July, 1950] MATERNITY AND CHILD WELFARE WORK : CHOPRA 317

Public Health Section

maternity and child welfare WORK IN RAILWAY COLONIES

By B. L.^CHOPRA, d.p.h., d.t.m". '(Liverpool) Dist. Medical Officer, E. I. R., Kanchra-para

The subject is divided below under different heads and sub-heads with a view, to simplifica- tion. and in the hope that the simplification will

help in -organizing maternity and child welfare work in railway areas. This subject is gaining great importance since India has attained her freedom. R^intly a symposium on maternal and child health^Work in India was opened for four days on 30th December, 1949, under the

patronage of Hon'ble Rajkumari Amrit Kaur.

.4. Accommodation, staff and organization OF A CENTRE

A useful Maternity and Child Welfare Centre should normally consist of two good rooms, one for the lady doctor and the other for the lady health visitor. There should be a grass lawn, small flower garden with a compound wall. On

the grass lawn a few outdoor children sports like see-saw should be installed. The staff should consist of a lady doctor, a lady health

visitor, an ayah, a female sweeper and a peon. As regards equipment it is essential to have a

maternity examination table, baby weighing machine, arrangement for washing and bathing of the infants, instruments like pelvimeter, forceps, douching can, etc., and a few useful

medicines for infants. Facilities for douching should also exist,. The rooms should be decorated with useful posters and pictures on the subject. By experience it is found that it is no use leaving the centre in charge of midwives who are

really not up to the mark. On the N.W.R. it was customary to have a lady doctor and

lady health visitors in charge of the Maternity and Child Welfare Centres at the Divisional

Headquarters. In case of other small hospitals and dispensaries these centres were left in

charge of midwives but by experience it was

found that such centres did very little useful

work. Properly trained lady health visitors

were considered necessary if these centres were

to be made useful and popular. Then there

has been some controversy about having lady doctor or lady health visitors in charge of

these centres. It was found by experience that both these ladies are essential for running of

such a centre. Lady doctors take up the

curative side of the work whilst lady health visitors the propaganda and educative side of the work as well as training of the mid- wives. Each centre should be provided with printed cards for keeping a record of the mothers, infants, toddlers and children visiting the centre. The staff should be controlled by a Maternity

and Child Welfare Council which may be formed

in "every railway colony. Besides controlling the staff of these centres these councils can do

educative work by enlightenment of the mothers on the subject and dispel superstitions. By experience I find that these councils should be

formed from amongst the ladies of the colony with the head medical man in the colony as

the Honorary Secretary of the Council. The seniorniost lady becomes the president and the others elected as vice-presidents and members

by annual voting from amongst the registered members of each centre. The vacancy caused

by any member of the council leaving the centre on transfer or otherwise should be filled

by the council by voting. Besides these executive councils, a Central Maternity Council for each railway with the chief medical officer as its chairman should also be formed with an accounts officer and a personnel officer as

members. The local Maternity Council should meet once a month and Central Council once in three months. Each local council should send their delegates to Central Council at their

quarterly meetings. Members of the local councils should in turn be the visiting members of the centre for one month. They should super- vise daily the' bathing and washing of babies, distribution of milk to the needy children, treat- ment of ailments by the staff of the centre. The Central Maternity Councils should frame

general rules for running of these centres on

each railway and local councils have their by- rules wherever necessary to suit local conditions. To stimulate further interest in these centres, annually Baby Health weeks should be organized and prizes given to best babies. Educative films on these subjects should also be exhibited during these health weeks. Charity dances and shows should also be organized to collect funds for providing useful addition for the centre. I

organized such charity dances at Lonavla

(Poona district) beginning with the year 1927 and also at Ferozepore beginning with the year 1942. In one year at Ferozepore we collected some five hundred rupees and amongst other useful things purchased from this money was a cow for the centre to provide pure milk to needy and poor children.

B. Work done in the centre The work in these centres is usually divided

into ante-natal work, post-natal work and house visits. I will describe below in brief maternity and child welfare work in railway colonies under these three headings :?

I. Ante-natal work

This mainly consists of .advice on the nutrition for the mother and the

'

expectant newborn \

318 i THE INDIAN MEDICAL GAZETTE [July, 1950

Emphasis concerning nutrition in pregnancy has always been on its maternal aspects. But in the

light of recent developments advice on nutrition for the '

expectant newborn ' should be equally

stressed.

Diet of the expectant mother

Needs of expectant mothers : From the

start of pregnancy expectant mothers need

increasing amount of proper nourishment.

During this period the exact daily requirements of proteins, carbohydrates, fats, vitamins and

minerals should be based on the following three principles :?

(i) To correct existing maternal nutrient

deficiency as quickly as possible. (w) To compensate for the physiological

changes in pregnancy as they affect the expectant mother and possibly to abort some complications of pregnancy.

(Hi) To supply the nutrients for the proper formation, development and growth of the

expectant newborn.

Generally speaking the following deficiencies are most important : (a) night blindness and xeroses due to deficiency of vitamin A, (b) dis- turbances in sensation of the feet, legs and hands with muscular weakness (thiamine), (c) inflammation of tongue and skin troubles

(nicotinamide), (d) disease of the gums due to

deficiency of vitamin C, (e) disease of the eyes, ears and oedema with flattening of the tongue papillae due to deficiency of riboflavin.

The level of vitamin C in the maternal blood falls progressively as pregnancy advances because of the demands of the fcetus. Vitamin C deficiency as above stated harms the teeth and gums and causes gingivitis in the expectant mother. Vitamin D is needed to prevent maternal osteomalacia.

It cannot be definitely stated whether poor nutrition is- the cause of emesis or hyperemesis gravidarum though there are reports which link the two and thiamine has been given with

advantage in these conditions. Then there is evidence to show that nausea of pregnancy is benefited with the use of pyridoxine hydro- chloride though no actual deficiency of this vitamin has been shown early in pregnancy. In my experience Esdavite capsule (Sharp and Dohme), one daily, is very useful for

expectant mother and expectant newborn as it contains all the abovementioned vitamins. Contents of each Esdavite capsule are given in the following table which also gives the minimal daily requirements.

Mineral requirements for the expectant mother

(i) Calcium.?There is retention of about 45 gm. of calcium during pregnancy of which one-half forms a reserve in the bones of the

expectant mother for lactation. The necessary

Vitamin A ..

Vitamin. D Thiamine hydro-

chloride. Riboflavin Pyridoxine hydro-

chloride. Calcium panto-

thenate. Niacinamide Ascorbic acid Mixed tocopherols

Esdavite capsule

20,000 units 2.000 units

5 mg.

10 mg. 1 mg.

10 mg.

50 mg. 150 mg. 10 mg.

Daily requirements

4.000 units 400 units

1 mg.

2 mg. No standard yet

fixed. Do.

Do. 30 mg.

No standard yet fixed.

needs for calcium are better obtained and utilized from natural foods. Calsid is recom- mended for ante- and post-natal calcium

deficiency. (ii) Iron.?In true pregnancy anjemia diet

plays an important part in prevention and correction. The pregnant mother generally absorbs 2 to 10 times more iron. Whatever the

cause, every effort should be made to correct

existing anaemia in early pregnancy. Later 18 to 20 mg. iron intake per day is required and can usually be secured from regular foodstuff.

Polyhsemin tablets in my experience are excellent for this purpose if any drug is required.

(Hi) Use of folic acid and crude oral liver extract and an increase in proteins are also helpful.

(iv) Iodine.?Iodine is useful during preg- nancy due to increase in metabolism, particularly in areas where goitre is prevalent. For successful lactation expectant mother

should store essential proteins, vitamins and minerals during ante-natal period by ample daily intake.

Diet suitable to help the expectant newborn

Coming to the nutritional needs of '

expectant newborn ' (the term used by W. F. Guerriero in Texas State Journal of Medicine, May 1949), it should be noted that

(i) There is progressive increase of the needs of vitamin A in the expectant newborn liver as pregnancy advances.

(ii) Riboflavin is also essential for normal growth of the foetus. Abnormal children are

sometimes born due to nutritional deficiency in the mother as this arrests the developments of the expectant newborn.

(iii) The foetus draws on the mother for its requirements of vitamin C. The effect of vitamin D in the maternal diet requires further investigation. It helps the utilization of calcium. Vitamin D in human milk is also an

important factor in preventing rickets more than the minerals. Vitamin K has been administered fo the pregnant mother shortly before and

July, 1950] MATERNITY AND CHILD WELFARE WORK : CHOPRA 319

during labour to influence the concentration in the blood of the newborn but this has recently been given up.

(iv) Amongst the mineral requirements calcium and phosphorus require to be increased with the life of the expectant newborn and during the period of its growth.

Congenital rickets and imperfect bony structures in the infant have been noted in

association with calcium, phosphorus and

vitamin D lack in the diet of the expectant mother. The structure of the deciduous teeth is also affected by the content of calcium, phosphorus, vitamin D and proteins in her

diet. She generally begins pregnancy in a

negative calcium balance and should immediately be given good quantities of calcium, phosphorus, vitamin D and protein in the formation period.

Radio-active iron appears in the expectant newborn circulation within forty minutes after administration to the mother.

(v) Protein requirements of the expectant newborn require consideration. The fcetus

requires large amount of proteins. Progressive increase in the birth-weight and length with

increasing amount of proteins in the diet is quite striking. Then there is also strong relation

between protein availability for the expectant newborn and prematurity, immaturity, stillbirth, abortions, deciduous teeth and imperfect osseous structure development. The fcetus is parasitic for its protein needs only to a certain degree. As soon as the protein stores of the mother are exhausted to any major degree, she retains the

remaining stores due to some protective mechanism. Thus an adequate daily intake of proteins from the natural foods by the pregnant mother, particularly in the growth period when there is greatest demand of proteins for herself and the expectant newborn, is essential.

II. Post-natal work

(a) How to lower infant mortality

During the first year of existence infant

mortality reaches a very high level. Attempts have been made to put it down to nature. It

is, however, an error to consider mortality as

natural expediency since it is noticed that not

only those who are born weaklings but those who are born healthy perish if proper food and care are not administered to them. The contrary is known to be the fact. With proper nourish- ment and treatment those who are born before their time or born weak may be made to survive. Amongst the railway staff ignorance and obsolete tradition are great factors which cloud the sense of infant feeding and care, which are handed down to the young mother by every grandmother. Therefore it is necessary that the

object of post-natal welfare should be achieved through publicity and guidance given to the mother so that the infant's normal growth may be bettered. Hence is the necessity of extensive

enlightenment of the mother on the subject. This work should be entrusted to Maternity- Welfare Council which may be started in every railway colony to dispel the superstitions.

(b) Welfare of the child after birth

Such councils will achieve their purpose most if instructions regarding the proper feeding and care of the infants are given to the mother and she is also instructed to have periodical medical consultations. It, therefore, becomes very necessary that in organizing these centres we

should, in addition to a lady health visitor, have a lady doctor as stated in the first

para before attached to every Child Welfare Centre. The growth of the child can be watched if it is regularly examined at the centre and entered on post-natal cards. It is necessary that a young and inexperienced mother should be able to recognize from the start the illness or disorders of the child. The young mothers often get very panicky about every ordinary ailments of the children. The medical person attached to the centre should be able to give advice on prognosis and the prevention of the child's disease.

Then again it is very necessary that proper understanding or precautionary measures for the newly born are to begin early as infant mortality is known to be at its highest during the first month of its existence. The mother should be advised as to what constitutes a proper food and as to how she should conduct her life just before delivery.

(c) Welfare of the mother and child at and after delivery

The mother should always be instructed to

nurse her newly born baby. The mother's milk is the best and the most suitable form of nourishment for the suckling. The greatest number of infants are known to die in the first month owing to incidental chills. In my experi- ence it is chiefly those children who are fed on artificial food that fall victims to the disease of

digestive system but those who are breast-fed rarely suffer from such complaint. Some advice on weaning is also necessary.

As a rule this is an easy matter for the majority of the mothers. Only slight inconvenience felt on the first day.

(d) Hints regarding baby's feeding and dwelling During the summer infant mortality reaches a

high figure. Not only in a hot climate but in

overheated places the baby who is warmly clad, runs the danger of being too warm. The

regulation of children's body warmth is also

endangered when they suffer from stomach trouble and are exposed to overheating at the same time.

The question of baby's dwelling is also of

very great importance and it is commonly known

320 THE INDIAN MEDICAL GAZETTE [July, 1950

that much is left in this direction by parents to be decided by lady health visitor who should advise the parent rightly because unhealthy conditions present still another danger. The adults who are suffering from cold, cough or

from other chest troubles and who share the same living space with infants may infect the latter. In case of chest trouble it is

advisable to keep apart infant from the grown- up especially if the latter is also entrusted with

feeding or looking after it. Infection may be

prevented with the help of layers of gauze and may be advocated by lady health visitor in suitable cases. The lady health visitor should use her discretion in such cases according to the circumstances of each case. She should explain to those concerned that the babies are helpless in this matter as they are not equipped with the power of resistance and that they should be protected against the danger of their

surroundings. Their nourishment and fostering should be done in the best possible way. The infant during the suckling period has

difficulty in maintaining its iron balance. For the first six months of life the infant is depen- dent on its iron stores secured during its life as an expectant newborn. Failure of the- fcetus to store iron may result from anaemia in the

expectant mother.

(e) British method of supplying vitamin require- ments of mother and child after its birth About two years ago I saw a circular from the

British Ministry of Food. The Ministry of Food in conjunction with the Ministry of Health and Secretary of State for Scotland announced that from 1st August, 1947, every mother will be entitled under the Welfare Food Services to vitamins A and D tablets free of charge for

thirty weeks after the birth of her child. The chief purpose of providing these tablets after the birth of the child is to help supply the nutri- tional requirements of breast-feeding mothers but they are also of benefit to all mothers of

young children whether they are breast-feeding their child or not. The tablets were being supplied in addition to the free cod-liver oil

supplied to the children. They were available at all Maternity and Child Welfare Centres and all mothers who had babies under thirty weeks old on 1st August, 1947, had to apply to their local food offices and were given coupons for tablets to last them until the baby was 30 weeks old. After 1st August, 1947, mothers were given these coupons automatically when they notified the food offices of the birth of a child. A similar scheme was found most useful by me in the year 1947 in Delhi railway area.

IJI. House visits

It must be realized by all concerned that in all civilized countries the precautionary measures for mothers and children have made great strides during the last twelve years. The idea that

children of to-day are the nation of to-morrow is being more and more realized. The war,

pestilence and famine do cause a great havoc but at the same time thought of the future

generation should receive great attention and new methods for the maintenance, particularly of the coming generation, should be thought of. It is the duty of the health visitor to visit the expectant mother in her home at the time of

delivery and teach her on the spot the correct method of living during this period at and after delivery.

C. Opening new centres on co-operative basis

Due to financial stringency, the Railway Administrations are not able to open new health centres. A scheme of voluntary contribution of one or two annas a month from each railway employee in the workshops (over 12,000 men are working in Kanchrapara Loco, and Carriage Workshops at present) is under consideration and is meeting with excellent response and it is hoped a Health Centre will be started at Kanchrapara in near future on co-operative basis. This may be done at other workshops too.

Mv thanks are due to Dr. S. S. Kent, m.d., Chief Medical Officer, E. I. R., for his kind permission to contribute this article.