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Maternal and Child Health. Learning Objectives. By the end of this session, participants will be able to: Explain the importance of maternal and child health Describe the indicators for maternal and child health status - PowerPoint PPT Presentation
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Maternal and Child HealthMaternal and Child Health
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 20122
Learning ObjectivesLearning Objectives
By the end of this session, participants will be able to: Explain the importance of maternal and child health Describe the indicators for maternal and child health status Use MCH indicators to discuss status of maternal and child health in a community or country Enumerate the determinants of maternal and child health status
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 20123
Why invest in maternal and child health?Why invest in maternal and child health?
Women and children form a large proportion of the population; especially in developing countries
The mortality and morbidity among women and children is very high
There are proven and affordable ways of saving the lives of women and children
Investing in maternal and child health improves social stability and human security
Reproductive, maternal, newborn and child health access and outcome indicators are sensitive indicators
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 20124
Matlab, BangladeshPercent distribution of population & death (1987)
Matlab, BangladeshPercent distribution of population & death (1987)
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 20125
SwedenPercent distribution of population & death (1985)
SwedenPercent distribution of population & death (1985)
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 20126
A pregnant woman has one foot in the grave.
- Traditional African
Saying
Measuring maternal and child health
Measuring maternal and child health
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 20128
IndicatorsIndicators
Indicators are variables that help to measure changes, directly or indirectly. - WHO
Indicators are variables that indicate or show a given situation, and thus can be used to measure change.
- Green
• Count indicator• Proportion indicator• Rate indicator• Ratio indicator• Index
• Input indicator• Process indicator• Output indicator• Outcome indicator• Impact indicator• Determinant indicator
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 20129
Types of indicatorsTypes of indicators
Mortality & morbidity indicators
Coverage indicators
Knowledge, attitude & practice indicators
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 201210
Mortality indicatorsMortality indicators
Under-five mortality rate
Infant mortality rate
Neonatal mortality rate
Maternal mortality ratio
Maternal mortality rate
Life-time risk of maternal death
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 201211
Morbidity indicatorsMorbidity indicators
Proportion of children 0-5 years who suffered an episode of diarrhea in the last 2 weeks
Proportion of children 0-5 years who suffered an episode of cough or difficult breathing in the last 2 weeks
Proportion of children 0-3 years with weight for age (underweight) less than – 2 SD
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 201212
Coverage indicatorsCoverage indicators
Children 12-23 months received primary doses of immunization against six vaccine preventable diseases
Children under five years of age with acute respiratory infection and fever (ARI) taken to facility (%)
Children under five years of age with diarrhoea who received oral rehydration therapy (ORT) (%)
Children under five years of age who received treatment with any antimalarial (%)
Children 6-59 months of age who received vitamin A supplementation (%)
Births by Caesarean section
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 201213
The Life-cycleThe Life-cycle
7days
28 days
1 year
Birth
5 years
10 years
19 years
Early neonatal period
Perinatal period
Neonatal periodPregnancy
Adulthood
Infancy
Adolescence
Childhood
Reproductive period
Ageing
Death
Pre-school years
"School-age"
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 201214
Defining Neonatal, Infant and Under-5 mortality
Defining Neonatal, Infant and Under-5 mortality
7days
28 days
1 year
Birth
5 years
10 years
19 years
Early neonatal period
Perinatal period
Neonatal periodPregnancy
Adulthood
Infancy
Adolescence
Childhood
Reproductive period
Ageing
Death
Pre-school years
"School-age"
All these are expressed per 1000 live births
in one year, which is
defined as the rate.
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 201215
Child mortality ratesChild mortality rates
Under-5 mortality rate
Infant mortality rate
Neonatal mortality rate – Early neonatal mortality rate– Late neonatal mortality rate
Post-neonatal mortality rate
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 201216
What is the problem?What is the problem?
India contributes to:
22% of under-five deaths globally.
30% of global neonatal deaths.
CountryNeonatal
Mortality RateInfant
Mortality RateUnder Five
Mortality Rate
India 32 (2010) 44 (2011) 59 (2010)
Other BRICS Nations
Brazil 8 14 17
Ruissia 6 9 12
China 11 16 18
South Africa 18 41 57
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 201217
Trends of U5MR & IMR from 1990 -2009Trends of U5MR & IMR from 1990 -2009
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 201218
Child health situation in IndiaChild health situation in India
IndicatorMillennium
Development Goal
Current status(per 1000 live
births )
U5MR 38 59 (2010)
IMR<3028
44 (2011)
NMR18
<2032 (2010)
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 201219
Under-five Mortality rate: Comparison with other countries
Bangladesh Egypt
Nepal Indonesia
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 201220
Child mortality rates: importanceChild mortality rates: importance
Good indicator of overall health status of the population
Major determinant of the life expectancy at birth
Sensitive to levels and changes in socio-economic status of a population
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 201221
Time wise distribution of neonatal deaths
Time wise distribution of neonatal deaths
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 201222
Infant Mortality Rate: Status in 2009Infant Mortality Rate: Status in 2009
Only two large states have met the NRHM goal of IMR < 30, while two others are close to achieving it.
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 201223
Infant Mortality rate in India (2009)Infant Mortality rate in India (2009)
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 201224
In many of the larger states, there is decline in IMR but neonatal mortality mostly remains unchanged.
State wise Change in IMR and NMR in 2005 & 2009
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 201225
Malnutrition34%
Causes of under-five deaths in India: 2010
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 201226
Determinants of Child Mortality Determinants of Child Mortality
Distal causes
Intermediate causes
Proximal causes
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 201227
NMR IMR U5 MRResidence
Rural 42.5 62.2 82Urban 28.5 41.5 51.7Caste / TribeSC 46.3 66.4 88.1ST 39.9 62.1 95.7OBC 38.3 56.6 72.8Other 34.5 48.9 59.2Wealth IndexLowest 48.4 70.4 100.5Second 44.6 68.5 89.6Middle 39.3 58.3 71.9Fourth 31.9 44 51.2Highest 22 29.2 33.8
Equity and Childhood Mortality Rates Equity and Childhood Mortality Rates
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 201228
Key messagesKey messages
Many interventions pertaining to neonatal and child health can be delivered at home exclusively like breast feeding and some like vaccination need to be done by involving the health system.
The decision to seek care and initial treatment for many childhood diseases starts from home.
Thus, community behaviour plays a critical role in ensuring child survival.
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 201229
Maternal Death: DefinitionMaternal Death: Definition
Maternal death’ is death of a woman • while pregnant • or within 42 days of termination of pregnancy
– ,irrespective of the duration and the site of the pregnancy
– from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.”
ICD 9 & 10
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 201230
Maternal Mortality IndicatorsMaternal Mortality Indicators
Maternal Mortality Ratio: Maternal deaths per 100,000 live births
Maternal Mortality Rate: Maternal deaths per 100,000 women aged 15-45 years.
Life Time Risk of Maternal Death: The estimated risk of an individual woman dying from pregnancy or childbirth during her lifetime.
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 201231
Maternal Deaths: ClassificationMaternal Deaths: Classification
DirectIndirect:
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 201232
Why maternal mortality is difficult to measure?
Why maternal mortality is difficult to measure?
Maternal deaths are hard to identify because this requires information about: 1) deaths among women of reproductive age
2) pregnancy status at or near the time of death
3) the medical cause of death
All three components can be difficult to measure accurately
Even with levels of maternal mortality high, maternal deaths are relatively rare events
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 201233 33
Trend of maternal mortality ratio in India
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 201234
Decline in MMR from 2001-2009 in states of IndiaDecline in MMR from 2001-2009 in states of India
MMR 2001 – 03 MMR 2004 – 06 MMR 2007 – 09
INDIA 301 254 212
Assam 490 480 390
Bihar / Jharkhand 371 312 261
Madhya Pradesh / Chhattisgarh
379 335 269
Odisha 358 303 258
Rajasthan 445 388 318
Haryana 162 186 153
Maharashtra 149 130 104
Kerala 110 95 81
Tamil Nadu 134 111 97
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 201235
Common causes of maternal deaths in India
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 201236
Three Delays Model
Source: Operational Guidelines on Maternal and Newborn Health, NRHM, MoH & FW
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 201237
Source: Ronsmans C & Graham W J, 2006, Lancet (368): 1189-200
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 201238
MDG 4: Reduce child mortalityMDG 4: Reduce child mortality
Target 4.A: Reduce by two-thirds, between 1990 and 2015, the under-five mortality rate
– 4.1 Under-five mortality rate4.2 Infant mortality rate4.3 Proportion of 1 year-old children immunised against measles
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 201239
MDG 5: Improve Maternal HealthMDG 5: Improve Maternal Health
Target 5.A: Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio
– 5.1 Maternal mortality ratio5.2 Proportion of births attended by skilled health personnel
Target 5.B: Achieve, by 2015, universal access to reproductive health
– 5.3 Contraceptive prevalence rate5.4 Adolescent birth rate5.5 Antenatal care coverage (at least one visit and at least four visits)5.6 Unmet need for family planning
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 201240
Key messagesKey messages
Most life-saving interventions require considerable skills
Most problems could not be predicted or prevented
Excessive bleeding is the main cause of maternal death
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 201242
Exercise: Conceptual Framework for
understanding reasons of high maternal and child deaths in India
Exercise: Conceptual Framework for
understanding reasons of high maternal and child deaths in India
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 201243
Fish-bone diagramFish-bone diagram
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 201244
Continuum of Care
Continuum of Care
Home and Community
First level Facility
Referral Facility
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 201246
Continua of CareGuiding principles for planning maternal and child health programmes
Continua of CareGuiding principles for planning maternal and child health programmes
Continuum across Life-stages (which interventions?)
Continuum across Health System (at which level?)
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 201247
Continuum of CareAcross Life-stages
Continuum of CareAcross Life-stages
Factors which help decide interventions across the life-cycle:– Causes and distribution of child deaths– Proven efficacy of interventions– Feasibility– Cost– Acceptability– Issues related to health services
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 201248
Most effective interventions require implementation at each level
Factors guiding levels at which interventions are implemented:
– Community acceptability and demand
– Availability of trained staff– Access to health services– Technical complexities– Equity issues
Balance between implementation at different levels is important
Continuum of CareAcross Health Systems
Continuum of CareAcross Health Systems
Home and Community
First level Facility
Referral Facility
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 201249
Example:
Interventions to improve Child Health
Example:
Interventions to improve Child Health
Home and Community
First-level facility
Referral Facility
Pregnancy
At birth
Newborn period
Infancy and Childhood
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 201250
Example:
Interventions to improve Child Health
Example:
Interventions to improve Child Health
Home and Community
First-level facility
Referral Facility
Pregnancy Promote & support antenatal care
Detection & management of complications of pregnancy
Management of severe complications
At birth Promote and support skilled care at birth
Immediate newborn care
Management of obstetric complications
Newborn period
Promote and support key newborn care practices
Management of newborn illnesses
Immunization
Management of severe newborn illnesses
Infancy and Childhood
Community case management of diarrhea & ARI
Standard case management during childhood illnesses
Management of severe childhood illnesses
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 201251
Packaging of InterventionsPackaging of Interventions
A way of integrating and combining health interventions– Essential for making programmes feasible as it reduces programme
costs and improves program effectiveness
Several Maternal and Child Health intervention packages already exist.
Sometimes, there might be need for adding a new package.
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 201252
Intervention PackagesSkilled obstetric and immediate newborn care including resuscitation
Emergency obstetric care to manage complications such as obstructed labour and hemorrhage
Antibiotics for preterm rupture of membranes#
Corticosteroids for preterm labour#
Emergency newborn care for illness, especially sepsis management and care of very low birth weight babies
Cli
nic
al
care
Folic acid #
Counseling and preparation for newborn care and breastfeeding, emergency preparedness
Healthy home care including breastfeeding promotion, hygienic cord/skin care, thermal care, promoting demand for quality care
Extra care of low birth weight babies
Case management for pneumonia
Fam
ily
-co
mm
un
ity
Clean home delivery
Simple early newborn care
15 - 32%
4-visit antenatal package including tetanus immunisation,detection & management of syphilis, other infections, pre-eclampsia, etc
Malaria intermittent presumptive therapy*
Detection and treatment of bacteriuria#
Ou
trea
ch
serv
ices
Postnatal care to support healthy practices
Early detection and referral of complications6 - 9%
23 - 50%NMR effect
InfancyNeonatal periodPre- pregnancy PregnancyBirth
Administering basic community-based intervention packages at full coverage can save ~ 37% of all newborn deaths!
Child Nutrition
Child Nutrition
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 201254
4540
23
0
10
20
30
40
50
60
Stunted Underweight Wasted
Percent
Undernutrition in Children under Age 3 YearsUndernutrition in Children under Age 3 Years
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 201255
5145 43 40
20 23
0
10
20
30
40
50
60
Stunted Underweight Wasted
NFHS-2 NFHS-3
Percent
Undernutrition in Children under Age 3 yearsUndernutrition in Children under Age 3 years
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 201256
Children under age 5 years who are underweight (%)
2022 23
25 25 25 26 26
3033 33
36 37 37 38 38 39 40 40 40 41 42 4345
4749
56 5760
20
0
10
20
30
40
50
60
70
SK
MZ
MN
KE PJ
GA
NA
JK DL
TN AP
AR
AS
HP
MH
KA
UT
WB
HR
TR RJ
OR
UP IN GJ
CH
MG
BH JH MP
Children’s Nutritional Status Varies by StateChildren’s Nutritional Status Varies by State
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 201257
Stunted
Wasted
Under weight
Target Population for Nutrition Interventions
Nearly 30% of the children start at a disadvantage at birth with Low birth weight
The proportion of underweight and stunted children rises from 6 moths onwards plateaus at 24 months
Window of Opportunity: -9 to +24 months
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 201258
Target population for Nutrition InterventionsTarget population for Nutrition Interventions
Key Points: Target group for nutrition programmes Under five Children with a focus on under twos
Women during pregnancy and lactation
Adolescents (10-19 years)
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 201259
DeterminantsDeterminants
Many interventions pertaining to neonatal and child health can be delivered at home exclusively like breast feeding and some like vaccination need to be done by involving the health system.
The decision to seek care and initial treatment for many childhood diseases starts from home.
Thus, community behaviour plays a critical role in ensuring child survival.
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 201260
Nutrition Goals Nutrition Goals
Eleventh Five Year Plan Goals Reducing Maternal Mortality Ratio
(MMR) to 1 per 1000 live births. Reducing Infant Mortality Rate (IMR) to
28 per 1000 live births. Reducing Total Fertility Rate (TFR) to
2.1. Providing clean drinking water for all by
2009 and ensuring no slip-backs. Reducing malnutrition among children
of age group 0–3 to half its present level (from 45.9 to 23.0% wt/age).
Reducing anaemia among women and girls by 50%.(from 56% to 28%).
Raising the sex ratio for age group 0–6 to 935 by 2011–12 and 950 by 2016–17.
Millennium Development Goals
MDG 1: – Target 1c: Reduce by half the
proportion of people who suffer from hunger
Indicators for MDG 1– 1.8 Prevalence of underweight
children under-five years of age
– 1.9 Proportion of population below minimum level of dietary energy consumption
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 201261
54 5449
41
2821 20
16
55
4843
34
0
10
20
30
40
50
60
Stunted Wasted Under weight
Scheduled Tribe Scheduled Caste Other Backward Class Other
Inequities in Nutritional Status of Children
25 2219 17
13
49
4134
20
6054
49
41
25
57
0
10
20
30
40
50
60
70
Poorest Second Middle Fourth Highest
Wasting Under weight Stunting
No difference in male and female children
Percentage of under weight increases with increasing birth order
Under weight decreases with increasing birth interval
Importance of birth spacing and limiting family size
Focus on tribals and Schedule caste
Wealth Quintiles
4447
43
51
64
52
58
52
0
10
20
30
40
50
60
70
Tribal (NNMB Tribal 2009)
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 201262
Hidden Hunger – Micronutrient deficiencies Hidden Hunger – Micronutrient deficiencies
6559
37
31
67
59
30
43
6767
1714
3736
50
40
58 55
88 85
0
10
20
30
40
50
60
70
80
90
100
1-3 yrs 4-6 yrs Source: NNMB 2004-06
% o
f R
DA
co
nsu
med
bas
ed
on
die
tary
rec
all
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 201263
How well are effective interventions reaching children?
How well are effective interventions reaching children?
Intervention coverage is the proportion of children under age 5 years (or their caregivers, or pregnant women) in the population who needed the intervention and have received it.
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 201264
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 201265
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 201266
CES 2009: 61%
DLHS-2Below 4040 to 5050 to 6060 to 70Above 70
India State
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 201267
Feeding Practices in children Feeding Practices in children
40.5
46.8
57.1
0
10
20
30
40
50
60
Early Initiation ofBreast Feeding
Exclusive breastfeeding
Complimentary foodwith breast feeding
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 201268
30
26
40
3
More in rural(71.5) as compared to urban (63) areas
Varies from 76% in lowest wealth index to 52% in highest
No sex differentials
Anemia in children 6 – 59 months
No Anemia
Severe Anemia
Moderate Anemia
Mild Anemia
Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 201269 Thank
You