maternal and child health interventions. introduction to maternal and child health; mch lecture...
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Maternal and Child Health Interventions
Maternal and Child Health Interventions
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 20122
Continuum of Care
Continuum of Care
Home and Community
First level Facility
Referral Facility
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 20123
Continua of CareGuiding principles for planning maternal and child health programmes
Continua of CareGuiding principles for planning maternal and child health programmes
Continuum across Life-stages (which interventions?)
Continuum across Health System (at which level?)
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 20124
Continuum of CareAcross Life-stages
Continuum of CareAcross Life-stages
Factors which help decide interventions across the life-cycle:– Causes and distribution of child deaths– Proven efficacy of interventions– Feasibility– Cost– Acceptability– Issues related to health services
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 20125
Most effective interventions require implementation at each level
Factors guiding levels at which interventions are implemented:
– Community acceptability and demand
– Availability of trained staff– Access to health services– Technical complexities– Equity issues
Balance between implementation at different levels is important
Continuum of CareAcross Health Systems
Continuum of CareAcross Health Systems
Home and Community
First level Facility
Referral Facility
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 20126
Example:
Interventions to improve Child Health
Example:
Interventions to improve Child Health
Home and Community
First-level facility
Referral Facility
Pregnancy
At birth
Newborn period
Infancy and Childhood
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 20127
Example:
Interventions to improve Child Health
Example:
Interventions to improve Child Health
Home and Community
First-level facility
Referral Facility
Pregnancy Promote & support antenatal care
Detection & management of complications of pregnancy
Management of severe complications
At birth Promote and support skilled care at birth
Immediate newborn care
Management of obstetric complications
Newborn period
Promote and support key newborn care practices
Management of newborn illnesses
Immunization
Management of severe newborn illnesses
Infancy and Childhood
Community case management of diarrhea & ARI
Standard case management during childhood illnesses
Management of severe childhood illnesses
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 20128
Packaging of InterventionsPackaging of Interventions
A way of integrating and combining health interventions– Essential for making programmes feasible as it reduces programme
costs and improves program effectiveness
Several Maternal and Child Health intervention packages already exist.
Sometimes, there might be need for adding a new package.
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 20129
Intervention PackagesSkilled obstetric and immediate newborn care including resuscitation
Emergency obstetric care to manage complications such as obstructed labour and hemorrhage
Antibiotics for preterm rupture of membranes#
Corticosteroids for preterm labour#
Emergency newborn care for illness, especially sepsis management and care of very low birth weight babies
Cli
nic
al
care
Folic acid #
Counseling and preparation for newborn care and breastfeeding, emergency preparedness
Healthy home care including breastfeeding promotion, hygienic cord/skin care, thermal care, promoting demand for quality care
Extra care of low birth weight babies
Case management for pneumonia
Fam
ily
-co
mm
un
ity
Clean home delivery
Simple early newborn care
15 - 32%
4-visit antenatal package including tetanus immunisation,detection & management of syphilis, other infections, pre-eclampsia, etc
Malaria intermittent presumptive therapy*
Detection and treatment of bacteriuria#
Ou
trea
ch
serv
ices
Postnatal care to support healthy practices
Early detection and referral of complications6 - 9%
23 - 50%NMR effect
InfancyNeonatal periodPre- pregnancy PregnancyBirth
Administering basic community-based intervention packages at full coverage can save ~ 37% of all newborn deaths!
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 201210
Packaging of InterventionsPackaging of Interventions
A way of integrating and combining health interventions– Essential for making programmes feasible as it reduces programme
costs and improves program effectiveness
Several Maternal and Child Health intervention packages already exist.
Sometimes, there might be need for adding a new package.
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 201211
Example:
Intervention package for maternal and child healthExample:
Intervention package for maternal and child health
ANC Care – TT vaccination, Anemia prophylaxis, Detection of complications, Counseling
Routine post-natal visits to mother and newborn - Exclusive breastfeeding, Thermal care, Hygienic cord care, Extra care of LBW infants, Prompt care-seeking for illness, Immunization, Management of newborn illness
IMNCI – Algorithm-based management of diarrhea, pneumonia, malaria, malnutrition and newborn illnesses, Promotion of ORS and Zinc
F-IMNCI – Management of inpatient children with severe illnesses
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 201212
Community based: •IMNCI, Management of diarrhea and ARI, IYCF, Immunization, IFA and Vitamin A, HBNC, MCTS and MCP Card.
Facility based: •Facility based new born care- FBNC (SNCU, NBSU, NBCC), F-IMNCI, NRC, JSSK.
Delivery strategies for the interventionsDelivery strategies for the interventions
Malnutrition34%
Causes of under-five deaths in India: 2010
Malnutrition34%
Causes of under-five deaths in India: 2010
Infections(sepsis / pneumonia, diarrhoea, tetanus)
Antibiotics for premature rupture of membranes
Syphilis screening & treatmentClean delivery practices
Hypothermia managementKangaroo mother care
BreastfeedingCommunity based pneumonia management
Tetanus toxoid immunization
Preterm / low birth weightDetection & treatment of asymptomatic
bacteriuriaSyphylis screening & treatment
(Pre) eclampsia preventionCorticosteroids for preterm labour
Hypothermia management - Kangaroo mother care
Skilled delivery practices
AsphyxiaInstitutional delivery
Skilled birth attendantUse of partograph for labour
surveillanceResuscitation of newborn
Malnutrition34%
Causes of under-five deaths in India: 2010Pneumonia:Breastfeeding counselling
Complementary feeding counsellingHib vaccination
AntibioticsEarly detection and management
Diarrhoea:Breastfeeding counselling
Complementary feeding counsellingVitamin A supplementationOral rehydration therapy
Zinc adjuvant therapyAntibiotics for dysentery
Measles:Measles vaccination
Complementary feeding counsellingVitamin A supplementation
Vitamin A therapy
Malnutrition:Breastfeeding counsellingComplementary feeding
counsellingVitamin A supplementation
Vitamin A therapyMeasles vaccination
Growth monitoring and promotionCommunity-based and Facility-
based management of malnutrition
Malaria and HIV:Insecticide treated netsAnti-malarial treatment
PPTCTComplementary feeding counselling
Vitamin A supplementationNiverapine and (replacement) feeding
Maternal and Child Health Interventions | RCH Program UG Class | 201216
Evidence-based interventions Child Health
Evidence-based interventions Child Health
Antenatal care 4%*
Skilled care at birth 13%*
Postnatal care: routine care for all newborns, additional care for LBW, treatment of neonatal sepsis
13%*
Exclusive breastfeeding 13%
Appropriate complementary feeding, including micronutrients
6%
Immunization 5%
Insecticide-treated bed nets 7%
ORT and zinc for diarrhoea 19%
Treatment of suspected pneumonia 6%
Treatment of malaria 5%
Maternal and Child Health Interventions | RCH Program UG Class | 201219
Summary: Child Health InterventionsPREGNANCY
Summary: Child Health InterventionsPREGNANCY
• Tetanus toxoid immunization
• Birth and emergency planning
• Detection and management of problems complicating pregnancy (e.g. hypertensive disorders, bleeding, mal-presentations, multiple pregnancies, anemia)
• Information and counseling on self-care, nutrition, breastfeeding, family planning
• Sleeping under an insecticide-treated bed net
• Prevention of mother-to-child transmission of HIV+
Maternal and Child Health Interventions | RCH Program UG Class | 201220
Summary: Child Health InterventionsLabor, birth and 1-2 hours after birth
Summary: Child Health InterventionsLabor, birth and 1-2 hours after birth
• Monitoring progress of labor, maternal and fetal well-being with partograph
• Social support (companion) during birth
• Immediate newborn care (resuscitation if required, thermal care, hygienic cord care, early initiation of breastfeeding)
• Emergency obstetric and newborn care for complications
• Antibiotics for preterm and/ or premature rupture of membranes*
• Antenatal corticosteroids for preterm labor
• Prevention of mother-to-child transmission of HIV+
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Summary: Child Health InterventionsNewborn period
(after the first 1-2 hours after birth up to 1 month)
Summary: Child Health InterventionsNewborn period
(after the first 1-2 hours after birth up to 1 month)
• Exclusive breastfeeding
• Thermal care
• Hygienic cord care
• Prompt care-seeking for illness
• Extra care of low-birth-weight (LBW) infants
• Immunization
• Management of newborn illness
• Prevention of mother-to-child transmission of HIV+
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Summary: Child Health InterventionsOlder infants and children
(1 month up to 5 years)
Summary: Child Health InterventionsOlder infants and children
(1 month up to 5 years)
Preventive Interventions
• Exclusive breastfeeding (up to age 6 months)
• Safe and appropriate complementary feeding starting at 6 months with continued breastfeeding (up to age 2 years and beyond)
• Prevention and management of malaria
• Immunization
• Vitamin A supplementation
• Hand washing and proper disposal of faeces
• Birth spacing of 24 months or more
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Treatment interventions
• Oral rehydration therapy for diarrhoea
• Zinc for diarrhoea
• Antibiotics for dysentery
• Antibiotics for pneumonia
• Antimalarials
• Management of severe malnutrition
• Management of HIV-exposed and HIV-infected children
Summary: Child Health InterventionsOlder infants and children
(1 month up to 5 years)
Summary: Child Health InterventionsOlder infants and children
(1 month up to 5 years)
Maternal and Child Health Interventions | RCH Program UG Class | 201224
Common causes of maternal deaths in India
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Common causes of maternal deaths in IndiaHemorrhageActive management of 3rd
stage of labour;Detect & Treat anaemia;Skilled attendant at birth
Referral transportBlood transfusion
Operative procedures
SepsisClean deliveryPost-natal care
Early detection and referralProper management at
facility
Hypertensive disordersANC Care
Early detection and referralProper management
Complications of abortionAccess to family planning
methods including emergency contraception
Use of medical methodsSafe abortion facility
Ensuring good quality of care
Obstructed laborNutrition of girl child
Detection of high risk pregnancy and institutional delivery
Use of partographSkilled care at birth
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Three Delays Model
Source: Operational Guidelines on Maternal and Newborn Health, NRHM, MoH & FW
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Summary: Maternal Health InterventionsPRE-PREGNANCY
Summary: Maternal Health InterventionsPRE-PREGNANCY
• Family Planning
• Folic acid fortification and/or supplementation to prevent Neural Tube Defects
• Prevention of mother-to-child transmission of HIV+
Maternal and Child Health Interventions | RCH Program UG Class | 201229
Summary: Maternal Health InterventionsPREGNANCY
Summary: Maternal Health InterventionsPREGNANCY
• Iron and Folic Acid Supplementation
• Tetanus toxoid immunization
• Birth and emergency planning
• Management of unintended pregnancy
• Detection and management of problems complicating pregnancy (e.g. hypertensive disorders, bleeding, mal-presentations, multiple pregnancies, anemia)
• Information and counseling on self-care, nutrition, breastfeeding, family planning
• Prevention and management of malaria
• Prevention of mother-to-child transmission of HIV+
Maternal and Child Health Interventions | RCH Program UG Class | 201230
Summary: Maternal Health InterventionsLabor, birth and 1-2 hours after birthSummary: Maternal Health InterventionsLabor, birth and 1-2 hours after birth
• Monitoring progress of labor, maternal and fetal well-being with partograph
• Social support (companion) during birth
• Prophylactic uterotonic and Active management of third stage of labor to prevent postpartum hemorrhage
• Emergency obstetric care for complications
• Management of Post-partum hemorrhage
• Induction of labor for prolonged pregnancy
• Caesarean section for maternal/foetal indication
• Antibiotics for preterm and/ or premature rupture of membranes
Maternal and Child Health Interventions | RCH Program UG Class | 201231
Summary: Maternal Health InterventionsPost-partum period
(after the first 1-2 hours after birth up to 6 weeks)
Summary: Maternal Health InterventionsPost-partum period
(after the first 1-2 hours after birth up to 6 weeks)
Advice and provision of family planning
Prevent, measure and treat maternal anemia
Detection and management of postpartum sepsis
Prevention of mother-to-child transmission of HIV+
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Obstetric CareObstetric Care
Essential Obstetric Care
Emergency Obstetric Care
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Current Approach to Reduction of Maternal Mortality
Maternal Mortality ReductionSri Lanka 1940–1985
Maternal Mortality ReductionSri Lanka 1940–1985
0
200
400
600
800
1000
1200
1400
1600
1800
1940–45 1950–55 1960–65 1970–75 1980–85Ma
tern
al
De
ath
s p
er
10
0 0
00
liv
eb
irth
s
85% births attended by trained personnel
Maternal and Child Health Interventions | RCH Program UG Class | 201234
Maternal Mortality: UK 1840–1960Maternal Mortality: UK 1840–1960
050
100150200250300350400450500
MaternalDeaths
Improvements in nutrition, sanitation
Antibiotics, banked blood, surgical improvements
Antenatal care
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How can maternal deaths be prevented?How can maternal deaths be prevented?
Skilled birth attendance
Prompt referral to an appropriately equipped facility if complications arise
24×7 hours availability of expert services – a team of specialists to perform surgery
Well equipped hospital with operation theatre and blood transfusion services
Keep the woman in the facility for at least 48 hours after delivery
The facilities should be accessible within a radius of 35 km
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Packages of interventions in different time frames related to pregnancy
Packages of interventions in different time frames related to pregnancy
Focused antenatal Care (delivered through outpatient or outreach service)
o Minimum four ANC check upso At least 1 ANC by Medical Officer, (preferably 3rd)o Timing of visits –– 1st: within 12 weeks/ preferably as soon as pregnancy
is suspected– 2nd: between 14 – 26 weeks– 3rd: between 28 – 34 weeks– 4th: between 36 weeks and term
Maternal and Child Health Interventions | RCH Program UG Class | 201237
Packages of interventions in different time frames related to pregnancy
Packages of interventions in different time frames related to pregnancy
Focused antenatal Care (delivered through outpatient or outreach service)
o Early registrationo Two doses of injection Tetanus Toxoido All pregnant women – 100 tabs IFA (200 for anemic)o Screening for treatment of disorderso Provision of preventive interventionso Counseling – diet, hygiene, HIV status, birth,
emergency preparedness, care and feeding of babies
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Packages of interventions in different time frames related to pregnancy
Packages of interventions in different time frames related to pregnancy
Intranatal care (facility based clinical care package)
o Promotion of institutional deliveries
o Skilled attendance for normal child birth, eg, monitoring labor progress by partograph
o Emergency obstetric care (basic & comprehensive) for complicated cases
o Effective referral system
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Packages of interventions in different time frames related to pregnancy
Packages of interventions in different time frames related to pregnancy
Postnatal care (Institutional in the first 48 hours and thereafter delivered through outpatient or outreach service for a 42 day period)
o Prevention and detection of complications
o Information and counseling on self-care at home, nutrition, family welfare, breast feeding
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Skilled Birth AttendantSkilled Birth Attendant
An accredited health professional (eg, midwife, doctor or nurse)
Educated and trained to proficiency in the skills needed to manage –
o Normal (uncomplicated) pregnancies
o Childbirth
o Immediate postnatal period
Helps in identification, management and referral of complications in women and newborns