Maternal and child health program

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1. Unit 2: Maternal and child
health programme
Nabina Paneru

2. Introduction
•Maternal and child health is an important dimension of community health
nursing.
•The term maternal & child health services refer to a package of integrated health
services design to promote the health & nutritional status of mothers & children
and ensure the birth of a healthy infant to every expected mother.
•Promotive, preventive, curative and rehabilitative care for mother and children.

3. Maternal Health
•Maternal health refers to the health of women during pregnancy, childbirth and
the postpartum period.
•The United Nations Population Fund (UNFPA) estimated that 289,000 women
died of pregnancy or childbirth related cause in 2013.
•Maternal mortality ration fallen from 380 (in 1990) to 210 (in 2013) per 100,000
live births.

4. Four elements essential to maternal death
prevention:
1.Prenatal care (At least 4 antenatal visit)
2.Skilled birth attendance
3.Emergency obstetric care
4.Postnatal care

5. Child Health
•Child health is a state of physical, mental, intellectual, social and emotional well
–being and not merely the absence of disease or infirmity. –WHO
•Children cannot achieve optimal health alone. They are dependent upon adults in
their family and community to provide them with an environment in which they
can learn and grow successfully.

6. Maternal and Child Health Services Include
•Antenatal care
•Postnatal care
•Essential new born care & child care
•Vitamin A prophylaxis & deworming program (Baisakh& Kartik)
•Immunization
•Family planning

7. Contd.
•Nutrition
•RTI/ STI
•Safe abortion (CAC, PAC)
•Appropriate management of ARI
•Exclusive breastfeeding and weaning food
•Treatment of anemia

8. Development of maternal and child heath
services in Nepal
1950
•Maternal & Child welfare program started combined with family planning handling by
NGO and INGO
1960
•Started in government
1987
•Safe motherhood conference held in Nairobi, Kenya. (sponsored by WHO, World bank,
UNFPA & UNDP)
1991
•Community made for study of safe motherhood programme.
1993
•Safe motherhood program launched in Nepal in 10 districts then continuously elaborated
in other districts.

9. Contd.
2007
•TheAamaProgram introduced to fully subsidize the cost and
ensure mothers do not pay anything out of pocket for
institutional deliveries.
2010
•Nepal was commended for its progress on achieving MDGs 4
and 5.
•MDGs 4: Reduce Child Mortality
•MDGs 5: Improve Maternal Health

10. Needs of Maternal and Child Health Services
•Mother and children constitute a major segment of total population. In Nepal,
they constitute 62% of total population.
•Mother of child bearing age: 22%
•Children less than 15 years of age: 40%
•Mother and children are a “Special Risk Group” or “Vulnerable Group” or
dependents or weaker group of the community.

11. Contd.
•Most of the health problem of mother and children are preventable.
•Infant mortality and maternal mortality are the most sensitive index of health.
Therefore, MCH services are of utmost importance in health services.
•Lives of many mother and babies will be saved if the health of the mother is
supervised during pregnancy, at child birth, & the puerperium.

12. Contd.
•Mothers are providers of health care. Health of family members depends on her
knowledge & practice related to good health and prevention of disease.
•Sick, pregnant and anemic mother will not be able to fulfill their maternal role
adequately.
•Health education & good health practices relating to safe water, basic sanitation,
personal and environment hygiene, & nutrition will benefit the health of the
family.

13. Contd..
•Hardworking day of mother

14. Contd.
•The economy of the family, local community & country will be improved when the
family is healthy. Poor health, death or handicap causes loss of working capacity &
family income.
•If women have no knowledge and access to services, that will enable them to plan their
families, repeated child bearing with no interval in between pregnancies, leads to
“maternal depletion syndrome” & the displacement of young children from the breast
feeding with malnutrition & a high infant mortality rate.

15. Goals of the MCH service
•To decrease maternal, prenatal and neonatal mortality and morbidity.
•To reduce child morbidity and mortality.
•To improve maternal and child health.

16. Child and maternal goals: MDG 4 and 5
•Total of 8 Millennium Development Goals (MDGs)
•MDG 4: Reduce child mortality
•MDG 5: Improve maternal health

17. MDG 4: Reduce child mortality
•Target 4: Reduce under 5 mortality rate by two-thirds between 1990 and
2015.
Indicators
4.1 Under 5 mortality rate
4.2 Infant mortality rate
4.3 Proportion of 1 year-old children immunized against measles

18. MDG 5: Improve maternal health
•Target 5: Reduce maternal mortality by three quarters between 1990 and 2015.
Indicators
5.1 Maternal mortality ratio
5.2 Proportion of births attended by skilled health personnel
5.3 Contraceptive prevalence rate
5.4 Adolescent birth rate
5.5 Antenatal care coverage (at least one visit and at least four visits)
5.6 Unmet need for family planning

19. Goals of MCH services contd.
Antenatal care

20. Activities of MCH clinic
•Child Health clinic
1. Care of illness
Diagnosis and treatment of acute and chronic illness.
X-ray and laboratory services
Referred services

21. Contd.
2. Preventive care
Immunization
Growth monitoring
Health check up ( Physical examination)
Health education
Vit. A distribution and deworming

22. Contd.
3. Growth monitoring
Weight according to age
Height according to weight & age

23. Maternal health clinic activities
•Registration of antenatal, postnatal mother
•Physical examination/ antenatal examination
•T.D vaccination
•Health education
•Family planning
•Safe abortion and post abortion

24. Antenatal care
•Systematic supervision of women during pregnancy.
•Comprehensive ante partum care program that involves a coordinated
approach to medical care and psychological support that optimally begins
before conception and extends throughout the antenatal period.

25. Objectives of Antenatal Care
•To screen the high risk cases.
•To prevent, detect and manage complications during pregnancy, whether medical,
surgical or obstetrical.
•To develop birth preparedness and complication readiness plan.
•To educate mother about physiology of pregnancy and labour.
•To motivate couple about the need of family planning.

26. Contd.
•To advice mother about breastfeeding, postnatal care and immunization.
•To reduce risk of pregnancy related complications.
•To reduce infant risk for complications.

27. Pre natal care and advice
•Pre-conceptionalcare
•Creating awareness in the community for maintenance of maternal health
•Early diagnosis of pregnancy
•Initial antenatal evaluation
•Assessment for referral
•Birth preparedness and complication readiness plan

28. Antenatal visits
As per WHO : 4 antenatal visits
1
st
visit around 16 weeks (4
th
month)
2
nd
visit around 24-28 weeks (6
th
month)
3
rd
visit at 32 weeks (8
th
month)
4
th
visit at 36 weeks (9
th
month)

29. Antenatal care

30. Indicators
•Maternal Indicators
•Morbidity Indicators
•Fertility Indicators
•Social and Mental Health Indicators
•Health Policy Indicators
•Quality of Life Indicators
•Nutritional Status Indicators

31. Maternal Indicators
•Maternal mortality ratio
“ the death of a women while pregnant or within 42 days of terminatonof pregnancy,
irrespective of the duration and site of the pregnancy, from any causes related to or
aggravated by the pregnancy or its management but not from accidental or incidental
causes”
MMR=
�������������������ℎ�����������??????���??????�����������ℎ??????���??????��ℎ
���??????�ℎ??????�42���������??????�����������������������??????������
��.���??????�������??????��−�??????��ℎ�??????��ℎ������
×100000

32. Morbidity Indicators
Following morbidity rates are used for assessing ill health in the community
•Incidence and prevalence
•Notification rates
•Attendance rates at out-patient departments, health centre’setc
•Admission, readmission and discharge rates
•Duration of stay in hospital and
•Spells of sickness or absence from work or school

33. Incidence Rate
“ number of new cases of a disease occurring in a defined population during
a specified period of time e.g. Incidence of ARI.
Incidence rate =
��.�����������������??????�??????��??????�����
���??????����??????����??????�����??????��(����)
���??????������??????�−�����������??????��
×1000

34. Special Incidence Rate
•Attack rate:
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���??????������??????�??????��??????��??????�������
���??????�����������������������??????��
×100
•Prevalence rate

35. Prevalence rate
Total number of all individuals who had an attack of the disease (new+old)
at a particular time (or during a particular period) divided by population at
risk of having the disease at this point in time. E.g. epidemic of diarrhea

36. •Point prevalence=
��.���������������������������������??????�??????��
�??????�������??????��??????������??????�����??????��??????��??????��
���??????������������??????�����ℎ�������??????�����??????��
×100
•Period prevalence=
��.����??????��??????������������������??????�??????��
�??????��������??????����??????����??????�����??????����??????�������
���??????������??????�??????��������������??????�����??????��
×100

37. Fertility Indicators
•Crude Birth Rate (CBR)
•General Fertility Rate (GFR)
•Age Specific Fertility Rate (ASFR)
•Total Fertility Rate (TFR)
•Contraceptive Prevalence Rate (CPR)
•Couples years of protection (CYP)

38. Crude Birth Rate
“ The number of live birth per 1000 estimated midyear population, in a given
year”
CBR=
���������??????���??????��ℎ����??????���ℎ�����
���??????������??????������������??????��
×1000

39. General Fertility Rate (GFR)
“ The number of live births per 1000 women in the reproductive age group
(15-49) years in a given year at certain areas”
GFR=
���������??????���??????��ℎ��������??????������
���??????������������������??????�������15−49��������??????�����
×1000

40. Age Specific Fertility Rate (ASFR)
“ The number of live births in a year to 1000 women in any specific age
group especially 5 years women age group of reproductive age. (15-19yrs,
20-24yrs, 25-29yrs, 30-34yrs, 35-39yrs, 40-44yrs, and 45-49yrs of age)
ASFR=
��.���??????���??????��ℎ����??????�??????���������������??????������
�������.����������ℎ����������??????��ℎ������??????��
×1000

41. Total Fertility Rate (TFR)
“ The number of children a women can bear throughout her life span.”
“TFR is a measure of the fertility of an imaginary women who passes through her
reproductive life subject to all the age specific fertility rates for ages 15-49 years that were
recorded for a given population in a given year”
TFR=
Ʃ??????���×5(??????��??????�������)
1000

42. Contraceptive Prevalence Rate (CPR)
“Percentage of married women of reproductive age using any modern
contraceptive device at a point of time.”
CPR=
�����������������������������??????���ℎ��
����??????������������������??????�����
×100

43. Couples years of protection (CYP)
CYP expresses the number of years for which a couple would be protected from being
pregnant by modern contraceptive methods provide during the year.
CYP is calculated as
Implant= 5 CYPs
IUCD= 12 CYPs
13 pill cycles = 1 CYP
4 doses Depo = 1 CYP
15 condom = 1 CYP

44. Social and Mental Health Indicators
As long as valid positive indicators of social and mental health are scarce, it is necessary to
use indirect measures, viz. indicators of social and mental pathology. These include suicide,
homicide, other acts of violence and other crime; road traffic accidents, juvenile
delinquency: alcohol and drug abuse, smoking; consumption of tranquillizers etc.
These social indicators provide a guide to social action for improving the health of people

45. Socio-economic indicators
They do not measure the health status directly. But it has certain value in the
interpretation of the indicators of the health care. These includes:
•Rate of population increase
•Per capita of GNP
•Level of unemployment

46. Contd.
•Dependency ratio
•Adult literacy rates
•Housing –a number of persons per room
•Per capital calorie (nutrition) availability

47. Dependency Ratio
Dependent population:Persons above 65 years of age and children below 15 years
In Nepal dependent population: Persons above 60 years of age and children below
15 years.
Dependent Ratio =
0−14�������??????��+60��������������������??????��
15−59�������??????��
×100

48. Health Policy Indicators
Measures the allocation of allocation of adequate resources, which are measured by:
•Proportion of GNP spent on health services
•Proportion of GNP spent on health-related activities (including water supply, and
sanitation, housing and nutrition, community development) and
•Proportion of total health resources devoted to primary health care.

49. Quality of life Indicators
No distinct or single indicator to measure the quality of life of a country
Scientists are trying to develop a new numerical scale on which
Figure 10 indicate: Perfect state of health
7,8,9 indicate: progressive worsening status
0: death

50. Contd.
At present, Physical Quality of Life Index (PQL) has been used in different
countries, which measures:
Infant mortality, life expectancy at age1 and literacy into a single composite
index having a minimum of zero and a maximum of 1000.

51. Health care Utilization Indicators
Measures the extent of use of health services. These utilization rates can be measured by the
following indicators:
•Percentage of immunized children against six target diseases
•Percentage of women using antenatal services
•Percentage of deliveries attended by trained birth attendants
•Average bed occupancy rate (i.e. Daily impatient record/ average number of beds, etc.)
•Average length of stay in hospital (i.e. days of care rendered/ discharge)
•Bed turn-over ratio i.e. discharges average beds etc.)

52. Nutritional Status Indicators
Measures the nutritional status of children ( mainly) below 5 years.
Indicators are:
•Mid-arm circumference
•Weight for age
•Weight for height
•Height for age
•Prevalence of low birth weight (less than 2.5kg)

53. Health care delivery indicators
Health care delivery indicators measure proper health distribution in different parts of the country.
It can be measured by:
•Doctor/population ratio
•Doctor/nurse ratio
•Population/bed ratio
•Population per centre/ sub centre
•Population per traditional birth attendant

54. Morbidity and its causes
Causes of maternal morbidity
The major causes of maternal morbidity and mortality are anemia, PIH, APH
or PPH or obstructed labor or puerperal sepsis.
In Nepal, more than 258/100000 live birth women die annually on account
of pregnancy.

55. Causes of maternal mortality in developing
countries
H: Hemorrhage (APH/ PPH)
O: Obstructed Labour
R: Ruptured Uterus
S: Sepsis
E: Eclampsia
S: Severe anemia (<7gm)

56. Indirect obstetric causes
Four Too
1.Too many pregnancies
2.Too early pregnancies
3.Too late pregnancies
4.Too complicated pregnancies

57. Indirect Obstetric Cause contd.
Three Delays
1.Delay in identifying mother “At risk” decision making
2.Delay in transportation or referral to services side or
3.Delay in starting treatment at service institute

58. Direct cause: Direct obstetric death
a)Hemorrhage (25%)
b)Infection (15%)
c)Hypertensive disorders (12%)
d)Obstructed labor (8%)
e)Abortion complications (12%)
f)Others (ectopic pregnancy, embolism etc.) (8%)

59. Indirect cause (20%)
a)Anemia
b)Hepatitis
c)Cardiovascular disease
d)UTI
e)Mothers age
f)Birth interval

60. Contd.
g) Economic circumstances
h) Cultural practice and beliefs
i) Environmental conditions
j) Viral infection etc.

61. Socio-economic and other causes
•Any disease associated with pregnancy
•Accidents
•Large family
•Malnutrition
•Poverty/ ignorance
•Lack of maternity services

62. Contd.
•Shortage of health manpower
•Delivery by untrained professionals
•Poor environmental sanitation
•Lack of transportation facilities
•Social customs/ values and beliefs
•Illiteracy
•Improper utilization of MCH service

63. Perinatal morbidity
Perinatal period: from 22 weeks of gestation to seven completed days after
birth.
Perinatal mortality refers to the number of stillbirths and deaths in the first
week of life (early neonatal mortality)

64. Cause of perinatal mortality
•Age of mother
•Parity
•Previous history of fetal loss
•Preterm birth (almost 30%)
•Infant respiratory distress syndrome (almost 1%)
•Birth defects (about 21%)

65. Contd.
•Medical care
•Poverty
•Unwanted pregnancy
•Education of the mother
•Multiple births
•Maternal morbid condition

66. Neonatal morbidity and mortality
•Early neonatal mortality refers to a death of a live-born baby within the
first seven days of life, while
•Late neonatal mortality covers the time after 7 days until before 28 days.
•The sum of these two represent neonatal mortality.

67. Causes of neonatal mortality
•Birth asphyxia
•Meconium Aspiration
•Infection/ Sepsis (including tetanus)
•Convulsions
•Hypothermia

68. Contd.
•Birth injury
Facial palsy, cephalohematoma,
Erbspalsy, humerusfracture, clavicle fracture
•Jaundice