Maternal and Child Health

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


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


Matlab, BangladeshPercent distribution of population & death (1987)

Matlab, BangladeshPercent distribution of population & death (1987)


SwedenPercent distribution of population & death (1985)

SwedenPercent distribution of population & death (1985)


A pregnant woman has one foot in the grave.

- Traditional African

Saying

Measuring maternal and child health

Measuring maternal and child health


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


Types of indicatorsTypes of indicators

Mortality & morbidity indicators

Coverage indicators

Knowledge, attitude & practice indicators


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


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


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


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"


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.


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


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


Trends of U5MR & IMR from 1990 -2009Trends of U5MR & IMR from 1990 -2009


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)


Under-five Mortality rate: Comparison with other countries

Bangladesh Egypt

Nepal Indonesia


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


Time wise distribution of neonatal deaths

Time wise distribution of neonatal deaths


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.


Infant Mortality rate in India (2009)Infant Mortality rate in India (2009)


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


Malnutrition34%

Causes of under-five deaths in India: 2010


Determinants of Child Mortality Determinants of Child Mortality

Distal causes

Intermediate causes

Proximal causes


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


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.


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


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.


Maternal Deaths: ClassificationMaternal Deaths: Classification

DirectIndirect:


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


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


Common causes of maternal deaths in India


Three Delays Model

Source: Operational Guidelines on Maternal and Newborn Health, NRHM, MoH & FW


Source: Ronsmans C & Graham W J, 2006, Lancet (368): 1189-200


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


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


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


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


Fish-bone diagramFish-bone diagram


Continuum of Care

Continuum of Care

Home and Community

First level Facility

Referral Facility


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?)


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


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


Example:

Interventions to improve Child Health

Example:


Home and Community

First-level facility

Referral Facility

Pregnancy

At birth

Newborn period

Infancy and Childhood


Example:


Example:


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


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.


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


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


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


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


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


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)


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.


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


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)


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


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.


CES 2009: 61%

DLHS-2Below 4040 to 5050 to 6060 to 70Above 70

India State


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


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

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Maternal and Child Health

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