10095752550
Section 7 : Family Health140   Maternal and Child Health                                           A S Kushwaha           ...
during childbirth, or after the baby has been born due to blood   140         Maternal and Child Health                   ...
of children under age five are stunted or too short for their           risks are highest for both mother and child.age. A...
Attributable Risk : This brings together three ideas - the  141      Risk Approach in MCH                                 ...
planned. The risk approach has to be studied by research and          To give an example, if it was the Perinatal and mate...
Basic information needed for planning the use of Risk                  negligent or dangerous work pattern and numerous in...
in maximizing the output from the limited resources available                                                     of the r...
that was not due to direct obstetric causes but was aggravated       to have a healthy mother and a healthy child at the e...
worm may be provided during 2nd/3rd trimester. Under RCH a          appear -minimum of three visits are to be made.       ...
as possible in labour and 50 mg in oral solution form to the        for vehicle, money and blood can be difficult to make ...
neglected postnatal period can be the cause of significant          Breakdowns of access to skilled care due to war, strif...
(b)	 Infection (sepsis)                                                             needing hospital care depends, to some...
Lack of decision making power in terms of family planning             also what mothers and their families ask for. Puttin...
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Human resources section7-textbook_on_public_health_and_community_medicine
Upcoming SlideShare
Loading in …5
×

Human resources section7-textbook_on_public_health_and_community_medicine

2,597 views

Published on

AFMC WHO Textbook Community Medicine

0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
2,597
On SlideShare
0
From Embeds
0
Number of Embeds
2
Actions
Shares
0
Downloads
48
Comments
0
Likes
1
Embeds 0
No embeds

No notes for slide

Human resources section7-textbook_on_public_health_and_community_medicine

  1. 1. 10095752550
  2. 2. Section 7 : Family Health140 Maternal and Child Health A S Kushwaha 809141 Risk Approach in MCH A S Kushwaha 811142 Maternal Health Care AS Kushwaha 814143 Care of Infants A S Kushwaha 826144 Integrated Management of Neonatal and Childhood Illnesses (IMNCI) A S Kushwaha 835145 Care of Under Five Children A S Kushwaha 848146 School Health Services A S Kushwaha 853147 Adolescent Health A S Kushwaha 856148 Children’s Right to Health A S Kushwaha 865149 Growth and Development of Children A S Kushwaha 869150 Genetics and Public Health Amitava Datta 878151 Preventive Health Care of the Elderly RajVir Bhalwar 887152 Demography and Public Health Dashrath R. Basannar 891153 Contraceptive Technology RajVir Bhalwar 895
  3. 3. during childbirth, or after the baby has been born due to blood 140 Maternal and Child Health loss and infections. The 5,29,000 annual maternal deaths, including 68,000 deaths attributable to unsafe abortion, almost all of these are occurring in poor countries with only A S Kushwaha 1% in rich countries. Each year 3.3 million babies are stillborn, more than 4 million (neonatal deaths) are dying within 28The health of women and children has always been an important days of coming into the world, and a further 6.6 million youngsocial goal of all societies. Over the years, maternal and child children die before their fifth birthday. Although an increasinghealth has evolved through various stages of conceptual number of countries have succeeded in improving the healthapproach, technological advances and social prioritization. and well-being of mothers, babies and children in recentThe realization that, improved maternal and child health is the years, in some countries the situation has actually worsened.key to the ultimate objective of lifelong health in any society, Slow progress, stagnation and reversal are closely relatedhas led to renewed interest and global focus towards this very to poverty, to humanitarian crises, and, particularly in sub-important social health issue. Saharan Africa, to the direct and indirect effects of HIV/AIDS.Mother and Child: A Single Entity Over 300 million women in the world currently suffer fromMother and child are often spoken of in one breath for a number of long-term or short-term illness brought about by pregnancy orreasons. Health of the child and the mother are so closely linked childbirth. Programmes to tackle vaccine preventable diseases,that each has the capacity to influence the other. The outcome malnutrition, diarrhoea, or respiratory infections still have aof pregnancy in terms of a healthy newborn is dependent on large unfinished agenda. the physical, physiological, mental and nutritional state of the Indiamother during pregnancy. Some specific health interventions Health of Women : The country has a falling low sex ratiojointly protect pregnant women and their babies e.g. tetanus of 933 female per thousand male. Early marriage in womentoxoid immunization and nutrition supplementation. At and universality of marriage are important social issues. Thechildbirth, both mother and child are at risk for complications median age at first marriage among women is 17.2 years.which can endanger their lives. The postpartum care of the Almost half (46%) of women age 18-29 years got married beforemother is inseparable from newborn care, immunization and the legal minimum age of 18. Among young women age 15-19,family planning advice, and this provides not only operational 16 percent have already begun childbearing. Indians have poorconvenience but offers continuity of care as well. knowledge about temporary contraceptive methods and thisImportant Sub Disciplines Related to MCH coupled with poor availability affects ‘delaying the first and spacing the second child’ doctrine adversely. Among the marriedThere are a number of sub disciplines that have developed over women, 13 percent have unmet need for family planning. Lessthe years in the field of maternal and child health. It is in this than half of women receive antenatal care during the firstendeavour that disciplines like social obstetrics, preventive trimester of pregnancy, as is recommended. Three out of everypediatrics, community obstetrics, family health and family five births in India take place at home; only two in five birthsmedicine have originated. Various initiatives in child health take place in a health facility. Less than half of births tookinclude essential newborn care, well baby clinics, under five place with assistance from a health professional, and moreclinics, Child guidance clinics and school health services. than one third were delivered by a Traditional Birth Attendant.Why So Much Attention to This Issue? The remaining 16 percent were delivered by a relative or otherFirstly, together, mothers (women 15-45 years of age) and untrained person. A Disposable Delivery Kit (DDK) is beingchildren (under 15 years of age) constitute 70-80% of the used only in 20% of births taking place at home. Most womenpopulation. They also belong to the most vulnerable section of receive no postnatal care at all. Only 37 percent of motherssociety in terms of death, disease, disability and discrimination. had a postnatal checkup within 2 days of birth. Every sevenWomen and Children represent economically dependent and minutes an Indian woman dies from complications related toleast empowered section of the society. The falling sex ratio pregnancy and childbirth. The maternal mortality ratio in India(from 972 in 1901 to 933 in 2001) is a grim reminder of the stands at 300 per 100,000 live births. (Table - 1).social disadvantage faced by women in India(1). The issue Child Health : Infant mortality is 77 per 1,000 for teenagealso merits attention because of high morbidity and mortality mothers, compared with 50 for mothers age 20-29. Infantfaced by this group. Most of the deaths and illnesses in these mortality in rural areas is 50 percent higher than in urban areas.groups are avoidable by cost effective interventions which are Perinatal mortality, which includes stillbirths and very earlyavailable to tackle them. infant deaths (in the first week of life), is estimated at 49 deathsScenario of Maternal and Child Health per 1,000 pregnancies, that lasted 7 months or more. Less than half (44%) of children 12-23 months are fully vaccinated againstGlobal Picture : Of the estimated 211 million pregnancies that the six major childhood illnesses: tuberculosis, diphtheria,occur each year, about 46 million end in induced abortion. pertussis, tetanus, polio, and measles. Although breast feedingAttending to all of the 136 million births every year is one of is almost universal in India, only 46 percent of children under 6the major challenges that is now faced by the world’s health months are exclusively breastfed. Many infants are deprived ofsystems. Globally, huge toll on account of maternal deaths the highly nutritious first milk (colostrum) as only 55 percentcontinues unabated. Often sudden, unpredicted deaths occur are put to the breast within the first day of life. Almost halfduring pregnancy itself (as a consequence of unsafe abortion), • 809 •
  4. 4. of children under age five are stunted or too short for their risks are highest for both mother and child.age. Anaemia is a major health problem in India, especially Place: Linking the delivery of essential services in a dynamicamong women and children. Among children between the ages primary-health-care system that integrates home, community,of 6 and 59 months, about 70 percent are anaemic including outreach and facility-based care. The impetus for this focus isthree percent who suffer from severe anaemia. More than half the recognition that gaps in care are often most prevalent atof women in India (55 percent) have anaemia with 17 percent the locations – the household and community – where care isof these have moderate to severe anaemia. most required. The continuum of care concept has emerged in recognition of the Table - 1: Important Mortality indicators of Maternal and fact that maternal, newborn and child deaths share a number of Child Health (Source-NFHS 3) similar and interrelated structural causes with undernutrition. Indicator 1994 2000 2001 2002 2003 2004 2005 The continuum of care also reflects lessons learned from IMR 74 68 65.9 64 60 58 58 evidence and experience in maternal, newborn and child health during recent decades. In the past, safe motherhood and NNMR 47.7 44 40.2 NA 37 37 37 child survival programmes often operated separately, leaving PNMR 26 23 25.7 NA 23 21 22 disconnections in care that affected both mothers and newborns. PMR 42.5 40 26.2 NA 33 35 37 It is now recognized that delivering specific interventions at pivotal points in the continuum has multiple benefits. Linking SBR 8.9 8 9.3 NA 9 10 9 interventions in packages can also increase their efficiency and MMR 327 301 cost-effectiveness. The primary focus is on providing universal coverage of essential interventions throughout the life cycle in an integrated primary-health-care system. IMR Infant Mortality rate NNMR Neonatal Mortality rate Road Ahead The NRHM and RCH are aimed at meeting this challenge and PNMR Post-Neonatal Mortality Rate have set out their targets as envisaged under various policies PMR Perinatal Mortality Rate and MDGs. (See Table - 2) SBR Still Birth Rate Table - 2 : The Road Ahead (National targets for MCH) MMR Maternal Mortality Ratio NationalChallenges in MCH 10th Plan RCH -2 Population MDGs (byThe look at statistics in Table - 1 gives a picture of many Indicator goals (2004- Policy 2015)unfulfilled promises in the field of maternal and child health (2002-07) 09) 2000 (bydespite a family welfare programme running since 1950s. The 2010)challenges include lack of universalisation of services, rural 35 perurban differential, poor status of women in society and lack of Infant 45 per 30 per 1000political will and acceptance of the issue as a social priority. The mortality 1000 live 1000 live - livemain challenge to child survival no longer lies in determining rate births births birthsthe proximate causes of or solutions to child mortality but Under 5in ensuring that the services and education required for Reduce mortality - - -these solutions reach the most marginalized countries and by 2/3rd ratecommunities. 150 perOpportunities in MCH Maternal 200 per 1 100 per 1 1 lakh ReduceA new paradigm in MCH - Continuum of Care : The continuum mortality lakh live lakh live live by 3/4thconsists of a focus on two dimensions in the provision of ratio births births birthspackages of essential primary-health-care services:Time: There is a need to ensure essential services for mothers Referencesand children during pregnancy, childbirth, the postpartum 1. National Family Health Survey NFHS - 3 India 2005-06, Internationalperiod, infancy and early childhood. The focus on this element Institute for Population Sciences, Mumbai, India. http://www.nfhsindia.org/ nfhs3.htmlwas engendered by the recognition that the birth period – before, 2. World Health Report 2005. Make Every Mother and Child count. WHO, 2005during and after –is the time when mortality and morbidity • 810 •
  5. 5. Attributable Risk : This brings together three ideas - the 141 Risk Approach in MCH frequency of the unwanted outcome when risk factor is present, frequency of the unwanted outcome when risk factor is absent, frequency of the occurrence of risk factor in the community. A S Kushwaha It indicates what might be expected to happen to the overall outcome in the community if the risk factor was removed.Risk as a Proxy for Need Risk Factors : Risk factor is defined as any ascertainableIn every society there are communities, families and individuals characteristic or circumstance of a person or group of personswhose chances of future illness, accident and untimely death that is known to be associated with an abnormal risk ofare greater than others; they are said to be vulnerable owing to developing or being especially adversely affected by a morbidpeculiar set of characteristics they share. These characteristics process. Risk factor is one link in a chain of association leadingcould be biological, genetic, environmental, psychosocial or to an illness or an indicator of a link.economic. Similarly there are others who have a chance to enjoy Risk factors can therefore be causes or signals but they arebetter health. Thus as an example we can see that pregnant, observable and identifiable. Risk factor could be related topoor, very young children and elderly are vulnerable and young individual, family, community or the environment. Examplesand affluent are not. Risk however has come to be associated include - first pregnancy, high parity, teenage pregnancies,with the vulnerability to disease or illness or death. A pregnant malnutrition, rural area, birth attendance etc.woman with high blood pressure is at risk of complicationslike eclampsia and this measured risk to her and the child is an The significance of risk factors from the point of applicationexpression of her need for medical help and intervention. The and utility in practice of preventive community medicine canrisk strategy utilizes these risk estimates as guide for action, be judged by -resource allocation, coverage and referral care. The hypothesis, (a) Degree of association with the outcome.on which risk strategy rests, therefore, is that more accurately (b) Frequency of the risk factor in the community.the risk is measured, the better is the understanding of the Combination of Risk Factorsneed. The combination of two or more risk factors increases theThe risk approach is a managerial tool based on the strategy probability of the outcome. For example in a pregnancy, thefor efficient utilization of scarce resources with more care for hypertensive disease and poor antenatal care are independentthose in need and proportionate to the need. risk factors for perinatal mortality but when both factors areTools of the Risk Approach present, the probability of perinatal mortality is much higher than expected. This is because the risk factors may have anThe characters shared by a cohort making them vulnerable additive or multiplicative effect.are referred to as risk factors. The measure of associationwith the outcome is known as the relative risk and estimation Risk Factors and Causesof the adverse outcome if these risk factors are present and Not all significant associations between the risk factor andcalculation of effect if these risk factors are removed have made the outcome are part of a chain of causality. Associations areour decisions in public health prioritization. Risks, predictions usually described as ‘causal’ if they can be seen to be directlyand possible effects are therefore the tools of the risk approach. related to pathological processes, even if the pathways are notBy quantifying the risks to the health of a population group fully understood. e.g. Maternal malnutrition and low birthand their associated risk factors, it focuses attention on the weight, placenta praevia and foetal death from anoxia, rubellaneed for prevention. in first trimester and congenital malformation. The important attributes in such association are ‘dose response relationship,Risk Approach Applied to MCH specificity, consistency of association, time relationship andThe mothers and children are most susceptible to good or biological plausibility. The complex relationship betweenharmful influences that will permanently affect their health. risk factor and outcome can be explained by an example ofThe harm can be inflicted or the good can be promoted in a very gastroenteritis in a child belonging to a poor family whereshort time. The preventive and promotive elements of primary the complex of poverty may include contributions to risk fromhealth care will have greatest yield if applied by using risk large family size, crowding, early weaning, poor nutrition withapproach in MCH. infection of infant and neglect of early Diarrhoea for a varietyDefinitions of reasons. Thus it is more than clear that family poverty is a risk factor for gastroenteritis and death from gastroenteritis.Risk : It implies that the probability of adverse consequences The advantage of risk approach is the attention being given tois increased by the presence of one or more characteristics all causes regardless of their medical, intersectoral, economic,or factors. It is a measure of statistical chance of a future political or social origins.occurrence.Relative Risk : It measures the strength of the association Methodology in Risk Approachbetween risk factor and the outcome e.g. RR of an outcome due The risk approach involves, first, decisions as to priorityto a risk factor is 1.3, means a 30% excess risk in those with ‘targets’ or unwanted outcomes, measurement of associationthe risk factor. between risk factors and the outcome, and then intervention • 811 •
  6. 6. planned. The risk approach has to be studied by research and To give an example, if it was the Perinatal and maternalthen only applied over a wide population. mortality (Outcome) then the identification of risk factorsOutcome, Risk and Measurement : The risk approach seeks will involve screening at various levels for different riskto use information about risk to prevent a variety of adverse factors depending upon the complexity of identification andoutcome (illness, injury and death) through the application of infrastructure available and training of the health worker.a strategy at many levels of care. These decisions to refer or to keep are based on some form ofOutcomes : This is the first information required. Collect risk scoring system. For example, while doing above exercise,details of morbidity and mortality rates which are our targets suppose there is a risk scoring from 0 - 5, the scheme wouldor priorities (prevalence and incidence, trends, distribution in look like (See Table - 1).geographical area and different groups). Table - 1 : Risk Scoring SystemRisk Factors : Collect information on the following :(a) Risk factors for each unwanted outcome. Health Func - Exam Keeps Refers Returns(b) Risk factors or combinations of risk factors for each group level tionary - ines of unwanted outcome. I TBA 0, 1, 2, 0 1, 2, 3, -(c) For all risk factors - 3, 4, 5 4, 5 (i) Prevalence and incidence and trends in the II ANM 1, 2, 3, 2 3, 4, 5 1 population 4, 5 (ii) Relative risk of unwanted outcomes associated with each risk factors or combinations III Senior 3, 4, 5 3 4, 5 2 (iii) Attributable risk associated with each risk factors Nurse (iv) Predictive power of each risk factor IV Doctor 4, 5 4 5 3 (v) The ease, accuracy and acceptability of screening for the V Specialist 5 5 - 4 presence of risk factor in communities and individuals.Priorities among Outcomes : This will depend upon many Issue of False Positives and False Negativesvariables like - When screening populations, some of the difficulties faced(a) Community priority and preference are related to the issues of false positive and false negatives.(b) Prevalence or frequency of occurrence The value of risk factors at predicting outcomes is gauged by(c) The seriousness of the problem (fatality rate) proportion of the true association. There are examples where(d) Degree of preventability the cases of gastroenteritis deaths may be seen in breastfed(e) Rising frequency or upward trend of the problem (emerging infants (though less likely) while some of the bottle fed infants issues) may not suffer from gastroenteritis (less likely). The issue ofSteps false positives and false negatives may make decisions for1. Identifying the risk factors and the populations and the interpreting and introducing screening tests difficult. individuals at risk2. Selection of risk factors Risk Scoring (i) Optimum grouping Scores must accurately reflect the risk to the mother and (ii) Usefulness in terms of proposed intervention children which in itself is a proxy for the need for care. Scoring (iii) Strength of association / cause - effect relationship attempts to provide simple, easy to use index of the urgency, (iv) Ease of modification (intervention) seriousness and complexity, of the future threat to health. The (v) Ease and accuracy of identification (test) risk scores are a good managerial tool. Sources of scores are -3. Who should do the screening? (Fig - 1) (a) Ad hoc - e.g. tall or short, poor or not poor, well fed or malnourished Fig. - 1 (b) Points or score based on experience - For example, while TBA approaches all scoring for poor outcome of pregnancy, 3 points for poor pregnant mothers obstetric history, 3 for high parity, 2 for maternal age, 1 for birth interval, family income, poor education etc. TBA examines (c) Absolute risk (d) Relative risk ANM examines (e) Attributable risk Most scoring systems use the relative risk. Senior Nurse/ Doctor examines Trade off : While deciding the cut off for continuous risk factor there is a compromise between yield and resources by trade Hospital doctor off between false positive and false negatives. This decision examines is arrived at by weighing how many more false positive can Specialist sees only be afforded by the community for the desired reduction in the very high risk mothers false negatives. Referred Kept Returned • 812 •
  7. 7. Basic information needed for planning the use of Risk negligent or dangerous work pattern and numerous intercurrentApproach illnesses. Some can be modified without delay, some will have1. Age and sex distribution and geographical distribution by to wait till next pregnancy while yet others will only be changed community and household in the next generation. Modification of the community risk2. Mortality by age, sex and cause factors is probably the most important potential achievement3. Local cultural factors, occupations, religion and attitude to of the risk approach. health and disease Selecting Target Health Problems : Among many health4. Services likely to have most impact from risk approach problems of mothers and children, it is usually a simple matter5. Information on environmental risk factors to choose the most important. This choice is often coloured6. Local community organizations, groups by opinions. Most important health problems are not always7. Local health care services including personnel and the best targets for prevention. A method of rating scale which infrastructure balances the factors like prevalence, seriousness, preventability,8. Present way to deal with the MCH problems trends in time and local concern (Table - 2) is shown as an9. Information about traditional systems of medicine and example. their acceptanceIntervention at different levels of care : This is used to define Table - 2 : Selecting a health problem by Rating / Scoringthe main point of impact of an intervention within the health Health Ratingcare system. Risk approach can be applied at all levels from self Criterion Max rating Problem accordedand home to intersectoral policy.Uses of the Risk Approach Extent 10 31. Self & Family Seriousness 10 10(a) Improved ability to recognize health priorities and health Maternal Preventability 10 8 lifestyle and behavior. mortality(b) Informed surveillance of self and family. Local concern 10 10(c) Earlier self and family referral. Time trend 10 22. Local community - village groups, self help groups, Extent 10 8 women’s group.3. Application within the health care system - resource Seriousness 10 10 Neonatal allocation. Preventability 10 10 tetanus4. Increasing coverage - e.g. Universal immunization, Local concern 10 4 essential maternal and newborn care.5. Improved referral - better facilities, technology and skills. Time trend 10 56. Regional and National level - for defining and planning Extent 10 3 priorities, capacity and staffing, design referral chain, Seriousness 10 10 resource allocation and evaluation. Childhood7. Intersectoral collaboration is the key to planning, designing Preventability 10 5 RTAs and executing any health intervention. Local concern 10 7Selecting Interventions : Steps involved are - Time trend 10 8(a) Potential for change in health care - managerial, avoid authoritarian approach, no conflict with local, regional The relative importance of each criterion is also given its and national interest, local values and religious customs weight e.g. say on a five point scale, if we rate, extent and (MTP Contraception). , seriousness are given 5/5, preventability and local concern is(b) Criteria for selection - importance, feasibility, given 3/5, time trend is given 2 out of 5. A simple matrix will acceptability. set the health problems in the order of priority as seen in the(c) Local priorities for action - Maternal mortality, Infant Table - 3. deaths, Perinatal mortality. Local priorities to be specific The order of priority in the above example is: first neonatal and well defined for application of risk approach. tetanus, second maternal mortality and third childhood RTAs.(d) Local resources - people (trained and trainable), institutions, facilities and technology, managerial skills, health Lessons from the Risk Approach - information systems, funds. Most important resources are 1. Application to the whole field of Primary Health care is time, commitment, enthusiasm and cooperation. limited due to shortage of support from evaluative research.(e) National priorities Need to develop health system research.(f) Decision pathway 2. Impediments and Barriers are related to Ethical (NoModifying Risk Factors : Individual risk factors capable of research without service), Sociological (not in sync withmodification are exemplified by some taboos and cultural local culture), Problems of human motivation, Political,practices (difficult to change), malnutrition, dwarfing, managerial and technical problems and Shortage of skilledinadequate family planning services, lack of concern for human resources.environmental hazards, unsatisfactory personal hygiene, The risk approach in MCH is a very useful tool and can help • 813 •
  8. 8. in maximizing the output from the limited resources available of the risk approach. The preventive and promotive elementsespecially in the developing countries. The risk approach helps of primary health care will have greatest yield if applied byto ease the pressure on the limited beds and facilities at the using risk approach in MCH. Risk factors could be related tohospital level and also saving the expert human resources and the individual, family, community and environment and theirsophisticated equipment for those who need it most. The risk significance can be judged by their frequency and the degreeapproach also helps in developing health auxiliaries at the of their association with the outcome. The risk approachperiphery providing the basic care in MCH close to home to the involves prioritizing targets, measuring associations and theclientele within acceptable socio - cultural milieu. The policies interventions to be applied. Info about the risk factors can beand principles of care under NRHM using ASHA are an example obtained through prevalence, incidence, trends, relative risk ofof this approach. unwanted outcomes and attributable risk associated with each risk factors and predictive power of risk factors. Prioritization Table - 3 : Selecting a problem by rating/scoring will depend upon community priority, prevalence, fatality rates, degree of preventability and rising trend. Risk scoring (most Criteria and Relative weightage of them use relative risk) if used must reflect the risk to the mother and the child. Health problem Preventability Local concern Increased coverage, improved referral, risk factor modification, Seriousness Total score Time trend local, national and regional reorganization and training are the (weight 5) (weight 5) (weight 3) (weight 3) (weight 2) some of the uses of risk approach. The risk approach in MCH Extent is a very useful tool maximizing the output with the limited number of tools available in addition to developing the health auxiliaries at the periphery. Maternal 3x5 10x5 8x3 10x3 2x2 123 mortality Study Exercises Neonatal Long Question : Risk approach in MCH 8x5 10x5 10x3 4x3 5x2 142 tetanus Short Notes : (1) Basic information needed for planning the Childhood use of risk approach (2) Risk scoring (3) Uses of risk approach 3x5 10x5 5x3 7x3 8x2 117 RTAs within and outside the health care system (4) Steps for selecting interventions.Summary ReferencesThe risk strategy utilizes the risk estimates as guide for action, 1. Backett E M, Davies A M, Petros - Barvazian A. Public Health Papers No 76: The Risk approach in health care, with special reference to maternal andresource allocation, coverage, referral and care. Therefore child health, including family planning, WHO Geneva, 1984the more accurately the risk is measured the better is the 2. Edwards L E et al. A simplified antepartum risk scoring system. Obstetricsunderstanding of the need for efficient utilization of scarce and Gynaecology, 54:237 - 240 (1979)resources with more care for those in need and proportionate 3. Sogbanmu M. Perinatal mortality and maternal mortality in General hospital, Ondo, Nigeria: Use of high risk pregnancy predictive scoring index. Nigerianto the need. Risk, predictions and possible effects are the tools Medical Journal, 9: 123 - 127 (1979) Definitions 142 Maternal Health Care Maternal Death : Maternal death is defined as death of a woman, while pregnant or within 42 days of termination of AS Kushwaha pregnancy, irrespective of the duration and site of pregnancy, from any cause related to or aggravated by pregnancy or itsAll mothers and newborns, not just those considered to be management but not from accidental or incidental causes.at particular risk of developing complications, need skilled (ICD-10)maternal and neonatal care. Maternal health care includes Direct Obstetric Deaths : The deaths resulting from obstetricAntenatal, Intranatal care and Postnatal care, Quality intranatal complications of the pregnant state (pregnancy, labour andcare is critical to achieve the aim of a healthy mother and a the puerperium), from interventions, omissions, or incorrecthealthy baby at the end of a pregnancy. This particular period treatment, or from a chain of events resulting from any of the(perinatal) though constitutes, only a small fraction in terms above are called direct obstetric deaths.of its share (0.5 %) in the maternity cycle, but is probably, the Indirect Obstetric Deaths : Those resulting from previousmost crucial. existing disease or disease that developed during pregnancy and • 814 •
  9. 9. that was not due to direct obstetric causes but was aggravated to have a healthy mother and a healthy child at the end ofby the physiological effects of pregnancy. pregnancy. Antenatal care includes visit to antenatal clinic,Late Maternal Death : Late maternal death is death of a examination, investigations, immunization, supplementswoman from direct or indirect obstetric causes, more than 42 (Iron, Folic acid, Calcium, Nutritional) and interventions asdays but less than one year, after termination of pregnancy. required. This is a comprehensive approach to medical care and psychosocial support of the family that ideally begins prior toPregnancy Related Death : To facilitate the identification conception and ends with the onset of labour. Preconception careof maternal death in circumstances in which cause of death refers to physical and mental preparation of both parents forattribution is inadequate, ICD-10 introduced a new category, pregnancy and childbearing in order to improve the pregnancythat of “pregnancy-related death” which is defined as : the death outcome (Refer Box - 1). Antenatal (Prenatal) care formallyof a woman while pregnant or within 42 days of termination of begins with the diagnosis of pregnancy and includes ongoingpregnancy, irrespective of the cause of death. assessment of risk, education and counselling and identifyingSkilled Birth Attendant : Skilled Birth Attendants are people and managing problems if they arise (Box - 2).with midwifery skills (e.g. doctors, midwives, nurses) who havebeen trained to proficiency in the skills necessary to manage a Box - 1 : Indications for Preconception Carenormal delivery and diagnose and refer obstetric complications.This includes capacity to initiate the management of Advanced maternal (>35 years) or paternal (>55 years)agecomplications and obstetric emergencies, including life-saving History of neural tube defects in family or previousmeasures where needed. Ideally skilled attendants live in, and pregnancyare part of the community they serve. Congenital heart disease, hemophilia, thalassemia, sickleMeasurement of Maternal Mortality cell disease, Tay-sach’s disease, cystic fibrosis, HuntingtonThere are three main measures of maternal mortality- the chorea, muscular dystrophy, Down’s syndrome.maternal mortality ratio, the maternal mortality rate and the Maternal metabolic disorderslifetime risk of maternal death. Recurrent pregnancy loss (>3)Maternal Mortality Ratio : This represents the risk associated Use of alcohol, recreational drugs or medicationswith each pregnancy, i.e. the obstetric risk. It is calculated asthe number of maternal deaths during a given year per 100,000 Environmental or occupational exposureslive births during the same period. This is usually referred to asrate though it is a ratio. Box - 2 : Objectives of Antenatal CareThe appropriate denominator for the Maternal Mortality Ratio To promote, protect and maintain health of the motherwould be the total number of pregnancies (live births, foetaldeaths or stillbirths, induced and spontaneous abortions, To detect ‘at risk’ cases and provide necessary careectopic and molar pregnancies). However, this figure is To provide advise on self care during pregnancyseldom available and thus number of live births is used as the To educate women on warning signals, child care, familydenominator. In countries where maternal mortality is high planningdenominator used is per 1000 live births but as this indicatoris reduced with better services, the denominator used is per To prepare the woman for labour and lactation1,00,000 live births to avoid figure in decimals. To allay anxiety associated with pregnancy and childbirthMaternal Mortality Rate: It measures both the obstetric risk To provide early diagnosis and treatment of any medicaland the frequency with which women are exposed to this risk. condition/ complication of pregnancyIt is calculated as the number of maternal deaths in a givenperiod per 100,000 women of reproductive age (usually 15- To plan for “Birth” and emergencies / complications (where,49 years). From the year 2000, the SRS (Sample Registration how, by whom, transport, blood)System) has introduced this method of verbal autopsy called To provide care to any child accompanying the motherRHIME (Representative, Re-sampled, Routine HouseholdInterview of Mortality with Medical Evaluation). Frequency : Under optimal conditions a women shouldLifetime Risk of Maternal Death undergo regular antenatal health check once a month during first seven months, twice a month for 8th month and everyThis parameter takes into account both the probability of week thereafter till delivery. However, a minimum of four visitsbecoming pregnant and the probability of dying as a result of are essential.the pregnancy cumulated across a woman’s reproductive years.Lifetime risk can be estimated by multiplying the maternal Essential Antenatal Care : Under CSSM program three antenatalmortality rate by the length of the reproductive period (around visits have been recommended as minimum acceptable level35 years). This is also approximated by the product of the Total of antenatal care. Early registration by 12-16 weeks followedFertility Rate and the Maternal Mortality Ratio. by visits at 20, 32 and 36 weeks is recommended during any pregnancy. At least one home visit by health worker must beAntenatal Care made. Essential Antenatal Care also includes immunizationThe care of women during pregnancy is called antenatal care. with tetanus toxoid and Iron Folic Acid supplements for 100This begins soon after conception. The ultimate objective is days. Deworming with mebendazole in areas endemic for hook • 815 •
  10. 10. worm may be provided during 2nd/3rd trimester. Under RCH a appear -minimum of three visits are to be made. (a) Bleeding PV at any point ( Antepartum haemorrhage)History Taking and Examination : During history taking (b) Excessive vomiting ( Hyperemesis gravidarum)important points to be covered are detailed medical, (c) Hypertension, proteinuriapsychosocial and immunization history followed by careful (d) Severe anaemiaphysical examination and certain relevant laboratory tests. (e) Abnormal weight gainPhysical examination should include measurement of height, (f) Multiple pregnancy, hydramnios, oligohydramniosweight, pelvimetry (not very important). Important laboratory (g) Abnormal presentation in 9th monthtests include hemoglobin, urinalysis, PAP smear, VDRL and any (h) Preterm Labour, PROMother test as warranted by the concerned physician. There is (i) Pre-eclampsia, eclampsiaan opportunity for health promotion like cessation of tobacco, Health Educationalcohol, manage pre-existing medical disorders, appropriate This is one of the most important and often neglected functionsimmunization and pregnancy planning. of antenatal care. This is also called prenatal advice. TheFirst Visit : The patient is registered and antenatal card is communication between the mother and the service providerinitiated. First visit should be made at the earliest possible should be free and encompass the issues concerning not onlyafter pregnancy is suspected, ideally at 8 weeks of gestation but pregnancy but should spillover to childbirth and childcare.not later than 12-16 weeks. This is important for determining The family planning issues like spacing and sterilization areaccurate EDD, evaluation of risk and to provide essential better received at this time. Important issues that need to bepatient education. The functions of this visit are- deliberated are given below.(a) Confirmation of pregnancy (a) Diet & Rest(b) Screening for high risk pregnancy (b) Personal Hygiene and Habits(c) Baseline investigations (c) Sexual intercourse(d) Initiation of Iron and Folic Acid supplementation (d) Drugs(e) Immunization with Tetanus toxoid (if visit in 2nd (e) Exercise trimester) (f) Travel(f) Education of the mother on pregnancy and childbirth (g ) Care of BreastsIdentification of “High Risk” Pregnancies (h) Weight Gain Warning signs : Besides education on common symptomsThe identification of high risk pregnancies involves meticulous and their management, the woman should be educated onhistory taking, careful examination and relevant investigations. warning signs during pregnancy which should not be ignored.The identification of these high risk pregnancies should follow She should report to health facility in case she has any of theneedful referral and care. History should cover all aspects as warning signs. The warning signs are-outlined for preconception care. The ‘at risk’ pregnancies canbe identified as under- (i) Swelling of feet (ii) Convulsions/ unconsciousnessMaternal Factors (iii) Severe headache(i) Age- <18 years or > 35 years (especially in primigravida) (iv) Blurring of vision(ii) Multiparity (> 4) (v) Bleeding or discharge per vaginum(iii) Short stature ( < 140 cms ) (vi) Severe abdominal pain(iv) Weight < 40 Kg / weight gain < 5 Kg (vii) Other unusual symptom(v) Rh negative Pregnancy & HIV InfectionBad Obstetric History(i) Recurrent abortions ( 2 x1st trimester or 1 mid-trimester) This situation is likely to be encountered in states where HIV(ii) Intrauterine death or intrapartum death/ stillbirth prevalence amongst antenatal cases is high. This will require(iii) Prolonged labour, birth asphyxia , early neonatal death special handling. The urgency of preventing mother-to-child(iv) Previous caesarean section / scar dehiscence transmission (PMTCT) of HIV is clear. Without treatment, half(v) Postpartum haemorrhage, manual removal of placenta of the infants born with the virus will die before age two.(vi) Baby which is LBW, SFD or large for date, congenitally Significant reductions in mother-to-child transmission, however, malformed can occur through implementation of basic but critical actions,(vii) Malpresentation, instrumental delivery, ectopic pregnancy such as identifying HIV-infected pregnant women by offering(viii) Twins, hydramnios, pre-eclampsia routine HIV testing, enrolling them in PMTCT programmes,Medical Disorders ensuring that health systems are fully able to deliver effective antiretroviral regimens both for prophylaxis and for treatment,(i) Cardiac (RHD, CHD, Valve defects), Renal, Endocrine and supporting women in adhering to optimal and safe (Thyroid) or Gastrointestinal disease. infant feeding. The counselling of women early in pregnancy(ii) Infections - TB, Leprosy, Malaria etc. on risk of transmission to the baby and testing of spouse is(iii) Hypertension, Diabetes, IHD and Seizures mandatory. AZT 300 mg every 12 hours is given from 36 weeks(iv) Anaemia of pregnancy till onset of labour and thereafter 300mg every 3Besides the above, the pregnancy at any stage can be classified hours. Alternatively, Nevirapine 200 mg single dose as earlyas high risk if any of the following conditions/ complications • 816 •
  11. 11. as possible in labour and 50 mg in oral solution form to the for vehicle, money and blood can be difficult to make if notnewborn within 72 hours is recommended to prevent mother already planned and can be crucial for the life of both motherto child transmission. After delivery, this also helps to make and child. Institutional delivery should be encouraged.required adaptations in infant feeding. Replacement feeding Institutional delivery should be advocated as it is the right ofusing principles of AFASS (acceptable, feasible, affordable, safe every pregnant woman.and sustainable) is a viable solution to prevent transmission ofinfection through breast feeding. Intranatal Care and Postnatal CarePlanning for Birth (Birth Plan) Objectives of Intranatal Care - (AMC-N) 1. Thorough Asepsis (“The Five Cleans” - clean hands,This is an important function of the prenatal care. The planning surface, blade, cord, tie)for birth and emergencies is very important as it can take care 2. Minimum injury to mother and childof many unforeseen complications which may endanger life of 3. To deal with any Complications during labourboth mother and the child and may arise at any point of time 4. Care of the Newbornwithout any prior warning in an otherwise normal pregnancy.Plans made early for emergencies during pregnancy and labour The Postpartum Carewill result in favourable outcomes. The birth plan helps to The Postpartum Care is aimed at achieving a Puerperium whichtide over the uncertain and sudden nature of complications of is free of any complications and to ensure a healthy newborn.labour. The delivery will take place at hospital or home must be (Box - 4)decided (See Box - 3). Box - 4 : Objectives of Postpartum care Box - 3 : Institutional delivery is a must if there is- 1. Restoration of mother to optimum health Mild pre-eclampsia 2. To prevent complications of puerperium PPH in the previous pregnancy 3. Provide basic postpartum care & services to mother and More than 5 previous births or a primi child Previous assisted delivery 4. Motivate, educate and provide family planning services Maternal age less than 16 years 5. To check adequacy of breast feeding H/o third-degree tear in the previous pregnancy The Postpartum Visits : The first 48 hours following delivery Severe anaemia are the most important. The next most critical period is the first Severe pre-eclampsia/eclampsia week following delivery. The mother is asked to pay another visit on day 3rd and day 7th, or the ANM in charge of that APH area should pay a home visit during this period. The second Transverse foetal lie or any other Malpresentation postpartum visit should be planned within 7-10 days after Caesarean section in the previous pregnancy delivery. A visit at 6 weeks is mandatory to see that involution of uterus is complete. Further visits can be once a month Multiple pregnancies for 6 month and thereafter every 2-3 months till the end of Premature or pre-labour rupture of membranes (PROM) one year. Efforts to organize 3 - 6 visits must be made. If the Medical illnesses such as diabetes mellitus, heart disease, woman misses her postpartum visits, she should be informed asthma, etc. regarding the danger signs which if appear she should report back (Box - 5).In case of delivery at home what arrangements are there to Complications of the Puerperium : The postpartum periodovercome any unanticipated complication? The arrangement is often neglected after having a successful parturition. Sadly, Box - 5 : Danger Signs in Puerperium Advise the woman and her family to go to an FRU Advise the woman that she should visit immediately, day or night, WITHOUT WAITING the PHC as soon as possible, if . . . (i) Excessive vaginal bleeding, i.e. soaking more than 2 (i) Fever or 3 pads in 20-30 minutes after delivery, or bleeding (ii) Abdominal pain increases rather than decreases after the delivery (iii) The woman feels ill (ii) Convulsions (iv) Swollen, red or tender breasts, or sore nipples (iii) Fast or difficult breathing (v) Dribbling of urine or painful micturition (iv) Fever and weakness; inability to get out of bed (vi) Pain in the perineum or pus draining from the perineal area (v) Severe abdominal pain (vii) Foul-smelling lochia • 817 •
  12. 12. neglected postnatal period can be the cause of significant Breakdowns of access to skilled care due to war, strife and HIVmortality in mother and the newborn. The infections and may rapidly result in an increase of unfavourable outcomes,haemorrhage are two serious dangers of Puerperium. Besides as in Malawi or Iraq. Malawi is one country that experienced athese UTIs, thrombophlebitis and psychiatric disorders are also significant reversal in maternal mortality: from 752 maternalseen (Box - 6). deaths per 100,000 live births in 1992 to 1120 in 2000 due to rise in HIV prevalence. Fewer mothers gave birth in health Box - 6 : Common Complications of the Puerperium facilities: the proportion dropped from 55% to 43% between 2000 and 2001. The quality of care within health facilities 1. Puerperal sepsis deteriorated in Iraq as sanctions during the 1990s severely 2. Urinary tract infections disrupted previously well-functioning health care services, and 3. Breast infections maternal mortality ratios increased from 50 per 100,000 in 1989 to 117 per 100,000 in 1997 (12). 4. Venous thrombosis Scenario in India 5. Pulmonary thromboembolism Every seven minutes an Indian woman dies from complications 6. Puerperal haemorrhage related to pregnancy and childbirth. The maternal mortality 7. Incontinence of urine ratio in India stands at 300 per 100,000 live births. It has 8. Psychiatric disorders some high performing states like Kerala with MMR of 110 and poorly doing states like Uttar Pradesh with MMR of 517 (13).Maternal Mortality The highlight is that most of the states recording unfavourable maternal mortality rates are the ones with the highest numberGlobal Burden of birth rates and huge population bases with poor healthMaternal mortality is currently estimated at 5,29,000 deaths infrastructure. There are a number of reasons India has suchper year, a global ratio of 400 maternal deaths per 100,000 a high maternal mortality ratio. Marriage and childbirth at anlive births (1). There are immense variations in maternal early age, lack of adequate health care facilities, inadequatedeath rates in different parts of the world (See Table - 1). Only nutrition and absence of skilled personnel, all contribute toa small fraction (1%) of these deaths occurs in the developed pregnancies proving fatal. The common causes of maternalworld. Maternal mortality ratios range from as high as 830 per mortality in India are anaemia, haemorrhage, sepsis, obstructed100,000 births in some African countries to as low as 24 per labour, abortion and toxaemia. Maternal morbidities are the100,000 births in European countries. Of the 20 countries with anaemias, chronic malnutrition, pelvic inflammations, liverthe highest maternal mortality ratios, 19 are in sub-Saharan and kidney diseases. In addition, the pathological processesAfrica. In sub-Saharan Africa, the lifetime risk of maternal of some preexisting diseases, such as chronic heart diseases,death is 1 in 16, (See Table 1) compared with 1 in 2800 in hypertension, kidney diseases and pulmonary tuberculosis arerich countries (2). Rural populations suffer higher mortality aggravated by pregnancy and childbirth.than urban dwellers, rates can vary widely by ethnicity or by ‘Delay’ Model Leading to Maternal Deathsocio-economic status, and remote areas bear a heavy burdenof deaths. Such deaths often occur suddenly and unpredictably. The maternal deaths can be explained by this model of delayBetween 11% and 17% of maternal deaths happen during which is due to:childbirth itself and between 50% and 71% in the postpartum (a) Delay in seeking careperiod (3-7). The fact that a high level of risk is concentrated (b) Delay in transport to appropriate health facilityduring childbirth itself, and that many postpartum deaths are (c) Delay in provision of adequate carealso a result of what happened during birth, focuses attention Causes of Maternal Mortalityon the hours and sometimes days that are spent in labour and Maternal deaths result from a wide range of indirect and directgiving birth. The postpartum period - despite its heavy toll of causes (See Fig. 1 & 2). Maternal deaths due to indirect causesdeaths - is often neglected. Within this period, the first week represent 20% of the global total. They are caused by diseasesis the most prone to risk. About 45% of postpartum maternal (pre-existing or concurrent) that are not complications ofdeaths occur during the first 24 hours, and more than two pregnancy, but complicate pregnancy or are aggravated by it.thirds during the first week (3). These include malaria, anaemia, HIV/AIDS and cardiovascular disease. Their role in maternal mortality varies from country Table - 1 : Life Time Risk of a Woman to country, according to the epidemiological context and the health system’s effectiveness in responding. Losing a Of dying due to Continents The lion’s share of maternal deaths is attributable to direct Neonate Maternal cause causes. Direct maternal deaths follow complications of Africa 1 in 5 1 in 16 pregnancy & childbirth or are caused by any interventions, Asia 1 in 11 1 in 132 omissions, incorrect treatment or events that result from these complications, including complications from unsafe abortion. Latin America 1 in 21 1 in 188 The four major direct causes of maternal loss are- Developed countries 1 in 125 1 in 2976 (a) Haemorrhage • 818 •
  13. 13. (b) Infection (sepsis) needing hospital care depends, to some extent, on the quality(c) Eclampsia of the first-level care provided to women; for example, active(d) Obstructed Labour management of the third stage of labour reduces postpartum bleeding. The proportion that dies depends on whether Fig. - 1 : World - Causes of Maternal Mortality appropriate care is provided rapidly and with the degree of skill with which it is provided. Infection : The second most frequent direct cause of death is sepsis, responsible for most late postpartum deaths. This Indirect causes is often a consequence of poor hygiene during delivery. The 20% introduction of aseptic (clean delivery) techniques brought a Severe bleeding (Haemorrhage) spectacular reduction of its importance in the developed world. 25% However, sepsis is still a significant threat in many developing countries. Other Direct causes 8% Eclampsia : Classic complications of pregnancy include pre- eclampsia and eclampsia which affect 2.8% of pregnancies in Infections developing countries and 0.4% in developed countries leading Unsafe abortion 15% to many life-threatening cases and over 63 000 maternal deaths 13% worldwide every year accounting for 12 % of the maternal Obstructed Eclampsia deaths (17). Labour 12% Obstructed Labour : The prolonged or obstructed labour 20% accounts for about 8% of maternal deaths. This is often caused by fetoopelvic disproportion or by malpresentation (transverse lie, mentoposterior, brow presentation). Disproportion is more Note : Total is more than 100% due to rounding off common where malnutrition is endemic, especially among populations with various traditions and taboos regarding the Fig. - 2 : India - Causes of Maternal Mortality diets of girls and women. It is worse where girls marry young and are expected to prove their fertility, often before they are fully grown. Others Abortions : More than 18 million induced abortions each 14% year are performed by people lacking the necessary skills or Anaemia in an environment lacking the minimal medical standards, 24% Malposition or both, and are therefore unsafe resulting in 68000 deaths 7% (18, 19). Almost all take place in the developing world. With 34 unsafe abortions per 1000 women, South America has the Puerperal highest ratio (19). Unsafe abortion is particularly an issue 10% for younger women. Around 2.5 million, or almost 14% of all unsafe abortions in developing countries, are among women Haemorrhage under 20 years of age. The proportion of women aged 15-19 23% Toxemia years in Africa who have had an unsafe abortion is higher than 10% in any other region. Abortion Others : Haemorrhage following placental abruption or 12% placenta praevia affects about 4% of pregnant women. Less common, but very serious complications include ectopic Source : Registrar General India.Causes of Maternal Mortality in Rural India pregnancy and molar pregnancy. Maternal malnutrition is a huge global problem, both as protein-calorie deficiency andHaemorrhage : The most common cause of maternal death as micronutrient deficiency. Anaemia is an important indirectis severe bleeding, a major cause of death in both developing cause of maternal death due to cardiovascular deaths but alsoand developed countries (14,15). Postpartum bleeding can kill is an important underlying factor in many direct causes likeeven a healthy woman within two hours, if unattended. It is haemorrhage and sepsis.the quickest of maternal killers. An injection of oxytocin or Factors underlying the medical causesergometrine given immediately after childbirth is very effective Socio-Economic : The factors underlying the direct causesin reducing the risk of bleeding. In some cases a fairly simple of maternal deaths operate at several levels. The low social- but urgent - intervention such as massage of the uterus, and economic status of girls and women is a fundamentalremoval of clot or manual removal of the placenta may solve determinant of maternal mortality in many developing countriesthe problem. Other women may need a surgical intervention including India. Low status limits the access of girls and womenor a blood transfusion, both of which require hospitalization to education and good nutrition as well as to the economicwith appropriate staff, equipment and supplies. The proportion resources to pay for health care or family planning services. • 819 •
  14. 14. Lack of decision making power in terms of family planning also what mothers and their families ask for. Putting it intoputs them to repeated childbearing. Excessive physical work practice is a challenge that many countries have not yet beencoupled with poor diet leads to poor maternal outcomes. Many able to meet.deliveries in rural areas are either conducted by relatives or Training of Traditional Birth Attendant - A Failedtraditional birth attendant or at times none. In India three out Experiment! : In the 1970s, training of traditional birthof every five births take place at home; only two in five births attendants (TBAs) to improve obstetric services becametake place in a health facility. However, the percentage of births widespread in settings where there was a lack of professionalin a health facility has increased steadily. health personnel to provide maternity care, and where thereNutritional : Poor nutrition before and during pregnancy were not enough beds or staff at hospital level to give allcontributes in a variety of ways to poor maternal health, obstetric women access to hospital for their confinement. TBAs alreadyproblems and poor pregnancy outcomes. Stunting predisposes existed and performed deliveries (for the most part in ruralto cephalopelvic disproportion and obstructed labour. Anaemia areas), they were accessible and culturally acceptable and theymay predispose to infection during pregnancy and childbirth, influenced women’s decisions on using health services. Whileobstetric haemorrhage and are poor operative risks in the event WHO continued to encourage this strategy until the mid-1980sif surgery is required. Severe vitamin A deficiency make women but evidence emerged that training TBAs has had little impactmore vulnerable to obstetric complications. Iodine deficiency on maternal mortality.increases the risk of stillbirths and spontaneous abortions. Actions for Safe Motherhood : Countries vary widely in termsLack of dietary calcium appears to increase the risk of pre- of the situations and challenges they face and their capacityeclampsia and eclampsia during pregnancy. to address these. However, it is seen that to reduce maternalImpact of Maternal Deaths (India) mortality requires coordinated, long term efforts. Actions are needed within families and communities, in society as a whole,Maternal death has implications for the whole family and an in health systems, and at the level of national legislation andimpact that rebounds across generations. The complications policy.that cause the deaths and disabilities of mothers also damagethe infants they are carrying. The impact is summarized as Legislative & Policy actions : Long term political commitmentunder- is an essential prerequisite. This leads to adequate resource(a) Children who lost their mothers are more likely to die allocation and policy decisions are taken. A supportive social, within two years of maternal death. economic and legislative environment allows women to access(b) 10 times the chance of death for the neonate. the healthcare. (transport, money, social barriers limit the(c) 7 times the chance of death for infants older than one access) month. (a) Family planning : To avoid pregnancies that are too early,(d) 3 times the chance of death for children 1 to 5 years. too late or too frequent.(e) Enrolment in school for younger children is delayed and (b) Adolescents : To encourage late marriage and childbearing older children often leave school to support their family. by increasing educational opportunities. To improve theirSignificant reduction in infant mortality can be achieved by nutritional status by supplementary nutrition (e.g. ICDS-improving the access to care during labour, birth and the critical Kishori Shakti Yojna). Education of adolescents on reproductivehours immediately afterwards. health and empowerment of women to control fertility andMeasures to Reduce Maternal Mortality reproduction.What is known about Reducing Maternal Mortality? (c) Barriers to access : Provision of skilled health worker at village level health facility to overcome problems of distance andThe countries that have successfully managed to make transport. These workers to be adequately trained in midwiferymotherhood safer have three things in common. and paid adequately and to be provided with adequate supplies(a) First, policy-makers and managers were informed: they and at minimal cost. were aware that they had a problem, knew that it could be tackled, and decided to act upon that information. (d) Develop protocols : Aimed at providing both routine(b) Second, they chose a common-sense strategy that proved maternal care and referral facilities for obstetric complications. to be the right one: not just antenatal care, but also (e.g. IMNCI, 2005-Guidelines on pregnancy by MCH Division of professional care at and after childbirth for all mothers, by Ministry of Health & Family Welfare) skilled midwives, nurse-midwives or doctors, backed up by (e) Decentralization and delegation : Decentralized facilities hospital care. available close to people’s homes together with written policies(c) Third, they made sure that access to these services - and protocols to allow delegation of certain functions at lower financial and geographical - would be guaranteed for the levels. entire population. (f) Abortion : Availability of safe abortion services and policyWhere strategies other than that of professionalization of to discourage illegal and unsafe abortions.delivery care are chosen or where universal access is not Society and Community Interventions : The long termachieved, positive results are delayed. This explains why many commitment of politicians, planners and decision makers todeveloping countries today still have high levels of maternal programmes on safe motherhood depends on popular supportmortality. To provide skilled care at and after childbirth and from community and religious leaders, women’s groups, youthto deal with complications is a matter of common sense - it is • 820 •

×