maternal and child health interventions

Maternal and Child Health Interventions

Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 20122

Continuum of Care

Home and Community

First level Facility

Referral Facility


Continua of CareGuiding principles for planning maternal and child health programmes

Continuum across Life-stages (which interventions?)

Continuum across Health System (at which level?)


Continuum of CareAcross Life-stages

Factors which help decide interventions across the life-cycle:– Causes and distribution of child deaths– Proven efficacy of interventions– Feasibility– Cost– Acceptability– Issues related to health services


Most effective interventions require implementation at each level

Factors guiding levels at which interventions are implemented:

– Community acceptability and demand

– Availability of trained staff– Access to health services– Technical complexities– Equity issues

Balance between implementation at different levels is important

Continuum of CareAcross Health Systems

Home and Community

First level Facility

Referral Facility


Example:

Interventions to improve Child Health

Home and Community

First-level facility

Referral Facility

Pregnancy

At birth

Newborn period

Infancy and Childhood


Example:

Interventions to improve Child Health

Home and Community

First-level facility

Referral Facility

Pregnancy Promote & support antenatal care

Detection & management of complications of pregnancy

Management of severe complications

At birth Promote and support skilled care at birth

Immediate newborn care

Management of obstetric complications

Newborn period

Promote and support key newborn care practices

Management of newborn illnesses

Immunization

Management of severe newborn illnesses

Infancy and Childhood

Community case management of diarrhea & ARI

Standard case management during childhood illnesses

Management of severe childhood illnesses


Packaging of Interventions

A way of integrating and combining health interventions– Essential for making programmes feasible as it reduces programme

costs and improves program effectiveness

Several Maternal and Child Health intervention packages already exist.

Sometimes, there might be need for adding a new package.


Intervention PackagesSkilled obstetric and immediate newborn care including resuscitation

Emergency obstetric care to manage complications such as obstructed labour and hemorrhage

Antibiotics for preterm rupture of membranes#

Corticosteroids for preterm labour#

Emergency newborn care for illness, especially sepsis management and care of very low birth weight babies

Clin

ical

ca

re

Folic acid #

Counseling and preparation for newborn care and breastfeeding, emergency preparedness

Healthy home care including breastfeeding promotion, hygienic cord/skin care, thermal care, promoting demand for quality care

Extra care of low birth weight babies

Case management for pneumonia

Fam

ily-

com

mun

ity

Clean home delivery

Simple early newborn care

15 - 32%

4-visit antenatal package including tetanus immunisation,detection & management of syphilis, other infections, pre-eclampsia, etcMalaria intermittent presumptive therapy*Detection and treatment of bacteriuria#

Out

reac

h se

rvic

es

Postnatal care to support healthy practices

Early detection and referral of complications6 - 9%

23 - 50%NMR effect

InfancyNeonatal periodPre- pregnancy PregnancyBirth

Administering basic community-based intervention packages at full coverage can save ~ 37% of all newborn deaths!


Packaging of Interventions

A way of integrating and combining health interventions– Essential for making programmes feasible as it reduces programme

costs and improves program effectiveness

Several Maternal and Child Health intervention packages already exist.

Sometimes, there might be need for adding a new package.


Example:Intervention package for maternal and child health

ANC Care – TT vaccination, Anemia prophylaxis, Detection of complications, Counseling

Routine post-natal visits to mother and newborn - Exclusive breastfeeding, Thermal care, Hygienic cord care, Extra care of LBW infants, Prompt care-seeking for illness, Immunization, Management of newborn illness

IMNCI – Algorithm-based management of diarrhea, pneumonia, malaria, malnutrition and newborn illnesses, Promotion of ORS and Zinc

F-IMNCI – Management of inpatient children with severe illnesses


Community based: •IMNCI, Management of diarrhea and ARI, IYCF, Immunization, IFA and Vitamin A, HBNC, MCTS and MCP Card.

Facility based: •Facility based new born care- FBNC (SNCU, NBSU, NBCC), F-IMNCI, NRC, JSSK.

Delivery strategies for the interventions

Malnutrition34%

Causes of under-five deaths in India: 2010

Malnutrition34%

Causes of under-five deaths in India: 2010

Infections(sepsis / pneumonia, diarrhoea, tetanus)

Antibiotics for premature rupture of membranes

Syphilis screening & treatmentClean delivery practices

Hypothermia managementKangaroo mother care

BreastfeedingCommunity based pneumonia management

Tetanus toxoid immunization

Preterm / low birth weightDetection & treatment of asymptomatic

bacteriuriaSyphylis screening & treatment

(Pre) eclampsia preventionCorticosteroids for preterm labour

Hypothermia management - Kangaroo mother care

Skilled delivery practices

AsphyxiaInstitutional delivery

Skilled birth attendantUse of partograph for labour

surveillanceResuscitation of newborn

Malnutrition34%

Causes of under-five deaths in India: 2010Pneumonia:Breastfeeding counselling

Complementary feeding counsellingHib vaccination

AntibioticsEarly detection and management

Diarrhoea:Breastfeeding counselling

Complementary feeding counsellingVitamin A supplementation

Oral rehydration therapyZinc adjuvant therapy

Antibiotics for dysentery

Measles:Measles vaccination

Complementary feeding counsellingVitamin A supplementation

Vitamin A therapy

Malnutrition:Breastfeeding counsellingComplementary feeding

counsellingVitamin A supplementation

Vitamin A therapyMeasles vaccination

Growth monitoring and promotionCommunity-based and Facility-

based management of malnutrition

Malaria and HIV:Insecticide treated netsAnti-malarial treatment

PPTCTComplementary feeding counselling

Vitamin A supplementationNiverapine and (replacement) feeding

Maternal and Child Health Interventions | RCH Program UG Class | 201216

Evidence-based interventions Child Health

Antenatal care 4%*Skilled care at birth 13%*Postnatal care: routine care for all newborns, additional care for LBW, treatment of neonatal sepsis

13%*

Exclusive breastfeeding 13%Appropriate complementary feeding, including micronutrients

6%

Immunization 5%Insecticide-treated bed nets 7%ORT and zinc for diarrhoea 19%Treatment of suspected pneumonia 6%Treatment of malaria 5%


Summary: Child Health InterventionsPREGNANCY

• Tetanus toxoid immunization

• Birth and emergency planning

• Detection and management of problems complicating pregnancy (e.g. hypertensive disorders, bleeding, mal-presentations, multiple pregnancies, anemia)

• Information and counseling on self-care, nutrition, breastfeeding, family planning

• Sleeping under an insecticide-treated bed net

• Prevention of mother-to-child transmission of HIV+


Summary: Child Health InterventionsLabor, birth and 1-2 hours after birth

• Monitoring progress of labor, maternal and fetal well-being with partograph

• Social support (companion) during birth

• Immediate newborn care (resuscitation if required, thermal care, hygienic cord care, early initiation of breastfeeding)

• Emergency obstetric and newborn care for complications

• Antibiotics for preterm and/ or premature rupture of membranes*

• Antenatal corticosteroids for preterm labor



Summary: Child Health InterventionsNewborn period

(after the first 1-2 hours after birth up to 1 month)

• Exclusive breastfeeding

• Thermal care

• Hygienic cord care

• Prompt care-seeking for illness

• Extra care of low-birth-weight (LBW) infants

• Immunization

• Management of newborn illness



Summary: Child Health InterventionsOlder infants and children

(1 month up to 5 years)

Preventive Interventions• Exclusive breastfeeding (up to age 6 months)

• Safe and appropriate complementary feeding starting at 6 months with continued breastfeeding (up to age 2 years and beyond)

• Prevention and management of malaria

• Immunization

• Vitamin A supplementation

• Hand washing and proper disposal of faeces

• Birth spacing of 24 months or more


Treatment interventions• Oral rehydration therapy for diarrhoea

• Zinc for diarrhoea

• Antibiotics for dysentery

• Antibiotics for pneumonia

• Antimalarials

• Management of severe malnutrition

• Management of HIV-exposed and HIV-infected children

Summary: Child Health InterventionsOlder infants and children

(1 month up to 5 years)


Common causes of maternal deaths in India


Common causes of maternal deaths in IndiaHemorrhageActive management of 3rd

stage of labour;Detect & Treat anaemia;Skilled attendant at birth

Referral transportBlood transfusion

Operative procedures

SepsisClean deliveryPost-natal care

Early detection and referralProper management at

facility

Hypertensive disordersANC Care

Early detection and referralProper management

Complications of abortionAccess to family planning

methods including emergency contraception

Use of medical methodsSafe abortion facility

Ensuring good quality of care

Obstructed laborNutrition of girl child

Detection of high risk pregnancy and institutional delivery

Use of partographSkilled care at birth


Three Delays Model

Source: Operational Guidelines on Maternal and Newborn Health, NRHM, MoH & FW


Summary: Maternal Health InterventionsPRE-PREGNANCY

• Family Planning

• Folic acid fortification and/or supplementation to prevent Neural Tube Defects



Summary: Maternal Health InterventionsPREGNANCY

• Iron and Folic Acid Supplementation

• Tetanus toxoid immunization

• Birth and emergency planning

• Management of unintended pregnancy

• Detection and management of problems complicating pregnancy (e.g. hypertensive disorders, bleeding, mal-presentations, multiple pregnancies, anemia)

• Information and counseling on self-care, nutrition, breastfeeding, family planning

• Prevention and management of malaria



Summary: Maternal Health InterventionsLabor, birth and 1-2 hours after birth

• Monitoring progress of labor, maternal and fetal well-being with partograph

• Social support (companion) during birth

• Prophylactic uterotonic and Active management of third stage of labor to prevent postpartum hemorrhage

• Emergency obstetric care for complications• Management of Post-partum hemorrhage

• Induction of labor for prolonged pregnancy

• Caesarean section for maternal/foetal indication

• Antibiotics for preterm and/ or premature rupture of membranes


Summary: Maternal Health InterventionsPost-partum period

(after the first 1-2 hours after birth up to 6 weeks)

Advice and provision of family planning

Prevent, measure and treat maternal anemia

Detection and management of postpartum sepsis

Prevention of mother-to-child transmission of HIV+


Obstetric Care

Essential Obstetric Care

Emergency Obstetric Care

Maternal and Child Health Interventions | RCH Program UG Class | 201233 33

Current Approach to Reduction of Maternal Mortality

Maternal Mortality ReductionSri Lanka 1940–1985

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1940–45 1950–55 1960–65 1970–75 1980–85Mat

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85% births attended by trained personnel


Maternal Mortality: UK 1840–1960

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MaternalDeaths

Improvements in nutrition, sanitation

Antibiotics, banked blood, surgical improvements

Antenatal care


How can maternal deaths be prevented?

Skilled birth attendancePrompt referral to an appropriately equipped facility if

complications arise24×7 hours availability of expert services – a team of

specialists to perform surgeryWell equipped hospital with operation theatre and blood

transfusion servicesKeep the woman in the facility for at least 48 hours after

deliveryThe facilities should be accessible within a radius of 35 km


Packages of interventions in different time frames related to pregnancy

Focused antenatal Care (delivered through outpatient or outreach service)

o Minimum four ANC check upso At least 1 ANC by Medical Officer, (preferably 3rd)o Timing of visits –– 1st: within 12 weeks/ preferably as soon as pregnancy

is suspected– 2nd: between 14 – 26 weeks– 3rd: between 28 – 34 weeks– 4th: between 36 weeks and term



Focused antenatal Care (delivered through outpatient or outreach service)

o Early registrationo Two doses of injection Tetanus Toxoido All pregnant women – 100 tabs IFA (200 for anemic)o Screening for treatment of disorderso Provision of preventive interventionso Counseling – diet, hygiene, HIV status, birth,

emergency preparedness, care and feeding of babies



Intranatal care (facility based clinical care package)

o Promotion of institutional deliveries

o Skilled attendance for normal child birth, eg, monitoring labor progress by partograph

o Emergency obstetric care (basic & comprehensive) for complicated cases

o Effective referral system



Postnatal care (Institutional in the first 48 hours and thereafter delivered through outpatient or outreach service for a 42 day period)

o Prevention and detection of complications

o Information and counseling on self-care at home, nutrition, family welfare, breast feeding


Skilled Birth Attendant

An accredited health professional (eg, midwife, doctor or nurse)

Educated and trained to proficiency in the skills needed to manage –

o Normal (uncomplicated) pregnancieso Childbirtho Immediate postnatal periodHelps in identification, management and referral of

complications in women and newborns

maternal and child health interventions

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