Maternal & Child Health-II

Dr. Aliya JunaidCommunity Medicine Dept.

Army Medical College

Contents

• Reproductive Health & its Components• Safe motherhood & its Components• Maternal Mortality Rate, causes &

prevention• Infant Mortality Rate, causes &

prevention• MCH Center• Child Care- IMCI

Reproductive Health

Reproductive Health

• Reproductive health is a state of complete physical, mental and social well-being, and not merely the absence of reproductive disease or infirmity.

Safe Motherhood

Safe Motherhood

• The ability of a mother to have Safe & Healthy pregnancy & Child Birth.

Safe Motherhood Components

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SAFE MOTHERHOOD

EQUITY FOR WOMEN

PRIMARY HEALTH CARE

BASIC MATERNITY CARE

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Health policy 1997

Maternal Mortality

Maternal Mortality

It is the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of duration and site of pregnancy from any cause related or aggravated by the pregnancy or its management and NOT due to any accidental or incidental cause.

Causes of Maternal Mortality

Causes of Maternal Mortality

• Hemorrhage • Septicemia• Toxemia( Eclampsia) of pregnancy• Abortions • Abnormalities of bony pelvis• Ectopic Pregnancy• Disproportion or mal-position of

fetus• Improper management• Poor technique in natal & postnatal

periods.

Prevention of Maternal Mortality

Prevention of Maternal Mortality

a. Pre - conception Guidance

b. Ante-natal Care c. Natal Cared. Post-natal care

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Routine antenatal care

Routine antenatal care

• History• Physical Examination i.e. Height, weight blood

pressure pulse, abdominal etc• Investigation i.e. complete Blood Picture, Urine

R/E, Blood group and Rh Factor, Random Blood Sugar, Ultrasound

• Prescribe Medications i.e. iron , folic acid, calcium

• Counseling i.e. nutrition, avoiding drugs, radiation, rest,

• Immunization • Reschedule Next visit

Schedule of Tetanus Toxoid (WHO) for Child bearing Age

(15-44 yrs)

TT1:TT1: During child bearing ageDuring child bearing age TT2:TT2: Four weeks after TT1Four weeks after TT1 TT3:TT3: Six months after TT2Six months after TT2 TT4:TT4: One year after TT3One year after TT3 TT5:TT5: One year after TT4 or One year after TT4 or

during next during next

pregnancy pregnancy

Schedule of Tetanus Toxoid for Pregnant

Women

1. TT1 – 7 months2. TT2 – 1 month after TT13. TT3 - 6 Months after TT24. TT4 - 1 Year after TT35. TT5 – 1 Year after TT4

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INFANT MORTALITY

• Childhood division into age-periods:

1. Infancy ( up to 1 year of age)a. Neonatal period (first 28 days of

life)b. Post neonatal period (28th day- to

1 yr)2. Pre-school age (1-4 years)3. School age (5-14 years)

Infant Mortality

Infant Mortality

• Death of the child under 1 year of age

Infant Mortality Rate

Infant Mortality Rate

• It is the ratio of infant deaths registered in a given year to the total number of live births registered in the same year ( usually expressed as a rate per thousand live births.)

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Infant Mortality Rate

Number of deaths of children less than 1 year of age in a year

Number of live births in the same year IMR= X 1000

Mortality In & Around Infancy

Still Birth

Still Birth

• Death of a fetus weighing 1000 g or equivalent to 28 weeks of gestation.

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Still Birth Rate

Fetal deaths weighing over 1000 g at Birth during the year

SBR = x 1000Total live + Stillbirths over 1000 g at

Birth during the year

Peri-natal Mortality Rate

Peri-natal Mortality Rate

• Includes both late fetal deaths (Still birth) and early neonatal deaths.

• Is defined as lasting from 28th week of gestation to the seventh day after birth.

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Peri- Natal Mortality Rate

Late fetal deaths (28 wks gestation & more) + early neonatal deaths (first week) in one year

PNMR = X 1000Late fetal deaths + Live Births In The Same Year

Neonatal Mortality Rate

Neonatal Mortality Rate

• These are deaths occurring during the neonatal period, commencing at birth and ending 28 completed days after birth. 1. Early neonatal death2. Late neonatal death

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Neonatal Mortality Rate

Number of deaths of children under 28 days of age in a year

NMR = x 1000Total live births in the same year

Early Neonatal Mortality Rate

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Early Neonatal Mortality Rate

Number of deaths of children <1 wk of age in a year

ENMR = x 1000

Total live births in the same year

Late Neonatal Mortality Rate

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Late Neonatal Mortality Rate

Number of deaths of children after 7th day till 28th day of age in a year

LNMR = x 1000

Total live births in the same year

Post- Neonatal Mortality Rate

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Post Neonatal Mortality Rate

Total number of deaths of children between 28 days and one year of age in a given year

PNMR = x 1000

Total live births in the same year

1 - 4 year Mortality Rate (Child Death Rate)

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1 - 4 year Mortality Rate (Child Death Rate)

No of deaths of children aged 1-4 years during a year

Child DR= X 1000Total no. of children aged 1-4 years

at the middle of the year

• Mid-year estimated population means population counted on the 1st of July

Under 5 Mortality Rate/ Child Mortality Rate

Under 5 Mortality Rate/ Child Mortality Rate

Number of deaths of < 5 years of age in a given year

U5MR = x 1000

Total number of live births in the same year

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Child Survival Index

1000 – under 5 mortality rate

CSR= 10

A child survival rate per 1000 births can be simply calculated by subtracting the Under -5 mortality rate from 1000. Dividing this figure by ten shows the percentage of those who survive to the age of 5 years.

= U5MR of Pakistan in 2003 = 107/1000 live births = 1000 – 107/10 = 89.3 %

Ref: Unicef

• Child Survival Index points towards the need for preventive services through:

1. Breast feeding2. Adequate nutrition3. Clean water4. Immunization5. Oral Rehydration Therapy6. Birth spacing

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Predisposing Factors of Infant Mortality

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1. Biological Factors Birth weight, Age of the mother,

Birth order, Birth spacing, Multiple births, Family size, High Fertility.

2. Economic Factors Low socioeconomic factors, quality

& availability of health care3. Cultural & Social Factors

Breast feeding, Early marriage, maternal education etc

Predisposing Factors of Infant Mortality

Infant Mortality Causes

Infant Mortality Causes

Neonatal Mortality (0-4wks)

• Low Birth weight• Prematurity• Birth injury/difficult

labour• Sepsis• Congenital anomalies• Hemolytic disease • Placenta/cord

conditions• Diarrheal disease• Acute resp. diseases

Post-neonatal Mortality (1-12 months)

• Diarrheal disease• Acute resp. diseases• Communicable

disease• Malnutrition• Congenital

anomalies• Accidents

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Multiple Causation Web Model For Infant Mortality

POOR OBS CARE

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Economic Loss

Social Problems

HIGH FERTILITY

MALNUTRITION

INFECTIONS MOTHER &

BABY

MISC…… CAUSES

QUALITY OF HEALTH CARE POORLY TRAINED TBAS, NON COMPLIANCE IGNORANCE, TRADITIONAL BELIEFS

NO FP

RELIGIOUS BELIEFS

INSUFFICIENT FOOD, EXTREME POVERTY, GENDER BIAS

DOMESTIC CONDITIONS

AGE,

PARITY ,

REPEATED PREGNENCIES

High Infant Morbidity & Morbidity

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Management & Prevention Of Infant

Mortality

Management & Prevention Of Infant

Mortality

• Prevention of Unwanted Pregnancies

• Identification of High Risk• Management of High Risk

Management & Prevention Of Infant Mortality

I. Prevention of Unwanted Pregnancya. Health Educationb. Family Planningc. Genetic Counseling

Identification of High Risk

High Risk Pregnancy

• Extremes of age• Grandmultipara

e• Intrauterine

infections• Bad obs. History• Pre-existing

Illness

High Risk New Born

• Prematurity• Low Birth weight• Congenital

Anomalies• Sepsis• Babies born to

mother with chronic disease

Management of High Risk

a.Early detection of High Risk Preg.

b.Antenatal carec.Natal cared.Postnatal Caree.Identification of High risk

babies

Management of High Risk New Born

a.Nursery Intensive careb. Medical Surveillance c. Nutritional Surveillanced. Social Monitoring after

discharge from the nurserye. Follow up in the under 5

clinic

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Flow chart of Optimum Newborn Care

Delivery

High risk InfantNormal Infant

With complicationsWithout complications

Temporary observation unit(recovery room for high-risk infants)

Special care nursery with Neonatal intensive care unit

Special Procedures

RegularNursery

Home

Care of the Baby

• Immediate Care• Late Neonatal Care

Care of The Baby

Immediate Care • Clearing the airway• APGAR score• Care of the cord• Care of the eyes• Care of the skin• Maintenance of

body temp. • Breast feeding

Late Neonatal Care

• Immunization• Growth

Monitoring• Nutritional

Surveillance

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Prevention of Child Morbidity and

Mortality

Prevention of Child Morbidity and Mortality

• Prenatal Nutrition• Prevention of infections esp. tetanus• Immunization • Breast feeding• Growth monitoring• Family planning• Sanitation• Provision of primary health care

• Socio-economic development• Family planning • Health Education• Screening for occult

treatable condition • Prevention of Specific Health

Problems

Screening for occult treatable condition

Screening for occult treatable condition

• In Preventable diseases esp. those with clear symptoms, screening would be helpful :1. Anemia2. Congenital hypothyroid3. Visual Impairment4. Physical growth & development5. BP management in 3 yrs and above6. Hearing Impairment

Prevention of Specific Health Problem

• Injuries/ Accidents• Psychological Problems• Dental Problems

Prevention of Specific Health Problem

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Prevention of specific health problems

a. Injuries/ accidents i. Modification of hazards.

Use of the products with child proof caps.

Lowering of temperature of hot H2O heaters.

Installation of window guards.

ii. Modification of behavior Motor cycle helmets Infants car seats.

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b. Psychosocial problems

Which will develop due to the environment, birth conditions and developmental delays.

These can be prevented if children are properly screened

Give preventive and remedial educational and psycho therapeutic services.

c. Dental problems. Which are of great concern in child

morbidity & they can be prevented by.

i. Regular Oral Hygieneii. Reduction of sugar in food, drinks

and medicine.iii. Community water Fluoridationiv. Topical fluoride application

Minimum # of Visits made to Assess the Child

Health Problems

• Visits in the 1st year of life 1. Once every month,12 visits

• Visits in 1 – 5 years of life 1. Once in 3 months, 4 visits

in a year

Priority Areas to Improve Newborn Health

• Before & during Pregnancy• During Pregnancy• During & soon after Delivery• During the First Month of

Life

Before & during Pregnancy

Before & during Pregnancy

• Well-timed, well-spaced, & wanted pregnancies

• Well-nourished & healthy Mother• pregnancy free of drug abuse,

tobacco & alcohol• Tetanus & rubella immunization• Prevention of mother to child

transmission of HIV• Female education

During Pregnancy

During Pregnancy

• Early contact with health system1. Birth & emergency preparedness2. Early detection & treatment of maternal

complications3. Monitoring of fetal well-being & timely

interventions for foetal complications4. Tetanus immunizations5. Prevention & tereatment of infections

(malaria, hookworm etc)

• Good diet• Prevention of violence against women

During & Soon After Delivery

During & Soon After Delivery

• Safe & clean delivery by skilled attendant

• Early detection & prompt mx. Of delivery & foetal complications

• Emergency obstetric care for maternal & foetal conditions

• Newborn resuscitation

• Newborn care ensuring warmth & cleanliness

• Newborn cord, eye & skin care• Early initiation of exclusive breast feeding• Early detection & treatment of newborn

complications• Prevention & control of infections• Information & counseling on home care,

danger signs & care seeking

During the First Month of Life

During the First Month of Life

• Early post-natal contact• Protection, Promotion & support

of exclusive breast feeding• Prompt detection &

management of disease in newborn infant

• Immunization• Protection of girl child

MCQs

1. A pale child of 4 yrs presents for checkup. On lab. Investigation Hemoglobin is 5 g/dL. What is the next best step in management?

a) Blood transfusion, oral iron and folic acid therapy

b) Parenteral iron and blood transfusionc) Bone marrow aspiration to rule out

leukemiad) Oral iron and assessment of diete) Small bowel biopsy to rule out celiac

disease

d) Oral iron and assessment of diet

• Infant Mortality Rate of Pakistan is :

a) 185 deaths/1000 live birthsb) 50 deaths/1000 live birthsc) 70 deaths/1000 live birthsd) 200 deaths/1000 live births

C) 70 deaths / 1000 live births

Ref: UNICEF 2010

1. Which of the following is the most common cause of maternal deaths in Pakistan?a) Abortionsb) Deliveries by TBAs c) Eclampsiad) Hemorrhagee) Sepsis

d) Hemorrhage

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A primigravida of 34 years had a normal vaginal delivery in a hospital. During the antenatal period she was labeled as hypertensive. She had a first stage of labour for 5 hours. She had a post partum hemorrhage, the likely cause of which was:

a. Primary gravidity

b. Age of the motherc. Hypertensiond. Long 1st stage e. Untrained birth attendant

Answer

a. Primary gravidity

b. Age of the mother

c. Hypertensiond. Long 1st stage e. Untrained birth

attendant

A tuberculous village woman of 36, reported at 7 months of pregnancy to a BHU with complaints of mild vaginal bleeding. The TBA did vaginal examination and the woman died of a hemorrhage. The most important factor resulting in this hemorrhage is:

a. Woman’s age b. Rural background c. Duration of pregnancy d. Untrained Birth Attendante. Underlying disease

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Answer

a. Age of woman b. Rural background c. Duration of pregnancy

d.Untrained Birth Attendant

e. Underlying disease

A village woman of 40, who had 6 children; died when she was pregnant for the seventh time during a home delivery:a. Categorize this mortality b. Which possible

predisposing factors initiated this death

Answer A

• Maternal Mortality

Answer B

• Age • Parity • Early marriage • Access /

Availability• Untrained TBA • Illiteracy

• Poverty• Bad environment• Nutritional

deficiency • Sepsis• Lack of FP

services• Social and

cultural factors

• Maternal Mortality Rate of Pakistan is :

a) 350 deaths/100,000 live birthsb) 150 deaths/100,000 live birthsc) 250 deaths/100,000 live birthsd) 450 deaths/100,000 live births

a) 250 deaths/100,000 live births

Ref: UNICEF 2010

Any Questions?

Thank you