Subject Topic Date Lecturer

OB-GYN Tranx No. 3 OB in Broad Perspectives 2009 December 15 Conrado P Crisostomo, MD

Pages

Transcriber Jcms

12

Batch 2012 / 2009-2010

OUTLINE
I. II. III. IV. V. VI. VII. VIII. IX. X. Introduction Obstetrics in the Philippines The Problems of Neonatal and Infant Mortality Reproductive Health UN MDGs Terminology Maternal Mortality Fertility Rate Skilled Health Attendant Department of Health

Subject Head

Ronnelaine Cortez

Sources: Powerpoint and Recordings

deletions and duplicationsOBSTETRICS IN BROAD PERSPECTIVES of genetic material. Howev

I.

INTRODUCTION

A. Obstetrics Obstetrix: means midwife Connected with the verb obstare meaning to stand by or in front of The art and science that deals with delivery, its antecedents and sequelae, or pregnancy, labor and puerperium (puerperium: period of confinement during and just after birth; includes the 6 subsequent weeks during which normal pregnancy involution occurs) Concerned with reproduction of the human species Aims to promote health and well-being as a branch of Medicine that is concerned with pregnancy, labor and puerperium of both normal and abnormal conditions Used as early as 15th century worldwide B. The Evolution of the Science of Obstetrics Humans have larger brains and smaller pelvic dimensions making the fetus negotiate a series of turns to accommodate along the widest diameter of the human pelvis resulting in the fetus being delivered in the occiput anterior position The pelvic inlet, where the fetus begins is transit, is widest from side to side. Midway through the pelvis, however, the orientation shifts 90 degrees and the widest dimension of the pelvis is from anterior to posterior. This change in pelvic dimensions means that the fetus must negotiate a series of turns as it passes through the birth canal so that its largest dimensions, which are the head and the shoulders, are always aligned with the widest dimension of the birth canal. As a consequence of this rotation, human fetuses predominantly assume the occiput anterior position at delivery. The human birth canal is a complicated passageway, there are series of turns: directed downward and then forward, so the baby needs to rotate in order for him/her to accommodate through the birth canal; the baby has to be in occiput anterior position to the mother for him/her to be delivered facing down) Human parturients need assistance because: 1. Of the big brains of the neonate 2. The maternal pelvis is designed for walking upright, diminishing its dimensions 3. Of rotational delivery in which the fetus is delivered facing downwards (complicated passageway) C. Related Specialties Affecting Obstetrics (multifaceted) OB: has surgical management and intervention 1. Gynecology: study of the diseases in women; deals with human physiology of ovulation, menstruation, and reproduction
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2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.

Pediatrics: deals with the newborn. Neonatologists handle high-risk cases such as premature deliveries Endocrinology Genetics Immunology Microbiology Biochemistry Physiology Pharmacology Psychology Nutrition Cardiology, Pulmonology Gastroenterology, Nephrology

D. Importance of Obstetrics Maternal and neonatal outcomes are universally used as index of the quality of health and life in the human society.

II. OBSTETRICS IN THE PHILIPPINES

A. The Beginning of Obstetrics in the Philippines Unknown period when the traditional or untrained birth attendants (Hilots) attended to deliveries By physicians, dates back to the establishment of San Juan de Dios Hospital before 1908 Followed by St. Pauls Hospital, Civil Hospital and Mary Johnston Hospital (92 OB cases from 1908 to 1909 were recorded)

B. The Problem of Maternal Morbidity and Mortality anything can happen: mothers are categorized as low-risk or high risk 40 % of women experience complications in any stage of pregnancy 15 % develop potentially life - threatening problems (be prepared and be recognized, and with diagnosis, may institute immediate management) Placenta previa: no implantation of the placenta C. Place of Delivery, Philippine situation (2003) 60 % at home attended by hilots and midwives (due to fear of health care facility, Philippine culture, and financial aspects; problems: special health care facility, surgery) 40% in a health facility attended by a trained birth attendant
Low birth with medical attendance in: Bicol, Caraga, & ARMM

Need for training of hilots and midwives to diminish maternal morbidity and mortality. Need for easy and immediate access to a facility w/ basic and comprehensive OB services.

III. THE PROBLEMS OF NEONATAL AND INFANT MORTALITY

According to WHO 8 million infants die before one year of age <1 month= neonatal death Within 1 year = infant death Less than half (< 4 million) die less than one month of age Social and Economic Impact 30-40% of infant deaths due to poor maternal health and poor infant care 20% of LBW babies due to poor maternal health and nutrition Motherless children are 3x more likely to die within 2 years of age (it is important for infants to grow up with their mothers)
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50 % of pregnant Filipino women are anemic (IDA is a good index)

Table 4.31 Prevalence of Iron Deficiency Anemia Among Children, Pregnant and Lactating Women Philippines, 1993, 1998 and 2003 Age group 1993 1998 2003 6-11 months 49.2 56.6 66.0 1-5 years old 25.1 29.6 29.1 6 months 5 years old 31.8 6-12 years old 42.0 35.6 37.4 Pregnant women 45.7 45.7 43.9 Lactating women 43.9 45.6 42.2
Source: National Nutrition Surveys,1993, 1998 and 2003

Table 4.32 Prevalence of Iodine Deficiency Disorder among Children, Pregnant and Lactating Women Philippines, 1998 and 2003 (IDD: potential to have babies with low IQ) 1998 2003 Age group Median UIE (ug/dl) Prevalence of IDD Median UIE (ug/dl) Prevalence of IDD 6-12 years old Pregnant women Lactating women 71 35.8 201 142 111 11.4 18.0 23.7

Source: National Nutrition Surveys, 1998 and 2003

Table 1.3 Leading Causes of Infant Mortality, Philippines, 2000 Cause Number Rate per 1000 Percent Share from Total Number livebirths of Infant Deaths 1. Pneumonia 2. Bacterial sepsis of the newborn 3. Disorders related to short gestation and low birth weight 4. Respiratory distress of the newborn 5. Other perinatal conditions 6. Congenital malformations of the heart 7. Congenital pneumonia 8. Diarrhea and gastroenteritis of presumed infectious origin 9. Other congenital malformations 10. Neonatal aspiration syndrome 3,463 3,174 2,569 2,446 2,347 1,596 1,596 1,207 1.156 1,063 2.0 1.8 1.5 1.4 1.3 0.9 0.9 0.7 0.7 0.6 13.8 12.6 10.2 9.7 9.3 6.3 6.3 4.8 4.6 4.2

Source: Philippine Health Statistics, 2000

IV. REPRODUCTIVE HEALTH (RH) State of complete physical, mental and social well-being and not merely the absence of disease and
infirmity, in all matters relating to the reproductive system and to its functions and processes RH implies that people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so. RH includes sexual health, the purpose of which is the enhancement of life and personal relations.
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A. Components 1. Counseling, information, education, communication and clinical services in family planning 2. Safe motherhood, including antenatal care, safe delivery care and postnatal care, breastfeeding and infant and womens health care 3. Gynecologic care, including prevention of abortion, treatment of complications of abortion and safe termination of pregnancy as allowed by law (but in the Philippines, abortion is illegal) 4. Prevention and treatment of sexually transmitted diseases (including HIV/AIDS), including condom distribution and universal precautions against transmission of blood-borne infections, voluntary testing and counseling 5. Prevention and management of sexual violence 6. Active discouragement of harmful traditional practices such as female genital mutilation 7. Reproductive health programs for specific groups such as adolescents, including information, education, communication and services B. Improvement in RH: 1. Better survival and education of children 2. Increased productivity of men, women and children 3. Reduced fertility increasing resources share for everyone House Bill No. 5043 Reproductive Health Bill An act providing for a national policy on reproductive health, responsible parenthood and population development and for other purposes Components: 1. Reproductive health education including but not limited to counseling on the full range of legal and medically-safe family planning methods including surgical methods; 2. Maternal, prenatal and postnatal education, care and services 3. Promotion of breastfeeding; 4. Promotion of male involvement, participation and responsibility in reproductive health as well as other reproductive health concerns; 5. Prevention of abortion and management of post-abortion complications; 6. Provision of information and services addressing the reproductive health needs of the poor, senior citizens, women in prostitution, differently-abled persons, and women and children in war and crisis situations

Good maternal health services can strengthen the entire health system since many of the health requirements for the health of the female would provide already for more than half of the susceptible population. -- Mario Festin, MD Maternal mortality can be reduced without first achieving economic development since many of the existing interventions and programs have been proven effective if utilized properly. -- Mario Festin, MD Reproductive Health Philippine Situation 1 in 100 lifetime risk of dying from maternal cause One of the highest maternal mortality ratios in Asia (10 Filipino women die every 24 hrs from pregnancyrelated causes) Socio-economic factors primary cause of disease, access to health services and maintenance of health

V. UNITED NATIONS MILLENNIUM DEVELOPMENT GOALS (2015)

Planned in 1990 Decrease Maternal Mortality ratio by (75%) Decrease under-five mortality by 2/3 (about 66%) -currently at 40 per 1000 LB Universal access to the widest possible range of family planning methods and reproductive health services Universal access to a wide range of safe and effective family planning methods Universal access to essential Obstetric care (preparation fro pregnancy, antenatal, delivery and postpartum care, management of abortion and its complications Prevention and management of reproductive tract infection

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VI. TERMINOLOGY
A. Vital Statistics National records are important which state the situation of important health indicators in the country Help in establishing trends in health ststus nationally and internationally Based on standard definition of terms and formulae 1. Birth complete expulsion or extraction of a fetus from the mother weight = 500 grams, crown to heel length = 25 cm (<500grams, <25 cm = abortus) 20 weeks AOG by LNMP whether umbilical cord is cut or the placenta is attached

2. Live Birth - complete expulsion or extraction of a fetus from the mother, regardless of the AOG (>20 weeks), which after separation, shows evidence of life like breathing, beating of the heart, pulsation of the umbilical cord or definite movement of voluntary muscle - whether umbilical cord is cut or the placenta is attached 3. Birth Weight - The first weight of the newborn obtained after birth - Measured within the first hour of life before significant postnatal weight loss has occurred (there is a significant 10-15% post natal loss of water during the first few weeks of life) Birth Weight Grams Low birthweight (LBW) < 2500 grams Very low birthweight (VLBW) < 1500 grams Extremely low birthweight (ELBW) < 1000 grams 4. Birth Rate - Refers to number of livebirths per 1000 population, usually also referred to as the crude birth rate 5. Fertility Rate - Number of live births per 1000 female population age 15 to 44(49) years 6. Women of Reproductive Age - Women aged 15 to 44 (49) years 7. Total Births - The total number of deliveries ( > 20 weeks AOG) including livebirths plus fetal deaths 8. Fetal Death/Stillbirth - death prior to the complete expulsion or extraction from the mother, irrespective of the duration of pregnancy (>20 weeks) - death as evidenced by the absence of breathing, beating of the heart, pulsation of the cord, definite movement of voluntary muscles 9. Fetal Death Rate - Number of stillbirths or fetal deaths after 20 weeks AOG per 1000 total livebirths

Fetal Death Rate Fetal deaths x 1000 Total births (LB + stillbirths) Fetal Death Ratio Fetal deaths x 1000 Live births Fetal Death Rate, weight specific (age specific)
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Fetal deaths weighing 1000 g and above x 1000 Total births weighing 1000 g and above 10. Neonate - A live born infant up to 28 days of life 11. Neonatal Death Early death of a liveborn neonate during the first seven days after birth Late death after 7 days but before 29 days Neonatal Mortality Rate Neonatal deaths x 1000 Livebirths Neonatal Mortality Rate, weight specific Neonatal deaths of infants weighing 1000 g and above at birth x 1000 Live births weighing 1000 g and above 12. Abortus - is an embryo or fetus expelled during the first half of pregnancy, less than 20 weeks, 500 gms or less. - Usually would need intervention in a medical facility 13. Gestational Age - refers to the number of completed weeks that have elapsed between the first day of the LNMP and the date of delivery, irrespective of whether the gestation results in a livebirth or a fetal death - When LNMP is unreliable, the AOG is based on best clinical estimates - Expressed in weeks and days 14. Gestational Age - Based on the LNMP - Completed days or completed weeks - 280 days or 40 weeks Preterm Term Post-term In weeks (days) 36 6/7 weeks (259 days) 37 completed weeks to 41 6/7 weeks (259-293 days) 42 completed weeks (294 days)

15. Perinatal Period - From 20 completed weeks to 28 completed days after birth 16. Perinatal Death - All fetal deaths/stillbirths of 20 or more weeks AOG plus neonatal deaths up to 1 week of age 17. Perinatal Mortality Rate - Number of fetal deaths or stillbirths (beyond 20 weeks AOG) plus number of early neonatal deaths per 1000 total births Perinatal Mortality Rate = Fetal deaths and Early Neonatal deaths x 1000 Total births Perinatal Mortality Ratio = Fetal deaths and Early Neonatal deaths x 1000 Livebirths Perinatal Mortality Rate, weight specific = Fetal deaths weighing 1000 g and above, plus Early Neonatal deaths of infants Weighing 1000 g and above at birth x 1000 Total births weighing 1000 g and above

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18. Infant Deaths - Any death at any time from birth up to the moment just before one year of age (infant= birth to 1 year) 19. Infant Mortality Rate - Number of infant deaths per 1000 livebirths 20. Maternal Death - Death of a woman while pregnant or within 42 days after termination of pregnancy irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes (42 days after delivery= puerperium: 6 weeks from the time of delivery is still part of pregnancy; there is a return of the reproductive organ from pregnant state to non pregnant state, by the end of puerperium, there is a complete involution of organ from gravid to non gravid state) i. Direct Obstetric Death o Resulting from obstetric complications of the pregnant state (pregnancy, labor, puerperium) o From interventions, omissions, incorrect treatment, or from a chain of events resulting from any of the above o Majority of maternal deaths

ii. Indirect Obstetric Death o Resulting from previous existing disease or disease that develop during pregnancy (aggravated disease during pregnancy, e.g. hypertension) o Which was not due to direct obstetric causes o But which was aggravated by physiologic effects of pregnancy iii. Non-obstetric Death o - Maternal deaths due to traumatic causes such as suicide, accident, gun shot wound and similar conditions

VII. MATERNAL MORTALITY

Maternal Mortality Ratio (Maternal deaths / 100,000 Live Births)

Year 1993 1998 2005

(according to WHO) 209 172 230

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Figure 1.10 Trends in Maternal Mortality Ratio Philippines, 1993-2003 (there is a decreasing trend in maternal mortality ratio)

Figure 4.41 Percentage Distribution of the Main Causes of Maternal Mortality Philippines, 2000

Maternal Mortality by Main Cause, 1998 CAUSE No. Rate/1000LB Complications related to pregnancy 603 0.4 Hypertension 425 0.3 Postpartum Hemorrhage 286 0.2 Pregnancy w/ Abortive outcome 144 0.1 Hemorrhage 121 0.1 Direct Causes of Maternal Deaths Source: Philippine Health Statistics 2002, DOH CAUSE NO. RATE 1. Other complications related to pregnancy occurring in 779 0.5 the course of labor, delivery and puerperium 2. Hypertension complicating pregnancy, childbirth and 533 0.3 puerperium 3. Postpartum Hemorrhage 327 0.2 4. Pregnancy with abortive outcome 161 0.1 5. Hemorrhage related to pregnancy 1 0.0 * Percent share to total number of maternal deaths

% 38.2 26.9 18.1 9.1 7.7

% 43.3 29.6 18.2 8.9 0.1

Indirect Causes of Maternal Deaths: 1. Heart disease (hypertension) 2. Pulmonary disease 3. Cerebrovascular accident 4. Cerebral aneurysm 5. Infectious disease 6. Breast cancer 7. Meningitis 8. Malaria

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Indirect Obstetric Deaths CAUSE 1. Cardiac (RHD, CHD, HPNHD) 2. Pulmonary (Pneumonia, TB, BA, CA) 3. Metabolic (Thyroid Storm, DM) 4. Urinary Tract (Hydronephrosis, Ruptured Renal Artery Aneurysm) 5. Hematologic (Aplastic Anemia, Leukemia) 6. Vascular ( Thrombosis/embolism, Pre-existing Hypertension, Aneurysm) 7. Reproductive Tract (Uterine anomalies) 8. Gastrointestinal (AGE, malignancy, cholangitis) 9. Others (Sepsis, CNS infection, MTX toxicity, Typhoid fever, spinal cord compression, acute peritonitis, CVA intracranial bleed)

Number 30 25 10 7 5 4 4 3 15

% 5.50 4.59 1.83 1.83 0.92 0.73 0.73 0.55 2.75

Non-Obstetric Deaths (Causes): 1. Vehicular accidents 2. Gunshot wounds 3. Stab wounds 4. Electrocution 5. Drowning 6. Food poisoning 7. Burns 8. Suicide

VIII.

FERTILITY RATE
Table 4.8 Wanted Fertility Rate, Total Fertility Rate and Mean Number of Children Ever Born to Women Age 40-49 Years by Region Philippines, 2003 Region Wanted Fertility Total Fertility Rate Mean Number of Rate Children Ever Born to Age 40-49 Years NCR 2.0 2.8 3.2 CAR 2.7 3.8 4.7 Ilocos 3.0 3.8 3.9 Cagayan Valley 2.6 3.4 4.1 Central Luzon 2.4 3.1 4.1 CALABARZON 2.3 3.2 3.8 MIMAROPA 3.6 5.0 5.1 Bicol 2.6 4.3 5.5 Western Visayas 2.7 4.0 4.9 Central Visayas 2.6 3.6 4.4 Eastern Visayas 2.9 4.6 5.4 Zamboanga Peninsula 2.6 4.2 4.9 Northern Mindanao 2.8 3.8 4.8 Davao Region 2.2 3.1 4.6 SOCCSKSARGEN 3.0 4.2 5.0 Caraga 2.8 4.1 5.4 ARMM 3.7 4.2 5.2 Philippines 2.7 3.5 4.3
Source: National Demographic and Health Survey, 2003

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Table 4.9 Philippines, 2003 Percentage of Married Women and All Women Age 15- 49 Years Who Ever Used Any Contraceptive Method by Age Group Age Group Percentage of Married Women Percentage of All Women 15-19 36.8 4.0 20-24 61.0 31.8 25-29 71.5 56.6 30-34 75.8 66.5 35-39 76.5 69.7 40-44 72.2 66.5 45-49 TOTAL 67.7 70.6 63.1 47.3

Source: National Demographic and Health Survey, 2003

Table 4.23 Selected Health Indices in Urban and Rural Areas Philippines, 2003 Health Indicators Rural Area Urban Areas Neonatal mortality 21 per 1,000 livebirths 14 per 1,000 livebirths Infant mortality 36 per 1,000 livebirths 24 per 1,000 livebirths Under-five mortality 52 per 1,000 live births 30 per 1,000 live births Total fertility rate 4.3 3.0 Child births at home 77% 45.5%
Source: National Demographic and Health Survey, 2003

Table 4.10 Percentage of Currently Married Women Age 15-49 Years Who Use Any Contraceptive Method, Philippines, 2003

IX. SKILLED HEALTH ATTENDANT

An accredited health professional such as midwife, doctor or nurse, who has been educated and trained to proficiency in the skilled needed to manage normal pregnancies, childbirth and immediate postnatal period Trained in the identification of, management and referral of complications in women and newborns Excluding traditional birth attendants whether trained or not Reporting Criteria: All livebirths and fetal deaths weighing at least 500 grams at birth should be included in the statistics and registered in the national civil registry of births

X. DEPARTMENT OF HEALTH (DOH)

What is DOH doing? A. DOH Programs 1. Womens Health Teams (WHTs) Barangay-Based Womens Health Teams (WHTs) Composed of the midwife as team leader Barangay Health Workers (BHWs) and traditional birth attendants TBAs) as members Municipal Health Officer (MHO) as overall supervisor of the WHTs. An important task of the WHT is to track every pregnancy within its catchment area and report the outcome. The WHTs base of operation in the community is the Barangay Health Station (BHS). The functions of the WHT include:
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To track every pregnancy occurring within the community using the Pregnancy Tracking Form. To assist the pregnant woman in accomplishing the Birth Plan. To provide quality maternal care, family planning, STI prevention and HIV control and adolescent and youth health services. To make accurate recordings. To provide good counseling services. To refer clients appropriately. To report maternal death. To discuss relevant womens issues with the community.

2. Facility-Based WHSMTs i. BEmOC Team (Basic Essential/Emergency Obstetric Care) o A basic essential/emergency obstetric care team is organized and trained to attend to normal births in BEmOC facilities designated to receive referrals from WHTs o A doctor who is either a specialist in obstetrics or is trained on emergency obstetric care service provision heads these teams. The team members include nurses, medical technologist and the midwife leader of the WHT. o Functions of BEmOC Team: a. To receive referrals from WHTs. b. Assist the woman during childbirth and administer the following BEmOC services when needed: - Parenteral antibiotics - Parenteral oxytocic drugs - Parenteral anticonvulsants - Manual removal of placenta - Removal of retained products of conception - Assisted vaginal delivery (forceps extraction) - Family planning counseling and contraceptive provision - IUD insertion - Screening for Sexually-Transmitted Illnesses - To ensure that newborn screening is done on time - To provide basic laboratory examination services c. To ensure that childbirth is properly registered at the local civil registrar and reported to the local FHSIS unit. d. To ensure that deaths are properly registered with the local civil registrar and reported to the Provincial Review Team and the FHSIS unit. e. To ensure that whenever a maternal death review is done, its results are discussed with the team for appropriate action. ii. CEmOC Team (Comprehensive Essential/Emergency Obstetric Care) o A comprehensive essential/emergency obstetric care team is likewise organized in CEmOC facilities and trained to attend to complicated cases referred by BEmOC facilities. o Team members include an obstetric-gynecology specialist or a general practitioner trained on CEmOC service provision, nurses, anesthesiologist, pathologist and fetologist (if available). o Functions of CEmOC team: a. To provide basic maternal care services to women with complicated pregnancies. b. To medically manage complications of pregnancy, labor and puerperium. c. To provide CEmOC services: Perform caesarian section and Blood transfusion d. e. f. g. To perform surgical Family Planning methods To administer medical management of STDs and HIV. To refer suspected HIV-AIDS cases to higher-level facility for medical management. To make appropriate endorsement to WHT for succeeding follow-up care to post-partum woman and child. h. To ensure that deaths are properly registered with the local civil registrar and reported to the Provincial Review Team and local FHSIS unit. i. To discuss maternal death review results among the team members and undertake appropriate course of action.

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iii. CEmONC o CEmOC plus Neonatal care o Ideal number: one CEmONC facility per 500,000 population B. Strategies for Reduction of Perinatal Mortality 1. Prevention of neonatal tetanus and other infections 2. Improvement of Obstetric care 3. Community involvement in perinatal and neonatal care 4. Improvement of maternal conditions affecting perinatal death C. Maternal Conditions associated with Perinatal Mortality: 1. Preterm labor most common 2. Placenta previa 3. Multiple factors 4. Post-term pregnancies 5. Cephalo-pelvic disproportion 6. Hypertension in pregnancy D. Antenatal Care in the Philippines 1. DOH recommends at least four ANC 2. Complied by 70% (2003) 3. First ANC must be during the first trimester 4. 53% had first ANC between 4 to 5 months AOG 5. 10 % had their first prenatal check-ups between 6 to 7 months AOG
Table4.11:Health-Related Practices Affecting Maternal Health Philippines,199 8and 2003 Maternal Health Practice NDHS NOH Targets NDHS 2003 1998 2004 Pregnant women with at least 4 prenatal visits 77% 80% 70% Pregnant women with at least 2 doses of 38% 80% 37% tetanus toxoid Births attended by professional health 56% 80% 60% providers Women with at least 1 postnatal visit witin one 43% 80% 51% week of delivery
Source: National Center for Disease Prevention and Control, DOH, 2005

E. Past Interventions Done 1. Proper Antenatal Care not achieved and complications not diagnosed early 2. Training of traditional birth attendants lead to delayed referrals and still lack proper skills *Linkages with adequately manned and equipped Emergency facility is vital. F. Strategies for Reduction of Maternal Mortality 1. Better training of health attendants, midwives, doctors, TBA (traditional birth attendants) training of TBAs is still questionable 2. Improve quality and quantity of pre-natal, natal, and post natal care for all women (Safe Motherhood Program) 3. Provide skilled obstetrical care for high risk and emergency cases 4. Family planning G. Improvement of Maternal Care 1. Role of Midwives Know when to refer. 2. Role of Obstetricians Philippine Obstetrical and Gynecological Society (POGS) 3. Role of Government Philhealth Expansion: Normal deliveries are covered until 3rd or 4th pregnancy + newborn screening and immunization 4. Role of Community Access to hospitals 5. Paradigm shift
* Implement strategies that employ a combination of financial incentives, advocacy and communication to change stakeholders behavior in the context of their particular roles in the fulfillment of a common goal.

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