Maternal and Child Health Interventions

1. Maternal and Child Health Interventions

2. Continuum of Care Referral Facility First level Facility Home and Community

3. Continua of CareGuiding principles for planning maternal and child health programmes Continuum across Life-stages (which interventions?) Continuum across Health System (at which level?)

4. 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

5. 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 Referral Facility First level Facility Home and Community

6. Example:Interventions to improve Child Health

7. Example:Interventions to improve Child Health

8. Packaging 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.

9. Intervention Packages Skilled 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 Clinical care 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# Postnatal care to support healthy practices Early detection and referral of complications Administering basic community-based intervention packages at full coverage can save ~ 37% of all newborn deaths! Outreach services Folic acid # Counseling and preparation for newborn care and breastfeeding, emergency preparedness Clean home delivery Simple early newborn care 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 Family-community Infancy Neonatal period Pregnancy Pre- pregnancy Birth 23 - 50% NMR effect 6 - 9% 15 - 32%

10. Packaging 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.

11. Example:Intervention package for maternal and child health ANC Care – TT vaccination, Anemia prophylaxis, Detection of complications, Counseling Routine post-natal visits to mother and newborn - Exclusive breastfeeding, Thermal care, Hygienic cord care, Extra care of LBW infants, Prompt care-seeking for illness, Immunization, Management of newborn illness IMNCI – Algorithm-based management of diarrhea, pneumonia, malaria, malnutrition and newborn illnesses, Promotion of ORS and Zinc F-IMNCI – Management of inpatient children with severe illnesses

12. Delivery strategies for the interventions • Community based: • IMNCI, Management of diarrhea and ARI, IYCF, Immunization, IFA and Vitamin A, HBNC, MCTS and MCP Card. • Facility based: • Facility based new born care- FBNC (SNCU, NBSU, NBCC), F-IMNCI, NRC, JSSK.

13. Causes of under-five deaths in India: 2010 Malnutrition 34%

14. Causes of under-five deaths in India: 2010 Asphyxia Institutional delivery Skilled birth attendant Use of partograph for labour surveillance Resuscitation of newborn Preterm / low birth weight Detection & treatment of asymptomatic bacteriuria Syphylis screening & treatment (Pre) eclampsia prevention Corticosteroids for preterm labour Hypothermia management - Kangaroo mother care Skilled delivery practices Malnutrition 34% Infections (sepsis / pneumonia, diarrhoea, tetanus) Antibiotics for premature rupture of membranes Syphilis screening & treatment Clean delivery practices Hypothermia management Kangaroo mother care Breastfeeding Community based pneumonia management Tetanus toxoid immunization

15. Causes of under-five deaths in India: 2010 Pneumonia: Breastfeeding counselling Complementary feeding counselling Hib vaccination Antibiotics Early detection and management Malnutrition: Breastfeeding counselling Complementary feeding counselling Vitamin A supplementation Vitamin A therapy Measles vaccination Growth monitoring and promotion Community-based and Facility-based management of malnutrition Diarrhoea: Breastfeeding counselling Complementary feeding counselling Vitamin A supplementation Oral rehydration therapy Zinc adjuvant therapy Antibiotics for dysentery Malnutrition 34% Measles: Measles vaccination Complementary feeding counselling Vitamin A supplementation Vitamin A therapy Malaria and HIV: Insecticide treated nets Anti-malarial treatment PPTCT Complementary feeding counselling Vitamin A supplementation Niverapine and (replacement) feeding

16. Evidence-based interventions Child Health

17. Summary: Child Health InterventionsPREGNANCY Tetanus toxoid immunization Birth and emergency planning Detection and management of problems complicating pregnancy (e.g. hypertensive disorders, bleeding, mal-presentations, multiple pregnancies, anemia) Information and counseling on self-care, nutrition, breastfeeding, family planning Sleeping under an insecticide-treated bed net Prevention of mother-to-child transmission of HIV+

18. Summary: Child Health InterventionsLabor, birth and 1-2 hours after birth Monitoring progress of labor, maternal and fetal well-being with partograph Social support (companion) during birth Immediate newborn care (resuscitation if required, thermal care, hygienic cord care, early initiation of breastfeeding) Emergency obstetric and newborn care for complications Antibiotics for preterm and/ or premature rupture of membranes* Antenatal corticosteroids for preterm labor Prevention of mother-to-child transmission of HIV+

19. Summary: Child Health InterventionsNewborn period (after the first 1-2 hours after birth up to 1 month) Exclusive breastfeeding Thermal care Hygienic cord care Prompt care-seeking for illness Extra care of low-birth-weight (LBW) infants Immunization Management of newborn illness Prevention of mother-to-child transmission of HIV+

20. Summary: Child Health InterventionsOlder infants and children (1 month up to 5 years) Preventive Interventions Exclusive breastfeeding (up to age 6 months) Safe and appropriate complementary feeding starting at 6 months with continued breastfeeding (up to age 2 years and beyond) Prevention and management of malaria Immunization Vitamin A supplementation Hand washing and proper disposal of faeces Birth spacing of 24 months or more

21. Treatment interventions Oral rehydration therapy for diarrhoea Zinc for diarrhoea Antibiotics for dysentery Antibiotics for pneumonia Antimalarials Management of severe malnutrition Management of HIV-exposed and HIV-infected children Summary: Child Health InterventionsOlder infants and children (1 month up to 5 years)

22. Common causes of maternal deaths in India

23. Hemorrhage Active management of 3rd stage of labour; Detect & Treat anaemia; Skilled attendant at birth Referral transport Blood transfusion Operative procedures Common causes of maternal deaths in India Complications of abortion Access to family planning methods including emergency contraception Use of medical methods Safe abortion facility Ensuring good quality of care Sepsis Clean delivery Post-natal care Early detection and referral Proper management at facility Hypertensive disorders ANC Care Early detection and referral Proper management Obstructed labor Nutrition of girl child Detection of high risk pregnancy and institutional delivery Use of partograph Skilled care at birth

24. Three Delays Model Source: Operational Guidelines on Maternal and Newborn Health, NRHM, MoH & FW

25. Summary: Maternal Health InterventionsPRE-PREGNANCY Family Planning Folic acid fortification and/or supplementation to prevent Neural Tube Defects Prevention of mother-to-child transmission of HIV+

26. Summary: Maternal Health InterventionsPREGNANCY Iron and Folic Acid Supplementation Tetanus toxoid immunization Birth and emergency planning Management of unintended pregnancy Detection and management of problems complicating pregnancy (e.g. hypertensive disorders, bleeding, mal-presentations, multiple pregnancies, anemia) Information and counseling on self-care, nutrition, breastfeeding, family planning Prevention and management of malaria Prevention of mother-to-child transmission of HIV+

27. Summary: Maternal Health InterventionsLabor, birth and 1-2 hours after birth Monitoring progress of labor, maternal and fetal well-being with partograph Social support (companion) during birth Prophylactic uterotonic and Active management of third stage of labor to prevent postpartum hemorrhage Emergency obstetric care for complications Management of Post-partum hemorrhage Induction of labor for prolonged pregnancy Caesarean section for maternal/foetal indication Antibiotics for preterm and/ or premature rupture of membranes

28. Summary: Maternal Health InterventionsPost-partum period (after the first 1-2 hours after birth up to 6 weeks) Advice and provision of family planning Prevent, measure and treat maternal anemia Detection and management of postpartum sepsis Prevention of mother-to-child transmission of HIV+

29. Obstetric Care • Essential Obstetric Care • Emergency Obstetric Care

30. Maternal Mortality ReductionSri Lanka 1940–1985 85% births attended by trained personnel Current Approach to Reduction of Maternal Mortality

31. Maternal Mortality: UK 1840–1960 Improvements in nutrition, sanitation Antibiotics, banked blood, surgical improvements Antenatal care

32. How can maternal deaths be prevented? • Skilled birth attendance • Prompt referral to an appropriately equipped facility if complications arise • 24×7 hours availability of expert services – a team of specialists to perform surgery • Well equipped hospital with operation theatre and blood transfusion services • Keep the woman in the facility for at least 48 hours after delivery • The facilities should be accessible within a radius of 35 km

33. Packages of interventions in different time frames related to pregnancy • Focused antenatal Care (delivered through outpatient or outreach service) • Minimum four ANC check ups • At least 1 ANC by Medical Officer, (preferably 3rd) • Timing of visits – • 1st: within 12 weeks/ preferably as soon as pregnancy is suspected • 2nd: between 14 – 26 weeks • 3rd: between 28 – 34 weeks • 4th: between 36 weeks and term

34. Packages of interventions in different time frames related to pregnancy • Focused antenatal Care (delivered through outpatient or outreach service) • Early registration • Two doses of injection Tetanus Toxoid • All pregnant women – 100 tabs IFA (200 for anemic) • Screening for treatment of disorders • Provision of preventive interventions • Counseling – diet, hygiene, HIV status, birth, emergency preparedness, care and feeding of babies

35. Packages of interventions in different time frames related to pregnancy • Intranatal care (facility based clinical care package) • Promotion of institutional deliveries • Skilled attendance for normal child birth, eg, monitoring labor progress by partograph • Emergency obstetric care (basic & comprehensive) for complicated cases • Effective referral system

36. Packages of interventions in different time frames related to pregnancy • Postnatal care (Institutional in the first 48 hours and thereafter delivered through outpatient or outreach service for a 42 day period) • Prevention and detection of complications • Information and counseling on self-care at home, nutrition, family welfare, breast feeding

37. Skilled Birth Attendant • An accredited health professional (eg, midwife, doctor or nurse) • Educated and trained to proficiency in the skills needed to manage – • Normal (uncomplicated) pregnancies • Childbirth • Immediate postnatal period • Helps in identification, management and referral of complications in women and newborns