12 Maternal and Child Health

Ms. Shumayla and Meenal Dhall

epgp books

 

 

 

Contents:

 

1.      Definition and Background of Maternal and Child Health (MCH)

2.      Key trend indicators

3.      Indicators of MCH

1.1 Maternal Mortality Ratio

1.2 Maternal Health Services

1.2.1     Ante-natal care

1.2.2     Delivery care

3.2.3     Post-natal care

3.3 Immunization

3.4 Family Planning

4.  STDs and RTI

Summary

 

Learning Objective:

  • To study maternal and child health and the factors associated with it.

    1. Definition and Background of Maternal and Child Health (MCH)

 

Motherhood and childbirth is a time to celebrate new life. Yet, this miracle of birth leads to masses of unnecessary deaths every year due to inadequate healthcare. Maternal and child health (MCH) is the professional and academic field that focuses on the determinants, mechanisms and systems that promote and maintain the health, safety, well-being and appropriate development of children and their families in communities and societies, in order to enhance the future health and welfare of society and subsequent generations.

 

MCH should be considered as a profession rather than a discipline. It’s an umbrella concept. It is a dynamic field that aims to improve the health of women, children, youth, and entire families and communities, while addressing health inequities and the systems and policies that contribute to family health, women’s health across the lifespan- sexual and reproductive health, the peri-natal period and birth outcomes, inter-conception care, child health including mental health and special needs, adolescent and youth development are some of the many maternal and child public health challenges. This work uses a life course perspective to address these issues, combining an understanding of human development and the social determinants of health as they accumulate and interact across the lifespan and across generations.

 

The South-East Asia (SEA) region accounts for more than 1, 74,000 maternal and 1.3 million neonatal deaths every year, which is approximately a third of the global burden. This region also accounts for one million stillbirths and 3.1 million deaths of children `under’ five years of age annually (Bhutta and Black, 2013; WHO, 2013). Thus, the SEA region faces a great challenge in reducing maternal, new-born and child mortality as targeted in the Millennium I- development. Globally, maternal and child mortality are in decline, although the pace of decline is not sufficient to attain Millennium Development Goals (MDGs) 4 and 5 for 128/137 developing countries (Lozano et al., 2011).

 

Due to slow progress in reducing infant and maternal mortality and the moral urgency of reinvigorating efforts to tackle slow progress; the United Nations (UN) launched the Global Strategy for Women’s and Children’s Health in 2010. As part of this strategy, India committed to spend US$ 3.5 billion annually, for strengthening maternal and child health services in 235 districts, which account for nearly 70% of infant and maternal deaths (Bhutta and Black, 2013; WHO, 2013).

 

2. Key trend indicators

 

The estimated population of India is 1.16 billion as of now and is projected to be 1.48 billion by 2030, surpassing China as the world’s most populous nation. The total fertility rate has been declined from 3.4 in 1998-99 (IIPS, 2000) to 2.7 in 2005-06 (IIPS & MI, 2007) versus. It is now 2.1 (replacement level) in urban areas, and 3.0 in rural areas. In 2005-06, 56% of married women were using contraception compared with 41% in 1990-92 and 48% in 1998-99.

 

The estimated maternal mortality ratio showed a 36% reduction from 398 per 1, 00,000 live-births in 1997-08 to 254 per 1,00,000 live-births in 2004-06. However, this decrease is not sufficient to achieve a maternal mortality ratio of less than 100 per 1, 00,000 live-births to meet national goals or the Millennium Development Goal (MDG).

 

In 2008, infant mortality rate in India was 53 per 1,000 live births. The national goal is to attain a rate of less than 30 per 1,000 live births by 2010. In an analysis by Paul and colleagues in 2011, it was shown that most states and rural areas as a whole, will not achieve this even by 2015 (Paul et. al. 2011). In 2008, a neonatal mortality rate of 35 per 1,000 live births meant that more than two-thirds of infant deaths happened in the first 28 days of life. More than 48% of children (age <5 years) are stunted 43% are underweight and about 20% have wasting. Between 1998-99 and 2005-06 stunting showed a steady but slight reduction in the prevalence of 1% per year. At the current rate of decline, India will not achieve the national goals for child nutrition or the MDG 1 target for child nutrition, which is to reduce the prevalence of underweight among children (age <5 years) to 27% by 2015.

 

While undernutrition in children has been the major public health concern in India over the past several decades (Subramanyam et al., 2010), little attention has been paid to childhood overweight and obesity still recently. The emerging evidence suggests an increase in over-nutrition status among children as well as adults. The National Family Health Survey (NFHS-3) 2005-2006 data showed that combined prevalence of obesity (body mass index >25 kg/m2) was 9.3% and 12.6% among men and women aged 15-49 years, respectively.

 

3. Indicators of MCH

 

According to WHO, there are 11 indicators of maternal and child-health which are as follows:

i.         Maternal mortality ratio

ii.       Children under five who are stunted

iii.     Under-five child mortality, with proportion of newborn deaths

iv.     Skilled birth attendant

v.       Met need for contraception

vi.     Antenatal care coverage

vii.    Postnatal care for mothers and babies

viii.  Antiretroviral (ARV) prophylaxis among HIV positive pregnant women to prevent HIV transmission and antiretroviral therapy for pregnant women who are treatment-eligible

ix.     Three doses of combined diphtheria-tetanuspertussis (DTP3) immunization coverage (12–23 months)

x.       Exclusive breastfeeding for at least six months

xi.     Antibiotic treatment for suspected pneumonia

    Below are the some indicators of MCH described briefly:

 

3.1 Maternal Mortality Ratio

 

Maternal mortality ratio may be defined as the number of deaths from any cause, during pregnancy or within 42 days of its termination, irrespective of the duration and site of pregnancy, per 100 000 live births. Depending on the standard of maternity care, or the extent of its availability and acceptance, this mortality rate varies.

 

Maternal mortality may be due to:

  • Direct causes such as complications of pregnancy, labor and puerperium;
  • Indirect or associated causes such as aggravation of pre-existing diseases like hypertension, diabetes or anemia; or
  • Unrelated causes such as traffic accidents, intestinal obstruction or cancer.

  Deaths due to direct causes (also called true maternal deaths) are mainly due to sepsis, hemorrhage, toxemias and accidents of labor including rupture of the uterus.

 

Factors influencing maternal mortality:

(1)  Place of  delivery: Over 90% of maternal deaths occur in home delivery or emergency admissions.

(2)  Reproductive efficiency is highest at 21-25 years. In teenagers, the risk is slightly higher. In women over 35 years, it is three to four times greater; after 40 years, it is 6-10 times more (WHO, 1977).

(3)  Parity: It is safest with the second or third delivery. With primiparae, the risk is slightly increased; with grand multiparae, it is three times more subjected to haemorrhage, mal presentations or ruptured uterus.

(4)   Social class: Maternal mortality is six times higher in the poor and the unskilled than in the wives of the managerial group (Llewellyn-jones, 1974). This could be explained by the poor nutritional status and lack of antenatal care in the former.

(5)  Other factors: The risk of maternal death is greater in single women than in married women, and in rural areas than in urban areas. Anemia is responsible for 20% of maternal deaths in developing countries, mainly due to congestive failure, shock, sepsis, or thromboembolism. Such women are poor risks for any operative delivery or anesthetic procedures.

Source Link: https://newint.org/features/2009/03/01/maternal-mortality-facts/

 

Avoidable factors in maternal death

 

Maternal deaths are preventable. It is considered avoidable when there is a departure from the generally accepted standard of satisfactory care. Avoidable factors have been reported in 54-85% of maternal deaths (Rao and Malika, 1977). In order of frequency, the responsibility may be with the hospital staff, the patient or her relatives, the general practitioner, the midwife and anesthesia or transport services. Most preventable deaths occur in the antenatal period, and about 25% during labor.

 

3.2 Maternal Health Services

 

3.2.1 Ante-natal care:

Ante-natal period is best time to provide the mother with necessary health related information and even interventions if required which leads to their better health and survival along with the infant (UNICEF, 2008). Maternal and neonatal morbidity has been shown to be reduced because of many ante-natal interventions. Ante-natal care can be defined as the care a woman get during childbearing which helps and ensure the healthy outcomes for both, mother and infant.

 

WHO has recommended 4 minimum ante-natal visits for lowering risk during pregnancy. Ante-natal care may not necessarily prevent the complications from occurring but lower the risk for maternal death and could provide enough time to cope up with the complication. Jejeebhoy (1997) also reported that women who visited for ante-natal check-up for at least one time had a higher chances for survival as compared to those who did not visit at all.

 

Also, utilizing ante-natal care services during childbearing may lead to seek women for the treatment of various other complications during pregnancy and after the delivery. Many of the thousands mother could save their lives if proper medical care and appropriate health management system should be provided. Singh and Yadav (2000) found that 9% of the pregnant women had at least one ante-natal visits while 62% of them had three or more ante-natal visits. While 11% of the women did not visit for ante-natal check-ups even once. For antenatal visits there is a huge gap in access for urban and rural women.

 

According to NFHS-3, 91% of the women in urban areas were having access to ante-natal care as compared to 72% of women in rural areas. Also a direct association was found in NFHS-3 between ante-natal care access and education. 85.3% of women with 10 years of education, 67.3% of women with 8-9 years of education, 59% of the women with less than 8 years of education and 29.8% of women with no education receives ante-natal care. Besides reducing specific causes for maternal mortality and morbidity, antenatal care can encourage the birth preparedness and use of skilled assistance during labor and delivery.

 

3.2.2 Delivery care:

Maternal health is considered as a social event as much as a medical phenomenon where access and use of maternal health care services are influenced by social contextual factors. Traditionally in India pregnancy is considered to be a natural state of being a women and not a condition which requires medical attention and care. These perception and beliefs create a “lay-health culture” which acts as an intervening factor between presence of morbidity and its corresponding treatment. Such lay-health culture apparently has substantial effects on the utilization of maternal health services in regions where poverty and illiteracy are widespread. To achieve reduction in maternal mortality there are two challenges, first is to obtain skilful services by a birth attendant during labor and delivery; secondly to access high level of obstetric care in case of complications (Weil and Fernendez, 1999). To meet these challenges competent health professionals and an environment in which these health professionals can perform effectively is required.

 

According to the definition jointly given by WHO, UNFPA, UNICEF and World Bank, “a skilled birth attendant is a person with midwifery skills like a nurse, physician or midwife, who has been given training in skills which are necessary to manage normal labor and delivery (WHO, 1999). Most of the childbirth in all developed countries and in many urban areas of developing countries take place in hospitals with skilled birth attendant. On the other hand most of the childbirths in rural parts of developing countries took place at home without any skilled birth attendant and generally with poor access to medical care.

 

Researchers have attempted to measure and identify factors affecting the use of maternal health services. From the data of NFHS-1, analysis was done to look for factors affecting the use of maternal and child health services in rural part of four northern states and it was found that socioeconomic factors like education, standard of living and media exposure creates a demand for services and is affected by availability and physical access to health services (Das et al 2001). Also in another study from NFHS-1 data in north and south India, women’s education was found to be an important factor affecting maternal health services utilization (Govindaswamy & Ramesh, 1997).

 

Majority of the research have stressed on the role of demographic and socioeconomic factors which influences the utilization of and demand for maternal and child health services. Many of these studies have also shown the importance of factors like urban-rural residence, caste/tribe membership, religion, woman’s status relative to men, woman’s work status, household standard of living and community development etc in utilizing maternal health care services. Despite many benefits of institutional delivery, India’s program of maternal and child health did not aggressively promote institutional deliveries except in cases of high-risk. This is because institutional deliveries providing facilities on a mass scale (especially in rural areas) is viewed as a long term goal which requires massive health infrastructure investments.

 

3.2.3 Post-natal care:

 

Mothers and their child need to be cared beyond time of birth and also throughout postpartum period, which extends until 42nd day after delivery, a period which is unfortunately ignored by many (UNICEF, 2008) as there is the highest risk for both mother and child during childbirth or immediately after birth. Hence it become critically important to ensure appropriate postnatal care to safeguard new-born and mother. More than 2/3rd of deaths of new-born occurs within first week of birth and out of these most of the deaths occur within 24 hours of delivery (Lawn et al., 2005). In India, almost 39% of new-born deaths occur on first day while around 57% between first 3 days. Maximum of the maternal deaths occur between third trimester and the end of first week after birth.

 

Only promoting antenatal care, institutionalized delivery and skilled attendance at birth is not enough to promote maternal and child health. Post natal care for all mothers and neo-natal should be recommended with special reference to low birth-weight and small babies. Despite government initiatives and policies, there has been a lack of follow up after childbirth. Furthermore mothers only seek postnatal care during complications after birth. Poor knowledge, lack of schooling, poverty and insufficient services of follow up in health care systems prevent women to seek post natal care.

 

For post natal care there has not been any systematic national analysis for population data to understand factors affecting the use of post natal care in India. Limited data exist on the timing and extent of postnatal care and how difference exist between the women receiving care during birth at home and institution (Singh et al., 2012). In general, uptake of post natal care is limited in South Asia (Halder et al., 2007) predominantly in India. According to NFHS-3, merely 42% of women receives post-natal care (IIPS, 2007).

 

3.3 Immunization

 

The pregnant mother and her newborn should be protected from infections. Immunization of all prenatal women with tetanus toxoid is a routine procedure throughout the world to prevent puerperal and neonatal tetanus. The EPI (Expended program on Immunization) was introduced in 1974. This programme cover 5 vaccine preventable diseases i.e Tetanus, Tuberculosis, Diphtheria, Poliomyelitis and Pertussis. The UIP (Universal immunization Programme) was came into existence in 1985-86 in which vaccination for measles has been included. In 1992, this programme became a part of the “Child Survival and safe Motherhood Programme” (CSSM). Then the Reproductive & Child Health Programme was introduced in 1997, which was targeted to cover all the pregnant woman with Tetanus immunization and also infants with primary immunization.

 

All the cold chain equipment and the vaccines are supplied by the Central Government free of cost. Also vaccines are given to all the beneficiaries at every immunization session free of cost. The surveillance of vaccination preventable disease is done by visiting homes and OPD and IPD cases. The main objective of the immunization is reduction in maternal and infant morbidity and mortality because of vaccine preventable disease. At present elimination of neonatal tetanus (NNT), measles and eradication of poliomyelitis are important objectives. These vaccination has been done under the supervision of some health experts. The schedules recommended by Government of India is followed during the programme. The primary aim of this program is to immunize at proper age, with proper dose and appropriate route before first birthday of the child.

 

3.4 Family Planning

 

Family planning has been considered as the most effective way of controlling massively and rapidly growing population (WHO, 1971). Family planning is an influential factor in controlling maternal mortality level by decreasing total number of births and the number of unwanted pregnancies. In developing countries, programmes to promote family planning initiated in 1960s, in response to improvement in child survival which ultimately lead to population growth (Cleland et al., 2006). Since the inception of the programme, fertility levels in India has been declined with varying paces at different regions. The total fertility rate reduced from 6.4-6.6 lifetime births per women in 1970s to 3.4 lifetime births per women in 1990 and 2.68 found in NFHS-3.

 

India is moving slowly but steadily towards goal of replacement level of fertility with decrease in birth rate and increase in contraceptive prevalence. Despite of increased use and awareness, significant unmet need for family planning still exist. (NFHS, 1,2,3). The most common reasons responsible for unmet need of family planning are lack of information, unsatisfactory or inconvenient services, and fear of side effects of contraceptives, opposition from partner, family and others. There is an inter-related complex of factors which effect the use of family planning. For instance, women’s status, educational level of women, employment of women, involvement in political activity and mobility, and autonomy.

 

Along with these factors religion was found to be an individual strong predictor for adopting family planning methods specially sterilization. According to NFHS-3 only 52% of the Muslim women used any kind of contraception as compared to 68% Hindu women and 73% Christian women. The unmet need among Muslim women for spacing and limiting was 16.1% as compared to average of 8% women in Delhi. Also female sterilization was least (11.5%) among Muslim women as compare to 24.5% among Hindu and 24.7 % among women of other religion. (NFHS-3). Also Son preference in most of the Asian societies is an integral part of the culture and apparent in various demographic and ethnographic analysis. Hence, number of sons among offspring influences the couple’s decision to use contraceptives and also the choice of method (Dang, 1995).

4. STDs and RTI

 

Worldwide Reproductive Tract Infections (RTI) including Human Immuno Deficiency Virus (HIV) continue to be a serious public health concern. Many men and women both are affected from reproductive tract infections (RTIs) along with sexually transmitted infections (STIs). Around 340 million new treatable cases of STIs befall each year, with approx. 151 million cases of them in Southeast and South Asia (Prasad et.al., 2005). STIs are considered among top five categories for which individuals in developing countries seeking treatment or health care and one third of STIs occur in people below 25 years of age globally.

 

Pelvic inflammatory disease (PID), infertility, cervical cancer, spontaneous abortion and ectopic pregnancy are the most serious long term consequences in women, which may lead to maternal death later. Previous studies has reported that in Indian context PID is more likely to be an obstetric problem in origin rather than a result of STDs (Belsey, 1976; Brabin et.al., 1998).

 

In India, through 1990s and 2000s research regarding women’s experience to RTIs along with STDs has been increased considerably. Many policies and programs like National Population Policy 2000, National Health Policy 2002, National Rural Health Mission 2005 and First National AIDS Control Programme (1992-1999) have been launched for increasing women’s access to health services for prevention, management and screening of RTIs (MoHFW, 2013).

 

For many reasons, there is a lack of information about the epidemiology of RTI in India. Situation in tribal and rural areas are worse as they hardly have any access to health care facilities during childbirth. So many STIs and RTIs go undiagnosed or many do not have any treatment available. It became crucial to prevent their transmission. By adopting safer behaviors, risk can be reduced by an individual. Encouragement of these safer behaviors should then be incorporated in programs and policies (Ravi & Athimulam, 2014). Around the world lives of women are changing vividly in different settings. Still gap exist between the reality of women reproductive lives and women’s reproductive hope.

 

Summary

 

Maternal and child health care is central not only to the immediate objective of improving the health of mothers and children, but also to the broader objective of optimal human development, and life-long individual and community health. The health facilities for mothers and children must be available to the majority of the population. This can be accomplished best by comprehensive planning to distribute resources according to needs rather than the ability to pay. MCH should be considered as a broader aspect which covers all the necessary points. These health functions are best handled as an integral priority of general health services focused on basic human needs. In some peripheral areas because of their priority, MCH and/or family planning activities have developed initially as isolated services. When other services are developed, integration with MCH as a nuclear service avoids wasteful duplication and fragmentation. Where general health services are already in place, they must devote adequate attention to maternal and child health priorities. A wide range of cultural, religious and political attitudes influence maternal and child health concerns, and the status of women is of particular importance.

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    Suggested Readings

  • Kotch, J. B. (2012). Maternal and child health. Jones & Bartlett Publishers.
  • Ehiri, J. (2014). Maternal and Child Health. Birkhauser.
  • Green, M. (1994). Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. National Maternal and Child Health Clearinghouse, 8201 Greensboro Drive, Suite 600, McLean, VA 22102.
  • Pillitteri, A. (2010). Maternal & child health nursing: Care of the childbearing & childrearing family. Lippincott Williams & Wilkins.