Delivery of Mother and Child Care Services PRESENT SCENARIO

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Delivery of Mother and Child Care
ServicesPRESENT SCENARIO

• Dr. Sanil Kumar.M.C,
• Lecturer,
• Govt Homoeopathic Medical College, Calicut

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MCH Programme

• A method of delivering health care to a special
  group in the population which is especially
  vulnerable to disease, disability or death.
• Groups Children under age 5 years Women in the
  reproductive age group (15 44 yrs)

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MCH Programme

• Aim Curative, preventive and social aspects of
  obstetrics, paediatrics, family welfare,
  nutrition, child development and health
  education.
• Ultimate objective Life-long health.

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MCH Programme

• Special objectives
• Reduction of morbidity and mortality rates for
  mother and children
• Promotion of reproductive health, and
• Promotion of the physical and psychological
  development of the child within the family.

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MCH Programme

• Components
• Maternal Health
• Family planning
• Child health
• School health
• Handicapped children
• Care of the children in special settings such as
  day care centres.

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MCH Programme

• Recent trends in MCH care.
• Integration of care
• Risk approach
• Manpower changes
• Primary health care

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MCH Programme

• INTEGRATION OF CARE
• Integration of conventional MCH services,
  previously fragmented into antenatal care,
  postnatal care, family planning etc.
• This helps to promote continuity of care as well
  as improves efficiency and effectiveness of MCH
  care

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MCH Programme recent trends

• RISK APPROACH
• Based on the early detection of mothers and
  children with high risk factors.
• All mothers and children with hrf are given
  additional and more skilled care including
  hospitalization.
• To assess the degrees of risk of each factor by
  scoring (a) Magnitude, (b) treatability (c) cost
  effect and (d) community attitude

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MCH Programme recent trends

• MANPOWER CHANGES
• Maternal and child health worker to
• (i) Professionals Specialists
• (ii) Field workers MPW, Health guides, Dais,
  AMM, ASHA, etc
• (iii) Voluntary workers

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MCH Programme recent trends

• PRIMARY HEALTH CARE
• Has all the elements i.e, MCH care, family
  planning, control of infections, education about
  health problems how to prevent them, and
  measures to ensure nutritious food.

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MCH Programme Targets
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MCH Programme - Organization

• MCH was a part of family welfare programme from
  its inception.
• In 1992, the Child Survival and Safe Mother hood
  Programme integrated all the schemes for better
  compliance.
• Recently, RCH was launched in 1997, which
  integrated CSSMP, preventive management of
  STTD/RTI, AIDS and a client approach to health
  care.
• RCH entered phase II NRHM.

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MCH Programme - milestones

• 1952 Family Planning Programme adopted by GOI
• 1961 Dept of Family Planning created in MOH
• 1971 MTP Act, 1971
• 1977 Renaming of Family Planning to Family
  Welfare
• 1978 Expanded Programme on Immunization (EPI)
• 1985 UIP National oral rehydration therapy
  Progr
• 1992 Child Survival and Safe Motherhood
  Programme (CSSM)
• 1996 Target free approach
• 1997 RCH Phase I
• 2005 RCH Phase II
• 2005 NRHM

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MCH Care - Indicators

• Maternal Mortality Rate (MMR)
• Mortality in infancy and childhood
• a. Perinatal mortality rate
• b. Neonatal mortality rate
• c. Post-neonatal mortality rate
• d. Infant mortality rate
• e. 1 4 year mortality rate
• f. Under 5 mortality rate
• g. Child survival rate

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Maternal Mortality Rate (MMR)

• According to WHO, a maternal death is defined as
  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 to or aggravated by the pregnancy or its
  management but not from accidental or incidental
  causes.

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Maternal Mortality Rate (MMR)

• ICD Recommendation, 2 causes
• (1) Direct obstetric deaths those resulting from
  obstetric complications of the pregnant state
  (pregnancy, labour and puerperium), from
  interventions, omissions, incorrect treatment, or
  from a chain of events from any of the above

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Maternal Mortality Rate (MMR)

• ICD Recommendation
• (2) Indirect obstetric deaths those resulting
  from previous existing illness or disease that
  developed during pregnancy and which was not due
  to direct obstetric causes, but which was
  aggravated by physiological effects of pregnancy.

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Maternal Mortality Rate (MMR)
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Maternal Mortality Rate (MMR)

• Maternal deaths mostly occur from the 3rd
  trimester to the 1st week after birth.
• Most maternal death related to obstetric
  complications including PPH, Infections,
  eclampsia prolonged or obstructed labour.
• Direct causes for MMR reduced if skilled care are
  on hand key drugs, equipments referral
  facilities available

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Maternal Mortality Rate (MMR)

• 80 maternal deaths due to direct causes
• Single most common causes is PPH
• Death preventable through careful monitoring
  during pregnancy and treatment with relatively
  simple drugs.
• 20 deaths due to indirect causes
• Most significant indirect cause is anaemia.

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Maternal Mortality Rate (MMR)

• Other important causes for indirect death are
  hepatitis, CV diseases, diseases of endocrine and
  metabolic system and infections such as TB,
  malaria and increasing HIV/AIDS.

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Maternal Mortality Rate (MMR)

• Social factors influencing MMR
• (a) Womans age Optimum age b/w 20 30
  years.
• (b) Birth interval
• (c) Parity
• (d) Other factors economic circumstances,
  cultural practices and beliefs, nutritional
  status, environmental conditions and violence
  against women.

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Maternal Mortality Rate (MMR)

• MMR _at_ 1997 407 per 100,000 live births
• MMR _at_ 2003 301 per 100,000 live births.
• Kerala 110 per 100,000 live births.
• 78000 woman die each year due to large number of
  deliveries conducted at home by untrained
  persons.

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Maternal Mortality Rate (MMR)

• Determinants of maternal mortality in India.
• Obstetric causes
• Toxaemias of pregnancy
• Haemorrhage
• Infection
• Obstructed labour
• Unsafe abortion

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Maternal Mortality Rate (MMR)

• Determinants of maternal mortality in India.
• Non-obstetric causes
• Anaemia
• Associated diseases
• Malignancy
• Accidents

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Maternal Mortality Rate (MMR)

• Determinants of maternal mortality in India.
• Social factors
• Age of child birth Ignorance prejudices
• Parity Lack of maternity
  services
• Too close pregnancies
• Family size Shortage of manpower
• Malnutrition Delivery by dais
• Poverty Social customs
• Illiteracy
• Poor communications and transport facilities

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Maternal Mortality Rate (MMR)

• New approaches
• 1) Essential Obstetric care and establishments of
  FRUs for emergency obstetric care
• Attack on social and cultural factors to reduce
  MMR by socio-economic development of the
  community through active community involvement.

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Maternal Mortality Rate (MMR)

• National Health Care Indicators

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Maternal Mortality Rate (MMR)

• Preventive and social measures
• Early registration of pregnancy
• At least three antenatal check-ups
• Dietary supplementation, including correction of
  anaemia
• Prevention of infection and haemorrhage during
  pueperium
• Prevention of complications, e.g., eclampsia,
  malpresentations, ruptured uterus.

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Maternal Mortality Rate (MMR)

• 6. Treatment of medical conditions, e.g., HTN,
  DM, TB, etc.
• 7. Anti malarial and tetanus prophylaxis.
• 8. Clean delivery practice
• 9. Institutional deliveries for women with bad
  O/H and risk factors
• 10. Promotion of family Planning
• 11. Identification of all maternal deaths and
  search for its cause.

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Mortality in infancy and childhood

• Perinatal period
• Early neonatal period
• Late neonatal period
• Post neonatal period

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Perinatal mortality rate

• Includes both late foetal deaths (stillbirths)
  and early neonatal deaths.
• ICD definition (8th revision) as lasting from the
  28th week of gestation to the seventh day after
  birth.
• 9th revision of ICD, added
• i) Babies with min 1000 g at birth
• ii) gestation period of at least 28 weeks
• iii) body length at least 35 cm.

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Perinatal mortality rate

• WHO expert committee on the Prevention of
  Perinatal Mortality and Morbidity (1970
  recommends Late foetal and early neonatal deaths
  weighing over 1000 g at birth, expressed as a
  ratio per 1000 live births weighing over 1000 g
  at birth.

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Perinatal mortality rate

• Incidence
• It accounts about 90 of all foetal and infant
  mortality in develop countries.
• In India, 2006, PMR is about 37 per 1000 total
  births, with about 41 for rural areas and 24 for
  the urban areas.
• Kerala 15 per 1000 live births
• PMR now declining due to improved obstetric and
  perinatal technologies.

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Perinatal mortality rate

• Risk groups
• Low socio-economic status
• High maternal age (35 years or more)
• Low maternal age (under 16 years)
• High parity
• Heavy smoking (10 or more cigars daily)
• maternal height (short stature)
• Poor past O/H
• Malnutrition and severe anaemia
• Multiple pregnancy.

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Perinatal mortality rate

• Causes
• Main causes Intrauterine and birth asphyxia,
  LBW, birth trauma, and IU or neonatal infections.
• Antenatal causes
• Maternal ds- HTN, TB ,DM, Anaemia
• pelvic ds- Myoma, endometr, ov tumors
• Anatomical defects of female G.O
• Endocrine imbalance

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Perinatal mortality rate

• Blood incompatibilities
• Malnutrition
• Toxaemias of pregnancy
• APH
• Congenital defects
• advanced maternal age.

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Perinatal mortality rate

• Intranatal causes
• Birth injuries
• Asphyxia
• Prolonged effort time
• Obstetric complications
• Postnatal causes
• Prematurity
• RDS
• Respiratory alimentary infections
• Congenital anomalies

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Neonatal mortality rate

• Causes are multi-factorial LBW, birth asphyxia
  and atelectasis, birth injuries, congenital
  malformations and infections.
• Neonatal mortality is a measure of intensity with
  which endogenous factors affect infant life.
• The neonatal mortality is directly related to the
  birth weight and gestational age.

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Neonatal mortality rate

• The main causes of neonatal mortality are
  intrinsically linked to the health of the mother
  and the care she receives before, during and
  after giving birth.
• Neonatal mortality is greater in boys throughout
  the world, because newborn boys are biologically
  more fragile than girls.

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Neonatal causes of death
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Neonatal mortality rate

• Incidence
• World, 40 of under-5 mortality.
• 50 of infant mortality
• 98 deaths in developing countries
• India, 2006, 28 per 1000 live births in early
  neonatal period (0 7 days), with about 32 for
  rural areas and 16 for urban areas.
• Kerala 8 per 1000 live births

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Neonatal mortality rate

• Priority areas to improve neonatal health
• Before and during pregnancy
• delayed child-bearing
• well-timed, well-spaced and wanted
  pregnancies
• well-nourished and healthy mother
• preg free of drug abuse, tobacco and alcohol.
• tetanus and rubella prevention
• prevention of mother-to-child transmission of
  HIV
• female education

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Neonatal mortality rate

• Priority areas to improve neonatal health
• During pregnancy
• Early contact with health systems including
• - Birth emergency preparedness
• - Early detection Rx of maternal
  complications
• - Monitoring of fetal well-being timely
  intervention in fetal complications
• - tetanus immunization
• - Prevention and Rx of anaemia
• - Voluntary HIV counseling and testing
• Good diet
• Prevention of violence against women

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Neonatal mortality rate

• Priority areas to improve neonatal health
• During and soon after delivery
• safe and clean delivery by skilled attendant
• Early detection prompt management of
  delivery fetal complications
• Emergency obstetric care for maternal fetal
  conditions
• new-born resuscitation
• newborn care ensuring warmth and cleanliness
• newborn cord, eye and skin care
• early initiation of exclusive breast-feeding

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Neonatal mortality rate

• early detection and treatment of complications
  of newborn
• special care for infants born too early or too
  small and/or complications
• prevention and control of infections
• prevention of mother-to-child HIV transmission
• information counselling on homecare, danger
  signs care seeking

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Neonatal mortality rate

• Priority areas to improve neonatal health
• During the first month of life
• early post-natal contact
• protection, promotion support of exclusive
  breast feeding
• prompt detection and management of
  disease in newborn infant
• immunization
• protection of girl child

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Post-Neonatal mortality rate

• The ratio of post-neonatal deaths in a given year
  to the total number of live births in the same
  year
• Deaths occurring from 28 days of life to under
  one year are called post-neonatal deaths.
• India, 2003, 23 per 1000 live births, 25 for
  rural and 16 for urban
• Kerala, 2003, 5 per 1000 live births.

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Infant mortality rate (IMR)

• The ratio of infants registered in a given year
  to the total number of live births registered in
  the same year usually expressed as a rate per
  1000 live births.
• Major factors Malnutrition, high parity of
  mother, LBW, congenital anomalies, deliveries by
  untrained dais.
• India, 2007, 54 per 1000 live births.
• Kerala, 2007, 15 per live births.

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Infant mortality rate (IMR)

• Factors affecting IMR
• (1) Biological factors
• Birth weight (Due to poor nutrition)
• Age of mother
• Birth order (Highest IMR 1st Born)
• Birth spacing
• (Khanna study in India showed that IMR was
  highest for those infants born after an interval
  of one year, lower for those born after an
  interval of 2-3 years, and lowest for those born
  after an interval of 4 years).

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Infant mortality rate (IMR)

• Multiple births
• family size (fewer children means better
  maternal care, a better share of
  family resources, less morbidity and
  greatly decreased IMR)
• High Fertility
• (2) Economic factors
• Socio-economic status
• (3) Cultural and social factors
• Breast feeding (Early weaning bottle
  feeding)
• Religion and Caste
• Early marriages

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Infant mortality rate (IMR)

• Sex of the child (statistics show that female
  IMR is higher than male IMR but neonatal death
  rate is higher for males than for females post
  neonatal death rate is higher for female infants
  than male infants).
• Quality of mothering efficient mother
• Maternal education (Women with schooling tend
  to marry later, delay child-bearing and are more
  likely to practice family planning. They
  generally fewer children with wider spacing
  between births).
• Quality of health care
• Broken families
• Illegitimacy
• Bad environmental sanitation.

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Infant mortality rate (IMR)

• Preventive and social measures
• Prenatal nutrition (In a controlled study in
  India, poor women were fed an additional 500
  kcals and 10 g of protein during the last 4 weeks
  of pregnancy. Their infant birth weight were on
  an average 3000 g above those infants born to the
  control group.
• Prevention of infection (UIP aims at
  providing protection to alll the expectant
  mothers children against 6 vaccine preventable
  diseases)
• Breast-feeding (to safeguard against
  gastro-intestinal and respiratory infections and
  PEM).
• Growth-monitoring

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Infant mortality rate (IMR)

• Preventive and social measures
• Family planning
• Sanitation
• Provision of primary health care
• Socio-economic development (spread in
  education, provision of safe water basic
  sanitation, improvement of housing conditions,
  the growth of agriculture and industry
  availability of commerce and communication)
• Education (Educated women generally do not
  have early pregnancies, are able to space their
  pregnancies, have better access to information
  related to personal hygiene and care of their
  children, and better use of health care service.

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1 4 mortality rate

• The number of deaths of children aged 1 4 years
  per 1000 children in the same age group in a
  given year.
• India, 2006, 5.1 of total deaths.
• Kerala, 2006, 0.5, TN, 1.5.

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1 4 mortality rate

• Leading causes of death in 1 4 years age

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Under 5 mortality rate

• UNICEF annual number of deaths of children age
  under 5 years, expressed as a rate per 1000 live
  births.
• India, 2007, 72 per 1000 live births.

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Under 5 mortality rate

• Under 5 causes of death

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New initiatives in child health

• Launching of Immunization Strengthening Project
• Organisation of RCH camps, health meals and RCH
  outreach scheme to reach disadvantageous segments
  of the population
• Launch of project for Hepatitis B vaccine in the
  immunization programme
• Operationalization of newborn care facilities in
  identified weak districts
• Operations research by ICMR for provision of
  home-based neonatal care through community level
  providers

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New initiatives in child health

• Policy for exclusive breast feeding up to 6
  months of age
• Preparation approval of concept note on
  development of community based mid-wives
• Implementation of Dai training to provide key
  messages for newborn health in 166 district, and
• Adaptation of IMCI to incorporate newborn
  diseases and development of IMNCI

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IMNCI

• Integrated Management of Neonatal and Childhood
  Illness central pillar of child health
  interventions under RCH II strategy
• Objectives
• To reduce deaths and the frequency and severity
  of illness and disability and to contribute to
  improved growth and development.

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IMNCI

• IMCI strategy, developed by WHO in collaboration
  with UNICEF and many other agencies in mid-
  1990s, is a curative, preventive and promotive
  strategy aimed at reducing the death and
  frequency and severity of illness and disability,
  and contributes to improved growth and nutrition
  of under five children.

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IMNCI

• IMNCI combines improved management of childhood
  illness with aspects of nutrition, immunization,
  and other components.
• The core of the INMCI strategy is integrated case
  management of the most common childhood
  problems., like diarrhoea, ARI, malaria, measles
  and malnutrition.
• Clinical guidelines designed for management of
  sick children aged 1 week upto 5 years.

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IMNCI

• GOI decided to launch IMNCI in 4 selected
  district each in Uttaranchal, MP, Orissa,
  Rajasthan, Maharashtra, Gujarat, Delhi, Haryana
  and TN.
• IMNCI will be implemented in a phased manner
  throughout the country.

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IMNCI

• INMCI Includes methods for assessing signs that
  indicate severe disease
• Assessing a childs nutrition, immunization
  feeding
• Teaching parents how to care for a child at home
• Counseling parents to solve feeding problems
• And advising parents about when to return to a
  health faculty.

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IMNCI

• INMCI classifications are action oriented and
  allow a health care provider to determine if a
  child should urgently referred to another health
  facility, if the child can be treated at the
  first-level facility or if the child can be
  safely managed at home.

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IMNCI

• An evidence based syndromic approach
• IMNCI promotes (i) optimum utilization of the
  curative interventions to the capacity and
  functions of the health system and (ii) active
  involvement of family and the community in the
  health care process.

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IMNCI

• Principles of integrated care
• The IMNCI guidelines are based on the following
  principles
• All sick children under 5 years of age must be
  examined for conditions which indicate immediate
  referral or hospitalization
• Children must be routinely assessed for major
  symptoms, nutritional and immunizational status,
  feeding problems and other potential problems

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IMNCI

• Only a limited number of carefully selected
  clinical signs are used based on evidence of
  their sensitivity and specificity to detect
  disease
• Based on the presence of selected clinical signs,
  the child is placed in a classification
• Classifications are colour coded and suggest
  referral (pink), treatment in health facility
  (yellow) and management at home (green)

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IMNCI

• IMNCI guidelines address most common, but not all
  pediatric problems.
• Caretakers are actively involved in the treatment
  of children
• Counseling of caretakers about homecare including
  feeding, fluids and when to return to health
  facility

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IMNCI

• IMNCI case management process
• Assess the young infant/child
• Classify the illness
• Identify treatment
• Treat the young infant/child
• Counsel the mother
• Provide follow-up care

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IMNCI

• Steps I III
• Start with pink rows. If no severe
  classifications, look at yellow ones. If no signs
  in pink and yellow ones, select the
  classification in green row.
• All treatments required are listed in the
  identify treatment column.

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IMNCI

• Step IV
• Management with pre-referral treatment for severe
  complications, outpatient and management at home.
• Referral all young infants and children with a
  severe classification are referred to a hospital
  as soon as assessment is completed and necessary
  pre-referral treatment is administered.

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IMNCI

• OP treatment Yellow and green. Use minimum of
  affordable essential drugs. The health care taker
  also needs to teach the mother or caretaker how
  to give oral drugs at home.

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IMNCI

• Step V Counseling a mother or caretaker
• Effective communication Teach a mother how to
  treat a child, use three basic teaching steps
  give information show an example let her
  practice.
• Give feedback when she practices, praise what she
  has done well, allow more practice, if needed.

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IMNCI

• Advice to continue feeding and increase fluids
  during illness
• Teach how to give oral drugs or to treat local
  infection
• Counsel to solve feeding problem
• Advise when to return if child is not breast
  feeding or drinking properly, becomes sicker,
  develops a fever or feels cold to touch, has fast
  or difficult breathing, or has diarrhoea with
  blood in stools.

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IMNCI

• Step Vi Follow-up care
• See if the child is improving on the drug or
  other treatment that was prescribed.
• If the child or condition worsens, refer to the
  hospital.
• If the child has new problem, use the IMNCI
  protocol afresh.

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