B5124
B5124
Preconception care
Report of a regional expert group consultation
6–8 August 2013, New Delhi, India
© World Health Organization 2014
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Printed in India
Contents
Acronyms v
1. Introduction 1
3. Proceedings 6
References 55
Annexes
4. Programme 78
1
Introduction
Sexual and reproductive health is fundamental for individuals, couples and
families, as well as for the social and economic development of communities
and nations. Everyone has the right to enjoy reproductive health, which is the
basis for having healthy children, a healthy reproductive life and happy families.
Women living in low- and middle-income countries suffer excessively from
unintended pregnancies; maternal death and disability; sexually transmitted
infections (STIs), including HIV; gender-based violence; and other problems
related to their reproductive system and their partners’ sexual behaviour.
Young people often face barriers in trying to get the information and care
they need, which places adolescent reproductive health as another issue
that needs attention. According to the World Health Organization (WHO)
publication, “A framework for implementing the reproductive health strategy
in the South-East Asia Region” (1), the critical importance of reproductive
health to development has been acknowledged at the highest level, with the
commitment to achieve universal access to reproductive health by 2015. This
is the culmination of more than a decade of advocacy since the consensus
and Programme of Action of the International Conference on Population and
Development held in Cairo in 1994 (2).
However, there has been increasing recognition that a gap exists in this
continuum of care. A growing body of evidence is showing that preconception
care could reduce this gap in the continnum of care, by increasing the
health and well-being of women and couples, and improving the subsequent
pregnancy and child-health outcomes. However, until now, preconception
care and counselling have largely been provided through two avenues. In
high-income countries, couples planning a pregnancy meet with a health-care
professional to identify biomedical risks, whereas in low- and middle-income
countries, community groups educate women about pregnancy and birth
preparedness. Importantly, interventions in both settings have the potential
Meeting participants
The meeting brought together numerous stakeholders: experts from the groups
who have led reviews and research on preconception care – The Centers for
Disease Control and Prevention (CDC), United States of America (USA), the
March of Dimes Foundation (MoD), United Nations agencies (UNICEF and UNFPA,
and WHO); programme managers from ministries of health of selected Member
States; partners such as the Bill and Melinda Gates Foundation, FHI 360, the
International Association of Adolescent Health, the International Paediatric
Association, the International Planned Parenthood Federation (IPPF), JHPIEGO,
PATH, NGOs, and the United States Agency for International Development
(USAID); experts from institutions of excellence, WHO collaborating centres
and academic institutes in the Region.
3 Proceedings
Dr Neena Raina, Regional Adviser, Child and Adolescent Health, WHO Regional
Office for South-East Asia, New Delhi, India, welcomed the experts attending
the meeting and expressed confidence that the deliberations would achieve
the objective of developing a consensus and way forward for preconception
care. The aim should be for all women in their reproductive years, and their
partners, to receive preconception care at any contact with a health-care
provider, regardless of pregnancy status or desire, and to involve communities
and policy-makers so that demand for and provision of preconception care is
universal. She thanked the Department of Paediatrics, AIIMS for organizing
the meeting.
It was mentioned that most of the risk factors like tobacco use and substance
misuse are initiated in the age group of 11–15 years. The median age for the
onset of mental disorders like anxiety and impulse control disorders is also in
this age range, and 75% of mental disorders are already present before 24
years of age. The ongoing interventions in most countries of the South-East
Asia Region are made available during pregnancy, childbirth, postnatal period
(for newborns and mother) and during infancy and child health across the
life-course continuum as shown in Figure 1.
Figure 2. Pre-conception care completes the coverage across the life course
Additional benefits
In addition, the following benefits are also expected:
ρρ social and economic benefits for families and communities;
ρρ participation by men in women’s health and improvement in their own
health, irrespective of immediate plans to become parent(s); and
ρρ controlling exposure to environmental risk factors in early life and their
long-term effect (for example, eliminating smoking before or during
pregnancy could avoid 5–7% of preterm-related deaths and 23–24% of
cases of sudden infant death syndrome).
It was also mentioned that the WHO Regional Office for South-East Asia
is the first region to conduct a consultative meeting on preconception care as
per the plan made at the global meeting in Geneva in 2012 (4).
Figure 3: Major risk factors affecting maternal and child health outcomes
Mental
health
Human
Nutritional Infertility/ immuno-
conditions subfertility deficiency
Too early,
unwanted and virus (HIV)
Genetic Psychoactive
rapid
conditions substance
successive
Vaccine Female pregnancies use
preventable genital Interpersonal
diseases mutilation violence
Sexually
Environmental transmitted Tobacco use
Health infections
The process followed in the global meeting was explained by citing the
example of the nutrition issues that focus on the three areas described in Table 1.
Health problems/problem
behaviours/risk factors
Evidence-based preven- Existing delivery mecha-
that could be addressed
tive and curative health nisms that could be used
through promotional,
interventions that could to deliver interventions at
preventive and curative
be delivered in pre-preg- scale in low- and middle-
health interventions in
nancy/inter-pregnancy income countries
pre-pregnancy/inter-
pregnancy
Consequences of folic acid Iron and folic acid supple- Food fortification (e.g. pro-
deficiency mentation motion of national policies,
use of in-home micronutri-
ent powders containing
folic acid); folic acid supple-
mentation (higher dose for
women with previously af-
fected pregnancies); public-
awareness campaigns (with
physicians recommending
use); primary care
Consequences of anaemia Iron and folic acid supple- Food fortification (e.g. pro-
and iron deficiency mentations; screening for motion of national policies,
anaemia use of in-home micronutri-
ent powders containing
iron); primary care
Underweight Micronutrient education Community-based educa-
(counselling about risks tion; primary care; com-
to own health and future munity-based food supple-
pregnancies); nutritional mentation; dietary diversity
monitoring; provision of programmes
energy- and nutrient-dense
supplementary foods; inter-
ventions to improve food
security
4 5 6 7 8 9 10 11 12
Central Nervous System
Early prenatal
care is not Heart
enough, and in Arms
many cases it is
Eyes
too late!
Legs
Teeth
Palate
External Genitalia
Ears
To address these issues, CDC has partnered with the US Office of the
Assistant Secretary of Health, to further reduce teenage pregnancy and address
social disparities in teenage pregnancy and birth rates. CDC works with state
and local public health agencies, to monitor preconception health and health
care in the USA.
She informed participants that states in the USA have identified 45 specific
indicators in 11 domains as core state indicators and CDC supports data systems
that can be used for monitoring, such as the Pregnancy Risk Assessment
Monitoring System (PRAMS).
Though there has been growing global interest in preconception care in the
past three years, the interventions are being conducted only in middle- and
high-income countries with preconception care components. However, most
of the interventions are not methodologically robust and lack quality or
convincing outcome data, with the notable exception of folic acid fortification/
supplementation. In low-income countries, there is no preconception care
component in existing programmes. Preconception care has not been widely
implemented because its aims and objectives are not widely understood and
accepted. The potential benefit of preconception care thus remains largely
unrealized. It needs collaborative, multi-country studies, systematic reviews,
and economic data on benefits and the impact of preconception care.
The mHealth programme in Lebanon for the age group of 18–25 years,
aims to evaluate the impact of a mobile-technology-based preconception health
education programme to improve the health knowledge and behaviour of
It was also suggested that March of Dimes Foundation, the WHO Regional
Office for South-East Asia and other partners can take the following steps
together in a preconception care initiative:
ρρ agree to provide health education to girls and young women (and boys
and young men) in targeted measurable ways;
ρρ partner in refining a needs assessment tool;
ρρ incorporate novel methods for reaching and engaging target populations;
ρρ incorporate economic analyses;
ρρ partner with civil society, academic institutions, media and government
in supporting this effort;
ρρ publish findings on an ongoing basis in peer-reviewed literature.
Health, education, media and other sectors were identified as the major
stakeholders to contribute to adolescent health and development. The health
sector is mainly responsible for the provision of health and counselling services.
In contrast, the education sector should be responsible for building life skills,
and the media should contribute to acquisition of appropriate knowledge.
The responsibility of providing a safe and supportive environment is shared by
families, schools and society at large.
Participants were also briefed on progress made by the Regional Office for
South-East Asia in the area of prevention of birth defects. The initiative began
with an expert group meeting on prevention of birth defects in November
2011, followed by a regional programme managers’ meeting on birth defects
March 2012, followed by a series of dissemination meetings, namely a birth
defects surveillance meeting in April 2012, a regional situation analysis on
birth defects, a regional strategy for prevention of birth defects, a regional
network meeting on strengthening neonatal health and birth defects in April
2013, and the most recent regional workshop on birth defect surveillance,
15–18 July 2013.
Adolescent-friendly
Adolescent-friendly
health services
health services
Education and
Newborn care
Immunization
development
development
Child health,
care at birth
Early child
Preconception care
Preconception care in the WHO South-East Asia Region: pre- and inter-
pregnancy care
Dr Arvind Mathur, WHO Regional Office for South-East Asia, New Delhi, India
Worldwide, the maternal mortality ratio (MMR) declined from 400 per 100 000
births in 1990 to 260 per 100 000 births in 2008, a 34% decline over this
period, with an annual change of 2–3%. This decline reflects a decrease in
maternal deaths from 546 000 in 1990 to 348 000 in 2008. Across all WHO
regions, MMR has declined since 1990, but by less than the 75% reduction
called for by MDG 5. The greatest decline in MMR of 59% occurred in the WHO
South-East Asia and African regions. In the WHO African Region, it declined
from 850 per 100 000 births in 1990 to 620 per 100 000 births in 2008, a
27% decline in MMR with an annual change of 1.7%.
IND
56 000 (73%)
BAN: Bangladesh; BHU: Bhutan; DPRK: Democratic People’s Republic of Korea; IND: India; INO: Indonesia;
MAV: Maldives; MMR: Myanmar; NEP: Nepal; SRL: Sri Lanka; TLS: Timor-Leste; THA: Thailand.
245
219
189 170
141 143138 132 143
101 97
84 73
65
46
It was mentioned that the effect of longer birth intervals is to reduce the
risk of child death, fetal death, fetuses that are small for gestational age, low
birth weight and preterm birth and subsequent stunting and underweight in
childhood. Not only does appropriate birth spacing affect the child’s health
positively, but it also affects the mother’s health by lowering the risks of
maternal death, puerperal endometritis, premature rupture of membranes,
third-trimester bleeding and anaemia (which is prevalent in almost 48% of
pregnant women and 36% of non-pregnant women in countries of the WHO
South-East Asia Region). He further stated that it is very important to train
both health providers and the community regarding preconception care, as
in most countries the first antenatal check-up happens in the third month of
pregnancy, by which time the neural tube has already closed (by day 28 of
gestation) – before many women realize they are pregnant.
It was stated that many of the pre-conception care interventions are currently
available to adolescents and women, as well as to couples. However, they are
not systematically delivered as a defined service package for preconception care
in the WHO South-East Asia Region. The highlights of the existing interventions
were described as below.
The participants were informed that abortion is legal in all countries of the
Region, though each of these countries allows abortion on different grounds.
Some countries allow abortion in cases of rape, incest or fetal impairment
or on other grounds. Some restrict abortion by requiring parental or spousal
authorization. Countries that allow abortion on socioeconomic grounds, or
without restriction as to reason, have gestational age limits (generally the first
trimester); abortions may be permissible after the specified gestational age,
but only on prescribed grounds.
Work in the area of infertility has been initiated by the WHO Regional
Office for South-East Asia, with four WHO collaborating centres in India, where
research has been conducted to assess the capacity of the public health system.
Following this, guidelines have been developed on prevention and management
of infertility, focusing on the level of primary health care.
Immunization
As per the WHO Regional Office for South-East Asia initiative to intensify
immunization efforts (11), pentavalent vaccine (DTP [diphtheria, tetanus,
pertussis] + hepatitis +Hib [Haemophilus influenzae type B]) has been introduced
in Bangladesh, Bhutan, Nepal, Sri Lanka and in eight states in India in the last
two years. The vaccines relevant for pre-conception programmes include the
following.
ρρ Rubella vaccination has been introduced in Bangladesh, Bhutan, India
(some states), Maldives, Nepal, Sri Lanka and Thailand in their national
Expanded Programme on Immunization (EPI).
ρρ HPV vaccination is included in two countries, namely Bhutan and Nepal. In
Bhutan, it is included in the national immunization programme. In Nepal,
an HPV vaccination programme is implemented by the Australian Cervical
Cancer Foundation with support from government and nongovernment
organizations, though at present it is not part of the national immunization
programme. Other countries of the Region have not included HPV as
part of their immunization programme, owing to the high cost of the
vaccination. However, pilot studies to include HPV vaccine are ongoing
in these countries.
Nutrition
Most countries of the South-East Asia Region have functional large-scale nutrition
programmes that focus on maternal and child undernutrition.
Maternal health
Almost all the countries of the Region are implementing the standard
components in their maternal and child health programme: antenatal care that
includes screening for anaemia and STI/HIV; PMTCT; skilled care at birth; and
postpartum care. The scale of implementation of these interventions varies
among and within countries.
Genetic services
Genetic services and counselling are available in many institutions in major
cities in most countries of the Region. Screening for genetic conditions is
available in selected institutions in some cities of the countries. Pre-marital and
pre-conception counselling is offered in a limited manner.
Noncommunicable disease
All countries except the Democratic People’s Republic of Korea and Timor-
Leste have initiated national programmes for prevention and management of
noncommunicable diseases. Prevention programmes could be effectively offered
during adolescence, by promoting health behaviours and lifestyles through a
preconception care package.
Mental health
India, Maldives and Nepal have national mental health programmes. Bhutan,
Indonesia and Thailand have community-based mental health programmes.
Bangladesh, Sri Lanka and Timor-Leste each have a mental health policy
and strategy. Mental health promotion could be an essential element in
Tobacco control
The tobacco burden in the South-East Asia Region is one of the highest among
WHO regions. The widespread use of many forms of tobacco, including smokeless
tobacco, complicates efforts to implement effective tobacco-control initiatives.
Nevertheless each country in the Region has taken important steps to combat
the tobacco epidemic. Ten out of 11 countries of the Region have ratified
the WHO Framework Convention on Tobacco Control. Although Indonesia is
not yet a party to the Convention, it has recently undertaken initiatives at the
subnational level. Services for prevention of tobacco use should be offered
to adolescents before they initiate tobacco use. Cessation programmes are
essential for the periconceptional period and pregnancy.
Number of
Geographic
public health Outreach
coverage of Other sites for
services services
implementation adolescent-
Country implementing through
of adolescent- friendly health
adolescent- public health
friendly health services
friendly health system
services
services
Bangladesh 40/60 districts 100% No NGO
NGO and
India All 35 states No data Yes
private clinics
Youth health
Maldives 2/20 atolls 2 hospitals No
café NGO
National
Myanmar 18/75 townships 100% No
organization
National
Nepal 10/75 districts 20% No
organization
Marie Stopes
Timor-Leste 2010 Data not available No
Clinic (Dili)
The current service package in most Member States comprises antenatal care,
childbirth care, abortion services, HIV counselling and testing, STI treatment,
PMTCT, contraceptive services (where legal), emergency contraception, control
of anaemia, and counselling for psychosocial issues. There have been increasing
examples of collaboration between health and other sectors.
Sri Lanka
Dr Nethanjalie Mapitigama, Family Health Bureau, Ministry of Health,
Colombo, Sri Lanka
With a well-established and well-staffed health system, Sri Lanka has been ahead
of many countries in the South-East Asia Region with respect to maternal and
child health indicators. However, it was observed that the rate of progress for
these indicators remained stagnant in the last few decades, where 72–75%
of maternal deaths were still preventable. In November 2011, the Ministry of
Health launched a new package focusing on newly married couples. The main
objectives of this initiative were:
Delivery channel
This package would be delivered by the medical officer of the health team.The
services provided under the package are risk screening, physical assessment,
vaccinations, raising awareness, counselling and provision of other services.
The tools used in the package are:
ρρ invitation card: congratulating the couple, to wish them a happy married
life and fixing an appointment with a trained health worker to discuss
reproductive health;
ρρ screening tool: to screen both partners for risk factors, including selected
past and present medical conditions and use of medications, family
history, sexual and reproductive health, family nutrition and lifestyle,
environmental conditions, psychosocial concerns (depression/violence)
and rubella vaccination and folic acid supplementation (see Figure 9);
ρρ guide book for health workers: includes guidelines to screen for risk
factors by using the screening tool and clinical examination by trained
health workers (PHM – public health midwife), basic investigations,
measurement of body mass index, and referral for further diagnosis/
treatment/for specialized care and follow up.
ρρ book for the new couples: during the home visit, the PHM hands over
a book to raise awareness among couples on topics including sexuality
and sexual relationship, sexually transmitted diseases and responsible
sexual behaviour, a planned family, good nutrition, good health habits/
healthy behaviour/healthy lifestyle, good marital relationship and well-
being of the family, benefits of nonviolence, health before conception,
male participation and parenthood, and tobacco and alcohol.
Screening tool
Screen both husband and wife for risk factors:
ρρ Selected past and present medical conditions,
medications and family history
ρρ Sexual and reproductive health
ρρ Family nutrition, lifestyle
ρρ Environmental conditions
ρρ Psychosocial concerns (depression/violence)
ρρ Rubella vaccine/folic acid
ρρ Physical assessment, height, weight
ρρ Clinical examination
ρρ Basic investigations
ρρ Referral for further diagnosis/treatment/for specialized care
Area of improvement
Though this package provides a broad range of preventive services (covering
preconception care components), it is restricted to married couples and does
not include adolescents. Sri Lanka has a high prevalence of thalassaemia and
yet the screening tool in this package does not include thalassaemia screening.
The project covered adolescents in grades 6 and 8, aged 10–16 years; with
a two-year intervention. The programme components consisted of:
ρρ classroom curriculum: to increase knowledge about the health and
social consequences of tobacco use and increase skill to identify and
resist influences to use tobacco;
ρρ school posters and parents’ post card: to provide opportunities to
learn about school and community policies on tobacco; and
ρρ peer-led health activism: to create tobacco-free norms in school, the
home and surrounding neighbourhoods, and to increase exposure to
non-tobacco-using role models.
Trend in current tobacco use among girls Trend in Intention to smoke among 10-14
year old youth
2.5 9
2.38 8.41
8
2 7
1.76 6.24
6
Prevalence
Prevalence
1.5
5
1.14 4 4.07
1
3
0.76 0.83
0.5 0.69 2 2.14
1 1.69
1.24
0 0
Baseline Intermediate Endline Baseline Intermediate Endline
Knowledge to policy
ρρ Evaluation of project MYTRI showed an increased sensitization and
acceptance by schools of the need for lifestyle-related health intervention
for adolescents, and inculcating healthy lifestyle practices among Indian
youth.
ρρ The project provided robust research evidence and has been used
effectively by HRIDAY, to advocate with policy-makers for scaling up the
Government of India’s tobacco-control efforts. As a result, school health
programmes form a key component of the National Tobacco Control
Programme.
Figure 11. The programme to use key informants to identify birth defects and
childhood disability
ANM: Auxilliary nurse midwife ; AWW: Anganwadi workers; KI: key informant;
Discussions
The session ended with a strong sense that preconception care would be a
useful adjunct to providing the continuum of care across the RMNCAH life
course and it would be important to include adolescents and young adults.
There was an agreement that this is just as relevant for low- and middle-
income countries as it is for high-income countries. The participants largely
agreed to the range of issues that it could address to ensure overall health of
men and women through their life. However, it was strongly felt that it was
important to use an appropriate term for programmes to ensure acceptability
at community level and policy- and decision-making levels. It was clear from the
presentations that the programme must include both adolescents and young
adults. The service package and delivery channels of such a programme must
be designed to suit the needs of the target groups.
A strong focus on preconception care could run the risk of defining girls
as being in perpetual preconception state, even before their menarche, and
viewing a woman as somebody who delivers and raises children for the
entire duration of her fertile period. This could lead to women being barred
from participating in some situations or taking up work in some areas, on the
grounds that it would increase the risk of adverse maternal and child health
outcomes. Further, in relation to predisposing factors such as tobacco and
alcohol, it could lead to moral policing, particularly for girls, stigmatizing them
for their conduct, such as for smoking or drinking alcohol.
Basic package
ρρ Family planning (more than just contraception)
ρρ Vaccine-preventable diseases
ρρ Nutrition and micronutrients (including food and micronutrient supplementation,
food fortification, nutrition education)
ρρ Tobacco cessation (including exposure to second-hand smoke)
ρρ Reducing harmful environmental exposures (e.g. indoor air pollution)
ρρ Improving sexual health and behaviour (screening, counselling, treatment)
Efforts must also be made to work with other sectors such as schools and
workplaces, and with civil society groups such as faith-based organizations.
Conclusion
The health, economic and social benefits of preconception care need to be
communicated effectively to decision-makers at the international level, whose
support is crucial for global and regional action and research, as well as to
decision-makers at the country level, whose support is critical to incorporating
preconception care into existing programmes. Beyond that, the community
must be educated about preconception care, and informed about ways to
avail these services.
Actions are needed on at least three fronts. First, policy-makers and funding
agencies must be convinced that there is a need to include preconception
care – “healthy transitions for adolescents” and “pre-pregnancy” packages in
the existing national effort to prevent maternal and childhood mortality and
morbidity; that such packages can be delivered successfully; that its delivery
will lead to improved functioning of related social sector programmes; and
that, as a whole, it will bring tangible health outcomes and other benefits.
4 Conclusions and
recommendations
These studies may require desk review, pilot studies and exploratory studies.
The process needs to be carried forward to suit individual countries according to
their context. The situation and the environment in Member States is different,
and it also differs in different population groups within countries The profile of
intervention packages chosen would depend on the epidemiological situation/
disease burden and disease profile, as well as the national policy.
Recommendations
ρρ consolidate the experience in the Member States and undertake a situation
analysis, elaborate on successes and lessons learnt, and publish and
disseminate the experiences to expand the efforts;
ρρ document pregnancy wastage, birth defects, preterm births and intrauterine
growth retardation and maternal risk factors;
ρρ expand and elaborate the intervention packages, delivery channels,
stakeholders, and implementation mechanisms in preconception care in the
country situation;
ρρ optimize established programmes, such as maternal, reproductive, child health
and adolescent health programmes, and existing “entry points”, such as birth
defects surveillance, prevention of adolescent pregnancy, and prevention of
noncommunicable diseases.
ρρ develop and sustain partnerships within the health sector and other key
stakeholders (multisectoral), including adolescents and young people to
provide support to preconception care programmes.
ρρ support demonstration/pilots that are rigorously implemented with cost-
effectiveness built into them, in order to make a stronger case for healthy
transitions for healthier families.
ρρ organize meetings of health programme managers, officials from health
and non-health sectors, including partners to advocate and promote
national policies, plans, and strategies for implementing preconception care
programmes.
Table 1: Health problems, problem behaviours and risk factors related to tobacco
use that contribute to maternal and childhood mortality and morbidity
Table 12: Health problems, problem behaviours and risk factors related
to environmental factors that contribute to maternal and
childhood mortality and morbidity
Intervention area Target group Health-sector Hospitals and Outreach Community and Other sectors
policy health facilities families as partners
Preventing initia- Children, adoles- Ban on advertising, Health-education Community-based Media, schools,
tion of tobacco use cents and young high taxation, age messages during organizations workplace and
68
communication
Screening for to- Yes Yes Schools and
bacco use workplace
Intervention area Target group Health-sector Hospitals and Outreach Community and Other sectors
policy health facilities families as partners
Preventing initia- Children, adoles- Ban on advertising, Health-education Community-based Media, schools,
tion of alcohol use cents and young high taxation, age messages during organizations workplace and
through communi- people below which it is outreach law enforce-
cation not allowed, statu- ment
tory warning
Screening for alco- Yes Yes Schools and
hol use workplace
69
zations, e.g.
Alcoholics
Anonymous
Intervention area Target group Health-sector Hospitals and Outreach Community and Other sectors as
policy health facilities families partners
70
centres, reproduc-
tive tract infection/
sexually trans-
mitted infection
centres
Intervention area Target group Health-sector Hospitals and Outreach Community and Other sectors
policy health facilities families as partners
Promotion – con- Community and Laws for pre- Awareness Raise awareness Media, schools,
sanguinity, age at family venting consan- raising on consanguinity workplace, law
pregnancy guinity and promote timely enforcement
childbearing
Prevention – folic acid Adolescents, Policy guideline Yes, especially Distribution Schools and
newly-wed for folic acid adolescent clin- workplace
couples, and distribution ics, family plan-
inter-pregnancy ning clinics
71
genetic disorders couples, and past history), high risk and and through
inter-pregnancy laboratory tests referral education
for prevalent sector and
disorders, e.g. workplace
thalassaemia
and prenatal
testing for spe-
cific disorders
Management Those diagnosed Management Specific man- Care and sup- Care and support
with genetic guidelines agement and port, community
disorders counselling rehabilitation
Intervention area Target group Policy and law Hospitals and Outreach Community and Other sectors
health facilities families as partners
72
referral of depression, awareness of
stress and anger, common symp-
suicidal ten- toms
dency, psychiatric
disorders
Prevention Target group af- Standard guide- Psychiatric Community- Family-based sup- Prevent stigmati-
fected by mental lines, service-de- treatment and based rehabilita- port and care zation of those
health problems livery system to counselling tion and support affected
support mental
health
Management High-risk individu- Management Provision of ser- Community- Community-based
als or those who guidelines vices in tertiary based care and care and support
are diagnosed care hospitals support
with mental health
disorder
Annex 3
Defining delivery channels for the identified
packages of pre-conception care
Table 1: Nutrition
Table 5: HIV/AIDS