Maternal & Child Health-II

Dr. Aliya Junaid Community 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

SAFE MOTHERHOOD
Antenatal care Clean/Safe Delivery Essential Obstetric Care
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Family Planning

BASIC MATERNITY CARE PRIMARY HEALTH CARE EQUITY FOR WOMEN

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. b. c. d. Pre - conception Guidance Ante-natal Care Natal Care Post-natal care

14

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: TT2: TT3: TT4: TT5:

During child bearing age Four weeks after TT1 Six months after TT2 One year after TT3 One year after TT4 or during next pregnancy

Schedule of Tetanus Toxoid for Pregnant Women

1. 2.

3.
4. 5.

TT1 7 months TT2 1 month after TT1 TT3 - 6 Months after TT2 TT4 - 1 Year after TT3 TT5 1 Year after TT4

INFANT MORTALITY

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 Childhood division into age-periods:

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)
1.

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.)

Infant Mortality Rate

IMR=

Number of deaths of children less than 1 year of age in a year Number of live births in the same year

1000

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Mortality In & Around Infancy

Still Birth

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

Still Birth Rate

Fetal deaths weighing over 1000 g at Birth during the year SBR = x 1000 Total live + Stillbirths over 1000 g at Birth during the year

30

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.

Peri- Natal Mortality Rate

Late fetal deaths (28 wks gestation & more) + early neonatal deaths (first week) in one year PNMR = X 1000 Late fetal deaths + Live Births In The Same Year

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Neonatal Mortality Rate

Neonatal Mortality Rate

These are deaths occurring during the neonatal period, commencing at birth and ending 28 completed days after birth.
Early neonatal death 2. Late neonatal death
1.

Neonatal Mortality Rate

Number of deaths of children under 28 days of age in a year NMR = x 1000 Total live births in the same year

36

Early Neonatal Mortality Rate

Early Neonatal Mortality Rate

Number of deaths of children <1 wk of age in a year ENMR = Total live births in the same year x 1000

38

Late Neonatal Mortality Rate

Late Neonatal Mortality Rate

Number of deaths of children after 7th day till 28th day of age in a year LNMR = Total live births in the same year x 1000

40

Post- Neonatal Mortality Rate

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

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1 - 4 year Mortality Rate (Child Death Rate)

1 - 4 year Mortality Rate (Child Death Rate)

No of deaths of children aged 1-4 years during a year Child DR= Total no. of children aged 1-4 years at the middle of the year X 1000

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

44

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

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
47

 Child Survival Index points towards the need for preventive services through:
1. 2. 3. 4.

5.
6.

Breast feeding Adequate nutrition Clean water Immunization Oral Rehydration Therapy Birth spacing

Predisposing Factors of Infant Mortality

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Predisposing Factors of Infant Mortality

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 care

3.

Cultural & Social Factors

Breast feeding, Early marriage, maternal education etc
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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

Multiple Causation Web Model For Infant Mortality

Economic Loss
High Infant Morbidity & Morbidity
I N F A N T M O R T

POOR OBS CARE

QUALITY OF HEALTH CARE POORLY TRAINED TBAS, NON COMPLIANCE IGNORANCE, TRADITIONAL BELIEFS NO FP

HIGH FERTILITY MALNUTRITI ON INFECTIONS MOTHER & BABY MISC CAUSES

RELIGIOUS BELIEFS INSUFFICIENT FOOD, EXTREME POVERTY, GENDER BIAS

DOMESTIC CONDITIONS AGE, PARITY ,
53 REPEATED PREGNENCIES

A
L

Social Problems

I T

Management & Prevention Of Infant Mortality

54

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 Pregnancy

Health Education b. Family Planning c. Genetic Counseling
a.

Identification of High Risk

High Risk Pregnancy High Risk New Born Prematurity Low Birth weight Congenital Anomalies Sepsis Babies born to mother with chronic disease

Extremes of age Grandmultiparae Intrauterine infections Bad obs. History Pre-existing Illness

Management of High Risk

a. Early detection of High Risk Preg. b. Antenatal care c. Natal care d. Postnatal Care e. Identification of High risk babies

Management of High Risk New Born

a. Nursery Intensive care b. Medical Surveillance c. Nutritional Surveillance d. Social Monitoring after discharge from the nursery e. Follow up in the under 5 clinic

Flow chart of Optimum Newborn Care

Delivery Normal Infant High risk Infant

Without complications

With complications

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

Regular Nursery

Special care nursery with Neonatal intensive care unit

Home

Special Procedures
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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

Prevention of Child Morbidity and Mortality

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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. 2. 3.

4.
5.

6.

Anemia Congenital hypothyroid Visual Impairment Physical growth & development BP management in 3 yrs and above Hearing Impairment

Prevention of Specific Health Problem

Injuries/ Accidents Psychological Problems Dental Problems

Prevention of Specific Health Problem

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.
Motor cycle helmets Infants car seats.

ii.

Modification of behavior

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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.

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c.

Dental problems.
Which are of great concern in child morbidity & they can be prevented by.

Regular Oral Hygiene ii. Reduction of sugar in food, drinks and medicine. iii. Community water Fluoridation iv. Topical fluoride application
i.

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 system
1. 2. 3. 4. 5.

Birth & emergency preparedness Early detection & treatment of maternal complications Monitoring of fetal well-being & timely interventions for foetal complications Tetanus immunizations 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)

b)
c) d)

e)

Blood transfusion, oral iron and folic acid therapy Parenteral iron and blood transfusion Bone marrow aspiration to rule out leukemia Oral iron and assessment of diet Small bowel biopsy to rule out celiac disease

d) Oral iron and assessment of diet

 Infant Mortality Rate of Pakistan is :

185 deaths/1000 live births b) 50 deaths/1000 live births c) 70 deaths/1000 live births d) 200 deaths/1000 live births
a)

C) 70 deaths / 1000 live births

Ref: UNICEF 2010

1. Which of the following is the most common cause of maternal deaths in Pakistan?
Abortions b) Deliveries by TBAs c) Eclampsia d) Hemorrhage e) Sepsis
a)

d) Hemorrhage

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.
c. d. e.

Age of the mother Hypertension Long 1st stage Untrained birth attendant
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Answer
a.

Primary gravidity

b.

Age of the mother

c.
d.
e.

Hypertension
Long 1st stage 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. b. c. d. e.

Womans age Rural background Duration of pregnancy Untrained Birth Attendant Underlying disease

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

d. Untrained Birth Attendant

e. Underlying disease

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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 :

350 deaths/100,000 live births b) 150 deaths/100,000 live births c) 250 deaths/100,000 live births d) 450 deaths/100,000 live births
a)

a) 250 deaths/100,000 live births

Ref: UNICEF 2010

Any Questions?

Thank you