important programmes related to OBGY

1. HEALTH BUDGET 2021

2. l

5. • As part of the plan process, many different programmes have been brought together under the
overarching umbrella of National Health Mission (NHM), with National Rural Health Mission
(NRHM) and National Urban Health Mission (NUHM) as its two subMissions.
• The National Health Mission was approved in May 2013. The main programmatic components
include health system strengthening in rural and urban areas; Reproductive - Maternal -
Newborn - Child and Adolescent Health (RMNCH+A); and control of communicable and
noncommunicable disease
A list of interventions currently being implemented under NHM to reduce IMR and MMR is
given below
• Promotion of institutional deliveries through Janani Suraksha Yojana.
• Capacity building of health care providers in basic and comprehensive obstetric care.
• Operationalization of sub-centres, primary health centres, community health centres and district
hospitals for providing 24 x 7 basic and comprehensive obstetric care services.

6. • Name based web enabled tracking of pregnant women to ensure antenatal, intranatal and
postnatal care.
• Mother and child protection card in collaboration with the Ministry of Women and Child
Development to monitor service delivery for mothers and children.
• Antenatal, intranatal and postnatal care including iron and folic acid supplementation to
pregnant & lactating women for prevention and treatment of anaemia.
• Village health and nutrition days in rural areas as an outreach activity, for provision of maternal
and child health services.
• Janani Shishu Suraksha Karyakram (JSSK)
Entitles all pregnant women delivering in public health institutions to absolutely free and no
expense delivery including caesarean section. The initiative stipulates free drugs, diagnostics,
blood and diet, free transport from home to institution, between facilities in case of a referral, and
drop back home.
Similar entitlements have been put in place for all sick infants accessing public health institutions
for treatment.

7. • JANANI SURAKSHA YOJANA
• The National Maternity Benefit scheme has been modified
into a new scheme called Janani Suraksha Yojana (JSY). It
was launched on 12th April, 2005. The objectives of the
scheme are - reducing maternal mortality and neonatal
mortality through encouraging delivery at health institutions,
and focusing at institutional care among women in below
poverty line families.
• The salient features of Janani Suraksha Yojana are as follows
1. It is a 100 per cent centrally sponsored scheme.
2. Under National Rural Health Mission, it integrates the benefit
of cash assistance with institutional care during antenatal,
delivery and immediate post-partum care.

9. • special focus in 10 low performing states (LPS)
(states having low institutional delivery rate), namely Uttar Pradesh, Uttarakhand,
Madhya Pradesh, Jharkhand, Bihar, Rajasthan, Chattisgarh, Odisha,
Assam and Jammu & Kashmir.
• In LPS, all women are given cash incentive while in HPS only below poverty line, SC, ST
women are given cash incentive.

10. New addition to the national health mission in budget 2021

11. •Mission lndradhanush
Launched by the ministry of health and family welfare (govt. of india)
On dec 25, 2014.
The mission indradhanush, depicting seven colours of the rainbow, aim to cover all those
children by 2020 who are either unvaccinated, or are partially vaccinated against seven
vaccine preventable diseases which include-
1. Diphtheria
2. Pertussis or Whooping Cough
3. Tetanus
4. Polio
5. Tuberculosis
6. Measles
7. Hepatitis B
Four phases of Mission Indradhanush have been conducted till August 2017 and more than 2.53
crore children have been vaccinated.

12. • INTENSIFIED MISSION INDRADHANUSH(IMI)
• launched the Intensified Mission Indradhanush (IMI) on October 8, 2017. Through this
programme, Government of India aims to reach each and every child up to two years of age and
all those pregnant women who have been left uncovered under the routine immunisation
programme/UIP.
• immunisation coverage in select districts and cities to ensure full immunisation to more than
90% by December 2018.
• consecutive immunization rounds were conducted for 7 days - every month between October
2017 and January 2018.
• Intensified Mission Indradhanush has covered low performing areas in the selected districts
(high priority districts) and urban areas.
• Special attention was given to unserved/low coverage pockets in sub-centre and urban slums
with migratory population. The focus was also on the urban settlements and cities identified
under National Urban Health Mission (NUHM).

13. • INTENSIFIED MISSION INDRADHANUSH(IMI) 2.0
• To boost the routine immunization coverage in the country, Government of India has introduced
Intensified Mission Indradhanush 2.0 to ensure reaching the unreached with all available
vaccines and accelerate the coverage of children and pregnant women in the identified districts
and blocks from December 2019-March 2020.
• The salient features of IMI 2.0 are:
1. Conduction of four rounds of immunization activity over 7 working days excluding the RI
days, Sundays and holidays.
2. Enhanced immunization session with flexible timing, mobile session and mobilization by
other departments.
3. Enhanced focus on left outs, dropouts, and resistant families and hard to reach areas.
4. Focus on urban, underserved population and tribal areas.
5. Enhance political, administrative and financial commitment, through advocacy.
• With the launch of Intensified Mission Indradhanush 2.0, India has the opportunity to achieve
further reductions in deaths among children under five years of age, and achieve the Sustainable
Development Goal of ending preventable child deaths by 2030

14. •Mother and Child Tracking System (MCTS):
• A name based mother and child tracking system has been put in place which is web based to
ensure registration and tracking of all pregnant women and new born babies so that provision of
regular and complete services to them can be ensured.
•Rashtriya Bal Swasthya Karyakram (RBSK)
• For health screening and early intervention services has been launched to provide
comprehensive care to all the children in the age group of 0-18 years in the community.
• The purpose of these services is to improve the overall quality of life of children through early
detection of birth defects, diseases, deficiencies, development delays including disability.

15. •Under National Iron Plus Initiative (NIPI)
• Through life cycle approach, age and dose specific IFA supplementation programme is being
implemented for the prevention of anaemia among the vulnerable age groups like under-5
children, children of 6-10 years of age group, adolescents, pregnant and lactating women and
women in reproductive age along with treatment of anaemic children and pregnant mothers at
health facilities.

22. REPRODUCTIVE, MATERNAL, NEWBORN, CHILD
AND ADOLESCENT HEALTH (RMNCH+A)
STRATEGY( 2013 )

23. • In June 2012, the Government of India, Ethiopia, USA and the UNICEF convened the "Global
Child Survival Call to Action :
• A Promise to Keep" summit in Washington, DC to energize the global fight to end preventable
child deaths through targeted interventions in effective, life-saving interventions for children.
• To reduce child mortality to 20 child deaths per 1000 live births in every country by 2035.
• Eight months after the event, in February 2013, the Government of India held its own historic
Summit on the Call to Action for Child Survival, where it launched "A Strategic Approach to
Reproductive, Maternal, Newborn, Child, and Adolescent Health (RMNCH+A) in India.'' Since
that time, RMNCH + A has become the heart of the Government of India's flagship public
health programme, the National Health Mission .

24. 5 x 5 matrix for high impact RMNCH + A interventions To be
Implemented with High Coverage and High Quality

27. Maternal and Child Health (MCH) Wing
• Most health facilities, especially those at secondary and tertiary level are having high case load
of pregnant women and newborn due to increase in institutional deliveries following launch of
JSY and JSSK.
• Therefore, it has been decided that dedicated Maternal and Child Health Wings will be
established in high case load facilities with adequate provision of beds.
• The new MCH wings will be comprehensive units (30/50/100 bedded) with antenatal waiting
rooms, labour wing, essential newborn care room, SNCU, operation theatre, blood storage units
and a postnatal ward and an academic wing. This will ensure provision of emergency maternal
and newborn care services as well as 48 hours stay, i.e ., quality postnatal care to mothers and
newborns.

28. Antenatal visits
• Ideally the mother should attend the antenatal clinic once a month during the first 7 months;
twice a month, during the next month; and thereafter, once a week, if everything is normal.
• Minimum of 4 visits covering the entire period of pregnancy should be the target, as shown
below : The suggested schedule is as follows :
1st visit - within 12 weeks, preferably as soon as the pregnancy is suspected, for registration of
pregnancy and first antenatal check-up.
2nd visit - between 14 and 26 weeks.
3rd visit - between 28 and 34 weeks.
4th visit - between 36 weeks and term.
Registration of pregnancy within 12 weeks is the primary responsibility of the ANM.

29. ASHA
(Accredited Social Health Activist)
• ASHA must be resident of the village - a woman (married/ widow/divorced) preferably in the
age group of 25 to 45 years with formal education upto eight class, having communication skill
and leadership qualities.
• Adequate representation from the disadvantaged population group will ensure to serve such
groups better. The general norm of selection is one ASHA for 1000 population. In tribal, hilly
and desert areas the norm could be relaxed to one ASHA per habitation.

30. 1. ASHA will take steps to create awareness and provide information to the community on
determinants of health such as nutrition, basic sanitation and hygienic practices, healthy
living and working conditions, information on existing health services, and the need for
timely utilization of health and family welfare services.
2. She will counsel women on birth preparedness, importance of safe delivery, breast-feeding
and complementary feeding, immunization, contraception and prevention of common
infections including reproductive tract infection/sexually transmitted infection and care of
the young child.
3. ASHA will mobilize the community and facilitate them in accessing health and health
related services available at the anganwadi/subcentre/primary health centres, such as
immunization, antenatal check-up, postnatal check-up, supplementary nutrition, sanitation
and other services being provided by the government.

31. 4. She will arrange escort/accompany pregnant women and children requiring
treatment/admission to the nearest pre-identified health facility i.e. primary health
centre/community health centre/First Referral Unit.
5. ASHA will provide primary medical care for minor ailments such as diarrhoea, fevers, and
first-aid for minor injuries. She will be a provider of directly observed treatment short-course
(DOTS) under revised national tuberculosis control programme.
6. She will also act as a depot holder for essential provisions being made available to every
habitation like oral rehydration therapy, iron folic acid tablet, chloroquine, disposable delivery
kits, oral pills and condoms etc. A drug kit will be provided to each ASHA. Contents of the kit
will be based on the recommendations of the expert/technical advisory group set up by the
government of India, and include both AYUSH and allopathic formulations.

32. 7. She will work with the village health and sanitation committee of the gram panchayat
to develop a comprehensive village health plan.
8. Her role as a provider can be enhanced subsequently. States can explore the possibility of
graded training to her for providing newborn care and management of a range of common
ailments, particularly childhood illnesses.
9. She will inform about the births and deaths in her village and any unusual health
problems/disease outbreaks in the community to the sub-centre/primary health centre.
10. She will promote construction of household toilets under total sanitation campaign

33. LAQSHYA
• After launch of the National Health Mission (NHM), there has been substantial increase in the
number of institutional deliveries. However, this increase in the numbers has not resulted into
improvements in the key maternal and new-born health indicators.
• Ministry of Health & Family Welfare has launched an ambitious program 'LaQshya – Labour
room Quality Improvement Initiative' with objectives of reducing preventable maternal and new
born mortality, morbidity and stillbirths associated with the care around delivery in Labour
room and Maternity OT and ensure respectful maternity care.
• LaQshya is focused and targeted approach for improving intra-partum and post-partum care.

35. •RESPECTFUL MATERNITY CARE IMPORTANT
• Respectful Maternity Care is an integral part of Quality of Care (QoC), which is increasingly
recognized internationally as a critical aspect of the maternal and newborn health agenda.
• A woman’s positive or negative memories of childbearing experiences stay with her throughout
her lifetime. Women who experience disrespect and abuse are less likely to seek skilled health
care in the future.
• Studies show that violating women’s rights during childbirth leads women to distrust health care
providers and facilities.
• These women are not only less likely to seek out maternity care— such as postnatal and
emergency obstetric care— but other health services as well, such as family planning.

41. A birth companion plays a vital role in
1. Providing emotional support to the mother.
2. Early identification of danger signs and information to service providers.
3. Provide support in basic care practices such as maintaining hydration of mother during labor,
keeping the baby covered and early initiation of breast feeding, etc.

43. VANDEMATARAM SCHEME
• This is a voluntary scheme where any obstetric and gynaec doctor, maternity home, nursing
home, MBBS doctor can volunteer themselves for providing safe motherhood services. The
enrolled doctors will display 'Vandemataram logo' at their clinic.
• Iron and Folic Acid tablets, oral pills. TT injections etc. will be provided by the respective
District Medical Officers to the 'Vandemataram doctors/ clinics' for free distribution to
beneficiaries.
• The cases needing special care and treatment can be referred to the government hospitals, who
have been advised to take due care of the patients coming with Vandemataram cards.

44. MATERNAL MORTALITY RATIO
• According to WHO, a maternal death is defined as ''the death of a woman while pregnant or
within 42 days of termination of pregnancy, irrespective of the duration and site of pregnancy.
from any cause related to or aggravated by the pregnancy or its management.
• MMR =
Total no. of female deaths due to complications of pregnancy, childbirth
or within 42 days of delivery from "puerperal causes “
in an area during a given year X 1000 (or 100.000)
Total no. of live births in the same area and year

45. Major causes of maternal deaths in India

46. • Maternal deaths mostly occur from the third trimester to the first week after birth (with the
exception of deaths due to complications of abortion ).
• About 80 per cent of maternal deaths are due to direct causes i.e . obstetric complications of
pregnancy, labour and puerperium to interventions or incorrect treatment. As shown in Fig.
• single most common cause-accounting for a quarter of all maternal deaths - is obstetric
haemorrhage, generally occurring postpartum which can lead to death very rapidly in the
absence of prompt life-saving care.

47. CAUSES
• Medical causes:-
• A) Obstetric causes:
1. Haemorrhage
2. Infection
3. Obstructed labour
4. Unsafe abortion
• B)Non obstetric causes:
1. Anaemia
2. Associated diseases. e.g .. cardiac. renal, hepatic metabolic
3. Infectious
4. Malignancy
5. Accidents

48. • Social factors
1. Age at child birth
2. Parity
3. Too close pregnancies
4. Malnutrition
5. Poverty
6. Illiteracy
7. Lack of maternity services, Shortage of health manpower
8. Delivery by untrained dais
9. Poor environmental sanitation Poor communications and transport facilities
Social customs. etc.

49. According to the Ministry of Health and Family Welfare India has been witnessing
a progressive decline in maternal mortality
year MMR
2011-2013 167
2014-2016 130
2015-2017 122
2016-2018 113
India is on track to achieving the Sustainable Development Goals (SDG) of 70 per 1 lakh live
births by 2030 .
The number of states which have achieved the SDG target has now risen from 3 to 5 viz.
Kerala (43), Maharashtra (46) Tamil Nadu (60), Telangana (63) and Andhra Pradesh (65).
Chhattisgarh (159), Rajasthan (164), Madhya Pradesh (173), Uttar Pradesh (197) and Assam
(215) -- the MMR is above 150.

50. ATTEMPT TO LOWER MMR
1. Early registration of pregnancy, At least four antenatal check-ups.
2. Dietary supplementation, including correction of anaemia.
3. Prevention of infection and haemorrhage during puerperium.
4. Prevention of complications, e .g., eclampsia, malpresentations, ruptured uterus.
5. Treatment of medical conditions, e.g., hypertension, diabetes, tuberculosis, etc;
6. Tetanus prophylaxis.
7. Clean delivery practice. (clean hands, clean perineum, clean
delivery surface, clean cord and tying instruments, and clean cutting surfaces)
8. In India, a large number of maternal deaths could be prevented with the help of trained village
level health workers.
9. Institutional deliveries for women with bad obstetric history and risk factors.

51. 10. Promotion of family planning - to control the number of children to not more than two,
and spacing of births.
11. Identification of every maternal death and searching for its cause.
Safe abortion services
• Despite best antenatal care. some women may develop complications without warning signs and
require emergency care.
• Essential obstetric care and establishment of first referral units (FRUs) for emergency obstetric
care is, therefore, a high priority under the safe motherhood component of Reproductive and
Child Health programme, Janani Suraksha Yojna, Janani Shishu Suraksha Karyakram,
establishment of MCH wings and RMNCH+A are key strategies to accelerate the pace of
decline of MMR.
• Equally important is an attack on social and cultural factors.

52. Holistic Nutrition or POSHAN Abhiyaan or National
Nutrition Mission
To improve nutritional outcomes for children, pregnant women and lactating mothers. Launched
by the Prime Minister on the occasion of the International Women’s Day on 8 March, 2018

59. POSHAN ABHIYAN 2.0
• To strengthen nutritional content, delivery,
outreach, and outcome, merge the Supplementary
Nutrition Programme and the Poshan Abhiyaan
and launch the Mission Poshan 2.0.
• Adopt an intensified strategy to improve
nutritional outcomes across 112 aspirational
districts,

60. Surrogacy (Regulation) Bill, 2020

61. •SURROGACY-
• The word surrogate is derived from latin word “subrogare” (to substitute) means “appointed to
act in place of”.
• The world’s second and India’s first IVF (In Vitro Fertilization) baby Kanupriya alias Durga
was born in Kolkata on October 3, 1978.

62. Gestational surrogacy
• Mostly practiced in India and has also got a legal status in the country. This procedure is
generally preferred as there is no genetic relation of a surrogate to the child whom she is
nurturing. The gestational surrogacy is a process in which the eggs from biological mother and
father are fertilized in the lab using in vitro fertilization.
• The eggs are then transferred to surrogate’s embryo after three to five days after they are
matured enough to implant in surrogate mother’s womb. As gestational surrogacy, do not make
use of surrogate’s egg. Therefore, the child will not be related to the surrogate biologically.
Traditional surrogacy:
• unlike gestational surrogacy, in traditional surrogacy, the surrogate is related to child
genetically and acts both as the genetic and the surrogate of the child for parents. The surrogate
is making use of a procedure called intrauterine insemination, or IUI.

63. Altruistic or uncompensated surrogacy
• No payment is given to the surrogate as a reward for carrying the pregnancy. However, it is
possible all the expenses during pregnancy or as a consequence of being pregnant, including
maternity clothes, special care, emotional support, special diet, etc.
Commercial, gainful, or paid surrogacy
• When gestational carrier is paid to carry child to maturity in her womb, sometimes referred to as
“womb to rent” or “outsourced pregnancy” or “baby farms” this is illegal in india.
REVRESE SURROGACY
• Surrogate donates her eggs which is fertilized husband’s sperm and embryo is transferred to the
wife’s uterus.

64. • Eligibility criteria for intending couples which include ‘certificate of essentiality’ and a
‘certificate of eligibility’ issued by the appropriate authority.
• A certificate of essentiality shall be issued when the following conditions are fulfilled:
1. a certificate of a medical indication in favor of either or both members of the intending couple
or intending woman for gestational surrogacy from a District Medical Board.
2. An order of parentage and custody of the surrogate child passed by a Magistrate’s court
3. Insurance coverage for a period of 36 months from 16 months provided in the earlier version
which covers postpartum delivery complications for the surrogate.
4. The period of proven infertility has been reduced to one year instead of five year
• The certificate of eligibility for the intending couple shall be issued upon fulfilment of the
following conditions:
1. the couple being Indian citizens
2. between the ages of 23 to 50 years old (wife) and 26 to 55 years old (husband)
3. they do not have any child biologically, adopted or through surrogacy and it would not include
a child who is mentally or physically challenged or suffers from life-threatening disorder or fatal
illness.

65. • Eligibility criteria for surrogate mother and to obtain a certificate of eligibility from the
appropriate authority, the surrogate mother has to be:
1. a married and willing woman(In 2019 bill only a close relative of a couple can be a surrogate
mother which restricts the availability of surrogate mothers) between the age of 25 to 35 years
having a child of her own.
2. surrogate only once in her lifetime
3. possess a certificate of medical and psychological fitness for surrogacy.
• For the abortion of the surrogate child, it requires the written consent of the surrogate mother
and the authorization of the appropriate authority.
• penalizes any person up to 10 years imprisonment and fine up to10 lakh rupees for offenses
such as advertising or undertaking commercial surrogacy in any manner, disowning or
exploiting the surrogate child or surrogate mother, selling or importing human embryo or
gametes for surrogacy purpose and conducting sex selection in any form for surrogacy.

66. HIV

67. PREVENTION OF PARENT-TO-CHILD
TRANSMISSION OF HIV
• The prevention of parent-to-child transmission of HIV/ AIDS (PPTCT) programme was started
in the country in the year 2002.
• The aim of the PPTCT programme is to offer HIV testing to every pregnant woman (universal
coverage) in the country so as to cover all estimated HIV positive pregnant women and
eliminate transmission of HIV from mother-to-child.

70. POST EXPOSURE PROPHYLAXIS

74. • CARE OF POSITIVE PREGNANT WOMEN
1. Anti Retro Viral Treatment for all the pregnant women irrespective of the CD4 count and
WHO clinical stage
2. Screening of all PPW for Tuberculosis and treat if necessary
3. Co-trimoxazole if the CD4 count is less than 350 cells/mm3
4. Screening for syphilis and other sexually transmitted infections
5. Counselling for ART adherence, Institutional delivery, exclusive breast feeding, safe sex
practice, disclosure to partner, and screening partner and other children for HIV
6. Regular antenatal check-ups and follow up
7. TT, iron and Folic acid, nutrition supplementation and other treatment as required
• Care during delivery:
1. Check the HIV status, if not done already or if reports are unavailable, screen for HIV
2. If known positive, and on ART, continue the same
3. If Positive Pregnant Women (PPW) is not on ART, initiate ART at the earliest

75. •Recommendations for normal delivery:
1. Follow Universal Work Precautions.
2. Minimize vaginal examinations as much as possible.
3. Do not rupture membranes artificially. Keep membranes intact for as long as possible.
Artificial rupture of membrane is reserved for cases of foetal distress or delays in the progress
of labour.
4. Avoid invasive procedures like foetal blood sampling and/or foetal scalp electrodes.
5. Avoid episiotomy as much as possible.
6. Avoid instrumental delivery as much as possible. Use low cavity outlet forceps if there is
foetal distress and maternal fatigue.
7. The cord should be clamped soon after birth. Use a gloved hand to cover the cord with gauze
before cutting to avoid splattering
8. Suctioning the new-born with a nasogastric tube should be avoided unless the meconium is
stained.

76. • Recommendations for caesarean sections:
1. Caesarean sections are not recommended unless there is an obstetric indication.
2. For elective caesarean sections, ensure ARV drugs and prophylactic antibiotics before surgery.
3. Clamp the cord as early as possible after delivery and do not milk the cord.
4. Use round-tip blunt needles for stitches.
5. Use forceps instead of fingers to receive and hold the needle.
6. Observe good practice when transferring sharps to the surgical assistant (e.g. use a holding
container).
7. For disposal of tissues, the placenta and other medical/infectious waste material from the
delivery, standard waste disposal management guidelines should be followed.
V. Post-partum care:
1. Initiate exclusive breast feeding.
2. Initiate exclusive replacement feeding if AFASS criteria are met.

77. Breastfeeding should only stop once nutritionally adequate and safe diet without
breast milk can be provided. (AFASS Criteria)

78. • ACOG :
• Pregnant women infected with HIV whose viral load is ≥ 1,000 copies/mL at or
near delivery should be offered scheduled pre labor cesarean delivery at 38 0/7
weeks of gestation.
• RCOG :For women with a plasma viral load is ≥400 HIV RNA copies/mL at 36
weeks, PLCS is recommended between 38 and 39 weeks’ gestation.

79. EPIDEMIOLOGICAL STUDY DESIGNS

86. •ADVANTAGES
1. Relatively easy to carry out.
2. Rapid and inexpensive (compared with cohort studies).
3. Require comparatively few subjects.
4. Particularly suitable to investigate rare diseases or diseases about which little is known.
•
5. No risk to subjects.
6. Allows the study of several different aetiological factors (e.g., smoking. physical
activity and personality characteristics in myocardial infarction).
7. Risk factors can be identified. Rational prevention and control programmes can be
established.
8. No attrition problems, because case control studies do not require follow-up of
individuals into the future.

87. •DISADVANTAGES
1. Recall bias-
Problems of bias relies on memory or past records. the accuracy of which may be uncertain:
validation of information obtained is difficult or sometimes impossible.
2. Selection of an appropriate control group may be difficult. Chances of miss classification in
exposed and un exposed.
3. We cannot measure incidence, and can only estimate the relative risk.
4. Do not distinguish between causes and associated factors.
5. Not suited to the evaluation of therapy or prophylaxis of disease.

88. COHORT STUDY
• ADVANTAGES
1. Incidence can be calculated.
2. Several possible outcomes related to exposure can be studied simultaneously - that is, we can
study the association of the suspected factor with many other diseases in addition to the one
under study.
3. (For example, cohort studies designed to study the association between smoking and lung
cancer also showed association of smoking with coronary heart disease, peptic ulcer, cancer
oesophagus and several others.)
4. Cohort studies provide a direct estimate of relative risk.
5. Dose response ratios can also be calculated, and Since comparison groups are formed before
disease develops, certain forms of bias can be minimized like mis-classification of individuals
into exposed and unexposed groups.

89. DISADVANTAGES
1. Cohort studies involve a large number of people. They are generally unsuitable for
investigating uncommon diseases or diseases with low incidence in the population.
2. It takes a long time to complete the study and obtain results (20-30 years or more in cancer
studies) by which time the investigators may have died or the participants may have changed
their classification. Even in very common chronic diseases like coronary heart disease, cohort
studies are difficult to carry out. It is difficult to keep a large number of individuals under
medical surveillance indefinitely.
3. Certain administrative problems such as loss of experienced staff, loss of funding and
extensive record keeping are inevitable.
4. It is not unusual to lose a substantial proportion of the original cohort - they may migrate. lose
interest in the study or simply refuse to provide any required information.
5. There may be changes in the standard methods or diagnostic criteria of the disease over
prolonged follow-up. Once we have established the study protocol, it is difficult to introduce
new knowledge or new tests later.

90. 6. Cohort studies are expensive.
7. The study itself may alter people's behaviour.
If we are examining the role of smoking in lung cancer, an increased concern in the study cohort
may be created. This may induce the study subjects to stop or decrease smoking.