Slide sem t

1
MATERNAL-CHILD HEALTH POLICY
DR. RENE CASTRO S.
Regional Forum on Social Protection in Health for
Women, Newborn and Child Populations in LAC
Lessons learned to prompt the way
forward. Tegucigalpa, 8 -10 November 2006
2
Maternal and child mortality is one of the
demographic facts that can be influenced in a
more or less serious way since it depends a great
deal on the care that the mother and child
receive before, during and after birth. Dr.
Salvador Allende, Minister of Health (1940)
3
LA REALIDAD MEDICO SOCIAL CHILENA
Chilean Medical Social Reality
4
REPRODUCTIVE RISK

• Each pregnancy implies a risk of Morbidity
• and Mortality for the mother and her child.
• The perinatal period represents the greatest
  vulnerability in the life of a human being.

5
Maternal, perinatal and child health indicators
reflect a countrys economic, cultural, social
and health development.
6
Risk of death in Latin America and the
Caribbean ( compared to USA and Canada)
Relative Risk 3 - 4 9 - 10
Child Mortality Maternal Mortality
7
Until 1920, the health situation in Chile
qualified as a savage state the highest child
mortality in the world. 1952 Life
expectancy at birth - 54.9 years among the
lowest at the global level, reflecting the poor
living conditions in the country.
8
INFANT MORTALITY PER 1,000 LIVE BIRTHS
9
Life expectancy at birth1
1
Average Age
2
PERIODS
Sex
Sex Differential
Men
Women
Men
Women
1919-22
30.90
32.21
1.31
28
29
1929-32
39.47
41.75
2.28
44
46
40.65
43.06
2.41
48
50
1939-42
1952-53
52.95
56.83
3.88
62
67
LIFE EXPECTANCY AT BIRTH ANDHALF LIFE 1920-2002
1960-61
54.35
59.90
5.55
63
70
1969-70
58.50
64.68
6.18
66
72
1980-85
67.37
74.16
6.79
72
78
1991-92
71.37
77.27
5.90
75
81
2001-02
74.42
80.41
5.99
77
83
1. The number of years a newborn would live if
age-specific mortality rates at time of birth
(shown in Table) continued throughout the childs
life.
2. Age at which 50 of the survivors from a
cohort of 100,000 live births are still alive
according to mortality observed at the time
referred to in the Mortality Table.
Infant Mortality3
Years of life lost from birth to age 854
Male Overmortality
PERÍODS
Men
Women
Men
Women
Difference
1919-22
264.0
248.7
1.1
54
53
-
1929-32
217.5
198.7
1.1
46
44
9
CHILD MORTALITY AND YEARS OF LIFE LOST 1920-2002
1939-42
205.4
188.5
45
42
1
1.1
1952-53
128.0
112.4
1.1
32
29
13
1960-61
125.6
108.3
1.2
31
26
2
1969-70
89.2
75.4
1.2
27
21
4
1980-85
25.8
21.6
1.2
18
12
9
1991-92
15.5
13.1
1.2
15
10
3
2001-02
9.4
7.5
1.2
12
8
2
3. Probability of dying under one year of age at
the time referred to in the Mortality Table.
4. Number of additional years that people who
died should have lived. The difference between
one period and another indicates the impact of
the change in mortality on human life.
10
MATERNAL-CHILD CARE

• 1901 National Childrens Board
• 1924 Workers Insurance Law
• 1942 Health Units (district-level)
• 1952 National Health Service
• 1980 National Health Service System
• Ministry Social Security Regional
• Ministerial Secretary (Seremi)
• (decentralization)
• 2000 Sector reform (ongoing)

11
EVOLUTION OF THE STATE
1925 1938 Health Welfare State (Liberal
state) from Beneficence (medicine-charity, for
indigent people) to Social Welfare (for society
as a whole). 1924, Law 4.054 for Compulsory
Insurance covers risks of invalidity, old age
and death, with a tripartite financing State,
employer, worker. Workers Compulsory Insurance
Fund (Caja de Seguro Obrero Obligatorio) (the
first in the Americas) ambulatory care, care at
doctors offices and home care for all workers,
their wives and children under 2 years old.
12
EVOLUTION OF THE STATE
1938-1952 Popular Unity governments Protective
welfare state (paternalistic) Committed to
economic and social policies humanization of the
People before the State 1939 to 1960 period of
awareness of social issues, of the second
transformation of the State An organic
commitment to an assistentialist State (Welfare
State).
13
NATIONAL HEALTH SERVICE (19521979)
August 1952 Law 10.383 creates the SSS and the
National Health Service (SNS) political will
for the search for social balance and
institutional justice new social pact - will
allow the working and proletariat classes to be
integrated into the system. Wide national
agreement support of the University (School of
Public Health) and the Medical Association. Socia
l Medicine incorporates the fundamental
principle of the WHO, created in 1948 health as
a right and obligation of every human being and
of countries as a group.
14
NATIONAL HEALTH SERVICE (19521979)

• Chile was the second country at the global level
  (4 years after England) it integrated 6
  institutions that addressed different areas of
  social security and health management.
• Objectives
• reduction of maternal and child mortality,
• control of infectious diseases,
• eradication of malnutrition and,
• coordination with other social sectors that have
  links to health determinants.

15
MATERNAL MORTALITY BY CAUSE CHILE 1951-2000
16
INFANT MORTALITY CHILE 1980 2003
() Rates per 1,000 LB
17
PERINATAL MATERNAL CONTROL (CLAP)
LOW RISK PRENATAL CONTROL
HIGH RISK PRENATAL CONTROL
AMBULATORY PUERPERAL CARE
MONITORING OF CHILD GROWTH AND DEVELOPMENT
DELIVERY CARE
HOSPITALIZATION DURING PREGNANCY
18
WOMENS HEALTH PROGRAM
Years Prenatal Family Plan. Skilled
Care Maternal Mortality Check-Up
Coverage at Birth Rate x
10,000 L. B.
1965 50.1
6.0 75.5 27.9 1970 52.0
13.7 81.1
16.8 1975 55.0 23.7
87.4 13.1 1980 57.4
26.7 91.4
7.3 1985 69.2 23.6
97.4 5.0 1990 85.0 17.3
99.1
4.0 1995 92.5 22.2
99.5
3.1 1998 92.6 22.5 99.7
2.0
19
S.N.S.S. CARE NETWORK

• PRIMARY CARE
• General Doctors Offices
• Urban 250
• Rural 150
• Rural Posts gt 1,100
• HOSPITAL-BASED CARE 162/177

20
FAMILY PLANNING IN CHILE

• 1967 POLICY BASED ON HEALTH OBJECTIVES
• Reduce Maternal Mortality due to Induced Abortion
• (Avoid Unwanted Pregnancy)
• Reduce Child Mortality associated with high
  fertility
• c. Promote Family Well-being
• (Responsible Parenting)

21
(No Transcript)
22
Abortion-related Mortality 1960 - 2000

• Year Number Rate
  Maternal
• Deaths
•  
• 1960 302 10.7 35.7
• 1970 185 7.1 42.1
• 1980 71 2.8 38.4
• 1990 23 0.7 18.7
• 1998 14 0.5 25.4
• 13 0.49 26.5
• 2001 4 0.15 13.3

23
Foundation for a Family Planning Policy
The Government of Chile recognizes the
benefit that the population achieves through
Family Planning activities, which allow
individuals to have the number of children with
the desired spacing and timing. For this reason,
it maintains its support for Family Planning
activities in order to promote the achievement of
adequate comprehensive reproductive health.
October 1990
24
PROFESSIONAL DELIVERY CARE
YEAR 1965 74.3 1975 87.4 1985
97.4 1998 99.6
From empiricism to professionalism in delivery
care Prof. F. Mardones-Restat
25
Maternal Mortality and Professional Delivery
Care 1950 - 2001
26
MATERNAL-CHILD HEALTH 1960 2000Rates per 1,000
LB

• 1960 2000
• Birth Rate 35.5 17.2
• Total Maternal Mort. 2.99 0.2
• M.M. due to Abortion 1.07 0.05
• Infant Mortality 125.1 8.9
• Neonatal Mort. lt 28 d. 36.2 5.6

27
(No Transcript)
28
REDUCTION OF MATERNAL MORTALITY IN CHILE
LESSONS LEARNED 1950-2000
Ministry of Health, CHILE Universidad de la
Frontera Pan American Health Organization PAHO/USA
ID
29
COMPARATIVE RESULTS
Experts
Users
Common Areas
Creation of the SNS Existence of Health
Plans Increase in Service Coverage Service
Network Early Prenatal Care Prevention of
Pathologies Standards of Care Increase in
Therapeutic Methods Strengthening of
HH.RR. Creation of New Schools for
Obstetricians (regional) Training of G-O
doctors Decline in fertility Increase in the
urban population
Availability and Distribution of
Midwives Expansion of Primary Care
Prenatal Care PNAC Supplementary
Feeding Program Technological
Advances Antibiotics Home for the
Rural Woman Professional Delivery Care
Family Planning program Development of the
Country Increase in schooling
Improved living conditions Increased
access to health services
Mapuches
Decrease in excessive work Decrease in family
violence
Existence of evil
30
Steps for Reducing Maternal Mortality

• Consider M.M. to be a human rights and social
  justice problem.
• Recognize that every pregnancy has some level of
  risk.
• Assure that skilled personnel attend births.
• Promote maternal health as a vital economic and
  social investment
• Postpone motherhood.
• Prevent unwanted pregnancy.
• Prevent unsafe abortion.
• Facilitate access to maternal health services.
• Improve the quality of maternal health services.
• Supervise and evaluate changes.

31
...the decade in Chile...
32
PEDIATRICS, 10 April 2006
33
MATERNAL CHILD HEALTH SITUATION

• Stable health policies during the last 50
• years
• Institutionalized National Health System
• Human resources that are committed to
• their work
• Culture of health among the population

34
Chile is better - Health Reform
35
(No Transcript)
36
SEXUAL AND REPRODUCTIVE HEALTH
DESIGN AND IMPLEMENTATION OF HEALTH
PRIORITIES Chilean Programmatic Reform
37
Sexual and Reproductive Health

• the possibility of a human being to have
• gratifying and enriching sexual relationships,
  without coercion and fear of infection or
  unwanted pregnancy
• to be able to regulate her fertility without the
  risk of unpleasant or dangerous secondary
  effects
• to have a safe pregnancy and delivery and,
• to raise healthy children

PAHO,1995
38
REPRODUCTIVE HEALTH
PRECON- CEPTION CARE
PRENATAL CARE
DELIVERY AND POSTPARTUM CARE



HEALTHY MOTHERS AND NEWBORNS
NEONATAL CARE

39
Health Objectives Cornerstone of the Reform

• Improve the health objectives attained
• Child health, womens health, infectious diseases
• Confront the challenges that result from aging
  and other changes in society
• Determinants of the health situation, primary
  causes of death and disability
• Reduce health inequalities
• Living conditions and determinants, health
  situation, access to health
• Provide services according to the populations
  expectations
• Financial justice, care according to
  expectations, quality of care

Health Objectives for the Decade 2000-2010
40
Model for Comprehensive Health Care Primary Care
constitutes the strategic axis for Health Reform
Community component
Inter-sectoral
F a m i l y
Health promotion
Service network
Disease prevention
Management team
PHC
Entire life cycle
Targeting by risk
Humanized
Welfare component
41
DALYs 15 leading causes Percent distribution
and ratio per 1,000 inhab.  
Disability-Adjusted Life Years years of life
lost due to premature death and disability
(measures the relative importance of diseases).
  Source Estudio Carga de Enfermedad, MINSAL
1996
42
Congenital Anomalies

• Health Objectives and Goals for Congenital
  Anomalies
• Impact Goals
  
• Prevent the occurrence of certain congenital
  anomalies (neural tube defects)
  
• Improve the quality of life of children with
  congenital anomalies
• Development Goals
  
• Fortify flour with folic acid
• Improve the problem-solving capacity of national
  referral centers with regard to the treatment of
  congenital cardiopathies
• Implement a national registry of congenital
  malformations
  
• Program for the integral treatment of children
  with cleft lips or palates

43
The study found a reduction of 42 in the
prevalence of anencephaly at birth during the
fortified period, compared to the period
immediately prior to fortification (1999-2000).
44
Unwanted Pregnancies

• Health Objectives and Goals for Unwanted
  Pregnancies
• Impact Goals
  
• Decrease the gap between desired and observed
  fertility the gap between desired and observed
  fertility should be under 20
• By age group, maternal educational level,
  socio-economic level, experience with use of
  contraceptive methods (methods used, duration of
  use)
• Reduce pregnancies in adolescents see Chapter 2
  on Risk Factors, Sexual Behavior
• Reduce abortion-related maternal mortality by 50
  (over the level in 2000)
• Counseling on Sexual and Reproductive Health for
  the population at greatest risk of abortion
  (detected using predictive instrument)
• Coverage for Fertility Regulation by five-year
  age groups
• Audit of complicated abortions by cause at the
  level of hospitals and/or primary care
  establishments

45
Maternal and abortion-related mortality, Chile
1990-2004
Maternal Mortality Abortion-related mortality
Rates x 10,000 LB
Objective Degree of progress
Reduce maternal mortality by 50 From 1.9 in 2000 to 1.2 en 2010 (per 10,000 L.B.) Advance of 29. 2004 Rate 1.7
Reduce abortion-related maternal mortality by 50. From 0.5 in 2000 to 0.25 in 2010 (per 10,000 L.B.) Reached. 2003 Rate 0.2
Reduce mortality due to obstetric complications. ? 47 1999 Rate 0.53 2003 Rate 0.28
Reduce adolescent pregnancies by 30. Fertility rate from 65.4 to 46 per 1,000 women age 15-19 years old. Advance of 77 2003 Rate 50.3
Reduce the gap between desired and actual fertility Gap between desired and actual fertility under 20. Reached. Global fertility rate of 1.9 children per women in 2003.
SO 1 Maintain the achievements attained
46
SO 1 Maintain the achievements attained
Infant mortality and its components, Chile
1995-2004
Post neonatal
Infant
Rates x 10,000 LB
Salud Infantil con avance
Objective Degree of progress
Reduce infant mortality by 25, from 10.1 in 1999 to 7.5 en 2010. Advance of 65. 2003 Rate 7.8 (2004 8.4)
Reduce neonatal morbi-mortality. ? Mortality by 12.5. 2000 Rate 5.6 2004 4.4 (per 1,000 L.B.)
Reduce late fetal mortality Rate under 3 per 10,000 L.B. Advance of 62. 1998 Rate 4.3 2003 3.5 (per 10,000 L.B.)
Prevent the occurrence of congenital anomalies (neural tube defects). ? 40 incidence of N.T.D. In the maternity wards of hospitals w/ RM base, bet. 1999 and 2005.
47
Millennium Development Goals
Eradicate extreme poverty and hunger
GOAL 1
GOAL 2
Achieve universal primary education
GOAL 3
Promote gender equality and empower women

GOAL 4
Reduce child mortality
GOAL 5
Improve maternal health
GOAL 6
Combat HIV/AIDS, malaria and other diseases
GOAL 7
Ensure environmental sustainability
48
Minimum Indicators, Millennium Development Goals
2015 Goal
Target 1
1. Proportion of Population Whose Income Is Below
1 (PPP) per Day
2. Coefficient of the Poverty Gap Ratio of 1 per
Day (incidence by depth)
GOAL 1 ERADICATE EXTREME POVERTY AND HUNGER
3. Share of Poorest Quintile in Total Monetary
Income
Target 2
4. Percentage of Children Under 6 Years of Age
Who are Malnourished
5. Proportion of Population Below Minimum Level
of Dietary Energy Consumption
2015 Goal
Additional Indicators - MDGs
Target 1
1. That the families in Solidarity Chile have
incomes above the poverty line
2. That at least one adult member of the families
in Solidarity Chile has a regular job with stable
remuneration
Target 2
3. Obesity rate in children under 6 years of age
49
This is how the AUGE works explicit health
guarantees
50
The regime of General Health Guarantees is a
health regulation instrument that is an integral
part of the Health Services Regime.
12 September 2004
51
12 September 2004
The Explicit Guarantees relate to access,
quality, financial protection and timeliness.
52
What if a boy or girl is born with an operable
congenital cardiopathy?
What if a boy or girl is born with an operable
malformation of the spinal cord?
What if a woman needs preventive services for a
premature birth?
What if a girl or boy is born with a cleft lip
and/or palate?
53
Government Program A good social protection
system accompanies people throughout their life
cycle, protecting their first steps,
54
My goal, at the end of the Administration, is
that we will have achieved the implementation of
a child protection system aimed at leveling the
development opportunities of Chilean children in
the first eight years of life, independent of
social origin, gender, geography or household
structure. A task of this magnitude far exceeds
the reach of traditional social policy approaches
and will require a set of programs and
instruments... Constitution Ceremony of the
Presidential Advisor for the Reform of Childhood
Policies, 30 March 2006.
55
Comprehensive focus on social
determinantsSocial Protection System for
Childhood under development
Link activities for support and social services,
considering childhood to be the final subject of
the intervention, including protection networks
that favor the role and participation of the
family.
WHO definition of health
BOY OR GIRL
Simultaneous approach to the distinct areas of
the life of the boy or girl and his/her family,
understanding that each one represents a
fundamental aspect Identification, learning,
health, family environment, living
conditions, income and work.
56
The logic of the intervention
The following matrices have been developed for
each stage of the boys or girls life cycle

• Baby from gestation until 3 months.
• From 3 months to 3 years.
• From 4 to 5 years.
• From 6 to 10 years (4th of basic).

The matrices have a logic of continuity the
boy/girl enters the System at the gestation stage
and the System accompanies him/her from that
moment throughout the different stages of the
life cycle.
57
The future of children is always today Proposals
by the Presidential Advisor for the Reform of
Childhood Policies
58
Chile grows with you
13.10.06
59
System for the Protection of Childhood Chile
Grows With You

• Pregnancy control will mark the entrance of women
  into the public health system.
• Automatic one-time family subsidy for the entire
  gestational period (R.N. Subsidy).
• Pregnancy and delivery manual, organized by weeks
  of gestation.
• Program for the integrated development of
• doctors visits (complement to prenatal and
  healthy child controls).
• Humanized delivery care (AUGE 2007)