infection
per year) / (Number of live births per year) * 100,000
Increase in the number of
emergencies from post-partum
infections treated according to
the proposed intervention
Cases treated for postpartum
infection
(Number of cases treated for postpartum infection per
month according to proposed intervention) / (Number of
vaginal deliveries per month)
Increased proportion of severe
post-partum infections
diagnosed and referred to
higher-level institutions
Cases of postpartum infection
referred to higher-level
institution
(Number of cases of postpartum infection referred to
higher-level institution per month) / (Number of vaginal
deliveries per month)
Increase the number of cases
of post-partum infection
treated at the community or
primary level according to the
proposed intervention
Cases of postpartum infection
treated initially in health centers
or health posts
(Number of cases of postpartum infection treated initially
in health centers or health posts per month according to
proposed intervention) / (Number of vaginal deliveries
per month)
Increase in personnel trained
in the treatment of
emergencies due to
postpartum infections at the
community and health facility
level
Personnel trained in the
treatment of emergencies due
to postpartum infection at the
community and health facility
level
Number of persons trained in the treatment of
emergencies from postpartum infection at the
community and health facility level.
MASTER PLAN: MATERNAL, NEONATAL AND REPRODUCTIVE HEALTH GROUP
Best practices
(interventions) to reduce
maternal mortality from
septic abortion
IMPACTS
OUTCOMES
OUTPUTS
Indicator
Definition
Reduction of maternal deaths
due to abortion
Maternal mortality ratio for
abortion
(Number of maternal deaths from abortion per year) /
(Number of live births per year) * 100,000
Increase in the number of
abortion emergencies treated
according to intervention
Septic abortion cases treated.
(Number of cases treated for septic abortion per month
according to proposed intervention) / (Total number of
abortions per month)
Septic abortion cases referred
to higher-level institution
(Number of septic abortion cases referred to higher-level
institution) / (Total number of abortions)
Cases of infection from septic
abortion initially treated in basic
health facilities or centers
(Number of cases of infection from septic abortion
initially treated in basic health facilities or centers) /
(Total number of cases treated for septic abortion)
Personnel trained in the
treatment of abortion
emergencies at the community
and health facility level
Number of persons trained in the treatment of abortion
emergencies at the community and health facility level.
Increase in the number of
abortion emergencies referred
to higher-level institution
Increase in the number of
cases of emergencies from
abortion treated at the
community or primary level
according to the intervention
Increase the personnel trained
in the treatment of abortion
emergencies at the community
and health facility level
MASTER PLAN: MATERNAL, NEONATAL AND REPRODUCTIVE HEALTH GROUP
NEONATAL HEALTH
*Due to the nature of the presentation of packages of neonatal health interventions, this set of indicators serves for all three bundled intervention
packages (Essential Newborn Care, Extra Newborn Care for the LBW Baby and Emergency Newborn Care). They differ in the degree of severity
of the health of the newborn but all share the same impact goals.
Newborn essential care, LBW care and
emergency care
Indicators
Reduction in intrapartum fetal mortality rate
Intrapartum mortality rate
(Babies born without heart beat and non sloughing skin
with no succesful resuscitation after ten minutes)/(total
births*) *1000
Decrease in neonatal& mortality rate
Neonatal mortality rate
(Number of babies born alive who die in the first 28
days of life)/(live births)*1000
Reduction in low birth weight neonatal&
mortality rate
Low birth weight neonatal mortality rate
(Number of babies born alive who wheigthed less than
2500g at birth and die in the first 28 days of life)/(live
births)*1000
Reduction in neonatal& mortality rate due to
asphyxia perinatal, hypothermia,
hypoglycemia, severe infectious
complications or serious bleeding.
Neonatal death rate for specific cause
(perinatal asphyxia, hypothermia and
complications, hypoglycemia, severe
infection or serious bleeding.
Definition
(Number of babies born alive who die from a specific
cause in the first 28 days of life)/(live births)*1000
IMPACTS
(Stillbirths+Infant (first year)) deaths/ (total births*)/1000
As a global result, reduction in Fetal-infant
mortality, infant mortality and under-5
mortality rates due to factors previously
mentionated.
Reduction of the gap between the
proportion of babies with adequate EEENC
at birth across income quintiles of
population
Fetal-Infant mortality
(Deaths of infants under one year of age)/(live
births)*1000
Infant mortality
Under-5 mortality
(Deaths of children under five years of age)/ the
(number of population at risk during a certain period of
time)*1000
Ratio of babies with EEENC at birth in
lowest and upper income quintiles of
population
Proportion of babies with EEENC at birth in lowest
income quintile over proportion of babies with EEENC
at birth in the upper income quintile
MASTER PLAN: MATERNAL, NEONATAL AND REPRODUCTIVE HEALTH GROUP
OUTCOMES
Decrease in perinatal asphyxia incidence
Perinatal asphyxia incidence
(New cases of perinatal asphyxia)/(live births)*100
Decrease in early neonatal sepsis
incidence
Early neonatal sepsis incidence
(New cases of neonatal sepsis which occured among
the three first days of life)/(live births)*100
Reduction in other specific early neonatal
complications incidence
Specific early neonatal complications
incidence
Improve mother/TBA´s/CHW´s/ health
provider identification of pregnancy danger
signs to refer high risk mother to a more
specialized facility for delivery
High risk pregnancies referred from
community/primary care units to a more
specialized facility for delivery
Improve mother/TBA´s/CHW´s/ health
provider identification of neonatal danger
signs to refer high risk babies to a more
specialized facility for treatment
Reduce the ratio of babies with perinatal
asphyxia with access to accurate
resuscitation if needed
(New cases of specific early neonatal complications
which occured among the first seven days of life)/(live
births)*100
Proportion of high risk pregnancies from
community/primary care units referred to a more
specialized facility for delivery
High risk neonates referred from
community/primary care units to a more
specialized facility for treatment.
Proportion of high risk neonates from
community/primary care units referred to a more
specialized facility for treatment
Ratio of perinatal axphyxiate babies
with accurate resuscitation
(Number of babies with perinatal asphyxia)/(number of
babies who receive neonatal resuscitation)
Improve in the number of skilled newborn
attendant at birth
Skilled newborn attendant proportion
(Number of skilled newborn attendants)/(Total of
newborn attendants)*100
Increase in the number of women who
breastfeed their baby in the first hour of life
and mantain it during the first six months
Mothers who breastfeed proportion
(Number of mothers who breastfeed)/(Number of
deliveries)*100
Increase in the number of baby friendly
hospitals
Friendly hospitals proportion
(Number of friendly hospitals)/(Number of hospitals
attending deliveries)*100
Increase in the number of babies who
receive eye prophylaxis, clean and warm
chain
Eye prophylaxis, clean and warm chain
proportion
(Number of eye prophylaxis, clean and warm
chain)/(live births)*100
OUTPUTS
MASTER PLAN: MATERNAL, NEONATAL AND REPRODUCTIVE HEALTH GROUP
REPRODUCTIVE HEALTH AND FAMILY PLANNING
Implement quality family planning
services for adolescents
Indicators
Number of new FP acceptors.
Decreased number of pregnancies and
deliveries in adolescents.
IMPACTS
Decreased number of STI in
adolescents.
Contraceptive prevalence in
adolescents (surveys).
Fertility rate in the 10-14 and 15-19
year old age brackets.
Percentage of all deliveries
occurring in women 10-19 years.
Increased access and utilization of
services.
OUTCOMES
Increased knowledge and use of
contraceptive methods.
Increased use of condoms for STI
prevention.
SRH services exclusive for
adolescents in health centers.
OUTPUTS
Services offering FP and STI
prevention for adolescents
Number of adolescents registered
in health centers.
Number of adolescents requesting
contraceptive methods and
condoms for STI prevention.
Number of services offering SRH
services for adolescents at least
twice a week.
User satisfaction (surveys).
Definition
New acceptors of contraception by method per
year who are adolescents (service statistics).
Percentage of adolescents using contraception
by methods (surveys).
Percentage of total deliveries occurring in women
10-19 years old (maternity statistics, national
register of deliveries).
Number of adolescents registered in health
centers.
Number of adolescents requesting family planning
and other sexual and reproductive health services
(health services statistics).
Number of adolescents receiving condoms from
health services (health services statistics).
Number of health centers offering services
exclusively for adolescents (a facility exclusively
for adolescents, dedicated space within the health
center, or reserved periods of time).
MASTER PLAN: MATERNAL, NEONATAL AND REPRODUCTIVE HEALTH GROUP
Ensure access to counseling and
services for at least six
contraceptive methods in health
centers and health posts
Indicators
Definition
New acceptors by method per year.
Number of new FP acceptors.
IMPACTS
Decrease in the number of unwanted
pregnancies and abortions.
Contraceptive prevalence (surveys).
Fertility rates by age and TFR.
Increase in the quality of FP services.
OUTCOMES
Increased in the number of people
asking for contraception in FP
services.
Proportion of women using contraceptive
methods (detailed by method).
Average number of children that women would
have during her entire reproductive life, if agespecific fertility rates are maintained.
Health statistics, number of FP consultations.
Number of consultations in FP.
User satisfaction studies.
Increase in the number of new
acceptors and continuous users.
User satisfaction, adherence to instructions and
follow-up.
Health statistics (number of new acceptors by
method and number of FP consultations.
More services offering at least six
methods.
OUTPUTS
Increased access to contraceptive
methods.
Number of services offering at least
six modern FP methods (counseling
and services).
Number of health posts and health centers
offering at least six FP methods (administrative
reports).
More options of contraceptive
methods.
MASTER PLAN: MATERNAL, NEONATAL AND REPRODUCTIVE HEALTH GROUP
Ensure access to vasectomy in
hospitals and health centers
Indicators
Number of men undergoing
vasectomy per year.
IMPACTS
Increased acceptance of the method.
Failure rate of the method.
Increased number of men undergoing
vasectomy.
Number of men requesting
vasectomy reversal.
Increased prevalence of use of the
method (surveys).
Increased access to and utilization of
vasectomy.
OUTCOMES
Increased knowledge about the
method and decrease of myths about
it.
Hospitals and health centers offering
vasectomy as a contraceptive option.
OUTPUTS
Increased numbers of men requesting
information about the method.
Definition
Number of men operated in hospitals or health
centers (Official health services statistics).
Failure rate (number of pregnancies after
vasectomy per 100 procedures).
Percentage of men who underwent vasectomy
requesting and undergoing a surgery for
vasectomy reversal (health services statistics).
Prevalence of vasectomy (DHS).
Men considering vasectomy.
Number of men requesting vasectomy.
Men utilizing vasectomy.
Number of men undergoing vasectomy.
Number of services (hospitals and
health centers) effectively offering
access to vasectomy.
Number of hospitals offering the no
scalpel technique vasectomy.
Number of men requesting
information on vasectomy.
Number of hospitals and health centers offering
vasectomy services (Official MOH statistics).
Number of services offering the no scalpel
technique.
MASTER PLAN: MATERNAL, NEONATAL AND REPRODUCTIVE HEALTH GROUP
Implement post-partum and postabortion contraceptive counseling
and services in all hospitals
attending deliveries and abortions
IMPACTS
OUTCOMES
Increase in contraceptive use after
delivery or abortion.
Acceptance of contraceptive
methods after delivery or abortion.
Contribute to an increase in
contraceptive prevalence.
Contraceptive prevalence
(surveys).
Increase in the intergestational period.
Intergestational period.
Increased access to and utilization of
contraceptive methods in the postpartum and post-abortion period.
Increased knowledge and use of
contraceptive methods.
Increase in trained personnel who offer
post-partum and post-abortion FP
counseling and services.
OUTPUTS
Indicators
Implementation of FP counseling and
services in hospitals and health
centers that attend deliveries and
complications of abortion.
Increased proportion of women
receiving contraceptive counseling
during the post-partum and postabortion period.
Increased proportion of women
having a delivery or an abortion
who accept and receive a
contraceptive method before
discharge from the hospital.
Number of hospitals and health
centers offering FP counseling and
services after delivery and abortion.
User acceptance and satisfaction
(studies, surveys).
Definition
Percentage of the total deliveries and abortions:
(hospital statistics).
Proportion of women using contraceptive
methods (detailed by method).
Time elapsed between the delivery and previous
delivery or abortion (statistics from clinical
records).
Proportion of women receiving contraceptive
counseling after a delivery or an abortion per
year.
Proportion of women who accept and receive a
contraceptive method before discharge from the
hospital (statistics of the hospital).
Number of hospitals that attend deliveries and
abortions that effectively offer post-partum and
post-abortion FP counseling and services.
MASTER PLAN: MATERNAL, NEONATAL AND REPRODUCTIVE HEALTH GROUP
10.
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MASTER PLAN: MATERNAL, NEONATAL AND REPRODUCTIVE HEALTH GROUP
MASTER PLAN: MATERNAL, NEONATAL AND REPRODUCTIVE HEALTH GROUP