At the end of the session, the students shall be able to Enumerate the MCH indicators and describe it List the SDGs related to MCH indicators

1. Preventive Medicine in
Obstetrics, Paediatrics and
Geriatrics
Dr. Jayaramachandran S
Associate Professor
Department of Community Medicine

2. At the end of this session, you will be able to
• Enumerate the MCH indicators and describe it
• List the SDGs related to MCH indicators

3. MCH Indicators
• Maternal and child health status is assessed through mortality,
morbidity and growth & development.
Commonly used mortality indicators
1. Maternal mortality ratio
Mortality in infancy and
childhood
1. Perinatal mortality rate
2. Neonatal mortality rate
3. Post neonatal mortality rate
4. Infant mortality rate
5. 1-4 mortality rate
6. Under 5 mortality rate
7. Child survival rate

4. Maternal mortality ratio
• Maternal Death: “Death of a female while pregnant or with in 42 days
of termination of pregnancy, irrespective of duration and site of
pregnancy from any cause related to or aggravated by pregnancy or
its management
• But not from accidental or incidental causes.
• In developed countries MMR has declined significantly

5. Causes of Maternal deaths
Direct obstetric causes
• Pregnancy
• Labour
• Postnatal period
• Incorrect treatment
Indirect obstetric causes
• Resulting from previous existing
disease
• Or disease that developed
during pregnancy

6. Maternal Mortality Ratio (contd.)
• Maternal Mortality Ratio:
• =
"#$.&#.#' '()*+( ,(*$-.
,/( $# 0#)1+20*$2#&. #' 13(4&*&05,
0-2+,723$- #3 82$-2& 9: ,*5. #' ,(+2;(35 '3#)
ʹpuerperal causesʹ
2& *& *3(* 2& * 42;(& 5(*3
$#$*+ &#.#' <= 2& $-( .*)( *3(* *&, 5(*3
×1000 (or 100 000)
Maternal mortality rate, direct and indirect obstetric death
rates are fine measures of the quality of maternal services

7. Approaches for measuring maternal mortality
• Civil registration system: Birth, death registration
• Household survey
• Sisterhood methods: Interviewing a representative sample about the
survival of all their adult sisters
• Reproductive age mortality studies (RAMOS): Identify & Investigate
the cause of deaths in women (reproductive age)

8. Approaches for measuring maternal mortality
• Verbal autopsy: done in case where medical certification of cause of
death is not available
• Census

9. Incidence
• Global: 400/100, 00 LB
• India: 122 /100,000 LB
• Anaemia is the leading
cause of death and also
the aggravating factor
in sepsis, haemorrhage
and toxemia
25%
20%
13%
15%
12%
8%
8%
MMR : Global causes
Severe bleeding
Indirect causes
Unsafe abortion
Infection
Eclampsia
Obstructed labour
Other direct causes

11. Medical causes of maternal deaths
Obstetric Causes
• Toxaemia
• Haemorrhage
• Infection
• Eclampsia
• obstructed labour
• Unsafe abortion
Non Obstetric Causes
• Anaemia
• Associated diseases
• Cardiac, renal, metabolic
• Malignancy
• Accidents

12. Social causes of maternal deaths
• Age of mother at child birth
• Parity
• Too close pregnancy
• Family size
• Malnutrition
• Poverty
• Illiteracy
• Ignorance
• Delivery by untrained dais
• Poor communication & transport
• Social customs
• Poor environmental sanitation

13. Preventive & social measures to reduce MMR
• Early registration of pregnancy
• At least 4 antenatal check-ups
• Dietary supplements: Iron & FA
• Prevention of infection & haemorrhage during labour
• Prevention of complications e.g., eclampsia, ruptured & malformation
of uterus
• Treatment of medical conditions

14. Preventive & social measures to reduce MMR
• Tetanus prophylaxis
• Clean delivery practices
• Training of birth attendants
• Promotional of institutional deliveries
• Promotion of family planning
• Identification of every maternal deaths and search for its cause

15. Initiatives to improve Maternal
Health

16. Initiatives to improve Maternal Health
• Establishment of Comprehensive Emergency Obstetric and Newborn
Care (CEmONC) Centers within 30 minutes reach
• Establishment of Basic Emergency Obstetric and Newborn Care
(BEmONC) PHCs at the rate of one per block

17. Initiatives to improve Maternal Health
• Audit of every maternal death for identifying the circumstances
leading to the death and prevention of similar deaths in future
• Dr. Muthu Lakshmi Reddy Maternity Benefit Scheme – mother is paid
amount Rs 18,000 to cover expenses of child birth.
• Establishment of 24x7 delivery centers in all PHCs
• Establishment of urban PHCs

18. Initiatives to improve Maternal Health
• Establishment of birth waiting homes in the foot hills, Birth
companion scheme
• Establishment of Blood Storage centers in PHCs
• EMRI 108 ambulance services
• Hospital on Wheels in 385 Blocks for RCH outreach services

19. Initiatives to improve Maternal Health
• Establishment of 42 MCH level-II centers (CEmONC PHC)
• Functional PHC Operation Theatres
• Pregnancy and Infant Cohort Monitoring System (PICME) at the
Health Sub centre level.
• Injection iron sucrose for anaemic mothers given in PHCs and Govt.
Hospitals

20. Initiatives to improve Maternal Health
• Emergency Referral Services (Toll
free no 108) introduced in all the
districts.
• 606 Ambulances on road.
• 7 Newborn transport
ambulances are also in service

21. Initiatives to improve Maternal Health
• Establishment of 24x7 delivery
centers in all PHCs with well
trained nurses
• Establishment of urban PHCs

22. Hospital on Wheels in 385 Blocks for RCH outreach services
Initiatives to improve Maternal Health

23. Initiatives to improve Maternal Health
Diet for Antenatal mothers visiting the Ante
Natal clinics, and postnatal mothers are
provided in all PHCs.
Establishment of
Blood Storage
centers in PHCs

24. Mortality in Infancy & childhood
Still birth
Perinatal death
Early
neonatal Late
neonatal
Post neonatal deathNeonatal death
Infant death
1 year28 weeks Birth 7 days 28 days

25. Foetal death
• Death prior to complete expulsion or extraction from its mother of a
product of conception, irrespective of duration of pregnancy.
• Signs: foetus doesn’t breathe, heartbeat or pulsation of umbilical
cord & voluntary movements is absent
• Still birth rate: death of foetus weighing 1000gm (which is equal to 28
wks. of gestation) or more, occurring during one year in 1000 total
births (live + dead)

26. Foetal death – Prevention
• Diagnosis and Rx of infection
• High BP
• Rh incompatibility
• Diabetes
• Premature rupture of membranes

27. 1. Perinatal mortality rate
• Includes both late foetal deaths (still births) & early neonatal deaths
(7days) in one year/ live births.
• Minimum birth wt = 1000 g ≈ 28wks of Gestation
• or if age & wt isn’t available, body length crown to heal of at least 35
cm.
• India – 23/1000 births in 2016
•
• PMR =
"#$% &'%$#" (%#$)* (,-./* '& 0%*$ '1 2'1%)
4 %#1"5 6%'6#$#" (%#$)* 7*$ .%%/ 86 '6% 51
"89% :81$)*4"#$% &'%$#" (%#$)* 86 *#2% 51
× 1000

28. Perinatal mortality rate (contd.)
• PMR gives a good indication of the extent of pregnancy wastage as
well as the quality and quantity of health care available to the mother
and the new born
• It reflects the results of maternity care more clearly than the neonatal
death rate

29. Perinatal mortality rate (contd.)
Social / biological factors:
• Maternal age > 35 or < 16
• High parity ( with short spacing)
• Heavy smoking
• Malnutrition – severe anaemia
• Infections

30. Perinatal mortality rate (contd.)
Main Causes
• Intrauterine and birth asphyxia
• Low birth weight
• Birth trauma
• Intrauterine and neonatal infection
Antenatal causes
• Maternal diseases
• Anatomical defects
• Endocrine imbalance
• Blood incompatibilities
• Malnutrition
• Toxaemia of pregnancy
• Ante partum haemorrhage
• Congenital defects
• Advanced maternal age

31. Perinatal mortality rate (contd.)
Intra natal causes
• Birth injuries
• Asphyxia
• Obstetric complications
Postnatal causes
• Prematurity
• Respiratory distress syndrome
• Infection
• Congenital anomalies

32. 2. Neonatal mortality rate
• Number of deaths of children < 28 days of age in a year/ total number
of LB in same year
Causes of NMR
• LBW
• Birth asphyxia
• Atelectasis
• Birth injuries
• Congenital malformation
• Infections (tetanus, diarrhoea)
• NMR is more in boys as they are
biologically more fragile than
girls
• NMR in India = 18 / 1000 LB in
2016

33. 3. Post neonatal mortality rate
• Number of deaths of children between 28 days to 1 year of age in a
year / total number of LB in same year
• Exogenous factors are responsible
• Girls die more frequently than boys because of neglect of female child
in terms of nutrition and health care
• India – 23 / 1000 LB

34. 4. Infant mortality rate
• Number of deaths of children <
1 year / total number of live
births.
• Indicates:
• Health status of community
• Level of living
• Effectiveness of MCH services
• It is given a separate treatment
because:
• It is largest single age category of
mortality
• Deaths are due to peculiar set of
disease and conditions
• It is affected quickly by special
health programme

35. Infant mortality Rate (contd.)
• IMR in developed countries = 5 / 1000 LB
Reasons of low IMR in developed countries:
• Improved quality of life
• Improved perinatal care
• Better control of communicable diseases
• Advances in chemotherapy
• Better nutrition, emphasis on breast feeding
• Family planning
Any further reduction will depend upon preventing congenital anomalies

36. Infant mortality Rate (contd.)
• IMR in India – 38 / 1000 LB in 2016
State wise variations
• Kerala – 10 / 1000 LB
• Tamilnadu – 17/1000 LB
• Orissa, MP, Assam, Bihar, UP, Haryana and Raj have IMR above national
level
• Mortality patterns:
• Age – 67.6 % deaths in first month of life, of these 52 % die in first week
• Sex – females die more than males

37. Medical causes of Infant mortality
Neonatal mortality
• LBW and prematurity
• Birth injury & difficult labour
• Sepsis
• Congenital anomalies
• Haemolytic diseases of new born
• Communicable diseases
• Conditions of placenta and cord
• Diarrhoea, ARI, tetanus
Post neonatal mortality
• Diarrhoea
• ARI
• Malnutrition
• Cong anomalies
• Accidents

38. Factors affecting Infant Mortality
Cultural and social factors
• Breast feeding
• Early marriage
• Sex of child
• Quality of mothering
• Maternal education
• Quality of health care
• Broken families
• Brutal habits & customs
• Bad sanitation
• Economic factors
Biological Factors
• Birth weight
• Age of mother
• Birth order
• Birth spacing
• Multiple births
• Family size
• High fertility

39. Preventive and social measures
Multi approach
• Prenatal nutrition
• Prevention of infection – EPI
• Breast feeding
• Growth monitoring
• Family planning
• Sanitation
• PHC – detecting mothers with
high risk factors
• Socioeconomic development
• Education

40. 5. 1-4 years mortality rate
• Number of deaths of children aged 1-4 years / Total number of
children aged 1-4 years at the middle of year X 1000
• More refined indicator of situation of country than IMR.
• Reflects environmental hazards
• In developing countries – 30
• In developed countries – < 1
• 2nd year of life accounts 50% of all deaths in 1-4 yrs. Of life

41. Causes of 1-4 years mortality
Developing countries
• Diarrhoea
• ARI
• Malnutrition
• Infectious diseases
• Accidents
Developed countries
• Accidents
• Cong anomalies
• Malignancies
• Influenza
• Pneumonia

42. 6. Under 5 mortality rate (birth-5yrs)
• UNICEF defines and considers it as “Annual number of deaths of
children under 5 years expressed as a rate / 1000 LB”
• Best single indicator of social development and well being as it
reflects the income, nutrition, health care and basic education
• World – 39 / 1000 LB (2017)
• India – 39 / 1000 LB (2017)

44. 7. Child Survival Index
• The basic measure of infant and child survival is the Under-5 mortality
• Child survival rate/ 1000 LB is calculated as
CSI = 1000 – Under 5 mortality rate / 10
• CSI of India = 96.06%

45. Initiatives to improve Infant Health
• Nutrition interventions through ICDS
• High level of immunization coverage
• Establishment of Newborn Intensive Care Units
• Sick Newborn Care units
• Inclusion of Paediatric emergencies under Hon’ble
• Chief Minister’s Comprehensive Health Insurance

46. Initiatives to improve Child Health
• To control anaemia among the children in the age group of 1-3 yrs, 1
ml ( 20 mg) of IFA syrup is given for 100 days.
• IFA tablet is given to the children in the age group of 3- 5 years
• All 2 - 5 years children are given one dose of albendazole once in 6
months.
• Vitamin A administration is organized on Campaign basis (during
March and September) for all children in the age group of 6 – 60
months .

47. SDGs related to MCH indicators

51. Written assignment to be submitted
1. List the MCH mortality indicators.
2. Enumerate the causes of MCH mortality
indicators and discuss the measures in brief
to improve MCH indicators.

52. The test of any civilization is the
measure of consideration and care
which it gives to its weaker members
Any Questions?