MCH LECTURE

Maternal and Child Health Care lecture is an important lecture of Community Medicine.

1. Maternal And Child Health

2. In any community, mothers and children constitute a priority group. Mothers and children constitute a large group of our society. Health status of mother and child indicates the health situation of any country .

3. Maternal and child health The term "maternal and child health" refers to the promotive , preventive, curative and rehabilitative health care for mothers and children.

4. Maternal and child health Maternal and child health includes the sub-areas of maternal health, child health, family planning, school health, handicapped children, adolescence, and health aspects of care of children in special settings such as day care.

5. Maternal and child health The specific objectives of MCH are – (a) reduction of maternal , perinatal, infant and childhood mortality and morbidity ; ( b) promotion of reproductive health; and (c) promotion of the physical and psychological development of the child and adolescent within the family. The ultimate objective of MCH services is lifelong health.

6. Mother and child - one unit Mother and child must be considered as one unit. It is because : ( 1) during the antenatal period, the foetus is part of the mother. (2) child health is closely related to maternal health . A healthy mother brings forth a healthy baby; there is less chance for a premature birth, stillbirth or abortion ; {3) certain diseases and conditions of the mother during pregnancy (e.g., syphilis, german measles, drug intake) are likely to have their effects upon the foetus ; (4) after birth,the child is dependant upon· the mother. At least up to the age of 6 to 9 months, the child is completely dependant on the mother for feeding . (5) in the care cycle of women, postpartum care is inseparable from neonatal care and family planning advice ; ( 6) the mother is also the first teacher of the child.

7. Components of MCH Maternal health Child health Family planning S chool health, Handicapped children, adolescence, and H ealth aspects of care of children in special settings such as day care.

8. Maternity cycle The stages in maternity cycle are : (i) Fertilization (ii) Antenatal or prenatal period (iii) lntranatal period (iv) Postnatal period (v) Inter- conceptional period 1. Prenatal period : (a) Ovum -0 to 14 days (b) Embryo -14 days to 9 weeks (c) Foetus -9th week to birth 2. Premature infant - from 28 to 37 weeks 3. Birth, full term -average 280 days.

9. MCH problems 1. MALNUTRITION 2. INFECTION 3. UNCONTROLLED REPRODUCTION

10. MCH problems 1. MALNUTRITION- Pregnant women, nursing mothers and children are particularly vulnerable to the effects of malnutrition. The adverse effects of maternal malnutrition have been well documented-maternal depletion, low birth weight,anaemia , toxemias of pregnancy, postpartum haemorrhage,all leading to high mortality and morbidity. Severe malnutrition coincides with the age at which babies are usually weaned. Nutrition protection and promotion is, therefore,an essential activity of MCH care.

11. MCH problems 2. INFECTION - Maternal infections may cause a variety of adverse effects such as foetal growth retardation, low birth weight, embryopathy , abortion and puerperal sepsis. In industrial societies , the risk of the mother acquiring infections during pregnancy is relatively low, but in underdeveloped areas, the mother is exposed to significantly higher risks . Many women are infected with HIV, hepatitis B, cytomegalo viruses, herpes simplex virus or toxoplasma during pregnancy.Furthermore , as many as 25 per cent of the women in rural areas suffer at least one bout of urinary infection. A good knowledge and practice of personal hygiene and appropriate sanitation measures are essential pre-requisites for the control of the most common infections.

12. MCH problems 3. UNCONTROLLED REPRODUCTION- The health hazards for the mother and the child resulting from unregulated fertility have been well recognized -increased prevalence of low birth weight babies, severe anaemia , abortion, antepartum haemorrhage and a high maternal and perinatal mortality , The introduction of new types of· IUD; easier and safer techniques of pregnancy termination and female sterilization ; oral pills and long-acting injectable medroxyprogesterone acetate (MPA) have contributed a good deal in the utilization of family planning services. family planning has a striking impact on the health of the mother and the child.

13. ANTENATAL CARE Antenatal care is the care of the woman during pregnancy . The primary aim of antenatal care is to achieve at the end of a pregnancy a healthy mother and a healthy baby . Ideally this care should begin soon after conception and continue throughout pregnancy.

14. ANTENATAL CARE

15. ANTENATAL CARE The objectives of antenatal care are : (1) To promote, protect and maintain the health of the mother during pregnancy. (2) To detect "high-risk" cases and give them special attention . (3) To foresee complications and prevent them. (4) To remove anxiety and dread associated with delivery . (5) To reduce maternal and infant mortality and morbidity . (6) To teach the mother elements of child care, nutrition , personal hygiene, and environmental sanitation . (7) To sensitize the mother to the need for family planning , including advice to cases seeking medical termination of pregnancy; and (8) To attend to the under-fives accompanying the mother .

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

17. ANTENATAL CHECK-UP I. History-taking- (1) Confirm the pregnancy (first visit only ); ( 2) Identify whether there were complications during any previous pregnancy/confinement that may have a bearing on the present one ; (3) Identify any current medical/surgical or obstetric condition(s) that may complicate the present pregnancy; ( 4) Record the date of 1st day of last menstrual period and calculate the expected date of delivery by addding 9 months and 7 days to the 1st day of last menstrual period.

18. (CONTD.) (5) Record symptoms indicating complications, e.g. fever, persisting vomiting, abnormal vaginal discharge or bleeding, palpitation, easy fatigability, breathlessness at rest or on mild exertion, generalized swelling in the body, severe headache and blurring of vision, burning in passing urine, decreased or absent foetal movements etc ; ( 6} History of any current systemic illness, e.g., hypertension, diabetes, heart disease, tuberculosis,renal disease, epilepsy, asthma, jaundice, malaria,reproductive tract infection,· STD, HIV/AIDS etc. Record family history of hypertension, diabetes, tuberculosis, and thalassaemia . Family history of twins or congenital malformation ; and ( 7) History of drug allergies and habit forming drugs.

19. (CONTD.) II. Physical examination 1 . Pallor 2. Pulse 3. Respiratory rate 4. Oedema 5. Blood pressure 6. Weight 7. Breast examination

20. (CONTD.) III. Abdonimal examination- 1. Measurement of fundal height 2. Foetal heart sounds 3. Foetal movements 4. Foetal parts 5. Multiple pregnancy 6. Foetal lie and presentation 7. Inspection of abdominal scar or any other relevant abdominal findings . IV. Assessment of gestation age

21. (CONTD.) V. Laboratory investigations- The following laboratory investigations are carried out at the facilities indicated below : a. At the sub- centre : Pregnancy detection test - Haemoglobin examination - Urine test for presence of albumin and sugar - Rapid malaria test . b. At the PHC/CHC/FRU : - Blood group, including Rh factor - VDRL/RPR - HIV testing - Rapid malaria test (if unavailable at SC) - Blood sugar testing - HBsAg for hepatitis B infection.

22. HIGH RISK MOTHERS 1. Elderly primi (30 years and over) 2. Short statured primi (140 cm and below ) 3. Malpresentations , viz breech, transverse lie, etc. 4. Antepartum haemorrhage , threatened abortion 5. Pre- eclampsia and eclampsia 6. Anaemia 7. Twins, hydramnios 8. Previous still-birth, intrauterine death, manual removal of placenta 9. Elderly grand multiparas 10. Prolonged pregnancy (14 days-after expected date of delivery) 11. History of previous caesarean or instrumental delivery 12. Pregnancy associated with general diseases, viz. cardiovascular disease, kidney disease, diabetes, tuberculosis , liver disease, malaria, convulsions, asthma, HIV, RTi , STi , etc. 13. Treatment for infertility. 14. Three or more spontaneous consecutive abortions.

23. HOME VISITS Home visiting is the backbone of all MCH services. Even if the expectant mother is attending the antenatal clinic regularly , it is suggested that she must be paid at least one home visit by the Health Worker Female or Public Health Nurse . More visits are required if the delivery is planned at home . The mother is generally relaxed at home. The home visit will win her confidence.

24. (CONTD.) (2) Prenatal advice- (i) DIET (ii) PERSONAL HYGIENE (iii) DRUGS (iv) RADIATION (v) WARNING SIGNS (vi) CHILD CARE

25. (CONTD.) Specific health protection- (i) ANAEMIA (ii) OTHER NUTRITIONAL DEFICIENCIES {iii) TOXEMIAS OF PREGNANCY (iv) TETANUS (v) SYPHILIS (vi) GERMAN MEASLES (vii) Rh STATUS (viii) HIV INFECTION (ix) HEPATITIS B INFECTION (x) PRENATAL GENETIC SCREENING

26. (CONTD.) Family planning Paediatric component

27. WARNING SIGNS The mother should be given clear-cut instructions that she should report immediately in case of the following warning signals : ( a) swelling of the feet (b) fits (c) headache (d) blurring of the vision ( e) bleeding or discharge per vagina, and ( f) any other unusual symptoms

28. Domiciliary care Mothers with normal obstetric history may be advised to have their confinement in their own homes, provided the home conditions are satisfactory. In such cases, the delivery may be conducted by the Health Worker Female or trained dai . This is known as "domiciliary midwifery service .“ The advantages of the domiciliary midwifery service are : (1) the mother delivers in the familiar surroundings of her home and this may tend to remove the fear associated with delivery in a hospital , (2) the chances for cross infection are generally fewer at home than in the nursery/hospital, and (3) the mother is able to keep an eye upon her children and domestic affairs; this may tend to ease her mental tension.

29. (CONTD.) Domiciliary midwifery is also not without disadvantages : (1) the mother may have less medical and nursing supervision than in the hospital, ( 2) the mother may have less rest, ( 3) she may resume her domestic duties too soon,and ( 4) her diet may be neglected.

30. Rooming-in Keeping the baby's crib by the side of the mother's bed is called "rooming-in". This arrangement gives an opportunity for the mother to know her baby. Mothers interested in breast feeding usually find there is a better chance for success with rooming-in. Rooming-in also allays the fear in the mother's mind that the baby is not misplaced in the central nursery . It also builds up her self-confidence.

31. INTRANATAL CARE Childbirth is a normal physiological process, but complications may arise. Septicaemia may result from unskilled and septic manipulations, and tetanus neonatorum from the use of unsterilized instruments . The need for effective intranatal care is therefore indispensable, even if the delivery is going to be a normal one.

32. INTRANATAL CARE The emphasis is on -the cleanliness . 1) It entails clean hands and fingernails, 2) A clean surface for delivery, clean cord care i.e., clean blade for cutting the cord and clean tie for the cord, 3) N o application on cord stump, and keeping birth canal clean by avoiding harmful practices. 4)Hospitals and health centres should be equipped for delivery with midwifery kits, a regular supply of sterile gloves and drapes, towels, cleaning materials, soap and antiseptic solution, as well as equipment for sterilizing instruments and supplies .

33. INTRANATAL CARE The aims of good intranatal care are : (i) thorough asepsis (ii) delivery with minimum injury to the infant and mother (iii) readiness to deal with complications such as prolonged labour , antepartum haemorrhage , convulsions , malpresentations , prolapse of the cord , etc. (iv) Care of the baby at delivery resuscitation, care of the cord, care of the eyes, etc.

34. INTRANATAL CARE The 'danger signals' during labour are – (1) sluggish pains or no pains after rupture of membranes (2) good pains for an hour after rupture of membranes , but no progress (3) prolapse of the cord or hand (4) meconium-stained liquor or a slow irregular or excessively fast foetal heart. (5) excessive 'show' or bleeding during labour . ( 6) collapse during labour (7) a placenta not separated within half an hour after delivery. (8) post-partum haemorrhage or collapse, and (9) a temperature of 38 deg C or over during labour.There should be a close liaison between domiciliary and institutional delivery services.

35. POSTNATAL CARE Care of the mother (and the newborn) after delivery is known as postnatal or postpartal care. Broadly this care falls into two areas: 1)care of the mother which is primarily the responsibility of the obstetrician; and 2)care of the newborn,which is the combined responsibility of the obstetrician and paediatrician . This combined area of responsibility is also known as perinatology .

36. POSTNATAL CARE The objectives of postpartal care are : {1) To prevent complications of the postpartal period. (2) To provide care for the rapid restoration of the mother to optimum health. (3) To check adequacy of breast-feeding. (4) To provide family planning services. (5) To provide basic health education to mother/family.

37. POSTNATAL CARE Complications of the postpartal period : (1) Puerperal sepsis : This is infection of the genital tract within 3 weeks after delivery. This is accompanied by rise in temperature and pulse rate, foul-smelling lochia , pain and tenderness in lower abdomen, etc. Puerperal sepsis can be prevented by attention to asepsis,before and after delivery. This is particularly important in domiciliary midwifery service. ( 2) Thrombophlebitis : This is an infection of the veins of the legs, frequently associated with varicose veins. The leg may become tender, pale and swollen. ( 3) Secondary haemorrhage : Bleeding from vagina anytime from 6 hours after delivery to the end of the puerperium (6 weeks) is called secondary haemorrhage , and may be due to retained placenta or membranes. ( 4) Others:Urinary tract infection and mastitis, etc.

38. CARE OF CHILDREN The childhood is divided into the following age-periods : 1. Infancy ( upto 1 year of age) a. Neonatal period (first 28 days of life) b. Post neonatal period (28th day to 1 year) 2. Pre-school age (1-4 years) 3. School age (5-14 years)

39. Early neonatal care The objective of early neonatal care is to assist the newborn in the process of adoption to an alien environment, which involves : {i) establishment and maintenance of cardiorespiratory functions. (ii) maintenance of body temperature (iii) avoidance of infection (iv) establishment of satisfactory feeding regimen, and (v) early detection and treatment of congenital and acquired disorders, especially infections.

40. Identification of "at-risk" infants The basic criteria for identifying these babies include : 1. birth weight less than 2.5 kg 2. twins 3. birth order 5 and more 4. artificial feeding 5. weight below 70 per cent of the expected weight (i.e., II and III degrees of malnutrition) 6. failure to gain weight during three successive months 7. children with PEM, diarrhoea . 8. working mother/one parent .

41. LOW BIRTH WEIGHT Low birth weight has been defined as a birth weight of less than 2.5 kg ( upto and including 2499 g), the measurement being taken preferably within the first hour of life, before significant postnatal weight loss has occurred .

42. LOW BIRTH WEIGHT Babies can be classified into 3 groups according to gestational age, using the word "preterm", "term" and " postterm ", as follows : a. Preterm : Babies born before the end of 37 weeks gestation (less than 259 days). b. Term : Babies born from 37 completed weeks to less than 42 completed weeks (259 to 293 days) of gestation. c. Postterm : Babies born at 42 completed weeks or any time thereafter (294 days and over) of gestation .

43. SMALL-FOR-DATE (SFD) BABIES SMALL-FOR-DATE (SFD) BABIES : These may be born at term or preterm. They weigh less than the 10th percentile for the gestational age. These babies are clearly the result of retarded intrauterine foetal growth .

44. KANGAROO MOTHER CARE Kangaroo mother care for low birth-weight babies was introduced in Colombia in 1979 by Drs . Hector Martinez and Edzar Rey as a response to high infection and mortality rates due to overcrowding in hospitals. It has since been adopted across the developing world and has become essential element in the continuum of neonatal care . The four components of kangaroo mother care are all essential for ensuring the best care option, especially for low birth weight babies . They include skin-to-skin positioning of a baby on the mother's chest; adequate nutrition through breast-feeding ; ambulatory care as a result of earlier discharge from hospital; and support for the mother and her family in caring for the baby .

45. Breast-feeding Advantages of breast-feeding are the following : (1) it is safe, clean, hygienic, cheap and available to the infant at correct temperature (2) it fully meets the nutritional requirements of the infant in the first few months of life (3) it contains · antimicrobial factors such as macrophages,lymphocytes , secretory IgA, anti-streptococcal factor, lysozyme and lactoferrin which provide considerable protection not only against diarrhoeal diseases and necrotizing enterocolitis , but also against respiratory infections in the first months of life (4) it is easily digested and utilized by both the normal and premature babies ( 5) it promotes " bonding“ between the mother and infant ( 6) sucking is good for the baby- it helps in the development of jaws and teeth (7) it protects babies from the tendency to obesity

46. Breast-feeding (8) it prevents malnutrition and reduces infant mortality (9) it provides several biochemical advantages such as prevention of neonatal hypocalcaemia and hypomagnesemia (10 ) it helps parents to space their children by prolonging the period of infertility and ( 11) special fatty acids in breast milk lead to increased intelligence quotients and better visual acuity. A breast-fed baby is likely to have an IQ of around 8 points higher than a non-breast fed baby .

47. WEANING It is a gradual process of adding supplimentary food along with breast feeding starting around the age of 6months .Because the mother's milk alone is not sufficient to sustain growth beyond 6 months. It should be supplemented by suitable foods rich in protein and other nutrients. These are called "supplementary foods". These are usually cow's milk , fruit juice, soft cooked rice, suji , dhal and vegetables

48. GROWTH AND DEVELOPMENT The term growth refers to increase in the physical size of the body, and D evelopment to increase in skills and functions .

49. THE GROWTH CHART The growth or "road-to-health" chart (first designed by David Morley and later modified by WHO) is a visible display of the child's physical growth and development. It is designed primarily for the longitudinal follow-up (growth monitoring) of a child, so that changes over time can be interpreted .

50. Uses of GROWTH CHART 1. for growth monitoring 2. diagnostic tool 3. planning and policy making 4. educational tool 5. tool for action 6. evaluation 7. tool for teaching 6 . evaluation

51. CHILD HEALTH PROBLEMS 1. low birth weight 2. malnutrition 3. infections and parasitosis 4. accidents and poisoning 5. behavioural problems

52. INDICATORS OF MCH CARE 1. Maternal mortality ratio 2. Mortality in infancy and childhood a. Perinatal mortality rate b. Neonatal mortality rate c. Post-neonatal mortality rate d. Infant mortality rate e. 1-4 year mortality rate f. Under-5 mortality rate g. Child survival rate .

53. MATERNAL MORTALITY RATIO According to WHO, a maternal death is defined as " the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site pregnancy , from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes" . Maternal mortality ratio measures women dying from "puerperal causes" and is defined 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 -------------x 1000 (or 100,000) Total no. of live births in the same area and year