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Maternal and
Child Health
Interventions
Continuum
of Care
Referral Facility
First level Facility
Home and Community
2
Introduction to Maternal and Child Health; MCH Lecture Class
MGIMS, Sewagram;; 04 Jul 2012
Continua of Care
Guiding principles for planning maternal and child health programmes
 Continuum across Life-stages
(which interventions?)
 Continuum across Health System
(at which level?)
3
Introduction to Maternal and Child Health; MCH Lecture Class
MGIMS, Sewagram;; 04 Jul 2012
Continuum of Care
Across Life-stages
 Factors which help decide interventions across the life-cycle:
–
–
–
–
–
–
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Causes and distribution of child deaths
Proven efficacy of interventions
Feasibility
Cost
Acceptability
Issues related to health services
Introduction to Maternal and Child Health; MCH Lecture Class
MGIMS, Sewagram;; 04 Jul 2012
Continuum of Care
Across Health Systems
 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
5
Introduction to Maternal and Child Health; MCH Lecture Class
MGIMS, Sewagram;; 04 Jul 2012
Referral Facility
First level Facility
Home and Community
Example:
Interventions to improve Child Health
Home and
Community
Pregnancy
At birth
Newborn
period
Infancy and
Childhood
6
Introduction to Maternal and Child Health; MCH Lecture Class
MGIMS, Sewagram;; 04 Jul 2012
First-level
facility
Referral Facility
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
Management of
severe newborn
illnesses
Immunization
Infancy and
Childhood
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Community case
management of diarrhea &
ARI
Introduction to Maternal and Child Health; MCH Lecture Class
MGIMS, Sewagram;; 04 Jul 2012
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.
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Introduction to Maternal and Child Health; MCH Lecture Class
MGIMS, Sewagram;; 04 Jul 2012
Intervention Packages
Clinical
care
Skilled obstetric and immediate newborn care
including resuscitation
Emergency obstetric care to manage
complications such as obstructed labour and
hemorrhage
Emergency newborn care for illness,
especially sepsis management and
care of very low birth weight babies
23 - 50%
NMR
effect
Antibiotics for preterm rupture of membranes#
Corticosteroids for preterm labour#
4-visit antenatal package
including
Postnatal care to support healthy
practices
Administering basic community-based
Early detection and referral of
intervention packages
at
full coverage
6 - 9%
complications
Malaria intermittent
can
save
presumptive
therapy*~ 37% of all newborn deaths!
Outreach
services
tetanus immunisation,
detection & management of
syphilis, other infections, preeclampsia, etc
Familycommunity
Detection and treatment
of bacteriuria#
Folic
acid #
Counseling and preparation
for newborn care and
breastfeeding, emergency
preparedness
Clean home
delivery
Simple early
newborn care
Healthy home care including
breastfeeding promotion, hygienic
cord/skin care, thermal care, promoting
demand for quality care
15 - 32%
Extra care of low birth weight babies
Case management for pneumonia
Pregnancy
Pre- pregnancy
Introduction to Maternal
and Child Health; MCH Lecture Class
9 MGIMS, Sewagram;; 04 Jul 2012
Birth
Neonatal period
Infancy
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.
10
Introduction to Maternal and Child Health; MCH Lecture Class
MGIMS, Sewagram;; 04 Jul 2012
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 careseeking 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
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Introduction to Maternal and Child Health; MCH Lecture Class
MGIMS, Sewagram;; 04 Jul 2012
Delivery strategies for the interventions
Community based:
•IMNCI, Management of diarrhea and ARI, IYCF,
Immunization, IFA and Vitamin A, HBNC, MCTS
and MCP Card.
Facility based:
•Facility based new born care- FBNC (SNCU,
NBSU, NBCC), F-IMNCI, NRC, JSSK.
12
Introduction to Maternal and Child Health; MCH Lecture Class
MGIMS, Sewagram;; 04 Jul 2012
Causes of under-five deaths in India: 2010
Malnutrition
34%
Asphyxia
Institutional
delivery
Causes
of under-five
deaths in India: 2010
Skilled birth attendant
Use of partograph for labour
surveillance
Resuscitation of newborn
Preterm / low birth weight
Detection & treatment of asymptomatic
bacteriuria
Syphylis screening & treatment
(Pre) eclampsia prevention
Corticosteroids for preterm labour
Hypothermia management - Kangaroo
Malnutrition
mother
care
Infections
34%
Skilled delivery practices
(sepsis / pneumonia, diarrhoea, tetanus)
Antibiotics for premature rupture of
membranes
Syphilis screening & treatment
Clean delivery practices
Hypothermia management
Kangaroo mother care
Breastfeeding
Community based pneumonia management
Tetanus toxoid immunization
Pneumonia:
Breastfeeding counselling
Complementary feeding counselling
Hib vaccination
Antibiotics
Early detection and management
Malnutrition:
Causes
of under-five deaths in India: 2010
Breastfeeding counselling
Complementary feeding counselling
Vitamin A supplementation
Vitamin A therapy
Measles vaccination
Growth monitoring and promotion
Community-based and Facilitybased management of malnutrition
Malnutrition
34%
Malaria and HIV:
Insecticide treated nets
Anti-malarial treatment
PPTCT
Complementary feeding counselling
Vitamin A supplementation
Niverapine and (replacement) feeding
Diarrhoea:
Breastfeeding counselling
Complementary feeding counselling
Vitamin A supplementation
Oral rehydration therapy
Zinc adjuvant therapy
Antibiotics for dysentery
Measles:
Measles vaccination
Complementary feeding counselling
Vitamin A supplementation
Vitamin A therapy
Evidence-based interventions
Child Health
Antenatal care
Skilled care at birth
Postnatal care: routine care for all newborns, additional care
for LBW, treatment of neonatal sepsis
Exclusive breastfeeding
Appropriate complementary feeding, including
micronutrients
4%*
13%*
13%*
13%
6%
Immunization
5%
Insecticide-treated bed nets
7%
ORT and zinc for diarrhoea
19%
Treatment of suspected pneumonia
6%
16
Maternal and Child Health Interventions | RCH Program
UG Class | 2012
Treatment of malaria
5%
Summary: Child Health Interventions
PREGNANCY
• Tetanus toxoid immunization
• Birth and emergency planning
• Detection and management of problems complicating
pregnancy (e.g. hypertensive disorders, bleeding, malpresentations, 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+
19
Maternal and Child Health Interventions | RCH Program
UG Class | 2012
Summary: Child Health Interventions
Labor, birth and 1-2 hours after birth
• Monitoring progress of labor, maternal and fetal well-being
with partograph
• Social support (companion) during birth
• Immediate newborn care (resuscitation if required, thermal
care, hygienic cord care, early initiation of breastfeeding)
• Emergency obstetric and newborn care for complications
• Antibiotics for preterm and/ or premature rupture of
membranes*
• Antenatal corticosteroids for preterm labor
• Prevention of mother-to-child transmission of HIV+
20
Maternal and Child Health Interventions | RCH Program
UG Class | 2012
Summary: Child Health Interventions
Newborn period
(after the first 1-2 hours after birth up to 1 month)
• Exclusive breastfeeding
• Thermal care
• Hygienic cord care
• Prompt care-seeking for illness
• Extra care of low-birth-weight (LBW) infants
• Immunization
• Management of newborn illness
• Prevention of mother-to-child transmission of HIV+
21
Maternal and Child Health Interventions | RCH Program
UG Class | 2012
Summary: Child Health Interventions
Older 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
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Maternal and Child Health Interventions | RCH Program
UG Class | 2012
Summary: Child Health Interventions
Older infants and children
(1 month up to 5 years)
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
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Maternal and Child Health Interventions | RCH Program
UG Class | 2012
Common causes of maternal deaths in India
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Maternal and Child Health Interventions | RCH Program
UG Class | 2012
Hemorrhage
Active management of 3rd
stage of labour;
Detect & Treat anaemia;
Skilled attendant at birth
Referral transport
Blood transfusion
Operative procedures
Common causes of maternal deaths in India
Complications of abortion
Access to family planning
methods including emergency
contraception
Use of medical methods
Safe abortion facility
Ensuring good quality of care
Obstructed labor
Nutrition of girl child
Detection of high risk pregnancy and
institutional delivery
Use of partograph
Skilled care at birth
25
Maternal and Child Health Interventions | RCH Program
UG Class | 2012
Sepsis
Clean delivery
Post-natal care
Early detection and referral
Proper management at facility
Hypertensive disorders
ANC Care
Early detection and referral
Proper management
• Delay in
reaching the
health
facility
DELAY 3
• Delay in
recognizing
the problem
• Delay in
deciding to
seek care
DELAY 2
DELAY 1
Three Delays Model
• Delay in
receiving
adequate
treatment
once a
woman has
arrived at the
health
facility
Source: Operational Guidelines on Maternal and Newborn Health, NRHM, MoH & FW
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Maternal and Child Health Interventions | RCH Program
UG Class | 2012
Summary: Maternal Health Interventions
PRE-PREGNANCY
• Family Planning
• Folic acid fortification and/or supplementation to prevent
Neural Tube Defects
• Prevention of mother-to-child transmission of HIV+
28
Maternal and Child Health Interventions | RCH Program
UG Class | 2012
Summary: Maternal Health Interventions
PREGNANCY
• Iron and Folic Acid Supplementation
• Tetanus toxoid immunization
• Birth and emergency planning
• Management of unintended pregnancy
• Detection and management of problems complicating pregnancy
(e.g. hypertensive disorders, bleeding, mal-presentations, multiple
pregnancies, anemia)
• Information and counseling on self-care, nutrition, breastfeeding,
family planning
• Prevention and management of malaria
• Prevention of mother-to-child transmission of HIV+
29
Maternal and Child Health Interventions | RCH Program
UG Class | 2012
Summary: Maternal Health Interventions
Labor, 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
30
•
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
Maternal and Child Health Interventions | RCH Program
UG Class | 2012
Summary: Maternal Health Interventions
Post-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+
31
Maternal and Child Health Interventions | RCH Program
UG Class | 2012
Obstetric Care
 Essential Obstetric Care
 Emergency Obstetric Care
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Maternal and Child Health Interventions | RCH Program
UG Class | 2012
Maternal Deaths per 100 000 livebirths
Maternal Mortality Reduction
Sri Lanka 1940–1985
1800
1600
1400
1200
1000
85% births attended
by trained personnel
800
600
400
200
0
1940–45
1950–55
1960–65
1970–75
Current Approach to Reduction of Maternal Mortality
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Maternal and Child Health Interventions | RCH Program
UG Class | 2012
33
1980–85
Maternal Mortality: UK 1840–1960
500
450
400
350
300
250
200
150
100
50
0
Maternal
Deaths
40 850 860 870 880 890 900 910 920 930 940 950 960
8
1
1
1
1 1
1
1
1
1 1
1
1
1
Improvements in
nutrition, sanitation
34
Maternal and Child Health Interventions | RCH Program
UG Class | 2012
Antenatal
care
Antibiotics, banked blood,
surgical improvements
How can maternal deaths be prevented?
 Skilled birth attendance
 Prompt referral to an appropriately equipped facility if
complications arise
 24×7 hours availability of expert services – a team of
specialists to perform surgery
 Well equipped hospital with operation theatre and blood
transfusion services
 Keep the woman in the facility for at least 48 hours after
delivery
 The facilities should be accessible within a radius of 35 km
35
Maternal and Child Health Interventions | RCH Program
UG Class | 2012
Packages of interventions in different time frames
related to pregnancy
 Focused antenatal Care (delivered through outpatient
or outreach service)
o Minimum four ANC check ups
o 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
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Maternal and Child Health Interventions | RCH Program
UG Class | 2012
Packages of interventions in different time frames
related to pregnancy
 Focused antenatal Care (delivered through outpatient or
outreach service)
o Early registration
o Two doses of injection Tetanus Toxoid
o All pregnant women – 100 tabs IFA (200 for anemic)
o Screening for treatment of disorders
o Provision of preventive interventions
o Counseling – diet, hygiene, HIV status, birth,
emergency preparedness, care and feeding of babies
37
Maternal and Child Health Interventions | RCH Program
UG Class | 2012
Packages of interventions in different time frames
related to pregnancy
 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
38
Maternal and Child Health Interventions | RCH Program
UG Class | 2012
Packages of interventions in different time frames
related to pregnancy
 Postnatal care (Institutional in the first 48 hours and
thereafter delivered through outpatient or outreach
service for a 42 day period)
o Prevention and detection of complications
o Information and counseling on self-care at home,
nutrition, family welfare, breast feeding
39
Maternal and Child Health Interventions | RCH Program
UG Class | 2012
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) pregnancies
o Childbirth
o Immediate postnatal period
 Helps in identification, management and referral of
complications in women and newborns
40
Maternal and Child Health Interventions | RCH Program
UG Class | 2012