Maternal & Child Health-III Dr. Aliya Junaid Community Medicine Dept. Army Medical College

Contents  Reproductive Health & its Components  Safe motherhood & its Components  Maternal Mortality Rate, causes & prevention  Infant Mortality Rate, causes & prevention  MCH Center  Child Care- IMCI  STDs and its Control.

Hierarchy of Health System Higher level care facilities First level care facility First level referral facility Tertiary hospital District Headquartes Hospital Tehsil/Taluka Headquarters hospital Rural Health Centers Basic Health Units

Need For MCH  MCHC is a strategy to unite interventions for women and children in order to increase and improve their Health status.  Early evidence suggests that implementing maternal and child health interventions simultaneously is cost-effective and convenient, and some estimate that this model could prevent up to two-thirds of maternal & child deaths

Objectives of MCHC  Reduction of Morbidity & Mortality rates for mother & children  Promotion of Reproductive Health  Promotion of the Physical & Psychological development of the children within family.

MCH Center  Preconceptional guidance  Ante-natal, Intra-natal, Post-natal services  Family planning services.  Marriage counseling.  Growth Monitoring  Special services for the children with special needs.  Home sanitation.  Nutritional guidance.  Immunization services.  TBA training. It includes:

Preventive Interventions At MCHC  Folic acid, Vitamin A  Tetanus toxoid (neonatal)  Pre-eclampsia and eclampsia prevention (calcium supplementation)  Detection and management of breech  Clean delivery practices  Breastfeeding Advise  Prevention and management of Hypothermia  Insecticide-treated materials

Treatment interventions at MCHC  Detection and treatment of asymptomatic bacteriuria.  Corticosteroids for preterm labor  Newborn resuscitation  Oral rehydration therapy  Anti-malarials  Antibiotics for dysentery, Neonatal sepsis, pneumonia.  Vitamin A

Requirements / Concerns For MCHC Site Site Building Building Staff Staff Budget Budget Work load Work load MCH Organization MCH Organization

Site For an ideal MCH centre it should be located centrally in the areas where population can easily drain into.

Building  A reception or a waiting-room.  OPD Rooms for medical officers.  A waiting room  An immunization room.  Store room  Conference room.  Dispensary  Family planning room for advice to mothers  Antenatal care room  Delivery room  Under – 5 clinic

Staff  Doctor, preferably female  Health education  Antenatal, intranatal, postnatal care  Growth monitoring  Immunization services  Pharmacist  LHV  Dai  Peon  Sweeper  Guard  etc Staff is required for following services;

Budgeting Pays for all staff, electricity bills, transports expenses, phone bills and others

Work load Work load basis of such a unit would be as follow: Work load basis of such a unit would be as follow: a. Population b. Yearly new births approx c. Pregnant women under care approx e. Infants under care f. Preschoolers (15% of the total population=.15 x 5000 =750)

Integrated Management of Childhood Illness ( IMCI)

IMCI  A strategy for reducing mortality and morbidity associated with major causes of childhood illness  A joint WHO/UNICEF initiative since 1992  Comes as a general Guidelines for Curative & Preventive Management which have been adapted to each country at first level health facilities

IMCI - Aim & Objectives  It aims to reduce death, illness and disability, and promote improved growth and development among children under five years of age.  Its objective is to reduces global morbidity and mortality associated with the major causes of illnesses in children under 5 years of age.

Why IMCI ?  Every day, millions of parents seek health care for their sick children, taking them to hospitals, health centers, pharmacists, doctors and traditional healers.  Surveys reveal that many sick children are not properly assessed and treated by these health care providers

 Their parents are poorly advised.  At first-level health facilities in low- income countries, diagnostic supports such as radiology and laboratory services are minimal or non-existent, and drugs and equipment are often inadequate.

 These factors make providing quality care to sick children a serious challenge.  WHO and UNICEF have addressed this challenge by developing a strategy called the Integrated Management of Childhood Illness (IMCI).

IMCI Components i.Improving case management skills of health-care staff ii.Improving overall health systems iii.Improving family and community health practices

i. Improving case management skills of health care staff  Teaches health care worker about the integrated case management process.  Provision of locally adopted guidelines on IMCI  Activities to promote their use.

ii. Improving overall health systems  Identify actions to prevent illness through the;  Immunization of sick children  Supplementation of micronutrients  Promotion of breast feeding  Counseling of mothers to solve feeding problems.

iii. Improving Family & Community Health Practices  Children who can be treated at home. Caregivers are taught how to provide treatment and when to seek care for their children.

The CASE MANAGEMENT PROCESS is used to assess and classify two age groups: Age Group = 1 week up to 2 months Age Group = 2 months up to 5 years

THE CASE MANAGEMENT PROCESS THE CASE MANAGEMENT PROCESS The charts describes the following steps; 1. Assess the child or young infant 1. Assess the child or young infant 2. Classify the illness 2. Classify the illness 3. Identify the treatment 3. Identify the treatment 4. Treat the child 4. Treat the child 5. Counsel the mother 5. Counsel the mother 6. Give follow up care 6. Give follow up care

SELECTING THE APPROPRIATE CASE MANAGEMENT CHARTS For all sick children age 1 week up to 5 years who are brought to the clinic, what do you do ? ASK THE CHILDS AGE

SELECTING THE APPROPRIATE CASE MANAGEMENT CHARTS FOR ALL SICK CHILDREN age 1 week up to 5 years who are brought to the clinic ASK THE CHILD’S AGE IF the child is from 1 week up to 2 months IF the child is from 2 months up to 5 years USE THE APROPRIATE CHART:

THE SICK CHILD Age 2 Months to 5 Yrs ASSESS AND CLASSIFY

When the child is brought to the clinic Use Good Communication Skills:  Listen carefully to what the mother tells you  Use words the mother understands  Give mother time to answer questions  Ask additional questions when mother not sure of answer Record important information

GENERAL DANGER SIGNS ASK:  Is the child able to drink or breastfeed?  Does the child vomit everything?  Has the child had convulsions? LOOK:  See if the child is lethargic or unconscious

Ask the mother or caretaker about the 4 main symptoms:  cough or difficult breathing  diarrhoea  fever, and  ear problem SUMMARY OF ASSESS AND CLASSIFY When a main symptom is present:  Assess the child further for signs related to the main symptom, and  Classify the illness according to the signs which are present or absent

THE CASE MANAGEMENT PROCESS THE CASE MANAGEMENT PROCESS The charts describes the following steps; 1. Assess the child or young infant 1. Assess the child or young infant 2. Classify the illness 2. Classify the illness 3. Identify the treatment 3. Identify the treatment 4. Treat the child 4. Treat the child 5. Counsel the mother 5. Counsel the mother 6. Give follow up care 6. Give follow up care

THE CLASSIFICATION TABLE have 3 ROWS (pink, yellow & green) on the assess and classify section. COLOR of the row helps to IDENTIFY RAPIDLY whether the child has SERIOUS DISEASE requiring URGENT ATTENTION or not.

 Each row is colored either –  PINK - means the child has a severe classification and needs urgent attention and referral or admission for inpatient care  YELLOW- means the child needs a specific medical treatment such as an appropriate antibiotic, an oral anti-malarial or other treatment; also teaches the mother how to give oral drugs or to treat local infections at home. The health worker teaches the mother how to care for her child at home and when she should return.  GREEN- not given a specific medical treatment such as antibiotics or other treatments. The health worker teaches the mother how to care for her child at home.

Any general danger sign or Chest indrawing or Stridor in calm child. SEVERE PNEUMONIA OR VERY SEVERE DISEASE Give first dose of an appropriate antibiotic. Refer URGENTLY to hospital. Fast breathing PNEUMONIA Give an appropriate oral antibiotic for 5 days. Soothe the throat and relieve the cough with a safe remedy. Advise mother when to return immediately. Follow-up in 2 days. No signs of pneumonia or very severe disease. NO PNEUMONIA: COUCH OR COLD If coughing more than 30 days, refer for assessment. Soothe the throat and relieve the cough with a safe remedy. Advise mother when to return immediately. Follow-up in 5 days if not improving. CLASSIFICATION TABLE FOR COUGH OR DIFFICULT BREATHING SIGNSCLASSIFY AS IDENTIFY TREATMENT (Urgent pre-referral treatments are in bold print.)

 Always start at the top of the classification table. If the child has signs from more than 1 row always select the more serious classification.

Integrated Case management process

Summary of the Integrated case Management Process For all sick children age 1 week up to 5 years who are brought to a first- level health facility

Summary of the Integrated case Management Process ASSESS the Child: Check for danger signs Check for danger signs (or possible bacterial infection). (or possible bacterial infection). Ask about main symptoms. Ask about main symptoms. If a main symptom is reported, assess further. Check nutrition and immunization status. If a main symptom is reported, assess further. Check nutrition and immunization status. Check for other problems Check for other problems

Summary of the Integrated Case Management Process Classify the child’s illness: Use a color-coded Use a color-coded triage system to classify triage system to classify the child’s main the child’s main symptoms and his or symptoms and his or her nutrition or feeding her nutrition or feeding status. status.

Summary of the Integrated Case Management Process IF URGENT REFERRAL is needed and possible

Summary of the Integrated Case Management Process IDENTIFY URGENT PRE-REFERRAL TREATMENT(S) Needed prior to referral of the child according to classification

Summary of the Integrated Case Management Process TREAT THE CHILD: Give urgent pre- referral treatment(s) needed.

Summary of the Integrated Case Management Process REFER THE CHILD: Explain to the child’s caretaker the need for referral. Explain to the child’s caretaker the need for referral. Calm the caretaker’s fears and help resolve any problems. Write a referral note. Calm the caretaker’s fears and help resolve any problems. Write a referral note. Give instructions and supplies needed to care for the child on the way to the hospital Give instructions and supplies needed to care for the child on the way to the hospital

Summary of the Integrated Case Management Process IF NO URGENT REFERRAL is needed or Possible

Summary of the Integrated Case Management Process IDENTIFY TREATMENT needed for the child’s classifications: identify specific medical treatments and/or advice

Summary of the Integrated Case Management Process TREAT THE CHILD: Give the first dose of oral drugs in the clinic and/or advice the child’s caretaker. Give the first dose of oral drugs in the clinic and/or advice the child’s caretaker. Teach the caretaker how to give oral drugs and how to treat local infections at home. Teach the caretaker how to give oral drugs and how to treat local infections at home. If needed, give immunizations. If needed, give immunizations.

Summary of the Integrated Case Management Process COUNSEL THE MOTHER: Assess the child’s feeding, including breastfeeding practices, and solve feeding problems, if present. Assess the child’s feeding, including breastfeeding practices, and solve feeding problems, if present. Advise about feeding and fluids during illness and about when to return to a health facility. Advise about feeding and fluids during illness and about when to return to a health facility. Counsel the mother about her own health. Counsel the mother about her own health.

Summary of the Integrated Case Management Process FOLLOW-UP CARE: Give follow-up care when the child returns to the clinic and, if necessary, re- asses the child for new problems.

 If the mother complain is regarding Cough or difficult breathing

Cough or Difficult Breathing? IF YES, ASK:  For how long? LOOK, LISTEN, FEEL:  Count the breaths in one minute mos = fast breathing >/= 50/min 2-12 mos = fast breathing >/= 50/min 12 mos-5yrs = fast breathing >/= 12 mos-5yrs = fast breathing >/= 40/min 40/min  Look for chest indrawing  Look and listen for stridor Classify COUGH or DIFFICULT BREATHING

Any general danger sign or Chest indrawing or Stridor in calm child. SEVERE PNEUMONIA OR VERY SEVERE DISEASE Give first dose of an appropriate antibiotic. Refer URGENTLY to hospital. Fast breathing PNEUMONIA Give an appropriate oral antibiotic for 5 days. Soothe the throat and relieve the cough with a safe remedy. Advise mother when to return immediately. Follow-up in 2 days. No signs of pneumonia or very severe disease. NO PNEUMONIA: COUCH OR COLD If coughing more than 30 days, refer for assessment. Soothe the throat and relieve the cough with a safe remedy. Advise mother when to return immediately. Follow-up in 5 days if not improving. CLASSIFICATION TABLE FOR COUGH OR DIFFICULT BREATHING SIGNSCLASSIFY AS IDENTIFY TREATMENT (Urgent pre-referral treatments are in bold print.)

The Sick Young Infant Age 1 Week upto 2 Months: Assess & Classify

Ask the mother or caretaker about the young If this is an INITIAL VISIT for the problem, follow the steps below. (If this is a follow-up visit for the problem, give follow-up care according to PART VII) Check for POSSIBLE BACTERIAL INFECTION and classify the illness. Ask the mother or caretaker about DIARRHOEA: If diarrhoea is present: assess the infant further for signs related to diarrhoea, and classify the illness according to the signs which are present or absent. Check for FEEDING PROBLEM OR LOW WEIGHT and classify the Check the infant’s immunization status and decide if the infant needs any immunization today. Assess any other problems. Then: Identify Treatment, Treat the Infant and Counsel the Mother SUMMARY OF ASSESS AND CLASSIFY

GIVE FOLLOW-UP CARE

Follow-up care for the sick young infant  When to return immediately  Signs of any of the following:  Breastfeeding or drinking poorly  Becomes sicker  Develops a fever  Fast breathing  Difficult breathing  Blood in the stool

Follow-up care for the sick young infant  Follow-up in 2 days – on antibiotics for local bacterial infection or dysentery  Follow-up in 2 days - with a feeding problem or oral thrush  Follow-up in 14 days – with low weight for age

Breast feeding

Breast Feeding  Mothers milk is the ideal food for the infant no other supplementation is required for the baby until 4-6 months.  The first milk which is called colostrum is ideal for the child during the early days, it is rich in proteins it also contains protective factors against infections. Advantages:  Safe, clean, hygienic, cheap and at the right temp.  Fully meets the nutritional requirement (infant)  Promotes bonding between mother and child  Contains macrophages, lymphocytes, secretory IgA.

Weaning It is the gradual process of starting liquid and semi liquid diet in addition to breast milk at the age of 4-6 months. Weaning foods:.Mashed banana.Dahlia.Khichery.Halwa.Fruit juices

Advantages of Breast feeding  Advantages to baby  Advantages to Mother

69 Advantages to baby  Natural source and devoid of feeding difficulties.  Easily available  Proper temperature  Adequate caloric value  Fresh and free of contamination, free from ill effects of lower-socio-economic group and unsanitary conditions  Decreased chances of cow’s milk intolerance.  Decreased atopic disorders due to IgA which prevents absorption of dietary antigen in the gut of baby.  Colostrum is rich in proteins, salts and leukocytes.  If mother is adequately nourished there is a sufficient reserve of all nutrients.

70 Advantages to mother  Family planning and birth spacing  Prevents mastitis  Decreased chances of breast cancer  Involution of uterus  Good way to lose weight  Psychological advantage, sense of accomplishment.

Baby Friendly Hospital Initiative (BFHI)  Launched in  Effort by UNICEF & WHO.  It ensure that all maternities become centers of breastfeeding support.  The initiative is a global effort for improving the role of maternity services to enable mothers to breastfeed babies for the best start in life.

Baby Friendly Hospital Initiative (BFHI)  It aims at improving the care of pregnant women, mothers and newborns at health facilities that provide maternity services for protecting, promoting and supporting breastfeeding.  Breast feeding could prevent about 1 million children deaths a year.

BFHI- Steps for Successful Breast Feeding in Hospitals 1. Maintain a written breastfeeding policy that is routinely communicated to all health care staff. routinely communicated to all health care staff. 2. Train all health care staff in skills necessary to implement this policy. implement this policy. 3. Inform all pregnant women about the benefits and management of breastfeeding. and management of breastfeeding. 4. Help mothers initiate breastfeeding within one hour of birth. hour of birth. 5. Show mothers how to breastfeed and how to maintain lactation, even if they are separated from their infants. their infants.

BFHI- Steps for Successful Breast Feeding in Hospitals 6. Give infants no food or drink other than breast milk, unless medically indicated. breast milk, unless medically indicated. 7. Practice “rooming in”-- allow mothers and infants to remain together 24 hours a day. infants to remain together 24 hours a day. 8. Encourage unrestricted breastfeeding. 9. Give no pacifiers or artificial nipples to breastfeeding infants. breastfeeding infants. 10. Foster the establishment of breastfeeding support groups and refer mothers to them on support groups and refer mothers to them on discharge from the hospital or clinic. discharge from the hospital or clinic.

Sexually Transmitted Diseases

 These are a group of communicable diseases that are transmitted predominantly by sexual contact.  Caused by a wide range of bacterial, viral, protozoal and fungal agents and ectoparasites.

Control of STDs A. Initial Planning B. Intervention Strategies C. Support Component D. Monitoring and evaluation

Control of STDs- Initial Planning  Problem definition  Prevalence, health effects, geographical distribution etc  Establishing priorities  Priority groups maybe categorized on basis of age, sex, place, occupation etc  Setting Objectives  Achievable & measurable.  Considering strategies  Most appropriate for the setting.

Control of STDs A. Initial Planning B. Intervention Strategies C. Support Component D. Monitoring and evaluation

Control of STDs-Interventional Strategies  Case Detection  Screening, Contact Tracing, Cluster Testing.  Case Holding & Treatment  Complete & adequate Treatment  Epidemiological Treatment  Contact Treatment  Personal Prophylaxis  Contraceptives, Proper hygiene of exposed parts, HBV vaccine.  Health Education

Control of STDs-Support Components  STD Clinic  Laboratory Services  Primary Health Care  Information System  Legislation  Social Welfare Measures/Social Therapy

Control of STDs-Monitoring & Evaluation  Monitoring & Evaluation of disease trends will provide a more direct measure of program effectiveness.