Learning Objectives

At the end of the session, students shall be able to:

● Define Reproductive health (RH) and enlist it’s 8 components

Reproductive ● Discuss the paradigm shift from MCH to RH in the light of

ICPD and the Pakistan commitments for ICPD 25.
Health ● Explain Right based approach of RH.
● Explain life cycle approach to RH.
● Out line the components of National RH Package
● Discuss salient features of quality health care services and
Introduction to RH different levels of quality of care in reproductive health.
Lecture- 1 ● Illustrate different levels and practices of RH in Pakistan.
Dr Tahira Amjad
Assoc Prof ● Enlist 17 short listed global indicators of RH by WHO.
0
Community Medicine, FUMC

Back ground Reproductive Health Defined

● Most of the morbidities and mortalities related to “A state of complete physical, mental and social
RH are preventable wellbeing and not merely the absence of disease or
● By improving mother and child health, health of the infirmity,
general population improved in all matters relating to the reproductive system and
● Special health services for mother and children to its functions and process.”
formulated all over the world (ICPD1994)
● A multi factorial issue and the present strategy is to
provide these services as an integrated package
● A holistic approach
through
● Include both men and women
“ Essential health care” ie Primary Health Care.
0
● Covers all age groups 0

Reproductive Health Care The Old standard of RH

● Before 1994, RH care was focused on:
* Family Planning:
“ Constellation -unmet need for contraception
of * Maternal care:
methods, techniques and services that contribute -Antenatal care
- safe child birth
to - Post partum care
RH and wellbeing * Child Health care:
by - Breast Feeding promotion
- Nutrition
preventing and solving reproductive health - Growth Monitoring
problems.” - Immunization
( ICPD) 0
- Sickness care 0
 A paradigm shift from MCH to ICPD Paradigm shift ( 1994)
RH-why?? RH caught global attention since International Conference
● Three elements were of importance for the shift: on Population and Development (ICPD) held at Cairo
1. Strong women’s movement and criticism on in1994
the control of female fertility and their
sexuality Many countries(179) including Pakistan committed to the
2. HIV/AIDS pandemic holistic approach of RH care
3. The concept of reproductive rights
To move beyond a narrow focus on family planning to a
more comprehensive program of integrating population
and health activities to meet the individual
0 Reproductive Health needs 0

Pakistan’s Commitments at ICPD25 Nairobi

ICPD (cont) Summit-Nov 2019
● Special focus on :
● Reviewed the progress made by 179 countries which
● Fulfilling women’s health needs
adopted ICPD Program of Action in Cairo in 1994.
● Safe guarding their reproductive rights
● More focus on human lives and their human rights than
● Involving men as equal partners in meeting the goal
numbers
of responsible parenthood.
● Emphasizing on improving the lives of individuals and
● Shift to Rights Based Approach increasing respect for their human rights.
● Shift away “From macro concerns at population ● Again agreed that “Reproductive Health is a basic
level” for reduction in its growth “To micro concern at human right”
individual level” for improvement in well being. ● Empowerment of women was urged being a key to
improving the quality of life for everyone
0 0

Contd…. Contd….
● Pakistan made following commitments at Nairobi Summit
– ICPD25- 2019:
● The transformative vision of RH – i. Lower the present Average Population Growth Rate of 2.4 % to
commitment to the three zeros by 2030: 1.5 % by 2025, and to 1.1 % by 2030
1. No unmet need for contraception ii. Increase the present Contraceptive Prevalence Rate of 34 % to 50
2. No preventable maternal deaths % by 2025 and 60 % by 2030
3. No violence or harmful practices against iii. Reduce the present Total Fertility Rate of 3.6 births per
women and girls woman to 2.8 births by 2025 and 2.2 birth per woman by 2030
iv. Reduce Maternal Mortality Rate from 170 to less than 70 per
100,000 live births by 2030
v. No preventable maternal deaths
vi. Life Skills Based Education for Adolescents & Youth
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 Contd…. Rights Based Approach
THE RIGHT( Recognized in national, international
● vii. raising the per capita expenditure on FP to $2.50 by
allocation of additional resources human rights documents)
viii. Offer greater choices in Contraceptive Mix Of couples/individuals to decide freely with
ix. Cross Party support for Population Issues
x. Strengthen Procurement and Logistic Systems for timely, responsibility:
regular and uninterrupted availability of contraceptives at all ● the number of children
Public SDPs ● spacing of children
xi. Creating a population fund worth Rs. 10 billion/ per
annum which will be replenished every year. ● to have information and means to do so.
● Federal Task Force ( FTF) under the chair of the President of To attain the highest standard of sexual and
Pakistan has been constituted. reproductive health.
● FTF members include Provincial Chief Ministers, Chief To make decisions free of discrimination, coercion or
Minister of GB ; Prime Minister of AJK, Provincial Chief violence.
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Secretaries and key Federal Ministers

Enabling conditions for RH 8 x Component of

identified by ICPD Reproductive Health
1. Comprehensive FP for males and females:
-Empowering women and promoting gender equality counseling, information-education-
and equity communication(IEC) & services
-Eliminating discrimination against the GIRL CHILD: 2. Safe motherhood: Education and services for
● Discrimination because of sex prenatal care, safe delivery and post natal care
● Son preference including breast feeding, infant and women's
-Ensuring male responsibility and participation health and male involvement in RH
● Male involvement
3. Prevention of abortions and management of
● Attitude and behavioral change
complications of unsafe abortion
-Achieving universal education
4. Fertility regulation: prevention and treatment of
0 infertility 0

Component of Reproductive
Health contd….
1. Reproductive tract infections treatment:
sexually transmitted diseases (STD) including
HIV/AIDS
2. Malignancies of reproductive tract (both male
and female eg. Cancers of Breast, cervix and
prostate
3. Newborn care, IEC on sexual problems
associated with children/adolescence and
responsible parenthood REPRODUCTIVE HEALTH
4. Discouragement of harmful traditional
practices such as female genital mutilation 0 0
concepts & vision
 Situation in Pakistan
Total population: 229.22 million (Urban : 84.6936.38, Rural: 1 44.53
64%) Women’s Health Life Cycle
Transgender: 10,418
5th most populous country of the world –2.77% of the world ● Women’s health life cycle should be considered
population ie 7.6 billions*
Life Expectancy at birth : 66.1 yrs
throughout in three phases:
Annual Growth Rate: 1.8 % 1. Conception to adolescence
Women : 48% of population (101.3 millions)
Women of reproductive age group (15 – 49 years): 22% 2. Child bearing (Reproductive years)
Literacy Rate (10 yrs & above): 62.3%(male:72.5% ,Females: 51.8%)
3. Post child bearing (Post reproductive,
CBR: 25.4/ 1000 persons
CDR: 6.6/ 1000 persons Menopause and beyond)
CPR:34.2% Unmet Need FP:17.3% TFR:3.6
IMR:58.50 / 1000 LB
u/5 mortality rate: 74 / 1000 LB
0 0
MMR: 154 /100000 LB in 2020 Sources: Pakistan Economic Survey 2022-2023,
World population review*

Life Cycle Approach to Life Cycle Approach to

Reproductive Health Reproductive Health..
● RH is not merely confined to the health of the ● RH concerns increases during adolescence and
individual at his or her reproductive age. particularly for women during the reproductive
● The life cycle approach recognized that there are years.
reproductive needs at each stage of life, from ● Earlier reproductive events will have a bearing
infancy to old age. on the general health of an individual when one
● The health of the infant is largely dependent on gets old.
the mother’s health status and access to health
● RH needs are therefore from
care:
● During pregnancy “cradle to grave” or “womb to tomb”
● Childbirth
● Immediate postpartum period.
0 0

Reproductive Health: Life Cycle Reproductive Health: Life Cycle Approach…

Approach… Stages in Health Issues Promotion, prevention, Treatment,
life cycle Rehabilitation
Stages in life Health Issues Promotion, prevention,
cycle Treatment, Rehabilitation Infancy • Abnormal •Care of mother & newborn (mother
(Birth – 1 growth and baby care package)
Perinatal • Fetal death •Prenatal care. year) development •Breast feeding
•Malnutrition •Immunization(EPI)
(28 wks of •Intra-uterine growth •Nutrition.
Gestation to 7 retardation (low Birth •Communica •Growth monitoring (mile stones)
days after weight & prematurity) ble disease. •Nutrition, education & counseling.
birth) •Immunizable •Accidents. •Oral rehydration therapy (ORT)
•Immunization with Tetanus
diseases. •Child abuse. •Chronic diarrheal diseases. (CDD)
Toxoid.
•Control of upper respiratory tract
infection.
•Education and counseling on prevention
0
against accidents and abuse. 0
Reproductive Health: Life Cycle Approach….. Reproductive Health: Life Cycle Approach…
Stages in life Health Issues Promotion, prevention, Treatment, Stages in Health Issues Promotion, prevention,
cycle Rehabilitation life cycle Treatment, Rehabilitation

Child hood •Infectious •Immunization (EPI) Adolescence •Unhealthy lifestyle •Education on healthy
(1 – 10 diseases. •Oral rehydration therapy (ORT) (11 – 19 yrs) •Early marriage lifestyles.
years) •Malnutrition. •Chronic diarrheal diseases. (CDD) •Unwanted pregnancy •Nutrition and fertility
•Accidents and •Acute respiratory tract infection •Complication of teen awareness.
injury (ARI) control. age pregnancy •FP information and service.
•Child abuse. •Growth monitoring. •Morbidity and mortality •Counseling on sexuality.
•Nutrition supplementation. due to early pregnancy •Treatment of RTIs and
•Parent’s counseling on normal •RTIs / STDs referral.
growth & development of a child.
•Prevention against accidents and
0 0
abuse.

Reproductive Health: Life Cycle Approach… Reproductive Health: Life Cycle Approach…
Stages in Health Issues Promotion, prevention,
Stages in life Health Issues Promotion, prevention, Treatment,
life cycle Treatment, Rehabilitation
cycle Rehabilitation
Adulthood / •Pregnancy and related problems •Maternal care
Adulthood / •Unhealthy life style. •Education on healthy life style.
reproductive •Maternal mortality •Nutrition
reproductive •Nutritional problems •Balanced diet. Calcium & Iron years & morbidity.
years(15- •Menstrual •Early detection, counseling and
49yrs) 20 – 49 •Complications of •FP information and service.
abnormalities. treatment. years
•Genital tract cancers. •Screening, diagnosis & treatment.
abortions.
•Fertility regulation •Infertility
diagnosis / referral
•Breast lumps. •Screening and counseling.
•Infertility •Counseling on human
•Genital tract benign •Early diagnosis and treatment.
tumors. •Sexual abuse / harassment. sexuality.
•Violence against women &
•Excessive vaginal •Counseling, reassurance &
discharge. •Harmful traditional Violence against Men
treatment of pathological discharge
practices •RTIs, HIV/AIDS diagnosis
•Premarital general •Counseling and screening.
health. . •RTIs /STDs /
& management / referral
•Early detection and treatment.
•Anemia. HIV/AIDS
0 Contd…
0

Reproductive Health: Life Cycle Approach… Reproductive Health: Life Cycle Approach…
Stages in life Health Issues Promotion, prevention, Stages in Health Issues Promotion, prevention,
cycle Treatment, Rehabilitation life cycle Treatment, Rehabilitation
Post •Sexual dysfunction. •Counseling / assurance
Reproductive •Menopausal
Male •Male Sexual dysfunction. •Counseling / assurance
Years problems. •Occupation related RH •Nutrition
•Nutrition
Female •Osteoporosis. illness. •Supportive care
•Supportive care
•Inability to cope. •Earlydiagnosis and
•Cancers of •Early diagnosis and treatment
reproductive tracts. •Depression treatment of cancers
of cancers
•Inability to cope.
•Depression

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 NATIONAL REPRODUCTIVE
HEALTH (RH) PACKAGE
Developed after Cairo ICPD conference (1994)
1- Comprehensive family planning services for men
and women
2- Safe motherhood including antenatal, intranatal
and post natal care and management of pre and post
abortion cases
3- Infant health care
4- Adolescent reproductive health care
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NATIONAL REPRODUCTIVE FACTORS INFLUENCING

HEALTH (RH) PACKAGE contd…. PROVISION OF RH SERVICES
5- Management of other health related problems
• Resource constraints
like menopause
• Number of service delivery points
6- Management of infertility
• Geographical, physical and social accessibility
7- Diagnosis and prevention of cervical and breast
cancer • Proper advertisement of services
8- Male reproductive health care • Quality of care
9- Management and control of RTI, STI, including
HIV/AIDS

0 0

QUALITY OF CARE QUALITY OF CARE

a- Provider level: b- Facility level:
• Technical competence ● Opening and closing timings
• Protocol ● General cleanliness
• Clinical techniques ● Maintenance of privacy
• Meticulous asepsis ● Proper waiting area
• Interpersonal relations, between provider and client ● Trained staff
• Mechanism to encourage continuity ● Availability of range of services (medicine/ equipments)
• Appropriate constellation of services ● Client/ provider interaction

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 CLIENT/ PROVIDER
INTERACTION QUALITY HEALTH SERVICES
SAHR: ● Must be based on:
● SALUTATION: greet/ ice breaking, assure client, * Needs especially of women
show patience
● ASSESS: decision making about other RH problems
*Respect various religious, ethical
of client values and cultural background
● HELP: encourage client to speak, inform about * Conform to universally recognized
options, cost, time etc international human rights standards
● REASSURE: request client to repeat her / his
solution, reassure about solution
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Levels and Practices of RH Partners in RH

Tertiary Level
(Teaching, Specialist Hosp) ● Public Sector
Gynecologists, pediatricians
all services
Secondary Level
● Population Welfare Deptt
(Tehsil and Dirtrict Hosp) ● Health Deptt
Doctors, antenatal, intra and postnatal, family planning, immunization,
normal/complicated delivery ● Higher Education Deptt
Primary Level ● Zakat, Ushar, Social Welfare and Women
(BHUs and RHCs)
LHVs, TBAs, Doctors, antenatal, intranatal Development Deptt
Postnatal, family planning, immunization ● Local Govt, Rural Development Deptt
Normal delivery
● Industries, commerce, labor, mineral
development, technical education and manpower
Community
TBA’s LHVs, Midwives 0 0
Antenatal, Natal, Postnatal, Family

RH SERVICES OUTLETS IN
Partners in RH contd…. PAKISTAN
● Private Sector Public sector programs:
● Private hospitals a-Community Based Services
● Hakeems, Homeopaths National Program for Family Planning and
● Target Group Institutions PHC
● Railways LHW Program
● Defense Services Registered trained midwives
● WAPDA Registered Lady health visitors
● NGOs b- Family Based Services:
● Green Star MCH Centers
● Key Social Marketing BHUs, RHCs
● APWA etc THQs
0
DHQs 0
Specialized institutions/ Teaching hospitals
 RH SERVICES OUTLETS IN WHO 17 Indicators Short-listed for
PAKISTAN contd.. Global Monitoring of RH
Purpose:
PRIVATE SECTOR : ●To emphasis on the global commitments in the light of
➢ Qualified doctors (GP & Specialists) ICPD 1994
➢ Non-qualified practitioners (quacks) ●To standardize the reporting to WHO
➢ Hakeems/ Tabib, practice of Unani medicine ●To provide an overview of the RH situation at global and
➢ Homeopaths national levels
➢ NGOs as Rozan and Sahil in Punjab, Aahung in Sindh ●For international comparison
●Global monitoring
● Follow-up to the international conferences
●Data collected for reporting the indicators should be
useful at the program management level.
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WHO 17 Indicators Short-listed for 17 Indicators (cont)

1. Availability of Basic Essential Obstetric Care : # of facilities
Global Monitoring of RH with functioning basic essential obstetric care per 500 000
Total Fertility Rate (TFR) :Total number of children a woman population
would have by the end of her reproductive period if she experienced 2. Availability of Comprehensive Essential Obstetric Care :No of
the currently prevailing age-specific fertility rates throughout her facilities with functioning comprehensive essential obstetric care
childbearing life per 500,000 population
Contraceptive Prevalence Rate (CPR): %of women of reproductive 3. Perinatal Mortality Rate (PMR) :Number of perinatal deaths per
age (15-49) who are using (or whose partner is using) a contraceptive 1,000 total births
method at a particular point in time. 4. Low Birth Weight Prevalence :Percent of live births that weigh
Maternal Mortality Ratio (MMR) :Annual number of maternal less than 2,500g
deaths per 100,000 live births 5. Positive Syphilis Serology Prevalence in Pregnant Women:
Antenatal Care Coverage :% of women attended by skilled health Percent of pregnant women (15-24) attending antenatal clinics,
personnel at least once during pregnancy for reasons relating to whose blood has been screened for syphilis, with positive serology
pregnancy for syphilis
Percent of Births Attended by Skilled Health Personnel : 0 0

(excluding trained or untrained traditional birth attendants)

17 Indicators (cont) 17 Indicators (cont)

1. Prevalence of Infertility in Women :Percent of women of
reproductive age (15-49) at risk of pregnancy (not pregnant,
1. Prevalence of Anemia in Women:Percent of women of
sexually active, non-contracepting, and non-lactating) who report
reproductive age (15-49) screened for hemoglobin levels with
trying for a pregnancy for two years or more
levels <11g/dl for pregnant women, and <12g/dl for non-
pregnant women are considered anaemic. 2. Reported Incidence of Urethritis in Men :Percent of men
2. Percent of Obstetric and Gynecological Admissions Owing aged (15-49) interviewed in a community survey reporting
episodes of urethritis in the last 12 months
to Abortion :Percent of all cases admitted to service delivery
points providing in-patient obstetric and gynecological services, 3. HIV Prevalence among Pregnant Women: Percent of
which are due to abortion (spontaneous and induced, but pregnant women (15-24) attending antenatal clinics, whose
excluding planned termination of pregnancy) blood has been screened for HIV and who are sero-positive for
HIV
3. Reported Prevalence of Women with FGC :Percent of
women interviewed in a community survey reporting having 4. Knowledge of HIV-related Prevention Practices :Percent of
undergone FGC all respondents who correctly identify all three major ways of
0 0
preventing the sexual transmission of HIV and who reject three
major misconceptions about HIV transmission or prevention
References
● Park’ s Text Book of Preventive and Social Medicine , 23rd

●
Edition
Public Health and Community Medicine , Ilyas Ansari, 8th THANK YOU
Edition
● nhsrc.gov.pk
● www.measureevaluation.org/prh/rh_indicators/family-
planning/global/whos-short-list-of-reproductive-health-
indicators-for-global-monitoring

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 MATERNAL MORTALITY
Lecture: 2
By
Assoc Prof Dr. Tahira Amjad
Community Medicine, FUMC
0

Learning Objectives Maternal Mortality: A Global Tragedy

By the end of lecture, students shall be able to:
Discuss WHO approach of “Maternal near miss” for maternal health. ( WHO 2020 report)
Define Maternal mortality, late maternal deaths and pregnancy related ● About 287 000 women died during & following
deaths.
pregnancy and childbirth
Outline the statistical measures of maternal mortality.
● Every day in 2020, almost 800 women died
Calculate Maternal Mortality Ratio and Maternal Mortality Rate.
from preventable causes related to pregnancy and
Outline different methods / approaches for collecting data of
childbirth.
maternal mortality.
Enlist causes of Maternal mortality.
● A maternal death occurred almost every two
minutes .
Discuss WHO model of delays in Maternal Mortality.
Enlist current strategies to reduce Maternal Mortality ● Between 2000 and 2020, the maternal mortality
Outline preventive & social measures to reduce maternal mortality.
ratio dropped by about 34% worldwide.
Discuss Traditional and Skilled birth attendants ● Almost 95% of all maternal deaths occurred in
0
low and lower middle-income countries
0

Contd…
● SDG: 3 (between 2016 and 2030) to reduce the global
Maternal Mortality Ratio to less than 70 per 100 000
live births, with no country having a maternal
mortality rate of more than twice the global average.
● Global MMR in 2020 was 223 per 100 000 live
births; achieving global MMR target, by the year
2030 will require an 11.6% annual reduction rate.
● Care by skilled health professionals before, during and
after childbirth can save the lives of women and
newborns
● Source: WHO FACT SHEETS www.who.int/fact-sheets/detail/maternal-
mortality 0 0
 Maternal Death Watch
● 380 women become pregnant
Every Minute... ● 190 women face unplanned
or unwanted pregnancy
● 110 women experience a
pregnancy related
complication
● 40 women have an unsafe
abortion
● 1 woman dies from a
pregnancy-related
complication
● I Maternal death=30
Maternal Morbidities
0 0
Source: Global heath observatory 2016

Country Comparison of Maternal Why is the maternal mortality rate going up

Mortality Ratio (UN SDG Data base 2020) in the United States ?
United States, one of the wealthiest nations in the world, is
Country Maternal Mortality % Births attended by now one of only eight countries -- including Afghanistan ,
Ratio/ 100000 Live SBAs Congo and South Sudan – where MMR is going up.
Births
SIERRA LEONE 442.8 86.9
From 1987 to 2013, the number rose from 7.2 to 28 deaths
AFGHANISTAN 620.4 61.8
per 100,000 births.
PAKISTAN 154.2 68 Due to number of issues:
BANGLADESH 123 59 Obesity-related complications such as hypertension and
INDIA 102 89.4 diabetes
SRI LANKA 28.8 100 Dramatic increase in the number of cesarean section
CHINA 23 100 births
UNITED STATES 21.1 99.1 Lack of access to affordable, quality health care
0 More women giving birth at older ages. 0

GREECE 7.7 7.7 99.9

WHO Maternal Near Miss approach for Maternal Near Miss Surveillance
maternal health(2011) Women can only be recognized as a maternal near miss case
●Defined as “A woman who nearly died but survived a
complication that occurred during pregnancy, childbirth or retrospectively….she needs to survive the complication
within 42 days of termination of pregnancy”. “near- miss” to become a maternal near miss case.
or Severe Acute Maternal Morbidity cases (SAMM). Clinically useful as it can prospectively identify the
●A tool to assess retrospectively:
women presenting with life-threatening conditions
– Pregnancy complications Severe maternal complications are defined as “potentially
– Maternal health services life-threatening conditions”.
– Pregnancy outcome Five potentially life-threatening conditions are used : severe
– quality of maternal health care
postpartum haemorrhage, severe pre-eclampsia, eclampsia,
Maternal morbidity was suggested to be a more useful indicator
of obstetric care sepsis/severe systemic infection, and ruptured uterus
●Identifying and addressing health systems failures in Prospective surveillance on severe complications among
obstetric care and then addressing them. Source: apps.who.int/iris/bitstream
0
which maternal near miss cases would emerge. 0
 WHO Definition of Maternal deaths Statistical Measures Of
Maternal Death: “ The death of a woman while
1.
pregnant or within 42 days of termination of Maternal Mortality
pregnancy irrespective of the duration or site of
pregnancy, from any cause related to or aggravated • Maternal Mortality Ratio (MMR)
by the pregnancy or its management but not from • Maternal Mortality Rate
accidental or incidental cause ’’
2. LATE MATERNAL DEATH: • Adult Lifetime Risk of Maternal
“It is the death of a woman from direct or indirect Death
obstetric causes , more than 42 days but less than • The proportion of maternal deaths of
one year after termination of pregnancy.” women of reproductive age (PM)
3. PREGNANCY-RELATED DEATH:
It is the death of a woman while pregnant or within
42 days of termination of pregnancy irrespective of
the cause of death.
0 0

Statistical Measures Of Maternal

Maternal mortality ratio
Mortality…..
1.MATERNAL MORTALITY RATIO (MMR) :
“Number of maternal deaths during a given time ● Example: in 2020, a town which had 150,000
period per 100,000 live births during the same people, there were 10000 live births and 7
time period”
women died due to complications of child birth.
Total no. of female deaths due to
complications of pregnancy, childbirth ● Calculate Maternal Mortality Ratio ???
or within 42 days of delivery from
“puerperal causes” in an area during
a given year
● Maternal mortality ratio =7/10000 x100,000
Total no. of live births in the same area X 100,000 OR =70 / 100,000 LB
and year 1000

Why 100,000????? 0 More calculations……. 0

Contd… Maternal mortality rate….

2. Maternal Mortality Rate: The number of
maternal deaths* in a given period per 100,000 Example: In a town of 15,000 people,1500
women of reproductive age group during the are women. Among them 1000 women are
same time period. of reproductive age. There were 100 live
births in 2017. 17 women died due to
Number of maternal deaths in a given period
complications of pregnancy during the
x 100,000
same year.
Total No of women of reproductive age
● Calculate maternal mortality rate:??
( 15-49 yrs)during the same period
● 17/1000x 100,000= 170/ 100,000
* Note: Refer to the definition of “ Maternal Deaths”
WCBA or WRA
0 0
Pseudo rate…. Why????
3. Adult Lifetime Risk of Maternal Death: the probabilitycontd…
of contd…
becoming pregnant and the probability of dying from a maternal 4. The proportion of maternal deaths of
cause during a woman’s reproductive lifespan.
woman of reproductive age (PM):
-Probability that a 15-year-old woman will eventually die from a
maternal cause. The number of maternal deaths in a given
-In high income countries, this is 1 in 5300, versus 1 in 49 in low- time period divided by the total deaths,
income countries (https://www.who.int/news-room/fact-sheets/detail/maternal-mortality) among women aged 15-49 yrs
Eg. In 2018, in a population of 500000 of
Lahore District, there were 890 maternal
deaths. Total deaths of WCBA were
10000.
PM= 990/10000X100=8.9%
0 0

Approaches for collecting data of Approaches for collecting data of

maternal mortality maternal mortality…
Civil Registration systems: Routine registration of
births and deaths 4. Reproductive Age Mortality Studies
House hold surveys: Where civil registration data ( RAMOS):Identifying and investigating the causes of all
not available deaths of WRA in a defined area/ population by using
multiple sources of data.
Sisterhood methods: Interviewing a representative
sample of respondents about the survival of their 5. Verbal Autopsy: Interviews with family and the
adult sisters( No of ever married sisters, how many community to find out the cause of death where medical
alive and dead and how many died during pregnancy, certification of cause of death is not available. Birth and
delivery, or within six weeks of pregnancy) death records are collected periodically among small
populations under demographic surveillance system by the
0 research institutes. 0

Approaches for collecting data Classification of maternal deaths as

of maternal mortality… per International Classification of
Diseases (ICD)
6. Census: National census with addition of Direct obstetric deaths: “These are deaths resulting
limited questions can give estimates of maternal from obstetric complications of pregnant state
mortality; this eliminates sampling errors and ( pregnancy, labour and puerperium), from
give detailed results including: interventions, omissions, incorrect treatment or from a
-Time trends chain of events resulting from any of the above”
-Geographic distribution 2. Indirect obstetric deaths: “These are deaths resulting
- Social strata from previous existing disease or disease that developed
during pregnancy and which was not due to direct
obstetric causes, but which was aggravated by
0 physiological effects of pregnancy.” 0
 Causes of Maternal Medical Causes Of Maternal
Mortality Mortality
● CAUSES OF DIRECT ● CAUSES OF INDIRECT
● Medical OBSTETRIC DEATHS OBSTETRIC DEATHS
• Toxemia of pregnancy • Anemia
● Social • Hemorrhages • Associated diseases,
• Infections e.g., cardiac, renal,
• Obstructed labor hepatic, metabolic and
• Unsafe abortion infections
• Others: Ectopic • Malignancy
pregnancy, embolism, • Accidents
anaesthesia related etc • Malaria etc
0 0

Big 5:Direct obstetrical Causes of Social Causes of Maternal Mortality…

Global maternal mortality ● Age at child birth:>30 yrs
● Parity : ≥ 5
The “Big 5” ● Too close pregnancies
Major complications that account for nearly 75% of ● Family size
all maternal deaths ● Malnutrition
● Severe Hemorrhage (24% ● Poverty
● Infection( 15%) ● Illiteracy
● Unsafe abortions( 13%) ● Shortage of health manpower
● Eclampsia (12%) ● Delivery by untrained dais
● Obstructed labor(8%) ● Cultural and religious beliefs
( WHO-2020 fact sheet) 0 0

WHO Three Delays Model of Maternal mortality.

Social Causes Of Maternal “3 Ds” ( 4 Ds)
Delay in decision to seek care
Mortality… Lack of understanding of complications
Acceptance of maternal death
● Poor Environmental conditions Low status of women
● Poor communication and transport facilities Socio-cultural barriers to seeking care
● Women abuse Delay in reaching the health facility
Transportation of the client to health facility
● Ignorance & prejudices
May be because of terrain(Mountains, rivers etc) lack of
● Lack of Maternity services transport, poor organization to manage the transfer of client
Delay in receiving care
3..Reception of health facility , 4..instituting treatment, Supplies,
personnel, Finances
Poorly trained personnel with punitive attitude
0 0
 INTERVENTIONS HISTORICAL REVIEW OF
to reduce maternal mortality INTERVENTIONS
HISTORICAL REVIEW The flawed assumption:
a: Traditional birth attendants Most life-threatening obstetric complications can be
b: Antenatal care predicted or prevented
c: Risk screening
CURRENT APPROACH
● Skilled birth attendant at delivery
● EmONC services
● Post partum care 0 0

Interventions to reduce MMR:

Good Maternal Health Services
Traditional Birth Attendants…
Advantages Disadvantages
● Good quality maternal health services are not ● Community-based ● Technical skills
universally available and accessible: ● Sought out by limited
– Mortality risks elevated within first 2 days of women ● May keep women
child birth ● Low technology away from life-
– > 35% receive no antenatal care saving interventions
● Teaches clean
– Aprox 50% of deliveries unattended by due to false
delivery
skilled provider reassurance
– 70% receive no postpartum care during 1st 6 Conclusion:
weeks following delivery TBAs are useful in the maternal health network but their skills are
0
limited. Therefore there will not be a substantial reduction in maternal
0
mortality by TBAs who are delivering clinical services alone

SKILLED BIRTH ATTENDANT

“Professionally trained health workers with the skills
necessary to manage a normal delivery and diagnose or SKILLED BIRTH ATTENDANT…
refer obstetric complications.”
A doctor, trained midwife or nurse. ● Their classification as skilled attendants refers to
Must be able to recognize complications early. their training more than to the site of practice.
Perform any essential interventions, start treatment, and ● Trained and untrained traditional birth attendants
supervise the referral of mother and baby to the next level
of care if necessary. May practice in a health-care facility (TBAs) are not included in this category.
or at home.
99% of all births attended by SBAs in most high income and upper (WHO/UNFPA/UNICEF/WORLD BANK. JOINT
middle income countries, while 68% in low income and 78% in STATEMENT FOR REDUCING MATERNAL MORTALITY,
LMIC ( WHO fact sheet 2020)
1999. )
54% of deliveries attended by SBAs yr 2020 in Pakistan
( PES-2022-2023)
0 0
They should reflect patience and empathy
 PREVENTIVE and SOCIAL contd…
MEASURES to reduce MMR ● Prevention of medical conditions eg.
Hypertension, diabetes, tuberculosis
Early registration of Pregnancy
● Anti-malaria & tetanus prophylaxis
At least 4 antenatal check-ups/ 8 contacts
Dietary supplementation, including correction of ● Skilled birth attendants and Trained Birth
anemia attendants.
Prevention of infection & hemorrhage during ● Institutional deliveries of high risk pregnancies.
puerperium ● Promotion of family planning
Prevention of complications e.g.. Eclampsia, ● Identifying every cause of maternal death
malpresentations ,ruptured uterus
● Safe abortion practices
Clean delivery practice
Avoidance of 3 Ds
0 0

Projects and Programs: Pakistan Exercise-1

● USAID-PAIMAN- Maternal and Neonatal Health ● In Kohat District of 300000 population,
(The Pakistan Initiative for Mothers & Newborns) there were 3000 live births in the year
● USAID-FALAH– Family Planning 2017. During the same year , 100 women
(Family Advancement for Life and Health)
died of accidents, Diabetes Mellitus and
● USAID- TACMIL
heart diseases. Whereas 6 women died
(Technical Assistance for Capacity building in Midwifery,
Information and Logistics)
because of severe Haemorrhage during
● MoH-MNCH-- (Maternal, neonatal and child health delivery. 50 died after 3 months of
● UN- UNICEF,UNFPA, FAMILY PLANNING delivery. Calculate Maternal Mortality
0
Ratio of this District. 0

Exercise-2 References
● In the Baluchistan province, there were
20,000 live births in year 2017. There ● Park’ s Text Book of Preventive and Social Medicine ,
23rd Edition
were 100,000 women and out of these,
● Public Health and Communty Medicine , Ilyas Ansari,
10000 women were of reproductive age. 8th Edition
During the same year,50 maternal death
were reported.

Calculate Maternal Mortality Rate of

Baluchistan province.
0 0
 Learning objectives
▪ Define MCH services and enlist it’s objectives.
▪ Outline the importance of taking mother and child as one unit.
▪ Enlist different services provided through MCH services.
▪ Explain the triad of MCH problems.
▪ Outline the recent trends in MCH care.
MATERNAL AND CHILD HEALTH ▪ Discuss Maternal health services under MCH care*
▪ Discuss ANC aim, objectives and health care services for achieving
(MCH) objectives of ANC.
Lecture 1&2 ▪ Discuss WHO recommended visits/contacts as per ANC Models.
By ▪ Discuss High Risk Approach during ANC
Dr Tahira Amjad ▪ Enlist different indicators to assess the functioning of MCH services
Assoc Prof ▪ Calculate the expected work load of MCH Centre covering a
population of 5000.
Community Medicine, FUMC
▪ Discuss Community mid wife and the salient features of Community2
mid wife model of MNCH programme.

Maternal & Child Health WHO definition of Maternal

Services and child health ( MCH)
“The services which are provided to mothers and children
for
promoting their health, prolonging their life and ensuring “Promotive, preventive, curative and rehabilitative
their happiness, preventing diseases, health care
for for
early diagnosis and prompt treatment,
mothers and children”
for
disability limitation and for physical, social and emotional
rehabilitation”
(Recall levels of prevention……….) 3 4

Planning Healthcare and

Supervision of Mother and Child Mother and Child- one unit…..
▪ Mother and Child – One Unit, why????
1. The fetus is the part of the mother during the antenatal 4. Even after birth a child is dependent on his
period (280 days), mother provides all nutrition, mother for feeding at least completely for 6-9
building material and oxygen to baby via blood months, mental and social development - the
2. Health status of the fetus is directly proportional to mother-child bond , Maternal Deprivation
the maternal health ; a healthy mother= healthy baby , Syndrome
less chance of premature birth, still birth or abortion 5. Postpartum care is inseparable from neonatal
3. Disease of mother during pregnancy like syphilis, care and family planning advice
German measles, AIDS/HIV, Tetanus and drug intake 6. The mother is the first teacher of the child
have direct effect on the baby
COVID?? 5 6
 Maternal & Child Health Services… Aim of MCH Services
▪ Includes:
▪ Special services for the children with special needs
▪ Making available the best possible care for
▪ Family planning services
women during pregnancy, labour and
▪ Marriage counseling
▪ Pre-conception guidance, Ante-natal / Pre-natal care
puerperium.
▪ Intranatal Care,Post-natal care ▪ Best possible care to children while they
▪ Parent craft training are growing and when they are vulnerable.
▪ Home economics
▪ Nutritional guidance
▪ Home sanitation
▪ Immunization services 7 8
▪ TBA training

Objectives of MCH Services

Objectives of MCH Services…
Objectives Of Mother Health Care ▪ Objectives Of Child Health Care:
▪ Reduction of maternal mortality and morbidities ▪ Health promotion and growth monitoring
▪ Nutritional education of parents
▪ Provision on intelligent and desirable parenthood
▪ Immunization
▪ Prevention and treatment of sterility and infertility ▪ Periodic health examinations
▪ Health education of the parents ▪ Psychosocial growth promotion
▪ Reduction in childhood morbidity and mortality
▪ Training of TBA’s, CMWs, Midwives, LHVs,
▪ Rehabilitation of the handicapped
Medical students, Post graduate students and GPs ▪ Training of the health workers, parents and family
▪ Research 9 ▪ Research 10

Importance of MCH Importance of MCH….

▪ Investment in the future of the nation ▪ Reduction in the extra expense on health
▪ Health promotion of the major bulk of the ▪ Introduction to rational medicine
population ▪ Improvement of nutritional status
▪ Women & children are the most vulnerable ▪ Improvement in per capita GNP
▪ Maternal & child morality is almost preventable ▪ Overcoming the in-articulation of the children
▪ Reduction in the economic loss by decreasing ▪ Proper assessment of nutritional problems
childhood morbidity ▪ MCH services is the primary care
▪ MCH services bridges the gaps between the
11
community and referral centers 12
 Importance of MCH… Triad of MCH problems

▪ Training of the health personnel 1. Malnutrition

▪ Most cost-effective comprehensive health 2. Infection
services 3. Uncontrolled Reproduction

▪ Existing gender disparities are addressed

▪ Research into the health problems of the
child and mother

13 14

Triad of MCH problems… Triad of MCH problems…

1. Malnutrition: ▪ Period of weaning: Severe malnutrition on weaning
▪ Pregnant women, nursing mothers and children are increases the susceptibility to severe infections as
more vulnerable compared to those who are well nourished
▪ Maternal malnutrition- maternal depletion leading to ▪ Nutrition protection and promotion is an essential
low birth weight, anemia, toxemia of pregnancy, post activity of MCH care.
partum haemorrhage – all leading to mortality and ▪ Measures to improve the Nutritional status of mothers
morbidity and children:
▪ Critical periods of malnutrition: ▪ Direct interventions:
▪ Intra uterine period: Infants born with adequate ▪ Supplementary feeding programmes
birth weight have a low mortality even under poor
▪ Distribution of iron and folic acid tablets
environmental conditions
▪ Fortification and enrichment of food
15
▪ Nutrition education contd… 16

Triad of MCH problems… Triad of MCH problems…

▪ Indirect interventions: 2. Infection:
▪ Immunization to control communicable ▪ Maternal infections can cause a variety of adverse
diseases effects on the fetal growth and development.
▪ Improvement of environmental sanitation ▪ Prevention and treatment of infections in mother and
▪ Safe and clean drinking water child -a major role of MCH Services
▪ Family planning ▪ Immunization of mother and the child
▪ Food Hygiene ▪ Educating mothers in ORS in Diarrhoea and Febrile
illnesses
▪ Education
▪ Personal hygiene and sanitation
▪ Primary health care
▪ Nutritional surveillance 17 18
Triad of MCH problems… Recent trends in MCH CARE
▪ MCH care has been unable to achieve its objective
in developing countries mainly because of their
3. Uncontrolled Reproduction: cost.
▪ Unregulated fertility leading to increase in maternal
▪ Some new concepts are now changing the
and child mortality and morbidity
organization and management of MCH care:
▪ Increased prevalence of low birth wt, abortions,
▪ Integration of care
Anaemia, APH etc.
▪ Risk approach
▪ More after 4th child
▪ Manpower changes
▪ Family planning services now an integral part of
MCH services. ▪ Primary health care

19 20

Maternal Health care services….

Maternal Health care services
1.PRE-CONCEPTIONAL GUIDANCE
Contraceptive guidance
1. Pre - conceptional guidance Habit modification
2. Ante-natal / Pre-natal care Emotional well being
3. Intranatal Care Rubella immunization
4. Post-natal care Genetic counseling

21 22

Maternal Health care services….

Maternal Health care services…. • Objectives of ANC:
I. To promote, protect and maintain the health of the mother
2. Ante-natal / Pre-natal care : during pregnancy.
▪ Primary aim of antenatal care: to achieve at the II. To detect “high risk” cases and give them special attention
end of a pregnancy, a healthy mother and a III. To foresee complications and prevent them.
healthy baby.
IV. To remove anxiety and dread associated with delivery.
▪ Ideal starting time: soon after conception and
continue throughout pregnancy. V. To reduce maternal and infant mortality and morbidity
▪ New concept - screening healthy women: for signs VI. To teach the mother elements of child care: breast feeding,
of disease and notification of pregnancy to bring the nutrition, personal hygiene and environmental sanitation.
mother under preventive care cycle asap. VII. To sensitize mother to need for family planning incl
advice to cases seeking medical termination of pregnancy.
23 24
VIII. To attend accompanying under-five children.
 Health care services for achieving objectives of ANC:
1. Antenatal visits: Ideal schedule for AN VISITS:
contd… - Once a month during the first 7 month
- Twice a month during the 8th month
Health care services for achieving objectives - Thereafter weekly
of ANC: WHO minimum recommended AN VISITS to assess AN coverage
(%) & contacts :ref:www.who.int/data/gho/indicator
1. Antenatal visits WHO Focused Antenatal Care Model & 2016 WHO ANC model
2. Prenatal advice
3. Specific health protection
4. Maternal preparation
5. Family planning
6. Pediatric component

WHO FocusedANCModel Relevant links

Goals First visit 8-12 Second visit 24- Third visit 32 weeks Fourth visit 36-
weeks 26 weeks 38 weeks
Confirm pregnancy Assess maternal and Assess maternal and Assess maternal
and EDD, classify fetal well being fetal well being and fetal well being
women for basic ANC
( 4 visits) or more
specialized care.

Screen, treat and give Exclude PIH,and Exclude PIH, and Exclude PIH, and
preventive measures. Anemia. Anemia, multiple Anemia multiple
pregnancy. pregnancy,
malpresenta tion.
Develop a birth and Give preventive Give preventive Give preventive
emergency plan measures. measures. measures.

Advise and counsel. Review and modify Review and modify Review and modify Infographics
birth and birth and birth and www.who.int/reproductiv
emergency plan. emergency plan. emergency plan. ehealth/publications/mater
Advise and counsel. Advise and counsel. Advise and nal_perinatal_health/ANC
_infographics/en/index.ht
counsel.
27 ml

▪ Detection of pregnancy:
▪ Urine Pregnancy test is offered to all women in reproductive
age group who gives history of missed periods or signs of
pregnancy.
contd…
▪ To confirm pregnancy in first trimester.
▪ Reasons for early detection of pregnancy: Components of first AN Visit:
1. For planning of services for the mother and fetus 1. History taking
2. Record of LMP and calculation of EDD 2. Physical examination
3. Health status assessment and any past history
3. Abdominal examination
4. To record baseline examination of wt, BP and Hb etc.
5. Early detection of complications and appropriate management
4. Assessment of gestational age
with timely referral if required 5. Laboratory investigations
6.To confirm whether the pregnancy was wanted or not
7. Facilitates a good inter personnel relationship between the care
giver and the pregnant woman.
 Components of first AN Visit…. Components of first AN Visit….
1. History taking 2. Physical examination
a. Pallor: Indicating anaemia, correlate with lab investigation
a. Confirm the pregnancy( first visit only)
b. Pulse: Low or high(60-90 / min)
b. Past history
c. Respiratory rate: Look for breathlessness( 18-20 breaths/min)
c. Record LMP and calculate expected date of delivery( 9 d. Oedema: Abnormal when it is on hands, face or abdominal wall.
m+7 days) If associated with HTN, heart disease and proteinuria then
d. Record symptoms including complications immediate referral is required
e. History of any current systemic illness eg. e. Blood pressure: record on each visit, PIH when on two
consecutive recording four hours apart 140/90 mmg , look for
Hypertension, DM, heart disease, TB, Epilepsy etc. proteinuria
f. Record family history of DM, HTN, TB, twins, f. Weight: record on each visit, 9-11 kg through out pregnancy,
Thalasemia, Congenital Malformation 2kg/m after 1st trimester normal if < or >3kg/m may lead to
g. Drug history, drug allergies and habit forming drugs IUGR or may be due to eclampsia, DM respectively.
g. Breast examination: for inverted or flat nipples

Components of first AN Visit…. Components of first AN Visit….

3.Abdominal examination 4. Assessment of gestational age

Examine the abdomen for the progress of pregnancy ▪ USG is the “Gold standard”
and fetal growth ▪ Best obstetric estimates take into account LMP and
a. Measurement of fundal height: 12wks to 36 wks USG findings
b. Fetal heart sounds: 6 th month, 120-140/min ▪ Where USG not available, LMP, Fundal Height
c. Fetal movements: 18-22nd wk 5. Laboratory investigations:
d. Fetal parts: 22nd wk Pregnancy test, Hb, urine R/E,blood gp and Rh
e. Multiple pregnancies: FH > or multiple fetal parts factor, Blood sugar, HIV test, HBsAg, HCV etc
f. Fetal lie and presentation: relevant 32 wks 6. Record keeping: AN card to be maintained and
g. Abdominal scars or any other findings instructed to bring along on all AN visits and at the
time of delivery

Essential components of every Interventions and counseling

subsequent antenatal check up during ANC
1. History taking ▪ Iron and folic acid supplementation and treatment
▪ Immunization against tetanus
2. Physical examination ( weight, BP, RR,
▪ Treat malaria
pallor and oedema
▪ Advise for diet, personal hygiene,, drugs, radiation,
3. Abdominal examination for faetal growth, warning signs, delivery and parenthood, preparing for
lie, heart sounds according to stage of breast feeding
pregnancy ▪ Referral services where indicated
4. Laboratory examination eg Hb, urine RE, ▪ Record keeping
▪ Home visits
High Risk Approach during ANC
▪ To identify and ensure the services for those who need
High Risk Approach during ANC…
them most primarily at Primary health care level. ▪ Elderly grand multipara ≥ 5
▪ High risk cases include: ▪ Prolonged pregnancy-14 days post EDD
▪ Elderly primigravida-30 yrs and above ▪ History of previous caesarian or instrumental
▪ Short statured – 140 cm and below deliveries
▪ Mal presentation ▪ Pregnancy associated with other diseases
▪ APH, threatened abortion ▪ Treatment for infertility
▪ Pre Eclampsia, Eclampsia ▪ Three or more consecutive abortions
▪ Anemia
▪ Twins, hydramnios
▪ Previous still birth, IUD, retained placenta
▪

2. Prenatal Advice:
MANAGEMENT OF HIGH RISK CASES
An important component of ANC as women are more
receptive in this period.
a. Diet: A balanced diet is important to meet the increased
needs of the mother during pregnancy and lactation.
Total addl calories consumed during pregnancy-
60,000 kcal
or 350 kcal /day . Lactation demands 600 kcal/ day
b. Personal hygiene:
c. Drugs
d. Radiations.

Contd…

3. Specific health protection

e. Warning signs:
▪ Swelling of feet ▪ Anemia: Low socio economic status –Anaemia
▪ Headache more marked in 3rd trimester mostly due to iron
▪ Blurring of vision and folic acid deficiency. Associated with high
incidence of premature births, post partum
▪ Fits
hemorrhage, puerperal sepsis,
▪ Bleeding or discharge per vagina thromboembolism etc. Iron and Folic acid
▪ Any other unusual symptoms supplementation
f. Child Care: ▪ Other nutritional deficiencies: eg protein,
Mother craft education: Home economics, vitamin, minerals, iodine
nutrition education, child rearing, family planning ▪ Toxemias of pregnancy: Early detection and
etc. 41
management
3. Specific health protection…. Tetanus Toxoid Immunization of Women of
CBA and pregnant women ( WHO)
▪ Tetanus Toxoid vaccination : To prevent
Neonatal Tetanus-
-Non immunized mother:
2 doses-1st dose at 16-20 wks, 2nd dose at 20-24
wks( 4 wks apart)
-Already immunized mother: One booster dose
in second or third trimester will be sufficient for
next pregnancies as well within 5 years
-Mothers reporting late: TT immunization
should not be denied, even a single dose to be
given

Contd… Contd…
▪ Syphilis: Mothers having Syphilis can transmit ▪ HIV infection: Trans placental, during
it to the faetus. Congenital syphilis can be delivery or breast feeding, High risk
prevented by Injectable Procaine Penicillin screening, primary prevention through
▪ German measles ie Rubella- Congenital Rubella health education on safe sexual practices
Syndrome-MMR vaccination of women of child
bearing age
▪ Hep B infection: Vertical transmission
can be prevented by Hep B
▪ Rh status: Rh antibodies analysis of RH
negative mothers and RH positive husbands to immunoglobulin and Hepatitis B
prescribe Rh - Anti D immunoglobulin to vaccination after delivery. Vaccination at
prevent hydrops fetalis or icterus neonatorum of the time of delivery
RH positive fetus. ▪ Prenatal genetic counseling: age > 35 yrs
and h/o having already afflicted child

Contd..

4. Maternal preparation:
Mental preparation of to be mothers,
“MOTHERCRAFT” classes can help
▪ To be continued…….
5. Family planning:
More receptive, candidates fit for sterilization can
be motivated
6. Pediatric component:
Pediatrician should be available at all AN clinics to
attend u/5 accompanying the mothers

48
3. INTRANATAL CARE…. INTRANATAL CARE…
Emphasis on cleanliness during delivery and
prevention of Neonatal Tetanus- 7Cs as ▪ Aim of good Intranatal care is:
recommended by WHO ▪ Thorough asepsis
7Cs: ▪ Delivery with minimum damage to mother
1. Clean hands of the attendant and baby
2. Clean delivery surface ▪ Readiness to deal with any complication eg.
APH, mal presentation, prolonged labour etc.
3. Clean cord tie
▪ Care of the baby at delivery: resuscitation,
4. Clean Cutting
care of cord and eyes.
5. Clean cord stump
TYPES OF NATAL SERVICES :
6. Clean towels to dry the baby and then wrap the
-Domiciliary care -Institutional care
baby
- Rooming in
7. Clean Water 49

Contd…
DANGER SIGNALS : midwife must be aware of danger
INTRANATAL CARE… signals and seek help immediately when required and there
1. Domiciliary care: Domiciliary midwifery care should be close liaison between domiciliary and the
institutional services :
Advantages:
▪ Sluggish or no pains after rupture of membranes
-Familiar surrounding, ▪ Good pains but no progress after rupture of membranes
-No cross infection, ▪ Prolapsed cord or hand
-Mother can keep an eye on domestic affairs ▪ Meconium-stained liquor or slow irregular or excessively fast
fetal heart
Disadvantages
▪ Excessive “show” or bleeding during labour
-Less medical and nursing supervision ▪ Collapse during labour
- Less rest ▪ A placenta not detached after half an hour of delivery
- Diet neglected ▪ Post partum hemorrhage or collapse
- Resumes her duties soon ▪ A temperature of 38 deg C or >
52

INTRANATAL CARE… 3. ROOMING-IN

2. Institutional care: 1%deliveries are abnormal ▪ Keeping the baby’s crib by the side of the
and 4% are difficult and all the pregnancies with mother’s bed.
high risk must be attended by a doctor in an ADVANTAGES
institute ▪ Mother knows her baby- mother child bonding
▪ Good opportunity for Breast feeding
▪ Every pregnancy is at risk.
▪ Removes the fear for the baby to be misplaced
▪ ROUTINE AFTER A NORMAL DELIVERY
▪ Builds self-confidence in mother
▪ Rest in bed on the first day.
▪ Prevents cross-infections (nosocomial)
▪ Allowed to be up and about on next day.
▪ Discharged after five days lying-in period.
54
4. MATERNITY WAITING HOMES 4. POSTNATAL CARE /
POST-PARTAL CARE
▪ Residential facilities where women defined as “high TWO AREAS
risk” can await for their delivery and be transferred
▪ Care of mother; responsibility of the
to a nearby medical service shortly before
delivery—or sooner, if complications arise. obstetrician.
▪ THE GOAL ▪ Care of newborn; responsibility of
To minimize the delay in receiving care for an obstetrician and pediatrician.
obstetric emergency by dramatically reducing the PERINATOLOGY
transit time.

55 56

POSTNATAL CARE OF MOTHER…. POSTNATAL CARE OF MOTHER….

OBJECTIVES ▪ To provide basic health education to mother and

▪ To prevent complications of the postpartum family.
period. ▪ Immunization for future (Rh-factor).
▪ To provide care for the rapid restoration of the ▪ Diagnosis and treatment for minor problems.
mother to optimum health. ▪ Immunization, feeding, weighing of baby.
▪ To check adequacy of breast feeding. ▪ To monitor the period of puerperium (42 days) by
▪ To provide family planning services. TBA.

57 58

Minimum recommended COMPLICATIONS OF

Postnatal Visits x 3 POSTPARTAL PERIOD
VISITS Postnatal period ▪ Puerperal sepsis (within 3 weeks)
▪ Thrombo-phlebitis
First PN visit <3 days
▪ Secondary hemorrhage (6 hours to 6 weeks)
Second PN visit 1 week ▪ Other complications
▪ Urinary tract infection
Third PN Visit 8 Weeks
▪ Mastitis etc

60
RESTORATION OF MOTHER HEALTH
▪ PHYSICAL BASIC HEALTH EDUCATION
• Postnatal examination
• Anemia ▪ Hygiene; personal and environmental
• Nutrition
▪ Feeding of mother and infant
• Postnatal exercise
▪ Family planning
▪ PSYCHOLOGICAL
Postpartum psychosis ▪ Importance of health check-up
▪ SOCIAL ▪ Birth registration
▪ To nurture and raise the child in a wholesome
family atmosphere.
▪ Breast feeding
61 62
▪ Family planning

Minimal Module Of Maternal Health REQUIREMENTS FOR

MCH CENTER
▪Community based services (PHC)
▪First referral centre for essential obstetric care ▪ Site
▪Effective communication and transportation ▪ Building
between the community based services and the first ▪ Staff
level referral centre
▪The modules should be related to family planning ▪ Budget
services and to specialist obstetric services at the ▪ Work load
tertiary level.
▪ MCH organization
▪Training of health personnel.

63 64

BUILDING OF MCH CENTER

▪ Reception
SITE OF MCH CENTER ▪ Weighing room
▪ Examination room
▪ Centrally located in a community
▪ Laboratory
▪ Easily accessible to all ▪ Immunization room
▪ Approach roads ▪ Room for medical officers
▪ Transportation ▪ Conference room
▪ Store
▪ Dispensary
▪ Family planning room
▪ Well baby clinic
65 66
▪ Under 5 clinic
 STAFF OF MCH CENTER BUDGET OF MCH CENTER
▪ Doctor ▪ Pays
▪ Lady health visitor
▪ Mid wives ▪ Utility bills
▪ Dias / Trained birth attendants (TBA) ▪ Transport
▪ Motivators (for FP counseling)
▪ Medicines and LAB chemicals
▪ Clerk
▪ Peon ▪ Contingency / repairs
▪ Sweeper ▪ Maintenance
▪ Driver
▪ Watchman
▪ Other unavoidable requirements
67 68

INDICATORS OF MCH SERVICES MCH Centre work load

Work load can be calculated which is required for the
• Maternal mortality ratio estimation of resources required at the centre.
• Mortality in infancy and
childhood a. Population-----------5000
b. B.R ------------------- 26/1000
• Peri-natal mortality rate c. Expected No of live births/Year: 26 X 5000 = 130
• Neonatal mortality rate 1000
• Post-neonatal mortality rate
d. Pregnant women under care-----------143 approx
• Infant mortality rate
• 1-4 year mortality rate (10% correction factor= 13 for pregnancy wastage/ fetal
loss)
• Under 5 mortality rate e. Infants under care-----------130 approx
• Child survival rate 69 70

The organizational chart of an economic and efficient MCH district

serving 100,000 population.
District Health services
Health officer

Director MCH ▪ To improve the maternal and neonatal health specially of

(Physician)
the poor and disadvantaged at all levels of health care
Pop
25,000 25,000 25,000 25,000 delivery system
▪ Aims at providing improved access to high quality mother
MCH MCH MCH MCH
Physician Physician Physician Physician
and child health and FP services
▪ Train 10000 CMWs
▪ Comprehensive EmONC at 275 hospitals/ health facilities
▪ Basic EmONC at 550 health facilities
▪ FP services in all health outlets
5000 5000 5000 5000 71 72
5000
(MCH Centre)
 • ”The Community Midwives are specially trained
Skilled Birth Attendants who are equipped to conduct
a normal home delivery under safe and clean
conditions.”
•The CMW model includes the following functions:
•Providing individualized care to the pregnant
women throughout the maternity cycle and the
newborn, in her own environment and helping her in
self-care.
•Monitoring the physical, social and emotional well-
being of the pregnant woman as needed.
73 74

• Taking appropriate action within the resources

available.
• Providing guidance and counseling to the community
for healthy habits, and involving the family in
preparation for childbirth and for unforeseen
emergencies.
• Identifying actual or anticipated conditions requiring
medical attention and making timely referrals.
• Practicing midwifery within the legal framework and
following the professional code of conduct provided by
the relevant authority.

75 76

77 78
 References
▪ Park’ s Text Book of Preventive and Social Medicine ,
Chapter 9, 23rd Edition
▪ Public Health and Community Medicine , Ilyas Ansari,
Section 11,Chapter 51, 8th Edition

79 80

Thankyou
81
 Safe Motherhood
&
EmONC
Lecture: 3 ▪ https://www.youtube.com/watch?v=-
Dr Tahira Amjad 1
jkVyb2fFk8 2
Assoc Prof C/Med

Learning Objectives
At the end of the session, students shall be able to:
▪ Define Safe motherhood
▪ Discuss the aim and different strategies of safe
mother hood.
▪ Illustrate and discuss different components of
safe motherhood initiative
▪ Enlist the 6 Cs of clean and safe delivery.
▪ Difference between Basic EmONC and
Comprehensive EmONC
▪ Discuss Newborn care.
3 4

Safe Motherhood Initiative

Safe Motherhood -defined
(SMI) Historical background
“ A woman's ability to have a safe and ▪ 1987: Globally launched at Nairobi at an
healthy pregnancy and child birth “ International Conference
▪ 1990: A series of global pledges particularly to
the vulnerable and underserved populations to
Through continuous antenatal, ensure:
intranatal and postnatal care, including
▪ Access to a wide range of high- quality RHS
family planning services
▪ Affordable RHS
▪ Including safe motherhood
▪ Family planning,
5 6
 Safe Motherhood Initiative
contd…
▪ March 1990: (SMI) Historical background...
▪ An international conference held at Lahore on
the subject “ Safe motherhood, a challenge ▪ 1994: ICPD at Cairo, Govts agreed to reduce
for South Asia” MMR by half by the year 2000 and in half again
▪ Highlighted the MMR in Pakistan and South by 2015
Asia which was 100% higher as compared to ▪ 1995: Fourth World Conference on Women
the developed countries (FWCW) in Beijing gave substantial attention to
▪ An exception to Sirilanka ( MMR < 100/ 100,000 high MMR and the ICPD commitments
Live births) because of: ▪ 2000: 189 countries of UN Millennium General
▪ late marriages Assembly in New York endorsed through
▪ lower fertility MDGs 5, to reduce MMR by 75% between
7 8
▪ > 85% deliveries by trained persons 1990 and 2015

Safe Motherhood Initiative Safe Motherhood programme

Aim Basic requisites
To ensure that every woman has :
▪ Access to a full range of high-quality, affordable sexual ▪ Proper nutrition, health and family
and reproductive health services
planning services at the community
▪ Maternal care and treatment of obstetric emergencies
level
to reduce deaths and disabilities.
▪ Attaining optimal maternal and newborn health by:
▪ Community health care from
community to hospital
▪ Reducing obstetrical complications
▪ A programme to communicate the
▪ Decreasing case fatality rate
health messages
▪ Providing essential new born care

9 10

Strategies for Safe Motherhood Initiative WHO Strategic interventions

▪ Advance Safe motherhood through human rights for Safe Motherhood Initiative
▪ Empower women : ensure choices
▪ Delay marriages and first birth
▪ Ensure emergency obstetrical care -Every pregnancy faces ▪ It includes six strategic interventions or
risk six pillars/ principles, which should be
▪ Ensure skilled birth attendants
▪ Improve access to quality RH services delivered through primary health care
▪ Family planning to plan their pregnancies and to prevent and rest on the foundation of equity for
unwanted pregnancies
▪ unsafe abortions Services to prevent and manage their women and Communication for
complications .
behavior change.
▪ Health education and services for the adolescents
▪ Community education: for women, their families and
decision makers
▪ Measure the progress
11 12
▪ Power of partnership
Old Safe Motherhood – WHO The Six Pillars / Principles of current
Strategies Safe motherhood initiative
Safe
Motherhood

Clean/Safe Delivery

Essential Obstetric Care

Antenatal Care
Family Planning

Basic Maternity Care

Primary Health Care

Equity for Women

13 14

PRIMARY HEALTH CARE

“It is essential health care based
on PRINCIPLES OF PHC
practical, scientifically sound & socially acceptable methods &
technology made universally accessible
to ➢ Equity
individual and families in the community
through ➢ Intersectoral coordination
their full participation and
at ➢ Community participation
a cost that the community and country can afford
to ➢ Appropriate technology
maintain at every stage of their development in
the spirit of self reliance and self determination.”
15
➢ Health promotion 16

Eight ELEMENTS / COMPONENTS OF PHC

PRINCIPLES OF PHC… 1. Education concerning prevailing health problems
and the methods of controlling and preventing them
▪ EQUITY / Equitable distribution:
2. Promotion of food supply and proper nutrition
(Does not mean equal)
3. Adequate supply of safe water and basic sanitation
✓According to the needs of the individuals
or the community 4. Maternal and child health care including family
✓Equal health services for all- rich or poor, health
rural or urban, men or women 5. Immunization against major infectious diseases
✓Acceptable 6. Prevention and control of locally endemic diseases
✓Accessibility to health care 7. Appropriate treatment of common diseases &
✓Affordable injuries
✓ Equal utilization of health care 8. Provision of essential drugs
✓ Effective and efficient 17 18
Behavior change communication Behavior Change Model

▪ Behavior change communication (BCC) is an

interactive process of any intervention
with individuals, communities and/or societies (as
integrated with an overall program)
▪ To develop communication strategies to promote
positive behaviors which are appropriate to their
settings. ( Socio cultural, economical)
▪ Provides a supportive environment which will
enable people to initiate, sustain and maintain
positive and desirable behavior outcomes 19 20

Safe Motherhood – Six Pillars Safe Motherhood–six Pillars…

1 . Family Planning. 2. Antenatal Care.
To ensure that individuals and couples have the Info To prevent complications where possible and
and services to plan the timing, number and spacing to ensure that complications of pregnancy are
of pregnancies detected early and treated appropriately- the
* > 4 children increases the health risks for 3 Ds
pregnancy and child birth * Delay in seeking care
* Mothers body require minimum 2 years to * Delay in reaching to the care providers
recover from effects of pregnancy and childbirth * Delay in providing the care
* After the age of 35 years the health risks of Now the 4th D: Delay at the reception of the
pregnancy and child birth increases health facility
21 22

Safe Motherhood–six Pillars…

3. Obstetric care: Ensure that all birth attendants
have the knowledge, skills and equipment to
perform a clean and safe delivery and to ensure
that emergency care is provided.
Emergency Obstetric and Newborn Care( from EmOC to
EmONC):
a. Basic EmONC
b. Comprehensive EmONC
WHO stress upon the 6 Cleans
23 www.healthynewbornnetwork.org 24
 The 6 Cleans of WHO
Commodities required for 6 Cs
For a safe and clean delivery: ▪ Soap (to wash hands and perineum),
▪ a piece of plastic (to provide a clean delivery
1. Clean hands surface)
▪ a clean blade (to cut the cord)
2. Clean perineum
▪ clean thread (to tie the cord).
3. Clean delivery surface ▪ Unfortunately, these commodities are unavailable
4. Clean cord cutting or may be too expensive for families to purchase.
5. Clean cord tying ▪ Or are available but not used- complex behavioural
6. Clean cord care attitude
▪ . ▪ change may be required to ensure birth attendants
practice the “six cleans” and to ensure cultural
25 acceptability to women and their families. 26

2010 WHO

27 28

EmOC to EmONC
▪ Obstetric complications may occur suddenly It is estimated that, if untreated, death occurs on
average in :
▪ If women do not receive medical treatment on time, 02 hours 12 hours 02 days 06 days
they will probably suffer disability… or die
▪ If women receive effective treatment of obstetric • Postpartum • Antepartum • Obstructed
• Infection
complications in time…almost all maternal lives Hemorrhage Hemorrhage labor
can be saved

To avert death and disability…we need to ensure

that women have the access to emergency obstetric
29 care(Emoc) 24 hours 30
 EMERGENCY OBSTETRIC CARE
(EmOC)
▪ Access to Health facilities that can perform
essential emergency interventions such as:
▪ Caesarean sections Obstetric First Aid
▪ Manual removal of placenta
▪ Blood transfusions Basic EmONC Services
▪ Administration of antibiotics
Comprehensive EmONC
Services
31 32

Antibiotics (Parenteral)

Oxytocic Drugs (Oral ,parenteral or rectal)

Anticonvulsants (Parenteral)
can help save a woman’s
life Manual Removal of Placenta

Removal of Retained Products of conception

Assisted Vaginal Delivery

New born care

33 34

Antibiotics (Parenteral)

Oxytocic Drugs (Oral ,parenteral or rectal)

Anticonvulsants (Parenteral)

Manual Removal of Placenta

Removal of Retained Products of conception

Assisted Vaginal Delivery

Surgery (Cesarean Section, laparotomy)

Blood Transfusion Services

neonatal care( incubator care, exchange transfusion, specialized

35 36
new born care etc.)
Source: National MNCH program-2013
 New Born Care: New Born Care….
▪ Infections, birth asphyxia, and preterm/low birth weight
account for 86 percent of newborn deaths ▪ Newborn deaths by up to 40 percent can be
▪ Most occur during the first hours and days of life. reduced by:
▪ Approximately 70 percent of newborn deaths could ▪ Strengthening family community and outreach
be averted through cost-effective interventions. health services
▪ Health education
▪ Interventions include :
▪ Preventive services such as tetanus vaccination
▪ Ensuring clean delivery coverage
▪ Treating infections with antibiotics
▪ Promoting immediate and exclusive breastfeeding .

37 38

New Born Care….. Newborn Services at basic

Common health conditions of the new born:
▪ Birth asphyxia and birth trauma
EmONC level
▪ Low birth weight or premature babies ▪ Management of neonatal infection
▪ Tetanus ▪ Very low birth weight infants
▪ Meconium aspiration ▪ Complications of asphyxia
▪ Neonatal Jaundice ▪ Severe neonatal jaundice
▪ Other infections ▪ Skills and supplies for intravenous fluid therapy,
thermal care including radiant warmers,
▪ Congenital problems
Kangaroo Mother Care, oxygen, parenteral
▪ Inappropriate breast feeding antibiotics, intragastric feeding, oral feeding using
By introducing integrated newborn packages at clinical, alternative methods to breast feeding and breast
outreach and community level brings down newborn feeding support.
mortality by 40%, 25% and 30% respectively 39 40

Risk factors for a high Emergency newborn care

mortality or morbidity in new ▪ ENC as a part of Comprehensive EmONC
born: services in selected facilities are identified in the
National MNCH Program.
▪ In addition, newborn resuscitation and
▪ Delivery conducted by un-trained attendant
immediate newborn care protocols already
▪ Birth interval of less then 24 months developed under Women’s Health Project will be
▪ More than six pregnancies provided to 7000 labor rooms in public sector
▪ Illiterate mother and/or father and 3000 maternity homes in the private sector.
▪ Community based low cost and low tech
interventions will be scaled up through LHWs
and CMWs.
▪ Community IMNCI, Community Case Management and
41 Behavior Change communication. 42
 Safe Motherhood–six Pillars…
4. Postnatal care: To ensure that postpartum care Safe Motherhood–six Pillars…
is provided to mother and the baby, including
lactation assistance, Family planning and managing 6. STD/HIV/AIDS Control:
danger signs
▪ To screen, prevent and manage transmission
5. Post abortion care: prevention and early to baby
detection of complications of abortions and timely
▪ to assess risk for future infections
management
▪ to provide voluntary counseling and testing
▪ to encourage prevention and where applicable
to expand services to address mother to child
transmission

43 44

IMPAC

Source:apps.who.int 45 46

Conclusion References

“ Improvement in women's health need ▪ Park’ s Text Book of Preventive and Social Medicine ,
Chapter 9, 23rd Edition
more than better science and health
▪ Public Health and Community Medicine , Ilyas Ansari,
care- they require state actions to correct Section 11,Chapter 51, 8th Edition
injustices to women”

Federation of Gynecology and Obstetrics- FOGO- world report 1994

47 48
THANK YOU

49
 Learning Objectives

▪ Discuss Maternal health care services

Safe motherhood ▪ Discuss ANC aim, objectives and health care
services for achieving objectives of ANC.
Maternal health care services ▪ Discuss WHO recommended visits/contacts as per
RH-5 ANC Models.
By
▪ Discuss High Risk Approach during ANC
Dr Tahira Amjad ▪ Discuss Intra and post natal care.
Assoc Prof
Community Medicine, FUMC
2

Maternal Health care services….

Maternal Health care services
1.PRE-CONCEPTIONAL GUIDANCE
Contraceptive guidance
1. Pre - conceptional guidance Habit modification
2. Ante-natal / Pre-natal care Emotional well being
3. Intranatal Care Rubella immunization
4. Post-natal care Genetic counseling

3 4

Maternal Health care services….

Maternal Health care services…. • Objectives of ANC:
1. To promote, protect and maintain the health of the mother
2. Ante-natal / Pre-natal care : during pregnancy.
▪ Primary aim of antenatal care: to achieve at the 2. To detect “high risk” cases and give them special attention
end of a pregnancy, a healthy mother and a 3. To foresee complications and prevent them.
healthy baby.
4. To remove anxiety and dread associated with delivery.
▪ Ideal starting time: soon after conception and
continue throughout pregnancy. 5. To reduce maternal and infant mortality and morbidity
▪ New concept - screening healthy women: for signs 6. To teach the mother elements of child care: breast feeding,
of disease and notification of pregnancy to bring the nutrition, personal hygiene and environmental sanitation.
mother under preventive care cycle asap. 7. To sensitize mother to need for family planning incl
advice to cases seeking medical termination of pregnancy.
5 6
8. To attend accompanying under-five children.
 Health care services for achieving objectives of ANC:
1. Antenatal visits: Ideal schedule for AN VISITS:
contd… - Once a month during the first 7 month
- Twice a month during the 8th month
Health care services for achieving objectives - Thereafter weekly
of ANC: WHO minimum recommended AN VISITS to assess AN coverage
(%) & contacts :ref:www.who.int/data/gho/indicator
1. Antenatal visits WHO Focused Antenatal Care Model & 2016 WHO ANC model
2. Prenatal advice
3. Specific health protection
4. Maternal preparation
5. Family planning
6. Pediatric component

WHO FocusedANCModel Relevant links

Goals First visit 8-12 Second visit 24- Third visit 32 weeks Fourth visit 36-
weeks 26 weeks 38 weeks
Confirm pregnancy Assess maternal and Assess maternal and Assess maternal
and EDD, classify fetal well being fetal well being and fetal well being
women for basic ANC
( 4 visits) or more
specialized care.

Screen, treat and give Exclude PIH,and Exclude PIH, and Exclude PIH, and
preventive measures. Anemia. Anemia multiple Anemia multiple
pregnancy. pregnancy,
malpresenta tion.
Develop a birth and Give preventive Give preventive Give preventive
emergency plan measures. measures. measures.

Advise and counsel. Review and modify Review and modify Review and modify Infographics
birth and birth and birth and www.who.int/reproductiv
emergency plan. emergency plan. emergency plan. ehealth/publications/mater
Advise and counsel. Advise and counsel. Advise and nal_perinatal_health/ANC
_infographics/en/index.ht
counsel.
9 ml

▪ Detection of pregnancy:
▪ Urine Pregnancy test is offered to all women in reproductive
age group who gives history of missed periods or signs of Components of first AN Visit
pregnancy.
▪ To confirm pregnancy in first trimester.
▪ Reasons for early detection of pregnancy: 1. History taking
1. For planning of services for the mother and fetus 2. Physical examination
2. Record of LMP and calculation of EDD 3. Abdominal examination
3. Health status assessment and any past history
4. Assessment of gestational age
4. To record baseline examination of wt, BP and Hb etc.
5. Early detection of complications and appropriate management
5. Laboratory investigations
with timely referral if required
6.To confirm whether the pregnancy was wanted or not
7. Facilitates a good inter personnel relationship between the care
giver and the pregnant woman.
 Components of first AN Visit….
1. History taking Contd….
a. Confirm the pregnancy( first visit only)
b. Past history of any complication during previous e. History of any current systemic illness eg.
pregnancy Hypertension, DM, heart disease, TB, Epilepsy etc.
c. Record LMP and calculate expected date of delivery( 9 f. Record family history of DM, HTN, TB, twins,
m+7 days) Thalasemia, Congenital Malformation
d. Record symptoms including complications eg. Fever, g. Drug history, drug allergies and habit forming
persisting vomiting, vaginal discharge or bleeding, drugs
palpitations, easy fatigability, breathlessness at rest or
on mild exertion, generalized swelling in the body,
severe headache, blurring of vision, burning micturition,
decreased or no fetal movement etc. 14

Components of first AN Visit…. Components of first AN Visit….

2. Physical examination 3.Abdominal examination
a. Pallor- Anaemia
b. Pulse- Normal 60 to90/min Examine the abdomen for the progress of pregnancy
c. Respiratory rate: Normal18-20 breaths/ min and fetal growth
d. Oedema: Abnormal if on hands, face , abdominal wall.
a. Measurement of fundal height: 12wks to 36 wks
If with HTN and Proteinuria then need immediate ref
e. Blood pressure: record on each visit, PIH when on two b. Fetal heart sounds: 6 th month, 120-140/min
consecutive recording four hours apart 140/90 mmg , look c. Fetal movements: 18-22nd wk
for proteinuria d. Fetal parts: 22nd wk
f. Weight: record on each visit, 9-11 kg wt gain through e. Multiple pregnancies: FH > or multiple fetal parts
out pregnancy, 2kg/m after 1st trimester is normal, if <
f. Fetal lie and presentation: relevant 32 wks
may lead to IUGR or if 3kg/m or > wt gain, may be due
to eclampsia, DM . g. Abdominal scars or any other findings
g. Breast examination: for inverted or flat nipples

Components of first AN Visit….

4. Assessment of gestational age

▪ USG is the “Gold standard”

▪ Best obstetric estimates take into account LMP and
USG findings
▪ Where USG not available, LMP & Fundal Height
5. Laboratory investigations:
Pregnancy test, Hb, urine R/E,blood gp and Rh
factor, Blood sugar, HIV test, HBsAg, HCV etc
6. Record keeping: AN card to be maintained and
instructed to bring along on all AN visits and at the
17 time of delivery
Essential components of every Interventions and counseling
subsequent antenatal check up during ANC
1. History taking ▪ Iron and folic acid supplementation and treatment
▪ Immunization against tetanus
2. Physical examination ( weight, BP, RR,
▪ Treat malaria
pallor and oedema
▪ Advise for diet, personal hygiene,, drugs, radiation,
3. Abdominal examination for faetal growth, warning signs, delivery and parenthood, preparing for
lie, heart sounds according to stage of breast feeding
pregnancy ▪ Referral services where indicated
4. Laboratory examination eg Hb, urine RE, ▪ Record keeping
▪ Home visits

High Risk Approach during ANC

▪ To identify and ensure the services for those who need
High Risk Approach during ANC…
them most primarily at Primary health care level. ▪ Twins, Multiple Pregnancies, hydramnios ,IUGR
▪ High risk pregnancy is defined as one which is ▪ Elderly grand multipara ≥ 5 children
complicated by factor or factors that adversely affects the
▪ Prolonged pregnancy-14 days post EDD
pregnancy outcome –maternal or perinatal or both.
▪ History of previous caesarian or instrumental
▪ High risk cases include:
deliveries
▪ Elderly primigravida-30 yrs and above
▪ Pregnancy associated with other diseases
▪ Short statured – 140 cm and below
▪ Pregnancy after treatment for infertility
▪ Mal presentation
▪ Three or more consecutive abortions
▪ APH, threatened abortion
▪ Previous still birth, IUD, retained placenta
▪ Pre Eclampsia, Eclampsia
- Genetic or structural abnormalities in previous or
▪ Anemia current pregnancy.

Management of High Risk Management of High Risk

Cases Cases….

23 24
 Contd…
2. Prenatal Advice:
An important component of ANC as women are more
receptive in this period. e. Warning signs:
▪ Swelling of feet
a. Diet: A balanced diet is important to meet the increased
needs of the mother during pregnancy and lactation. ▪ Headache
Total addl calories consumed during pregnancy- ▪ Blurring of vision
60,000 kcal ▪ Fits
or 350 kcal /day . Lactation demands 550 kcal/ day ▪ Bleeding or discharge per vagina
b. Personal hygiene: Personal cleanliness, Rest and sleep ▪ Any other unusual symptoms
Bowels, Exercise, Smoking, Alcohol, Dental care, Sexual activity f. Child Care:
c. Drugs: serious effects between 4 to 8 wks of regnancy. Mother craft education: Home economics,
Eg streptomycin: 8th nerve damage-deafness, iodine nutrition education, child rearing, family planning
preparations: congenital goiter etc etc. 27
d. Radiations.

3. Specific health protection….

3. Specific health protection ▪ Tetanus Toxoid vaccination : To prevent
▪ Anemia: Low socio economic status –Anaemia Neonatal Tetanus-
more marked in 3rd trimester mostly due to iron -Non immunized mother:
and folic acid deficiency. Associated with high
2 doses-1st dose at 16-20 wks, 2nd dose at 20-24
incidence of premature births, post partum
hemorrhage, puerperal sepsis, wks( 4 wks apart)
thromboembolism etc. Give Iron and Folic acid -Already immunized mother: One booster dose
supplementation in second or third trimester will be sufficient for
▪ Other nutritional deficiencies: eg protein, next pregnancies as well within 5 years
vitamin, minerals, iodine
-Mothers reporting late: TT immunization
▪ Toxemias of pregnancy: PIH with proteinuria,
should not be denied, even a single dose to be
Early detection and management
given

Tetanus Toxoid Immunization of Women of Contd…

CBA and pregnant women ( WHO) ▪ Syphilis: Mothers having Syphilis can transmit
it to the faetus. Congenital syphilis can be
prevented by Injectable Procaine Penicillin
▪ German measles ie Rubella- Congenital Rubella
Syndrome-MMR vaccination of women of child
bearing age
▪ Rh status: Rh antibodies analysis of RH
negative mothers and RH positive husbands to
prescribe Rh - Anti D immunoglobulin to
prevent hydrops fetalis or icterus neonatorum of
RH positive fetus.
 Contd… Contd..
▪ HIV infection: Trans placental, during 4. Maternal preparation:
delivery or breast feeding, High risk Mental preparation of to be mothers,
screening, primary prevention through “MOTHERCRAFT” classes can help
health education on safe sexual practices 5. Family planning:
▪ Hep B infection: Vertical transmission More receptive, candidates fit for sterilization can
can be prevented by Hep B be motivated
immunoglobulin and Hepatitis B 6. Pediatric component:
vaccination after delivery. Vaccination at Pediatrician should be available at all AN clinics to
the time of delivery attend u/5 accompanying the mothers
▪ Prenatal genetic counseling: age > 35 yrs
and h/o having already afflicted child

3. INTRANATAL CARE…. INTRANATAL CARE…

Emphasis on cleanliness during delivery and
prevention of Neonatal Tetanus- 7Cs as ▪ Aim of good Intranatal care is:
recommended by WHO ▪ Thorough asepsis
7Cs: ▪ Delivery with minimum damage to mother
1. Clean hands of the attendant and baby
2. Clean perineum ▪ Readiness to deal with any complication eg.
APH, mal presentation, prolonged labour etc.
3. Clean delivery surface
▪ Care of the baby at delivery: resuscitation,
4. Clean cord and tying instruments
care of cord and eyes.
5. Clean cutting surface
TYPES OF NATAL SERVICES :
6. Clean towels to dry the baby and then wrap the baby
-Domiciliary care -Institutional care
7. Clean Water
- Rooming in - Maternity Homes
34

INTRANATAL CARE…
1. Domiciliary care: Domiciliary midwifery care
Advantages:
▪ The 3 D model for reducing -Familiar surrounding,
Maternal Mortality????? -No cross infection,
-Mother can keep an eye on domestic affairs
Disadvantages
-Less medical and nursing supervision
- Less rest
- Diet neglected
36
- Resumes her duties soon
 Contd…
DANGER SIGNALS : In domiciliary out reach care, the
midwife must be aware of danger signals and seek help INTRANATAL CARE…
immediately when required and there should be close liaison
between domiciliary and the institutional services :
▪ Sluggish or no pains after rupture of membranes 2. Institutional care: 1%deliveries are abnormal
▪ Good pains but no progress after rupture of membranes and 4% are difficult and all the pregnancies with
▪ Prolapsed cord or hand high risk must be attended by a doctor in an
▪ Meconium-stained liquor or slow irregular or excessively fast institute
fetal heart
▪ Every pregnancy is at risk.
▪ Excessive “show” or bleeding during labour
▪ Collapse during labour
▪ ROUTINE AFTER A NORMAL DELIVERY
▪ A placenta not detached after half an hour of delivery ▪ Rest in bed on the first day.
▪ Post partum hemorrhage or collapse ▪ Allowed to be up and about on next day.
▪ A temperature of 38 deg C or > ▪ Discharged after five days lying-in period.
38

3. ROOMING-IN 4. MATERNITY WAITING HOMES

▪ Keeping the baby’s crib by the side of the ▪ Residential facilities where women defined as “high
mother’s bed. risk” can await for their delivery and be transferred
▪ ADVANTAGES to a nearby medical service shortly before
▪ Mother knows her baby- mother child bonding delivery—or sooner, if complications arise.
▪ Good opportunity for Breast feeding ▪ THE GOAL
▪ Removes the fear for the baby to be misplaced To minimize the delay in receiving care for an
▪ Builds self-confidence in mother obstetric emergency by dramatically reducing the
▪ Prevents cross-infections (nosocomial) transit time.

40 41

4. POSTNATAL CARE /
POSTNATAL CARE OF MOTHER….
POST-PARTAL CARE
TWO AREAS OBJECTIVES
▪ Care of mother; responsibility of the ▪ To prevent complications of the postpartum
obstetrician. period.
▪ To provide care for the rapid restoration of the
▪ Care of newborn; responsibility of
mother to optimum health.
obstetrician and pediatrician.
▪ To check adequacy of breast feeding.
PERINATOLOGY ▪ To provide family planning services.

42 43
 Minimum recommended
POSTNATAL CARE OF MOTHER….
Postnatal Visits x 3
▪ To provide basic health education to mother and VISITS Postnatal period
family.
▪ Immunization for future (Rh-factor). First PN visit <3 days
▪ Diagnosis and treatment for minor problems.
▪ Immunization, feeding, weighing of baby. Second PN visit 1 week
▪ Growth monitoring of baby
Third PN Visit 8 Weeks
▪ To monitor the period of puerperium (42 days) by
TBA.

44

COMPLICATIONS OF
Monitoring high risk babies
POSTPARTAL PERIOD
▪ Puerperal sepsis (within 3 weeks)
▪ Thrombo-phlebitis
▪ Secondary hemorrhage (6 hours to 6 weeks)
▪ Other complications
▪ Urinary tract infection
▪ Mastitis etc

46 47

RESTORATION OF MOTHER HEALTH

▪ PHYSICAL BASIC HEALTH EDUCATION
• Postnatal examination
• Anemia ▪ Hygiene; personal and environmental
• Nutrition
▪ Feeding of mother and infant
• Postnatal exercise
▪ Family planning
▪ PSYCHOLOGICAL
Postpartum psychosis ▪ Importance of health check-up
▪ SOCIAL ▪ Birth registration
▪ To nurture and raise the child in a wholesome
family atmosphere.
▪ Breast feeding
48 49
▪ Family planning
Thankyou
50
 Learning objectives
FAMILY PLANNING By the end of session , students should be able to:

Define Family Planning and outline its objectives

Outline WHO modern concept of FP
Give various definitions relating to FP
Part-1 Discuss health concept of FP
Identify factors to be Considered for Selecting an
appropriate Contraceptive method.
Outline principles, topics and steps that should be
followed for the Counseling of a family planning
by client
Discuss attributes of an ideal contraceptive method
Describe Cafeteria choice
Assoc Prof Dr Tahira Amjad
Community Medicine, FUMC
0
0

MILESTONES IN FAMILY
FACT
>400 million people in developing countries PLANNING
have unmet needs for family planning ● 1968-UN Conference in Tehran on Human
GOAL Rights- recognized FP as “a basic human
Where there is a gap between right “
contraceptive use and the proportion of ● August 1974 – Bucharest Conference on
individuals expressing a desire to space world population stated :
or limit their families, countries should “ All couples and individuals have the
basic human right to decide freely and
attempt to close this gap by at least 50 with responsibility the number and
per cent by 2005, 75 per cent by 2010 spacing of their children and to have
and 100 per cent by 2050 information , education and means to
(Key actions ICPD+5, paragraph 58) do so”.
0 0

GLOBAL SITUATION
Situation in Pakistan
At the current birth rate and death rate , world ● 5th most populous country of the world
population will double in 39 years ● Estimated to be doubled in 2045
Universal access to FP and strong public support for ● Women are 48% of population with reproductive age group
small families can increase the contraceptive use from (15 – 49 years) 22%
current 50% to 75% ● CBR: 25.4/ 1000 persons
Then average family size will drop to 2 children per ● CDR: 6.3/ 1000 persons
couple in 15 years ● CPR:34.2% Unmet Need FP:17.3% TFR:3.6
Average annual expenditure of $ 1600/ yr / couple ● MMR: 170 /100000 LB
can provide adequate FP services in developing
Sources: Pakistan Economic Survey 2017-2018, World population review*
countries
Focusing on Information, training and research

0 0
 FAMILY PLANNING OBJECTIVES OF FAMILY
“A way of thinking and living that is
adopted voluntarily, PLANNING
upon the basis of Family planning refers to practices that helps
knowledge, attitudes & responsible decisions individuals and couples to attain certain objectives :
●To avoid unwanted births.
by
●To bring about wanted births.
individuals and couples,
●To regulate the intervals between pregnancies.
in order to
●To control the time at which births occur in
promote the health and welfare of the family group relation to the ages of the parents.
and ●To determine the number of children in the
thus contribute effectively to the social development family.
of a country”
(WHO Expert Committee 1971)
0 0

WHO MODERN CONCEPT OF

MODERN CONCEPT (cont)
FAMILY PLANNING SERVICES
Scope of Family Planning according to WHO includes:
● Premarital consultation and examination
● The proper spacing and limitation of births
● Marriage counseling
● Advice on sterility
● Carrying out pregnancy tests
● Education for parenthood
● Teaching home economics and nutrition
● The preparation of couples for the arrival of their
first child ● Providing adoption services
● Screening for pathological conditions related to ● Sex education
reproductive system ● Providing services for unmarried mothers
● Genetic counseling

0 0

RELEVANT DEFINITIONS …
RELEVANT DEFINITIONS TARGET COUPLE
Having 2-3 living children contd….
To target priority group of couples out of eligible
● ELIGIBLE COUPLES ones.
A currently married couple wherein the Family planning was largely directed towards them.
Later families with one living child or newly
wife is in the reproductive age, which is married couple were also included
generally assumed to be between the age The term eligible couple is now widely used
of 15 and 49 years. CONTRACEPTIVE PREVALENCE RATE
Percentage of women of reproductive age (15-49) who
are using (or whose partner is using) a contraceptive
method at a particular point in time.

0 0
 RELEVANT DEFINITIONS (cont)
RELEVANT DEFINITIONS (cont) ● NET REPRODUCTION RATE ( NRR )
• The number of daughters a newborn girl will bear
● COUPLE PROTECTION RATE (CPR)
during her lifetime assuming fixed age specific
The percent of eligible couples effectively fertility and mortality rates.
protected against childbirth by one or the • NRR of one means that each generation of mothers
other approved methods of family planning like is having exactly enough daughters to replace
sterilization, IUCD, condoms, oral pills etc. themselves in the population.
• A demographic indicator
CPR is an indicator of prevalence of • If the NRR is < 1, then the reproductive
contraceptive practices in the community performance of the population is below replacement
level.
Demographic goal of NRR= 1 can be achieved
only if CPR exceeds 60% ● REPLACEMENT FERTILITY LEVEL: When NRR=1

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RELEVANT DEFINITIONS contd…. HEALTH CONCEPT OF FAMILY

AGE SPECFIC FERTILITY RATE ( ASFR)
Sensitive indicator for family planning achievement
PLANNING
Number of births in a year to 1000 women in any
specified age group.
No of LB in a particular age gp
1. WOMEN,S HEALTH
ASFR=---------------------------------- X 1000 2. FETAL HEALTH
Mid yr female population of the same age gp 3. INFANT AND CHILD HEALTH

TOTAL FERTILITY RATE ( TFR )

Average number of children a woman would have if
she were to pass through the reproductive years
bearing children at the same rates as the women
now in each age gp.
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HEALTH CONCEPT OF FAMILY

PLANNING
Contd…
1. WOMEN'S HEALTH
● Timing the births particularly the first and the
● Maternal Mortality- in developing countries 10-20
last, in relation to age of the mother
times high
● Morbidity of women of child bearing age
●The avoidance of unwanted pregnancies –leading
to induced abortions & mental stress ● Nutritional status.( weight , Hb %)
●Limiting the number of births and proper spacing-
● Preventable complications of pregnancy and
repeated pregnancies an increased risk of maternal abortion.
mortality and morbidity
●Increased risk beyond third preg & significant risk
beyond fifth.( Uterine rupture, uterine atony, toxemias,
eclampsia, anemia, increased risk of still births,
association between Ca cervix )

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 HEALTH CONCEPT OF FAMILY HEALTH CONCEPT OF FAMILY PLANNING
contd….
PLANNING contd…. 3. Infant and child Health
2. Fetal health: Neonatal, infant and preschool mortality
Child Mortality :
• Fetal mortality, Health of the infant at birth - increases with pregnancies in rapid successions
• Abnormal development.eg Down’s - Birth interval of 2-3 yrs can decrease the child mortality
syndrome associated with inc in age Child growth , Development and Nutrition:
• FP can avoid unwanted pregnancies and - proper birth spacing – full share of love, care and nutrition to
sterilization of individuals suffering from every child- prevention of malnutrition
Infectious diseases
Leprosy and Psychosis etc. (compulsory ?...) ●

- children in large size families more Vulnerable to

diseases – increased respiratory, GIT, Skin infections
● Intelligence
- Decrease in IQ Scores among children in large families

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FACTORS TO BE COSIDERED FOR SELECTING

AN APPROPRIATE CONTRACAPTIVE
When a couple comes for FP

1. The woman's age, parity and sex of her children

2. The couple’s desire for further Pregnancies Counseling is done, which involves:
3. Duration of birth spacing required
4. Previous obstetric history 6 Principals
5. Whether she is currently breastfeeding 6 Topics to cover
6. Menstrual history especially regarding 6 Steps
menorrhagia
7. Associated medical conditions such as diabetes
8. The couple's compliance potential.
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When a couple comes for FP… When a couple comes for FP…

● 6 PRINCIPALS ● 6 TOPICS
1. Effectiveness of method chosen
1. Treat each client need interaction
2. Advantages and disadvantages
2. Interact
3. Tailor info to client need 3. Side effects and complications
4. Avoid too much of info ie. info 4. How to use?
Cock tail info
5. Provide the method client wants
5. Role in STD prevention
6. Help client to understand method 6. When to return ? ( follow ups )
and remember

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 When a couple comes for FP… When a couple comes for FP…

● 6 STEPS ● 6 STEPS …
For new clients use GATHER technique
SAHR -Another method which can be used
G- Greet the client
A- Ask client about themselves
T- Tell them about choices S- Salutation ( ice breaking )
A- Assess ( decision making about RH )
H-Help them to make informed choices H– Help ( encourage to speak, inform about
E- Explain fully how to use chosen method cost, time etc)
R – Return visit should be welcomed R –Reassure ( request client to repeat her
solution)
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FERTILITY
DETERMINANTS OF HUMAN
FERTILITY
* Biological factors: age, primary infertility,
● Human fertility is the ability in man or woman to secondary infertility
cause conception of a child * Social & religious factors: age at marriage,
● Infertility the reverse of fertility temporary separation of the couple, social
● Secondary infertility-inability to conceive again norms, restraints on widow marriage, religious
after one or more pregnancies taboos to contraception
* Contraception and use of contraceptives:
fertility regulation

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CONTRACEPTIVE METHODS ATTRIBUTES OF

( Fertility Regulation Methods) AN IDEAL CONTRACEPTIVE
● Measures which are contra conception ● Safe
● Effective
thus preventing conception-CONTRACEPTION
● Acceptable
● Fertility regulation methods
● Inexpensive
● Definition:
● Reversible
“ Contraceptive methods are preventive methods ● Simple to administer
to help women avoid unwanted pregnancies.”
● Requiring little or no medical supervision
They include all temporary and permanent measures ● Long lasting to avoid frequent administration
to prevent pregnancy

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 ATTRIBUTES OF
CAFETERIA CHOICE
AN IDEAL CONTRACEPTIVE…
● In ideal contraceptive approach, no single ● Presently we are following this choice
method likely to meet social, cultural ,
aesthetic and service needs of all the “ Cafeteria choice is to offer all the methods from
individuals and communities which individuals can choose according to
● A method suitable for one group may be his/her needs and wishes and to promote family
unsuitable for another planning as a way of life .”
● Search for an ideal contraceptive is now
replaced with” Cafeteria choice” ● Counseling of the client can be done by SAHAR
or GATHER technique

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SUCCESS OF CONTRACEPTIVE
METHODS
● Depends on : FAMILY PLANNING
1- Effectiveness in preventing pregnancy
2- Rate of continuation of its proper use
CONTRACEPTIVE METHODS

Part -2
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Learning objectives CLASSIFICATION OF CONTRACEPTIVE

By the end of session you should be able to:
Classify and discuss Family Planning methods METHODS-(K.PARK)
Discuss types of IUCDs , their mode of action, Terminal Methods
1.Spacing Methods
Barrier Methods Female Sterilization
absolute and relative contraindications, •

complications and follow ups etc (a) Physical Methods • Male Sterilization
Discuss hormonal contraceptives, mode of action , (b) Chemical Methods
contraindications, side effects etc (c) Combined Methods
Outline a Check list for advising OCP. 2 Intra uterine Devices
Discuss Natural family planning methods 3. Hormonal Methods
4. Post conception
Methods
5. Miscellaneous

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 SPACING METHODS
1.BARRIER
Aim: to prevent live spermMETHODS
from meeting the ovum. BARRIER METHODS (cont)
“ OCCLUSIVE” methods both suitable for men and a. Physical methods: Condoms, female condoms,
women(CONDOMS, FEMALE CONDOMS , diaphragm/ Diaphram, vaginal sponges
cervical cap, Vaginal sponges)
i. Condoms:
Advantages
* Most widely used, effective , simple spacing method
Absence of side effects associated with pills and of contraception with minimal side effects
IUDs
* Prevents semen from being deposited in the vagina
protection from STDs
* more effective when used in conjunction with
Protection from PID.( significant decrease in its spermicidal jelly
incidence )
* pregnancy rate varying from 2 – 3 / 100 women -years
Protection from cervical cancer to some extent of exposure to more than 14 in typical users mostly
Disadvantages due to incorrect use.
Require high degree of motivation (100 women observed over one year of use, or 10
Less effective than the pill or the lUCDs. women over 10 years).
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BARRIER METHODS (cont) BARRIER METHODS

(cont)
Advantages of condoms: ii. Female condoms:
● Easily available ● pouch made up of polyurethane, which lies in
● Easy to use the vagina
● Safe and inexpensive ● Internal ring is close and covers the cervix,
● No side effects external ring outside the vagina
● Light, compact and disposable ● Pre lubricated with silicon- no spermicidal is
● Protection against pregnancy and STIs required
Disadvantages: ● Failure rate 5- 21 / 100 women years
● May slip or tear off in typical users
● Interferes with sex sensation- not used regularly
by many men 0 0

BARRIER METHODS (cont) BARRIER METHODS (cont)

iii- Diaphragm:
● a vaginal barrier also called “ Advantages:
Dutch cap “
● Almost total absence of risks and medical complications
● Variations include cervical cap,
vimule cap, vault cap Disadvantages:
● Shallow cup made up of synthetic ● Initially physician and trained persons needed to
rubber or plastic demonstrate insertion
● Used according to proper size ● After delivery, it can be used only after complete
involution of uterus
● Held in position by spring tension or
muscle tone of vagina ● Privacy and practice for insertion
● Inserted before intercourse and ● Facilities required for washing and storage
must remain in position for not less ● If left in vagina for extended period, Toxic shock
than 6 hrs afterwards & spermicidal syndrome occurs which is peripheral shock requiring
jelly must be used resuscitation
● Failure rate is 6-12 / 100 woman
yrs 0 0
 BARRIER METHODS (cont) BARRIER METHODS (cont)
iv- Vaginal sponges: b. CHEMICAL METHODS
● Polyurethane foam sponge saturated with ● Mechanism of Action:
spermicidal These are surface-active substances which attach
● Failure rate 20-40/100 woman yrs themselves to spermatozoa and inhibit oxygen
uptake and kill sperms.
( parous) 9-20/100 woman yrs ( nulliparous)
● Important point to remember:
-Spermicide should be free from systemic toxicity
-No inflammatory or carcinogenic effect

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CHEMICAL METHODS (cont) SPACING METHODS….

Four categories
● Foams: Foam tablets, foam aerosols 2. INTRA UTERINE CONTRACEPTIVE DEVICES
● Creams, jellies and pastes
● Suppositories • BASIC PRINCIPLE
● Soluble Films The control of conception by introduction of
DISADVANTAGES foreign body into the uterus.
● high failure rate
● Use almost immediately before intercourse
● Must be introduced in regions of vagina where
sperms are likely to be deposited
● Less effective when used alone
● Concern about possible teratogenic effects
• Local irritant action.
● Create a mess. 0 0

TYPES OF IUCDs FIRST GENERATION IUCDs

Two main types: LIPPES LOOP
• NON MEDICATED * Double S shaped device.
Made of polyethylene * Material- non toxic, non tissue reactive and
or other polymers durable.
-1st generation or inert IUCDs * Small amount of Barium Sulfate.
* Loop has attached threads or "tail"- re assurance
and removal.
* available in four sizes-A, B, C, D
* may be left in uterus as long as no problem
• MEDICATED occurs
Release metal ions or hormones ● SECOND GENERATION IUCDs:
-2nd Generation or Copper lUCDs
-3rd Generation or hormone releasing lUCDs. ● Copper in different strengths eg CuT380
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●
THIRD GENERATION lUCDs
PROGESTASERT
THIRD GENERATION lUCDs…
* T-shaped device filled with progesterone
-38mg. ● LEVONORGESTREL- Mirena
* Hormone is released slowly in the uterus at the * T- shaped device also releasing
rate of 65mcg/day synthetic steroid.
* Direct local effect on the uterus lining, sperms * Lower menstrual blood loss.
and on the cervical mucus.
* As hormone depletes- regular replacement is * Effective life of 10 years.
required * Low preg rate 0.2/100 woman yrs
* Higher failure rate * Low blood loss and less number of ectopic
preg
* Expensive.

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IUCDs
IUCDs
MECHANISM OF ACTION
MECHANISM OF ACTION ● 2nd Gen: in addition to foreign body effects:
● Ist Gen: * Copper enhances the cellular response and affects
enzymes in the uterus.
* Cause a foreign body reaction, *Copper ions alter biochemical composition of cervical
Cellular and biochemical changes in the mucus.
endometrial and uterine fluids *Affect sperm motility, capacitation and survival
*Hormone releasing devices increase the viscosity of
* These changes impair the viability of cervical mucus and effects the sperm motility.
gamete and reduce chances of ● 3rd Gen:
fertilization. * Inc viscosity of cervical mucous and thereby prevent
sperm from entering the cervix.
* High levels of progesterone and relatively low levels of
0
estrogen sustain an endometrium unfavorable for 0
implantation of ovum.

IUCDs
ADVANTAGES IUCDs
ABSOLUTE CONTRA INDICATIONS
● Simplicity
● Pregnancy or failure rate 3-5/ 100 woman year
–all typical users ● Suspected pregnancy.
● Insertion takes only a few minutes ● Active Pelvic inflammatory diseases.
● Inexpensive ● Vaginal bleeding of undiagnosed etiology.
● Reversible ● Cancer of the uterus or adenexa and other
● Free of systemic metabolic side effects pelvic tumors.
● No need for continual motivation ● Previous ectopic pregnancy.
● No interference with lactation
● Independent of time of intercourse
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 IUCDs IDEAL IUCD CANDIDATE
RELATIVE CONTRA INDICATIONS ● According to Planned Parenthood Federation of
America ( PPFA), is a woman:
* Who has borne at least one child.
● Anemia
* Has no history of pelvic disease.
● Menorrhagia * Has normal menstrual periods.
● History of PID * Is wiling to check the IUCD tail.
● Purulent cervical discharge * Has access to follow up and treatment of
● Distortions of the uterine cavity potential problems.
● Fibroids * Not rec for woman who have no children????
and multiple partners because of risk of PID and
● Unmotivated persons infertility
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IUCDs IUCDs
1. During menstruation INSERTION
TIMING OF TIMING OF INSERTION….
2. within 10 days of the beginning of the menstrual 4. Post puerperal insertion- 6-8 wks after delivery,
period, because: advantage of combining with post natal follow
* Diameter of cervical canal is greater and ups and also after 1st trimester abortions
insertion technically easy. 5. Not rec after 2nd trimester abortions and
* Uterus is relaxed and myometrial contractions illegal abortions because of risk of perforation
are at a minimum. and infections
*The risk of pregnancy is remote.
3. Immediate post partum insertion or during 1st
week after delivery-disadvantages of
perforation and expulsion

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Follow up for IUCD INSTRUCTIONS TO USER OF IUCDs

● Objectives:
* To provide motivation and emotional support.
* To confirm the presence of IUCD. ● She should regularly check the tail and
• To diagnose and treat any side effect or consult the doctor, if she:
complication. • Fails to locate the thread.
Timings of follow-ups: • Experiences any side effects e.g.. Pain ,fever,
● After 1st menses as chances of expulsion are bleeding
higher • Misses a period.
● After 3rd menses for pain and bleeding
● After 6 months and 1 year intervals

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 IUCDs COMPLICATIONS/ SIDE EFFECTS IUCDs COMPLICATIONS/ SIDE EFFECTS
6. Uterine Perforation: incidence 1/150 to 1/9000
insertions- depends on type, time of insertion,
1. Bleeding- accounts for 10- 20 % removal of technique, operators experience- most commonly occur
IUCD, usually settles in2-3 months, heavy between 48 hrs to 6wks of postpartum
persistent bleeding leads to Anemia 7. Pregnancy: failure rate 3%, 50% uterine pregnancies
2. Pain- 15-40% of removal, low back ache, with devises in situ
dysmenorrhea, low abdominal pain- disappears Ectopic Pregnancy: with levenorgestrol and CuT 380
within 3months A rate is 0.2/ 1000 woman yr of contraception
3. Pain during insertion may be because of Expulsion: rate varies between 12-20% and
disparity of size, uterine perforation, infection. unfortunately 20 % expulsions go unnoticed
4. Pain more common in nulliparous or in Infertility after removal: if frequent episodes of PID, >
woman having no child for many years 70% of IUCD users conceive within a year of removal
5. Pelvic Infection:2-8% of developing PID through Cancers and teratogenic effects- no evidence
tail, or during insertion- 1to 2 episodes of PID can Mortality: Extremely rare- 1 death/ 100,00 WY
lead to infertility
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SPACING METHODS… GONADAL STEROIDS

3. HORMONAL CONTRACEPTIVES ( Oestrogens and Progestogens)
1. Synthetic Estrogens:
• Ethinyl Oestradiol
• The most effective spacing methods, • Mestranol
2. SYNTHETIC PROGESTOGENS:
when properly used. • PREGNANES- Megesterol,
• Oral contraceptives of combined Chlormadinone, Medroxy progesterone
Acetate.
type are almost 100% effective in • OESTRANES (19-nortestosterones)--
preventing pregnancy. Norethisterone, Norethisterone Acetate,
Lynesterol, Ethynodiol Diacetate and
Norethynodrel.
• GONANES- Levonorgestrel
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CLASSIFICATION OF HORMONAL
Oral Pills CONTRACEPTIVES
COMBINED ORAL PILLS COC
Combined Oral Contraceptive
Pill (COC). • It is one of the major spacing methods of
Progestogen only pill (POP). contraception.
Post coital pill-EC
Once a month (long acting) pill. ● Contain 30-35 mcg of a synthetic estrogen and
Male Pill. 0.5 to 1 mg of a progestogen
Depot (slow release ) ● If the user forgets to take a pill, she should take
formulations
- Injectables it as soon as she remembers, and she should
- Subcutaneous Implants take the next day's pill at the usual time.
- Vaginal Rings

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 ORAL PILLS MODE OF ACTION
COMBINED ORAL PILLS COC (cont)
● Inhibits ovulation: Prevent the release of
the ovum from the ovary by Blocking the
● The pill is given orally for 21 consecutive pituitary secretion of gonadotrophin that is
necessary for ovulation to occur.
days beginning on the 5th day of ● Inhibits Implantation of the Zygote
menstrual cycle followed by a break of 7 ● Progestogen Only preparations, render the
days during which menstruation occurs. cervical mucus thick and scanty and thereby
inhibit sperm peneteration.
● It is an episode of uterine bleeding from ● Inhibits sperm capacitations and survival
an incompletely formed endometrium ● Progestogens also inhibit tubal motility and
caused by the withdrawal of exogenous delay the transport of the sperm and of the
ovum to uterine cavity
hormones— "withdrawal bleeding". ● Offers reversible contraception
● The pill should be taken every day at a
fixed time.
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POST COITAL CONTRACEPTION

PROGESTOGEN ONLY PILL(POP) Recommended within 72 hours of
•”Minipill” or “Micropill”- Contains only unprotected intercourse, rape or failed
progestogen( Norethisterone and contraception.
Levonorgestrel), which is given in small Advocated as an emergency method:
doses throughout the cycle. • Hormonal:
Advantages One tab Levonorgestrel 0. 75 mg within 72
hrs and the second tab after 12 hrs of first
• Older women because of cardiovascular dose. OR
risks. Two OCP 50ugm Ethinyl oestradiol) within
• Young women with risk factors for 72 hrs and the same dose after 12 hrs. OR
neoplasia. Four OCP 30- 35 ugm Ethinyl oestradiol
No effect on lactating baby within 72 hrs and 4 tablets after 12 hrs.
●
OR
Disadvantages Mifepristone 10mg once within 72 hrs.
• Poor cycle control • IUCD: Emergency IUCD insertion within 5
• Increased pregnancy rate. days (Cu T 380 A)
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ONCE A MONTH (LONG ACTING) PILL

• Absolute:
• Cancer of the
CONTRA breast and genitals.
INDICATIONS for OCP
* A combination of long acting • Liver disease.
estrogen quinestrol and short acting • Previous or present history of thrombo-
progestogen. Embolism.
* Pregnancy rate too high. • Cardiac abnormalities.
• congenital hyperlipidemia.
* Bleeding irregular.
• Undiagnosed abnormal uterine bleeding.

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 CONTRA INDICATIONS…. DANGER SIGNS OF PILL USE
Relative contraindications: which require
medical surveillance: A- Abdominal pain (sever)
* Age over 40 years now over 50 yrs C- Chest pain (sever), cough,
* Smoking and age over 35 years
shortness of Breath.
* Mild Hypertension
* Chronic Renal disease H- Headache (sever), dizziness, weakness
* Epilepsy or numbness.
• Gall Bladder disease E- Eye problems (vision loss or blurring).
• Migraine
S- Speech problems, sever leg pain
• Infrequent bleeding
• Amenorrhea (Calf or thigh).
• Nursing mothers
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ADVERSE EFFECTS OF ADVERSE EFFECTS OF

ORAL PILLS ORAL PILLS (cont)
● Cardiovascular Effects ● Carcinogenesis
• Myocardial Infarction increased risk of cervical cancer with
• Cerebral Thrombosis increasing duration of use
• Venous Thrombosis Metabolic Effects
• Hypertension • Alteration in serum lipids
• Blood clotting time decreases
• Carbohydrate metabolism modification
• Inc atherogenesis resulting in MI & Stroke

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OTHER ADVERSE EFFECTS

OF ORAL PILLS ORAL PILLS BENEFICIAL EFFECTS
Liver Disorders— Hepatocellular adenoma, Gall
bladder disease, Cholestatic jaundice
Lactation- quantity and constituents of breast milk
, premature cessation of lactation ● Protection against at least 6
Subsequent Fertility— slight delay in conception diseases:
Ectopic Pregnancy ● Benign breast disorders
Fetal developmental problems ● Ovarian cyst
● Iron Deficiency Anemia
● Pelvic Inflammatory Disease
COMMON UNWANTED SIDE EFFECTS
● Ovarian Cancer
• Breast Tenderness
• Weight Gain
• Headache and Migraine
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• Bleeding Disturbances
 CHECK LIST FOR PRESCRIPTION OF
OCPs CHECK LIST FOR PRESCRIPTION OF OCPs…

● By history and examination rule out: • Symptomatic varicose veins

• Age> 50 yrs • Lump breast
• Age >35 yrs and smoker • Lactation-for less than 6 months
• Seizures • Amenorrhea
• Severe headaches/ and or visual • Inter menstrual bleeding
disturbances • Post coital bleeding
• Severe chest pain • Yellow skin discoloration
• Shortness of breath • BP >140/90 mmHg
• Severe pain in calves and legs and If all the above are –ve then prescribe OCP,
thighs If any one is +ve then consult a doctor
• Swollen legs
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DMPA-Depomedroxy progesterone
DEPOT FORMULATIONS Acetate. Depo-Provera
Highly effective, reversible, long acting and
estrogen free with a single administration for It is safe, effective and acceptable contraceptive. It
several months or years. does not effect lactation.
● Injectable Contraceptives Mode of Action
* DMPA (Depot Medroxyprogesterone Suppression of ovulation.
Acetate) Indirect effect on endometrium.
* NET-EN (Norethisterone Enantate) Direct action on fallopian tube.
● Subdermal Implants: Norplant 35 mg Action on the production of cervical mucus.
Levonorgesterel, Norplant®-2 protection for Dose: 150 mg I/M injection every 3 months.
5 yrs Side Effects:
● Vaginal Rings: containing Levonorgesterel, Weight increase
worn for 3 wks and then removed
Irregular menstrual bleeding
Prolonged infertility
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SUBDERMAL IMPLANTS
NORPLANT Male pill (Gossypol)
Research based on four elements:
Preventing spermatogenesis
Consists of 6 silastic (silicone rubber) capsules
containing 35 mg each of Levonorgesterel. Interfering with sperm storage & maturation
Norplant ( R ) 2- most recent devise, 2 small rods of Preventing sperm transportation via vas
levonorgestrel Affecting constituents of seminal vesicles
Implanted beneath the skin of the forearm or the
upper arm.
Effective contraception provided for over 5 years. Ideal male contraceptive would decrease sperm
The contraceptive effect is reversible. count but leave testosterone at normal levels
DISADVANTAGES OF NORPLANT
Irregular menstrual bleeding Gossypol –a cotton seed derivative produces
Trained professional required azoospermia and significant oligospermia-10% may
Surgical procedure necessary to insert and remove be permanently azoospermic- a narrow toxic margin
implants 0 0
 4. POST-CONCEPTIONAL
5. MISCELLANEOUS
METHODS Abstinence
1. Menstrual regulation Coitus interruptus
aspiration of the uterine contents within 6- Safe period
14 days of a missed period. Natural Family Planning methods
2. Menstrual induction • Basal body temperature method: rise in
temp 0.3 to 0.50 C on ovulation
by disturbing the normal progestrone- • Cervical mucus method: BILLING’S
prostaglandin balance by intrauterine METHOD
application of 1-5 mg solution (or 2.5-5 • Symptothermic method: BBT+ cervical
mg pallet) of prostaglandin F2 under mucous+ calendar technique
sedation. Breast Feeding
0
Birth control vaccine: prepared from sub unit of 0
HCG, block early pregnancy
Yoga

Learning objectives
By the end of session you should be able to:
Classify and discuss Terminal methods of Family
Planning.
Evaluation of Contraceptive method.

FAMILY PLANNING WHO 5 types of evaluating family planning services

and the requirements to conduct this evaluation.
Unmet Need for FP , its reasons and different
approaches to address this issue.

Terminal methods and Evaluation

Part-3
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Terminal Methods (Sterilization) Guidelines for sterilization

Voluntary Surgical Contraception (VSC) ● Age of husband not <25 yrs nor >50 yrs
Well established method for couple desiring
no more children ● Age of wife not <20yrs nor >45 yrs
• Male Sterilization ● Two alive children
• Female Sterilization
• Advantages ● With 3 living children- relaxation of age
* One time method ● Written undertaking from the spouse
* Does not require sustained motivation
* Less risk of complications when performed as before undergoing sterilization
per medical stds
* The most effective protection
* The most cost effective method

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 MALE STERILIZATION
●
Magnitude of the problem
Sterilization is the most widely used VASECTOMY
TRADITIONAL INCISIONAL PROCEDURE:
contraceptive method worldwide.
● A simple procedure , can be performed in
● According to United Nations estimates, in
Primary health centres by trained doctors
2005, 262 million women of reproductive
age were using sterilization contraception. ● Under local anesthesia and aseptic
conditions
● Of these, 225 million relied on female
sterilization and 37 million on vasectomy, ● Piece of vas deferens (about 1 cm) is
accounting for 34% and 5.6%, removed. The ends are ligated and then
respectively folded back.
● Female sterilization is far more common ● ADVANTAGES OF vasectomy :
than male sterilization • Safer and Simpler
• About half the cost of female sterilization
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• Probably more effective.

Scalpel versus no-scalpel

Developed in China by Dr. Li Shunqiang ADVANTAGES OF NSV:
incision for vasectomy
● ●

● The aim was to reduce men’s fear related • Less bleeding, haematoma and pain
to the incision and increasing vasectomy during or after the procedure.
use in China. • Less operation time
● Since 1974, over 10 million Chinese men • Vasectomized men are able to resume
have undergone NO SCALPEL vasectomy sexual activity more quickly
• More acceptable
● Currently used in more than 40 countries.
● The vasectomy is done through one single Source:
puncture in the scrotum and requires no http://apps.who.int/rhl/fertility/contraception
suturing or stitches
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FEMALE STERILIZATION
Complications of vasectomy Done as an interval procedure, peri partum or at the
time of abortion.
At any time remote from pregnancy (referred to as
* Pain interval sterilization).
* Hematoma Approximately half of female sterilizations are interval
sterilizations
* Local infection The other half are performed at the time of cesarean
delivery or immediately postpartum.
* Spermatic granules Two procedures are commonly used
* Spontaneous re canalization * LAPAROSCOPY
* Autoimmune response Ligation is done through specialized instrument called
Laparoscope. The fallopian rings are applied to occlude
* Psychological the tubes.
* MINILAP OPERATION
conducted under local anesthesia. Safe, efficient and
suitable for post partum sterilization.
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 WHO MEDICAL ELIGIBILITY CRITERIA EVALUATION OF
FOR VARIOUS CONTRACEPTIVE CONTRACEPTIVE METHODS
METHODS-2015 ● Contraceptive efficacy is determined by:
* number of unplanned pregnancies during
a specified period of exposure
* contraceptive method used

● Two methods:
- Pearl index
● The MEC-wheel - Life table analysis
● http://www.who.int/reproductivehealth/pu
blications/family_planning/mec-wheel-
5th/en/ 0 0

EVALUATION OF CONTRACEPTIVE EVALUATION OF

METHODS…
CONTRACEPTIVE METHODS…
PEARL INDEX: “ Failures/ hundred woman ● Failure rate of 10/ HWY means, in life time of
year ( HWY ) average woman ¼th or 2.5 accidental preg will
Failure per HWY= occur since the average fertile period of a woman
*Total accidental pregnancies x **1200 is 25 yrs.
● Minimum of 600 months of exposure to a
***Total months of exposure contraceptive is considered necessary before any
( * Must include every known conception conclusion is reached
irrespective of the outcome ie. Live births, ● LIMITATIONS:
still births, abortions, pregnancy not yet With most contraceptives, failure rates decline
terminated. with duration of use, while pearl index is based
** 1200 is the No of months in 100 yrs on specific exposure usually a year- so fail to
compare methods at various duration of exposure
*** It is obtained by deducting 10 months for
a full term preg and 4 months for an
abortion from the period under review) This is overcome by life table analysis
0 0

EVALUATION OF EVALUATION OF FAMILY

CONTRACEPTIVE METHODS… PLANNING
LIFE TABLE ANALYSIS: Evaluation is:
● Calculate failure rate for each month of
use “ A process of making judgments
● A cumulative failure rate can compare about selected objectives and events
methods for any specific length of by comparing them with specified
exposure value standards- for the purpose of
Dropout females for reasons other than
●
unplanned preg , are removed from the
deciding alternative course of action”
analysis, contributing their exposure
until the time of exit

0 0
 EVALUATION OF FAMILY EVALUATION OF FAMILY
PLANNING… PLANNING…
WHO 5 types for evaluation of FP 3. Evaluation of performance:
services: a, Services: clinical, mobile, post partum,
1. Evaluation of need: contraceptive distribution svc, follow up svc,
education and motivation activities
Health, demographic and b, Response: No of new acceptors and
socioeconomic needs for FP .eg. characteristics of acceptors
MMR an indicator of the need for FP c, Cost analysis
2. Evaluation of plans: d, Other activities: Administration, manpower,
Assessment of the feasability and data system etc.
adequacy of programme plans 4. Evaluation of effects: Changes in
knowledge , attitude , motivation and behavior
0 0

EVALUATION OF FAMILY REQUIREMENTS FOR THE

PLANNING… PROCESS OF EVALUATION
5. Evaluation of impact: WHO study group
in 1976 proposed indices for evaluating
the impact: ● A technical activity
● Family size –No of living children
● Desired No of addl children
● Trained staff
● Birth interval ● Statistical facilities
● Age of mother at birth of first child and ● Adequate flow of data and info
last child
● birth order
● No of abortions
● Changes in birth and growth rate
0 0

UNMET NEED FOR FAMILY PLANNING…

UNMET NEED FOR FAMILY REASONS:
1. Difficulties with access to and quality of FP
PLANNING supplies and services
● The KAP- Gap for FP
Approaches to meet unmet need:
● Women who want to avoid preg but are
not using any contraceptive method * offer a choice of other contraceptive methods
including use by their partner, are having * Encourage availability through more outlets
– unmet need for family planning Start or expand social marketing programmes
● A challenge for Family planning Train the providers-empathic, respectful and
interpersonal relations with the clients
programme- to reach and serve millions of
women Provide privacy for client counseling and procedures
Reduce client waiting time and paper work
● Abortion as an indicator of unmet need
Keep contraceptives in stock

0 0
 UNMET NEED FOR FAMILY PLANNING- UNMET NEED FOR FAMILY
2. Health concernsREASONS…
about contraceptives & side
effects PLANNING-REASONS…
3. Lack of information
APPROACHES:
Address facts and myths about FP and health through
mass media communication; discuss specific methods APPROACHES:
Counseling should cover the side effects thoroughly • Expand mass media communication- radio, TV
Train the providers to manage the side effects ,print media..
Help the clients to accept method switching as normal
Offer a cafeteria choice • Inform communities about methods at public
Employ a testimonial of satisfied contraceptive user to meetings and community events like theatre
address the concerns of those who never used such • Train the providers to answer clients questions
methods
and concerns about FP

0 0

UNMET NEED FOR FAMILY

CONTD….
PLANNING-REASONS…
4. Opposition from husbands, families and
communities
● Encourage better communication between
husband and wife about FP& RH
APPROACHES: ● Help woman to learn how they can discuss it with
● Address men directly with information about their spouse
safety and benefits, recognizing men ‘s
dominant role in decision making but
promoting equal participation of women also 5. Little perceived risk of pregnancy
● Offer FP services to men in settings they feel APPROACHES:
comfortable ● Awareness about risks to the mother and child
● Demonstrate that FP is the community norm
and responsible personal behavior, endorsed
by religious and civic leaders

0 0

THANK YOU

0
 8/3/2023 2

Definitions
INFANT AND YOUNG
• Infant
CHILD GROWTH • A child less than one year

MANAGEMENT • Young child

• Biologically, a child is a human being between
Dr Nosheen Zaidi the stages of birth and puberty, or between the
developmental period of infancy and puberty.

8/3/2023 3 8/3/2023 4

Appropriate Nutrition
• 0-6 months breast feeding
• At 6 months add soft complementary food
• Continue breast feeding for two years with complementary
food

8/3/2023 7 8/3/2023 8

Advantages of breastfeeding for the

Advantages of breastfeeding for the mother
• The baby's sucking causes a mothers uterus to contract
baby and reduces the flow of blood after delivery
• During lactation, menstruation ceases, offering a form of
contraception
• Mothers who breastfeed tend to lose weight and achieve
their pre-pregnancy figure more easily than mothers who
bottle feed
• Mothers who breastfeed are less likely to develop breast
cancer later in life
• Breastfeeding is more economical than formula feeding
• There are less trips to the doctor and less money is spent
on medications
• Breastfeeding promotes mother-baby bonding
• Hormones released during breast-feeding create feelings
8/3/2023 9 8/3/2023 10

Comparison between human , formula

and cow milk
• Reference to a case study in China for formula milk

POSITIONING A BABY AT
THE BREAST
After completing this session participants will be
able to:
•Describe how a mother should support her
breast for feeding

8/3/2023 11 8/3/2023 12

Look for BF position

Observe 4 min. & look if ‘Attachment’ is good/ not well/ not
at all, by looking for 4 conditions: (Ilyas)
1. Chin touching breast
2. Mouth wide open
3. Lower lip turned outwards
4. More areola visible above than below mouth

If attachment seems poor, tell her correct positioning for

ensuring good attachment: Show her how to hold Infant,
close to her body, with It’s head & body straight, facing her
breast with It’s nose opposite her nipple, supporting It’s
whole body & not just neck & shoulders. While attaching,
wait for It’s mouth to open wide & then aim It’s lower lip
well below the nipple. (It’s=Infant’s)

8/3/2023 13 8/3/2023 14

BF position BF position
•A baby with cleft palate or tongue tie can get feed • Look if baby is suckling effectively/ not effectively/ not at
all by observing: 1. Deep sucks 2. Slow, with pause
easily in normal BF position.
sometime
• If he has cleft lip → feed him with sitting position &
dancer’s hold.
• If cleft lip + cleft palate → sitting position &
football position
• If he has receding chin → supine, dancer’s hold,
draw chin forward
 8/3/2023 15 8/3/2023 16

‘Not enough milk’

COMMON
This is one of commonest reasons for stopping
BREASTFEEDING •
breastfeeding
DIFFICULTIES • Usually when a mother thinks she does not have
enough breast milk, her baby is getting all he
After completing this session participants will be able to
needs
identify causes of, and help mothers with, the • Sometimes a baby does not get enough breast
following difficulties: milk. But this is usually because of ineffective
1. Not enough milk suckling. It is rarely because his mother cannot
2. Crying baby produce enough
3. Breast refusal

8/3/2023 17 8/3/2023 18 14/4

Reliable signs that a baby is not Possible signs that a baby is not
getting enough milk getting enough breast milk
1. Baby not satisfied after breastfeeds
• Poor weight gain
2. Baby cries often
3. Very frequent breastfeeds
• less than 500 grams per month
4. Very long breastfeeds
5. Baby refuses to breastfeed
• Small amount of concentrated urine
6. Baby has hard, dry, or green stools
7. Baby has infrequent small stools
• less than 6 times per day
8. No milk comes out when mother expresses
9. Breasts did not enlarge (during pregnancy)
10. Milk did not ‘come in’ (after delivery)

8/3/2023 19 8/3/2023 20

Reasons why babies refuse to

breastfeed
• Baby ill, sedated or in pain • Examine mother’s nipples & baby’s mouth
for ulcers which are signs of fungal
• Difficulty with breastfeeding technique
infection /thrush: Wash nipples with water,
• Change which upsets the baby air-dry, apply Nystatin cream on nipple, &
• Apparent, not real, refusal
put gentian violet/ nystatin drops in mouth
of baby.
8/3/2023 21 8/3/2023 22

1. Clean
breast

EXPRESSING BREAST
2. Apply
pump
3. Express

MILK 4.
5.
Collect
Store
6. Feed
After completing this session participants will be able to:
•List the situations when expressing breast milk is useful
•Explain how to stimulate the oxytocin reflex
•Rub a mother’s back to stimulate the oxytocin reflex
•Demonstrate how to select and prepare a container for
expressed breast milk
•Describe how to store breast milk
•Explain to a mother the steps of expressing breast milk
by hand

8/3/2023 23 8/3/2023 24

1. Latching issues: Some babies may have difficulty latching properly to

the breast, making breastfeeding challenging or ineffective. Cup-feeding
can be used as an interim solution while working on improving the latch
or to supplement feeding until the latch improves.
2. Premature or low birth weight babies: Premature infants or babies with
CUP-FEEDING low birth weight may have difficulty breastfeeding due to their
underdeveloped sucking reflex. Cup-feeding can be gentler and less
After completing this session participants will be able to: taxing for these delicate infants.
•list
the advantages of cup-feeding 3. Sucking difficulties: Some babies may have medical conditions that
affect their ability to create a strong enough sucking motion required for
•estimatethe volume of milk to give to a baby breastfeeding. In such cases, cup-feeding may be recommended as an
according to weight alternative.
•demonstrate how to cup-feed safely 4. Breastfeeding difficulties in mothers: Certain medical conditions,
medications, or surgeries may hinder a mother's ability to breastfeed
effectively. In such situations, cup-feeding can be used to provide breast
milk while addressing the underlying issues.
5. Transitioning from tube feeding: In some cases, when infants have
been fed through tubes due to medical conditions, transitioning to cup-
feeding may be a step toward eventually transitioning to breastfeeding.

8/3/2023 25 8/3/2023 26

Cup-feeding
• Avoids changes in sucking techniques that may arise from
the use of artificial teats.
• Allows baby to control the volume and time it takes BREAST CONDITIONS
to feed.
After completing this session participants will be able to
• Assists babies to stimulate tongue and jaw movements
recognize and manage these common breast
• 150 ml-200 ml of milk per kilogram of body weight per
conditions:
day three months
•Flat and inverted nipples
•Engorgement
•Blocked duct and mastitis
•Sore nipples and nipple fissure
 8/3/2023 27 8/3/2023 28 20/8

Symptoms of blocked duct and

Management of flat and inverted mastitis
nipples
• Antenatal treatment is not helpful non-infective infective
blocked duct milk stasis
• Build the mother’s confidence mastitis mastitis

• Help the mother to position her baby

• If a baby cannot suckle effectively in the first
week or two help his mother to feed with
expressed milk

• Lump • Hard area

• Tender Progresses to • Feels pain
• Localised redness • Red area
• No fever • Fever
• Feels well • Feels ill

8/3/2023 29 8/3/2023 30 20/10

Causes of blocked duct and mastitis Treatment of blocked duct and mastitis
• Poor drainage of whole breast: • Most important – improve drainage of milk
• infrequent feeds • Look for cause and correct
• short feeds • Suggest:
• Frequent Feeds
• Poor drainage of part of breast: • Gentle Massage Towards Nipple
• ineffective suckling • Warm Compresses
• Start Feed On Unaffected Side; Vary Position
• pressure from clothes
• pressure from fingers during feeds
• Antibiotics, analgesics, rest

8/3/2023 31 22/1 8/3/2023 32 22/2

Clean hands
• Afterusing toilet
• Aftercleaning baby’s
HYGIENIC PREPARATION bottom

OF COMPLEMENTRY • Before preparing or

serving food
FEEDS • Before feeding children
After completing this session participants will be able to: or eating
•explain the requirements for clean and safe
feeding of young children
•demonstrate how to prepare a cup hygienically
for feeding
8/3/2023 33 22/3 8/3/2023 34 22/4

Clean utensils Safe water and food

• Clean surface • Treatwater for drinking
• (table, mat or cloth) and baby’s feeds
• Wash utensils immediately • Keep water in clean
after use
covered container
• Keep clean utensils
• Boil milk before use
covered
• Use clean utensils for • Givefreshly prepared
baby complementary foods

8/3/2023 35 22/5 8/3/2023 36 22/6

Safe storage Disadvantages of feeding bottles

• Keep foods in tightly
covered containers
• Store foods dry if
possible (e.g. milk
powder, sugar)
• Use milk within one day
if refrigerated Difficult to clean Less adult
and sterilize attention
• Use prepared feeds
within one hour
May cause illness

8/3/2023 38 29/2 8/3/2023 39 29/3

Stomach size
FOODS TO FILL THE
ENERGY GAP
After completing this session participants will be able to:
•List
the local foods that can help fill the energy
gap
•Explain the reasons for recommending using
foods of a thick consistency
•Describe ways to enrich foods
 8/3/2023 40 29/1 8/3/2023 41 29/4

Energy required by age and the

amount supplied from breast milk Key Message 3
• Foods that are thick
1000
enough to stay in the
E Energy Gap Just right
n
spoon give more energy
e 800 to the child
r
600
g
y Energy from
400 breast milk
(k
c 200 Too thin
al
/d 0
a 0-2 m 3-5 m 6-8 m 9-11 m 12-23 m
y) Age (months)

8/3/2023 42 29/5 8/3/2023 43 30/1

Fats and oils

butter / margarine / ghee
FOODS TO FILL THE IRON
AND VITAMIN A GAPS
After completing this session participants will be able to:
•List the local foods that can fill the nutrient gaps
for iron and vitamin A
•Explain the importance of animal-source foods
•Explain the importance of legumes
•Explain the use of processed complementary
coconut foods
•Explain the fluid needs of the young child
•List the key messages from this session

8/3/2023 44 30/2 8/3/2023 45 30/3

Gap for iron Key Message 4

•Animal-source foods are especially good for children, to
Absorbed iron needed and amount provided
help them grow strong and lively
1. Iron gap poultry fish
2
Abs
orbe
0. Iron from
d
8 birth meat
iron stores
(mg/ liver
Iron from
day) 0. breast
4 milk cheese

0
0-2 m 3-5 m 6-8 m 9-11 m 12-23 m
Age (months) eggs
yoghurt
8/3/2023 46 30/3 8/3/2023 47 30/4

Key Message 4 Key Message 5

•Animal-source foods are especially good for children, to •Peas, beans, lentils, nuts and seeds are also good for
help them grow strong and lively children

seeds

cheese Groundnut
lentils
paste

beans

eggs
peas nuts
yoghurt

8/3/2023 48 30/5 8/3/2023 49 30/6

Key Message 6
Gap for vitamin A •Dark-green leaves and yellow-coloured fruits and

Vitamin A needed and amount provided vegetables help a child to have healthy eyes and fewer
infections
400
Vitamin A
V gap
it 300
a Vitamin A
m from birth
200 stores carrot
in
Vitamin A
A
from pumpkin yellow sweet
( 100 breast milk
potato
µ
g 0
R 0-2 m 3-5 m 6-8 m 9-11 m 12-23 m
E
Age (months) mango
/d
a papaya spinach
y)

8/3/2023 50 31/1 8/3/2023 51

•WHO recommends
•Infants start
receiving complementary
QUANTITY, VARIETY AND foods at 6 months of age in
addition to breast milk
FREQUENCY OF FEEDING •initially 2-3 times a day
between 6-8 months
After completing this session participants will be able to:
•increasing to 3-4 times
•Explain the importance of using a variety of foods daily between 9-11 months
•Describe the frequency of feeding complementary •2-24 months with
foods additional nutritious snacks
•Outline the quantity of complementary food to be offered 1-2 times per day,
as desired.
offered
•List the recommendations for feeding a non-
breastfed child
•List the key messages from this session
 8/3/2023 52 8/3/2023 53 31/2

Gaps to be filled by complementary

foods for a 12-23 months old child
P 100% Gap
e
rc 75%

Have Been Discussed In e

nt
50%

Previous Nutrition Class a Provided by

550 ml
g
breast milk
e 25%
of
d 0%
ai Energy Protein Iron Vitamin A
ly Nutrient
n
e
e

8/3/2023 54 31/3 8/3/2023 55 31/4

Three meals Percentage of daily needs

Iron rich food added
Percentage of daily needs
250% 250%
Gap
225% 225%
200% Evening meal
200%
175% Mid-day meal
175%
morning evening 150% Morning meal
150%
125%
125% Breast milk
100%
100%
mid-day 75%
75%
50%
50%
25%
Mid-day meal 0% 25%
Gap Morning meal Energy Protein Iron Vitamin A 0%
Evening meal Breast milk Nutrients from meals Energy Protein Iron Vitamin A
Nutrients from meals

8/3/2023 56 31/5 8/3/2023 57 31/6

Three meals and two Percentage

snacks of daily needs Key Message 7
250% • A growingchild needs 2-4 meals a day plus 1-2 snacks if
225% hungry: give a variety of foods
200%
morning
evening 175%
snack
150%
snack 125%
100%
mid-day 75%
50%
25%
Snacks Mid-day meal 0%
Gap Morning meal Energy Protein Iron Vitamin A

Evening meal Breast milk Nutrients from meals

 8/3/2023 58 31/7 8/3/2023 59

Snacks and liver, but no breast milk

P 100% Gap
e
rc 75%
e
RECOMMENDATIONS FOR
nt
50%
Nutrients
FEEDING THE NON-BREASTFED
a
g from foods
CHILD
e 25%
of
d 0%
ai Energy Protein Iron Vitamin A
ly Nutrient
n
e
e

8/3/2023 60 31/8 8/3/2023 61 31/9

The non-breastfed child should receive: Key Message 8

• Extra water each day (2-3 cups in temperate • A growing child needs increasing amounts of food
climate and 4-6 cups in hot climate)
• Essential fatty acids (animal-source foods, fish,
vegetable oil, nut pastes)
• Adequate iron (animal-source foods, fortified
foods or supplements)
• Milk (1-2 cups per day)
• Extra meals (1-2 meals per day)

8/3/2023 62 26/1 8/3/2023 63 26/2

The International Code

INTERNATIONAL CODE OF MARKETING • 1981 World Health Assembly adopted The Code,
OF BREAST-MILK SUBSTITUTES which aims to regulate promotion and sale of
formula
After completing this session participants will be able
• The Code is a code of marketing
to:
• The Code covers all breast-milk substitutes –
•Explain how manufacturers promote formula
including infant formula, other milks or foods,
milks
including water and teas and cereal foods which
•Summarize the main points of the international
are marketed for infants under 6 months, and teats
code of marketing of breast-milk substitutes and bottles
•Describe how the international code of
marketing of breast-milk substitutes helps to
protect breastfeeding
•Explain the difficulties with donations of formula
 Learning Objectives
At the end of session, students shall be able to:
• Discuss aim, strategies and types of preventive
Paediatrics
• Define a child and discuss the importance of care of
children.
• Enlist different periods of childhood.
• Discuss the objectives and strategies of early
Dr Tahira Amjad
neonatal care.
Assoc Prof
• Illustrate flow chart of optimum newborn care.
C/Med Department
FUMC

0 0

Learning Objectives… Introduction

• Outline different components of immediate new Approximately 71.14 per cent of the population of
born care. developing countries constitute mothers and children .
• Explain APGAR score and it’s interpretation, They are major consumers of health services
tabulate it’s features. Also a "vulnerable" or special-risk group
• Outline different examinations of the newborn. Risk associated with :
child-bearing in case of women
• Enlist different methods to measure the baby and growth, development and survival in case of infants and children
give WHO classification of anthropometric 50 per cent of all deaths are occurring among children
measurements. during the first five years of life, largely preventable.
• How and why to screen a newborn? Improving the health of mothers and children, a
contribution to the health of the general population
• Give the importance and criteria for the
identification of “at risk” infant.
0 0

Introduction…… Paediatrics ( Child Health)

• A close relationship of:
maternal health child health maternal and child
health health of the family general • “It is a branch of medical science that deals with the
care of children from conception to adolescence, in
health of the community health and disease.”
• Obstetricians and Paediatricians now looking beyond the • The first clinical subjects to link itself to preventive
four walls of hospitals into the community to meet the medicine. How????
health needs of mothers and children aimed at positive • Encompasses a large component of preventive and
social medicine.
health • Paediatrics is a comprehensive discipline which
• Linked preventive and social medicine, and terms such teaches the value of preventive medicine.
•

as "Social Obstetrics", "Preventive Paediatrics" and

"Social Paediatrics" have come into vogue.

0 0
 Specialized Branches of
Paediatrics
• Preventive Paediatrics Preventive Paediatrics
• Social Paediatrics comprises efforts
• Neonatology
• Perinatology to
• Developmental Paediatrics avert rather than cure
• Paediatric surgery disease and disabilities.
• Paediatric neurology, and so on.

0 0

Aim of preventive paediatrics

• “Prevention of disease and promotion of physical,
mental and social well-being of children so that each
Types of Preventive paediatrics child may achieve the genetic potential with which
he/she is born.”
• Antenatal Paediatrics • Strategies to achieve these aims:
• Postnatal Paediatrics Through "primary health care” ( vast coverage
through an integrated service delivery system):
• Growth monitoring
• Oral rehydration
• Nutritional surveillance
• Promotion of breast-feeding
• Immunization
• Community feeding
• Regular health check-ups, etc

0 0

• Back ground:
•
Antenatal Paediatrics
Recent technical developments such as Antenatal paediatrics…..
amniocentesis, ultrasonography, faetoscopy and • Objectives:
chorion biopsy have contributed significantly to the • To decrease perinatal mortality
diagnosis of congenital abnormalities and inborn • To prevent perinatal morbidity
errors of metabolism • To identify and care for the "foetus at risk".
• The concept of antenatal paediatrics recognizes
that causation and possible prevention may lie in
intra-uterine life.
• Prevention of disorders e.g., low birth weight, foetal
disorders and neonatal asphyxia

0 0
 Antenatal Paediatrics….
• Antenatal care should begin even before the mother • Definition: “The application of the principles of
conceives and enters the maternity cycle and should Social Paediatrics
social medicine to paediatrics to obtain a more
also include :
• Genetic counseling for prospective parents complete understanding of the problems of
• Limitation and proper spacing of births with children in order to prevent and treat disease and
intervals of 2-3 years promote their adequate growth and development,
• Delaying a young woman's first pregnancy until
she is physically and socially mature enough to through an organized health structure " (WHO)
cope with it • The challenge of the time is to study child health in
• Protection of the unborn against intrauterine relation to:
infections and other adverse influences.
• Improvement of maternal nutrition • Community
• Family planning and counseling • Social values
• Social policy
•
0 0

Who is a child?
Scope of Social paediatrics… • The term “child” comes from the Latin word infans which
means “ the one who does not speak”
• Bring these services within the reach of the total • “Human being from birth until adulthood. ”
community. • Definitions:
• Various social welfare measures to meet the total • “ A child is any human being below the age of eighteen
health needs of a child: years, unless under the law applicable to the child,
majority is attained earlier”
• Local ( The convention on the rights of the child-1989)
• National
• International • “ A child is a person 19 years or younger unless
national law defines a person to be an adult at an
earlier age”(WHO)

0 0

Care of children and it’s importance

• Most important age group is 0-14 yrs in all
Term “ Child” in Pakistan societies as :
• Under the age of 18 yrs( Laws for Registration of • They constitute about 40 per cent of the total
Citizens) population
• Under the age of 14 yrs( Constitution and Labour • Determinants of chronic disease in later life and
laws) health behaviour are laid down at this stage
• Under the age of 16yrs for women and 18 yrs for • Family influences and education are of the highest
men considered as child marriage (Pakistan's Child importance as they influence:
Marriage Restraint Act (CMRA) 1929 ) • Patterns of children future life-styles
• Occupational skills
• Political attitudes and leadership.

0 0
Care of children and it’s
importance….
Division of Child hood Period
• Transmission of attitudes, customs and behaviour : Childhood period is divided into the following age-
The childhood period is also a vital period of the periods:
socialization process • Infancy (upto 1 year of age)
• Vulnerable to disease, death and disability owing to • Neonatal period (first 28 days of life)
their age, sex, place of living, socio- economic class • Post neonatal period (>28th day to 1 year)
etc. • Pre-school age (1-4 years)
• Specific biological and psychological needs must be • School age (5-14 years)
met to ensure the survival and healthy development
of the child and future adult.

0 0

•
Care in INFANCY…..
NEONATAL CARE :( first 28 days of life)
• Care
Newbornsin
last 20 years,
INFANCY
survival has improved by 50 per cent in the •
•
Early Neonatal care( 0- 7 days)
Late neonatal care(8-28 days)
• Termed as Neonatology
• The first few hours, days and months of their lives are • Dependant on teamwork of :
still crucial • Obstetrics and Gynaecology
• Paediatrics
• From the time of birth, 20-30 per cent of babies are • Preventive and social medicine
under-weight. • Community health services
• Vulnerable to infection and disease. • Nursing
• Important to prevent perinatal and neonatal mortality
• About 40 per cent of total infant mortality occurs in the and morbidity.
first month of life. ? • The Paediatrician has a key role as a coordinator and
guide for the whole team.

0 0

• Early Neonatal
The first week care
of life is the most crucial period in the
•
Early
care are: Neonatal care….
Strategies to achieve the objective of Early Neonatal
life of an infant. 1. Establishment and maintenance of cardio-
• New born has to adapt itself rapidly and successfully respiratory functions
to an alien external environment. 2. Maintenance of body temperature
• The risk of death is greatest during the first 24-48 3. Avoidance of infection
hours after birth. 4. Establishment of satisfactory feeding regimen
• The problem is more acute in rural areas 5. Early detection and treatment of congenital and
acquired disorders, especially infections.
Congenital infections caused by TORCHES
Objective of early neonatal care : TOxoplasmosis, Rubella, Cytomegalovirus, HErpes
- to assist the newborn in the process of adoption to simplex, and Syphilis) is associated with high
an alien environment mortality rate in the neonates

0 0
 Care
Delivery

Normal Infant High risk Infant

Early Neonatal care….
Immediate new born care:
Without complications With complications 1. CLEARING THE AIRWAY
2. APGAR SCORE
Temporary observation unit
(recovery room for high-risk infants)
3. CARE OF THE CORD
4. CARE OF THE SKIN
Regular Special care nursery with
5. CARE OF THE EYES
Nursery Neonatal intensive care unit 6. MAINTENANCE OF BODY TEMPERATURE
7. BREAST-FEEDING
Home Special Procedures
0 0

An immediate and quick assessment tool to estimate the

1.CLEARING THE AIRWAY 2. APGAR
physical condition SCORE
of a newborn .
• Establishment & maintenance of cardio-respiratory functions Taken at 1 minute and again at 5 minutes after birth.
• airways should be cleared of mucus and other secretions. Positioning
A medical negligence to omit APGAR scoring of a
the baby with his head low may help.
newborn infant, especially low birth weight babies .
• gentle suction to remove mucus and amniotic fluid. Resuscitation
becomes necessary if natural breathing fails to establish within a Requires immediate and careful observation of the heart
minute, rate, respiration, muscle tone, reflex response and colour
• resuscitation may require active measures such as suction, oxygen of the newborn.
mask, intubation and assisted respiration. Each sign is given a score of 0, 1 or 2 and a score of 10
• All labour wards should be equipped with resuscitation equipment represents the best possible condition.
including oxygen. If the heart has stopped beating for 5 minutes, Newborns with low APGAR scores at 5 minutes of age are at high-
the baby is probably dead.
risk of complications and death during the neonatal period.

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Interpretation of APGAR score( total score=10) and

interventions required:
7-10 No depression, perfect score 9-10 : Routine post
delivery care
4-6 moderately depressed: some resuscitation
( oxygen, suction , stimulate baby, rub back etc)
0-3 severely depressed baby: Full resuscitation
< 5 needs prompt action.

Ref: pg 538 K park 23rd Edition.

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 Immediate Newborn Care…
3. CARE OF THE CORD
• Care must be taken to prevent tetanus of the newborn by
Immediate Newborn Care…
using properly sterilized instruments and cord ties. 5. CARE OF THE SKIN
•It is essential to apply an antiseptic preparation on the cord •When a baby is a few hours old, the first bath is given with
stump and the skin around the base. soap and warm water to remove vernix, meconium and
• The cord should be kept as dry as possible.. The Cs blood clots. Old version….?????
4. CARE OF THE EYES •Some prefer to apply warm oil before the bath.
•Before the eyes are open, the lid margins of the newborn •The first bathing is done by the nursing staff. Thereafter no
should be cleaned. further bathing is necessary until the day before discharge.
• Instill a drop of freshly prepared silver nitrate solution (1 per •The first bathing may be delayed for 12-24 hours after
cent) to prevent gonococcal conjunctivitis or a single birth to avoid cooling the body temperature.
application of tetracycline 1 per cent ointment can be given.

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Immediate Newborn Care…

6. MAINTENANCE OF BODY TEMPERATURE: O-FIRST EXAMINATION
• normal body temperature of a newborn is between 36.5 to 37.5°C. Neonatal examinations
(a) to ascertain any birth injuries to the baby during the
birth process
•A newborn has little thermal control and can lose body heat quickly. (b) to detect malformations especially those requiring urgent
• Immediately after birth; most of the heat loss occurs through treatment
evaporation of the amniotic fluid from the body of the wet child. (c) to assess maturity.
• The following abnormalities found on examination
•75 % of the heat loss can occur from the head. should be immediately attended to :
•Immediately after birth the child should be quickly dried with a clean (a) cyanosis of the lips and skin
cloth and wrapped in warm cloth and given to the mother for skin-to- (b) any difficulty in breathing
skin contact and breast-feeding.
(c) imperforated anus
(d) persistent vomiting
7. BREAST-FEEDING should be initiated within an hour of birth (e) signs of cerebral irritation such as twitching, convulsions,
neck rigidity, bulging of anterior fontanel
(g) temperature instability.

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Neonatal examinations…. Neonatal examinations….

SECOND EXAMINATION
Preferably by a Paediatrician within 24 hours after birth. 5. Neuro-behavioural activity : (i) Posture : neck retraction; frog-
The following protocol will be found useful for such an examination : like posture; hyper-extension of all limbs; hyperflexion of all
1. Body size: Body weight,crown-heel length, head and thoracic
limbs; asymmetrical posture (ii) Muscle tone : tendon reflexes;
perimeters
cry; movements.
2. Body temperature:Body temperature:N=36.5-37.5deg C
6. Head and face: Hydrocephalus; large fontanelles; prominent
Hypo=< 360 C Hyperthermia > 41deg C
scalp vein (i) Eyes : cataract; coloboma; conjunctivitis
3. Skin: Observe for cyanosis of lips and skin; jaundice;
(ii) Ears : dysmorphism; accessary auricles; pre- auricular pits
pallor; generalized erythema; vesicular and bullous
(iii) Mouth and lips : Hare lip; cleft
lesions.
palate ..
4. Cardio-respiratory activities: Cardiac murmurs; absence of
femoral pulse; central cyanosis, a respiratory rate of over 60 per 7. Abdomen : Signs of distension; abnormal masses; imperforate
minute; thoracic cage retraction on inspiration. anus.
N=35 breath/ min Tachypnae: >40 breath/min 8. Limbs and joints : Deformities of joints; congenital dislocation
slow respiration< 20 breath/min of the hips; extra digits
0 9. Spine: Neural tube defects 0
 The infected newborn
The infected newborn ….
• Neonatal infection is the main cause of neonatal mortality
in many developing countries.
• NEONATAL TETANUS: It can be prevented by
• Contributing factors are related to: vaccination of pregnant women and sero-vaccination of
• the environment (traditional practices, poor hygiene) newborns in case of at-risk delivery.
• the course of pregnancy (premature rupture of membranes) Ref: www.who.int/immunization/monitoring
• constitutional fragility (prematurity, small-for-date,
dysmaturity). • CONGENITAL SYPHILIS : Diagnosis is essentially
• Transplacental contamination. Early detection of based on the evidence of syphilis in the mother, since
newborns at risk of transplacental infection is important. clinical signs of congenital syphilis often do not occur
at once in the newborn.

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The infected newborn …..

The infected newborn … NEWBORN WITH AN HIV-POSITlVE MOTHER :
• NEWBORN WITH AN HBV-POSITIVE MOTHER
About 30 per cent babies born to HIV-positive mothers get
• Babies may be infected at birth when the
infected.
mother is a carrier of this virus.
Transmission of infection mostly occurs at the end of the
• Transmission occurs through the blood and the genital
pregnancy, and it is not influenced by the type of
secretions and therefore affects the newborn during the
delivery.
immediate perinatal period and throughout infancy.
The virus has been isolated in breast milk. So breast
• It is not a contraindication of breast-feeding.
feeding is decided upon the severity of the disease and the
Prevention:
child survival in developing countries.
• Sero prophylaxis combined with vaccination
Unlike hepatitis B, there is no prevention available for
• An IM injection of 0.5 ml of hepatitis B
newborns at present.
immunoglobulin along with Hep B vaccine within 24
BCG vaccination is contraindicated in infected children
hours of birth, then repeated at 6,10 &14 wks
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Anthropometric measurements as
• MEASURING
Birth-weight THE BABY classified by WHO
• Length (height)
• Head circumference (a) Weight :kg
• The purpose of taking these measurements are: (b) Length : total height, sitting height,
(i) to assess the baby's size against known heel knee-length
standards for the population (c) Perimeters: head, chest, abdomen,
(ii) to compare the size with estimated period of arm, calf
gestation (d) Diameters: biacromial, bicristal,
(iii) to provide a baseline against which biepicondylar, bistyloid, bicondylar
subsequent progress can be measured. (e) Skinfold thickness: triceps, biceps,
superiliac ,subscapular.
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 .
Weight: it should be recorded within an hour of
birth. Average weight for term babies is about
• OBJECTIVES:
2.5kg to 3.5kg • NEONATAL SCREENING
to detect infants with treatable genetic,
developmental and other abnormalities
• to provide their parents with genetic counseling
• Screening tests:
• APGAR score
• Routine clinical examinations
• Blood Tests: blood group typing, coombs' testing and other
tests if needed. 10 to 15 ml of cord blood should be collected
at birth and saved in the refrigerator for 7 days.
• Numerous tests for screening congenital metabolic
disorders, inherited haemoglobinopathies and red cell
disorders

NEONATAL SCREENING…
Identification of "at-risk" infants
• A large number of infants and children 1-5 years of
The most common disorders of newborns which are
age in a community, or attending a child health
screened: clinic
(a) Phenylketonuria • It may not be possible to give sufficient time and
(b) Neonatal hypothyroidism attention to all of them.
(c) Rh incompatibility: Coombs'test for infants of • It is therefore necessary to identify particularly
all Rh- negative mothers. those "at-risk" and give them special intensive
care
(d) Sickle cell or other Haemoglobinopathies • It is these "at-risk" babies that contribute largely
(e) Congenital dislocation of hip to perinatal, neonatal and infant mortality.

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Criteria for Identification of "at-

risk" infants….
1. Birth weight less than 2.5 kg
•
Late neonatal care
The remaining three weeks of the neonatal period
carry the common and serious hazards of:
2. Twins
• Infection
3. Birth order 5 and more • Failure of satisfactory nutrition.
4. Artificial feeding • Diarrhoea and Pneumonia take a heavy toll of life in
5. Weight below 70 per cent of the expected weight infants exposed to an unsatisfactory environment.
(i.e., II and III degrees of malnutrition) • The case fatality rate of mild diseases can increase
6. Failure to gain weight during three successive dramatically when basic care is not given.
months
7. Children with PEM, diarrhoea
8. Working mother/one parent.
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 References
• Park’ s Text Book of Preventive and Social Medicine , 23rd
Edition
• Public Health and Community Medicine , Ilyas Ansari, 8th
Edition
to be continued….

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 Dr Tahira Amjad
Assoc Prof
Community Medicine, FUMC
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Q.1 Q.2
• Which one of the following is not a specialized branch of • By WHO definition, a child is any human being below the
Paediatrics? age of :

a. Social Paediatrics a. 12 years

b. Community Paediatrics b. 14 years
c. Neonatology c. 18 years
d. Embryology
d. 19 years
e. Perinatology

Ans: d Ans: d

Q.3 Q.4
• The risk of early neonatal death after birth is greatest • The APGAR score of a moderately depressed newborn is
during the: between the range of:
a. 0-3
a. First 24-48 hours b. 4-6
b. First 72 to 96 hours c. 7-10
c. First 5 days d. 9-10
d. First Week
Ans: b
Ans: a
 Learning Objectives
By the end of lecture, students will be able to:
Q.5 • Discuss birth weight and the factors determining the
• Low birth weight infant is the one whose weight is less birth weight.
than: • Define low birth weight and classify LBW babies
• Classify babies according to gestational age.
a. 1 kg
• Define preterm babies and categorize them.
b. 2 kg
• Identify the causes of preterm babies.
c. 2.5 kg
d. 3 kg • Discuss Small for dates babies and give the factors and
risks associated with them.
Ans: c contd…

Birth Weight
• The simplest measurement and indicator of fetal well
Learning Objectives…. •
being and maturity
The birth weight of an infant is the single, most
• Calculate % age of LBW . important determinant of:
• Outline challenges associated with LBW babies • its chances of survival
• Discuss prevention of LBW babies • healthy growth and development.
• Describe Kangaroo mother care • Normal birth weight: 2.5 kg OR 2500gms(WHO)
• Discuss intensive LBW baby care and the causes of • Average full term infant weight at birth: 3400g
their death • Few babies weigh less than 2500g or more than 4500g at
birth
• Illustrate integrated service delivery package for
• Newborn looses 7 to 10% of weight within few days of
MNCH.
birth.
• A newborn should be weighed during First hour of
0
delivery. 0

Birth Weight…..
A healthy newborn with birth weight of 3 kg • Factors determining the birth weight:
will loose how much of weight after 3 days of • Genetic factors
• Birth spacing
birth??? • Sex of the child
• Parity
• Maternal Nutrition
• Duration of gestation
Ans: 300gms , so his weight on 3rd day will be • Height and age of the mother
• Social and economic status
2700 gms or 2.7 kg

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 Low Birth Weight
• Definition: a birth weight of less than 2.5 kg or 2500
gm(upto and including 2499 gm)
very low birth weight (< 1500 g)
• LBW baby <2500 g

extremely low birth weight (< 1 000 g)

• The measurement to be taken within the first hour of
life, before significant postnatal weight loss has occurred
• Two main groups of low birth weight babies :
• Premature Babies (short gestation periods)
• Babies with foetal growth retardation( SFD)
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How to calculate percentage of LBW

babies in any area?
Babies classification according to
Formula: % age of LBW babies =
• gestational agealive before the end of 37 weeks
Preterm: Babies born
Live-born babies with birth weight less than 2.5 Kg of gestation (less than 259 days).
___________________________________________ x 100 • Term: Babies born from 37 completed weeks to
Total number of live births less than 42 completed weeks (259 to 293 days)
Exercise: Calculate % age of LBW babies in District of gestation.
Rawalpindi for the year 2020. Total number of LB • Post term: Babies born at 42 completed weeks or
registered with NADRA were 50000 and LBW were any time thereafter (294 days and over) of
2500. gestation.
Ans:???
Interpretation: In ----------- , ????% of the total live born
babies in the year ------had low birth weights. 0 0

Babies classification according to

gestational age…. contd…
• Categories of preterm birth,
PRETERM BABIES :
• Definition: Babies born alive before based on gestational age:
37 weeks of pregnancy are completed. • extremely preterm (<28 weeks)
• Incidence: • very preterm (28 to <32 weeks)
• More than 1 in 10 of the world's babies born in 2010 • moderate to late preterm (32 to 37 weeks).
were born prematurely
• Estimated 15 million preterm births of which more • Their intrauterine growth may be normal. That is,
than 1 million died. their weight, length and development may be within
• Prematurity is now the second-leading cause of death normal limits for the duration of gestation.
in children under 5 years,
• The single most important cause of death in the • Given good neonatal care, these babies may catch up
critical first month of life. growth by 2 to 3 years of age
• Preterm babies who survive, many face significant
disability of a lifetime .
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Two Types of preterm births and involved risk factors
Types Risk Factors Examples
Two Types of preterm births and involved risk
1. Spontaneous -Age at pregnancy Adolescent pregnancy, advanced maternal factors…
preterm birth and pregnancy age or short inter pregnancy interval
(spontaneous onset of spacing Types Risk Factors Examples
labor or 2. Provider-initiated Medical induction or There is an overlap for indicated
following Prelabor -multiple pregnancies Increased rates of twin and higher order preterm birth caesarian birth for provider- initiated preterm birth
Premature Rupture Of pregnancies with assisted reproduction (defined as induction obstetric indications. with the risk factors for
Membranes (pPROM
-Infections UTI, Malaria, HIV, Syphilis of labor or elective Faetal indications. spontaneous preterm births.
caesarean birth Other: not medically
before 37 completed indicated
-underlying chronic DM, HTN, Anemia, thyroid disease
maternal conditions weeks of gestation
for maternal or fetal
-Nutritional Under nutrition, obesity, Micro nutrient indications (both
deficiencies "urgent“ or
-Lifestyle / work Smoking, drugs use, excessive physical "discretionary"), or
related work/ activity other non-medical
-Maternal Depression Violence against woman
reasons.
psychological health, , Genetic risks , cervical incompetence
Genetic and others
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Other Causes of preterm babies…. Small for dates ( SFD) babies

• These may be born at term or preterm.
• They weigh less than the 10th percentile for the
• Other possible factors: gestational age.
• gestational age
• Social and environmental factors • These babies are clearly the result of intrauterine foetal
• Maternal history of preterm birth growth retardation (IUGR).
• Unidentified in half of the cases
• Elevated risk of preterm birth also demands increased
attention to maternal health, including the antenatal
•

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Causes/Factors associated with Small •

•
Short maternal stature
Very young age contd…
for dates ( SFD) babies •
•
High parity
Close birth spacing
• Intrauterine growth retardation may be because of:
• Low education status etc.
1. Maternal Factors: 2.Placental causes :
• Malnutrition • Placental insufficiency
• Severe anemia • Placental abnormalities.
3.Foetal causes:
• Heavy physical work during pregnancy • Foetal abnormalities
• Hypertension • Intrauterine infections
• Malaria • Chromosomal abnormality
• Multiple gestations
• Toxaemia
• Smoking
• Low economic status

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 Conditions associated with child
Risks associated with SFD babies development
• High risk of dying during the neonatal period • 3 interrelated conditions :
• High risk of dying during their infancy • Malnutrition
• Immediate and long term health problems. • Infection
• Protein-energy malnutrition • Unregulated fertility
• infections. ( These conditions are often due to poor socio-
economic and environmental conditions. )

Thus significantly raising the rate of infant and perinatal

mortality

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•
Challenges associated with LBW
A public health challenge
• High incidence of LBW
• Mental retardation Prevention of LBW babies
• High risk of perinatal and infant mortality and morbidity • Rates of LBW babies could be reduced to not more than
(half of all perinatal and one-third
of all infant deaths are due to LBW) 10 per cent in all parts of the world
• Human wastage and suffering • Due to multiplicity of causes there is no universal
• The very high cost of special care solution
• Intensive care units • Cause-specific interventions
• Association with socio-economic underdevelopment • Good prenatal care and intervention programmes,
• A high percentage of LBW is an indicator of : rather than "treatment" of LBW babies born later.
• deficient health status of pregnant women
• inadequate prenatal care
• Deficient newborn care

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Prevention of LBW babies…

_DIRECT INTERVENTION MEASURES for

•
Mothers
Identification of pregnant women "at risk” contd…
• To achieve this goal, the mothers health card - (ii) Controlling infections: Diagnosis and
which is simple and can be used by primary health treatment(e.g., malaria, urinary tract infection,
care worker - has been found very useful.
• Addressing the Risk factors : infections due to cytomegalovirus, toxoplasmosis,
mother's malnutrition, heavy work load, diseases and rubella and syphilitic infection) or otherwise they
infections and high blood pressure. "Too many and should be prevented.
too frequent pregnancies”
(iii) Early detection and treatment of medical
• Direct interventions are :
(i) Increasing food intake : Malnourished pregnant disorders: Hypertension, Toxemias, and Diabetes.
woman should be provided with supplementary
feeding, iron and folic acid tablets, fortification and
enrichment of foods, etc.
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 INDIRECT INTERVENTION contd… Treatment of LBW babies
• Family planning
• Avoidance of excessive smoking • LBW babies can be divided in to 2 groups:
(a)First Group- those under 2 kg : requires first
• Improved sanitation measures
class modern neonatal care in an intensive care unit
• Improving the health and nutrition of young girls until the weight reaches that of the second
• Improvements in the socio-economic and group.
environmental conditions (b)Second Group- between 2-2.5 kg: may need an
• Distribution of health and social services especially in intensive care unit for a day or two.
the under-served areas.
• Government support could be provided through such
measures as maternity leave with full wages and
child benefits.
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KANGAROO
KANGAROO MOTHER CARE MOTHER CARE
for LBW babies for LBW babies….
• The four components of kangaroo mother care are
:
•Introduced in Colombia in 1979 1. Skin-to-skin positioning of
by Dr. Hector Martinez and Edzar Rey as a response to: a baby on the mother's chest
• high infection and mortality rates 2. Breast-feeding for adequate nutrition
• other legal aspects due to overcrowding in hospitals. 3. Ambulatory care as a result of earlier discharge
• It has since been adopted across the developing world and from hospital
has become essential element in the continuum of 4. Support for the mother and her family in caring
neonatal care. for the baby

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Intensive care of LBW babies Causes of death in low birth weight

(a) Incubatory care: adjustment of temperature,
humidity and oxygen supply. low levels of oxygen in babies
a baby's blood stream (hypoxia) can produce cerebral • Atelectasis
palsy. If the oxygen is excessive, it may lead to
blindness due to retrolental fibroplasia. • Malformation
(b) Feeding : Breast-feeding is rarely possible - the • Pulmonary haemorrhage
baby cannot suck. However, breast feeding should be • Intracranial bleeding, secondary to anoxia or birth
used if available. Feeding is often by nasal catheter. trauma
(c) Prevention of infection: Death may occur within a • Pneumonia and other infections.
few hours following respiratory infection. Prevention
of infection is therefore, one of the most important
functions of an intensive care unit.

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 Integrated Service Delivery packages for Mother ,
Newborn and Child Health(pg 538, K Park)

Conclusion
• Moderately preterm babies are at risk and must be
screened and referred for interventional therapies
• Preterm babies should not be considered “small ” full
term infants

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Assignment
References
1. In Sindh province of Pakistan, 100,000 live births • Park’ s Text Book of Preventive and Social Medicine , 23rd
were reported in 2019. 90,000 of new born weighed Edition pg 535 -538
more than 2.5 kgs while 5000 had a birth weight of • Public Health and Community Medicine , Ilyas Ansari, 8th
<1 kg. Rest of the babies weighed ≥ 1 kg to < 2.5 Edition
kg. Calculate percentage of LBW babies born in the
year 2019 in Sindh Province.
2. Tabulate the differences between preterm and
Small for date babies.
3. What measures should be adopted to prevent LBW
?
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QUIZ TIME
1. The single most best determinant of an infant survival 2. A healthy newborn with birth weight of 3 kg will
, growth and development is : loose how much of weight after 3 days of birth?
a.Height a.100 gms
b.Weight b.200 gms
c.Head circumference c.300 gms
d.Mid arm circumference d.400 gms
Ans: b
Ans: c

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 3. Preterm babies are born before gestational week of: 4. Which of the following statement is true for small for date
a.37 wks babies?
b.38 wks a.Account for 1/3rd of Neonatal deaths
c.39 wks b.Can catch up normal growth within 2-3 years
d.40wks c.Normal Birth weight
d.Intra uterine growth retardation
Ans:a
Ans: d

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Thank
5. Which of the following is not a component of Kangaroo you
mother care?
a. Incubator care
b. Skin-to-skin positioning of a baby
c. Breast-feeding
d. Ambulatory care

Ans: a

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 Learning Objectives
By the end of the session, the students will be able to:
• Illustrate mortality in and around infancy
• Define faetal death
• Define still birth , give it’s causes and do the calculations.
• Discuss Perinatal mortality rate and it’s calculations
• Discuss Neonatal mortality and it’s calculations.
• Define Infant Mortality Rate and how it can be calculated
and give it’s importance.
Dr Tahira Amjad contd..
Assoc Prof
Community Medicine Department 0
0

Learning Objectives ….
• Outline the predisposing factors to high infant INTRODUCTION
mortality. • Mortality rates are good indicators to:
• Outline the causes of infant mortality and illustrate it’s • Measure the level of health and health care in
web of causation. different countries.
• Discuss preventive and social measures to reduce IMR • Assess the overall socio-economic development of
a country and correlate well with certain economic
• Calculate 1-4 child mortality rate, u 5 mortality rate
variables such as GNP.
and child survival rate
• Medical and social progress have substantially
• List causes of u/5 child mortality
reduced mortality in childhood.
• Outline prevention of child mortality and morbidity in
general.
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MORTALITY IN & AROUND

INFANCY
Mortality in and around Infancy INFANT MORTALITY
POST-NEONATAL
• Perinatal period DEATH
• Early neonatal period NEONATAL DEATHS
EARLY - LATE-NEONATAL
• Late neonatal period
NEONATAL DEATHS
• Neonatal period DEATH
• Post neonatal period
PERINATAL DEATH

Why these different periods are developed? STILL BIRTH

≥28 WEEKS BIRTH 7 DAYS 28 DAYS 1 YEAR

Of GESTATION or
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1000gms or more
 FOETAL DEATH
• Death prior to the complete expulsion or extraction
from its mother of a product of conception, irrespective
of the duration of pregnancy
• Definition: A death of fetus after the 20th or 28th week
of gestation
(WHO)
• The average length of human gestation is 280 days, or 40
weeks, from the first day of the woman's last menstrual
period ( May vary in different countries)

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Still Births Still births….

• Over 40% of all stillbirths occur during labour – a loss that • Vital statistical reports are less reliable on foetal deaths
could be avoided occurring at 20-27 weeks than on those occurring after 28
completed weeks.
• Gobally, A tragedy insufficiently addressed
• Stillbirths are seldom reported in developing countries.
• Women and their families, face maternal depression, financial
• Definition Still Birth: ( WHO)
consequences, as well as stigma and taboo.
*for National comparisons:
• In 2014, the World Health Assembly endorsed the Every
Foetus born dead and weighing >500 gms when gestation age is
Newborn Action Plan (ENAP), a global target of 12 or fewer
not known.( corresponds to 22 wks of gestation)
third trimester (late) stillbirths per 1,000 total births in
• *for International comparisons:
every country by 2030.
“Foetus born dead and weighing 1000gms or more.”
• In 2021, 139 mainly high-income and upper middle-income
countries met this target (Corresponds to 28 wks of gestation)
• But 56 countries will not each this target by 2030 if further • Pakistan SBR 30.6 per 1,000 total births, year 2019
efforts are not made Source: https://www.who.int/health-topics/stillbirth
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Still Birth Rate ( SBR)

• Definition of still birth rate: Calculate SBR
“Death of a foetus weighing 1000 g (this is equivalent to 28 • In the year 2022, in a District X, 50 fetal deaths of 20 wks
weeks of gestation) or more occurring during one year in gestation ad 100 of 28-32 wks gestation were reported. In the
every 1000 total births” (live births + stillbirths). same year there were 8000 live births and 2000 Still births.
SBR: Calculate SBR of this District.
Foetal deaths weighing ≥ 1000 g at birth during year 2019
--------------------------------------------------------------X 1000
100 foetal deaths ( 28-32 wks of gestation) during year 2022
Total births (live births + stillbirths )weighing ≥ 1000 g at birth ____________________________________________ x1000
during year 2019
8000 lb+2000SB ( 28-32 wks of gestation) during year 2022
• Calculations……
90 foetal deaths weighing ≥ 1000gms during year 2019 Ans=100/ 8000+2000 x 1000= 100/ 10000 x 1000
____________________________________________ x1000 10/1000 total births
2800 lb+200SB weighing ≥ 1000 gms at birth during 2019 In the year 2022, Still Birth Rate of District x was 10 per 1000
Ans= 30/1000 total births 0 total births 0
 Births
Causes of Still births
a. Causes which can be prevented -by early detection
and treatment:
• Infections acquired during pregnancy or before
• High blood pressure and its complications
• Rh incompatibility, diabetes and premature rupture of
the membrane.
b. Causes which are difficult to eliminate:
• Multiple pregnancies
• Cord anomalies
• Foetal malformations
• Placental anomalies
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Perinatal Mortality
Includes both late foetal deaths (stillbirths) and early
neonatal deaths.
Perinatal Mortality Rate ….
•Definition: Deaths occurring from the 28th week of • "Late foetal and early neonatal deaths weighing over
gestation to the seventh day after birth. 1000 g at birth, expressed as a ratio per 1000 live
•A yard stick to measure the obstetric and paediatric births weighing over 1000 g at birth". WHO
care before and around the time of delivery of the • PMR:
country: Late foetal and early neonatal deaths weighing over 1000
a. When gestational period is not known.. Then deaths of g at birth X 1000
more than 1000 gm babies Total live births weighing over
b. When weight is not available then gestational age of 1000 g at birth
at least 28 wks
c. When a and b are not available then body length..
crown to heel length 35cm is used
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(7) Toxaemias of pregnancy

Causes of Perinatal Mortality (8) Antepartum haemorrhages
(9) Congenital defects
a) Antenatal causes :
(10) Advanced maternal age
(1) Maternal diseases: hypertension, cardiovascular
(b) Intranatal causes
diseases, diabetes, tuberculosis, anaemia
(1) Birth injuries
(2) Pelvic diseases : uterine myomas, endometriosis, (2) Asphyxia
ovarian tumours (3) Prolonged effort time
(3) Anatomical defects, uterine anomalies, incompetent (4) Obstetric complications
cervix (c) Postnatal causes
(4) Endocrine imbalance and inadequate uterine (1) Prematurity
preparation (2) Respiratory distress syndrome
(5) Blood incompatibilities (3) Respiratory and alimentary infections
(6) Malnutrition (4) Congenital anomalies
(d) Unknown causes : Causes not clinically proven
0 • Social and biological causes 0
 High risk predisposing factors of Interventions to reduce PNMR
Perinatal mortality
(1) Low socio-economic status
“Priority areas to improve newborn
(2) High maternal age (35 years or more) health”
( pg 567 park 23rd ed)
(3) Low maternal age (under 16 years)
(4) High parity (fifth and subsequent pregnancies, especially with
a. Before and during pregnancy
short intervals between pregnancies)
b. During Pregnancy
(5) Heavy smoking (10 or more cigarettes daily)
(6) Maternal height - short stature (as compared with average for c. During and soon after delivery
locality) d. During the first month of life
(7) Poor past obstetric history (one or more previous
stillbirths and neonatal deaths, one or more premature live- born
infants)
(8) Malnutrition and severe anaemia
(9) Multiple pregnancy. 0 0

contd…
a. Before and during pregnancy contd….
•Delayed childbearing. . • Monitoring of foetal well-being and timely interventions
•Well-timed, well-spaced and wanted pregnancies for foetal complications·
•Well-nourished and healthy mother • Tetanus immunization ·
•Pregnancy free of drug abuse, tobacco and alcohol • Prevention and treatment of anaemia
•Tetanus and rubella immunization • Prevention and treatment of infections (malaria,
hookworm, syphilis and other STIs)
•Prevention of mother-to-child transmission of HIV
• Voluntary HIV counselling and testing, and prevention of
•Female education
mother-to-child transmission of HIV
b. During pregnancy
• Good Diet
•Early contact with health systems including ;
• Prevention of violence against women
•Birth and emergency preparedness
•Early detection and treatment of maternal complications
0 0

contd…. Contd…
c. During and soon after delivery • Prevention and control of infections ·
•Safe and clean delivery by skilled attendant • Prevention of mother-to-child transmission of HIV
•Early detection and prompt management of delivery and foetal • Information and counselling (home care, danger signs
complications ,care seeking)
•Emergency obstetric care for maternal and foetal conditions d. During the first month of life
•Newborn resuscitation • Early post-natal contact
•Newborn care ensuring warmth and cleanliness • Protection, promotion and support of exclusive breast
•Newborn cord, eye and skin care feeding
•Early initiation of exclusive breast-feeding • Prompt detection and management of diseases in newborn
•Early detection and treatment of complications ofthe newborn infant
•Special care for infants born too early or too small and/or. • Immunization
complications
• Protection of girl child
0 0
 NEONATAL MORTALITY
• Definition: Neonatal mortality rate is the number of
RATE
Contd…… neonatal deaths in a given year per 1000 live births in
that year.
• International certificate of perinatal deaths:
• NMR:
For international comparisons, ICD-9 recommends a
Number of deaths of children under 28 days of age in a
A SPECIAL DEATH CERTIFICATE for PN
year x 1000
deaths showing the cause of death. ICD has a “P” list
of 100 causes for perinatal mortality and morbidity Total live births in the same year
Prevention of PNM: Pakistan situation:
preventive and social measures- NMR:39.4/1000live births
IMR: 52.8/ 1000Live Births
pg 571 Park 23rd edition
U/5 : 63.3/ 1000 Live Births
Source : Economic Survey of Pakistan 2022-2023
0 0

Causes of neonatal mortality- Global

2020
Definition: Death of the children under 01 year of age.”
INFANT MORTALITY
Global 26.052 deaths per 1000 live births–WHO
Pakistan IMR: 52.8/ 1000Live Births

“IMR is the ratio of infant deaths registered in a given

year to the total number of live births registered in the
same year. (Usually expressed as a rate per thousand live
births).”
IMR:
Number of deaths of children less than 1 year of age in a given year
x 1000
Total Number of live births in the same year

0 0

IMPORTANCE OF IMR
• Universally a most important indicator of: IMPORTANCE OF IMR….
• Socio economic development of a country ( • IMR IMPORTANCE by demographers because :
SECOND BEST) (a) It is the largest single age-category of mortality
( Best indicator of SE development is U 5 Mortality (b) deaths at this age are due to a peculiar set of diseases
Rate) and conditions to which the adult population is less
• Health status of a community exposed or less vulnerable
• Level of living of people in general (c) infant mortality is affected rather quickly and directly
• Effectiveness of MCH services in particular. by specific health programmes and hence may change
more rapidly than the general death rate.( most sensitive
indicator)

0 0
 PREDISPOSING FACTORS OF
Contd….
INFANT MORTALITY Multiple births: Increases in multiple births because of
low birth weight.
Biological, Economical and Socio Cultural
Family size: > as the family size increases, duration of
BIOLOGICAL FACTORS illness is longer with 3 or more children
Birth weight: IMR greater in BW<2.5 kg and >4 kg High Fertility : increases with high fertility
Age of the mother: IMR greater in age <19 and >30 yrs 2. ECONOMIC FACTORS:
Birth order: IMR >in birth order 1 or first born and least Affecting directly and indirectly
for the 2 born, It increases from birth order 3 onwards Highest in slums and lowest in rich localities
Birth spacing: decreases with wider birth spacing, the Availability and quality of health care services
risk to babies born within a year f each other is 2-4 dependent on SES
times more as compared to those born 2 years apart Child’s environment---SES

0 0

Contd… Contd…
Maternal education: low in educated mothers.
• CULTURAL AND SOCIAL FACTORS
• Breast feeding: IMR higher in early weaning Showing personnel health behavior, care and use of
and bottle fed babies living in poor hygienic health services. Delayed marriages, delay in child
conditions. bearing, family planning etc in educated woman.
• Religion and caste: IMR is affected by pattern, Quality of health care: Inadequate prenatal and natal
habits, customs, traditions etc. affecting care can result in high IMR
cleanliness, eating , clothing etc activities of Broken families: IMR high
daily life. Illegitimacy: IMR high
• Early marriages: baby of teen age mother has Brutal habits and customs: IMR high( not feeding
highest chances of neonatal and post neonatal colostrum, applying cow dung on the umbilical stump,
mortality faulty feeding etc.)
• Sex of the child: > in female children Untrained Dai / mid wife: high IMR
• Quality of mothering: if good can reduce IMR Bad Environmental Sanitation: High IMR– Lack of
safe water, poor sanitation, over crowding, insect
breeding. poor housing etc
0 0

Neonatal mortality + post neonatal mortality causes=

•
Infant Mortality
Infant Mortality causes Causes Infant Mortality Causes….
• Neonatal Mortality (0-4wks) Causes • Post-neonatal Mortality (1-12 months)
1. Low Birth weight 1. Diarrheal disease
2. Prematurity 2. Acute respiratory diseases
3. Birth injury/difficult labour 3. Communicable disease
4. Sepsis 4. Malnutrition
5. Congenital anomalies 5. Congenital anomalies
6. Hemolytic disease 6. Accidents
7. Placenta/cord conditions
8. Diarrheal disease
9. Acute respiratory diseases

0 0
MULTIPLE CAUSATION WEB MODEL
FOR INFANT MORTALITY Preventive and social measures to
ECONOMIC
I POOR OBS
CARE
QUALITY OF HEALTH
CARE, POORLY TRAINED
reduce
Prenatal IMRimprove the state of maternal nutrition.
nutrition:
food supplementation to the mother's basic diet
LOSS N
TBAS, NON COMPLIANCE
F IGNORANCE, Prevention of infection: infectious diseases, many of which
TRADITIONAL BELIEFS are preventable by immunization, for example, neonatal
A
HIGH
N
NO FP tetanus. EPI targeted diseases
FERTILITY
RELIGIOUS BELIEFS
T
MALNUTRITI Breast-feeding: most effective measure for lowering infant
ON INSUFFICIENT FOOD,
M
EXTREME POVERTY,
mortality
O GENDER BIAS
INFECTIONS Growth monitoring: All infants should be weighed
R MOTHER &
BABY
DOMESTIC CONDITIONS periodically (at least once a month) and their growth charts
T
AGE, maintained
SOCIAL A MISC……
PROBLEM CAUSES PARITY ,
L
0 0
I
REPEATED PREGNENCIES

Preventive and social measures to

reduce IMR… Preventive and social measures to
Family planning :The risk of death is greatly enhanced if
the last child was born less than 2 years ago, and if the reduce IMR…
mother already has four or more children. • Socio-economic development
Sanitation: Exposure to infections through contaminated • spread of education (especially female literacy),
food and polluted water, lack of elementary hygiene, flies improvement of nutritional standards, provision of
and poor housing safe water and basic sanitation, improvement of
Provision of primary health care : housing conditions, the growth of agriculture and
Collaboration of obstetrician to the local dai in maternity care industry and the availability of commerce and
Prenatal care to detect mothers with "high-risk factors” communication etc.
"Special care baby units" must be provided for all babies • Education : among women is associated with low
weighing less than 2000 g. fertility and low maternal mortality, as well as low
Proper referral services.
infant mortality.
0 0

Highest child mortality rate by country (1960 -

1 - 4 year MORTALITY RATE
2018)
(Child Death Rate)
No of deaths of children aged 1-4 years during
a year
Child DR= X 1000
Total no. of children aged 1-4 years at the middle
of the year

Mid-year estimated population means population counted on

the 1st of July . Why??

It excludes Infant Mortality Rate.

0 0
Causes of 1 - 4 year MORTALITY UNDER FIVE MORTALITY RATE
RATE (Child Mortality Rate)
Number of deaths of children less than 5 years
Developing countries Developed countries
• Diarrhoeal diseases in a given year
• Accidents
• Respiratory infections U5MR = x 1000
• Congenital anomalies
• Malnutrition Total number of children under 5 years in the same year
• Malignant neoplasms
• Infectious diseases (e.g., Best single indicator of social development and well being
• Influenza
measles, whooping rather GNP.
• Pneumonia
cough) As it shows income, nutrition, health care and basic education
• Other febrile diseases etc.
• Accidents and injuries

0 0

causes of death among children

under-5 (1-59 months) Child Survival Index
• Pneumonia (13% of all
1000 – under 5 mortality rate
under-five deaths), CSR=
• Preterm birth complications (13%), 10
• Diarrhoea (9%) A Child Survival Rate per 1000 births can be simply
calculated by subtracting the Under -5 mortality rate from
• Intrapartum-related complications (9%) 1000. Dividing this figure by ten shows the percentage of
• Malaria (7%) those who survive to the age of 5 years.
• Neonatal sepsis, meningitis and tetanus =1000-69.3 /10 = 93.07%
{U5MR of Pakistan in 2018 = 69.3 /1000 live births}
(6%).
UNICEF-2018
• HIV/AIDS (2%)
• Injuries (3%)
• Measles(1 %) 0 0

Prevention of Child Morbidity and Additional screening for

Physical growth and development
Mortality Measurement of BP (in children 3years or older)
1. Breast feeding, diet, weaning.
2. Immunization is one of the most cost effective Hearing assessment
procedure of preventing mortality and morbidity. Prevention of specific health problems
3. Screening for occult treatable condition Injuries/ accidents
• Those which are preventable and symptoms are Modification of hazards.
clear, screening would be helpful. For example Use of the products with child proof caps.
• Phenyl Ketonuria (Phenyl alanine hydrozylase)
• Anemia Lowering of temperature of hot H2O heaters.
• Congenital Hypothyroidism Installation of window guards.
• Vision impairment (3 to 4 years of age) Modification of behavior
Motor cycle helmets
Infants car seats.

0 0
 Psychosocial problems
5. All causes of maternal morbidity should be
Which will develop due to the environment, birth
prevented by proper Antenatal services as they have a
conditions and developmental delays. These can be
great effect on the health of the children as in
prevented if children are properly screened at the well
hypertension (low birth weight), Diabetes (over weight),
child conferences. Give preventive and remedial
TORCH (congenital defects), syphillis (a syndrome of
educational and psycho therapeutic services.
congenital defects) etc.
Dental problems.
Which are of great concern in child morbidity they
can be prevented by. Minimum no of Visits made to assess the child health
Reduction of sugar in food, drinks and medicine. problems:
Community Fluoridation Visits in the Ist year of life (once every month,12 visits)
Topical fluoride application Visits in 1 – 5 year of life (once in 3 months, 4 visits in
a year)

0 0

1. A newborn died on 5th day of birth due to Pneumonia. His

death has occurred in which period of infancy?

a.Perinatal period
b.Late neonatal period
c.Neonatal period
d.Post neonatal period

Ans: a

0 0

2. Infant Mortality Rate is expressed as total number of deaths of 3. Death of a foetus weighing 1000 g or more is categorized
infants per 1000: as:
a.Early Neonatal death
a.Births b.Neonatal death
b.Live Births c.Post neonatal death
c.Population d.Child death
d.Mid year Population e.Still birth

Ans: e
Ans: b
0 0
 4. The most sensitive indicator of mortality in children is: 5. Which of the following statements is true for Infant
Mortality ?
a.Perinatal mortality Rate a.Least importance given by demographers
b.Still birth Rate b.Mortality is due to exposure to atypical diseases
c.Infant Mortality Rate c.Most sensitive indicator of health of a community
d.1-4 years mortality Rate d.Response to specific health programmes very slow
e.Under 5 years mortality Rate e.Smallest single age-category of mortality

Ans: c Ans : c

0 0

References
Park’ s Text Book of Preventive and Social Medicine , 23rd

• THANK YOU
•
Edition pg 562 -576
• Public Health and Community Medicine , Ilyas Ansari, 8th
Edition

0 0
 INTEGRATED
MANAGEMENT of
NEONATAL and
CHILDHOOD ILLNESS
(IMNCI)
Dr TAHIRA AMJAD
C/MED DEPARTMENT
FUMC

Learning Objectives Why IMNCI ?

By the end of lecture , students shall be able to:
➢ Discuss the aim, objectives and strategies of Every day, millions of parents seek health care for
IMNCI their sick children, taking them to hospitals, health
centers, pharmacists, doctors and traditional healers.
➢ Outline the various components of “ IMNCI”
➢ Outline the principles of IMNCI
Surveys reveal that many sick children are not
➢ Illustrate and discuss the elements of case
properly assessed
management process in IMCI.
and treated
➢ Discuss the reasons for not using it for > 5 yrs old by these health care
children and less than one week. providers
➢ Outline the preventive and promotive elements of
IMNCI Contd…
➢ Pakistan scenario 0 0

➢ Their parents are poorly advised. ➢ IMNCI is an effective, low cost strategy for
improving child health
➢ From more syndromic approach to
➢ At first-level health facilities in low-income
integrated case management for better health
countries, diagnostic supports such as
outcomes
radiology and laboratory services are minimal
or non-existent, and drugs and equipment ➢ IMCI promotes:
are often inadequate. ➢ Prompt recognition & treatment of all co-
existing conditions.
➢ Active participation of family and
communities in the health care process
➢ Rapid & effective treatment through
standard case management.
➢ Prevention of illness through improved
nutrition including breast feeding &
vaccination.
0 0
 INTEGRATED MANAGEMENT of NEONATAL OBJECTIVES OF IMNCI
and CHILDHOOD ILLNESS (IMNCI) To reduce under-5:
A broad WHO/UNICEF initiative launched globally in 1995. ➢ Mortality
A new vision & general Guidelines for public child health. ➢ Morbidity
Through primary child health care, involving both the ➢ Disability
health system and the community. ➢ To improving child growth and
Including curative, preventive & promotional development.
elements.
AIM of IMNCI
➢ To move from the vertical disease-
specific approach of traditional
Reduce death, illness and disability
programmes to a more integrated &
Promote improved growth and development among
children under five years of age.
horizontal child approach, in line
with the philosophy of primary
Includes both preventive and curative elements
implemented by families, communities and health health care.
facilities.
0 0

3 x components of IMNCI
➢ Integration of services pertaining to: strategy
➢ Nutrition 1. Improving health care provider
➢ Immunization skills for case management of childhood
➢ Disease Prevention
➢ Health Promotion . illnesses
2. Improving overall health systems
to deliver IMNCI
3. Improving family and community
health practices related to child health
and development
CONTD…

0 0

2. Improving Health Systems to

1. Improving Health Providers deliver IMNCI
Skills Identify actions to prevent illness through :
Teaches health care worker about
the Integrated Case Management
Process and Steps
➢ Immunization
➢ Supplementation of micronutrients
➢ Promotion of breastfeeding
➢ Nutritional education to mothers
➢ Reduce indoor air pollution etc
➢ Disease Prevention
➢ Health Promotion

0 0
 6 X PRINCIPLES OF THE INTEGRATED
CLINICAL CASE MANAGEMENT
3. Improving Family and (1) Examining all sick children aged up to five years
Community Health practices of age for general danger signs and all young
infants for signs of very severe disease. Act as
an indication of severe illness and the need for
➢ Caregivers are taught how to provide immediate referral or admission to hospital.
treatment for Children who can be treated at
(2) The children and infants are then assessed for
home, and when to seek Help.
main symptoms:
➢ Counseling of mothers to solve feeding • In older children the main symptoms include:
problems ➢ Cough or difficulty breathing
➢ Diarrhoea
➢ Fever
➢ Ear infection etc contd….
0 0

(4) Only a limited number of clinical signs are

• In young infants, the maim symptoms used, selected on the basis of their sensitivity and
include: specificity to detect disease through
Local bacterial infection classification.
Diarrhoea A combination of individual signs leads to a child’s
Jaundice classification within one or more symptoms
groups rather than a diagnosis.
(3) Then in addition, all sick children are routinely
The classification of illness is based on a colour-
checked for:
coded triage system:
• Nutritional and immunization status • “PINK” indicates urgent hospital referral or
• HIV status in high HIV settings admission
• Other potential problems • “YELLOW” indicates initiation of specific
outpatient treatment
• “GREEN” indicates supportive home care
0
contd… 0

(5) IMCI management procedures use:

• A limited number of essential drugs
• Encourages active participation of
caregivers in the treatment of their
children.

(6) Counseling of caregivers regarding home 3 x Objectives,

3 x components of
care: IMNCI strategies,
An essential component of IMNCI 6 x principles???
• Appropriate feeding and fluids
• When to return to the clinic immediately?
• When to return for follow-up?

0 0
 INTEGRATED (IMNCI)

Aim of “integration” of care for children under-5:

Individual description of the To receive holistic care, whether:
at home
Components of IMNCI in the community
at the health facility

It brings together child care (curative, preventive

and development aspects) into one strategy
Enables clinical management of priority public child
health problems through a standardized, fully
integrated approach based on clinical guidelines

0 0

Levels of INTEGRATION MANAGEMENT(IMNCI)

Clinical management by a syndromic approach,
3 LEVELS: where signs and symptoms are considered.
➢ At patient level--- it means case management Most sick children present with
➢ At point of delivery of care---- multiple signs and symptoms related to
interventions through one delivery channel eg more than one condition.
u/5 clinics This overlap means that a single
➢ At system level-----bringing together diagnosis may not be possible or
management and support function of different appropriate, treatment may be
programmes of health system complicated and may need
combined therapy for several conditions

0 0

NEONATAL & ILLNESS ( IMNCI)

Causes of Neonatal deaths: prematurity, sepsis,
CHILDHOOD(IMNCI) asphyxia, tetanus, congenital anomalies etc.
Neonatal period also included in this strategy Conditions that are a major cause of death, severe
Children below 5 years of age. illness or disability in children under-5 are:
Most vulnerable to illness and death.
Many children are not properly
assessed and treated and
parents poorly advised.
Providing quality care
to children is a serious
challenge.

0 0
 The IMNCI CASE MANAGEMENT PROCESS
The IMNCI CASE MANAGEMENT at outpatient health facility
PROCESS
used to assess and classify two age groups:
Age Group = 1 week up to 2 months

Age Group = 2 months up to 5 years

And how to use the process is shown on the

specific chart that will help us to identify signs
of serious disease such pneumonia, diarrhea,
malaria, measles, DHF, meningitis,
malnutrition and anemia.
0 0

ELEMENTS OF THE CASE MANAGEMENT

3. Identify specific treatment of the child:
Contd ….
PROCESS
1. Assess the child or infant for: - Give pre referral treatment
- Danger Signs/Symptoms: convulsions, lethargy, - Give antibiotics, antimalarial, iron , Vit A etc
vomiting, inability to drink etc - immunization
- ask for cough, fever, diarrhea or ear problem etc 4. Provide treatment instructions:
- Check for nutrition and any feeding problem .How to give drugs?
- Check immunization status . How to feed the child?
- Any other problem . How to treat local infections at home?
2. Classification of the illness: . How to identify danger signs?
- Use a colour coded triage:
PINK- Urgent referral after pre referral treatment
at outpatient of health facility
YELLOW -Specific medical treatment and advice at
outpatient of health facility
GREEN - Home management 0 0

Contd… IMCI case management process

5. Counseling of the mother on :

- Breast feeding
- Food and feeding advice
- treat common ear, skin infections at home
- Fluids during illness
- When to return?
- Her own health
6. Follow up care: provide and assess the child
again for any new problems

0 0
 Why not use this process for children
age 5 years or more ?
➢ The case management process is designed for
children < 5yrs of age, although, much of the
advise on treatment of pneumonia, diarrhea,
malaria, measles and malnutrition, is also
applicable to older children, the ASSESSMENT
AND CLASSIFICATION of older children
would differ eg Breathing
➢ 2-12 months = fast breathing >/= 50/min
➢ 12 months-5yrs = fast breathing >/= 40/min

0
➢ 5yrs = fast breathing >/= 20/min
0
Contd…..

➢ Chest indrawing is not a reliable sign of Why not use this process for young
severe pneumonia as children get older
and the bones of the chest become more infants age < 1 week old?
firm. ➢ The process on young infant chart is designed
➢ Certain treatment recommendations or for infants age 1 week up to 2 months.
advice to mothers on feeding would differ ➢ It greatly differs from older infants and
for >5 yrs old. young children.
➢ In the first week of life, newborn infants are
➢ The drug dosing tables only apply to
often sick from conditions related to labor
children up to 5yrs old. and delivery.
➢ Their conditions require special treatment.

0 0

IMNCI IN PAKISTAN
Promotive & Preventive Elements
IMNCI strategy adopted in September 1998
A national coordinating committee setup
➢ Opportunities for immunization (vaccination
given if needed) Close collaboration between PHC, ARI, Diarrhoea,
Nutrition, Immunization Technical Programme
➢ Breastfeeding and other nutritional counseling
LHWs to have key role in the management of sick
➢ Vitamin A and iron supplementation
children in the community
➢ Treatment of helminthes infections

0 0
0
 Learning Objectives 2
By the end of the session, the students will be able to:
• Define the different categories related to adolescence.
• Understand the importance of Adolescent Health
ADOLESCENT HEALTH • Identify different stages of Adolescence.
• Enlist leading causes of adolescent mortality and morbidity.
• Factors influencing Adolescent health and increased vulnerability
Dr Tahira Amjad
• Discuss Priorities under adolescent health
Assoc Prof
Community Medicine Department • Outline major approaches to reduce Adolescent health contributing
factors
• Discuss major issues, determinants, recommendations for Adolescent
health in Pakistan

Introduction 3 Introduction…. 4

• Development is generally uneven; physical maturity

• “Adolescence” defined as those who are between 10-19 years of
age (WHO) achieved in advance of psychological or social maturity
• “Youth” those who are between 15-24 yrs .
• “Young people” covers both age groups ie- between 10-24 yrs • Reproductive capability is now established at an early
• “True adolescence” is the period of physical, Psychological and age as compared to the past
social maturing from childhood to adulthood
• Puberty sets in with spurt in growth and an increase
in metabolic rate
• Children above the age of 13 years need as much
energy as adults
• They show a good deal of physical activity

Importance of Adolescent Health

• New, poorly understood concept 5 Significance 6
• Rapid transition from childhood to adulthood
Adolescence is neither childhood nor adulthood
• Marriage issues and has its peculiar characteristics and
• Future parents requirements
• Very limited policies / programs / laws
• Limited research
• Concept gained increasing recognition in developing nations
• Four out of five of worlds young people live in these countries
• 50% of their population is under 25 yrs of age
• Every opportunity to be provided to develop to their full potential as healthy
individuals
Adolescence stages 7 World Adolescent Population 8

Column1

Source: United Nations, Department of Economic and Social Affairs, Population Division (2015). World
Population Prospects: The 2015 Revision, Volume II: Demographic Profiles (ST/ESA/SER.A/380)

Pakistan’s Population by Age 9 WHO Report 10

Percentage
10 – 24 Years
32%

World Average: 18 %*
Source: Census 1998, Pakistan Bureau of Statistics, Government of Pakistan
* United Nations, Department of Economic and Social Affairs, Population Division

http://apps.who.int/adolescent/second-decade/

Leading Causes of Mortality among

WHO Report 11 12
Adolescent
• First presented in 2014 World Health Assembly
• Described need for specific attention to adolescents
• Presented a global overview of adolescents’ health and
health-related behaviours
• Discussed the determinants that influence their health and
behaviours

Source: United Nations, Department of Economic and Social Affairs, Population Division (2015). World
Population Prospects: The 2015 Revision, Volume II: Demographic Profiles (ST/ESA/SER.A/380)
Leading Causes of Morbidity among
Adolescent 13 Factors Influencing 14
Adolescence

Source: United Nations, Department of Economic and Social Affairs, Population Division (2015). World
Population Prospects: The 2015 Revision, Volume II: Demographic Profiles (ST/ESA/SER.A/380)

Factors responsible for increased 15 Priorities under adolescent 16

vulnerability of adolescence
health
1. Nutrition

2. Mental health
3. Health education and counseling
4. sexual and substance abuse

1.Nutrition 17 Energy requirements 18

• . •
GENDER AGE GROUP BODY WEIGHT CALORIES/DAY CALORIES/KG/DAY
KG

SOURCE: k PARK
Dietary recommendations 19 Macronutrients 20

.
.

Micronutrients 21 Iron 22

• Adolescents have increased iron requirements

.
• Girls need more iron than boys to replace menstrual losses
(*RNI: boys 11.3 g/day, girls 14.8 g/day)

• Lack of iron leads to an increased risk of iron deficiency

anaemia and associated health consequences
*(RNI- Recommended nutrient intake)

Calcium 23 Salt 24

- Boys (11-14 years) 6.75 g/day

• Around 50% of the adult skeleton is formed during
growing years (15-18 years) 8.25 g/day
(RNI - boys 1000 mg/day, girls 800 mg/day)

• Low calcium intakes

(< LRNI) found in 24% of 11-14 year-old girls and 19% of - Girls (11-18 years) 5.75 g/day
15-18 year-old girls

• A lack of calcium may have consequences for future

bone health e.g. increased risk of osteoporosis • Excluding salt added in cooking
or at the table
 25 Breakfast 26
Physical activity • Eating breakfast leads to improved energy and
concentration levels throughout the morning

• At least 60 minutes of moderate-intensity physical • Breakfast consumption may improve cognitive

activity each day is recommended function related to performance when studying

• Other benefits of breakfast include better

nutrient intakes and weight control

Fluids and hydration 27 2. Mental Health 28

Anorexia nervosa
• 6-8 glasses/day (1.2 litres) to prevent • Defined as: the refusal to eat enough to maintain a normal
body weight
dehydration. People need to drink more when the
weather is hot or when they have been active
• Sufferers have the impression that they are overweight and
often picture themselves as being fat even though they are
• All drinks count in terms of fluid intake but those already underweight
without sugar are best between meals • In adolescent girls and young women, menstrual
abnormalities may occur including amenorrhea, which can
pose a significant risk to bone health

• Other physical symptoms include: constipation, stomach

pains; dry, patchy skin; low body temperature and loss of
hair

2. Mental Health ….. 29 3. Sexual abuse and 30

Bulimia nervosa reproductive health
• Sufferers are obsessed with the fear of gaining weight and • Sexual abuse among adolescents is a major global public
undergo a recurring pattern of binge eating, which is usually health problem
followed by self-induced vomiting • It’s a severe violation of human rights
• Has many physical and mental health consequences in the short
• Often feel a lack of self-control and have an excessive concern with and long term
their body weight and shape
• Adolescents may experience sexual abuse at the hands of their
• Sufferers may also use large quantities of laxatives, slimming relatives, peers or any other person
pills or strenuous exercise to control their weight
• Reproductive health and sexually transmitted diseases
• Many bulimics have poor dental health due to regular vomiting; • Child marriages
vomit is acidic and can erode teeth in a characteristic way
 3. Sexual abuse and reproductive 31 3. Sexual abuse and reproductive health…
32
health… Health education for RH
Health education
• Start educating at school level, addressing the evolving
• Promoting safety and providing sensitive care
capacities of adolescents by providing information that is
appropriate to age
• Raising public awareness of risk, signs and symptoms and • Protecting and promoting autonomy, privacy and
health consequences of sexual abuse and the need to seek confidentiality
timely care
• Health-care providers to receive training on the guiding
principles for reporting, and whether, when, to whom and how • Awareness about reproductive health issues
to report
• Observing non-discrimination in the provision of care • No child marriages

4. Substance abuse and 33 Substance abuse and delinquencies….

34
Health education
delinquencies • Should start at school level
• Tobacco is often the first substance used with an estimated 20 per cent
• Best conducted in small groups, interactive approaches
of young smokers worldwide beginning before the age of 10
• Parental monitoring of children’s behaviour and strong parent-
child relationships are positively correlated
• Students who are not succeeding in school, have few peer contacts or • Engaging adolescents in sports or extreme physical activities
are not involved in extra-curricular activities are at risk for a variety of
problems, including tobacco and other substance use • Peer based approaches with main stream youth and social media
are emerging tools with the potential to raise awareness and
• It effects the growth and development, especially of brain
motivation

• Contributes to the development of adult health problems, such as sleep

disorders, heart diseases, HIV and hepatitis c

• Also leads to other risky behaviors, such as dangerous driving, thefts

and other delinquencies

Adolescent Health in Pakistan- Major Issues

Major Approaches to reduce Adolescent health 35 36
contributing factors • Smoking
1. Informing, educating and sensitizing key groups in society to individual
• Malnutrition/ obesity
health and social development needs.
• Sexual Abuse
2. Advocating appropriate policy, legislation and programmes for promoting
adolescent reproductive health. • Reproductive health
3. Using appropriate and innovative research to improve knowledge and • Substance abuse
disseminate information about the factors that influence and determine young • Mental health
people's sexual, contraceptive and reproductive decisions and behaviour.
• Depression
4. Modifying, extending and evaluating services specially designed to meet
• Low self-esteem (minorities/low socioeconomic)
young people's needs.
• Adjustment disorders (especially females)
5. Mobilizing the energy, creativity and idealism of young people in promoting
health and developing appropriate activities in their communities. • Conflict zone

6. Facilitating action to extend education opportunities for girls.

 Reproductive Health 37 Determinants of Adolescent Health in 38
Pakistan
-Education and Formal Schooling
• Gross enrollment ratio
• Children out of school
-EMPLOYMENT:
8.6% of youth age 15-24 yrs unemployed
-Inability to utilize Services:
• Females affected more
• Sociocultural restrictions
• Lack of awareness
• Lack of specialized services

Recommendations/
Way Forward 39 References 40
AA-HA

• Global Accelerated Action for Health of Adolescents

• 15 December 2016 • K park 23 Ed

• Evidence Based Interventions

• Responding to children and adolescents who have been
• Positive Development sexually abused- WHO clinical guidelines
• Unintentional injury
• Youth and drugs
• Violence
https://www.un.org/
• Sexual and reproductive health, including HIV
• Communicable diseases
• Non-communicable diseases and nutrition
• Mental health, substance use and self harm

MCQs 41 42

Q.1 World Health Organization has defined

“Adolescence” as those , who are between the age Q.2 There are different
of:
• 8-16 yrs stages of adolescent based
on the age . A young boy
• 10-18 yrs
• 10-19 yrs
• 10-20 yrs
of 16 yrs will belong to
• ANS: c
which of the following
stages of adolescence?
a. Premature Adolescence
 43 44

Q.3 Which one of the following is not a Priority Q.4 Which one of the following is the top leading
under adolescent health? cause of Mortality among Adolescent ?
a. Health education a. Epilepsy
b. Life insurance b. Drowning
c. Mental health c. Road Injuries
d. Nutrition d. Self Harm

Ans: b
Ans: c

45

Q.5 Lack of iron leads to an increased risk of iron

deficiency anaemia and associated health consequences
among female adolescence. What is the recommended
daily requirement of iron among them?
a. 11.3 gms
12.5 gms
Thank You
b.

c. 13.8 gms
d. 14.8 gms

ANS: d