risk approach in nepal for maternal health

healthrisk approach in nepal for maternal health

1. Risk approach to maternal and child health

2. RISK APPROACH The risk approach is developed & promoted by WHO to identify precisely the “risk group” or “target group”( e.g. at risk mothers, at risk infants) in the population by certain defined criteria and direct appropriate action to them. The risk approach is a managerial device for increasing the efficiency of health care services within the limits of existing resources.

3. Risk approach The risk approach is developed & promoted by WHO to identify precisely the “risk group” or “target group”( e.g. at risk mothers, at risk infants) in the population by certain defined criteria and direct appropriate action to them. The risk approach is a managerial device for increasing the efficiency of health care services within the limits of existing resources.

4. Risk approach

5. Terminology used in risk approaches

6. Terminology used in risk approaches

7. Terminology used in risk approaches

8. Terminology used in risk approaches

9. Introduction A population at risk is a group of people who are more likely to be exposed to a specific negative outcome than the general population. This could be due to a number of factors, including: Biological risk, Environmental risk, Social risk factors, and Behavioral risk factors.

10. TERMINOLOGY USED IN RISK APPROACH

11. Terminology used in risk approaches

12. TERMINOLOGY USED IN RISK APPROACH Contingency table applied to hypothetical cigarette smoking & lung cancer example. Cigarette smoking Developed lung cancer Did not develop lung cancer Total Yes No 70 (a) 3 (c) 6930 (b) 2997 (d) 7000 (a+b) 3000 (c+d)

13. Terminology

14. TERMINOLOGY USED IN RISK APPROACH Relative risk Incidence of disease ( or death) among exposed RR Incidence of disease ( or death) among non exposed RR of lung cancer= 10 1 = 10

15. Terminology in risk approach

16. Terminology in risk approach

17. Terminology in risk approach

18. Terminoterlogy in risk apTerminology in risk approach proach Attributable risk (AR ) Attributable risk is the difference in incidence rates of disease (or death) between an exposed group and non- exposed group. Some authors use the term “ risk difference” to attributable risk. It is often expressed as a percent. It is given by formula;

19. TERMINOLOGY USED IN RISK APPROACH Incidence of disease rate among exposed minus incidence of disease rate among non exposed *100 Incidence rate among exposed 10- 1 * 100 = 90% 10

20. Terminology

21. Terminology

22. Terminology For example, multiparity in young mothers living in poverty usually results in high perinatal mortality. Risk factors are in fact, characteristics that have a significant association with a defined end- point. It is important to specify the end-point or outcome for which each risk.

23. Common maternal risk factor The characteristics of mothers whose infants have an increased chance of dying from hypoxia during delivery, for instance, may be quite different from those of mothers whose infant die more usually from gastro-enteritis. Thus maternal risk factors may be specific for a particular outcome, such as previous induced abortion leading to cervical incompetence.

24. Common maternal risk factor More frequently, one risk factor increases the frequency of occurrence of a number of end points. For example a grand multiparity with its increased risk of several complications of pregnancy and delivery, such as transverse lie, postpartum hemorrhage and precipitate birth etc

25. Common maternal risk factor More frequently, one risk factor increases the frequency of occurrence of a number of end points. For example a grand multiparity with its increased risk of several complications of pregnancy and delivery, such as transverse lie, postpartum hemorrhage and precipitate birth etc

26. Common maternal risk factor c. Medical and obstetrics disease – Anemia - Increased risk of pre-eclampsia, heart failure, preterm labour , PPH, shock. Hypertensive disorder – It can lead to eclampsia, pre-term labour , HELLP syndrome( helolysis,elivated liver enzyme, low lipid profile), DIC (disseminated intravascular coagulation). Diabetes mellitus- It increases risk of preterm labour due to infection or polyhydraminous , maternal distress , diabetic nephropathy , ketoacidosis, prolonged labour ,shoulder dystocia due to big body size.

27. Common maternal risk factor Jaundice – Increased risk of abortion , preterm labour , still birth , PPH , hemorrhagic manifestations and hepatic coma. Renal disease – Women with renal disease may develop severe anemia during pregnancy. Due to the use of corticosteroid by mother, infant may develop hyperglycemia.

28. Common maternal risk factor Tuberculosis – More likely to develop pre eclampsia , pre term labour , miscarriage , difficult labour , PPH. Cardiovascular disease – Increased risk of preterm labour , miscarriage , IUGR, risk of congenital heart disease and increased maternal mortality rate.

29. Common maternal risk factor d. Previous CS – Increased risk of postpartum hemorrhage that requires blood transfusion. Increased risk of ectopic pregnancy and still birth . More chance of infection in wound and anesthetic complications. e. History of sub fertility , PPH, and retained placenta

30. Common maternal risk factor 2.Psychosocial risk factors - Psychosocial risk is maternal behavior or adverse lifestyles that have a negative effect on the health of mother and fetus. -Risks include smoking, consuming alcohol, caffeine and drugs use, situational crisis, etc. -These psychological factors may increase the risk of PIH, premature rupture of membrane, abruption placenta, placenta previa. -Smoking causes premature birth, birth defects (heart defect), low birth weight, sudden infant death syndrome, miscarriage, still birth etc.

31. Common maternal risk factor 3.Socio-demographic status Low socioeconomic status- It is associated with increased risk of adverse pregnancy outcome, perinatal mortality, LBW, high risk of anemia, preterm labour , growth retardation. Lack of prenatal care- Due to the lack of prenatal care, progression or deterioration of labour can’t be determined that may lead to complications (anemia). Age (age at first pregnancy: 19 years or below and 35 years or above)

32. Common maternal risk factor Teenage pregnancy: complications associated with teenage pregnancy- preterm birth, LBW, perinatal mortality, sudden infant death syndrome, short interval to next pregnancy, abortion, high rate of hypertensive disorders, anemia and also increased risk of nutritional deficiencies, HIV infection and other STIs. - It has been suggested that competition for nutrition between fetus and mother could affect the pregnancy outcome in adolescents by interrupting the normal growth process.

33. Common maternal risk factor Advanced Maternal Age : women who are pregnant at age 35 or older are often referred to as “advanced maternal age.” There are six pregnancy-related risk factors associated advanced maternal age: decreased fertility, miscarriage, genetic problems, high blood pressure, stillbirth, and maternal death.

34. Common maternal risk factor Statistically, older women are less fertile. Advanced maternal age is widely recognized as increasing the risk for chromosomal abnormalities.  These are genetic problems that can cause health problems for the baby, including Down Syndrome, Tay-Sach’s disease, cystic fibrosis and others.

35. The rate of spontaneous miscarriage climbs gradually with age, from a 9% miscarriage rate among 22-year olds, to 18% among 30 year olds, ~20% at age 35, ~40% at age 40, and 84% at age 48. High rates of miscarriage in older women are more related to egg quality than the physical ability to stay pregnant. We know this because older women who use donor eggs from younger women do not have such high rates of miscarriage.

36. Women aged 40 and older are both more likely to have higher pre-pregnancy hypertension, and more likely to develop pregnancy-related hypertension.  High blood pressure can cause premature delivery or low-birth weight babies.

37. Also associated with advanced maternal age is stillbirth.  Women aged 40+ are two and-a-half times as likely to have a stillborn baby. Increased maternal age increased risk of maternal death during pregnancy, labor and delivery.  Some studies have indicated that women 35 and older may be three times as likely to die because of pregnancy or childbirth, compared to younger mothers

38. d.Weight Underweight woman- These women are more likely than women of normal weight to give birth to infant who are small for gestational age. Poor fetal growth increased birth asphyxia, neonatal hypoglycemia, hypothermia, perinatal mortality etc. Overweight- Increased risk of gestational diabetes mellitus, miscarriage, high risk of hypertension, pre-eclampsia, shoulder dystocia, PPH and still birth.

39. e. Ethnicity- It is one of the factors that is most strongly associated with LBW. f. Height- Height below 148 cm may lead to Cephalo Pelvic Disproportion leading to maternal and fetal distress. g. High parity - Multiparous women are at increased chance of anemia, malpresentation, PPH, ruptured uterus, transverse lie, prolapsed cord, hypertension, placenta previa, abruption placenta

40. Environmental factors Infection- Maternal infection may result in spontaneous abortion, preterm labour , premature rupture of membrane. Exposure to chemicals- It leads to increased risk of polycystic ovarian syndrome and shortened lactation.

41. 5. Surgical condition- Previous caesarean section and previous surgery like pelvic floor repair, vesicovaginal fistula repair, myomectomy, tubal ligation, pregnancy with fibroid, ovarian cyst, carcinoma of cervix can lead to various complications like ectopic pregnancy and uterine rupture. 6. Congenital genital tract anomalies- Congenital genital tract anomalies like septate uterus, bicornuate uterus can lead to ectopic pregnancy, abortion, birth defects in child etc.

42. Identification of high- risk women can be based on two classifications: Relationships between the risk factor and adverse out come. Causative or triggerring - maternal malnutrition- LBW, placenta previa, congenital malformation. Contributory - grand multiparty can lead to transverse lie, Prolapse of the cord, PPH . Predictive or associative – mother with multiple previous fetal loss have more risk of having another fetal loss.

43. Biological, medical, social condition Biological - Age, birth interval, weight gain Medical - diabetes, obstetric complications, pre eclampsia, health care utilization. Social - work load, birth attendant, economic status, specific culture/ customs of child bearing

44. Requires knowledge of the characteristics associated with poor outcomes and the ability to recognize and measure them. Some factors are easily detected even by untrained health worker, e.g. age, parity, maternal height and previous fetal or child loss. At this level, clear instructions must be given as to the action to be taken in each case.

45. With increased training, the proportion of detectable factors increases, leading to improved precision (accuracy) in predicting outcomes. Measurement of BP, detection of twin pregnancy and estimation of hemoglobin level are examples of methods of detecting further risk factors during pregnancy.

46. For the infant, the measurement of birth weight, monitoring of growth and knowledge of feeding practices all give desirable bits of information that permit the detection of risk factors and facilitate early intervention.

47. Unhealthy & illiterate mother, large families, crowded environment, poor sanitation, malnutrition and specific culture/customs of child bearing and rearing are well known examples of childhood risk factors. e.g. gastroenteritis as for a number of other diseases. Certain risk factors are specific for particular outcomes, but more often one risk factor- grand multiparity, for example- increases the frequency of various undesirable outcomes.

48. In some situations, culture and customs may act as risk factors by limiting the education or status of women. Climate, non-availability of certain foods, or poor environmental sanitation increases the risks for both mothers and children

49. Pre-term birth: Any infant born before completion of 37 weeks of gestation regardless of birth weight is called preterm birth. It may lead to consequences like birth asphyxia, feeding difficulties, hypothermia, hypoglycemia, hyperbilirubinemia, necrotizing enterocolitis, etc.

50. 2. Low birth weight: Birth weight of an infant is the single-most important determinant of its chances of survival and healthy growth and development. The consequences of low birth weight are : birth asphyxia, hypothermia, infection, hyperbilirubinemia, intra ventricular hemorrhage etc.