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
Essential
Obstetric Care
Clean/Safe
Delivery
Antenatal care
Family
Planning
SAFE MOTHERHOOD
BASIC MATERNITY CARE
PRIMARY HEALTH CARE
EQUITY FOR WOMEN
Health policy 1997
8
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
19
• 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
X
1000
Number of live births in the same
year
25
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
33
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 =
x 1000
Total live births in the same year
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 =
x 1000
Total live births in the same year
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
42
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=
X 1000
Total 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
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
49
Predisposing Factors of
Infant Mortality
Biological Factors
1.

Birth weight, Age of the mother, Birth order,
Birth spacing, Multiple births, Family size,
High Fertility.
Economic Factors
2.

Low socioeconomic factors, quality &
availability of health care
Cultural & Social Factors
3.

Breast feeding, Early marriage, maternal
education etc
50
Infant Mortality Causes
Infant Mortality Causes
Neonatal Mortality
(0-4wks)
Post-neonatal Mortality
(1-12 months)
• Low Birth weight
• Prematurity
• Birth injury/difficult
labour
• Sepsis
• Congenital anomalies
• Hemolytic disease
• Placenta/cord conditions
• Diarrheal disease
• Acute resp. diseases
•
•
•
•
•
•
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
POOR OBS
CARE
F
A
N
T
M
O
HIGH
FERTILITY
MALNUTRITI
ON
R
T
A
L
Social
Problems
I
T
Y
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 ,
53
REPEATED PREGNENCIES
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
• Extremes of age
• Grandmultiparae
• 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 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
Home
Special care nursery with
Neonatal intensive care unit
Special Procedures
60
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
64
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.



ii.
Use of the products with child proof
caps.
Lowering of temperature of hot H2O
heaters.
Installation of window guards.
Modification of behavior


Motor cycle helmets
Infants car seats.
71
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.


72
c.
Dental problems.
Which are of great concern in child
morbidity & they
can be
prevented by.
i.
ii.
iii.
iv.
Regular Oral Hygiene
Reduction of sugar in food, drinks
and medicine.
Community water Fluoridation
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 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.
Age of the mother
Hypertension
Long 1st stage
Untrained birth attendant
c.
d.
e.
92
Answer
a.
Primary gravidity
b.
Age of the mother
c.
Hypertension
d.
Long 1st stage
Untrained birth attendant
e.
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.
Woman’s 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
95
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