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Maternal and child health

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Anshu Mittal
Anshu Mittal

This document discusses maternal and child health, with a focus on India. Some key points: - Women and children make up over half of India's population and are the most vulnerable groups. Major causes of death among children under-5 and mothers are preventable. - The principles of primary health care and treating the mother-child unit as one are important for providing integrated health services. Activities like antenatal care, safe delivery practices, postnatal care, immunizations, and breastfeeding are covered. - High-risk groups for maternal and child deaths are identified such as teenage mothers, low birth weight babies, and families with poor access to health services. Efforts are needed to reduce preventable

Health & Medicine
1 of 275
Dr. Anshu Mittal Professor Department of Community Medicine
Mother and children are priority ???  Constitute 71.4% of the population in developing countries.  In India women of reproductive age group (15-50 yrs) and children under 15 yrs constitute 57.5% of the population (22.2% and 35.3% res).  Hence major consumers of any product and health services are no exception.  They are the most VULNERABLE or SPECIAL RISK group.
WHY vulnerable....  Menstruation, Child bearing among females  Dependent, growth and development among children  50% of all the deaths occurring in country are among underfives, but not true for developed countries where it is among old populations  Similarly maternal mortality is in range of 200-400 per thousand live births against less than 20 per thousand in developed countries.
Majority of these deaths are preventable
How???  Follow the principle of equity, intersectoral coordination and community involvement  Same is followed in providing PRIMARY HEAILTH CARE  It provides integrated package of health services to mother and child considering them as ONE UNIT.
MOTHER and CHILD –One Unit  During antenatal period child is part of mother’s body  All the nutritional requirements of the foetus are met through mother....so mother needs to be well nourished to have healthy baby  Many diseases occurring during pregnancy also affect the foetus  After birth also exclusive breast feeding and child care are again mother’s responsibility  Postpartum care including advice regarding family planning also affect the health of new born  This period of care makes mother the first teacher of the child.
Linking Obstetrics, Paediatrics and Preventive and Social Medicine  Though mother care is with obstetricians and child care is with paediatricians but the principle of prevention has led to various other terms  Social Obstetrics  Preventive Pediatrics  Social Pediatrics
Social Obstetrics Study of interplay of social and environmental factors and their effect on human reproduction.  Not only conception phase is important but also preconception and even premarital period is equally important.  Socio- environmental factors include: age at marriage, age at child bearing, child spacing, family size, fertility pattern, level of education, customs and beliefs and role of women in society.
Preventive Paediatrics  Aims at providing efforts to avoid rather than curing disease and disabilities among newborn and children.  So, divided into 2parts- antenatal paediatrics and postnatal paediatrics.  Important activities include growth monitoring, oral rehydration therapy, nutritional surveillance, promotion of breast feeding, immunisation, regular health check ups.
Social Paediatrics  Study the effect of social values and social policy on child health.  It is the application of principles of social medicine to paediatrics to obtain a more complete understanding of the problems of children in order to prevent and treat disease and promote their adequate growth and development through an organised health structure.  Examples include giving prelacteal feeds, son preference, restricting diet during illness etc.
How preventive medicine helps Obstetricians and Paediatricians  Collection and interpretation of data of the population to delineate at risk groups  Association of demographic characteristics with various morbidity and mortality rates  Effect of cultural factors on utilisation of health services  Evaluation of various programmes to see their impact
Maternity Cycle  Fertilisation  Antenatal period  Intranatal period  Postnatal period  Inter- conceptional period
MCH problems  Malnutrition  Infection  Uncontrolled reproduction In developed countries congenital malformations, genetic diseases and behavioural problems are issues of concern.
MATERNAL and CHILD HEALTH  It refers to promotive, preventive, curative and rehabilitative healthcare for mothers and children.  It aims at  reduction of maternal, perinatal, infant and childhood mortality and morbidity  Promotion of reproductive health  Promotion of physiological and physical and psychological development of the child and adolescent
Components of Maternal Care  Antenatal Care  Intranatal Care  Postnatal Care
Antenatal Care  Pregnancy Detection- Urine Examination. Kits are available with the health workers under the name NISHCHAY pregnancy test kits. Also available in market.  Antenatal visits- ideally pregnant female should visit health care provider once a month till 7th month of pregnancy, then twice a month during 8th and weekly thereafter. But if not feasible at least 4 visits are minimally required....
 1st ....before 12 wks (whenever pregnancy suspected and to be registered if confirmed)  2nd......between 14 and 26 weeks  3rd.......between 28 and 34 weeks  4th.......after 36 weeks till delivery
Purpose of 1st visit  Mainly provided by MPHW (female)/ANM  Facilitates proper planning for the care to be provided to mother and foetus.  Calculate expected date of delivery from LMP.  Assess the health status of mother for any pre-existing medical illness.  To know whether pregnancy is wanted or otherwise referral for safe abortion to PHC/FRU.  Helps in rapport building for continued antenatal care.
Tasks to be carried out during antenatal visits  Antenatal examination  Prenatal advice  Specific protection  Mental preparation  Family Planning  Paediatric component
ANTENATAL EXAMINATION  History taking: Any illness/ other problems, h/o drug intake etc.  Physical Examination: Pallor, Pulse, Respiratory rate, oedema, Blood pressure, Weight, breast examination.  Abdominal Examination: Fundal height, foetal heart sounds, fetal movements, multiple pregnancies, fetal lie and presentation, any scar (previous ceasarean) etc.  Assessment of gestation age  Laboratory Investigations
Laboratory investigations  Routine (at Sub- centre): Pregnancy detection, Hb estimation, urine test for albumin and sugar, rapid malaria test.  Screening (at PHC/CHC/FRU): Blood group and Rh factor, VDRL/RPR for syphilis, HIV testing, Blood glucose estimation, HBsAg for Hepatitis B. Considering significant changes in mother and child after 24 weeks, and also to perform screening tests, it is preferred that 3rd visit should be at the PHC to be examined by medical officer.
Identify high risk cases  Elderly primi (30 yrs and above)  Short statured primi (140 cm or less)  Malpresentations  Antepartum hemorrhage, threatened abortion  Pre-eclampsia and eclampsia  Anaemia  Twins  Bad obstetric history  Elderly grand multiparas  Prolonged pregnancy (>42 weeks)  Any medical illness  Previous caesarean  Treatment for infertility
Other benefits....  Maintenance of records: Number of pregnant females, estimating requirement for manpower, infrastructure and services, timely arrangements for emergency care.  Home visits: They are carried out by health workers so as to gain confidence of the mother and build a rapport. Also it helps to understand the socio- cultural practices which may adversaly affect the pregnancy outcome and accordingly counsel the family for rectification.
PRENATAL ADVICE  DIET: Total calorie requirement during pregnancy is 60, 000 kcal over and above the routine requirement averaging at 300 kcal extra per day. Not only calories other micronutrients are also required like iron, iodine, calcium and vitamins in increased amounts to compensate for baby’s needs.  Maintain personal health: Personal cleanliness and dental hygiene, adequate sleep, exercise, avoiding smoking and alcohol and sexual intercourse.  Drugs: No drugs should be taken without advice of health care provider.
 Radiation: x- rays exposure should be avoided.  Warning signs: Mother should be told about warning signs and symptoms where medical advice must be taken. Some signs include swelling of feet, fits, headache, blurring of vision, bleeding or discharge per vaginum.  Child care: Mother craft education consisting of nutrition education, cooking demonstrations, family planning education, hygiene and child bearing, family budgeting.
SPECIFIC HEALTH PROTECTION  Anemia and other nutritional deficiencies  Toxemia of pregnancy: Increased BP. Early detection is indicated must be accordingly managed.  Tetanus: Vaccination is conducted.  Syphillis: Leading cause of pregnancy wastage. If timely diagnosed can be treated by giving penicillin for 10 days.  Rubella/ german measles: Timely vaccination should be done otherwise major congenital malformations may occur.
 Rh status: Rh negative mother with Rh positive fetus may lead to immunogenic reaction leading to hemolysis and other complications. Timely screening should be done preferably at 28 weeks and if required Rh anti D immunoglobulin should be given to mother to prevent immune reactions.  HIV infection: ART should be given to decrease MTCT of HIV.  Hepatitis B infection: If mother is HBV positive, new born should immediately receive HB Igs and Hepatitis B vaccine.  Prenatal genetic screening: Screening for chromosomal aberrations esp when there is positive history, so that timely abortion can be carried out if required.
Mental Preparation  Apprehension regarding change in body appearance  Alleviate fears regarding child birth and child rearing  Mothercraft
 Family Planning: Mother is more motivated to adopt family planning measure and she should be advised accordingly like spacing methods or terminal methods  Paediatric Component: care of the underfives accompanying the pregnant female.
INTRANATAL CARE  Process of child birth  Mainly aims at:  Asepsis...3Cleans....i.e. Hands, Surface, Cord (blade & tie)......Dai Delivery Kit  Minimal injury to the new born  Immediate Care of the baby after birth..cord, eyes, resuscitation  Preparedness for any complications needing referral like prolonged labor, antepartum hemorrhage etc.
Intranatal Care....  Institutional care: When delivery is conducted at some health centre or hospital. Mothers are motivated to have delivery at institution.  ASHA workers play key role  JSY ...Janani Suraksha Yojna ...cash incentives, free ambulance, other lodging facilities.  Preferred so as to have timely specialist services in case of emergency.  48 hrs after normal delivery and 5-7 days after c/s are recommended stay in hospital
 Domiciliary Care: When delivery is conducted at home.  Advantages: • Familiar surroundings • Chances of cross infection are less • Mother is able to keep watch on other household chores  Disadvantages: • Less expert care • Less rest • Diet and other things such as breast feeding may be neglected If institutional delivery not possible, home delivery can be carried out by trained birth attendants after ensuring asepsis but few conditions demand compulsory institutional delivery.
Indications for institutional delivery  Sluggish/ no pains after ROM  Non progressive pains  Cord/ hand prolapse  Meconium stained liquor  Faster fetal heart rate  Excessive bleeding during labor  Placenta not separated within an hour of delivery  Postpartum hemorrhage
Rooming in  Keeping the baby by mother’s side is called rooming in  Seeing the baby gives more motivation to mother for breast feeding  Allays fear regarding child’s security
POSTNATAL CARE  Objectives:  To prevent complications of postpartal period  Restoring mother’s health and to ensure exclusive breast feeding  Family planning advice  Education of mother about child care services and mothercraft
Restoring mother’s health and preventing complications  Postnatal Examination: Twice a day for first 48 hrs and the once a day till cord falls off.  Look for the progress of involution of uterus  Any dysuria, enquire about bowel movements and condition of perineal stitches if applied.  Health care provider should look for any complication like fever indicating infection.  Afterwards monthly home visits should also be done by female health worker to assess and help the mother in maintaining nutrition and physical health including motivation for regular exercise.
Breast feeding  Exclusive breast feeding till 6 months of age.  On average 400-400 ml milk is secreted daily by mother which is sufficient to meet newborn’s nutritional needs for 1st six months including micronutrients like iron and vitamin C.
Other services  Family planning Advice:  Spacing methods if family expansion is desired  OCPs to be avoided till the mother is lactating  Terminal methods if family is complete but better to be postponed till the second child is 3years old.  Mother and Child care: Immunisation, seeking health care services in times of illness, birth registration etc.
CARE OF CHILDREN Divided into different phases:  Infancy (up to 1 year of age) 1)Neonatal period (0-28 days). First seven days are also labelled as early neonatal period 2)Post neonatal period (28 days- 1year)  Preschool age (1-4 years)  School age (5-14 years)
INFANCY  Key Points:  Constitute 2.92% of the population in India  20- 30% are LBW  >60% infant mortality occurs in first month of life  Low cost measures like breast feeding, immunisation, birth spacing, growth monitoring, improved weaning, oral rehydration can save more than 3/4th of theses deaths.
Objectives of neonatal care  Maintaining vitals  Avoiding infection  Establishing breast feeding  Management of congenital conditions- infections, disabilities and disorders
Immediate Care  Clearing Airway: Utmost importance to establish breathing  APGAR score: Noted at 1min, 5min and 10min if required. Includes assessment of heart rate, respiration, muscle tone, reflex response and colour of baby. It must be 9 or above.  Care of the cord: Asepsis must be maintained to avoid infections especially tetanus neonatorum. Nothing is required to be applied to the stump and it should be kept dry.
 Care of eyes: Clean with wet swabs and single application of silver nitrate solution to prevent any gonococcal infection is sufficient. Any discharge from eyes is abnormal and should be managed at the earliest.  Care of skin: Bathing should preferably be avoided to prevent hypothermia. Sponging should be done to clean vernix, meconium and clots.  Maintain body temperature: As baby is residing in mother,s body so the outer temperature is normally cooler, hence wrap the baby in warm clothes.....hypothalamus has still not taken up temperature regulation
 Breast feeding: Should be initiated as soon as possible. Within half hour in normal delivery and 2hrs or so in case of caesarean section.  Colostrum should be given.  High in protein and antibodies.  Demand feeding should be practiced  Body contact helps to maintain temperature of new born  Breast milk is untouched so no chance of infection
 Managing Infections: Common are Neonatal tetanus, Congenital syphillis, HIV, HBV.  Measuring the baby: Weight should be recorded preferably within first hour of birth before noticeable weight loss occurs. Similarly length, head circumference, chest circumference should be measured . Anthropometry helps us to assess the gestational age of the child and to know the nutritional status. Also child’s progress can be assessed by comparing with the previous records.
Identify at-risk babies  Birth wt less than 2.5 kg  Twins  Birth order 5or more  Artificial feeding Such babies need prolonged care because of high risk of morbidities and mortality.
Late neonatal period  After first week of life risk is mainly due to under nutrition and infections commonly diarrhoea and pneumonia.  Mothers should time to time be educated about the prevention of such infections and seeking help for their timely management.
Management of Low Birth Weight Babies
Low birth weight (LBW)  Definition : Birth weight <2500 g  Incidence : 30% of neonates in India
LBW: Significance  75% neonatal deaths and 50% infant deaths occur among LBW infants  LBW babies are more prone to:  Malnutrition  Recurrent infections  Neuro developmental delay LBW babies have higher mortality and morbidity
Types of LBW Preterm  < 37 completed weeks of gestation  Account for 1/3rd of LBW Small-for-date (SFD) / intra uterine growth retardation (IUGR)  < 10th centile for gestational age  Account for 2/3rd of LBW neonates 2 types based on the origin
Causation: LBW Etiology of prematurity  Low maternal weight, teenage / multiple pregnancy  Previous preterm baby, cervical incompetence  Antepartum hemorrhage, acute systemic disease  Induced premature delivery  Majority unknown
Etiology of SFD / IUGR  Poor nutritional status of mother  Hypertension, toxemia, anemia  Multiple pregnancy, post maturity  Chronic malaria, chronic illness  Tobacco use Causation: LBW
LBW (Preterm) : Problems  Birth asphyxia  Hypothermia  Feeding difficulties  Infections  Hyperbilirubinemia  Respiratory distress  Retinopathy of prematurity  Apneic spells  Intraventricular hemorrhage  Hypoglycemia  Metabolic acidosis
LBW (SFD) : Problems  Birth asphyxia  Meconium aspiration syndrome  Hypothermia  Hypoglycemia  Infections  Polycythemia
LBW: Issues in delivery  Transfer mother to a well-equipped centre before delivery  Skilled person needed for effective resuscitation  Prevention of hypothermia - topmost priority
LBW: Indications for hospitalization  Birth weight <1800 g  Gestation <34 wks  Unable to feed*  Sick neonate* * Irrespective of birth weight and gestation
Principles of Management for Low Birth Weight and Preterm Newborns • Warmth • Feeding • Detection and management of complications (e.g., resuscitation, assisted respiration, infection )
WARMTH As for all newborns: • Lay newborn on mother’s abdomen or other warm surface • Dry newborn with clean (warm) cloth or towel • Remove wet towel and wrap/cover with a second dry towel • Bathe after temperature is stable
LBW: Keeping warm at home Skin-to-skin contact Birth weight (Kg) Room temperature (0C) 1.0 – 1.5 34 – 35 1.5 – 2.0 32 – 34 2.0 – 2.5 30 – 32 > 2.5 28 - 30 Prevent heat losses Radiation Convection Evaporation Conduction
Definition of Kangaroo Mother Care • Early, prolonged and continuous skin-to- skin contact between a mother and her newborn • Could be in hospital or after early discharge
Kangaroo Mother Care
How to Use Kangaroo Mother Care • Newborn’s position: – Held upright (or diagonally) and prone against skin of mother, between her breasts – Head is on its side under mother’s chin, and head, neck and trunk are well extended to avoid obstruction to airways • Newborn’s clothing: – Usually naked except for nappy and cap – May be dressed in light clothing – Mother covers newborn with her own clothes and added blanket or shawl ……contd
How to Use Kangaroo Mother Care • Newborn should be: – Breastfed on demand – Supervised closely and temperature monitored regularly • Mother needs lots of support because kangaroo care: – Is very tiring for her – Restricts her freedom – Requires commitment to continue
Benefits of Kangaroo Mother Care (1) • Is efficient way of keeping newborn warm • Helps breathing of newborn to be more regular; reduce frequency of apneic spells • Promotes breastfeeding, growth and extra-uterine adaptation • Increases the mother’s confidence, ability and involvement in the care of her small newborn
Benefits of Kangaroo Mother Care (2)  Seems to be acceptable in different cultures and environments  Contributes to containment of cost— salaries, running costs (electricity, etc.)
FEEDING • Early and exclusive breastfeeding – Breastmilk = best nourishment – Already warm temperature – Facilitated by kangaroo care • If Breast milk is not availble, consider milk formula : Preterm formula --- until 2000 gm then change to After Discharged Formula
Guidelines for fluid requirements  First day 60-80 ml/kg/day  Daily increment 15 ml/kg  Add extra 20-30 ml/kg for infants under radiant warmer and 15 ml/kg for those receiving phototherapy
Fluid requirements (ml/kg/ day) Birth Weight Day of life >1500 g 1000 – 1500g 1 2 3 4 5 6 7 onwards 60 75 90 105 120 135 150 80 95 110 125 140 155 170
LBW: Adequacy of nutrition Weight pattern*  Loses 1 to 2% weight every day initially  Cumulative weight loss 10%; more in preterm  Regains birth weight by 10-14 days  Then gains weight up to 1 to 1.5% of birth weight daily Excessive loss or inadequate weight  Cold stress, anemia, poor intake, sepsis
LBW: Supplements  Vitamins : IM Vit K 1.0 mg at birth Vit A 1000 I.U. per day Vit D 400 I.U. per day  Iron : Oral 2 mg/kg per day from 8 weeks of age
Danger signals (Early detection and referral)  Lethargy, refusal to feed  Hypothermia  Tachypnea, grunt, gasping, apnea  Seizures, vacant stare  Abdominal distension  Bleeding, icterus over palms/soles
Transportation of LBW baby  Adequate warmth  Life support  With mother  Referral note
Prognosis  Mortality  Inversely related to birth weight and gestation  Directly related to severity of complications  Long term  Depends on birth weight, gestation and severity of complications
Preventive measures  Direct intervention:  Prevent malnutrition in mothers especially during antenatal period.....includes both calories and specific nutrients  Control medical conditions......includes infections and systemic disorders  Avoiding alcohol and smoking  Avoiding stress...physical and mental
 Indirect Measures:  Age at marriage and at the time of birth of first child  Family planning....spacing between kids and limiting the number of children  Improving hygiene and sanitation  Improving availability and utilisation of health services  Social measures: improving literacy, women empowerment etc.
FEEDING OF THE NEWBORN
ANATOMY OF BREAST  It consists of nipple, areola and soft tissue which is composed of mammary glands and supporting tissues.  Mammary glands have alveoli and ducts which have openings at nipple.  Before the actual opening ducts are little inflated to form sinuses which help to store the milk.
STRUCTURE OF BREAST
Physiology of Breast Feeding Two sets of reflexes are there:  Reflexes in Baby  Rooting reflex: touching the cheek of baby and baby turns head to that side  Sucking reflex: Nipple & areola inside the mouth of baby, nipple touches the palate and pressing on to breast tissue with gums releasing milk. POSITIONING AND ATTACHMENT ARE VERY IMPORTANT FOR ADEQUATE BREAST FEEDING.  Swallowing reflex: Milk thus expressed into mouth touches pharyngeal wall initiating swallowing reflex
 Reflexes in the mother  Sucking and thus stimulation of nerve endings of nipple sends signal to anterior and posterior pitutary gland leading to release of hormones  Anterior pitutary: Prolactin is released leading to formation of milk by alveoli. PROLACTIN ALSO INHIBITS OVULATION THUS NATURAL CONTRACEPTIVE.  Posterior pitutary: Oxytocin is released leading to stimulation of myoepethelial cells helping in expression of milk. OXYTOCIN HELPS IN CONTROLLING POSTPARTUM BLEEDING AND AIDS INVOLUTUION OF UTERUS.
Factors affecting reflexes  Physical: pain and tenderness at breast, sore nipple, fever.  Psychological: Anxiety, tension, depression etc.  Social: Family not supportive, lack of privacy especially strangers, unwanted child birth.  Drugs: Oral contraceptive pills  Attachment is not good  Baby is offered pacifier, may not suck when actually put to breast.
Signs of Good Attachment  Baby’s chin should touch the breast, or as close as it can be  Baby’s tongue should be under the lactiferous sinuses and nipple against the palate  Mouth wide open and lower lip turned outwards  Areola if visible should be from above and not below  No pain while breastfeeding
How much....  Demand feeding should be practiced  Normally every 2 hrs but not more than 3 hrs even if baby is sleeping  2-3 feeds should be given during night  Total of 10-12 feeds must be given in 24 hrs  Each breast feeding session should be continued for 15-20 min per breast to ensure feeding of hindmilk.
Human Milk Compositions  Colostrum: First milk or milk secreted for first 2-3 days after delivery. Small in quantity, yellowish colored, rich in proteins in the form of antibodies, low in fat. Antibodies provide immunity, hence considered to be first vaccination of the child.  Foremilk: Rich in carbohydrates, minerals and vitamins and water. So help to quench thirst of the child.  Hindmilk: Rich in fats and proteins hence provides more energy and also help in growth and development.
EXCLUSIVE BREAST FEEDING  Only mother’s milk is to be given  No water, honey, glucose, any appetiser etc. are required.  No supplements required if mother’s nutritional status is good.  Should be practised for 6months of age.  An average indian female secretes 700 ml of milk per day for first six months and then it starts declining, hence complementary feeding is started.  Breast feeding should be continued for 2yrs of age or till it is possible.
Human milk vs other milk Constituent Human Milk (gm/litre) Cow’s Milk (gm/ litre) Protein 11 33 Soluble Pro 7 5 Casein 4 28 Lipids 35 35 Linoleic acid 3.5 1 Carbohydrates 70 50 Calcium 0.33 1 Phosphorus 0.15 1 Iron 0.4-1.5 0.3-0.5 Vitamin C 60mg 20mg Vitamin D 50IU 25IU Energy 640-720kcal 650kcal
ADVANTAGES OF BREASTFEEDING BABY  Bonding between mother and child  Rich in nutrients and antibodies  Easily digestible and supports growth and development...better mental development too  Affordable  Sustainable: artificial feeding may not be provided every time  Temperature is appropriate, also curtails cost of fuel which is needed in topfeed.
MOTHER  Natural method of contraception...prolactin inhibits ovulation  Involution of uterus is better  Help in weight loss gained during pregnancy  Lactating mothers, if diabetic, have shown lesser insulin dependance  Seems to provide prevention against breast cancer HELPS TO STRENGTHEN THE BOND BETWEEN MOTHER AND CHILD WITHOUT EFFORT AND MONETARY INVESTMENT
WHEN ARTIFICIAL FEED IS NEEDED  Low birth weight babies  Baby with cleft lip/ palate  Twin babies  Baby is ill..nose blockage, vomitting, any such illness where sucking or oral diet is not possible  Mother is ill...open case of TB, HIV, Hepatitis B etc.  Death of mother
BABY FRIENDLY HOSPITAL INITIATIVE  A Global movement started by WHO in 1992  AIMS:  To ensure that every newborn gets the best start in its life  To encourage correct scientific practices in breastfeeding  OBJECTIVES:  To protect, promote and to support breastfeeding practices  To reduce infant mortality rate
Ten Key Points of BFHI  Have a written breastfeeding policy that is routinely communicated to all health care staff.  Train all health care staff in skills necessary to implement this policy.  Inform all pregnant women about the benefits and management of breastfeeding.  Help mothers initiate breastfeeding within a half-hour of birth.  Show mothers how to breastfeed and how to maintain lactation, even if they should be separated from their infants.
 Give newborn infants no food or drink other than breast milk unless medically indicated.  Practice rooming-in - allow mothers and infants to remain together - 24 hours a day.  Encourage breastfeeding on demand.  Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants.  Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.
Infant and Young Child Feeding  Infant Milk Substitutes, Feeding Bottles and Infant Food Act, 1992  Prohibits the promotion of infant food, infant milk substitutes and feeding bootles  Amended in 2004, with GOALS  Exclusive breast feeding upto 6 mths instead of 4-6 mths  Continue breast feed for 2 yrs and beyond  Decrease the prevalence of undernutrition among under three years  Enhance initiation of breastfeeding including colostrum at the earliest  Increase the rate of exclusive breast feeding to 80%  Complementary feeding rates to 75%
GROWTH AND DEVELOPMENT
 GROWTH (Physical) Refers to increase in size and mass  DEVELOPMENT  Refers to attainment of functional ability in response to external stimuli
Physical Growth Assessment  Weight for Age (WFA)  Height for Age (HFA)  Weight for Height (WFH)  Head Circumference  Chest Circumference  Dentition
Weight for Age  Regular measurements are important  Every month till 2 years and every 3months till 5 years  Readings plotted on GROWTH CHART  Weight doubles by 4-5 months  Triples at one year of age  Thereafter, One birth weight added every year till puberty  At least 500gm per month increment for first 3mths but normally 1 kg per month after regaining the initial loss  Weight is matched with standard values (derived from local population), if not available then reference values can be used
Height for Age  Length of baby at birth is 50 cm  Gains 25 cm in first year  Another 12 cm in second year  Then 6-7 cm every year till puberty  Pubertal spurt adds 20cm to boys and 16 cm to girls
Head and Chest Circumference  HC approx 34 cm at birth and is more than chest circumference  Chest circumference equals HC at 6-9 mths of age in well fed babies and then it starts overtaking  Anterior fontanelle closes by the age of 9-18 mths  Posterior fontanelle closes by 3 mths of age
Dental Milestones
Assessing Development- MILESTONES Four Categories 1. Motor Development 2. Socio- Personal Development 3. Adaptive Development 4. Language Development
Milestones Age Motor development Socio-personal Adaptive development Language development 6-8 wks - Social Smile - - 3 mths Holds head erect - - - 4-5 mths - Recognises mother Try to reach to objects Listening 6-8 mths Sits without support Play with objects Making noises with toys/ objects 9-10 mths Crawling Suspicious of strangers Releases object if asked 10-11 mths Stands with support - Monosyllable speech 12-14 mths Walking Identifies family - Words like mama, papa 18-21 mths Walk properly Interested in surroundings More words 24 mths running Toilet training for day time Sentences –short and simple
Determinants of Growth and Development  Genetic Inheritance  Nutrition- Malnutrition manifests as growth retardation  Age: more in childhood then declines, different parts grow at different times  Sex: maximum height achieved is different for girls and boys, pubertal spurt also happens at different ages  Physical surroundings: Sunshine, lighting and ventilation  Psychological Factors: Interpersonal relationships  Infections  Economic Factors: Indirectly plays role by providing better nutrition and environment  Social factors: Birth order, spacing between children, son preference, education of parents etc.
Why cartoon characters have normally bigger heads than bodies...
GROWTH CHART  Graphical presentation of anthropometric measurements of human beings specifically children  Commonly used for underfive kids as they are more prone to nutritional disorders  Commonly used growth charts depict weight for age since weight is the most sensitive measure of growth and similarly any intervention is firstly expressed in terms of weight gain  First devised by David Morley  Many versions are available...WHO, NCHS, CDC, IAP  Latest being released by WHO in 2006...based on multicentric study conducted worldwide and hence considered to be more appropriate for any population.
Key Features  WHO 2006 growth charts are different for boys and girls  Reference curves are there for making comparison  These curves correspond to Z scores at different ages  Z scores range from -3 to +3  Weight ranging between -2 to +2 is considered normal  <-2 indicates undernutrition and >+2 indicates overweight  Hence, zone between -2 and +2 is considered to be “road to health”
Mother and Child Protection Card  This card (actually a booklet) is prepared on the day pregnancy is registered and continues till the newborn attains 5 years of age.  Carries information about antenatal, intranatal and postnatal period  Also carries information about infant regarding birth history, immunisation and supplementation and growth (weight for age) of the child  It is available with the health worker and mother both  Growth charts are there at the end of booklet
 To make it readable by the workers and to make it understandable for the mothers zones have been coloured accordingly  Blue band on the top of chart indicates –chart for boys pink band on the top of chart indicates –chart for girls  Three coloured zones are there on actual graph  Green zone- between -2 to +2 Z scores-normal nutrition  Yellow- <-2 Z score- Mild and moderate malnutrition  Red-< -3 Z score- Severe malnutrition
 Readings noted at frequent intervals are joined to get a curve  Curve should be in green zone and run parallel to the reference curves  Any dip in the curve/ flattening of curve even though reading is in green zone indicates something wrong with diet and should be managed  Hence, direction of curve is more important than single reading
WHO Growth Charts 2006
Mother and Child Protection Card
Uses of Growth Chart  Growth Monitoring  Diagnostic Tool- malnutrition or at risk  Planning and Policy Making  Educational Tool  Tool for Action  Evaluation  Tool for Teaching: to show effect dietary restrictions during diseased phase
Why are new growth charts devised by WHO are depicting Z-scores instead of percentiles?
INTEGRATED CHILD DEVELOPMENT SERVICES (ICDS)
Background  Started in 1975  Managed and run by Ministry of Women and Child Development  Funded by State and Central Government on 50-50 sharing basis since 2005-06  Centre of function is Anganwadi
ANGANWADI  Angan means Courtyard  Giving the kids and females a homely environment and providing services which promote their health at no extra cost  One Anganwadi Centre caters to a population of 400- 800. More centres can be established if population increases in multiples of 800.  Mini Anganwadi centre... Population of 150-400 people...to cater small villages, habitations of SC/ST or any other minorities  In tribal/ hilly/ desert/ or difficult areas....300-800 population, Mini Anganwadi at 150-300 population.
OBJECTIVES  To improve the nutritional and health status of children in the age group of 0-6 years  To lay down foundation for proper psychological, physical and social development of the child  To reduce mortality and morbidity esp due to malnutrition among 0-6 years and hence decreasing school drop-outs  To provide coordination among various departments working for the promotion of child development  To enhance capability of the mother and nutritional needs of the child through proper nutrition and health education
Three Components  Functionaries: who are responsible for providing the services available  Fit to avail services ...Beneficiaries...People for whom services are available  Functions...Services avilable
FUNCTIONARY  Main functionary is Anganwadi Worker (AWW). Also one helper is there and one cook is there.  AWW is preferably chosen from the community she is expected to serve  She undergoes 4 month training  In lieu of her services provided she is paid monthly honorarium of Rs 2400/- approx.  Helper also gets the honorarium and cook gets money for fuel used in cooking & ration is provided by the government.
Beneficiaries Services Pregnant Women 1. Health Check up 2. Immunisation against Tetanus 3. Supplementary Nutrition 4. Nutrition and Health Education Nursing Mothers 1. Health Check up 2. Supplementary Nutrition 3. Nutrition and Health Education Children <3years 1. Supplementary Nutrition 2. Immunisation 3. Health Check up 4. Referral Services Children Aged 3-6 years 1. Supplementary Nutrition 2. Immunisation 3. Health Check up 4. Referral Services 5. Non – Formal Preschool Education Adolescent girls (11-18 years) 1. Supplementary Nutrition 2. Nutrition and Health Education All women 15-45 years 1. Nutrition and Health Education
SUPPLEMENTARY NUTRITION  It is to be provided for 300 days in a year to the beneficiaries who are assigned to have the benefit Beneficiary Food specification/ day Financial support Remarks All Children 6-72 month age Calories 500 kcal Proteins 12-15 gm Rs.4 per child Cooked Meal for 3-6 year old children Take home Ration for < 3 year aged kids and pregnant and lactating mothers Children 6-72 month age (severely malnourished) Calories 800 kcal Proteins 20-25 gm Rs.6 per child Pregnant and Nursing women Calories 600 kcal Proteins 18-20 gm Rs.5 per eligible female
 Nutrition and Health Education: Given to all females of 15-45 years of age esp the pregnant and lactating ones.  Immunisation: for all the kids and pregnant women with help of Multipurpose Health Workers. Records are maintained and available for any future reference.  Health Check up:  Antenatal care and postnatal care  Registration, Immunisation, IFA supplements  Care of children under 6 years of age  Growth monitoring, immunisation, detect malnutrition and management, Vitamin A and Iron supplements, deworming, management of diarrhoea, ARI and referral services.
 Non Formal Pre School Education:  Provided to 3-6 year old children  Help to develop healthy and socially acceptable attitude, values and behaviour pattern among children  Locally made inexpensive toys and other such objects are used  No specific syllabus is there  Help the child to express himself and adjust with the group  Help to give direction to the child's actions by letting him to show his creativity
Services to Adolescent Girls  Using the infrastructure of ICDS project, a new scheme for adolescent girls ...KISHORI SHAKTI YOJANA  Nutrition programme was also started for adolescent girls .
KISHORI SHAKTI YOJANA  11-18 year old girls are benefitted  Counselling sessions or peer groups are there to discuss their problems pertaining to physical, reproductive or psychological health  Nutrition education is also imparted  Literacy and numerical skills are gained  Girls are also provided some vocational training  All this , helps them to be better home makers in future life to support their family
NUTRITION PROGRAMME  Started in 2009-10  Running in some selected villages  Girls aged 11-15 year and weighing less than 30 kg, girls aged 15-19 years weighing less than 35 kg are considered undernourished and benefitted  These girls are provided with 6kg grain every month to supplement their dietary intake, hence betterment of nutritional status
Organisational Set up  Till 2012, 6908 ICDS projects were running through 13.04 lakh AWCs  751.03 lakh children and 167.62 lakh mothers (pregnant and lactating)are getting benefits  COMMUNITY DEVELOPMENT BLOCK....Administrative Head Office of one project covering a population of 1,00,000
THE ICDS TEAM:  The ICDS team comprises the  Anganwadi Workers and Anganwadi Helpers  Supervisors ( ONE for 20-25 AWCs) also called MUKHYASEVIKA  Child Development Project Officers (CDPOs)- Incharge for 4 Mukhyasevikas and 100 AWCs  Along with: (people from Health and Family Welfare Department)  District Programme Officers (DPOs)  Medical officers  Auxiliary Nurse Midwife (ANM)  Accredited Social Health Activist (ASHA) form a team with the ICDS functionaries to achieve convergence of different services
INTERNATIONAL PARTNERS Government of India partners with the following international agencies to supplement interventions under the ICDS:  United Nations International Children’ Emergency Fund (UNICEF)  Cooperative for Assistance and Relief Everywhere (CARE)  World Food Programme (WFP)
INDICATORS OF MCH CARE  MATERNAL MORTALITY RATIO (Rate)  MORTALITY IN INFANCY AND CHILDHOOD  Perinatal mortality rate  Neonatal mortality rate  Post- neonatal mortality rate  Infant mortality rate  1-4 year mortality rate  Under five mortality rate  Child survival rate
MATERNAL MORTALITY RATIO  Death of a woman who is pregnant or within 42 days of termination of pregnancy, irrespective of the site or duration of pregnancy, from any cause related to or aggravated by the pregnancy or its management  It is expressed as: 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 Total no. Of live births in the same area and year * 1000
 The appropriate denominator for the maternal mortality ratio would be the total number of pregnancies (live births, fetal deaths or stillbirths, induced and spontaneous abortions, ectopic and molar pregnancies).  However, this figure is seldom available and thus number of live births is used as the denominator.  In countries where maternal mortality is high denominator used is per 1000 live births but as this indicator is reduced in numbers with better services, the denominator used is per 1,00,000 live births to avoid figure in decimals.
Other terms:  Late maternal death Late maternal is death of a woman from direct or indirect obstetric causes, more than 42 days but less than one year, after termination of pregnancy.  Pregnancy related death defined as : the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the cause of death.
 Direct obstetric deaths The deaths resulting from obstetric complications of the pregnant state, from interventions, omissions, or incorrect treatment, or from a chain of events resulting from any of the above are called direct obstetric deaths.  Indirect obstetric deaths Those resulting from previous existing disease or disease that developed during pregnancy and that was not due to direct obstetric causes but was aggravated by the physiological effects of pregnancy.
Statistical measures of maternal mortality  Maternal Mortality Ratio: (MMR) Number of maternal deaths during a given time period per 1000 (or 100,000) live births during the same period.  Maternal mortality Rate: Number of maternal deaths during a given time period per 1000 (or 100,000) women of reproductive age during the same period.  Adult lifetime risk of maternal death: Probability of dying from a maternal cause during a woman’s reproductive life span.  Proportional maternal deaths of women of reproductive age : Number of maternal deaths in a given time period divided by the total deaths among women aged 15- 49 years.
Sources of data providing information about Maternal Mortality  Civil Registration Systems: Birth and Death Registration  Sample Registration System  Household Surveys  Reproductive age mortality studies  Verbal autopsy to know the cause of death among women  Census
RHIME  Representative, re-sampled, routine, Household Interview of Mortality with Medical Evaluation  Started in year 2000  Modification of SRS  Conducted by independent team  Enhanced form of Verbal Autopsy  Cause of maternal death is tried to be established and classified as ICD-10 coding  Helps to compare the status on a global level in terms of nos. And the underlying causes
MMR in India and states India and States MMR Lifetime risk India 178/100,000 live births 0.4% Haryana 146 0.4 Punjab 155 0.3 Kerala 66 0.1 Tamil Nadu 90 0.2 Gujarat 122 0.3 Maharashtra 87 0.2 UP 292 1.0 Bihar 219 0.8 Rajasthan 255 0.9 Assam 328 0.8
Causes of Maternal Mortality  Direct causes- 80%  Indirect Causes- 20% (include anaemia, malaria, heart diseases etc.) Hemorrhage, 25 Infection, 15 Eclampsia, 12 Obstructed labour, 8 Unsafe Abortion, 13 Other Direct Causes, 8 Indirect Causes, 20 Causes of maternal mortality worldwide Hemorrhage Infection Eclampsia Obstructed labour Unsafe Abortion Other Direct Causes Indirect Causes
Causes of maternal mortality in India 38 115 5 8 34 Causes Hemorrhage Sepsis Hypertensive disorders Obstructed labour Abortions Other Conditions
Determinants of Maternal Mortality Medical Causes Social Factors Obstetric Causes Age at child birth Hemorrhage Parity Infection Too close pregnancies Toxemia of Pregnancy Family Size Obstructed Labour Malnutrition Unsafe Abortion Poverty Non- Obstetric causes Illiteracy Anemia Gender preference Associated systemic diseases like cardiac, renal, hepatic, metabolic etc. Women- weaker sex- often neglected and prone to domestic violence Malignancy Poor Sanitation Accidents Lack and underutilisation of MCH sevices Delivery by untrained dais Delay in availing expert services
Reasons for DELAY  Delay in identifying the danger signs  Delay in seeking care  Delay in transport to appropriate health facility  Delay in provision of adequate care ASHA worker and other local leaders and social groups can help a lot in decreasing the time lag during these events to a great extent.
Indicators for maternal health care services utilisation and current status INDICATORS NFHS-III (2005-2006) 1. Antenatal Care a. Any Visit 77.0% b. 4 visits 50.7% 2. Deliveries a. Institutional 41.0% b. Safe Delivery 48.2% 3. IFA tablets for 100 days 22.3% 4. Postnatal Check up within 2 days 36.4%
Preventive and Social Measures  Early registration of pregnancy  Atleast 4 ANC visits  Dietary supplementation esp anamia  Prevent infection  Prevent hemorrhage  Prevent and timely management of complications  Treating medical problems  Tetanus prophyllaxis  Safe delivery: Three cleans and trained birth attendants  Institutional delivery esp in high risk cases  Promote family planning  Safe abortion  Involve local leaders and NGOs for social support in terms of women literacy, no gender bias, women epowerment.
INFANT MORTALITY RATE - the ratio of infant deaths registered in a given year to the total number of live births registered in the same year; usually expressed as a rate per 1000 live births. - it is given by the formula: Number of deaths of children less IMR = than one year of age in a year ×1000 Number of live births in the same year
Why Infant mortality is important  It is largest single age-category of mortality  Cause(s) of death is very different from adults  These underlying causes are in majority preventable and hence impact of national programme implementation is noticeable  It reflects the socio-economic development of the country  Indirect determinant of human development index
Infant mortality in India  41 in the year 2012  204 during 1911-15  Madhya Pradesh- IMR of 56, & Kerala- as low as 12 per 1000 live births during the year 2012.  Kerala, Maharashtra, Punjab, T.N, W.B, A.P, Haryana, K’taka, Gujarat, H.P and Jharkhand have achieved IMR below national average of 42.  Odisha, M.P, U.P, Assam and Rajasthan- IMR > 42!
Global Scene  Average IMR of 34 per thousand live births  Ranges between 5 and 61 per thousand live births  In south east Asia – 43 per thousand live births  International comparisons Country 2013 India 41 Srilanka 8 Bangladesh 33 Pakistan 69 USA 6 UK 4 Japan 2
IMR in India (2012) State Rural Urban Combined INDIA 46 28 42 Haryana 46 33 42 Punjab 30 24 29 Himachal Pradesh 37 25 36 Delhi 36 23 25 Kerala 13 9 12 Tamil Nadu 24 18 21 Gujarat 45 24 38 Uttar Pradesh 56 39 43 Rajasthan 54 31 49 Madhya Pradesh 60 37 56 Assam 58 33 55
Medical causes of infant mortality Neonatal mortality (0-4 weeks) Post-neonatal mortality (1-12 months) 1. Low birth weight and prematurity 2. Congenital malformations 3. Birth injury and difficult labour 4. Sepsis 5. Haemolytic diseases of newborn 6. Conditions of placenta and cord 7. Diarrhoeal diseases 8. Acute respiratory infections 9. Tetanus 1. Acute respiratory infections 2. Diarrhoeal diseases 3. Other communicable diseases 4. Malnutrition 5. Congenital anomalies 6. Accidents
Causes of infant mortality 57 17 4 523 12 Causes LBW ARIs ADDs Congenital Malformations Sepsis Birth injury Others
Factors affecting Infant mortality 1. BIOLOGICAL FACTORS (a) Birth weight: - babies of low birth weight and high birth weight are at special risk. - causes: poor nutrition during pregnancy.. (b) Age of the mother: - IMR are greater when the mother is either very young (<19yrs) or relatively older (>30 yrs).
(c) Birth order - the highest mortality is found among first born, and the lowest among those born second. - The risk of infant mortality escalates after the third birth. - the fate of fifth and later children is always worse than the fate of the 3rd child.
(d) Birth spacing - repeated pregnancies- malnutrition and anaemia in the mother- predispose to LBW.. - prematurely weaned- PEM, diarrhoea and dehydration. (e) Multiple births - Infants born in multiple births face a greater risk of death than do those in single births due to the greater frequency of low birth weight among the former.
(f) Family size - the number of episodes of infectious diarrhoea, prevalence of malnutrition, and severe respiratory infections have been found to increase with family size. - fewer children-better maternal care, a better share of family resources, less morbidity and greatly decreased infant mortality. (g) High fertility high fertility and high infant mortality go together.
2. ECONOMIC FACTORS The availability and quality of health care and the nature of the child’s environment are closely related to socio-economic status.
3. CULTURAL AND SOCIAL FACTORS (a)Breast feeding: Early weaning and bottle-fed infants living under poor hygienic conditions are more prone to die than the breast-fed infants living under similar conditions.
(b) Religion and caste The differences are attributed to socio-cultural patterns of living, involving age-old habits, customs, traditions affecting cleanliness, eating, clothing, child care and almost every detail of daily living. (c) Early marriages ..teen-age mother- greater risk of neonatal and post- neonatal mortality.
(d) Sex of the child Statistics show that female infant mortality is higher than the male infant mortality. (e) Quality of mothering (f) Maternal education Women with schooling tend to marry later, delay child- bearing and are more likely to practice family planning.
(g) Quality of health care Shortage of trained personnel like dais, midwives and health visitors is another determinant of high mortality in India. According to estimates only 47% of the deliveries are attended by trained birth attendants. (f) Broken families (g) Illegitimacy
(j) Brutal habits and customs -depriving the baby of the first milk or colostrum, frequent purgation, branding the skin, application of cow-dung to the cut end of umbilical cord, faulty feeding practices and early weaning. (k) The indigenous dai ..untrained midwife- unhygienic delivery. (l) Bad environmental sanitation- Increased incidence of diarrhoeal diseases, overcrowding leading to respiratory diseases, insect breeding etc.
Preventive and social measures 1. Prenatal nutrition - improve the state of maternal nutrition.. 2. Prevention of infection - eg. Neonatal tetanus, UIP- protect against 8 vaccine preventable diseases. 3. Breast feeding - prevents gastro-intestinal, respiratory infections and PEM.
4. Growth monitoring - all infants should be weighed periodically and their growth charts maintained. - these charts help to identify children at risk of malnutrition early. 5. Family planning - smaller sibship and longer spacing between pregnancies are associated with improved infant and child survival.
6. Sanitation 7. Provision and utilisation of primary health care - all those involved in maternity care ( obstetrician-local dai) should collaborate and work together as a team. - Educating people to use maternal services
- Prenatal care must be improved with a view to detecting mothers with “high-risk factors”, and those with prenatal conditions associated with high- risk are hospitalised and treated. - “Special care baby units” : for babies weighing less than 2000g. - Proper referral services.
8. Socio-economic development this must include spread of education, improvement of nutritional standards, improvement of housing conditions, the growth of agriculture and industry and the availability of commerce and communication; in short it implies all round health and social development of the community. 9. Education Educated women generally do not have early pregnancies, are able to space their pregnancies, have better access to information related to personal hygiene and care of their children, and make better use of health care services.
Mortality in and around infancy Infant mortality Neonatal death Post-neonatal death Early neonatal death Late-neonatal death 29 days - 1 year Perinatal death Still birth 28 weeks of gestation 7 days 28 days Birth
Still Birth Rate  Death of a foetus beyond viability period i.e. If separated from mother, it will be able to survive with/without life support  This period has been marked at 22 weeks of gestation globally but in our country it is at 28weeks  Hence, still birth is death of a foetus weighing 1000g(equivalent to 28 wks of gestation) or more occurring during one year in every 1000 total (live+still births).  Weight cut off is suggested to overcome the difficulty to assess period of gestation in cases where date of last menstrual period is not known.
Calculate Still BirthRate  Current still birth rate in India is 5/1000 births/year.  It is same in urban and rural areas.  High in states where better services and literacy status is high- high reporting  Low in states in which are poor in these parameters –low reporting Fetal deaths weighing over 1000g at birth during the year Total live+ stillbirths weighing over 1000g at birth during the same year *1000
Perinatal death rate Perinatal period: The period which begins from the twenty eight weeks of a pre-natal life of a fetus (at this time body weight is 1000 g in norm or crown-heel length of 35 cm atleast) and finishes after 7 full days (168 hours) after a birth. Perinatal death rate includes three periods:  Antenatal (beginning with the 28th week of pregnancy up to delivery);  Intranatal (the period of delivery);  Early neonatal (the first 168 hours of life of a child i.e first 7 days of life).
Perinatal mortality rate • Perinatal mortality rate which is calculated as Number of born dead + number of died at the first 168 hours of life × 1000 Number of born alive and dead • The analysis of perinatal death rates allows to estimate succession in work of obstetric and pediatric services. Late registering of pregnancy, rare visiting of antenatal clinic by the expectant mother, absence of qualitative, interested supervision over the health of the pregnant woman are behavioral risk factors of perinatal death rates.
Perinatal mortality is a problem of serious dimensions in all countries.  In developed countries, perinatal mortality rates 15-20 per 1000 total births.  The perinatal mortality rate in India is reported to be 31 per 1000 live births in rural areas, 17 per 1000 live births in urban areas and 28 per 1000 live births combined in rural and urban areas.
Causes of Perinatal Mortality • About two-thirds of all perinatal deaths occur among infants with less than 2500 g birth weight. • Main causes: The main causes of death are • intrauterine and birth asphyxia • low birth weight • birth trauma • intrauterine or neonatal infections. The various causes of perinatal mortality may be grouped as below: Antenatal Causes: Maternal diseases - hypertension, cardiovascular diseases, diabetes, tuberculosis, anaemia, pelvic diseases, anatomical defects, toxemias of pregnancy; Intranatal Causes: Prolonged effort time, obstetric complications; Postnatal Causes: Prematurity, respiratory distress syndrome, respiratory and alimentary infections, congenital anomalies
Neonatal mortality rate (NMR)  Neonatal deaths are deaths occurring during the neonatal period, commencing at birth and ending 28 completed days after birth.  The neonatal mortality rate is tabulated as:  In INDIA current figures are 29/ 1000 live births/year (33:rural, 16:urban)  60-70% of the total infant deaths 1000 yearsametheinbirthsliveTotal yearainageofdays28 underchildrenofdeathsofNumber 1000 yearsametheinbirthsliveTotal yearainageofdays28 underchildrenofdeathsofNumber
Causes of neonatal mortality in INDIA
Post-neonatal mortality rate (PNMR)  Deaths occurring from 28 days of life to under one year are called "post-neonatal deaths". The post-neonatal death rate is defined as: "the ratio of post-neonatal deaths in a given year to the total number of live births in the same year; usually expressed as a rate per 1000".  The post neonatal mortality rate is tabulated as:  Whereas neonatal mortality is dominated by endogenous factors, post-neonatal mortality is dominated by exogenous (e. g., environmental and social) factors. 1000 yearsametheinbirthsliveTotal yeargivenainageofyearoneanddays28 betweenchildrenofdeathsofNumber
Cause of post-neonatal mortality  In the developed countries, the main cause of post-neonatal mortality is congenital anomalies.  Post-neonatal mortality increases steadily with birth order, and that infants born into already large families run a higher risk of death from infectious diseases and malnutrition  In India the post neonatal mortality rate is estimated to be 14 in rural areas, 12 in urban areas and 13 combined in rural and urban areas.
Relation between IMR, NMR, PNMR  IMR= NMR+ PNMR  NMR= IMR- PNMR  PNMR= IMR- NMR
PREVENTING MORTALITY IN INFANTS  Measures related to mother:  Efficient antenatal care: minimum 4 visits, nutrition education and supplementation esp IFA  Two doses of TT to prevent tetanus neonatorum  Identifying high risk mothers  Intranatal care to avoid infections and birth injuries  Timely management of complications, if any
 Measures related to infant:  Essential care of the newborn babies  Special Care to at risk newborn like LBW babies  Breast feeding  Immunisation  Growth monitoring  Oral rehydration therapy during diarrhoea
 General measures:  Family planning  Female literacy  Avoiding early marriages  Health education of mothers regarding feeding practices, weaning practices and child rearing practices  Improvement of sanitation and providing safe water
Find....and comment  In a rural PHC with a population of 30,000; there were 800 live births and 15 still births in the year 2014. There were 80 infant deaths out of which 50 deaths occurred during the first 28 days of their lives and of these 50 deaths 25 deaths occurred in 1st week of life. Calculate ...  Still birth rate  Perinatal mortality rate  Neonatal mortality rate  Post neonatal mortality rate  Infant mortality rate  Comment on the health services available to this population
Rates for referenceParameter India Still Birth rate 5/1000 births Perinatal mortality rate 28/1000 live births Neonatal Mortality Rate 29/1000 live births Post neonatal Mortality Rate 13/1000 live births Infant Mortality rate 41/ 1000 live births Maternal Mortality Ratio 178/100,000 live births Crude Birth Rate 21.6/1000 mid year population Crude Death Rate 7.0/ 1000 mid year population
 In a rural PHC with a population of 2,00,000; there were 6050 live births and 110 still births in the year 1990. There were 750 infant deaths out of which 480 deaths occurred during the first 28 days of their lives and of these 480 deaths 250 deaths occurred in 1st week of life. Calculate ...  Still birth rate  Perinatal mortality rate  Neonatal mortality rate  Post neonatal mortality rate  Infant mortality rate  Comment on the health services available to this population
Maternal Mortality Ratio (MMR)  In a CHC with population of 1,60,000; there were 4500 births and 20 deaths of mothers were reported due to obstetric causes. Calculate MMR and comment on the health services.
Birth Rate and Death Rate  Calculate crude birth rate and crude death rate of a town with population of 5,00,000. Live births reported were15,000 for the last year and 7,000 deaths were reported during the same year and comment on the services.
UNDER-5 MORTALITY RATE  No. Of deaths of children aged less than 5 years per 1000 live births  Calculated as No. Of deaths of children less than 5 years * 1000 No. Of live births in the same year  It is one single parameter which gives measure of any country’s social and economic development
1-4 YEAR MORTALITY (Death) RATE  CHILD DEATH RATE is commonly used for this parameter  It is expressed as deaths of children of age 1-4 years per thousand children of the same age in a given calendar year.  Calculated as No. Of deaths of children aged 1-4 years during a year *1000 Mid year population of children of age 1-4 years  It is type of age specific death rate which is no. Of deaths in a any particular age
Causes of 1-4 year mortality  Causes are mainly exogenous Developing countries Developed countries Diarrhoeal diseases Accidents Respiratory infections Congenital Anomalies Malnutrition Malignancies e.g. Leukemias Infectious diseases (vaccine preventable) Influenza Accidents and injuries Pneumonia
Current Status- Year 2013 Country Infant mortality Rate (IMR) Mortality in 1-4 year age group Under-5 Mortality Rate India 41 12 53 Srilanka 8 2 10 Bangladesh 33 8 41 Pakistan 69 17 86 China 11 2 13 USA 6 1 7 UK 4 1 5 Japan 2 1 3
CHILD SURVIVAL INDEX  This parameters tells us the chance of a survival of new born beyond age of 5 years  Calculated as 1000 - under-5 mortality rate 10 For India (2013) , hence calculated as ( 1000-53)/10= 94.7%
Programmes to improve child survival All activities have now been put under one umbrella of NRHM- NATIONAL RURAL HEALTH MISSION  Universal Immunization Programme  Baby Friendly Hospital Initiative  Integrated Management of Neonatal and Childhood Illness  Every Newborn Action Plan  Reproductive Maternal Neonatal and Child Health along with Adolescent component
INTEGRATED MANAGEMENT OF NEONATAL AND CHILDHOOD ILLNESS (IMNCI)  Strategy developed by WHO and UNICEF.....IMCI ...to provide comprehensive package of health care for children of age 7days -5 years  Modified in our country as IMNCI to include all children i.e . Kids of age 0day – 5 years  Mainly aims at :  Improving case management skills of healthcare workers  Improving health system to be more capable of managing the illnesses  Improving family’s and community’s practice towards child’s bringing up
 Grass root level workers are trained to assess and manage the health problems  Also trained to identify danger signs for timely referral to higher health facility and to tell the same to the parents, ....helping to decrease mortality due to lack of timely expert care  IMNCI deals with kids in two groups and charts are provided to the health care worker for reference  1st group: kids between 0day- 2 months  2nd group: kids 2months -5 years
KEY ELEMENTS  ASK and ASSESS  CLASSIFY  IDENTIFY mode of treatment  TREATMENT instructions to family  COUNSEL for other contributory factors  FOLLOW UP
ASK and ASSESS  Ask about presenting complaints specifically about DANGER SIGNS...inability to take feeds, vomiting out everything, any episode of convulsions.  Assess for DANGER SIGNS...lethargic or unconscious  In-depth detail of presenting illness  Nutritional Status of the child  Immunisation of the Child  Based on all the signs and symptoms severity of disease is established
CLASSIFY  Every disease has been classified in three classes corresponding to three colour codes  PINK: Urgent pre-referral treatment and referral  YELLOW: Specific medical treatment and advice  GREEN: Advice for home management IDENTIFY After classifying and planning the treatment arrangements for the plan of action are to be made like need for transportation if referral, drugs for specific treatment, immunisation and supplementation (vit A in measles). First dose preferably be given by the health worker.
FLOW CHART FOR IMNCI 1. Check for danger signs..convulsions, lethargy, inability to feed, vomiting 2. Assess main symptoms...cough, difficulty breathing, diarrhoea, fever, ear problems 3. Assess nutritional status and immunisation status 4. Any other problem IF DANGER SIGN IS THERE...urgent referral along with pre-referral treatment No danger sign...but antibiotics needed Home based treatment
 INSTRUCTIONS to the care taker for compliance and administration of treatment  COUNSELLING the parents for regular feeding of the child as per age requirement, regarding immunization, safe water, sanitation, vector control measures etc.  FOLLOW UP visit is must to assess the outcome and accordingly modify the plan of action.
CONGENITAL DISORDERS  Defined as those diseases that are substantially determined before or during birth which are in principle recognizable in early life.  Their incidence worldwide has been reported as 1 in 33 newborns, responsible for more than 2,70,000 deaths in neonates globally  Two substitutes are suggested by WHO  Malformations: structural defects  Anomaly: includes all biochemical, structural or functional disorders
Causes of Congenital disoders  Genetic Factors: Includes  Chromosomal abnormalities: During meiotic divisions e.g. Down’s Syndrome, Klinefelter’s syndrome, Turner’s syndrome  Inborn errors e.g. Phenylketonuria, galactossemia etc.  Inheritance of gene defects like thalassemia, sickle cell etc.  No specific aetiology: club foot, congenital dislocation of foot  Environmental Factors: Includes defects arising due to exposure to external agent which could affect the growing fetus:  Infection like rubella leading to congenital cataract, patent ductus and auditory problems  Drugs like thalidimide causing limb deformity  Radiation exposure leading to metabolic anomalies  Dietary factors: Folic acid deficiency may lead to neural tube defect
RISK FACTORS  Maternal Age: Advancing age of mother has been significantly associated with high incidence of down’s syndrome  Consanguinity: Marriages in close relation especially first cousins often lead to expression of recessive disorders. Incidence of Mental retardation is also relatively higher in kids born of such wedlocks.
PRENATAL DIAGNOSIS  Alpha feto proteins: neural tube defect  Ultrasonography: Structural defects can be visualised  Amniocentesis: For down’s syndrome  Chorionic Villi Sampling: For chromosomal disorders
PREVENTIVE MEASURES Health Promotional Measures: Includes  EUGENICS: Not much acceptable  Negative: sterilization of people with known defects  Positive: healthy people are encouraged to have parenthood  EUTHENICS: providing healthy environment and nutrition  GENETIC COUNSELLING:  Prospective: Premarital genotyping to know any carrier state for genetic disorder and accordingly avoiding marriage between people carrying recessive gene for some disorder  Retrospective: Avoiding further births if already there is such history in the family.  MODIFYING SOCIAL FACTORS:  Avoiding marriages among close relatives  Avoiding pregnancies in advanced age hence avoiding late marriages
Specific Protection  Avoiding radiation  Avoiding drugs  Dietary supplements  Immunisation against known mutagenic diseases  Managing the disease before it precipitates as in Rh incompatibility where Anti D globulin is given to prevent haemolytic disease among subsequent births
Early Diagnosis and Treatment  Detection of genetic carriers  Prenatal diagnosis  Screening of newborns  Screening during childhood List of diseases is long but investing little effort can prevent damaging outcome Though genetic diseases are not completely curable but many of them tend to be manageable if timely recognised with some modification in lifestyle
Introduction  Adolescence means the growing period derived from latin word ADOLESCERE (to grow)  Rapid growth is experienced by indvidual leading to physical, psychological, emotional and spiritual changes  Adolescence is one of the healthy periods of life....
 BUT DRASTIC TRANSITION IN EVERY ASPECT OF HUMAN BODY PUTS THIS AGED PEOPLE AT SOME SPECIAL RISK  Accidents, Suicides, violence, teen age pregnancy, drug abuse, sexually transmitted infections, unhealthy life style pertaining to eating and physical activity
Subgroups • Total period: 10-19 years of age (WHO) • Early Adolescence: 10-13 years (physical Changes) • Middle Adolescence: 14-16 years (Behavioural Changes- acceptance of oneself and experimentation) • Late Adolescence: 17-19 Years (regaining stability with independent opinion) • Youth: 15-24 years • Young people: 10-24 years
Health problems  Physical including nutritional deficiencies and STIs  Psychological like depression, anxiety etc.  Behavioural like risk taking behaviour, juvenile delinquency  Social like teenage pregnancy, addictions etc.
Physical Health problems • Period of growth spurt and followed by no growth • Any deficiency or hormonal imbalance can leave a permanent effect • Delayed or slowed pubertal growth may lead to long lasting after effects • Counselling and education regarding balanced diet and physical activity is must • Iron deficiency: both girls and boys are prone • Similarly increased demand for calories, proteins, calcium, iodine, vitamin C and D is there • Since mucosal barrier and ph of vaginal mucosa is not effective against micro-organisms, hence they are more prone to STIs including HIV
Psychological Problems • Changes in body appearance in both males and females • Reproductive changes in females i.e. Menstruation, growth of breast tissue, growth of hair at underarms and around genitals, acne etc. • Similarly among males growth of hair –beard, underarms, around genitals, deepening of voice, increase in size of testicles and penis, ejaculation, acne etc. • Attraction to opposite sex • Psychosomatic Complaints like tremors, headache, delusion, hallucinations • If not supported-Lead to depression, confinement or even aggression to hide the actual impact of these changes
Behavioural Problems  Psychological changes ultimately lead to unacceptable behaviour  Habit Disorders: Thumb Sucking, nail biting, bed wetting etc.  Educational difficulties like failures and school phobias  Personality Disorders like jealousy, tantrums, shyness, day dreaming, fears and anxieties etc.
Social Problems  Non acceptance by parents, family, society leads to social problems  Drug Addiction, stealing, gambling, destructiveness, sexual offences are various unlawful projections of ones fight with oneself and the outer world
JUVENILE DELINQUECY • The Children Act, 1960 defines delinquent as a child who has committed offence • Juvenile is boy below 16 years and girl below 18 years • It is one of the major destructive outcome of industrialisation and urbanisation • Highest incidence is seen among children above 15 years of age and 4-5 time more in boys than in girls
Causes of Juvenile delinquency  Biological: Heredity, lack of self esteem and presence of extra Y chromosome  Social: Broken families, step father/ mother, parental neglect, too many children  Non specific: Absence of healthy recreation, urbanisation etc.
Prevention of Juvenile Delinquency  Improvement of family life  Schooling  Social Welfare Services: Counselling of parents, child guidance, educational facilities and general health services, peer groups.
PREVENTION AND INTERVENTION • EDUCATION: Peer education and life skill education • Community Mobilisation: Involving parents, teachers, leaders to promote positive behaviour and also to act as inspiring role models • Youth development programmes: Imparting skills to help young people to earn their livelihood • Social marketing: for condoms, emergency contraception
ADOLESCENT REPRODUCTIVE AND SEXUAL HEALTH (ARSH)  Sensitive and not to be talked about  Leading to public health challenges  Increased incidence of STIs/ RTIs  Increased teenage pregnancies  Increased unsafe abortions  Increased MMR and IMR
SOME FACTS • 225 million adolescent • Comprise 22% of India’s total population • Of this 12%-10-14year age group • 10%-15-19 year age group • Female comprise 47% of adolescent population • About 20% of total adolescent female population are married before the age of 15 years are already mother
• >70% girls between 10-19 year age group suffer from severe or moderate anemia • Mortality rate is higher in 15-19 year then 10-14 year age group • Unmet need of contraception is much higher in this age group • Over 35%of all reported HIV infection occur among 15- 24 years age group • Indicating young people are highly vulnerable and majority of them infected by unprotected sex
ARSH-NRHM  Started under RCH-II  Involvement of ASHA worker, Multipurpose worker (female), Medical Officer
Package of services  Promotive services:  Focused care during antenatal period  Counselling & provision of emergency contraceptives  Counselling & provision of reversible contraceptives  Information/advice on SRH services
 Preventive services:  Services for TT and prophylaxsis against nutritional anemia  Nutritional counselling  Services for early and safe termination of pregnancy and management of post abortion complications
• Curative services: – Treatment for common RTI/STIs – Treatment & counselling of menstrual disorders – sexual concerns of males and female adolescents • Referral services: – Integrated Counselling and Testing Centre – Prevention of Parent to Child Transmission • Outreach services: – Periodic health checkups and community camps – Periodic health education activities – Co-curricular activities
NRHM - ARSH • Vision – Improve availability of quality healthcare in rural areas – Synergy between health and determinants of good health – Community ownership of health facilities – Undertake architectural corrections of the health system • Expected outcomes by 2012 – IMR -30/1000 live births – MMR – 100/1000 live births – TFR -2.1
Objective  Reducing teenage pregnancies  Meeting unmet contraceptive needs  Reducing number of teenage maternal deaths  Reducing incidence of STIs  Reducing proportion of HIV positive in 10 – 19 years age group
 We must Develop sensitivity towards adolescent clients  NON JUDGMENTAL, FRIENDLY, COMPETENT PROVIDER is required.
GERIATRIC HEALTH
INDEX  INTRODUCTION  PHYSIOLOGICAL CHANGES DUE TO AGING  HEALTH PROBLEMS OF THE AGED  PSYCHOLOGICAL PROBLEMS  PREVENTION AND MANAGEMENT a. PREVENTIVE HEALTH CARE b. INTERVENTION IN REHABLITATION  SERVICES PROVIDED BY THE GOVT.  NON-GOVT. ORGANISATIONS
What is GERIATRICS ??????  The care of aged is called geriatrics or clinical gerontology.
 The study of the physical & psychological changes which are incidental to old age is clinical gerontology. What is clinical gerontology???
AGEING  It is a progressive and generalized impairment of body functions resulting in, loss of adaptive responses to stress and increasing the risk of age-related diseases.  People more than 60 yrs are considered elderly.  Old age is not a disease but a normal and inevitable biological phenomenon.
Theories of aging  Genetic theories-  somatic mutation of genes.  genetically determined life span.  cross linkage/loss of important cellular components and DNA.  Random damage theories-  accumulation of toxic metabolites and free oxygen radicals.  reduced physiological capacity and wear-n-tear of cells of vital organs.  non-enzymatic glycosylation of proteins.
Branches of geriatrics  Gerontology  Clinical gerontology  Social gerontology  Geriatric gynecology  Experimental gerontology  Preventive gerontology
Demography of geriatric population  World population: current >6.7688 billion  projected >8 billion (by 2025)  India has 16.94% of total population  Population of elderly(>65yrs) in India: approx 8% of total population.
Indian population
Physiological changes due to aging and their consequences  Problems in elderly are multi-faceted and often a single problem may be the result of a complex chain of decompensation of body functions.
Health problems of the aged  Physical problem  Psychological problems  Social problem  Economical
Physical problems Ailments % of occurrence Visual complaints 88 % Locomotor system disorders 40 % Neurological complaints 18.7 % Cardiovascular system 17.4 %
Respiratory system 16.1 % Skin conditions 13.3 % GI tract 9 % Psychiatric complaints 8.5 % Hearing loss 8.2 % Genito-urinary complaints 3.5 %
Visual complaints  88% of the complaints in old age is visual problems like  Cataract  Glaucoma  Retinopathy
Locomotor system disorders  It forms 40% of the old age complaints  They are:  Fibrositis  Osteoarthritis  Rheumatoid arthritis  Myositis  Neuritis  Gout  Spondilitis of spine
Neurological complaints  Neurological problems form 18.7% of the old age complaints  These are:  Dementia  Parkinson's disease  Alzheimer’s disease
Cardiovascular complaints  CVS disorders for 17.4% of the different old age complaints  These include:  Atherosclerosis  Thrombus formation  Myocardial Infarction  Hypertension
Respiratory complaints  Respiratory condition make 16.1% of the old age complaints  These are:  Chronic bronchitis  Asthma  Emphysema
Skin conditions  Skin conditions form a major part of old age complaints  Skin conditions include:  Senile wrinkles  Scaly lesions  Scaly dermatosis  Blistering diseases  Neoplastic disorders
Gastrointestinal complaints  GI disorders for about 9% of the old age complaints  These are:  Peptic ulcer  Constipation  Ulcerative colitis  Carcinoma of GIT
Hearing loss  Hearing complaints form about 8.2% of the old age complaints  These include  Nerve deafness  Conductive hearing loss
Genito-urinary complaints  These form about 3.5% of the old age complaints  They are:  Enlargement of prostate  Dysuria  Nocturia  Frequency and urgency of micturation
Psychiatric complaints  These form 8.5% of the old age complaints  These include  Alzheimer’s disease  Depression  Anxiety  Delirium  Schizophrenia  Personality disorder  Suicide and deliberate self harm
Psychological problems  Elderly patients less willing to talk about psychological problems  Pay attention to:  anxiety  physical discomfort  adaptation to a new lifestyle
PSYCHOLOGICAL SYMPTOMS  Sleep  Interest  Guilt (“Are you a burden to others?”)  Energy  Concentration  Appetite  Psychomotor changes  Suicidality (“Do you wish you could die?”)
INCIDENCE IN ELDERLY  MAJOR DEPRESSION  3% community dwelling  14% two years after spouse dies  15% medically ill  25% long-term-care settings
Social problems  Abuse  Dependancy  Insecurity  Rehabilitation
PREVENTIVE HEALTH CARE
Preventive Health Care in Elderly  The role of prevention in geriatrics is to delay the onset of age-related decompensatory problems of body functions.  It includes-  Primary prevention.  Secondary prevention.  Tertiary prevention.
Primary prevention  Health habits-  Inadequate nutrition  Addiction to smoking & alcohol  Lack of exercise  Inadequate sleep  Predisposing factor for coronary heart disease  Modifiable-  smoking, obesity, HT, DM, hyperlipidemia, hypercholesterolemia, etc.  Non-modifiable-  age, sex, genetic factors, etc.
 Immunization-  Influenza  Pneumococcal  Tetanus.  Osteoporosis prevention-  Calcium and vit-d supplementation.  Hip protector devices.
Injury prevention  Burns accidents and falls should be prevented by;-  Removal of obstacles  Keep the floor dry  Bright lighting  Flat shoes  Railing/holding bars in bathrooms  Low level switches  Easy and safe access to water.
Secondary prevention  Screening helps in early detection of modifiable risk factors and their adequate management.  Hyper/hypotension, diabetes mellitus  Dental problems  Drug adverse effects  Cancers  Infections  Nutritional deficiency states  Eyes /ears Screening
 Early detection and treatment is an important step in secondary prevention of disease and disability.
Tertiary prevention  It deals with rehabilitation and caregiver support.  Rehabilitation is a problem solving process focused on the patients functional abilities.  Rehabilitation team includes; a physician, a physiotherapist, an occupational therapist, a speech and language therapist, a psychiatrist, a dietitian, a nurse and a social worker.
Interventions in rehabilitation  Hard interventions-  drugs.  physiotherapy.  occupational therapy.  aids and adaptation.  speech and language therapist.  Soft interventions-  advice.  education.  counseling.  encouragement.  listening.
Supporting the caregiver EVEN THE CAREGIVER NEEDS SUPPORT  Social attitude  Physicians support  Organization of “day care centers”  Hospitalization in c/o chronic illness  Counseling the caregiver
Prevention and management of elder abuse  Assessment of physical and mental capacity of the elderly.  Assessment of general quality of care  Assessment of relation with the abuser  Assessment of abusers for their problems  Counseling the abusers  Institutionalization in old age homes
Laws in India to protect the old people  Section 125(1) (d): If any person having sufficient means neglects or refuses to maintain his father or mother, unable to maintain himself or herself, a Magistrate of the first class may, upon proof of such neglect or refusal, order such person to make a monthly allowance for the maintenance of his father or mother.
 Section 125(3): If any person so ordered fails without sufficient cause to comply with the order, any such Magistrate may, for every breach of the order, issue a warrant for levying the amount due in the manner provided for levying fines, and may sentence such person, for the whole or any part of each month’s allowance remaining unpaid after the execution of the warrant, to imprisonment for a term which may extend to one month or until payment if sooner made
Helpage India Helpage India supports the following programmes to make life easier for older people: 1. Free cataract operation 2. Mobile Medicare units 3. Income generation and micro-credits 4. Old age home and day care centers 5. Adopt a grant parents 6. Disaster mitigation
THANK YOU

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Maternal and child health

  • 2. Mother and children are priority ???  Constitute 71.4% of the population in developing countries.  In India women of reproductive age group (15-50 yrs) and children under 15 yrs constitute 57.5% of the population (22.2% and 35.3% res).  Hence major consumers of any product and health services are no exception.  They are the most VULNERABLE or SPECIAL RISK group.
  • 3. WHY vulnerable....  Menstruation, Child bearing among females  Dependent, growth and development among children  50% of all the deaths occurring in country are among underfives, but not true for developed countries where it is among old populations  Similarly maternal mortality is in range of 200-400 per thousand live births against less than 20 per thousand in developed countries.
  • 4. Majority of these deaths are preventable
  • 5. How???  Follow the principle of equity, intersectoral coordination and community involvement  Same is followed in providing PRIMARY HEAILTH CARE  It provides integrated package of health services to mother and child considering them as ONE UNIT.
  • 6. MOTHER and CHILD –One Unit  During antenatal period child is part of mother’s body  All the nutritional requirements of the foetus are met through mother....so mother needs to be well nourished to have healthy baby  Many diseases occurring during pregnancy also affect the foetus  After birth also exclusive breast feeding and child care are again mother’s responsibility  Postpartum care including advice regarding family planning also affect the health of new born  This period of care makes mother the first teacher of the child.
  • 7. Linking Obstetrics, Paediatrics and Preventive and Social Medicine  Though mother care is with obstetricians and child care is with paediatricians but the principle of prevention has led to various other terms  Social Obstetrics  Preventive Pediatrics  Social Pediatrics
  • 8. Social Obstetrics Study of interplay of social and environmental factors and their effect on human reproduction.  Not only conception phase is important but also preconception and even premarital period is equally important.  Socio- environmental factors include: age at marriage, age at child bearing, child spacing, family size, fertility pattern, level of education, customs and beliefs and role of women in society.
  • 9. Preventive Paediatrics  Aims at providing efforts to avoid rather than curing disease and disabilities among newborn and children.  So, divided into 2parts- antenatal paediatrics and postnatal paediatrics.  Important activities include growth monitoring, oral rehydration therapy, nutritional surveillance, promotion of breast feeding, immunisation, regular health check ups.
  • 10. Social Paediatrics  Study the effect of social values and social policy on child health.  It is the application of principles of social medicine to paediatrics to obtain a more complete understanding of the problems of children in order to prevent and treat disease and promote their adequate growth and development through an organised health structure.  Examples include giving prelacteal feeds, son preference, restricting diet during illness etc.
  • 11. How preventive medicine helps Obstetricians and Paediatricians  Collection and interpretation of data of the population to delineate at risk groups  Association of demographic characteristics with various morbidity and mortality rates  Effect of cultural factors on utilisation of health services  Evaluation of various programmes to see their impact
  • 12. Maternity Cycle  Fertilisation  Antenatal period  Intranatal period  Postnatal period  Inter- conceptional period
  • 13. MCH problems  Malnutrition  Infection  Uncontrolled reproduction In developed countries congenital malformations, genetic diseases and behavioural problems are issues of concern.
  • 14. MATERNAL and CHILD HEALTH  It refers to promotive, preventive, curative and rehabilitative healthcare for mothers and children.  It aims at  reduction of maternal, perinatal, infant and childhood mortality and morbidity  Promotion of reproductive health  Promotion of physiological and physical and psychological development of the child and adolescent
  • 15. Components of Maternal Care  Antenatal Care  Intranatal Care  Postnatal Care
  • 16. Antenatal Care  Pregnancy Detection- Urine Examination. Kits are available with the health workers under the name NISHCHAY pregnancy test kits. Also available in market.  Antenatal visits- ideally pregnant female should visit health care provider once a month till 7th month of pregnancy, then twice a month during 8th and weekly thereafter. But if not feasible at least 4 visits are minimally required....
  • 17.  1st ....before 12 wks (whenever pregnancy suspected and to be registered if confirmed)  2nd......between 14 and 26 weeks  3rd.......between 28 and 34 weeks  4th.......after 36 weeks till delivery
  • 18. Purpose of 1st visit  Mainly provided by MPHW (female)/ANM  Facilitates proper planning for the care to be provided to mother and foetus.  Calculate expected date of delivery from LMP.  Assess the health status of mother for any pre-existing medical illness.  To know whether pregnancy is wanted or otherwise referral for safe abortion to PHC/FRU.  Helps in rapport building for continued antenatal care.
  • 19. Tasks to be carried out during antenatal visits  Antenatal examination  Prenatal advice  Specific protection  Mental preparation  Family Planning  Paediatric component
  • 20. ANTENATAL EXAMINATION  History taking: Any illness/ other problems, h/o drug intake etc.  Physical Examination: Pallor, Pulse, Respiratory rate, oedema, Blood pressure, Weight, breast examination.  Abdominal Examination: Fundal height, foetal heart sounds, fetal movements, multiple pregnancies, fetal lie and presentation, any scar (previous ceasarean) etc.  Assessment of gestation age  Laboratory Investigations
  • 21. Laboratory investigations  Routine (at Sub- centre): Pregnancy detection, Hb estimation, urine test for albumin and sugar, rapid malaria test.  Screening (at PHC/CHC/FRU): Blood group and Rh factor, VDRL/RPR for syphilis, HIV testing, Blood glucose estimation, HBsAg for Hepatitis B. Considering significant changes in mother and child after 24 weeks, and also to perform screening tests, it is preferred that 3rd visit should be at the PHC to be examined by medical officer.
  • 22. Identify high risk cases  Elderly primi (30 yrs and above)  Short statured primi (140 cm or less)  Malpresentations  Antepartum hemorrhage, threatened abortion  Pre-eclampsia and eclampsia  Anaemia  Twins  Bad obstetric history  Elderly grand multiparas  Prolonged pregnancy (>42 weeks)  Any medical illness  Previous caesarean  Treatment for infertility
  • 23. Other benefits....  Maintenance of records: Number of pregnant females, estimating requirement for manpower, infrastructure and services, timely arrangements for emergency care.  Home visits: They are carried out by health workers so as to gain confidence of the mother and build a rapport. Also it helps to understand the socio- cultural practices which may adversaly affect the pregnancy outcome and accordingly counsel the family for rectification.
  • 24. PRENATAL ADVICE  DIET: Total calorie requirement during pregnancy is 60, 000 kcal over and above the routine requirement averaging at 300 kcal extra per day. Not only calories other micronutrients are also required like iron, iodine, calcium and vitamins in increased amounts to compensate for baby’s needs.  Maintain personal health: Personal cleanliness and dental hygiene, adequate sleep, exercise, avoiding smoking and alcohol and sexual intercourse.  Drugs: No drugs should be taken without advice of health care provider.
  • 25.  Radiation: x- rays exposure should be avoided.  Warning signs: Mother should be told about warning signs and symptoms where medical advice must be taken. Some signs include swelling of feet, fits, headache, blurring of vision, bleeding or discharge per vaginum.  Child care: Mother craft education consisting of nutrition education, cooking demonstrations, family planning education, hygiene and child bearing, family budgeting.
  • 26. SPECIFIC HEALTH PROTECTION  Anemia and other nutritional deficiencies  Toxemia of pregnancy: Increased BP. Early detection is indicated must be accordingly managed.  Tetanus: Vaccination is conducted.  Syphillis: Leading cause of pregnancy wastage. If timely diagnosed can be treated by giving penicillin for 10 days.  Rubella/ german measles: Timely vaccination should be done otherwise major congenital malformations may occur.
  • 27.  Rh status: Rh negative mother with Rh positive fetus may lead to immunogenic reaction leading to hemolysis and other complications. Timely screening should be done preferably at 28 weeks and if required Rh anti D immunoglobulin should be given to mother to prevent immune reactions.  HIV infection: ART should be given to decrease MTCT of HIV.  Hepatitis B infection: If mother is HBV positive, new born should immediately receive HB Igs and Hepatitis B vaccine.  Prenatal genetic screening: Screening for chromosomal aberrations esp when there is positive history, so that timely abortion can be carried out if required.
  • 28. Mental Preparation  Apprehension regarding change in body appearance  Alleviate fears regarding child birth and child rearing  Mothercraft
  • 29.  Family Planning: Mother is more motivated to adopt family planning measure and she should be advised accordingly like spacing methods or terminal methods  Paediatric Component: care of the underfives accompanying the pregnant female.
  • 30. INTRANATAL CARE  Process of child birth  Mainly aims at:  Asepsis...3Cleans....i.e. Hands, Surface, Cord (blade & tie)......Dai Delivery Kit  Minimal injury to the new born  Immediate Care of the baby after birth..cord, eyes, resuscitation  Preparedness for any complications needing referral like prolonged labor, antepartum hemorrhage etc.
  • 31. Intranatal Care....  Institutional care: When delivery is conducted at some health centre or hospital. Mothers are motivated to have delivery at institution.  ASHA workers play key role  JSY ...Janani Suraksha Yojna ...cash incentives, free ambulance, other lodging facilities.  Preferred so as to have timely specialist services in case of emergency.  48 hrs after normal delivery and 5-7 days after c/s are recommended stay in hospital
  • 32.  Domiciliary Care: When delivery is conducted at home.  Advantages: • Familiar surroundings • Chances of cross infection are less • Mother is able to keep watch on other household chores  Disadvantages: • Less expert care • Less rest • Diet and other things such as breast feeding may be neglected If institutional delivery not possible, home delivery can be carried out by trained birth attendants after ensuring asepsis but few conditions demand compulsory institutional delivery.
  • 33. Indications for institutional delivery  Sluggish/ no pains after ROM  Non progressive pains  Cord/ hand prolapse  Meconium stained liquor  Faster fetal heart rate  Excessive bleeding during labor  Placenta not separated within an hour of delivery  Postpartum hemorrhage
  • 34. Rooming in  Keeping the baby by mother’s side is called rooming in  Seeing the baby gives more motivation to mother for breast feeding  Allays fear regarding child’s security
  • 35. POSTNATAL CARE  Objectives:  To prevent complications of postpartal period  Restoring mother’s health and to ensure exclusive breast feeding  Family planning advice  Education of mother about child care services and mothercraft
  • 36. Restoring mother’s health and preventing complications  Postnatal Examination: Twice a day for first 48 hrs and the once a day till cord falls off.  Look for the progress of involution of uterus  Any dysuria, enquire about bowel movements and condition of perineal stitches if applied.  Health care provider should look for any complication like fever indicating infection.  Afterwards monthly home visits should also be done by female health worker to assess and help the mother in maintaining nutrition and physical health including motivation for regular exercise.
  • 37. Breast feeding  Exclusive breast feeding till 6 months of age.  On average 400-400 ml milk is secreted daily by mother which is sufficient to meet newborn’s nutritional needs for 1st six months including micronutrients like iron and vitamin C.
  • 38. Other services  Family planning Advice:  Spacing methods if family expansion is desired  OCPs to be avoided till the mother is lactating  Terminal methods if family is complete but better to be postponed till the second child is 3years old.  Mother and Child care: Immunisation, seeking health care services in times of illness, birth registration etc.
  • 39. CARE OF CHILDREN Divided into different phases:  Infancy (up to 1 year of age) 1)Neonatal period (0-28 days). First seven days are also labelled as early neonatal period 2)Post neonatal period (28 days- 1year)  Preschool age (1-4 years)  School age (5-14 years)
  • 40. INFANCY  Key Points:  Constitute 2.92% of the population in India  20- 30% are LBW  >60% infant mortality occurs in first month of life  Low cost measures like breast feeding, immunisation, birth spacing, growth monitoring, improved weaning, oral rehydration can save more than 3/4th of theses deaths.
  • 41. Objectives of neonatal care  Maintaining vitals  Avoiding infection  Establishing breast feeding  Management of congenital conditions- infections, disabilities and disorders
  • 42. Immediate Care  Clearing Airway: Utmost importance to establish breathing  APGAR score: Noted at 1min, 5min and 10min if required. Includes assessment of heart rate, respiration, muscle tone, reflex response and colour of baby. It must be 9 or above.  Care of the cord: Asepsis must be maintained to avoid infections especially tetanus neonatorum. Nothing is required to be applied to the stump and it should be kept dry.
  • 43.  Care of eyes: Clean with wet swabs and single application of silver nitrate solution to prevent any gonococcal infection is sufficient. Any discharge from eyes is abnormal and should be managed at the earliest.  Care of skin: Bathing should preferably be avoided to prevent hypothermia. Sponging should be done to clean vernix, meconium and clots.  Maintain body temperature: As baby is residing in mother,s body so the outer temperature is normally cooler, hence wrap the baby in warm clothes.....hypothalamus has still not taken up temperature regulation
  • 44.  Breast feeding: Should be initiated as soon as possible. Within half hour in normal delivery and 2hrs or so in case of caesarean section.  Colostrum should be given.  High in protein and antibodies.  Demand feeding should be practiced  Body contact helps to maintain temperature of new born  Breast milk is untouched so no chance of infection
  • 45.  Managing Infections: Common are Neonatal tetanus, Congenital syphillis, HIV, HBV.  Measuring the baby: Weight should be recorded preferably within first hour of birth before noticeable weight loss occurs. Similarly length, head circumference, chest circumference should be measured . Anthropometry helps us to assess the gestational age of the child and to know the nutritional status. Also child’s progress can be assessed by comparing with the previous records.
  • 46. Identify at-risk babies  Birth wt less than 2.5 kg  Twins  Birth order 5or more  Artificial feeding Such babies need prolonged care because of high risk of morbidities and mortality.
  • 47. Late neonatal period  After first week of life risk is mainly due to under nutrition and infections commonly diarrhoea and pneumonia.  Mothers should time to time be educated about the prevention of such infections and seeking help for their timely management.
  • 48. Management of Low Birth Weight Babies
  • 49. Low birth weight (LBW)  Definition : Birth weight <2500 g  Incidence : 30% of neonates in India
  • 50. LBW: Significance  75% neonatal deaths and 50% infant deaths occur among LBW infants  LBW babies are more prone to:  Malnutrition  Recurrent infections  Neuro developmental delay LBW babies have higher mortality and morbidity
  • 51. Types of LBW Preterm  < 37 completed weeks of gestation  Account for 1/3rd of LBW Small-for-date (SFD) / intra uterine growth retardation (IUGR)  < 10th centile for gestational age  Account for 2/3rd of LBW neonates 2 types based on the origin
  • 52. Causation: LBW Etiology of prematurity  Low maternal weight, teenage / multiple pregnancy  Previous preterm baby, cervical incompetence  Antepartum hemorrhage, acute systemic disease  Induced premature delivery  Majority unknown
  • 53. Etiology of SFD / IUGR  Poor nutritional status of mother  Hypertension, toxemia, anemia  Multiple pregnancy, post maturity  Chronic malaria, chronic illness  Tobacco use Causation: LBW
  • 54. LBW (Preterm) : Problems  Birth asphyxia  Hypothermia  Feeding difficulties  Infections  Hyperbilirubinemia  Respiratory distress  Retinopathy of prematurity  Apneic spells  Intraventricular hemorrhage  Hypoglycemia  Metabolic acidosis
  • 55. LBW (SFD) : Problems  Birth asphyxia  Meconium aspiration syndrome  Hypothermia  Hypoglycemia  Infections  Polycythemia
  • 56. LBW: Issues in delivery  Transfer mother to a well-equipped centre before delivery  Skilled person needed for effective resuscitation  Prevention of hypothermia - topmost priority
  • 57. LBW: Indications for hospitalization  Birth weight <1800 g  Gestation <34 wks  Unable to feed*  Sick neonate* * Irrespective of birth weight and gestation
  • 58. Principles of Management for Low Birth Weight and Preterm Newborns • Warmth • Feeding • Detection and management of complications (e.g., resuscitation, assisted respiration, infection )
  • 59. WARMTH As for all newborns: • Lay newborn on mother’s abdomen or other warm surface • Dry newborn with clean (warm) cloth or towel • Remove wet towel and wrap/cover with a second dry towel • Bathe after temperature is stable
  • 60. LBW: Keeping warm at home Skin-to-skin contact Birth weight (Kg) Room temperature (0C) 1.0 – 1.5 34 – 35 1.5 – 2.0 32 – 34 2.0 – 2.5 30 – 32 > 2.5 28 - 30 Prevent heat losses Radiation Convection Evaporation Conduction
  • 61. Definition of Kangaroo Mother Care • Early, prolonged and continuous skin-to- skin contact between a mother and her newborn • Could be in hospital or after early discharge
  • 63. How to Use Kangaroo Mother Care • Newborn’s position: – Held upright (or diagonally) and prone against skin of mother, between her breasts – Head is on its side under mother’s chin, and head, neck and trunk are well extended to avoid obstruction to airways • Newborn’s clothing: – Usually naked except for nappy and cap – May be dressed in light clothing – Mother covers newborn with her own clothes and added blanket or shawl ……contd
  • 64. How to Use Kangaroo Mother Care • Newborn should be: – Breastfed on demand – Supervised closely and temperature monitored regularly • Mother needs lots of support because kangaroo care: – Is very tiring for her – Restricts her freedom – Requires commitment to continue
  • 65. Benefits of Kangaroo Mother Care (1) • Is efficient way of keeping newborn warm • Helps breathing of newborn to be more regular; reduce frequency of apneic spells • Promotes breastfeeding, growth and extra-uterine adaptation • Increases the mother’s confidence, ability and involvement in the care of her small newborn
  • 66. Benefits of Kangaroo Mother Care (2)  Seems to be acceptable in different cultures and environments  Contributes to containment of cost— salaries, running costs (electricity, etc.)
  • 67. FEEDING • Early and exclusive breastfeeding – Breastmilk = best nourishment – Already warm temperature – Facilitated by kangaroo care • If Breast milk is not availble, consider milk formula : Preterm formula --- until 2000 gm then change to After Discharged Formula
  • 68. Guidelines for fluid requirements  First day 60-80 ml/kg/day  Daily increment 15 ml/kg  Add extra 20-30 ml/kg for infants under radiant warmer and 15 ml/kg for those receiving phototherapy
  • 69. Fluid requirements (ml/kg/ day) Birth Weight Day of life >1500 g 1000 – 1500g 1 2 3 4 5 6 7 onwards 60 75 90 105 120 135 150 80 95 110 125 140 155 170
  • 70. LBW: Adequacy of nutrition Weight pattern*  Loses 1 to 2% weight every day initially  Cumulative weight loss 10%; more in preterm  Regains birth weight by 10-14 days  Then gains weight up to 1 to 1.5% of birth weight daily Excessive loss or inadequate weight  Cold stress, anemia, poor intake, sepsis
  • 71. LBW: Supplements  Vitamins : IM Vit K 1.0 mg at birth Vit A 1000 I.U. per day Vit D 400 I.U. per day  Iron : Oral 2 mg/kg per day from 8 weeks of age
  • 72. Danger signals (Early detection and referral)  Lethargy, refusal to feed  Hypothermia  Tachypnea, grunt, gasping, apnea  Seizures, vacant stare  Abdominal distension  Bleeding, icterus over palms/soles
  • 73. Transportation of LBW baby  Adequate warmth  Life support  With mother  Referral note
  • 74. Prognosis  Mortality  Inversely related to birth weight and gestation  Directly related to severity of complications  Long term  Depends on birth weight, gestation and severity of complications
  • 75. Preventive measures  Direct intervention:  Prevent malnutrition in mothers especially during antenatal period.....includes both calories and specific nutrients  Control medical conditions......includes infections and systemic disorders  Avoiding alcohol and smoking  Avoiding stress...physical and mental
  • 76.  Indirect Measures:  Age at marriage and at the time of birth of first child  Family planning....spacing between kids and limiting the number of children  Improving hygiene and sanitation  Improving availability and utilisation of health services  Social measures: improving literacy, women empowerment etc.
  • 77. FEEDING OF THE NEWBORN
  • 78. ANATOMY OF BREAST  It consists of nipple, areola and soft tissue which is composed of mammary glands and supporting tissues.  Mammary glands have alveoli and ducts which have openings at nipple.  Before the actual opening ducts are little inflated to form sinuses which help to store the milk.
  • 80. Physiology of Breast Feeding Two sets of reflexes are there:  Reflexes in Baby  Rooting reflex: touching the cheek of baby and baby turns head to that side  Sucking reflex: Nipple & areola inside the mouth of baby, nipple touches the palate and pressing on to breast tissue with gums releasing milk. POSITIONING AND ATTACHMENT ARE VERY IMPORTANT FOR ADEQUATE BREAST FEEDING.  Swallowing reflex: Milk thus expressed into mouth touches pharyngeal wall initiating swallowing reflex
  • 81.
  • 82.  Reflexes in the mother  Sucking and thus stimulation of nerve endings of nipple sends signal to anterior and posterior pitutary gland leading to release of hormones  Anterior pitutary: Prolactin is released leading to formation of milk by alveoli. PROLACTIN ALSO INHIBITS OVULATION THUS NATURAL CONTRACEPTIVE.  Posterior pitutary: Oxytocin is released leading to stimulation of myoepethelial cells helping in expression of milk. OXYTOCIN HELPS IN CONTROLLING POSTPARTUM BLEEDING AND AIDS INVOLUTUION OF UTERUS.
  • 83. Factors affecting reflexes  Physical: pain and tenderness at breast, sore nipple, fever.  Psychological: Anxiety, tension, depression etc.  Social: Family not supportive, lack of privacy especially strangers, unwanted child birth.  Drugs: Oral contraceptive pills  Attachment is not good  Baby is offered pacifier, may not suck when actually put to breast.
  • 84. Signs of Good Attachment  Baby’s chin should touch the breast, or as close as it can be  Baby’s tongue should be under the lactiferous sinuses and nipple against the palate  Mouth wide open and lower lip turned outwards  Areola if visible should be from above and not below  No pain while breastfeeding
  • 85. How much....  Demand feeding should be practiced  Normally every 2 hrs but not more than 3 hrs even if baby is sleeping  2-3 feeds should be given during night  Total of 10-12 feeds must be given in 24 hrs  Each breast feeding session should be continued for 15-20 min per breast to ensure feeding of hindmilk.
  • 86. Human Milk Compositions  Colostrum: First milk or milk secreted for first 2-3 days after delivery. Small in quantity, yellowish colored, rich in proteins in the form of antibodies, low in fat. Antibodies provide immunity, hence considered to be first vaccination of the child.  Foremilk: Rich in carbohydrates, minerals and vitamins and water. So help to quench thirst of the child.  Hindmilk: Rich in fats and proteins hence provides more energy and also help in growth and development.
  • 87. EXCLUSIVE BREAST FEEDING  Only mother’s milk is to be given  No water, honey, glucose, any appetiser etc. are required.  No supplements required if mother’s nutritional status is good.  Should be practised for 6months of age.  An average indian female secretes 700 ml of milk per day for first six months and then it starts declining, hence complementary feeding is started.  Breast feeding should be continued for 2yrs of age or till it is possible.
  • 88. Human milk vs other milk Constituent Human Milk (gm/litre) Cow’s Milk (gm/ litre) Protein 11 33 Soluble Pro 7 5 Casein 4 28 Lipids 35 35 Linoleic acid 3.5 1 Carbohydrates 70 50 Calcium 0.33 1 Phosphorus 0.15 1 Iron 0.4-1.5 0.3-0.5 Vitamin C 60mg 20mg Vitamin D 50IU 25IU Energy 640-720kcal 650kcal
  • 89. ADVANTAGES OF BREASTFEEDING BABY  Bonding between mother and child  Rich in nutrients and antibodies  Easily digestible and supports growth and development...better mental development too  Affordable  Sustainable: artificial feeding may not be provided every time  Temperature is appropriate, also curtails cost of fuel which is needed in topfeed.
  • 90. MOTHER  Natural method of contraception...prolactin inhibits ovulation  Involution of uterus is better  Help in weight loss gained during pregnancy  Lactating mothers, if diabetic, have shown lesser insulin dependance  Seems to provide prevention against breast cancer HELPS TO STRENGTHEN THE BOND BETWEEN MOTHER AND CHILD WITHOUT EFFORT AND MONETARY INVESTMENT
  • 91. WHEN ARTIFICIAL FEED IS NEEDED  Low birth weight babies  Baby with cleft lip/ palate  Twin babies  Baby is ill..nose blockage, vomitting, any such illness where sucking or oral diet is not possible  Mother is ill...open case of TB, HIV, Hepatitis B etc.  Death of mother
  • 92. BABY FRIENDLY HOSPITAL INITIATIVE  A Global movement started by WHO in 1992  AIMS:  To ensure that every newborn gets the best start in its life  To encourage correct scientific practices in breastfeeding  OBJECTIVES:  To protect, promote and to support breastfeeding practices  To reduce infant mortality rate
  • 93. Ten Key Points of BFHI  Have a written breastfeeding policy that is routinely communicated to all health care staff.  Train all health care staff in skills necessary to implement this policy.  Inform all pregnant women about the benefits and management of breastfeeding.  Help mothers initiate breastfeeding within a half-hour of birth.  Show mothers how to breastfeed and how to maintain lactation, even if they should be separated from their infants.
  • 94.  Give newborn infants no food or drink other than breast milk unless medically indicated.  Practice rooming-in - allow mothers and infants to remain together - 24 hours a day.  Encourage breastfeeding on demand.  Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants.  Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.
  • 95. Infant and Young Child Feeding  Infant Milk Substitutes, Feeding Bottles and Infant Food Act, 1992  Prohibits the promotion of infant food, infant milk substitutes and feeding bootles  Amended in 2004, with GOALS  Exclusive breast feeding upto 6 mths instead of 4-6 mths  Continue breast feed for 2 yrs and beyond  Decrease the prevalence of undernutrition among under three years  Enhance initiation of breastfeeding including colostrum at the earliest  Increase the rate of exclusive breast feeding to 80%  Complementary feeding rates to 75%
  • 97.  GROWTH (Physical) Refers to increase in size and mass  DEVELOPMENT  Refers to attainment of functional ability in response to external stimuli
  • 98. Physical Growth Assessment  Weight for Age (WFA)  Height for Age (HFA)  Weight for Height (WFH)  Head Circumference  Chest Circumference  Dentition
  • 99. Weight for Age  Regular measurements are important  Every month till 2 years and every 3months till 5 years  Readings plotted on GROWTH CHART  Weight doubles by 4-5 months  Triples at one year of age  Thereafter, One birth weight added every year till puberty  At least 500gm per month increment for first 3mths but normally 1 kg per month after regaining the initial loss  Weight is matched with standard values (derived from local population), if not available then reference values can be used
  • 100. Height for Age  Length of baby at birth is 50 cm  Gains 25 cm in first year  Another 12 cm in second year  Then 6-7 cm every year till puberty  Pubertal spurt adds 20cm to boys and 16 cm to girls
  • 101. Head and Chest Circumference  HC approx 34 cm at birth and is more than chest circumference  Chest circumference equals HC at 6-9 mths of age in well fed babies and then it starts overtaking  Anterior fontanelle closes by the age of 9-18 mths  Posterior fontanelle closes by 3 mths of age
  • 103. Assessing Development- MILESTONES Four Categories 1. Motor Development 2. Socio- Personal Development 3. Adaptive Development 4. Language Development
  • 104. Milestones Age Motor development Socio-personal Adaptive development Language development 6-8 wks - Social Smile - - 3 mths Holds head erect - - - 4-5 mths - Recognises mother Try to reach to objects Listening 6-8 mths Sits without support Play with objects Making noises with toys/ objects 9-10 mths Crawling Suspicious of strangers Releases object if asked 10-11 mths Stands with support - Monosyllable speech 12-14 mths Walking Identifies family - Words like mama, papa 18-21 mths Walk properly Interested in surroundings More words 24 mths running Toilet training for day time Sentences –short and simple
  • 105. Determinants of Growth and Development  Genetic Inheritance  Nutrition- Malnutrition manifests as growth retardation  Age: more in childhood then declines, different parts grow at different times  Sex: maximum height achieved is different for girls and boys, pubertal spurt also happens at different ages  Physical surroundings: Sunshine, lighting and ventilation  Psychological Factors: Interpersonal relationships  Infections  Economic Factors: Indirectly plays role by providing better nutrition and environment  Social factors: Birth order, spacing between children, son preference, education of parents etc.
  • 106. Why cartoon characters have normally bigger heads than bodies...
  • 107. GROWTH CHART  Graphical presentation of anthropometric measurements of human beings specifically children  Commonly used for underfive kids as they are more prone to nutritional disorders  Commonly used growth charts depict weight for age since weight is the most sensitive measure of growth and similarly any intervention is firstly expressed in terms of weight gain  First devised by David Morley  Many versions are available...WHO, NCHS, CDC, IAP  Latest being released by WHO in 2006...based on multicentric study conducted worldwide and hence considered to be more appropriate for any population.
  • 108. Key Features  WHO 2006 growth charts are different for boys and girls  Reference curves are there for making comparison  These curves correspond to Z scores at different ages  Z scores range from -3 to +3  Weight ranging between -2 to +2 is considered normal  <-2 indicates undernutrition and >+2 indicates overweight  Hence, zone between -2 and +2 is considered to be “road to health”
  • 109. Mother and Child Protection Card  This card (actually a booklet) is prepared on the day pregnancy is registered and continues till the newborn attains 5 years of age.  Carries information about antenatal, intranatal and postnatal period  Also carries information about infant regarding birth history, immunisation and supplementation and growth (weight for age) of the child  It is available with the health worker and mother both  Growth charts are there at the end of booklet
  • 110.  To make it readable by the workers and to make it understandable for the mothers zones have been coloured accordingly  Blue band on the top of chart indicates –chart for boys pink band on the top of chart indicates –chart for girls  Three coloured zones are there on actual graph  Green zone- between -2 to +2 Z scores-normal nutrition  Yellow- <-2 Z score- Mild and moderate malnutrition  Red-< -3 Z score- Severe malnutrition
  • 111.  Readings noted at frequent intervals are joined to get a curve  Curve should be in green zone and run parallel to the reference curves  Any dip in the curve/ flattening of curve even though reading is in green zone indicates something wrong with diet and should be managed  Hence, direction of curve is more important than single reading
  • 113. Mother and Child Protection Card
  • 114. Uses of Growth Chart  Growth Monitoring  Diagnostic Tool- malnutrition or at risk  Planning and Policy Making  Educational Tool  Tool for Action  Evaluation  Tool for Teaching: to show effect dietary restrictions during diseased phase
  • 115. Why are new growth charts devised by WHO are depicting Z-scores instead of percentiles?
  • 117. Background  Started in 1975  Managed and run by Ministry of Women and Child Development  Funded by State and Central Government on 50-50 sharing basis since 2005-06  Centre of function is Anganwadi
  • 118. ANGANWADI  Angan means Courtyard  Giving the kids and females a homely environment and providing services which promote their health at no extra cost  One Anganwadi Centre caters to a population of 400- 800. More centres can be established if population increases in multiples of 800.  Mini Anganwadi centre... Population of 150-400 people...to cater small villages, habitations of SC/ST or any other minorities  In tribal/ hilly/ desert/ or difficult areas....300-800 population, Mini Anganwadi at 150-300 population.
  • 119. OBJECTIVES  To improve the nutritional and health status of children in the age group of 0-6 years  To lay down foundation for proper psychological, physical and social development of the child  To reduce mortality and morbidity esp due to malnutrition among 0-6 years and hence decreasing school drop-outs  To provide coordination among various departments working for the promotion of child development  To enhance capability of the mother and nutritional needs of the child through proper nutrition and health education
  • 120. Three Components  Functionaries: who are responsible for providing the services available  Fit to avail services ...Beneficiaries...People for whom services are available  Functions...Services avilable
  • 121. FUNCTIONARY  Main functionary is Anganwadi Worker (AWW). Also one helper is there and one cook is there.  AWW is preferably chosen from the community she is expected to serve  She undergoes 4 month training  In lieu of her services provided she is paid monthly honorarium of Rs 2400/- approx.  Helper also gets the honorarium and cook gets money for fuel used in cooking & ration is provided by the government.
  • 122. Beneficiaries Services Pregnant Women 1. Health Check up 2. Immunisation against Tetanus 3. Supplementary Nutrition 4. Nutrition and Health Education Nursing Mothers 1. Health Check up 2. Supplementary Nutrition 3. Nutrition and Health Education Children <3years 1. Supplementary Nutrition 2. Immunisation 3. Health Check up 4. Referral Services Children Aged 3-6 years 1. Supplementary Nutrition 2. Immunisation 3. Health Check up 4. Referral Services 5. Non – Formal Preschool Education Adolescent girls (11-18 years) 1. Supplementary Nutrition 2. Nutrition and Health Education All women 15-45 years 1. Nutrition and Health Education
  • 123. SUPPLEMENTARY NUTRITION  It is to be provided for 300 days in a year to the beneficiaries who are assigned to have the benefit Beneficiary Food specification/ day Financial support Remarks All Children 6-72 month age Calories 500 kcal Proteins 12-15 gm Rs.4 per child Cooked Meal for 3-6 year old children Take home Ration for < 3 year aged kids and pregnant and lactating mothers Children 6-72 month age (severely malnourished) Calories 800 kcal Proteins 20-25 gm Rs.6 per child Pregnant and Nursing women Calories 600 kcal Proteins 18-20 gm Rs.5 per eligible female
  • 124.  Nutrition and Health Education: Given to all females of 15-45 years of age esp the pregnant and lactating ones.  Immunisation: for all the kids and pregnant women with help of Multipurpose Health Workers. Records are maintained and available for any future reference.  Health Check up:  Antenatal care and postnatal care  Registration, Immunisation, IFA supplements  Care of children under 6 years of age  Growth monitoring, immunisation, detect malnutrition and management, Vitamin A and Iron supplements, deworming, management of diarrhoea, ARI and referral services.
  • 125.  Non Formal Pre School Education:  Provided to 3-6 year old children  Help to develop healthy and socially acceptable attitude, values and behaviour pattern among children  Locally made inexpensive toys and other such objects are used  No specific syllabus is there  Help the child to express himself and adjust with the group  Help to give direction to the child's actions by letting him to show his creativity
  • 126. Services to Adolescent Girls  Using the infrastructure of ICDS project, a new scheme for adolescent girls ...KISHORI SHAKTI YOJANA  Nutrition programme was also started for adolescent girls .
  • 127. KISHORI SHAKTI YOJANA  11-18 year old girls are benefitted  Counselling sessions or peer groups are there to discuss their problems pertaining to physical, reproductive or psychological health  Nutrition education is also imparted  Literacy and numerical skills are gained  Girls are also provided some vocational training  All this , helps them to be better home makers in future life to support their family
  • 128. NUTRITION PROGRAMME  Started in 2009-10  Running in some selected villages  Girls aged 11-15 year and weighing less than 30 kg, girls aged 15-19 years weighing less than 35 kg are considered undernourished and benefitted  These girls are provided with 6kg grain every month to supplement their dietary intake, hence betterment of nutritional status
  • 129. Organisational Set up  Till 2012, 6908 ICDS projects were running through 13.04 lakh AWCs  751.03 lakh children and 167.62 lakh mothers (pregnant and lactating)are getting benefits  COMMUNITY DEVELOPMENT BLOCK....Administrative Head Office of one project covering a population of 1,00,000
  • 130. THE ICDS TEAM:  The ICDS team comprises the  Anganwadi Workers and Anganwadi Helpers  Supervisors ( ONE for 20-25 AWCs) also called MUKHYASEVIKA  Child Development Project Officers (CDPOs)- Incharge for 4 Mukhyasevikas and 100 AWCs  Along with: (people from Health and Family Welfare Department)  District Programme Officers (DPOs)  Medical officers  Auxiliary Nurse Midwife (ANM)  Accredited Social Health Activist (ASHA) form a team with the ICDS functionaries to achieve convergence of different services
  • 131. INTERNATIONAL PARTNERS Government of India partners with the following international agencies to supplement interventions under the ICDS:  United Nations International Children’ Emergency Fund (UNICEF)  Cooperative for Assistance and Relief Everywhere (CARE)  World Food Programme (WFP)
  • 132. INDICATORS OF MCH CARE  MATERNAL MORTALITY RATIO (Rate)  MORTALITY IN INFANCY AND CHILDHOOD  Perinatal mortality rate  Neonatal mortality rate  Post- neonatal mortality rate  Infant mortality rate  1-4 year mortality rate  Under five mortality rate  Child survival rate
  • 133. MATERNAL MORTALITY RATIO  Death of a woman who is pregnant or within 42 days of termination of pregnancy, irrespective of the site or duration of pregnancy, from any cause related to or aggravated by the pregnancy or its management  It is expressed as: 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 Total no. Of live births in the same area and year * 1000
  • 134.  The appropriate denominator for the maternal mortality ratio would be the total number of pregnancies (live births, fetal deaths or stillbirths, induced and spontaneous abortions, ectopic and molar pregnancies).  However, this figure is seldom available and thus number of live births is used as the denominator.  In countries where maternal mortality is high denominator used is per 1000 live births but as this indicator is reduced in numbers with better services, the denominator used is per 1,00,000 live births to avoid figure in decimals.
  • 135. Other terms:  Late maternal death Late maternal is death of a woman from direct or indirect obstetric causes, more than 42 days but less than one year, after termination of pregnancy.  Pregnancy related death defined as : the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the cause of death.
  • 136.  Direct obstetric deaths The deaths resulting from obstetric complications of the pregnant state, from interventions, omissions, or incorrect treatment, or from a chain of events resulting from any of the above are called direct obstetric deaths.  Indirect obstetric deaths Those resulting from previous existing disease or disease that developed during pregnancy and that was not due to direct obstetric causes but was aggravated by the physiological effects of pregnancy.
  • 137. Statistical measures of maternal mortality  Maternal Mortality Ratio: (MMR) Number of maternal deaths during a given time period per 1000 (or 100,000) live births during the same period.  Maternal mortality Rate: Number of maternal deaths during a given time period per 1000 (or 100,000) women of reproductive age during the same period.  Adult lifetime risk of maternal death: Probability of dying from a maternal cause during a woman’s reproductive life span.  Proportional maternal deaths of women of reproductive age : Number of maternal deaths in a given time period divided by the total deaths among women aged 15- 49 years.
  • 138. Sources of data providing information about Maternal Mortality  Civil Registration Systems: Birth and Death Registration  Sample Registration System  Household Surveys  Reproductive age mortality studies  Verbal autopsy to know the cause of death among women  Census
  • 139. RHIME  Representative, re-sampled, routine, Household Interview of Mortality with Medical Evaluation  Started in year 2000  Modification of SRS  Conducted by independent team  Enhanced form of Verbal Autopsy  Cause of maternal death is tried to be established and classified as ICD-10 coding  Helps to compare the status on a global level in terms of nos. And the underlying causes
  • 140. MMR in India and states India and States MMR Lifetime risk India 178/100,000 live births 0.4% Haryana 146 0.4 Punjab 155 0.3 Kerala 66 0.1 Tamil Nadu 90 0.2 Gujarat 122 0.3 Maharashtra 87 0.2 UP 292 1.0 Bihar 219 0.8 Rajasthan 255 0.9 Assam 328 0.8
  • 141. Causes of Maternal Mortality  Direct causes- 80%  Indirect Causes- 20% (include anaemia, malaria, heart diseases etc.) Hemorrhage, 25 Infection, 15 Eclampsia, 12 Obstructed labour, 8 Unsafe Abortion, 13 Other Direct Causes, 8 Indirect Causes, 20 Causes of maternal mortality worldwide Hemorrhage Infection Eclampsia Obstructed labour Unsafe Abortion Other Direct Causes Indirect Causes
  • 142. Causes of maternal mortality in India 38 115 5 8 34 Causes Hemorrhage Sepsis Hypertensive disorders Obstructed labour Abortions Other Conditions
  • 143. Determinants of Maternal Mortality Medical Causes Social Factors Obstetric Causes Age at child birth Hemorrhage Parity Infection Too close pregnancies Toxemia of Pregnancy Family Size Obstructed Labour Malnutrition Unsafe Abortion Poverty Non- Obstetric causes Illiteracy Anemia Gender preference Associated systemic diseases like cardiac, renal, hepatic, metabolic etc. Women- weaker sex- often neglected and prone to domestic violence Malignancy Poor Sanitation Accidents Lack and underutilisation of MCH sevices Delivery by untrained dais Delay in availing expert services
  • 144. Reasons for DELAY  Delay in identifying the danger signs  Delay in seeking care  Delay in transport to appropriate health facility  Delay in provision of adequate care ASHA worker and other local leaders and social groups can help a lot in decreasing the time lag during these events to a great extent.
  • 145. Indicators for maternal health care services utilisation and current status INDICATORS NFHS-III (2005-2006) 1. Antenatal Care a. Any Visit 77.0% b. 4 visits 50.7% 2. Deliveries a. Institutional 41.0% b. Safe Delivery 48.2% 3. IFA tablets for 100 days 22.3% 4. Postnatal Check up within 2 days 36.4%
  • 146. Preventive and Social Measures  Early registration of pregnancy  Atleast 4 ANC visits  Dietary supplementation esp anamia  Prevent infection  Prevent hemorrhage  Prevent and timely management of complications  Treating medical problems  Tetanus prophyllaxis  Safe delivery: Three cleans and trained birth attendants  Institutional delivery esp in high risk cases  Promote family planning  Safe abortion  Involve local leaders and NGOs for social support in terms of women literacy, no gender bias, women epowerment.
  • 147.
  • 148. INFANT MORTALITY RATE - the ratio of infant deaths registered in a given year to the total number of live births registered in the same year; usually expressed as a rate per 1000 live births. - it is given by the formula: Number of deaths of children less IMR = than one year of age in a year ×1000 Number of live births in the same year
  • 149. Why Infant mortality is important  It is largest single age-category of mortality  Cause(s) of death is very different from adults  These underlying causes are in majority preventable and hence impact of national programme implementation is noticeable  It reflects the socio-economic development of the country  Indirect determinant of human development index
  • 150. Infant mortality in India  41 in the year 2012  204 during 1911-15  Madhya Pradesh- IMR of 56, & Kerala- as low as 12 per 1000 live births during the year 2012.  Kerala, Maharashtra, Punjab, T.N, W.B, A.P, Haryana, K’taka, Gujarat, H.P and Jharkhand have achieved IMR below national average of 42.  Odisha, M.P, U.P, Assam and Rajasthan- IMR > 42!
  • 151. Global Scene  Average IMR of 34 per thousand live births  Ranges between 5 and 61 per thousand live births  In south east Asia – 43 per thousand live births  International comparisons Country 2013 India 41 Srilanka 8 Bangladesh 33 Pakistan 69 USA 6 UK 4 Japan 2
  • 152. IMR in India (2012) State Rural Urban Combined INDIA 46 28 42 Haryana 46 33 42 Punjab 30 24 29 Himachal Pradesh 37 25 36 Delhi 36 23 25 Kerala 13 9 12 Tamil Nadu 24 18 21 Gujarat 45 24 38 Uttar Pradesh 56 39 43 Rajasthan 54 31 49 Madhya Pradesh 60 37 56 Assam 58 33 55
  • 153. Medical causes of infant mortality Neonatal mortality (0-4 weeks) Post-neonatal mortality (1-12 months) 1. Low birth weight and prematurity 2. Congenital malformations 3. Birth injury and difficult labour 4. Sepsis 5. Haemolytic diseases of newborn 6. Conditions of placenta and cord 7. Diarrhoeal diseases 8. Acute respiratory infections 9. Tetanus 1. Acute respiratory infections 2. Diarrhoeal diseases 3. Other communicable diseases 4. Malnutrition 5. Congenital anomalies 6. Accidents
  • 154. Causes of infant mortality 57 17 4 523 12 Causes LBW ARIs ADDs Congenital Malformations Sepsis Birth injury Others
  • 155. Factors affecting Infant mortality 1. BIOLOGICAL FACTORS (a) Birth weight: - babies of low birth weight and high birth weight are at special risk. - causes: poor nutrition during pregnancy.. (b) Age of the mother: - IMR are greater when the mother is either very young (<19yrs) or relatively older (>30 yrs).
  • 156. (c) Birth order - the highest mortality is found among first born, and the lowest among those born second. - The risk of infant mortality escalates after the third birth. - the fate of fifth and later children is always worse than the fate of the 3rd child.
  • 157. (d) Birth spacing - repeated pregnancies- malnutrition and anaemia in the mother- predispose to LBW.. - prematurely weaned- PEM, diarrhoea and dehydration. (e) Multiple births - Infants born in multiple births face a greater risk of death than do those in single births due to the greater frequency of low birth weight among the former.
  • 158. (f) Family size - the number of episodes of infectious diarrhoea, prevalence of malnutrition, and severe respiratory infections have been found to increase with family size. - fewer children-better maternal care, a better share of family resources, less morbidity and greatly decreased infant mortality. (g) High fertility high fertility and high infant mortality go together.
  • 159. 2. ECONOMIC FACTORS The availability and quality of health care and the nature of the child’s environment are closely related to socio-economic status.
  • 160. 3. CULTURAL AND SOCIAL FACTORS (a)Breast feeding: Early weaning and bottle-fed infants living under poor hygienic conditions are more prone to die than the breast-fed infants living under similar conditions.
  • 161. (b) Religion and caste The differences are attributed to socio-cultural patterns of living, involving age-old habits, customs, traditions affecting cleanliness, eating, clothing, child care and almost every detail of daily living. (c) Early marriages ..teen-age mother- greater risk of neonatal and post- neonatal mortality.
  • 162. (d) Sex of the child Statistics show that female infant mortality is higher than the male infant mortality. (e) Quality of mothering (f) Maternal education Women with schooling tend to marry later, delay child- bearing and are more likely to practice family planning.
  • 163. (g) Quality of health care Shortage of trained personnel like dais, midwives and health visitors is another determinant of high mortality in India. According to estimates only 47% of the deliveries are attended by trained birth attendants. (f) Broken families (g) Illegitimacy
  • 164. (j) Brutal habits and customs -depriving the baby of the first milk or colostrum, frequent purgation, branding the skin, application of cow-dung to the cut end of umbilical cord, faulty feeding practices and early weaning. (k) The indigenous dai ..untrained midwife- unhygienic delivery. (l) Bad environmental sanitation- Increased incidence of diarrhoeal diseases, overcrowding leading to respiratory diseases, insect breeding etc.
  • 165. Preventive and social measures 1. Prenatal nutrition - improve the state of maternal nutrition.. 2. Prevention of infection - eg. Neonatal tetanus, UIP- protect against 8 vaccine preventable diseases. 3. Breast feeding - prevents gastro-intestinal, respiratory infections and PEM.
  • 166. 4. Growth monitoring - all infants should be weighed periodically and their growth charts maintained. - these charts help to identify children at risk of malnutrition early. 5. Family planning - smaller sibship and longer spacing between pregnancies are associated with improved infant and child survival.
  • 167. 6. Sanitation 7. Provision and utilisation of primary health care - all those involved in maternity care ( obstetrician-local dai) should collaborate and work together as a team. - Educating people to use maternal services
  • 168. - Prenatal care must be improved with a view to detecting mothers with “high-risk factors”, and those with prenatal conditions associated with high- risk are hospitalised and treated. - “Special care baby units” : for babies weighing less than 2000g. - Proper referral services.
  • 169. 8. Socio-economic development this must include spread of education, improvement of nutritional standards, improvement of housing conditions, the growth of agriculture and industry and the availability of commerce and communication; in short it implies all round health and social development of the community. 9. Education Educated women generally do not have early pregnancies, are able to space their pregnancies, have better access to information related to personal hygiene and care of their children, and make better use of health care services.
  • 170.
  • 171. Mortality in and around infancy Infant mortality Neonatal death Post-neonatal death Early neonatal death Late-neonatal death 29 days - 1 year Perinatal death Still birth 28 weeks of gestation 7 days 28 days Birth
  • 172. Still Birth Rate  Death of a foetus beyond viability period i.e. If separated from mother, it will be able to survive with/without life support  This period has been marked at 22 weeks of gestation globally but in our country it is at 28weeks  Hence, still birth is death of a foetus weighing 1000g(equivalent to 28 wks of gestation) or more occurring during one year in every 1000 total (live+still births).  Weight cut off is suggested to overcome the difficulty to assess period of gestation in cases where date of last menstrual period is not known.
  • 173. Calculate Still BirthRate  Current still birth rate in India is 5/1000 births/year.  It is same in urban and rural areas.  High in states where better services and literacy status is high- high reporting  Low in states in which are poor in these parameters –low reporting Fetal deaths weighing over 1000g at birth during the year Total live+ stillbirths weighing over 1000g at birth during the same year *1000
  • 174. Perinatal death rate Perinatal period: The period which begins from the twenty eight weeks of a pre-natal life of a fetus (at this time body weight is 1000 g in norm or crown-heel length of 35 cm atleast) and finishes after 7 full days (168 hours) after a birth. Perinatal death rate includes three periods:  Antenatal (beginning with the 28th week of pregnancy up to delivery);  Intranatal (the period of delivery);  Early neonatal (the first 168 hours of life of a child i.e first 7 days of life).
  • 175. Perinatal mortality rate • Perinatal mortality rate which is calculated as Number of born dead + number of died at the first 168 hours of life × 1000 Number of born alive and dead • The analysis of perinatal death rates allows to estimate succession in work of obstetric and pediatric services. Late registering of pregnancy, rare visiting of antenatal clinic by the expectant mother, absence of qualitative, interested supervision over the health of the pregnant woman are behavioral risk factors of perinatal death rates.
  • 176. Perinatal mortality is a problem of serious dimensions in all countries.  In developed countries, perinatal mortality rates 15-20 per 1000 total births.  The perinatal mortality rate in India is reported to be 31 per 1000 live births in rural areas, 17 per 1000 live births in urban areas and 28 per 1000 live births combined in rural and urban areas.
  • 177. Causes of Perinatal Mortality • About two-thirds of all perinatal deaths occur among infants with less than 2500 g birth weight. • Main causes: The main causes of death are • intrauterine and birth asphyxia • low birth weight • birth trauma • intrauterine or neonatal infections. The various causes of perinatal mortality may be grouped as below: Antenatal Causes: Maternal diseases - hypertension, cardiovascular diseases, diabetes, tuberculosis, anaemia, pelvic diseases, anatomical defects, toxemias of pregnancy; Intranatal Causes: Prolonged effort time, obstetric complications; Postnatal Causes: Prematurity, respiratory distress syndrome, respiratory and alimentary infections, congenital anomalies
  • 178. Neonatal mortality rate (NMR)  Neonatal deaths are deaths occurring during the neonatal period, commencing at birth and ending 28 completed days after birth.  The neonatal mortality rate is tabulated as:  In INDIA current figures are 29/ 1000 live births/year (33:rural, 16:urban)  60-70% of the total infant deaths 1000 yearsametheinbirthsliveTotal yearainageofdays28 underchildrenofdeathsofNumber 1000 yearsametheinbirthsliveTotal yearainageofdays28 underchildrenofdeathsofNumber
  • 179. Causes of neonatal mortality in INDIA
  • 180. Post-neonatal mortality rate (PNMR)  Deaths occurring from 28 days of life to under one year are called "post-neonatal deaths". The post-neonatal death rate is defined as: "the ratio of post-neonatal deaths in a given year to the total number of live births in the same year; usually expressed as a rate per 1000".  The post neonatal mortality rate is tabulated as:  Whereas neonatal mortality is dominated by endogenous factors, post-neonatal mortality is dominated by exogenous (e. g., environmental and social) factors. 1000 yearsametheinbirthsliveTotal yeargivenainageofyearoneanddays28 betweenchildrenofdeathsofNumber
  • 181. Cause of post-neonatal mortality  In the developed countries, the main cause of post-neonatal mortality is congenital anomalies.  Post-neonatal mortality increases steadily with birth order, and that infants born into already large families run a higher risk of death from infectious diseases and malnutrition  In India the post neonatal mortality rate is estimated to be 14 in rural areas, 12 in urban areas and 13 combined in rural and urban areas.
  • 182. Relation between IMR, NMR, PNMR  IMR= NMR+ PNMR  NMR= IMR- PNMR  PNMR= IMR- NMR
  • 183. PREVENTING MORTALITY IN INFANTS  Measures related to mother:  Efficient antenatal care: minimum 4 visits, nutrition education and supplementation esp IFA  Two doses of TT to prevent tetanus neonatorum  Identifying high risk mothers  Intranatal care to avoid infections and birth injuries  Timely management of complications, if any
  • 184.  Measures related to infant:  Essential care of the newborn babies  Special Care to at risk newborn like LBW babies  Breast feeding  Immunisation  Growth monitoring  Oral rehydration therapy during diarrhoea
  • 185.  General measures:  Family planning  Female literacy  Avoiding early marriages  Health education of mothers regarding feeding practices, weaning practices and child rearing practices  Improvement of sanitation and providing safe water
  • 186. Find....and comment  In a rural PHC with a population of 30,000; there were 800 live births and 15 still births in the year 2014. There were 80 infant deaths out of which 50 deaths occurred during the first 28 days of their lives and of these 50 deaths 25 deaths occurred in 1st week of life. Calculate ...  Still birth rate  Perinatal mortality rate  Neonatal mortality rate  Post neonatal mortality rate  Infant mortality rate  Comment on the health services available to this population
  • 187. Rates for referenceParameter India Still Birth rate 5/1000 births Perinatal mortality rate 28/1000 live births Neonatal Mortality Rate 29/1000 live births Post neonatal Mortality Rate 13/1000 live births Infant Mortality rate 41/ 1000 live births Maternal Mortality Ratio 178/100,000 live births Crude Birth Rate 21.6/1000 mid year population Crude Death Rate 7.0/ 1000 mid year population
  • 188.  In a rural PHC with a population of 2,00,000; there were 6050 live births and 110 still births in the year 1990. There were 750 infant deaths out of which 480 deaths occurred during the first 28 days of their lives and of these 480 deaths 250 deaths occurred in 1st week of life. Calculate ...  Still birth rate  Perinatal mortality rate  Neonatal mortality rate  Post neonatal mortality rate  Infant mortality rate  Comment on the health services available to this population
  • 189. Maternal Mortality Ratio (MMR)  In a CHC with population of 1,60,000; there were 4500 births and 20 deaths of mothers were reported due to obstetric causes. Calculate MMR and comment on the health services.
  • 190. Birth Rate and Death Rate  Calculate crude birth rate and crude death rate of a town with population of 5,00,000. Live births reported were15,000 for the last year and 7,000 deaths were reported during the same year and comment on the services.
  • 191. UNDER-5 MORTALITY RATE  No. Of deaths of children aged less than 5 years per 1000 live births  Calculated as No. Of deaths of children less than 5 years * 1000 No. Of live births in the same year  It is one single parameter which gives measure of any country’s social and economic development
  • 192. 1-4 YEAR MORTALITY (Death) RATE  CHILD DEATH RATE is commonly used for this parameter  It is expressed as deaths of children of age 1-4 years per thousand children of the same age in a given calendar year.  Calculated as No. Of deaths of children aged 1-4 years during a year *1000 Mid year population of children of age 1-4 years  It is type of age specific death rate which is no. Of deaths in a any particular age
  • 193. Causes of 1-4 year mortality  Causes are mainly exogenous Developing countries Developed countries Diarrhoeal diseases Accidents Respiratory infections Congenital Anomalies Malnutrition Malignancies e.g. Leukemias Infectious diseases (vaccine preventable) Influenza Accidents and injuries Pneumonia
  • 194. Current Status- Year 2013 Country Infant mortality Rate (IMR) Mortality in 1-4 year age group Under-5 Mortality Rate India 41 12 53 Srilanka 8 2 10 Bangladesh 33 8 41 Pakistan 69 17 86 China 11 2 13 USA 6 1 7 UK 4 1 5 Japan 2 1 3
  • 195. CHILD SURVIVAL INDEX  This parameters tells us the chance of a survival of new born beyond age of 5 years  Calculated as 1000 - under-5 mortality rate 10 For India (2013) , hence calculated as ( 1000-53)/10= 94.7%
  • 196. Programmes to improve child survival All activities have now been put under one umbrella of NRHM- NATIONAL RURAL HEALTH MISSION  Universal Immunization Programme  Baby Friendly Hospital Initiative  Integrated Management of Neonatal and Childhood Illness  Every Newborn Action Plan  Reproductive Maternal Neonatal and Child Health along with Adolescent component
  • 197. INTEGRATED MANAGEMENT OF NEONATAL AND CHILDHOOD ILLNESS (IMNCI)  Strategy developed by WHO and UNICEF.....IMCI ...to provide comprehensive package of health care for children of age 7days -5 years  Modified in our country as IMNCI to include all children i.e . Kids of age 0day – 5 years  Mainly aims at :  Improving case management skills of healthcare workers  Improving health system to be more capable of managing the illnesses  Improving family’s and community’s practice towards child’s bringing up
  • 198.  Grass root level workers are trained to assess and manage the health problems  Also trained to identify danger signs for timely referral to higher health facility and to tell the same to the parents, ....helping to decrease mortality due to lack of timely expert care  IMNCI deals with kids in two groups and charts are provided to the health care worker for reference  1st group: kids between 0day- 2 months  2nd group: kids 2months -5 years
  • 199. KEY ELEMENTS  ASK and ASSESS  CLASSIFY  IDENTIFY mode of treatment  TREATMENT instructions to family  COUNSEL for other contributory factors  FOLLOW UP
  • 200. ASK and ASSESS  Ask about presenting complaints specifically about DANGER SIGNS...inability to take feeds, vomiting out everything, any episode of convulsions.  Assess for DANGER SIGNS...lethargic or unconscious  In-depth detail of presenting illness  Nutritional Status of the child  Immunisation of the Child  Based on all the signs and symptoms severity of disease is established
  • 201. CLASSIFY  Every disease has been classified in three classes corresponding to three colour codes  PINK: Urgent pre-referral treatment and referral  YELLOW: Specific medical treatment and advice  GREEN: Advice for home management IDENTIFY After classifying and planning the treatment arrangements for the plan of action are to be made like need for transportation if referral, drugs for specific treatment, immunisation and supplementation (vit A in measles). First dose preferably be given by the health worker.
  • 202. FLOW CHART FOR IMNCI 1. Check for danger signs..convulsions, lethargy, inability to feed, vomiting 2. Assess main symptoms...cough, difficulty breathing, diarrhoea, fever, ear problems 3. Assess nutritional status and immunisation status 4. Any other problem IF DANGER SIGN IS THERE...urgent referral along with pre-referral treatment No danger sign...but antibiotics needed Home based treatment
  • 203.  INSTRUCTIONS to the care taker for compliance and administration of treatment  COUNSELLING the parents for regular feeding of the child as per age requirement, regarding immunization, safe water, sanitation, vector control measures etc.  FOLLOW UP visit is must to assess the outcome and accordingly modify the plan of action.
  • 204. CONGENITAL DISORDERS  Defined as those diseases that are substantially determined before or during birth which are in principle recognizable in early life.  Their incidence worldwide has been reported as 1 in 33 newborns, responsible for more than 2,70,000 deaths in neonates globally  Two substitutes are suggested by WHO  Malformations: structural defects  Anomaly: includes all biochemical, structural or functional disorders
  • 205. Causes of Congenital disoders  Genetic Factors: Includes  Chromosomal abnormalities: During meiotic divisions e.g. Down’s Syndrome, Klinefelter’s syndrome, Turner’s syndrome  Inborn errors e.g. Phenylketonuria, galactossemia etc.  Inheritance of gene defects like thalassemia, sickle cell etc.  No specific aetiology: club foot, congenital dislocation of foot  Environmental Factors: Includes defects arising due to exposure to external agent which could affect the growing fetus:  Infection like rubella leading to congenital cataract, patent ductus and auditory problems  Drugs like thalidimide causing limb deformity  Radiation exposure leading to metabolic anomalies  Dietary factors: Folic acid deficiency may lead to neural tube defect
  • 206. RISK FACTORS  Maternal Age: Advancing age of mother has been significantly associated with high incidence of down’s syndrome  Consanguinity: Marriages in close relation especially first cousins often lead to expression of recessive disorders. Incidence of Mental retardation is also relatively higher in kids born of such wedlocks.
  • 207. PRENATAL DIAGNOSIS  Alpha feto proteins: neural tube defect  Ultrasonography: Structural defects can be visualised  Amniocentesis: For down’s syndrome  Chorionic Villi Sampling: For chromosomal disorders
  • 208. PREVENTIVE MEASURES Health Promotional Measures: Includes  EUGENICS: Not much acceptable  Negative: sterilization of people with known defects  Positive: healthy people are encouraged to have parenthood  EUTHENICS: providing healthy environment and nutrition  GENETIC COUNSELLING:  Prospective: Premarital genotyping to know any carrier state for genetic disorder and accordingly avoiding marriage between people carrying recessive gene for some disorder  Retrospective: Avoiding further births if already there is such history in the family.  MODIFYING SOCIAL FACTORS:  Avoiding marriages among close relatives  Avoiding pregnancies in advanced age hence avoiding late marriages
  • 209. Specific Protection  Avoiding radiation  Avoiding drugs  Dietary supplements  Immunisation against known mutagenic diseases  Managing the disease before it precipitates as in Rh incompatibility where Anti D globulin is given to prevent haemolytic disease among subsequent births
  • 210. Early Diagnosis and Treatment  Detection of genetic carriers  Prenatal diagnosis  Screening of newborns  Screening during childhood List of diseases is long but investing little effort can prevent damaging outcome Though genetic diseases are not completely curable but many of them tend to be manageable if timely recognised with some modification in lifestyle
  • 211.
  • 212. Introduction  Adolescence means the growing period derived from latin word ADOLESCERE (to grow)  Rapid growth is experienced by indvidual leading to physical, psychological, emotional and spiritual changes  Adolescence is one of the healthy periods of life....
  • 213.  BUT DRASTIC TRANSITION IN EVERY ASPECT OF HUMAN BODY PUTS THIS AGED PEOPLE AT SOME SPECIAL RISK  Accidents, Suicides, violence, teen age pregnancy, drug abuse, sexually transmitted infections, unhealthy life style pertaining to eating and physical activity
  • 214. Subgroups • Total period: 10-19 years of age (WHO) • Early Adolescence: 10-13 years (physical Changes) • Middle Adolescence: 14-16 years (Behavioural Changes- acceptance of oneself and experimentation) • Late Adolescence: 17-19 Years (regaining stability with independent opinion) • Youth: 15-24 years • Young people: 10-24 years
  • 215. Health problems  Physical including nutritional deficiencies and STIs  Psychological like depression, anxiety etc.  Behavioural like risk taking behaviour, juvenile delinquency  Social like teenage pregnancy, addictions etc.
  • 216. Physical Health problems • Period of growth spurt and followed by no growth • Any deficiency or hormonal imbalance can leave a permanent effect • Delayed or slowed pubertal growth may lead to long lasting after effects • Counselling and education regarding balanced diet and physical activity is must • Iron deficiency: both girls and boys are prone • Similarly increased demand for calories, proteins, calcium, iodine, vitamin C and D is there • Since mucosal barrier and ph of vaginal mucosa is not effective against micro-organisms, hence they are more prone to STIs including HIV
  • 217. Psychological Problems • Changes in body appearance in both males and females • Reproductive changes in females i.e. Menstruation, growth of breast tissue, growth of hair at underarms and around genitals, acne etc. • Similarly among males growth of hair –beard, underarms, around genitals, deepening of voice, increase in size of testicles and penis, ejaculation, acne etc. • Attraction to opposite sex • Psychosomatic Complaints like tremors, headache, delusion, hallucinations • If not supported-Lead to depression, confinement or even aggression to hide the actual impact of these changes
  • 218. Behavioural Problems  Psychological changes ultimately lead to unacceptable behaviour  Habit Disorders: Thumb Sucking, nail biting, bed wetting etc.  Educational difficulties like failures and school phobias  Personality Disorders like jealousy, tantrums, shyness, day dreaming, fears and anxieties etc.
  • 219. Social Problems  Non acceptance by parents, family, society leads to social problems  Drug Addiction, stealing, gambling, destructiveness, sexual offences are various unlawful projections of ones fight with oneself and the outer world
  • 220. JUVENILE DELINQUECY • The Children Act, 1960 defines delinquent as a child who has committed offence • Juvenile is boy below 16 years and girl below 18 years • It is one of the major destructive outcome of industrialisation and urbanisation • Highest incidence is seen among children above 15 years of age and 4-5 time more in boys than in girls
  • 221. Causes of Juvenile delinquency  Biological: Heredity, lack of self esteem and presence of extra Y chromosome  Social: Broken families, step father/ mother, parental neglect, too many children  Non specific: Absence of healthy recreation, urbanisation etc.
  • 222. Prevention of Juvenile Delinquency  Improvement of family life  Schooling  Social Welfare Services: Counselling of parents, child guidance, educational facilities and general health services, peer groups.
  • 223. PREVENTION AND INTERVENTION • EDUCATION: Peer education and life skill education • Community Mobilisation: Involving parents, teachers, leaders to promote positive behaviour and also to act as inspiring role models • Youth development programmes: Imparting skills to help young people to earn their livelihood • Social marketing: for condoms, emergency contraception
  • 224. ADOLESCENT REPRODUCTIVE AND SEXUAL HEALTH (ARSH)  Sensitive and not to be talked about  Leading to public health challenges  Increased incidence of STIs/ RTIs  Increased teenage pregnancies  Increased unsafe abortions  Increased MMR and IMR
  • 225. SOME FACTS • 225 million adolescent • Comprise 22% of India’s total population • Of this 12%-10-14year age group • 10%-15-19 year age group • Female comprise 47% of adolescent population • About 20% of total adolescent female population are married before the age of 15 years are already mother
  • 226. • >70% girls between 10-19 year age group suffer from severe or moderate anemia • Mortality rate is higher in 15-19 year then 10-14 year age group • Unmet need of contraception is much higher in this age group • Over 35%of all reported HIV infection occur among 15- 24 years age group • Indicating young people are highly vulnerable and majority of them infected by unprotected sex
  • 227. ARSH-NRHM  Started under RCH-II  Involvement of ASHA worker, Multipurpose worker (female), Medical Officer
  • 228. Package of services  Promotive services:  Focused care during antenatal period  Counselling & provision of emergency contraceptives  Counselling & provision of reversible contraceptives  Information/advice on SRH services
  • 229.  Preventive services:  Services for TT and prophylaxsis against nutritional anemia  Nutritional counselling  Services for early and safe termination of pregnancy and management of post abortion complications
  • 230. • Curative services: – Treatment for common RTI/STIs – Treatment & counselling of menstrual disorders – sexual concerns of males and female adolescents • Referral services: – Integrated Counselling and Testing Centre – Prevention of Parent to Child Transmission • Outreach services: – Periodic health checkups and community camps – Periodic health education activities – Co-curricular activities
  • 231. NRHM - ARSH • Vision – Improve availability of quality healthcare in rural areas – Synergy between health and determinants of good health – Community ownership of health facilities – Undertake architectural corrections of the health system • Expected outcomes by 2012 – IMR -30/1000 live births – MMR – 100/1000 live births – TFR -2.1
  • 232. Objective  Reducing teenage pregnancies  Meeting unmet contraceptive needs  Reducing number of teenage maternal deaths  Reducing incidence of STIs  Reducing proportion of HIV positive in 10 – 19 years age group
  • 233.  We must Develop sensitivity towards adolescent clients  NON JUDGMENTAL, FRIENDLY, COMPETENT PROVIDER is required.
  • 235. INDEX  INTRODUCTION  PHYSIOLOGICAL CHANGES DUE TO AGING  HEALTH PROBLEMS OF THE AGED  PSYCHOLOGICAL PROBLEMS  PREVENTION AND MANAGEMENT a. PREVENTIVE HEALTH CARE b. INTERVENTION IN REHABLITATION  SERVICES PROVIDED BY THE GOVT.  NON-GOVT. ORGANISATIONS
  • 236. What is GERIATRICS ??????  The care of aged is called geriatrics or clinical gerontology.
  • 237.  The study of the physical & psychological changes which are incidental to old age is clinical gerontology. What is clinical gerontology???
  • 238. AGEING  It is a progressive and generalized impairment of body functions resulting in, loss of adaptive responses to stress and increasing the risk of age-related diseases.  People more than 60 yrs are considered elderly.  Old age is not a disease but a normal and inevitable biological phenomenon.
  • 239. Theories of aging  Genetic theories-  somatic mutation of genes.  genetically determined life span.  cross linkage/loss of important cellular components and DNA.  Random damage theories-  accumulation of toxic metabolites and free oxygen radicals.  reduced physiological capacity and wear-n-tear of cells of vital organs.  non-enzymatic glycosylation of proteins.
  • 240. Branches of geriatrics  Gerontology  Clinical gerontology  Social gerontology  Geriatric gynecology  Experimental gerontology  Preventive gerontology
  • 241. Demography of geriatric population  World population: current >6.7688 billion  projected >8 billion (by 2025)  India has 16.94% of total population  Population of elderly(>65yrs) in India: approx 8% of total population.
  • 243. Physiological changes due to aging and their consequences  Problems in elderly are multi-faceted and often a single problem may be the result of a complex chain of decompensation of body functions.
  • 244. Health problems of the aged  Physical problem  Psychological problems  Social problem  Economical
  • 245. Physical problems Ailments % of occurrence Visual complaints 88 % Locomotor system disorders 40 % Neurological complaints 18.7 % Cardiovascular system 17.4 %
  • 246. Respiratory system 16.1 % Skin conditions 13.3 % GI tract 9 % Psychiatric complaints 8.5 % Hearing loss 8.2 % Genito-urinary complaints 3.5 %
  • 247. Visual complaints  88% of the complaints in old age is visual problems like  Cataract  Glaucoma  Retinopathy
  • 248. Locomotor system disorders  It forms 40% of the old age complaints  They are:  Fibrositis  Osteoarthritis  Rheumatoid arthritis  Myositis  Neuritis  Gout  Spondilitis of spine
  • 249. Neurological complaints  Neurological problems form 18.7% of the old age complaints  These are:  Dementia  Parkinson's disease  Alzheimer’s disease
  • 250. Cardiovascular complaints  CVS disorders for 17.4% of the different old age complaints  These include:  Atherosclerosis  Thrombus formation  Myocardial Infarction  Hypertension
  • 251. Respiratory complaints  Respiratory condition make 16.1% of the old age complaints  These are:  Chronic bronchitis  Asthma  Emphysema
  • 252. Skin conditions  Skin conditions form a major part of old age complaints  Skin conditions include:  Senile wrinkles  Scaly lesions  Scaly dermatosis  Blistering diseases  Neoplastic disorders
  • 253. Gastrointestinal complaints  GI disorders for about 9% of the old age complaints  These are:  Peptic ulcer  Constipation  Ulcerative colitis  Carcinoma of GIT
  • 254. Hearing loss  Hearing complaints form about 8.2% of the old age complaints  These include  Nerve deafness  Conductive hearing loss
  • 255. Genito-urinary complaints  These form about 3.5% of the old age complaints  They are:  Enlargement of prostate  Dysuria  Nocturia  Frequency and urgency of micturation
  • 256. Psychiatric complaints  These form 8.5% of the old age complaints  These include  Alzheimer’s disease  Depression  Anxiety  Delirium  Schizophrenia  Personality disorder  Suicide and deliberate self harm
  • 257. Psychological problems  Elderly patients less willing to talk about psychological problems  Pay attention to:  anxiety  physical discomfort  adaptation to a new lifestyle
  • 258. PSYCHOLOGICAL SYMPTOMS  Sleep  Interest  Guilt (“Are you a burden to others?”)  Energy  Concentration  Appetite  Psychomotor changes  Suicidality (“Do you wish you could die?”)
  • 259. INCIDENCE IN ELDERLY  MAJOR DEPRESSION  3% community dwelling  14% two years after spouse dies  15% medically ill  25% long-term-care settings
  • 260. Social problems  Abuse  Dependancy  Insecurity  Rehabilitation
  • 262. Preventive Health Care in Elderly  The role of prevention in geriatrics is to delay the onset of age-related decompensatory problems of body functions.  It includes-  Primary prevention.  Secondary prevention.  Tertiary prevention.
  • 263. Primary prevention  Health habits-  Inadequate nutrition  Addiction to smoking & alcohol  Lack of exercise  Inadequate sleep  Predisposing factor for coronary heart disease  Modifiable-  smoking, obesity, HT, DM, hyperlipidemia, hypercholesterolemia, etc.  Non-modifiable-  age, sex, genetic factors, etc.
  • 264.  Immunization-  Influenza  Pneumococcal  Tetanus.  Osteoporosis prevention-  Calcium and vit-d supplementation.  Hip protector devices.
  • 265. Injury prevention  Burns accidents and falls should be prevented by;-  Removal of obstacles  Keep the floor dry  Bright lighting  Flat shoes  Railing/holding bars in bathrooms  Low level switches  Easy and safe access to water.
  • 266. Secondary prevention  Screening helps in early detection of modifiable risk factors and their adequate management.  Hyper/hypotension, diabetes mellitus  Dental problems  Drug adverse effects  Cancers  Infections  Nutritional deficiency states  Eyes /ears Screening
  • 267.  Early detection and treatment is an important step in secondary prevention of disease and disability.
  • 268. Tertiary prevention  It deals with rehabilitation and caregiver support.  Rehabilitation is a problem solving process focused on the patients functional abilities.  Rehabilitation team includes; a physician, a physiotherapist, an occupational therapist, a speech and language therapist, a psychiatrist, a dietitian, a nurse and a social worker.
  • 269. Interventions in rehabilitation  Hard interventions-  drugs.  physiotherapy.  occupational therapy.  aids and adaptation.  speech and language therapist.  Soft interventions-  advice.  education.  counseling.  encouragement.  listening.
  • 270. Supporting the caregiver EVEN THE CAREGIVER NEEDS SUPPORT  Social attitude  Physicians support  Organization of “day care centers”  Hospitalization in c/o chronic illness  Counseling the caregiver
  • 271. Prevention and management of elder abuse  Assessment of physical and mental capacity of the elderly.  Assessment of general quality of care  Assessment of relation with the abuser  Assessment of abusers for their problems  Counseling the abusers  Institutionalization in old age homes
  • 272. Laws in India to protect the old people  Section 125(1) (d): If any person having sufficient means neglects or refuses to maintain his father or mother, unable to maintain himself or herself, a Magistrate of the first class may, upon proof of such neglect or refusal, order such person to make a monthly allowance for the maintenance of his father or mother.
  • 273.  Section 125(3): If any person so ordered fails without sufficient cause to comply with the order, any such Magistrate may, for every breach of the order, issue a warrant for levying the amount due in the manner provided for levying fines, and may sentence such person, for the whole or any part of each month’s allowance remaining unpaid after the execution of the warrant, to imprisonment for a term which may extend to one month or until payment if sooner made
  • 274. Helpage India Helpage India supports the following programmes to make life easier for older people: 1. Free cataract operation 2. Mobile Medicare units 3. Income generation and micro-credits 4. Old age home and day care centers 5. Adopt a grant parents 6. Disaster mitigation