and Safe Motherhood
refer to Chapter Two for the aspects of Safe
Motherhood which must be dealt with in the initial phase of a
The activities within the MISP related to Safe Motherhood help
prevent excess neonatal and maternal morbidity and mortality by:
providing clean delivery kits for use by mothers or birth
attendants to promote
clean home deliveries; providing midwife delivery kits (UNICEF
or equivalent) to facilitate clean and safe deliveries at
the health facility; and by
initiating the establishment of a referral system to manage
The individual appointed as RH Coordinator should be responsible
for all RH services including Safe Motherhood, to ensure optimum
integration of all the various aspects of reproductive health.
Motherhood in Stabilised Situations
soon as feasible, comprehensive services for antenatal, delivery
and postpartum care must be organised. Planning for such services
should take into account existing facilities for the local population.
Both refugee and local population needs should be considered.
Services should be able to deal with obstetric and other medical
emergencies. For obstetric emergencies, it is preferable to support
host-country services rather than establish new and refugee-specific
facilities that will not be maintained in the long term.
Approximately 15 per cent of pregnant women will develop complications
that require essential obstetric care, and up to five per cent
of pregnant women will require some type of surgery. The following
ratios have been found to be successful in many situations:
one health post/ clinic with trained community health workers
and traditional birth attendants (TBAs) able to identify problems
and refer for every 5,000 people;
one equipped health centre providing basic essential obstetric
care for every 30,000-40,000 people; one operating theatre and
staff, capable of performing 24 hour comprehensive essential obstetric
care, for every 150,000 to 200,000 people.
To make sure that the services provided are appropriate and of
the highest quality and will be fully used, it is essential to:
identify skilled care providers involved in childbirth (physicians,
midwives, experienced nurses, trained TBAs); provide refresher
training and close supervision as indicated;
be aware of and discuss community beliefs and practices and
health-seeking behaviour related to delivery, such as position
for delivery, presence of relatives for support and traditional
practices both positive (breastfeeding) and harmful (female
genital mutilation); and
ensure that all refugee women and their families know where
to obtain assistance for antenatal care and delivery and how
to recognise signs of complications.
primary objective of antenatal care is to establish contact with
the women, and identify and manage current and potential risks
and problems. This creates the opportunity for the woman and her
health care provider to establish a delivery plan based on her
unique needs, resources and circumstances. The delivery plan identifies
her intentions about where and with whom she intends to give birth
and contingency plans in the event of complications (transport,
place of referral, etc.).
At least three antenatal visits are recommended, ideally with
the first visit early in the pregnancy. This number may vary based
on national policies. Appropriate antenatal care should include:
Assessment of maternal health.
This includes not only determining the pregnant woman's overall
health status, but also identifying factors which may adversely
affect pregnancy outcome. These factors include: age (younger
than 17 or older than 40), grand multipara, significantly short
stature, and obstetric history of any previous complications,
including surgery. While this screening may help identify some
women who will develop complications, it will not identify all
of them. Thus it is critically important to identify and manage
complications as they arise among all pregnant women. The home-based
maternal record at the end of the Chapter should be adapted
and used to record care provided to women during pregnancy.
Female genital mutilation is a particular risk in some countries
(see Chapter Seven). Women who have been subjected
to this procedure, especially to infibulation, should be identified
during the antenatal period.
Detection and management of complications.
Special emphasis should be placed on identifying the acute complications
of unsafe abortions or ante-partum haemorrhages. Other complications,
such as hypertensive diseases, anaemia, diabetes, malaria or an
STD, are less obvious and require more detailed physical examination.
Treatment for existing health conditions should be undertaken.
Syphilis testing is recommended at least once during pregnancy,
preferably before the third trimester. Systematic testing for
syphilis in pregnancy is cost-effective if the prevalence of syphilis
is one per cent or more in the general population.
Observation and recording of clinical data.
Height, blood pressure, search for oedemas, proteinuria and haemoglobin
(if indicated by clinical signs), uterine growth, fetal heart
rate and presentation should be recorded.
Maintenance of maternal nutrition.
The recommended minimum nutritional requirements for a pregnant
woman have been set at 2,300 kcal per day of a balanced and culturally
acceptable diet. Supplementary food may be required if the basic
food ration available or distributed to refugees is inadequate.
The offer of supplemental food can be a good incentive to get
women to attend for antenatal care. Health care providers should
be alert to signs of iron-deficiency anaemia and iodine deficiency
The following topics should be part of the educational activity
related to antenatal care:
choosing the safest place for delivery;
clean delivery; the major symptoms of complications (bleeding,
severe abdominal pain, headache);
where and when to seek care for complications;
STD/ HIV/ AIDS prevention;
and family planning.
Prevention of major diseases.
Preventive measures should include: iron folate prophylaxis (anaemia
occurs in about 60 per cent of pregnant women in developing countries);
tetanus toxoid immunisation; Vitamin A supplements; antimalarials
(according to country policies) and antihelminthics (hookworms)
in endemic areas. Iodized oil/ salt may be given in areas of moderate
or severe IDD and following national protocols.
Field Manual does not contain details of how to conduct deliveries.
See the Further Reading list for this information.
Even with the best possible antenatal screening, any delivery
can become a complicated one requiring emergency intervention.
Therefore, skilled assistance is essential to delivery care. In
the absence of midwives or nurses, TBAs (who usually perform home
deliveries, often as a source of income) should be trained to
identify complications, provide immediate first aid, and know
when and where to refer women for additional care. It should also
be remembered that:
the first priority for a delivery is to be safe, atraumatic
and clean; and
most maternal deaths are due to a failure to get skilled help
in time for delivery complications.
It is critical to have a well-coordinated system to identify complications
and ensure their management with immediate first aid and/ or referral.
As a rule, the further away the referral facility, the earlier
Delays in obtaining help may be at the community level (in identifying
and referring women with difficulties); en route to the referral
facility (inability to get transport, poor road conditions); or
on arrival at the referral facility (absence of staff, lack of
drugs or other materials). All three possibilities for delay must
Midwives and TBAs should also take care of the newborn by: clearing
the airway, keeping the baby warm, providing eye and cord care,
helping mothers begin breastfeeding (and not giving any other
foods or liquids to the baby), and identifying complications which
require referral. Birth weights should also be measured.
Deliveries outside an equipped health facility.
TBAs or family members will often assist deliveries. Therefore,
early identification of midwives or TBAs within the community,
their training and supervision on the proper use of clean delivery
kits (clean place, clean hands, proper cord care) and identification
and management of complications (when and where to refer), are
essential to prevent excess maternal morbidity and mortality.
Deliveries in equipped health centres.
These health facilities, whether temporary or permanent, should
be equipped with the appropriate human and material resources
to take care of all but surgical cases. Wherever possible, national
health facilities should be used and supported. The following
basic essential obstetric care should be provided and standard
protocols used to monitor and manage labour. These include:
initial assessment, duration, use of a partograph (see Annex
assessment of fetal well being;
special care for women who have undergone genital mutilation
(see Chapter Seven);
use of vacuum extractor;
management of haemorrhage;
management of eclampsia;
and procedures for referral to next level of care, if necessary.
Protocols must be taught to health staff, publicly displayed and
made available in all health centres.
Basic essential obstetric care should be performed at the health-centre
level to address, or stabilise before referral, the main complications
of delivery, such as ante-partum haemorrhage, eclampsia, prolonged
labour, uterine rupture, post-partum haemorrhage, repair of vaginal
and cervical tears, and retained placenta.
These facilities should therefore be equipped with broad spectrum
injectable and oral anti-biotics (ampicillin, penicillin, doxycycline,
gentamicin, metronidazole), plasma expanders, anti-convulsants,
oxytocics, ergometrine, analgesics, magnesium sulphate, suturing
kits, "high" sterilisation techniques, gloves, syringes and needles,
delivery equipment, and materials for universal precautions.
These facilities should also be able to provide for resuscitation
and basic care of the newborn (e. g., management of hypothermia
and hypoglycemia), including measurement of birth weight. A readily
available prophylactic to prevent neonatal ophthalmia, ideally
tetracycline eye ointment, should be given to all newborns.
Deliveries at referral hospitals.
A referral hospital in which surgical procedures can be performed
may exist in some major refugee operations. However, very often,
severe complications will be managed at the nearest major health
facility of the host country. In this case, try to avoid swamping
the facility with the demands of the refugee population to the
detriment of the local people.
Timely and appropriate support to the local health facility must
be given as soon as possible. The agreement and support of the
Ministry of Health should be secured in order to formalise the
integration and coordination of obstetric services between the
refugee settlement and the local health facility.
The referral hospital should be able to perform safely comprehensive
essential obstetric care, such as Caesarean sections, laparotomy,
hysterectomy, repair of cervical and severe (third degree) vaginal
tears, care for complications due to unsafe abortion, and safe
An appropriate referral system requires referral protocols specifying
when and where to refer and an adequate record of referred cases.
This implies coordination, communication, confidence and understanding
between the TBAs and their supervisors (usually midwives) and
between the health centre and the hospital with surgical facilities.
An effective referral system will also have to take into account
security, geographical and transport constraints.
up to 50 per cent of maternal deaths occurs after delivery, a
midwife or a trained and supervised TBA should visit all mothers
as soon as possible within the first 24-48 hours after birth.
The midwife or TBA should assess the mother's general condition
and recovery after childbirth and identify any special needs.
This attention is particularly important when the woman is alone
as head of the family.
The postpartum visit provides an occasion for assessing and discussing
issues of cleanliness, care of the newborn, breastfeeding and
appropriate methods and timing of family planning (see Chapter
Six). Health providers should support early and exclusive
breastfeeding, and discuss proper nutrition with the mother. Iron
folate tablets should be continued and Vitamin A and iodised oil/
salt should be provided when necessary.
During the postpartum visit, the health and well being of the
newborn should also be assessed and its birth weight measured.
Newborns should be referred to the under-five clinic to start
immunisations, growth monitoring and other well-child services.
Community Health Workers (CHW) and TBAs should be trained for
appropriate referral of postpartum complications, such as haemorrhage,
sepsis, perineal trauma, breastfeeding problems, and newborn complications,
such as prematurity or failure to thrive, that may require additional
surveillance and/ or treatment.
the stabilisation phase, antenatal and post-natal services should
be offered in an appropriate environment, in the same location
as family planning, STD services, the "baby clinic" and any other
services related to primary health care.
Some situations may benefit from a "women's house" which offers
peer support, counselling and health promotion in a non-threatening
environment. This resource is especially important for adolescent
and new mothers. Such a place might also provide a suitable venue
for small-scale income-generating or female literacy activities.
Effective dissemination of information is vital if women are to
enjoy access to available services. The community's knowledge
and attitudes regarding medical care during pregnancy and childbirth
must be assessed. If there is suspicion and fear of medical interventions,
such as hospital delivery, Caesarean section or blood transfusion,
appropriate IEC activities may be necessary. New procedures, such
as screening blood for syphilis, should be preceded by educational
activities that explain and dispel misconceptions about the procedures.
Health workers should consider inviting a companion who will be
present at the time of delivery to attend antenatal clinics with
the pregnant woman. Through TBAs and/ or CHWs, the refugee population,
as a whole, should be made aware of the warning signs of impending
complications in pregnancy and labour and encouraged to plan how
to reach the equipped medical facility, if necessary. Given that
men and older family members often make the decisions within the
family, it is particularly important that educational activities
target these groups.
midwife or an experienced nurse is best suited to organise and
supervise the Safe Motherhood programme. A midwife can effectively
supervise 10 to 15 TBAs for an estimated population of 20,000-30,000.
In many societies, TBAs are usually the key people at the community
level who will influence maternal and newborn care, although their
influence and skills may vary from culture to culture. In general,
one TBA can look after 2,000 to 3,000 refugees. With a crude birth
rate of three per cent per year, this means roughly five to eight
deliveries per month per TBA.
With adequate training and supervision, some experienced TBAs
refer women with delivery complications to appropriate medical
provide care for normal pregnancy through labour, delivery
and the postpartum period; and
offer family planning information and services.
TBAs, however, are no substitute for a more skilled attendant
Bear in mind that female health care providers are usually preferred
to attend births.
Training and supervision of health workers in Safe Motherhood
practices should be evaluated and planned in coordination with
the community (both refugee and host), NGOs and UN agencies. The
nature of the training will vary depending on the services the
health worker provides and the skills required for those services.
should be continuously reviewed. Efforts should be made to collect
reliable information on maternal deaths. Every maternal death
should be investigated to determine the cause and action taken
and to ensure that the referral system is responding appropriately
to obstetric emergencies.
Record keeping (adapted to the literacy level of record keepers)
is essential for appropriate surveillance. Home-based maternal
records (see Annex 1), kept by the mother,
have proven advantages.
The following is a list of suggested indicators for monitoring
Safe Motherhood interventions in refugee situations. Refer to
Chapter Nine for further information.
Indicators to be collected from the health-facility level
Crude birth rate
Neonatal mortality rate
Coverage of antenatal care
Coverage of syphilis screening
Coverage of trained delivery services
Coverage of postpartum care
Incidence of obstetric complications
Indicators collected at the community level
Indicators concerning training and quality of care