Maternal and Child Health

1. Maternal and Child Health

2. 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 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

3. 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

4. Matlab, Bangladesh Percent distribution of population & death (1987)

5. Sweden Percent distribution of population & death (1985)

6. A pregnant woman has one foot in the grave. - Traditional African Saying

7. Measuring maternal and child health

8. Indicators • 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 • Input indicator • Process indicator • Output indicator • Outcome indicator • Impact indicator • Determinant indicator • Count indicator • Proportion indicator • Rate indicator • Ratio indicator • Index

9. Types of indicators • Mortality & morbidity indicators • Coverage indicators • Knowledge, attitude & practice indicators

10. Mortality indicators • Under-five mortality rate • Infant mortality rate • Neonatal mortality rate • Maternal mortality ratio • Maternal mortality rate • Life-time risk of maternal death

11. Morbidity 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

12. Coverage 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

13. The Life-cycle Perinatal period Death Pregnancy Neonatal period Ageing Birth 7days Early Infancy neonatal period 28 days 1 year Adulthood Pre-school years Reproductive 19 years 5 years period 10 years Childhood Adolescence "School-age"

14. Defining Neonatal, Infant and Under-5 mortality Perinatal period Death Pregnancy Neonatal period Ageing Birth 7days Early Infancy neonatal period 28 days 1 year Adulthood Pre-school years Reproductive 19 years 5 years period 10 years Childhood Adolescence "School-age" All these are expressed per 1000 live births in one year, which is defined as the rate.

15. Child mortality rates • Under-5 mortality rate • Infant mortality rate • Neonatal mortality rate • Early neonatal mortality rate • Late neonatal mortality rate • Post-neonatal mortality rate

16. What is the problem? India contributes to: 22% of under-five deaths globally. 30% of global neonatal deaths.

17. Trends of U5MR & IMR from 1990 -2009

18. Child health situation in India

19. Under-five Mortality rate: Comparison with other countries Bangladesh Egypt Nepal Indonesia

20. Child 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

21. Time wise distribution of neonatal deaths

22. Infant 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.

23. Infant Mortality rate in India (2009)

24. State wise Change in IMR and NMR in 2005 & 2009 In many of the larger states, there is decline in IMR but neonatal mortality mostly remains unchanged.

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

26. Determinants of Child Mortality • Distal causes • Intermediate causes • Proximal causes

27. Equity and Childhood Mortality Rates

28. Key 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.

29. Maternal 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

30. Maternal 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.

31. Maternal Deaths: Classification • Direct • Indirect:

32. 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

33. Trend of maternal mortality ratio in India

34. Decline in MMR from 2001-2009 in states of India

35. Common causes of maternal deaths in India

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

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

38. MDG 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

39. MDG 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

40. Key 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

41. Exercise: Conceptual Framework for understanding reasons of high maternal and child deaths in India

42. Fish-bone diagram

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

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

45. 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

46. 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

47. Example:Interventions to improve Child Health

48. Example:Interventions to improve Child Health

49. 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.

50. 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%