Child and Maternal Mortality in TurkeyCOMCEC, WG Meeting Nov. 6 2019 Ankara

Dr. Bekir KESKİNKILIÇ

EVLİLİĞE SAĞLIKLI BAŞLANGIÇTurkish Health System I

• Universal Health Coverage (%97 Of Citizens, All Under The Age Of 18)

• All Primary Healthcare Services Are Free Of Charge

• Every Citizen Has A Family Physician

• There is NO Gate Keeping System in Place

• All Healthcare Facilities Have An IT System For EHR

• All Health Data Collected in A Big Data Pool

• Obligatory Service Guarantees Equitable Distribution Of Personnel

• Performance Based Payment For MDs

• Free Home Care, Ambulance Transport, Emergency and Intensive

Care Services For All

• All Infrastructural Problems Of Healthcare Facilities Are Solved

During The 1st Phase Of HTP

EVLİLİĞE SAĞLIKLI BAŞLANGIÇTurkish Health System II

• 24.470 Family Physician in 7.991 Family Health Centers

• Roughly Responsible From 3.100 Citizen

• All Electronic Health Records Data Collected On FP’s Computer

• Per-capita Fixed Payment (+ Some Incentives)

• Negative Performance Cut-offs Up to 20%

• All performance Criteria Related To Mother and Child Health(Follow-ups and Vaccination)

• …

• Managerial Performance Criteria For Hospital Managers and LocalManagers (Incl. Mother and Child Related Criteria)

• All Hospitals Classified According To Expected Roles and Thanks ToWidely Used Outsourcing System, No Hospital ExperiencingShortage From Laboratory or Imaging Support

EVLİLİĞE SAĞLIKLI BAŞLANGIÇWomen and Reproductive Health Programs

1. Monitoring Women Aged Between 15-49

2. Pre-marital Counseling

3. Reproductive Health In-service Trainings

4. Prenatal Care

5. Pregnancy Information Classes

6. Nutritional Support

7. Monitoring and Management of Risky Pregnancies

8. Guest Mother Project

9. Emergency Obstetric Care Trainings

10. Birth Management and C/S Control

11. Mother Friendly Hospitals

12. Postpartum Care

13. Maternal Mortality Monitoring

EVLİLİĞE SAĞLIKLI BAŞLANGIÇMonitoring Women Aged Between 15-49

It is carried out by family physicians twice a year in order to;

• make risk assessment in the women of reproductive age,

• provide safe maternity, performing pre-pregnancy counseling,

• provide information and deliver service on the methods which can

prevent the pregnancy,

• determine pregnancy at the early stage,

• arrange the interval between pregnancies,

• prevent unwanted pregnancies,

• help families who cannot have baby

EVLİLİĞE SAĞLIKLI BAŞLANGIÇPremarital Counseling Program

• Safe motherhood

• Sexually transmitted diseases

• Genetic blood diseases

(Hemoglobinopathies)

• Contraceptive methods

EVLİLİĞE SAĞLIKLI BAŞLANGIÇReproductive Health

In-service Training Program

• In order to provide qualified service delivery, the in-service

trainings of healthcare personels are continued in

Reproductive Health Regional Training Centers with

Reproductive Health Training Centers in all provinces

• Also, reproductive health educational programmes are

organized for public

EVLİLİĞE SAĞLIKLI BAŞLANGIÇPrenatal Care Program

Prenatal; Pregnant women are provided with services

in line with Prenatal Care Management Guide taken

part in the Annex of the Notice No.2010/27

up to first 14th weeks

18th-24th weeks

28th-32nd weeks At least 4 monitoring are carried out;

36th-38th weeks

• to inform the mother-to-be about

the hospital where the delivery

will take place, pregnancy and

delivery, in pregnant classes

• to determine the risky states

and monitor in accordance with

the protocols,

• to reduce the maternal mortality

EVLİLİĞE SAĞLIKLI BAŞLANGIÇPregnancy Information Classes

• It aims to prepare pregnants and her families to the delivery

consciously by providing them training/consultancy during the

pregnancy period

• It leads pregnant and her family to manage pregnancy and

puerperal period consciously

• It allows pregnant to know the signs of dangers and which way

to be tracked in states of emergencies and to realize risky

conditions at the early stages.

EVLİLİĞE SAĞLIKLI BAŞLANGIÇIron and Vitamin D Support for Pregnant Women

• In order to meet the increasing need of iron during the pregnancy,

providing 40-60mg/day iron support to any pregnants for 5 months

prior to delivery, starting from the 16th week of the pregnancy, and up

to 3 months post partum

• In order to prevent the vitamin D deficiencies seen during the

pregnancy and puerperal period, each pregnant women is given 1200

IU vitamin D every day beginning from 12th week of the pregnancy up

to 6 months after delivery

EVLİLİĞE SAĞLIKLI BAŞLANGIÇ

Monitoring and Management of Risky Pregnancies

“High-risk pregnants” are determined by

using risk assessment form for all

pregnant women

The protocols prepared for high-risk

pregnants:

• Pregnancy + diabetes

• Pregnancy + venous thromboembolism

• Pregnancy + epilepsy

• Pregnancy + asthma• Pregnancy + cardiovasculer disease

EVLİLİĞE SAĞLIKLI BAŞLANGIÇGuest Mother Project

• For pregnant women at the regions where the unfavorable

climatic and transportation conditions, or social

determinants may make it difficult to access healthcare

facilities in time

• They are detected, invited and transferred to the planned

centers, provided with accommodation and labor under the

hospital conditions and the mother and infant are taken

back to their home after their health conditions are suitable

EVLİLİĞE SAĞLIKLI BAŞLANGIÇEmergency Obstetric Care

It is a training program, aiming all kinds of capabilities (decision

making to operate) which may need to manage emergency conditions,

threatening the lives of mother and fetus during the course of

pregnancy and delivery to be gained by medical staff (incl.

gynecologists) working in this area.

EVLİLİĞE SAĞLIKLI BAŞLANGIÇBirth Management and C/S Control Program

• It is aimed to ensure that all pregnant women have safe and healthy

delivery at the hospitals and to keep the caesarean ratios at

acceptable levels

• Currently 98,1% of deliveries are performed in Hospitals.

• Ministry of Health prepared a joint action plan with Gynecology and

Obstetric Association of Turkey in April 2010 to decrease the high

caesarean ratios in Turkey

EVLİLİĞE SAĞLIKLI BAŞLANGIÇPrimary (first C/S) and Total C/S Ratios in Turkey (%)

91,6 93,7 96,8 98,1 98,0 98,5 98 98,1 98,1

45,5 46,6 48,0 50,4 51,1 53,1 53,153,1 54,9

25,7 24,9 24,6 25,9 26,3 27,2 26,4 25,7 26,3

0

20

40

60

80

100

120

2010 2011 2012 2013 2014 2015 2016 2017 2018

Hospital DeliveryRate

C/S Delivery Rate

Primary C/S Rate

EVLİLİĞE SAĞLIKLI BAŞLANGIÇPostpartum Care Program

• It has been introduced by the Notice No.No.2008-2010/13-2014 in order toprevent the maternal mortality takenplace during the postpartum period

• It is provided that the maternal to be keptat hospital for 24 hours following thenormal delivery, for 48 hours followingthe c-section and the monitoring thematernal 3 times in hospital 3 timesfollowing the discharge in line withPostpartum Care Management Guide arecarried out

EVLİLİĞE SAĞLIKLI BAŞLANGIÇMaternal Mortality Monitoring Program

Introduced just after the 2005 National Maternal Mortality Study,

maternal mortality has been monitored closely since January

2007

• All data regarding any maternal mortality are evaluated by

three levels of committees, local level, Subnational and

National

• Root causes of each death is determined and corrective

actions are taken accordingly

EVLİLİĞE SAĞLIKLI BAŞLANGIÇMaternal Mortality Ratios By Years

Maternal Mortality Ratio

100

70

28,521,2 19,4 18,4 16,4 15,8 15,2 15,7 15,1 14,6 14,7 14,5 13,6

0

20

40

60

80

100

120

1990 1998 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

EVLİLİĞE SAĞLIKLI BAŞLANGIÇNational Goals

1. To reduce the maternal mortality ratio to the same level with the developed

countries

2. After detecting all pregnant women and women after birth, monitor them in a

qualified manner and number

3. To provide iron and Vitamin D support for all pregnant women and women

after child birth

4. To increase the number of deliveries at the hospitals

5. To make the hospitals, where the deliveries occur, Mother Friendly

Hospitals

6. To open Pregnant Women classes to provide prenatal information to the

pregnant women

7. To reduce the caesarean ratio

8. To open Perinatal Centers to reduce the maternal mortality ratios

9. To prevent unplanned pregnancy and encourage the use of modern

contraceptive methods

10. To improve the quality of the premarital consultancy services to raise

healthier families and generations within the scope of reproduction concept

Child and Adolescent Health Programmes

• Hemoglobinopathy ScreeningProgramme

• Infant Child and AdolescentMonitoring Programme

• Infant and Child Mortality Monitoring Programme

• Birth Monithoring Programme

• Newborn Screening Programme

• Phenylketonuria,

• Congenital Hypothyroidis,

• Biotinidase,

• Cystic fibrosis,

• Congenital Adrenal Hyperplasia

• Hearing Screening

• Visual Screening

• Child Nutrition Programme

• Support of Breastfeeding

• Iron Support

• Vitamin D Support

• Training Programmes

• Neonatal Resusiation Programme

• Newborn Basic Care Programme

• Newborn Intensive Care Programme

• Child İntensive Care Programme

• Child Emergency Care Programme

• Child Safety Programme

To support routine health services, with the aim of reduce themorbidity and mortality depending on hemoglobinopathies, NationalHemoglobinopathy Control Program was initiated in 2000.

"Hereditary Blood Disease Control Program with HemoglobinopathyDiagnosis And Treatment Centers" regulation published in Official Gazette in 24 October 2002 and put into force.

Hemoglobinopathy Control Program

• It has been carried out since 1998

• Aims;

– To prevent of asphyxia-related deaths and sequelaes.

– To give resuscitation training to everyone touching baby in delivery room

– Improving the delivery rooms

Neonatal Resuscitation Programme

Newborn Intensive Care Programme

• The aim is to increase the knowledge and experiences ofpediatricians on neonatal intensive care.

• It has been carried out with the support of the Turkish Society of Neonatology since at the beginning of 2010.

• the course consists of 5 days theoretical and 30 days practical training in (the practical training are given at neonatal intensive care units)

The Emergency and Intensive Care Training Program in Childhood

• Training program was developed for pediatricians in cooperation with Pediatric Emergency Medical Intensive Care Association.

• The course consists of 2 days of theoretical and 18 dayspractical training.

• Practical training is given in Pediatric Intensive Care and Pediatric Emergency units.

Newborn Basic Care Training

• It is prepared for non-physician health care providers working in secondary carefacilities.

• The aim is to improve the knowledge of health care personnel so as to give basic care to healthy newborns.

– Umbilical cord care

– To determine the need for resuscitation

– Regular care

– Hypothermia protection

– Application of vitamin K

– Eye care

– Early breastfeeding

– The screenings on the national program

– Newborn hearing screening

– İmmunization

– Counseling for mothers

Neonatal Screening Programme

• Phenylketonuria Screening Programme

– It had been initiated in 1987, then expanded in 1993 all over Turkey.

• National Neonatal Screening Programme

– In 2006, Biotinidase Deficieny and Hypotiroidismadded to ongoing Phenylketonuria testing. Cystic Fibrosis added to panel in 2015. Now we are experiencing a pilot study on adding congenital adrenal hyperplazia.

Hearing Screening Programme

The incidence of hearing loss;• Neonatal Period 1-3/1000• Childhood Period 6/1000• Expected Case (Anual) 1800-2500

With early diagnosis and rehabilitation;• Appropriate psychological and social development• Appropriate training due to age and intelligences• Social adaptation

With this program, children born with hearing loss, can completepsychological and social development in a healthy manner andbecome self-contained, harmonious and productive individuals

Early Diagnosis and Treatment Program of DDH

• Developmental dysplasia of the hip is a dynamic disease which showed structural distortion for various reasons later, although the hip structures are normal during the intrauterine formation.

• Today “Developmental dysplasia of the hip (DDH)" term is used morecommonly instead of "congenital hip dislocation” because it is not always congenital fact.

• Screening coverage, 2018: %88

• “Infant and Child Monitoring Protocols", was created as a source of reference to be used by medical staff during the follow-up procedures.

• Protocols are prepared in accordance with the policies of the Ministry and the World Health Organization, with the support of the Turkish Association of Social Pediatrics and Neonatology Association.

Infant and Child Monitoring Protocols

Promotion of Breastfeeding and Baby

Friendly Hospitals Programme

Within cooperation with

UNICEF, the Programme has

been implemented since 1991

with view to ensuring,

supporting and expanding

breastfeeding.

“Criterias for Baby Friendly Province

• Ensuring all the children’s hospitals at city centre and all maternityhospitals become Baby Friend Hospital.

• Carrying out the studies about infant formula code in the province.

• Providing to become Baby-Friendly facility for at least 40% primaryhealth care facilities in the province.

• Operating at least 3 activities to disseminate breastfeeding and raiseawareness in the community.

Complementary Feeding

• This is a program for feeding babies at 6-24 months.

• The most common nutritional deficiencies being seen in this period.

• It includes nutritional recommendationsto families by trained health staff, according to baby's age, region and socio-economic status of the family.

• Family physicians and family health staff have been trained in 81 provinces.

• Remote training modules have beenprepared.

34

Mikronutrient Support

• “Turkey is as Iron” Program

– Iron supplementation for 4-12 months baby

• Programme coverage: %99

• Anemia prevelance in child: %6,3

• Prevention of Vitamin D Deficiency and Promotionof Bone Health Program

– Vitamine D supplementation for 0-12 months baby

• Programme coverage: %99

• Deficiency of vitamin D: %20

Infant and Child Mortality Evaluation• Phase 1: The determination of deaths.

• The collection of identified all deaths in the province at HealthDirectorate by the system.

• Reporting the all deaths Public Health Agency of Turkey

• Phase 2: Investigation of deaths• Each infant death have to be investigated (icluding still-birth)

• The basic cause, final cause and secondary causes have to be determined.

• The preventabilty of death in current circumstances have to be evaluated.

• Review Board Evaluation Form have to be filled.

• The Board have to determine the necessary precautions in the provinceand submit it Province Health Directorate.

– The forms and other documents have to be sent to Death Information System.

Child Mortality

Infant Mortality in Turkey Under 5 Mortality in Turkey3

1,5

29

26

21,4

16,5

16,4

14,8

13,1

10,1

9,8

9,5 10

,2

10,2

10,0

9,7

9,1

9,213

,9

12,1

10,2

7,8

7,8

7,3 7,7

7,5

7,6

7,3

6,8

6,8

0

5

10

15

20

25

30

35

200

2

200

3

200

4

200

5

200

6

200

7

200

8

200

9

201

0

201

1

201

2

201

3

201

4

201

5

201

6

201

7

201

8

tüm 28 hf ve üzeri

40

,0

37

,0

33

,4

28,6

23,5

20,0

16,8

14,1

11,7

11,3

11,0 12

,7

12,3

12,2

11,9

10,9

11,3

10,3

9,6

9,7

9,4

8,6 8,9

0,0

5,0

10,0

15,0

20,0

25,0

30,0

35,0

40,0

45,0

200

2

200

3

200

4

200

5

200

6

200

7

200

8

200

9

201

0

201

1

201

2

201

3

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4

201

5

201

6

201

7

201

8

tüm 28 hf ve üzeri