Maternal and Child Health Interventions

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Maternal and Child Health Interventions
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Continuum of Care
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Continua of CareGuiding principles for planning
maternal and child health programmes

• Continuum across Life-stages (which
  interventions?)
• Continuum across Health System (at which
  level?)

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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

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Continuum of CareAcross Health Systems

• 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

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ExampleInterventions to improve Child Health
Home and Community First-level facility Referral Facility
Pregnancy
At birth
Newborn period
Infancy and Childhood
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ExampleInterventions 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
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Packaging 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.

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Intervention Packages
23 - 50 NMR effect
6 - 9
15 - 32
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Packaging 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.

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ExampleIntervention 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

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Delivery strategies for the interventions

• 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.

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Causes of under-five deaths in India 2010
Malnutrition 34
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Causes of under-five deaths in India 2010
Asphyxia Institutional delivery Skilled birth
attendant Use of partograph for labour
surveillance Resuscitation of newborn
Preterm / low birth weight Detection treatment
of asymptomatic bacteriuria Syphylis screening
treatment (Pre) eclampsia prevention Corticosteroi
ds for preterm labour Hypothermia management -
Kangaroo mother care Skilled delivery practices
Malnutrition 34
Infections (sepsis / pneumonia, diarrhoea,
tetanus) Antibiotics for premature rupture of
membranes Syphilis screening treatment Clean
delivery practices Hypothermia management Kangaroo
mother care Breastfeeding Community based
pneumonia management Tetanus toxoid immunization
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Causes of under-five deaths in India 2010
Pneumonia Breastfeeding counselling Complementary
feeding counselling Hib vaccination Antibiotics E
arly detection and management
Malnutrition Breastfeeding counselling Complement
ary feeding counselling Vitamin A
supplementation Vitamin A therapy Measles
vaccination Growth monitoring and
promotion Community-based and Facility-based
management of malnutrition
Diarrhoea Breastfeeding counselling Complementary
feeding counselling Vitamin A supplementation Ora
l rehydration therapy Zinc adjuvant
therapy Antibiotics for dysentery
Malnutrition 34
Measles Measles vaccination Complementary
feeding counselling Vitamin A supplementation Vita
min A therapy
Malaria and HIV Insecticide treated
nets Anti-malarial treatment PPTCT Complementary
feeding counselling Vitamin A supplementation Nive
rapine and (replacement) feeding
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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
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Evidence-based interventions for Child
HealthPreventive

Breastfeeding 13
Insecticide-treated materials 7
Complementary feeding 6
Zinc 5
Clean delivery 4
Hb vaccine 4
Water, sanitation and hygiene 3
Antenatal steroid 3
Newborn temperature maintenance 2
Vitamin A 2
Nevirapine and replacement feeding 2
Tetanus toxoid 2
Antibiotics for premature rupture 1
Measles vaccine 1
Antimalarial intermittent preventive treatment in pregnancy lt1
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Evidence-based interventions for Child
HealthTreatment

Oral rehydration therapy 15
Antibiotics for sepsis 6
Antibiotics for pneumonia 6
Antimalarials 5
Zinc 4
Newborn resuscitation 359 (0) 4 (0) 4
Antibiotics for dysentery 310 3 3
Vitamin A 8 lt1
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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

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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)

• 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)

• 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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Summary Child Health InterventionsOlder infants
and children (1 month up to 5 years)

• 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

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Common causes of maternal deaths in India
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Hemorrhage Active management of 3rd stage of
labour Detect Treat anaemia Skilled attendant
at birth Referral transport Blood
transfusion Operative procedures
Common causes of maternal deaths in India
Complications of abortion Access to family
planning methods including emergency
contraception Use of medical methods Safe
abortion facility Ensuring good quality of care
Sepsis Clean delivery Post-natal care Early
detection and referral Proper management at
facility
Hypertensive disorders ANC Care Early detection
and referral Proper management
Obstructed labor Nutrition of girl
child Detection of high risk pregnancy and
institutional delivery Use of partograph Skilled
care at birth
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Key interventions to effectively prevent maternal
deaths by cause
Direct causes of maternal death Cost effective clinical interventions
Bleeding after delivery (24) Active management of 3rd stage of labour Detect Treat anaemia in pregnancy Skilled attendant at birth prevent/treat bleeding with correct medicines, eg, oxytocin, replace fluid loss by IV drip and transfusion if severe
Infection after childbirth (15) Skilled attendant at birth clean practices Antibiotic if infection arises
Unsafe abortion (13) Skilled attendant give antibiotics, empty uterus, replace fluids if needed, counsel provide family planning/ prevention. Access to safe abortion where not against law
High blood pressure, most dangerous when severe (eclampsia) (12) Detect high blood pressure in pregnancy refer to doctor at hospital. Treat convulsions with appropriate anticonvulsive medicines (MgSO4) Refer unconscious woman for expert urgent assistance
Other direct obstetric causes (8) Refer ectopic pregnancy for operation
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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-PREGNAN
CY

• Family Planning
• Folic acid fortification and/or supplementation
  to prevent Neural Tube Defects
• Prevention of mother-to-child transmission of HIV

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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

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Summary 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

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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 Care

• Essential Obstetric Care
• Emergency Obstetric Care

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Maternal Mortality ReductionSri Lanka 19401985
85 births attended by trained personnel
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Maternal Mortality UK 18401960
Improvements in nutrition, sanitation
Antibiotics, banked blood, surgical improvements
Antenatal care
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How can maternal deaths be prevented?

• Skilled birth attendance
• Prompt referral to an appropriately equipped
  facility if complications arise
• 247 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

• Focused antenatal Care (delivered through
  outpatient or outreach service)
• Minimum four ANC check ups
• At least 1 ANC by Medical Officer, (preferably
  3rd)
• 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

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Packages of interventions in different time
frames related to pregnancy

• Focused antenatal Care (delivered through
  outpatient or outreach service)
• Early registration
• Two doses of injection Tetanus Toxoid
• All pregnant women 100 tabs IFA (200 for
  anemic)
• Screening for treatment of disorders
• Provision of preventive interventions
• 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

• Intranatal care (facility based clinical care
  package)
• Promotion of institutional deliveries
• Skilled attendance for normal child birth, eg,
  monitoring labor progress by partograph
• Emergency obstetric care (basic comprehensive)
  for complicated cases
• Effective referral system

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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)
• Prevention and detection of complications
• Information and counseling on self-care at home,
  nutrition, family welfare, breast feeding

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Skilled Birth Attendant

• An accredited health professional (eg, midwife,
  doctor or nurse)
• Educated and trained to proficiency in the skills
  needed to manage
• Normal (uncomplicated) pregnancies
• Childbirth
• Immediate postnatal period
• Helps in identification, management and referral
  of complications in women and newborns