Maternal and Child Health

• Maternal and child health is an important

dimension of community health nursing.
• The term maternal & child health services
refer to a package of integrated health
services design to promote the health &
nutritional status of mothers & children and
ensure the birth of a healthy infant to every
expected mother.
• Promotive, preventive, curative and
rehabilitative care for mother and children.
Maternal Health
• Maternal health refers to the health of women
during pregnancy, childbirth and the
postpartum period.
• The United Nations Population Fund (UNFPA)
estimated that 289,000 women died of
pregnancy or childbirth related cause in 2013.
Maternal mortality ration fallen from 380 (in
1990) to 210 per 100,000 live births.
Four elements essential to maternal death
prevention:
1. Prenatal care (At least 4 antenatal visit)
2. Skilled birth attendance
3. Emergency obstetric care
4. Postnatal care
 CHILD HEALTH
• Child health is a state of physical, mental,
intellectual, social and emotional well – being
and not merely the absence of disease or
infirmity. – WHO
• Children cannot achieve optimal health alone.
They are dependent upon adults in their family
and community to provide them with an
environment in which they can learn and grow
successfully.
 Maternal and Child Health Services Include ;

• Antenatal care
• Postnatal care
• Essential new born care & child care
• Vitamin A prophylaxis & deworming program
(Baisakh & Kartik)
• Immunization
• Family planning
•   Nutrition
• RTI/ STI
• Safe abortion (CAC, PAC)
• Appropriate management of ARI
• Exclusive breastfeeding and weaning food
• Treatment of anemia
Development of maternal and child heath services in Nepal 1950

• Maternal & Child welfare program started

combined with family planning handling by
NGO and INGO 1960
• Started in government 1987
• Safe motherhood conference held in
Nairobi, Kenya. (sponsored by WHO, World
bank, UNFPA & UNDP) 1991
• Community made for study of safe
motherhood program . 1993
• Safe motherhood program launched in Nepal
in 10 districts then continuously elaborated in
other districts.  
• The Aama Program introduced to fully
subsidize the cost and ensure mothers do not
pay anything out of pocket for institutional
deliveries. 2010
• Nepal was commended for its progress on
achieving MDGs 4 and 5.
• MDGs 4: Reduce Child Mortality
• MDGs 5: Improve Maternal Health
Needs of Maternal and Child Health Services

•  Mother and children constitute a major

segment of total population. In Nepal, they
constitute 62% of total population.
• Mother of child bearing age: 22% Children
less than 15 years of age: 40%
• Mother and children are a “Special Risk
Group” or “Vulnerable Group” or dependents
or weaker group of the community.
 Cont....
•  Most of the health problem of mother and
children are preventable.
• Infant mortality and maternal mortality are
the most sensitive index of health. Therefore,
MCH services are of utmost importance in
health services.
• Lives of many mother and babies will be
saved if the health of the mother is supervised
during pregnancy, at child birth, & the
puerperium.
 Cont.....
• Mothers are providers of health care.
Health of family members depends on her
knowledge & practice related to good
health and prevention of disease.
• Sick, pregnant and anemic mother will not
be able to fulfill their maternal role
adequately.
• Health education & good health practices
relating to safe water, basic sanitation,
personal and environment hygiene, &
nutrition will benefit the health of the
• Hardworking day of mother
• The economy of the family, local
community & country will be improved
when the family is healthy. Poor health,
death or handicap causes loss of working
capacity & family income.
• If women have no knowledge and access to
services, that will enable them to plan their
families, repeated child bearing with no
interval in between pregnancies, leads to
“maternal depletion syndrome” & the
displacement of young children from the
breast feeding with malnutrition & a high
 Goals of the MCH service
• To decrease maternal, prenatal and neonatal
mortality and morbidity.
• To reduce child morbidity and mortality.
• To improve maternal and child health
 Cont..
• Antenatal care
 Activities of MCH clinic
Child Health clinic
1. Care of illness
• Diagnosis and treatment of acute and chronic
illness.
• X-ray and laboratory services
• Referred services
2. Preventive care
• Immunization
• Growth monitoring
• Health check up ( Physical examination)
• Health education
• Vit. A distribution and deworming
3.Growth monitoring
Weight according to age
Height according to weight & age
Maternal health clinic activities
• Registration of antenatal, postnatal mother
• Physical examination/ antenatal examination
• T.D vaccination
• Health education
• Family planning
• Safe abortion and post abortion
 Antenatal Care
Systematic supervision of women during
pregnancy.
Comprehensive ante partum care program that
involves a coordinated approach to medical
care and psychological support that optimally
begins before conception and extends
throughout the antenatal period.
 Objectives of Antenatal Care
• To screen the high risk cases.
• To prevent, detect and manage complications during
pregnancy, whether medical, surgical or obstetrical.
• To develop birth preparedness and complication
readiness plan.
• To educate mother about physiology of pregnancy
and labour.
• To motivate couple about the need of family
planning.
• To advice mother about breastfeeding,
postnatal care and immunization.
• To reduce risk of pregnancy related
complications.
• To reduce infant risk for complications.
 Pre natal care and advice
• Pre-conceptional care
• Creating awareness in the community for
maintenance of maternal health
• Early diagnosis of pregnancy
• Initial antenatal evaluation
• Assessment for referral
• Birth preparedness and complication
readiness plan
Antenatal visits As per WHO :
• 4 antenatal visits 1st visit around 16 weeks
(4th month)
• 2nd visit around 24-28 weeks (6th month)
• 3rd visit at 32 weeks (8th month)
• 4th visit at 36 weeks (9th month)
 INDICATORS
• Maternal Indicators
• Morbidity Indicators
• Fertility Indicators
• Social and Mental Health Indicators
• Health Policy Indicators
• Quality of Life Indicators
• Nutritional Status Indicators
 MATERNAL INDICATORS
• Maternal mortality ratio “ the death of a
women while pregnant or within 42 days of
terminaton of pregnancy, irrespective of the
duration and site of the pregnancy, from any
causes related to or aggravated by the
pregnancy or its management but not from
accidental or incidental causes.
 Morbidity Indicators
• Following morbidity rates are used for assessing
ill health in the community
• Incidence and prevalence
• Notification rates
• Attendance rates at out-patient departments,
health centre’s etc Admission, readmission and
discharge rates Duration of stay in hospital and
• Spells of sickness or absence from work or school
 Fertility Indicators
•   Crude Birth Rate (CBR)
• General Fertility Rate (GFR)
• Age Specific Fertility Rate (ASFR)
• Total Fertility Rate (TFR)
• Contraceptive Prevalence Rate (CPR)
• Couples years of protection (CYP)
Social and mental health Indicators
• As long as valid positive indicators of social
and mental health are scarce, it is
necessary to use indirect measures,
indicators of social and mental pathology.
These include suicide, homicide, other acts
of violence and other crime; road traffic
accidents, : alcohol and drug abuse,
consumption of tranquilizers etc. These
social indicators provide a guide to social
action for improving the health of people.
 Socio-economic indicators
They do not measure the health status directly.
But it has certain value in the interpretation of
the indicators of the health care.
These includes:
• Rate of population increase
• Per capita of GNP
• Level of unemployment
• Dependency ratio
• Adult literacy rates
• Housing – a number of persons per room
• In Nepal dependent population: Persons
above 60 years of age and children below 15
years.
  Health Policy Indicators
•  Measures the allocation of adequate resources, which are
measured by:
• Proportion of GNP spent on health services
• Proportion of GNP spent on health-related activities (including
water supply, and sanitation, housing and nutrition, community
development) and
• Proportion of total health resources devoted to primary health
care.
•  Health care Utilization Indicators Measures the extent of
use of health services. These utilization rates can be
measured by the following indicators:
• Percentage of immunized children against six target diseases
• Percentage of women using antenatal services
.)
• Percentage of deliveries attended by trained
birth attendants • Average bed occupancy rate
(i.e. Daily impatient record/ average number
of beds, etc.)
• Average length of stay in hospital (i.e. days of
care rendered/ discharge)
• Bed turn-over ratio i.e. discharges average
beds
 Nutritional Status Indicators
• Measures the nutritional status of children
( mainly) below 5 years.
• Indicators are:
• • Mid-arm circumference
• Weight for age
• Weight for height
• Height for age
• Prevalence of low birth weight (less than 2.5kg)
 Health care delivery indicators
Health care delivery indicators measure proper
health distribution in different parts of the
country. It can be measured by:
• Doctor/population ratio
• Nurse/population ratio
• Population/bed ratio
• Population per centre/ sub centre
Standard indicators of the quality of life
include
• wealth, employment, the environment,
physical and mental health, education,
recreation and leisure time, social
belonging, religious beliefs, safety,
security and freedom.
  Morbidity and its Causes
Causes of maternal morbidity
• The major causes of maternal morbidity
and mortality are anemia, PIH, APH or
PPH or obstructed labor or puerperal
sepsis. In Nepal, more than 186/100000
live birth women die annually on account
of pregnancy.
 Causes of maternal mortality in developing
countries
• H: Hemorrhage (APH/ PPH)
• O: Obstructed Labour
• R: Ruptured Uterus
• S: Sepsis
• E: Eclampsia
• S: Severe anemia (<7gm)
Indirect obstetric causes
• Too many pregnancies
• . Too early pregnancies
• Too late pregnancies
• Too complicated pregnancies
Three Delays
• Delay in identifying mother “At risk”
decision making .
• Delay in transportation or referral to
services side .
• Delay in starting treatment at service
institute
 Direct cause: Direct obstetric death
• Hemorrhage (25%)
• Infection (15%)
• Hypertensive disorders (12%)
• Obstructed labor (8%)
• Abortion complications (12%)
• Others (ectopic pregnancy, embolism etc.)
(8%)
Indirect cause (20%)
• a) Anemia
• Hepatitis
• Cardiovascular disease
• UTI
• Mothers age
Cont....
• Birth interval
• Economic circumstances
• Cultural practice and beliefs
• Environmental conditions
• Viral infection etc.
Socio-economic and other causes
• Any disease associated with pregnancy
• Accidents
• Large family
• Malnutrition
• Poverty/ ignorance
• Lack of maternity services
 Cont....
• Shortage of health manpower
• Delivery by untrained professionals
• Poor environmental sanitation
• Lack of transportation facilities
• Social customs/ values and beliefs
• Illiteracy
• Improper utilization of MCH service
 Perinatal morbidity
• Perinatal period: from 22 weeks of
gestation to seven completed days after
birth.
• Perinatal mortality refers to the number
of stillbirths and deaths in the first week
of life (early neonatal mortality)
 Cause of perinatal morbidity

• Age of mother
• Parity
• Previous history of fetal loss
• Preterm birth (almost 30%)
• Infant respiratory distress syndrome
(almost 1%)
• Birth defects (about 21%)
Cleft lip
Anencephaly
 Cont....
• Medical care
• Poverty
• Unwanted pregnancy
• Education of the mother
• Multiple births
• Maternal morbid condition
 Neonatal morbidity and mortality
• Early neonatal mortality refers to a
death of a live-born baby within the first
seven days of life, while
• Late neonatal mortality covers the time
after 7 days until before 28 days.
Causes of neonatal mortality
• Birth asphyxia
• Meconium Aspiration
• Infection/ Sepsis (including tetanus)
• Convulsions
• Hypothermia
• Birth injury
• Facial palsy,
• cephalohematoma,
• Erbs palsy,
• humerus fracture
• clavicle fracture
• Jaundice
• Erbs palsy,
Facial palsy