CHN 2e Chapter 07 (1).ppt

The Risk Management
Approach
in Maternal and Child
Health Care
6

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Community Health Nursing Second Edition
© Oxford Fajar Sdn. Bhd. (008974-T), 2019 6 – 3
Learning Objectives
At the end of this chapter, you should be able to:
 Explain the meaning of risk and why it is important
in maternal and child health care (MCH).
 Outline the high risk approach in MCH.
 Explain the concept of risk and risk factors.
 Identify risk factors for pregnant women.
 State what are ‘cut-off’ levels and why they are
important.

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Learning Objectives
(cont.)
 Explain the benefits of risk approach in MCH
care.
 Describe the classification system of risks
among pregnant women using the colour
coding system.
 Briefly describe the risk approach in child health.
 Describe the roles and responsibilities of the
community health nurse in the risk strategy for
both pregnant mothers and children.

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What is Risk Approach?
 Risk approach is considered a managerial tool for
the flexible and rational distribution of existing
resources, based on measurements of individual
risk and for developing local strategies and
determining the appropriate content of maternal
and child health care and family planning care.
 It is a rational approach to maximise utilisation of
resources.
 In Malaysia, the risk approach that has been
developed is more suitable for the primary health
care level rather than in hospitals.

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What is Risk Approach?
(cont.)
 By applying the risk strategy for mothers, first
identify the risk factors in the pregnant mother and
then provide special care to the mothers at risk.
 However, the mothers who are not at risk will be
provided normal antenatal and postnatal care.
 So it is ‘something for all and more for those in
need’.
 The risk approach strategy has been introduced in
the rural health infrastructure in the Malaysian
health care since the late 70’s.

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Basic Concept in
the Risk Approach Strategy
 First is to identify the risk factors in the mother
and then to provide the appropriate level of care
to the mother according to the risk.
 The managerial goals of the risk approach are:
• Maximum coverage of MCH care
• Optimal use of resources
• Upgrading and monitoring health services
• Objective measurement of health improvement

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What is a Risk Factor?
 Risk factor can be defined as the characteristics
or circumstances of a person or group that are
associated with an increased risk of having,
developing or being affected by the disease.
 Risk factors can be biological, socio-economic,
biological and environmental.
 Biological factors include age, sex and existing
disease. Socio-economic factors include
poverty and illiteracy. Environmental factors
include air and water pollution, etc.

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 All these factors influence the outcome of the
mother and the baby.
 However, in the implementation of the risk
approach, the biological factors are normally the
ones that are used in the implementation of the
strategy.
What is a Risk Factor?
(cont.)

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What are the Interventions
to the Malaysian Health Care
System?
The main interventions that were made in the risk
approach strategy included:
 Colour coding system during pregnancy to provide
appropriate care of the mother
 Retraining and utilisation of the Traditional Birth
Attendants (TBAs)
 Standardisation of the management procedures for
major complications of pregnancy and obstetric
emergency
 Organising and strengthening the referrals follow-up
of ‘at risk’ mothers

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 Upgrading of training and skills of personnel and
provision of essential obstetric care in the district
hospitals
 Introduction of the ‘Confidential Enquiry into
Maternal Deaths’ (CEMD)
 Focused health education for women, families and
the community
 Mobilisation of community, non-governmental
agencies to improve maternal care
What are the Interventions
to the Malaysian Health Care
System? (cont.)

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Some Risk Factors of MCH and
Possible Interventions
Risk factors Possible intervention
History Age < 17 and > 35 Health education for girls.
Availability of contraceptive
Unmarried mothers
Grand multiparty
Previous abortions
Poverty and starvation Community development programmes
Sterility or prolonged inter-pregnancy
interval
Health education before pregnancy
Chronic infections and malnutrition Control of epidemic diseases
Prenatal Vaginal bleeding (early or late) Early attendance of antenatal care
Pre-eclampsia and eclampsia Regular antenatal screening and proper
treatment
Prolonged pregnancy, poor weight gain,
diabetes, anaemia, hydramnious,
infections, signs of foetal hypoxia
Referral to hospital for special care

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What is the Colour Coding
System?
 The colour coding system is one of the tools used in
risk approach strategy to identify the risk mother
according to the level of risk and providing the care
according to the need.
 The levels of risk are red: high risk; yellow: medium
risk; green: low risk; and white: no risk.
 The red colour coding includes hypertension,
diabetes and anaemia (below 8 gm%).

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 At the health centre, the mother is screened and if
she has a risk factor, she is classified according to
the risk and the card is tagged with the appropriate
colour.
 Once the card is tagged, the mother will receive the
level of care accordingly.
 If she is tagged red, she is high risk and she will,
therefore, be advised to be followed up in a hospital
and recommended to be seen by a specialist or a
medical officer in the O&G department.
System? (cont.)

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 She will be told to deliver her baby in the nearest
hospital.
 If she is tagged white then she is classified as no
risk and therefore can be followed up in the health
centre. She can deliver at home or at the health
centre if the health centre has the birthing facilities.
 The main purpose of the colour coding system is to
classify the mothers according to the level of risk
and give appropriate care. This will help to lower
maternal mortality and infant mortality.
System? (cont.)

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Risk Factors and
Colour Coding System
No Red Yellow Green White 1 White 2
1 Eclampsia Mother is HIV-
positive
Rhesus negative Primigravida Gravida 2–5
2 Pre-eclampsia
(Hypertension
with urine
albumin 1+) or
BP >140/90
mmHg
Mother is
Hepatitis B
positive
Weight of mother
before pregnancy
or at time of
booking < 45 kg
Mother’s age
<18 years or
above 40
years
No past
obstetric
history
3 Blood pressure
>170/110 mmHg
Positive for
tuberculosis,
malaria and
syphilis
Medical problems
including
psychiatric and
physical handicap
except diabetes
and hypertension

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Risk Factors and Colour
Coding System (cont.)
4 Blood pressure
>140/90 mmHg
with
symptoms
Blood pressure
>140/90–
<170/100 with
urine
albumin
negative
Gynaecological
operation in
the past
5 Chest pain when
pregnant with
difficulty
in breathing
Diabetic
treated with
insulin
Dependent on
drugs/alcohol/
smoking
Gravida 6 and
above
No past
medical
history
6 Breathlessness
when
doing light
activity
(sweeping,
washing
dishes)
Low foetal
heart rate
when
pregnancy >32
weeks
Unsure of last
menstrual
period
Birth interval
<2 years
or > 5 years
No
complication
s
during
pregnancy

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7 Uncontrolled
diabetes
(urine with high
glucose, brick
red or
with ketone
bodies)
Pregnancy > 7
days after
expected day
of delivery
(EDD)
Past abortions > 3
times
Mother’s
height <145
cm
Elderly primi
(women
with first
pregnancy)
house,
unclean
environment
House,
environment
clean
8 Bleeding per
vaginam
including
abortion
Mother with
medical
problems who
needs
medical
attention
Past caesarean
sections
Height of
mother
>145 cm

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9 Foetal heart rate
(FHR)
abnormal
FHR < 110/min
on
or after 26 weeks
of
pregnancy
FHR > 160/min
after 34
weeks
Women who
has
medico-legal
issues
Age 18–40

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10 Anaemia with
symptoms at any
gestational age
Hb <7 gm %
Teenage
pregnancy
(<19
years)
• Pregnancy-induced
hypertension (PIH)/
eclampsia/diabetes
• Perinatal deaths
• Past history of low
birth
weight babies (<2.5 kg)
and macrosomia (>4
kg)
• 3rd degree perineum
tear
• Cord prolapse
• Postnatal bleeding
• Instrumental delivery
• Long delivery period
Married and
has
family
support

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11 Early
contractions of
uterus
Haemoglobin 7–
9 gm %
or symptomatic
Multiple babies
(twins)
Premature
ovarian
aging (POA) >
37
weeks or < 41
weeks
12 Leaking liquid
without
contractions
Placenta praevia
which is
stable and no
bleeding
Hypertension—
140/90 mmHg
with urine
albumin negative
Estimated
weight
of baby > 2 kg
or
< 3.5 kg
13 Uncontrollable
asthma
Maternal pyrexia
>38 or
> 3 days
Haemoglobin <
11 gm %
14 Fits Infertility Diabetes (Urine
green)

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15 Fever more than
5 days
Heart disease
with no
symptoms
Urine albumin
>1+
16 Drug addict
and/or smoker
Increasing
weight > 2 kg per
week
17 Body weight > 80
kg
18 Uterine size
more or less
than expected
19 False sign of
delivery after 36
weeks of
pregnancy

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20 Head not
engaged after 37
weeks for
primigravida
Action
Admit to
hospital
immediately
Refer to Family
Medicine
Specialist/
O&G specialist
at the
nearest hospital
Refer to
Medical and
Health officer
Hospital
delivery
Home delivery
or alternative
birthing
centre

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Colour Coding System and
Level of Care
Category of Risk Level of care Personnel who
should take care
Place of delivery
Red (high risk) Hospital O&G specialist Hospital
Yellow
(medium risk)
Hospital/health
centre
Family medicine
specialist in health
centre or O&G
specialist in
hospital
Hospital
Green (low risk) Health centre Medical & Health
Officer
Alternative birth centre
(ABC) /hospital
White (no risk) Health centre Midwife/Public
health nurse
Home/health centre
with birthing
facilities

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Role of CHN in Risk Approach
1. Identify the risk factor in the mother
• Identify the presence of biological risk factors like
hypertension, diabetes, anaemia and other risk
factors in the health centre during the antenatal
screening of the mother.
2. Decide the ‘cut off’ level of the risk factor.
• The presence of risk factor may not be able to
identify what the risk level is.
• A ‘cut off’ level is required to identify the level of risk.
• The ‘cut off’ level is the level of the risk factor where
the decision is made for action to be taken.

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3. Decide the level of care for the mother
• After confirmation of the level of the risk factor,
the colour coding system is used to decide the
level of care.
4. Provide the level of care as mentioned in the colour
coding system
• Public health nurse can provide care for white
colour codes
5. Once the mother is identified as risk, she is
referred to the hospital and given the appropriate
care.
Role of CHN in Risk
Approach (cont.)

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What are the Benefits of the Risk
Approach in MCH Care?
 The pregnant mother is given care according to the
level of risk.
 The resources (manpower, equipment) are effectively
utilised.
 The provision of care using risk approach will lower
maternal and infant mortality.
 The colour coding system will help the nurses to
prioritise the cases for home visit and postnatal care.
 The referral system of the mothers is utilised properly.

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What are the Main Problems in
the Implementation of the
Colour Coding System?
 Once the mother is classified as high risk and even if
her risk is reduced during the course of the pregnancy,
the nurses do not change the level of risk.
 Once the mother is classified as having risk, the tag
sometimes remains for the next pregnancy.
 The mothers sometimes are not given care according
to the level of risk.
 There is a tendency to refer most of the cases to
hospitals, thus increasing the cost of care.
 The risk strategy does not involve the other sectors
that are involved in the delivery of health care.

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What are the Main Problems in
the Implementation of the Colour
Coding System? (cont.)
 The hospital staff are not trained properly so when the
referral case arrives, they must follow the procedures
for further action.
 Even if the mother is identified as being ‘at risk’, she
may not receive the appropriate care.
 Women who have been identified as ‘low risk’ may fail
to recognise complications quickly because of false
sense of belief that they are at low risk.
 Women identified as ‘high risk’ may waste
unnecessary time looking for better care in other
facilities.

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Risk Approach in Child Health
 The risk approach in child health has the same
principles as the maternal risk strategy.
 The main objective is to identify the ‘at risk’ infants
and children and to provide special care
immediately. If the care is not available in the health
centre, the infant/child has to be referred to the
nearest hospital.
 It also means ‘to provide services for all children but
to provide more (special care) for those in need’.

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Risk Approach in Child
Health (cont.)
 It is important to also realise the WHO statement,
‘that every child wherever possible is brought up
in a family unit with love and security, receives
adequate nutrition, health supervision and
medical care and is taught the elements of
healthy living’.

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High-Risk Children
 Children having medical conditions
 Congenital malformations (cleft palate, physical
handicap, etc.)
 Communicable disease (measles, diphtheria,
pertussis, severe asthma, jaundice, etc.)
 Low weight for age (malnutrition), low height for age
(stunting)
 Breast feeding problems due to cleft palate or other
problems
 Delayed milestones development
 Children born with mother having complications

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 Mother with pre-eclampsia
 Gestational diabetes (hypoglycemia or
hyperglycemia)–Large baby
 Ante-partum haemorrhage (APH)
 Type of delivery may cause injury to child (breech,
forceps or precipated delivery)
 Foetal or neonatal problems
 Intra-Uterine Growth Retardation (IUGR)
 Pre-term or post-term babies
 Apgar score < 7
High-Risk Children (cont.)

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 Neonatal jaundice
 Neonatal infection
 G6PD deficiency
 Economic factors (poverty in the family)
 Maternal education low (no schooling or only primary
school)
 Poor environmental sanitation (poor water supply,
poor waste disposal, poor sewage disposal)
 Emotional stress in the family
High-Risk Children (cont.)

CHN 2e Chapter 07 (1).ppt

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CHN 2e Chapter 07 (1).ppt