Tài liệu MATERNAL NEWBORN CHILD AND ADOLESCENT HEALTH pptx

Highlights
Progress Report 2010-2011
m ATERNAL
n EWBORN
c HILD AND
a DOLESCENT
h EALTH
WHO Library Cataloguing-in-Publication Data
Maternal, newborn, child and adolescent health: progress report 2010-2011: highlights.
1.Child welfare. 2.Child health services. 3.Adolescent health services. 4.Maternal welfare. 4.Infant welfare.
4.Program evaluation. 5.Program development. I.World Health Organization.
ISBN 978 92 4 150360 0 (NLM classication: WA 310)
© World Health Organization 2012
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Highlights
Progress Report 2010-2011
m ATERNAL
n EWBORN
c HILD AND
a DOLESCENT
h EALTH
Message from the WHO
Assistant Director-General
The new decade has been marked by important new initiatives that focus
on the health of women and children and seek to accelerate progress
towards achieving the Millennium Development Goals 4 and 5. In
September 2010, the UN Secretary-General Dr Ban Ki-Moon presented
the Global Strategy for Women’s and Children’s Health. The Global
Strategy that was developed by a broad range of constituencies, seeks
to save 16 million lives of women and children by 2015 in the 49 poorest
countries.
Efciency and effectiveness are key words in the Global Strategy. We must
invest more, but also direct our investments rightly. WHO in collaboration
with the Partnership for Maternal, Newborn and Child Health summarized
and published in 2011 the essential low-cost interventions, commodities
and guidelines for women and children across the continuum of care. If
these are implemented at scale, the global community can dramatically
increase access to life-saving interventions for women, children and
adolescents living in the most vulnerable populations.
Governments and the global community at large have responded
overwhelmingly positively to the call for commitments and over 40 billion
US$ will be made available for the implementation of the Global Strategy.
Commitments range from governments pledging to increase domestic
health expenditure and expand the health work force to partners

increasing access to low-cost technologies and increasing nancial
support.
Commitments need to translate into action and action has to generate
results. The Commission on Information and Accountability for Women’s
and Children’s Health, established by our Director-General Dr Margaret
Chan in January 2011, came out with ten compelling recommendations
for tracking results and resources. Moreover,
the Commission called for a mechanism of
internal oversight and I am delighted that
an independent Expert Review Group was
appointed by the UN Secretary General in
September 2011, after a transparent and
open nomination process. The ERG will report
on progress every year and hold stakeholders
to account, in beneciary as well as donor
countries. WHO is privileged to host the
Secretariat of the ERG and to facilitate access to information through its
website at />It is now a time of unprecedented opportunity. Never before has the
global community rallied so strongly and uniformly around the cause of
reproductive, maternal, child and adolescent health. WHO is determined
to play its role and facilitate that indeed, investments will lead to improved
access and coverage of essential interventions. The Family, Women and
Children’s Health Cluster is uniquely positioned to take on the charge.
Its new structure permits us to act in a more coherent way and respond
efciently to the requirements for building the continuum of care. This
report highlights achievements of the Department of Maternal, Newborn,
Child and Adolescent Health. It pays testimony to a range of tools and
actions developed and supported by our extensive network of staff in
headquarter, regional and country ofces. WHO cannot do it alone, but
with so many committed stakeholders, I would like to convey the message

that we can and will deliver on the promises made.
Flavia Bustreo, Assistant Director-General, Family, Women's and
Children’s Health Cluster
4
Message
from the Director
The Department of Maternal, Newborn, Child and Adolescent Health
was established from the 2010 merger of the departments of Making
Pregnancy Safer and Child and Adolescent Health and Development. The
merger represents a consolidation of efforts and a conrmation of WHO’s
commitment to investing in Millennium Development Goals 4 and 5 and
ensures the application of the continuum of care from pregnancy through
infanthood and childhood to adolescence.
The Department provides evidence, norms and standards and supports
the adoption of evidence-based policies and strategies in line with
international standards of human rights, including the universal right of
access to health care. It also builds capacity for high-quality, integrated
health services for pregnant women, newborns, children and adolescents,
and monitors and measures progress in implementation and impact. To
do this, the Department works closely with other technical units at WHO's
headquarters and in regional and country ofces and with partners.
The process of research and development
of policies, norms, standards and tools,
implementation, monitoring and evaluation is
not a linear one but a cyclical one. WHO has
a unique mandate to play a leadership role in
that process. This highlights report for 2010-
11 shows examples of key achievements in the
period and demonstrates that the Department
has continued to be highly productive and

effective throughout its reorganisation.
Ultimately, it is the action and outcomes at country level measure the
success of the work of the Department. This report provides a good picture
of the depth and diversity of our work, and can serve as an inspiration for
renewed and strengthened action for the health of mothers, newborns,
children and adolescents.
Elizabeth Mason, Director, Department of Maternal,
Newborn, Child and Adolescent Health
Working
along the
continuum
of care
MATERNAL, NEWBORN, CHILD AND ADOLESCENT HEALTH PROGRESS REPORT 2010-2011
5
The UN Global Strategy for
Women’s and Children’s Health
In September 2010, the
UN Secretary-General
launched the Global
Strategy for Women’s
and Children’s Health as
a nal push towards the
attainment of Millennium
Development Goals
4 and 5. The Strategy
was developed with the
involvement of many
partners and stakeholders,
and generated commit-
ments in excess of US$ 40

billion.
Measuring results is key to the success of the Global Strategy, and in 2011
the Commission on Information and Accountability for Women’s and Children’s
Health, set up by the WHO Director-General, was charged with this task. Chaired by
President Jakaya Mrisho Kikwete of the United Republic of Tanzania and Canadian
Prime Minister Stephen Harper, the Commission made 10 recommendations for
tracking resources and measuring results. These recommendations form the
basis of a common global work plan on accountability that focuses on the 75
countries with the highest burden of maternal and child mortality.
The work plan calls for the strengthening of vital registration of births and deaths,
national health information systems, and quality-of-care assessments including
maternal death surveillance and response. It recommends that countries conduct
annual reviews of progress combined with advocacy. It also promotes national
digital health strategies and transparent reporting on resources by both recipient
and donor countries. An independent expert review group will report on progress
in the implementation of the Commission’s recommendations.
The Department is playing an important role in follow-up of the accountability
work plan together with the other H4+ agencies (UNICEF, UNFPA, WHO, the World
Bank and UNAIDS) and in partnership with development agencies, academic
institutions and non-governmental organizations. It will lead the working group
on quality-of-care and maternal deaths surveillance and response, and support
countries in the design and implementation of a national action plan to augment
accountability for results as well as resources.
From global strategy
to national reality
Efforts to put the UN Global Strategy for
Women’s and Children’s Health into action
reached an important milestone in 2011.
By the end of the year, all 49 of the lowest
income countries that are the focus of

the Global Strategy had made specic
commitments to accelerating action
towards the achievement of Millennium
Development Goals 4 and 5.
WHO together with its partners in the H4+ inter-agency mechanism facilitated the
development of national commitments. Now WHO is working with its H4+ partners
to support countries to turn these national commitments into action. In countries
with existing plans for maternal, newborn and child health interventions, the H4+
agencies are supporting faster implementation and linkages with national health
strategies and systems strengthening efforts, as well as with monitoring progress
in maternal, newborn, child and adolescent health.
In Burkina Faso, the Democratic Republic of the Congo, the Republic of Sierra
Leone, the Republic of Zambia and the Republic of Zimbabwe the H4+ agencies
have jointly supported the development of country plans with a specic focus
on accelerating progress in maternal and newborn health under the umbrella of
a grant from the Canadian International Development Agency. In addition, with
support of France, the H4+ agencies work in nine francophone countries in West
Africa and in Haiti to improve maternal and child health. This joint support will
continue over the next ve years to further reinforce the national scale-up of
integrated reproductive, maternal, newborn and child health interventions, and
national health systems strengthening and monitoring.
United Nations Secretary-General Ban Ki-moon
Global Strategy
for Women
,
s and
Children
,
s Health
6

gLOBAL CONTEXT AND
STRATEGIC DIRECTIONS
MATERNAL, NEWBORN, CHILD AND ADOLESCENT HEALTH PROGRESS REPORT 2011
7
The UN Convention on the Rights of
the Child: more relevant than ever
The 20
th
anniversary of
the UN Convention on the
Rights of the Child (CRC),
in 2009 was an ideal
opportunity to look at
how the CRC can be used
as a practical framework
and tool for improving
child and adolescent
health. With that in mind,
WHO, UNICEF, Save the
Children International,
and World Vision International organized a technical consultation in May 2010,
bringing together a diverse group of experts in the elds of child and adolescent
health, human rights and law, including representatives from UN agencies,
international aid organizations, academic institutions, and independent experts.
While the Convention had been extensively used to advocate for and raise
awareness of children’s and adolescents’ health, it had not been systematically
applied as a tool for strategic planning and programming. The consultation provided
a unique platform to explore and discuss both opportunities and challenges in
applying the Convention as an essential legal and normative framework, as well
as a programmatic tool, for advancing child and adolescent health in countries.

A number of recommendations adopted at the consultation are now being
implemented, including providing assistance to the UN Committee on the Rights of
the Child in the development of a General Comment on children’s right to health.
The consultation also revealed that raising awareness of the CRC must go hand-in-
hand with demonstrating its practical added value in planning and programming
for child and adolescent health.
Planning informed
by evidence
Having a national strategy and plan of action to increase access and coverage
of effective interventions is a pre-requisite for countries to make steady progress
towards the attainment of improved health outcomes of the population, including the
targets of the health-related MDGS.
The Department is providing guidance on strategy development that involves
identication of high impact interventions to address the burden of disease according
to context, and costing of the resulting action plan. To this effect, a new tool is now
available to guide the national dialogue. The United Nations OneHealth Costing Tool
developed by UN agencies can be used to ensure that national strategies and plans
for maternal, newborn and child health are appropriately prioritized and realistically
costed. The tool covers multiple public health areas (such as immunization, HIV
and tuberculosis) as well as health system functions such as human resources and
medicines, supplies and equipment. It thus has potential to consider the health
sector’s absorptive capacity and simplify and harmonise national planning and
costing processes under one unied platform.
Experts in health systems and maternal and child health programmes from nine
countries in the Western Pacic Region attended a training workshop on using the
OneHealth tool. At the end of the workshop, participants were able to cost health-
related interventions in different country contexts and generate basic costing
projections for their maternal and child health programmes. They could also
perform a strategic assessment of a health system’s performance and capacity for
key maternal and child health interventions. Additionally they could use the tool to

compare alternative scenarios for scale-up, examining the nancial implications and
the expected reduction in disease burden.
One key aspect of OneHealth is the Lives Saved Tool (LiST), which is used for
estimating intervention impact of different intervention packages and coverage levels
for countries. In the Region of the Americas, an intercountry training was held on LiST
in the Republic of Peru. This brought together government ofcials and academics
in the elds of health care planning, health economics and health care nancing
from six countries, together with technical staff from WHO country ofces in the
Republic of Honduras and Peru. The workshop resulted in each country developing
a plan of action to scale-up LiST with the ministries of health and other institutions.
In 2012, Honduras will host a Central American Sub-regional LiST Workshop for an
additional seven countries. Meanwhile, the Republic of Haiti is considering LiST for
the development of its new 10-year National Health Strategic Plan.
m ATERNAL HEALTH
8
Reducing maternal
mortality
Millennium Development Goal 5, to improve
maternal health, is one goal that seems unlikely to be
achieved under the current state of affairs. At 2.3%,
the annual rate of reduction in estimated maternal
mortality ratios over the past two decades (1990-
2008) remains well below 5.5%, the rate required to
reach MDG5 (Figure 1).
Maternal deaths are mostly concentrated in the
African and South-East Asia regions (Figure 2). These
two regions contribute to more than three-quarters of
all maternal deaths worldwide and the African Region
continues to have the highest maternal mortality
ratio. At 620 per 100000 live births, it is more than

44 times the average in more developed regions.
In three WHO regions—Western Pacic, South-East
Asia and Europe—the estimated maternal mortality
ratio has fallen by 50% or more. Several factors
may have contributed to the decline in estimated
maternal mortality rates, ranging from health systems
strengthening to increasing female literacy. Improved
vital registration and notication of maternal deaths
are urgently needed for better understanding of and
response to improve maternal health.
More than 60% of maternal deaths occur in the
postpartum period. The risk of death is highest
close to birth and then decreases over the
subsequent days and weeks. Delays in recognizing
and responding to life-threatening complications
at home are also important non-medical reasons
for maternal deaths. Globally, the proportion of
births attended by skilled health personnel has
increased (Figure 3) and many countries are actively
encouraging women to give birth in health facilities.
While the increasing in number of births in facilities
is encouraging, it is equally important to ensure
good quality of care there.
Figure 1 Trends in Maternal Mortality
Ratios 1990 - 2008*
0
100
200
300
400

500
600
700
800
900
1990 1995 2000 2005 2010
Africa Eastern
Mediterranean
South-East Asia
Western Pacic
Americas
Europe
World
Under-ve Mortality Rate per 1000 live births
* with extrapolation to 2010
Figure 2 Maternal Mortality Ratios by country - 2008
Figure 3 Trends in the proportion of births by
skilled health personnel 1990-2008
0
10
20
30
40
50
60
70
80
90
100
Global Africa Americas Eastern

Mediterranean
Europe South-East
Asia
Weatern
Pacic
Percentage
1990
2008
>20
20 - 99
100 - 299
300 - 549
550 - 999
≥1000
Not applicable
Data not available
MATERNAL, NEWBORN, CHILD AND ADOLESCENT HEALTH PROGRESS REPORT 2010-2011
9
Road Map for reduction
of maternal mortality in Africa
By the end of 2011, 44
countries in sub-Saharan
Africa had developed national
Road Maps for accelerating the
attainment of the Millennium
Development Goals 4 and 5.
As part of the implementation
process, countries review their
progress towards set objectives
and adjust their strategies

to ensure that targets are
achieved by 2015.
The Road Map review process developed by WHO (AFRO and HQ), together with
other H4+ partners, USAID and others, aims to measure what progress has been
made, identify constraints and bottlenecks, and propose solutions for accelerated
implementation.
In 2011, teams of Road Map review facilitators from 15 countries underwent
training, after which the review process was implemented in ve countries in the
region. Both processes showed that the Road Maps are playing a strategic role in
bringing together all stakeholders and highlighting maternal and neonatal survival.
There is still work to be done to improve quality and use of information for identifying
the gaps, setting priorities and allocating resources. Sub-national analysis needs
to be strengthened to highlight gaps in equity, access and distribution of maternal
and newborn services, especially to identify differences between rural and urban
areas and to ensure that the interventions are reaching the women and children
that need them most.
The Road Map review process will continue to roll out in the remaining countries
in 2012. It will feed into the national health sector review processes related to
monitoring country commitments to the UN Global Strategy for Women’s and
Children’s Health and monitoring of progress towards the Millennium Development
Goals related to maternal and newborn health.
Progress in reducing maternal
mortality in the Americas: A lot
but not enough to reach MDG's
Countries of the Region of the Americas
have made great efforts to reduce maternal
mortality. There has been a 41% reduction
in the maternal mortality rate since 1990,
and there have also been considerable
improvements in the surveillance and

monitoring of maternal mortality, allowing
more accurate identication of maternal
deaths than in previous years.
The majority of maternal deaths are
due to avoidable causes and are more
frequent among vulnerable groups: poor
adolescents, rural residents, indigenous
women and those of African descent. The
gains made so far are insufcient if the
region is to reach Millennium Development
Goal 5 by 2015.
The Plan of Action to Accelerate the
Reduction of Maternal Mortality and Severe Maternal Morbidity was developed
by the Latin-American Center for Perinatology/Women and Reproductive Health,
a WHO Regional Ofce of the Americas technical centre responsible for maternal
and perinatal health.
The plan focuses on four strategic areas: prevention of unwanted pregnancies
and resulting complications; universal access to affordable, high-quality maternity
services within a coordinated health care system; increasing the number of
skilled personnel in health facilities for preconception, antenatal, childbirth, and
postpartum care; and strategic information for action and accountability.
IMPLEMENTING
NATIONAL
STRATEGIES
m ATERNAL HEALTH
10
A better system for maternal and
neonatal health surveillance in the
Eastern Mediterranean Region
The vast majority of maternal

and newborn deaths occur
around the time of delivery or
shortly thereafter, most of which
could be avoided by simple
preventable measures and
referral to emergency services.
Effective surveillance, analysis
and reporting of maternal and
newborn morbidity and mortality
are crucial to guide improvements
in service quality.
In 2010, the Eastern Mediterranean Regional Ofce brought together experts
from 10 Member States, the American University of Beirut, the US Centers for
Disease Control and Prevention, the Aga Khan Foundation and the Royal College
of Obstetricians and Gynaecologists to formulate national plans of action
for strengthening maternal and neonatal health surveillance systems in the
participating countries. The meeting also produced technical recommendations to
support the implementation of these plans.
The Regional Ofce also developed generic facility-based maternal and newborn
health client record forms. These forms are due for eld testing in early 2012.
They will then be presented to the member states for adaptation and adoption to
improve national maternal and newborn health information systems.
Maternal mortality and morbidity
audit: 'Beyond the Numbers'
in the European Region
The average maternal mortality rate in the WHO
European Region dropped from 44 per 100 000 live
births in 1990 to 21 per 100 000 in 2008. However,
every year many women still suffer pregnancy-related
complications and a number of them die as a result.

There are also large discrepancies both between and
within countries. Even in countries where resources are
limited, most maternal and perinatal complications and
deaths can be averted with basic and effective low-cost
interventions. WHO in the European Region shows how
this can be accomplished, using tools such as Beyond
the Numbers.
The Beyond the Numbers tool was introduced in the European Region in 2004
and since then many countries have implemented it under the leadership of
Ministries of Health. In June 2010, 90 representatives from 16 countries gathered
in Charvak, the Republic of Uzbekistan to share experiences and lessons learned
using the tool, in order to further improve the quality of care for mothers and
babies in their countries.
There were a number of important lessons learned. The principles and practices
of WHO/Europe Effective Perinatal Care as well as national clinical guidelines on
major obstetric complications must be implemented for successful introduction
of the Beyond the Numbers tool. For appropriate implementation of Beyond the
Numbers, the support of ministries of health, together with external support from
experts, is crucial. Case reviews at the meeting also showed that many of the
recommendations were related to organizational issues.
STRENGHTENING
THE SURVEILLANCE
SYSTEM
MATERNAL, NEWBORN, CHILD AND ADOLESCENT HEALTH PROGRESS REPORT 2010-2011
11
DOCUMENTING
SUCCESS AND
CHALLENGES
Documenting lessons
learned

Lessons learned from any project
can only be effectively shared if
they are properly documented. This
documentation can also be used
for advocacy, policy planning and
simply for record-keeping. When
the Japan International Cooperation
Agency supported an Indian
National Rural Health Mission
project in ve districts in the Indian
state of Madhya Pradesh to improve
maternal and newborn health, it
invited the WHO’s South-East Asia
Regional Ofce to document the
experiences of this project, which
ran from 2005 to 2011.
The documentation process revealed several signicant ndings from which
lessons can be learned, such as how successfully the project was aligned with
the National Rural Health Mission. It also showed how having a well-designed
project design matrix as part of the organization and management of the project
contributed to its success. It demonstrated the usefulness of starting small and
having a scale-up plan, and how commitment and motivation compensated for
manpower shortages. It also documented quality improvements as seen from the
increase in institutional childbirths; the enhanced midwifery skills of front-line
health providers; improved conditions in health facilities; better data management;
demand generation for services and community perception.
Sound maternal death review
processes take time and commitment
Programme managers, maternal health experts
and partners from seven countries came together

to take part in an inter-country workshop on
maternal death review in the Western Pacic
Region. At the meeting, hosted by the WHO Western
Pacic Regional Ofce and held in Kuala Lumpur,
Malaysia in November 2011, participants from the
Kingdom of Cambodia, the Republic of Korea, Lao
People’s Democratic Republic, Malaysia, Papua
New Guinea, the Republic of the Philippines
and the Socialist Republic of Viet Nam shared
processes and tools for maternal death reviews
and learned from the Malaysian experience.
Malaysian experts explained the history of reducing maternal mortality and the
implementation of the country’s condential enquiry into maternal death. The
group also made a eld visit to observe a district facility-based maternal death
review. Country participants then evaluated maternal death review processes and
tools from various countries, identied the next steps to strengthen countries’
review processes and developed realistic action plans.
Several important messages emerged from the workshop. Firstly, maternal death
reviews do not need to cover all deaths to be useful. The most important step
is to carefully analyse cases to guide local action and stimulate national level
policy change. Secondly, it took time for Malaysia to have the maternal deaths
reported through the health system match the Bureau of Statistics’ data and
this was only possible once the country’s vital registration system was well-
established. Thirdly, Malaysia’s success story can be achieved in an environment
with a high commitment, supportive policies, a well-functioning health system and
adequate monitoring of processes and outcomes. Finally, maternal death review
implementation must be tailored to each country’s situation using the most
suitable methodology.
m ATERNAL HEALTH
12

NEW
GUIDELINES
Effective interventions
Many of the 358 000 maternal and 7.6 million newborn and child deaths that
occur each year could be avoided through the provision of essential interventions
along the continuum of care. However, coverage of the key interventions across
the continuum is variable with many not being delivered at each level of the health
service. Also, other interventions are often available.
WHO led the development of the Essential Interventions document in collaboration
with the Aga Khan University, supported by The Partnership for Maternal, Newborn
and Child Health (PMNCH). Consensus was reached through a consultative process
of more than a dozen multilateral, development and donor agencies, health care
professional associations, national governments, NGOs and academic institutions
Essential Interventions, Commodities and Guidelines for Reproductive, Maternal,
Newborn and Child Health compiles existing evidence on interventions which
can reduce the main causes of maternal, newborn and child deaths. Essential
Interventions consists of a list of: (a) 56 key selected reproductive maternal,
newborn and child survival interventions according to their specic delivery
levels, (b) types of professional health worker required for their delivery, (c) key
commodities required; and (d) corresponding available guidelines
The 56 essential interventions listed were identied based on the evidence of their
efcacy, effectiveness and impact on survival; their suitability for implementation
in low- and middle- resource settings; and their likelihood to be delivered through
the health sector from the community to the referral levels.
The primary aim of this document is to support policy makers and implementers of
RMNCH programs in the development of plans and strategies to improve the health
of women and children. This set of guidelines can help steer policy reviewing and
writing, indicate where existing interventions should be scaled up, and can help
guide healthcare professionals at all levels of care in which interventions should
be provided to reduce maternal, newborn, and child deaths. It can also guide

advocacy to support national efforts to improve women’s and children’s health.
An updated approach to
prevention and treatment of
pre-eclampsia and eclampsia
Hypertensive disorders of pregnancy are a signicant
cause of severe morbidity, long-term disability and
death among both mothers and their babies. There are
a number of hypertensive disorders that complicate
pregnancy, but pre-eclampsia and eclampsia stand out
as major causes of maternal and perinatal mortality and
morbidity. The majority of these deaths are avoidable if
women who present with these complications are given
timely and effective care. Thus, optimizing health care
to prevent and treat women with hypertensive disorders
is a necessary step towards achieving the Millennium
Development Goals.
In 2011, the WHO’s guidelines for the prevention and treatment of pre-
eclampsia and eclampsia were updated using the Grading of Recommendations,
Assessment, Development and Evaluation (GRADE) process. In all, 23
recommendations covering various aspects of prevention and treatment
of pre-eclampsia and eclampsia resulted from a technical consultation in
Geneva in April. The new recommendations [ />publications/2011/9789241548335_eng.pdf and evidence tables (http://
whqlibdoc.who.int/hq/2011/WHO_RHR_11.25_eng.pdf) are being disseminated
and will be used in updates of the WHO Integrated Management of Pregnancy
and Childbirth clinical guidelines.
WHO recommendations for
Prevention and treatment of
pre-eclampsia and eclampsia
MATERNAL, NEWBORN, CHILD AND ADOLESCENT HEALTH PROGRESS REPORT 2010-2011
13

Midwifery report: delivering
health, saving lives
Increasing women’s access to quality midwifery has
become a focus of global efforts to realize the right of
every woman to the best possible health care during
and after pregnancy and childbirth. The rst State
of the World’s Midwifery report conrms the critical
role that midwives play in improving maternal and
newborn health and survival. The report, launched
at the Triennial Congress of the International
Confederation of Midwives in Durban, Republic of
South Africa in June 2011, calls for investment in
midwives who can provide such care in communities
and primary health care services.
Data for the report was derived from surveys conducted in 58 countries, which
between them account for 60% of all births worldwide and 91% of all maternal
deaths. The report highlights the shortage of skilled midwives in many low-income
countries, stressing the need for training and deployment. Among the 38 countries
with the greatest need of midwives, 22 will have to double the workforce by 2015
in order to offer adequate levels of midwifery services. In seven countries the
number will need to triple or quadruple, while nine will need to dramatically scale
up midwifery by up to 15-fold.
The report is the product of collaboration among 29 organizations. It builds on
prior initiatives to strengthen midwifery worldwide and was closely followed by and
the publication of the Strengthening Midwifery Toolkit. The State of the World’s
Midwifery Report can be found at
www.stateoftheworldsmidwifery.org.
A toolkit for stronger midwifery
A clear consensus has emerged that providing
skilled attendance for every birth is essential to

reduce maternal and perinatal morbidity and
mortality. WHO recognizes that effective and
sustainable reductions in mortality, for both
mothers and newborn infants, require the presence
of health care personnel equipped with a full range
of midwifery skills. Without competent personnel,
international goals for maternal and newborn
health cannot be reached.
In 2010, WHO published the Strengthening
Midwifery Toolkit. This toolkit comprises nine
modules and focuses on the central role and
function of the professional midwife in the
provision of quality reproductive and sexual health services. Guidelines have
been prepared to assist Member States as they consider strategies to strengthen
midwifery services.
These guidelines have been developed by experts drawing on lessons learned
from countries where quality midwifery services have been successfully made
accessible to all women. The toolkit can be used for establishing or reviewing
midwifery programmes according to a country’s needs and priorities.
/>midwifery_toolkit/en/index.html
Supported by:
Coordinated by UNFPA
605 Third Avenue
New York, NY 10016
www.stateoftheworldsmidwifery.com
AFRICAN DEVELOPMENT
BANK GROUP
THE STATE OF THE
WORLD’S MIDWIFERY
2011

DELIVERING
HEALTH,
SAVING
LIVES
ISBN: 978-0-89714-995-2
E/4,000/2011
THE STATE OF THE WORLD’S MIDWIFERY 2011
DELIVERING HEALTH, SAVING LIVES
Module1
Strengthening Midwifery:
A background paper
Strengthening Midwifery Toolkit
STRENGHTENING
HEALTH CARE
SERVICES
m ATERNAL HEALTH
14
Supporting countries to
implement maternal and
newborn health programmes
In 2010-2011, Member
States in the Eastern
Mediterranean Region
implemented WHO strategies
to make pregnancy safer.
The Regional Ofce
supported them with the
latest evidence, a range of
inter-country activities and
eld missions to help them

identify priority areas, gaps,
and constraints of national
programmes. The Regional
Ofce also developed tools
and standards for monitoring,
programme evaluation and maternal and newborn health impact assessment
in Member States. At the same time, it launched an online reproductive health
research directory, an evidence-based tool that supports strategic planning for
maternal and newborn health promotion in the Region.
An inter-country meeting to promote maternal and neonatal health in the Region
held in Dubai, the United Arab Emirates, in April 2011, enabled countries to
develop work plans for the implementation of national programmes on maternal
and newborn health in 2012-13.
Although the region is broadly on track to reach the Millennium Development Goals,
some Member States will struggle to meet the targets of Goal 5. They continue
to need support in a number of priority areas, including medical education on
maternal and neonatal health; promotion of universal provision of skilled health
care for all women and newborns; promotion of good reproductive health practices
such as birth spacing and prevention of sexually transmitted infections; and better
maternal and neonatal health surveillance systems.
Making progress in Albania
For the past three years, the WHO Regional
Ofce for Europe has been providing
technical assistance to the Ministry of Health
of the Republic of Albania as it reforms its
maternal and child health services under
a project supported by the Spanish Agency
for International Development Cooperation.
The objectives of the project are to improve
capacity in regional hospitals; assure

equitable access to effective maternal,
neonatal and child health care services;
and strengthen the Ministry’s stewardship
role by increasing its capacity in planning
and costing health services, improving
transparency and accountability.
In 2009, maternity hospital services in
Tirana, Shkoder, Korce and Vlora were
assessed and 140 health professionals
involved in perinatal care received training
in effective perinatal care. The Ministry
of Health adapted the WHO/Europe assessment tool for maternity hospitals
and developed national clinical protocols for maternal, perinatal and paediatric
care. Two years on, these actions resulted in substantial and demonstrable
improvements in service quality.
Work in assuring equitable access to effective maternal, neonatal and child health
care services includes applying the WHO principle of involvement of individuals,
families and communities, and follow-up activities under the leadership of the
Institute of Public Health. Another example is the reorganization of school health
services. In future this will include implementation of the health promotion
principles in schools and training of school medical staff. Other cases of successful
initiatives can be found in Albania success stories in improving mother and child
health, published in 2011.
www.euro.who.int/__data/assets/pdf_le/0016/154141/e95980.pdf
Albania Success Stories
in improving mother and child health
IMPLEMENTING
NATIONAL
PROGRAMMES
MATERNAL, NEWBORN, CHILD AND ADOLESCENT HEALTH PROGRESS REPORT 2010-2011

15
Supporting integrated maternal,
neonatal and child health
services in Lao PDR
The Government of Lao People’s
Democratic Republic has developed
a Strategy and Planning Framework
for the Integrated Package of
Maternal Neonatal and Child
Health Services 2009-2015. With
Millennium Development Goals
4 and 5 in mind, the framework
has three strategic objectives:
improving leadership, governance
and management capacity for
programme implementation; strengthening efciency and quality of health service
provision; and mobilizing individuals, families and communities for maternal,
newborn and child health.
Since 2009, with funding from the Korea Foundation for International Healthcare,
the Ministry of Health supported by WHO (in collaboration with the Asian
Development Bank, UNICEF, UNFPA, the World Bank and other partners) has given
intensive support in selected districts to gain practical experience with delivery of
the integrated maternal, neonatal and child health service package.
In these districts, the focus has been on improving maternal, neonatal and child
health programme management, such as strengthening primary health care and
improving the capacity of district hospitals, health centres and village health
volunteers. The support has also enhanced coordination among development
partners to ensure that various partners align their activities to the strategy and
its implementation plan.
In some districts, coverage of antenatal care went from 16% to 2009 to 35% a

year later, while skilled care at birth went from 9.5% to 21.7% and levels of BCG
vaccination went from 26.6% to 59.2% over the same period. The model from
the selected districts is being scaled up by various donors such as the Joint UN
Programme and GAVI Alliance under Health System Strengthening funding
Working in partnership to improve
maternal and newborn health in
African and Caribbean countries
The programme EC/ACP/
WHO Partnership on Health
Millennium Development
Goals provided support
to the health sector
in eight African and
Caribbean countries
(Republic of Angola,
Burkina Faso, Republic
of Kenya, Republic of
Malawi, Republic of Niger,
and United Republic of
Tanzania, Co-operative
Republic of Guyana and Republic of Haiti), with a total funding of €25 million. The
programme co-funded by the European Commission and WHO focused on four
components (Progress in the achievement of the health related MDGs, Making
Pregnancy Safer, Disease Surveillance and Control Programmes and Health
Information Systems). It was implemented from March 2006 to December 2010.
Strong technical coordination led to effective country implementation. As a result
there was increased availability and access to qualied and skilled workers
providing maternal and newborn care. Community mobilization on maternal and
newborn health issues was enhanced and referral systems improved. In addition,
national capacity in planning and management were strengthened.

Increased awareness of donors and other stakeholders on women’s and
children’s health issues has allowed for more funding secured in most countries
to accelerate progress towards health MDGs. The nal external evaluation of the
project is planned for 2012.
NATIONAL
CAPACITY
STRENGHTENING
PLANNING AND
MANAGEMENT
N EWBORN HEALTH
16
Neonatal mortality declines
across all regions
Deaths among newborns declined worldwide from 4.4 million in 1990 to 3.1 million
in 2010 and this decline has occurred in every region of the world.
1
This represents
a decline in the rate of neonatal mortality by 28% between 1990 and 2010 with an
annual reduction of 1.7%. The European Region, the Region of the Americas and
the Western Pacic Region experienced the steepest decline, at 50%, followed by
the South-East Asia Region at 36% and the Eastern Mediterranean Region at 26%.
The slowest reduction, of 19%, was seen in the African Region.
Neonatal mortality is an increasingly signicant proportion of child mortality. Due
to the declining post neonatal mortality, globally the proportion of child deaths
that occurred among newborns increased from 37% in 1990 to 40% in 2010. The
South-East Asia Region at 27% and the Eastern Mediterranean Region at 23%

are
the regions with the largest proportional increases. In the Western Pacic Region,
the region with the largest decline in under-ve mortality, neonatal deaths now

account for 54% of all under-ve deaths.
Figure 5 Trends in neonatal mortality rates at global and regional levels. 1990-2010
23
25
28
31
32
0
5
10
15
20
25
30
35
40
45
50
1990 1995 2000 2005 2010
Africa Eastern
Mediterranean
South-East Asia
Western Pacic
Americas
Europe
World
Neonatal Mortality Rate per 1000 live births
1 UN-IGME. Levels & Trends in Child Mortality. Report 2011
Information
systems yield better

perinatal care
Co-operation between
countries in the Region of
the Americas and beyond
has helped promote the
Perinatal Information
System as an invaluable tool
for improving the quality of
maternal and newborn care.
The system can be used to
streamline patient record-
keeping and also to monitor
and evaluate efforts to
reduce maternal mortality.
The system is in use in hundreds of public and private health institutions, social
security and university hospitals across the region. To enable countries to share
their knowledge and expertise in using the system, in 2010 and 2011 the WHO
Regional Ofce for the Americas together with country ofces and ministries of
health launched a technical cooperation among countries project, ‘Strengthening
Perinatal Information Systems’, in four Latin American countries.
Under the project, the Republic of El Salvador, the Republic of Honduras, the
Republic of Nicaragua and the Republic of Panama agreed their work plans and
reached a consensus on using the Perinatal Information System for analysis
and follow-up of eight selected maternal and perinatal health indicators. These
are: maternal mortality ratio, access to contraception, four or more antenatal
visits, skilled birth attendant at delivery, corticosteroids prior to preterm delivery,
coverage of screening test for syphilis, timing of umbilical cord clamping and
neonatal resuscitation. Their experience in using this tool has been shared with
other countries in the region, and also beyond the Americas, in the Republic of
Equatorial Guinea, the Republic of Mozambique, the Republic of Namibia and

Spain. Such projects create opportunities for increased south-south cooperation.
IMPROVING
INFORMATION
SYSTEMS
MATERNAL, NEWBORN, CHILD AND ADOLESCENT HEALTH PROGRESS REPORT 2010-2011
17
Updated guidelines,
better care for newborns
New and updated guidelines developed
by the Department and published in
2010-11 include:
• recommendations for care of
the newborn after birth,
• care of the preterm and low-
birth-weight newborn, and
• management of newborn illness
and complications.
The time around birth is the period of highest risk for the newborn. Those who do
not start breathing on their own by one minute after birth should be resuscitated
with room air using a self-inating bag and mask. Updated basic neonatal
resuscitation guidelines will make it even simpler for a skilled birth attendant to
resuscitate asphyxiated newborns.
Preterm birth is the most common direct cause of newborn mortality. Preterm
birth and the birth of babies who are too small for gestational age, (lowbirth-
weight), are also important indirect causes of neonatal deaths. Countries can
reduce their neonatal and infant mortality rates by improving the care of low-birth-
weight infants. New WHO guidelines on optimal feeding of low-birth-weight infants
contain recommendations on what, when and how to feed a low birth weight
newborn. Furthermore, implementation of recommendations on kangaroo care
for preterm infants weighing less than 2 kg will help in improving their survival.

Guidelines on hospital care for newborns were also updated. Early identication
of infections in newborns and prompt and appropriate antibiotic treatment will
substantially reduce mortality due to sepsis and pneumonia. Newborns with
serious infections need intramuscular or intravenous antibiotics and supportive
care in hospitals. WHO is working with ministries of health and partners to
implement these guidelines.
Progress in assuring essential
care for newborns
There has been substantial
progress in implementing
a package of essential
care for newborns in the
African Region. Decision-
makers from the Republic
of Angola, the Republic of
Burundi, the Central African
Republic, the Republic of
Chad, the Republic of the
Congo, the Democratic
Republic of the Congo and
the Gabonese Republic,
underwent training at two
inter-country workshops
held in Gabon and the
Congo.
Following these workshops,
Gabon went on to organize
its own national training
sessions for health care
professionals in charge of

maternity and neonatal
services, as well as for midwives, and nurses engaged in newborn care. As a result
of this training, in both the Congo and Gabon numerous changes to maternity and
neonatal care were recommended.
At the community level, the Democratic Republic of the Congo started to train
community health workers in case management of the newborn child in three
health districts of the country.
BUILDING
HEALTH WORKERS'
CAPACITY
NEW
GUIDELINES
N EWBORN HEALTH
18
IMNCI Survey gives Ethiopia
roadmap for improvement
Although the Federal Democratic
Republic of Ethiopia is expanding
Integrated Management of Neonatal
and Childhood Illness (IMNCI), the extent
of implementation is still low and there
is lack of systematically documented
and timely data on the current status of
IMNCI service coverage.
In response, a health facility survey was
conducted to determine the current level of IMNCI service coverage at national
and regional levels. Based largely on telephone interviews as well as some direct
observation in public health centres and hospitals, the survey covered more than
2,500 public health facilities.
Some 82% of health facilities surveyed had at least one in-service or pre-service

IMNCI-trained health worker, while only 23% had two or more IMNCI-trained health
workers. Most health facilities had the crucial IMNCI job aids, i.e., registration
books and chart booklets. At facility level, availability of oral medicines was good
but parenteral pre-referral medicine supplies were very low except for gentamicin.
There was high availability of oral rehydration salts in the facilities but availability
of oral rehydration therapy materials and service provision was markedly low.
The relatively low IMNCI coverage in the two most populous regions of Oromiya
(45%) and Amhara (49%) as well as the two pastoralist regions of Somali (26%)
and Afar (47%) is of serious concern. The results of this survey will serve as a
baseline for future planning and resource allocation for scaling up IMNCI services
and for objective monitoring of the progress of implementation of the strategy in
the country.
Integrated management of
neonatal and childhood
illness in India saves lives
Infant mortality dropped by 15% in a district in the
Republic of India using the Integrated Management
of Neonatal and Childhood Illness strategy,
according to ndings from a cluster-randomized
trial. The strategy combines improved treatment of
illness in newborns and children with home visits
for newborn care. To evaluate its impact on infant
mortality, a trial was conducted in a total population
of 1.1 million in Faridabad district, Haryana, India.
In clusters where the strategy was implemented,
community health workers were trained to
conduct postnatal home visits and women’s group
meetings, and together with nurses and physicians
were also trained to treat or refer sick newborns
and children according to the specic guidelines. Under the strategy, medical

supplies and community health worker supervision were strengthened. All births
in the study population were captured via an independent surveillance system and
deaths during infancy were documented by visits at 29 days, six, and 12 months.
Both the intervention and control clusters had a similar number of births, but in
the intervention clusters, the adjusted infant mortality was 15% lower compared
to control clusters.
Appropriate newborn care practices such as early initiation of breastfeeding and
exclusive breastfeeding were more prevalent in the intervention compared to
control clusters and the prevalence of severe illness, pneumonia and diarrhoea
in infancy was signicantly lower in intervention clusters. The study concludes
that the IMNCI strategy can be an important component of efforts to reach the
Millennium Development Goal 4 on child survival.
EXPANDING
IMNCI
MATERNAL, NEWBORN, CHILD AND ADOLESCENT HEALTH PROGRESS REPORT 2010-2011
19
Newborn HIV and syphilis:
Beyond prevention to elimination
in Asia Pacic Region
The extensive progress in prevention
of mother-to-child transmission
of paediatric HIV and congenital
syphilis in the Asia Pacic Region
has made elimination a potentially
achievable goal. All relevant UN
agencies work closely together
under the Asia-Pacic Task Force
on prevention of mother-to-child
transmission, including UNAIDS, the
UNFPA, UNICEF, the WHO Regional

Ofce for South-East Asia and the WHO Regional Ofce for the Western Pacic.
The Task Force developed the Asia Pacic Conceptual Framework on elimination of
mother-to-child transmission. This is an excellent example of integration between
programmes addressing HIV/sexually transmitted infections and maternal and
neonatal health. It received an enthusiastic response when launched at the 10th
International Conference on AIDS in the Asia Pacic in September 2011 and has
highlighted the importance of appropriate maternal health services to prevent
onward transmission of HIV and syphilis.
Much work needs to be done to take this ambitious agenda forward, including
proles of HIV/sexually transmitted infections and maternal and neonatal health
programmes. These have already been developed for high-burden countries. An
advocacy document to translate the conceptual framework into messages for
garnering support and commitment is being nalized. An implementation guide
is underway, to make the framework customized and operational according to the
situation in different countries. In addition, a pilot project on stillbirth surveillance
has been initiated in India to address the paucity of information on the congenital
syphilis disease burden.

E-learning and telemedicine
reach the Maldives
Because newborn
health is inextricably
linked to maternal
health, it is dependent
on universal access to
essential services like
family planning, skilled
care during pregnancy,
childbirth and, in
the postpartum and

postnatal period essential newborn care and emergency obstetric care. Ensuring
that these measures become the standard of care is a challenge, and requires a
minimum level of competence among health providers especially at the primary
health care level.
In 2010, the Republic of Maldives was given support for essential newborn care
training and to develop national guidelines, culminating in a plan of action to
strengthen neonatal care at different levels, with emphasis on primary health
care. The special feature of this activity was use of information technology
with the introduction of e-learning through telemedicine. For countries like the
Maldives facing geographical challenges for service delivery, harnessing IT can
increase the accessibility and availability of health and telemedicine services. A
model has already been developed at the All India Institute of Medical Sciences,
a WHO collaborating centre, and faculty from the Institute facilitated training and
plan development. They also tested the telemedicine setup in the main referral
hospital, including videoconferencing.
Subsequently, two online courses enabled regular training of paediatricians and
nurses through telemedicine linkage with the Institute. Using the platform for
continuing professional development, the e-platform is also increasingly being
used for expanded purposes including tele-consultation.

STRENGHTENING
CARE THROUGH
E-LEARNING
N EWBORN HEALTH
20
DEVELOPING
NATIONAL
NETWORKS
Getting research priorities right
in Africa and South Asia

Policy-makers and
programme managers
have a crucial role to play
in setting implementation
research priorities that
can help countries scale
up maternal, newborn,
child and adolescent
health care. During 2011,
national implementation
research priority setting
exercises were conducted
by the Department in the
Republic of Cameroon,
the Arab Republic of Egypt, India, the Republic of Kenya, the Islamic Republic of
Pakistan and the Republic of Rwanda, and by the Department of Reproductive
Heath and Research in the Democratic Republic of Congo, Ethiopia, the Republic
of Guinea, the Republic of Mozambique and the Federal Republic of Nigeria. An
adapted Child Health and Nutrition Research Initiative methodology was used to
identify, score and rank potential research issues.
The exercise identied up to 10 research priorities for each country. While many
of the priorities were specic to the issues and context within the country, many
common themes emerged. These included provision of maternal, newborn, child
and adolescent health services in remote areas and improving motivation and
supervision of health workers. Use of telecommunications to improve maternal,
newborn, child and adolescent health services was another common priority, as
was community-based provision of care and improving quality of care in rst level
health facilities. National institutions in many of these countries have already
issued a call for letters of intent to conduct research studies to address the
priorities, and those in the remaining countries are in the process of doing so.

WHO is working with countries to hold workshops to develop high quality research
proposals, the rst of which was held in November 2011 in Pakistan.

Regional networks help
South-East
Asian countries
boost newborn care
The WHO Regional Ofce for South-
East Asia initiated strengthening
of the South-East Asia Regional
Neonatal-Perinatal Database
Network. Leaders and experts
from the Member States in the
region came together at a Regional
Meeting on Newborn Health Care,
Education and Training, held in New
Delhi, India, in March 2011. The
aim was to collaborate on efforts
to improve newborn health and
survival, and boost progress toward
Millennium Development Goal 4.
The meeting recommendations
included developing national
networks that would collaborate
with the regional network on
newborn health. The networks
could contribute in promoting
knowledge management, capacity
building (education and training)
and research in newborn health.

The Regional Ofce has followed up with WHO country ofces to support
development of national networks for newborn health. The People’s Republic
of Bangladesh, the Republic of the Union of Myanmar, the Federal Democratic
Republic of Nepal and the Democratic Socialist Republic of Sri Lanka have already
taken appropriate steps.
PRIORITY
RESEARCH

qUESTIONS
MATERNAL, NEWBORN, CHILD AND ADOLESCENT HEALTH PROGRESS REPORT 2010-2011
21
Improved care in the community
for newborns and children
Lay community health
workers will be better able
to care for newborns and
children thanks to newly
published materials from
WHO. The training materials
consist of a community
health workers’ manual,
facilitator notes, photograph
book, chart booklet, and
training videos and DVDs.
They are part of three-part
package that can be used
independently or sequentially (see box). Caring for the sick child in the community
was published in 2011. Caring for the newborn at home, and caring for the healthy
child’s growth and development will be published in early 2012.
Evidence that community health workers can play a key role in caring for newborns

and children is leading countries to adopt new policies. Preliminary results of
a survey conducted by the Department and partners in 2011 on provision of
postnatal care by community health workers in countries of sub-Saharan Africa
and South-East Asia showed encouraging results. Of the 47 countries that
responded, 24 countries reported that they have a policy and are implementing
a community-based maternal and newborn health home visit package. Similarly,
the Department has been monitoring the uptake of national policy that authorizes
CHWs to treat children with pneumonia in the community in high burden countries,
and the number has increased from 18 in 2008 to 39 in 2012.
The WHO/UNICEF package caring for newborn and children in the
community comprises three sets of materials for training and support.
These materials can be used independently or sequentially.
Caring for the newborn at home: Through a series of home visits, the
community health worker:
• Promotes antenatal care, and skilled care at birth;
• Provides care for the newborn in the rst week of life;
• Recognizes and refers any newborn with danger signs to a health
facility;
• Provides special care for low-birth-weight babies.
Caring for the sick child in the community: The community health worker is
able to assess and treat sick children aged 2 to 59 months and:
• Identify and refer children with danger signs;
• Treat (or refer) pneumonia, diarrhoea and fever;
• Identify and refer children with severe malnutrition to a health facility;
• Refer children with other problems that need medical attention;
• Advise on home care for all sick children.
Caring for the healthy child’s growth and development: The community
health worker counsels families on practices that they can carry out at
home and promotes:
• Care-giving skills

• Child development
• Infant and young child feeding
• Family’s response to a child’s illness
• Prevention of illness
NEW
TRAINING
MATERIAL
C HILD HEALTH
22
NEW
EVIDENCE
Progress in reducing
childhood mortality
Globally, the leading causes of morbidity and
mortality in children under the age of ve are
pneumonia, diarrhoea, prematurity, birth asphyxia
and malaria. The number of under-ve deaths
worldwide has declined from more than 12 million
in 1990 to 7.6 million in 2010, a 37% decrease.
Although the rate of decline in under-ve mortality
has accelerated in the past 10 years (2000-2010)
as compared to the previous decade (1990-
2000), it remains insufcient to reach Millennium
Development Goal 4 to reduce child mortality by
two thirds.
Of the 7.6 million child deaths, 40% occurred in the
neonatal period (0 to 28 days of life), 31% of occurred
between one and 11 months, and the remaining
29% occurred in children aged one to four years. As
under-ve mortality declines, the relative contribution

of deaths in the neonatal period increases.
Three WHO regions have reduced their under-ve
mortality rates by 50% or more: the Western Pacic
Region, the European Region and the Americas. The
highest rates of under-ve mortality are still seen in
the African Region (119 per 1000 live births), where
they are more than 17 times higher than the average
for developed regions (7 per 1000 live births).
Under-ve deaths are increasingly concentrated
in the African Region and in the South-East Asia
Region. While these two regions endured the burden
of two-thirds of all under-ve deaths in 1990, they
now hold nearly three-quarters of all deaths among
children less than ve years of age. About half of
all child deaths occur in only ve countries, most
of them from these two regions: India, Nigeria,
Democratic Republic of the Congo, Pakistan and
China. India and Nigeria together account for a third
of all under-ve deaths.
Children’s lives can only be saved if the distribution
and causes of their deaths are appropriately
established and tackled through evidence-based
action and positive changes in policies, strategies,
health systems, and ultimately in the status of
maternal, newborn and child health.
Figure 6 Trends in under-ve mortality by WHO region
57
65
73
82

88
97
111
0
50
100
150
200
250
1980 1985 1990 1995 2000 2005 2010
Africa Eastern
Mediterranean
South-East Asia
Western Pacic
Americas
Europe
World
Under-ve Mortality Rate per 1000 live births
Figure 7 Under-ve mortality - global distribution
Better evidence to
tackle pneumonia
Twelve systematic reviews were completed on
aspects of clinical management of pneumonia and
oxygen use. The synthesized evidence was used to
revise pneumonia case management guidelines at
various levels of the health system. Several research
studies addressing various aspects of pneumonia in
newborns and children are ongoing, including large
multi-centre trials in Africa (Democratic Republic of
the Congo, Kenya and Nigeria) and Asia (Bangladesh

and Pakistan).
In Pakistan, a landmark study evaluating community
case management of severe pneumonia by
community health workers documented their ability
to safely and effectively treat cases of severe
pneumonia at home with oral amoxicillin. In Haripur
district 28 clusters were randomly assigned to
the intervention group or to be controls. In the
intervention clusters, community health workers who
had undergone additional training treated children
aged two to 59 months in the community with oral
antibiotics for ve days. The control group was given
an initial dose of oral antibiotic and referred to a
health facility. Treatment failures occurred 50% less
often in the intervention group.
Guidelines and training materials for management
of pneumonia were updated in 2010-2011, and
introduced to programme staff and partners in
multiple events.
>10
10 - 49
50 - 99
100 - 199
200
Not applicable
Data not available
Source: UNICEF, WHO, The World Bank, the United Nations Population Division. Levels and
Trends in Child Mortality, report 2011. UNICEF, 2011.
MATERNAL, NEWBORN, CHILD AND ADOLESCENT HEALTH PROGRESS REPORT 2010-2011
23

IMPLEMENTING
REGIONAL
STRATEGIES
Coordinated approaches for
diarrhoea and pneumonia control
Diarrhoea and pneumonia remain
major causes of mortality and morbidity
in children under ve years of age. Of
the estimated 7.6 million child deaths
in the world in 2010, 18% were due to
pneumonia and 15% due to diarrhoea.
Both diseases are caused by multiple
pathogens and require concurrent,
complementary solutions. There
is a good deal of overlap between
pneumonia and diarrhoea prevention and treatment, and multiple interventions of
proven effectiveness exist. However, they are often not implemented in a coordinated
fashion. The WHO/UNICEF Global Action Plan for Prevention and Control of Pneumonia
aims to increase the coverage of evidence-based interventions and improve existing
case management guidelines. The WHO/UNICEF report on "Diarrhoea: Why children
are still dying and what can be done" contains two essential packages of prevention
and treatment. GAPP and diarrhoea reports were used to develop the coordinated
action plan for control of pneumonia and diarrhoea.
In collaboration with health ministries, UNICEF and other partners, WHO conducted
four regional workshops to facilitate the implementation of coordinated and
expanded interventions for the control of pneumonia and diarrhoea among under-
ves living in developing countries. Using the GAPP framework, workshops in the
WHO African Region covered 22 countries while all 11 countries in the WHO South-
East Asia Region participated in a workshop there. The workshops reinforced the
importance of a focused and coordinated approach to pneumonia and diarrhoea

control as part of the integrated approach to child survival and health.
The GAPP framework for pneumonia and diarrhoea prevention and treatment
focuses on increasing access to interventions of proven effectiveness, including
those addressing risk factors, providing vaccination and treating children when they
develop pneumonia. In addition to making a key contribution to the achievement of
Millennium Development Goal 4 on reducing child mortality, reducing the burden
of these diseases will also contribute to achieving Millennium Development Goal 1
for eradication of extreme poverty and hunger.
Better guidelines to curb
opportunistic infections
In 2010, there were 3.4
million children living with
HIV, including 390 000 newly
infected- an average of more
than 1000 every day. Moreover,
250 000 children died due
to AIDS. Only 21% of HIV-
infected children who needed
antiretroviral therapy received
it, and as a consequence,
HIV-associated opportunistic
infections continue to cause
considerable morbidity and
mortality, particularly in
resource-limited settings.
The previous UNAIDS/WHO guidelines on this topic were published in 1998, and
since then considerable new scientic evidence and programmatic experience
has emerged. In response, the Department, in collaboration with the HIV/AIDS
Department, launched the development of updated evidence-based guidelines on
opportunistic infections.

A guide to the management of pneumonia and diarrhoea in HIV-infected
infants and children was published, and the Department also developed
advice on management of cryptococcal infections in children and adults. The
new recommendations include diagnosis of cryptococcal infections with new
rapid lateral ow assays using serum, cerebrospinal uid and urine, as well as
standardized dosing schedules for treatment of cryptococcal meningitis. In
2012, the Department will address skin and oral opportunistic infections. The
opportunistic infections guidelines target programme managers and HIV and
maternal and child health focal persons at health ministries, as well as senior
health care professionals engaged in patient care. The key recommendations will
also be used to update other WHO tools such as those for IMCI.
NEW
GUIDELINES
C HILD HEALTH
24
IMCI computerised training
course (ICATT) goes online
Since 1996, integrated
management of childhood
illness (IMCI) has been
one of the key strategies
for reducing childhood
mortality. In an effort to
provide alternative training
methods on IMCI clinical
guidelines, the IMCI
Computerised Adaptation
and Training Tool (ICATT)
has been developed and is
available in four languages

(English, French, Russian
and Spanish). The innovative software has great potential to scale up in-service
and pre-service IMCI training and ensure timely updates of national clinical
guidelines. It has enough exibility to make it adaptable to the needs of a specic
country and to design the most suitable course for a particular group of trainees.
In 2011, four regional orientation courses trained more than 110 national trainers
in 23 countries in the use of the tool. All WHO regions have been oriented in its
application (see gure 7). More than 1000 health workers have been trained,
19 countries have conducted national orientation, 14 countries have adapted
national materials to the ICATT and eight countries are in the early stages of
implementation.
To make the ICATT even more exible and useful, the software has been updated
to allow countries to upload it onto institutional servers or to the Internet. This
means national versions can be accessible to all health workers, including those
in private practice. Meanwhile, web-based generic versions of the tool in English,
French, Russian and Spanish were launched in 2011. All the necessary resources
can be found at />ce5e9e01/AdminPage/
African countries fast
track computerized IMCI training
A series of train-the-trainers courses has helped 18 African countries get on the
fast track to using the ICATT. In 2011 three inter-country orientations held in
Malawi, the Republic of Mali and Rwanda brought together child health experts
and IMCI managers to learn about use of the tool as an alternative training
approach for strengthening in-service and pre-service training. They were joined
by staff from WHO and UNICEF country ofces, health training institutions and
non-governmental organizations.
These initial groups of trainers were used to build further capacity in using the
ICATT in their countries as well as in other countries in the region. Ethiopia, Malawi,
Mozambique, South Africa and Tanzania have adapted their IMCI training materials
into the ICATT. Ethiopia held a national ICATT orientation workshop and ofcially

launched the tool in October 2011. Kenya and Uganda have planned national
ICATT orientation and capacity building courses for early 2012.
The training conducted in Mali was in collaboration with the Novartis Foundation
and was the rst training event using the French translation of the tools.
Figure 7 Introduction and Early Implementation of ICATT in Countries, June 2011

0
2
4
6
8
10
12
14
16
18
20
AFRO AMRO EURO EMRO SEARO WPRO Total
No. of countries
WHO Regions

UPDATING AND
EXPANDING
IMCI
IMPLEMENTING
ICATT/UPDATING
AND EXPANDING
IMCI
MATERNAL, NEWBORN, CHILD AND ADOLESCENT HEALTH PROGRESS REPORT 2010-2011
25

Integrated management
of childhood illness: getting
it right from the start
For IMCI to be sustainable, it has to be effectively
incorporated into medical education. In the WHO
Eastern Mediterranean Region, 61 medical schools
have taken steps to introduce IMCI into their
paediatric teaching programmes.
The success of this integration was assessed at
Liaquat University of Medical and Health Sciences,
Jamshoro, Sindh province, Pakistan. The evaluation team conducted a site visit,
observed several theoretical and practical teaching sessions and held discussions
with students and staff. They assessed student knowledge of IMCI and clinical
skills through a written test and observation of case management. The team found
that all teaching staff at the paediatric department had been trained in IMCI, and
that over a third of teaching hours was dedicated to it.
The evaluation revealed that teaching of IMCI was consistent with traditional,
classical paediatric teaching methods. It also showed that when adequate
commitment, capacity building and planning were in place, IMCI pre-service
education effectively contributes to improving the quality of outpatient paediatric
teaching.
The WHO Regional Ofce for the Eastern Mediterranean has expanded the scope
of IMCI pre-service education to nursing schools. It conducted the rst orientation
and planning workshop for ve nursing schools in Jordan to introduce the guidelines
that are specically tailored to nurses and also developed an orientation e-lecture
for the same purpose.


Report card gives thumbs-up to
IMCI distance learning for nurses

Distance learning can
signicantly reduce the
cost of running IMCI
courses and reach
health workers who
are unable to leave the
workplace for outside
training. It also enables
them to combine
learning with hands-on
practice as they progress
through the course at
their own pace.
The rst cohort of 24 nurses who completed two distance learning IMCI courses
offered in the Eastern Cape, South Africa, were evaluated in 2011 using standard
WHO follow-up tools to assess their performance in implementing IMCI. Most
of the nurses followed IMCI steps in assessing and managing sick children with
general danger signs, main symptoms, immunization, vitamin A supplementation
and deworming. The Road to Health Card is regularly used, the weight of children
plotted and interpreted and almost all caregivers reported being satised or very
satised with the care provided by nurses. Facilities, including equipment, oral
rehydration therapy provision, and storage of medicines and supplies were found
to be adequate. Medicines and other supplies for HIV diagnosis and paediatric HIV
treatment were also surprisingly available in almost all facilities visited.
UPDATING AND
EXPANDING
IMCI
UPDATING AND
EXPANDING
IMCI