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Chapter 4 Health services Health services are referred to all activities aim to promote health, prevent or cure diseases

, or rehabilitate disabled. The term is used for authorized sites with health professionals offering the services in the different communities for group of people or for individuals. Health services providers in Palestine: The four most important providers of health services in Palestine are: 1. The Ministry of Health (MOH) 2. The United Nations Relief and Works Agency (UNRWA) 3. Non-Governmental Organizations (NGOs). 4. Private sector accounts for a relatively small proportion of health services delivered. Ministry of Health (MOH) The Palestinian MOH is the main health care provider for the Palestinian population. The Ministry of health had taken the responsibilities of Palestinian health since 1994. The responsibility of the Ministry focuses on primary and secondary health care services. Primary health care includes antenatal, natal and postnatal care, health

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education and health promotion, environmental health, psychological health, food safety and control, drinking water quality, vector control and diagnostic facilities. Primary health care is the vertebral column of the health services and offer health services through a network of primary health care centers distributed in all the Governates. The secondary health services are provided by the hospitals. Recently MOH develops tertiary health services through development of the local department and training of the local specialists to minimize referral outside the country. Furthermore, the MOH purchases tertiary services from other health providers, both locally and near counties (Israel, Jordan and Egypt) (MOH, 2001) United Nations Relief Works Agency (UNRWA) UNWRA operated in Palestine since 1948, the agency has been the main health care provider for the Palestinian refugee population, providing health service free of charge to all refugees. UNRWA plays an important role in primary health care mainly vaccination, antenatal and postnatal care, nutrition and supplementary feeding, assistance with secondary health care and environmental health in refugee camps. Additionally, UNRWA contracts for services with Non-Governmental Organization (NGOs), primarily for

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secondary and tertiary care, and with Israeli facilities for limited specialty particularly for tertiary care (UNRWA, 1999) Non-Governmental Organization (NGOs) The NGOs sector was first initiated in the late 1970s as a direct consequence of the many restrictions, which were imposed by Israeli Military Authorities on the charitable sector during the 1970s. NGO become well established during mid 1980s. As a result of the inability of NGO sector to obtain licenses for clinics from the Israeli Military Authorities, most of the NGO clinics had to operate out of the occupation registration laws. The main NGOs in the Occupied Territories are Health Services Council (HSC), the Union of Health Work Committees (HWC), the Health Care Committees (HCC) and the Union Palestinian Medical Relief Committees (UPMRC). In 2000, The NGOs sector of health operates 185 mini PHC centers distributed with larger number of centers in West Bank than Gaza Strip. Some of them include medical laboratory equipment to perform simple investigations, and include mini pharmacies the provide the attendants with low priced medicines ( MOH, 2001).

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The Private sector It includes a large number of private practitioners; private hospitals and private medical companies provide a range of primary and secondary level services and diagnostic testing. These centers provide a range of medical specialists and other services such as dentistry, physiotherapy, and laboratory testing.

Types of Health services 1. Promotive 2. Preventive 3. Curative 4. Rehabilitation Promotive health services are concerned with

1.

promotion of health status of the population. These services aim to maintain the human body in well functioning status such as improvement of the nutrition by taking healthy food that provides the body with the required nutrients and avoiding excess of undesirable food items. A second example is the physical exercises that insure fitness of the body and improvement of the circulation to ensure enough blood supply for the vital organs in the human body.

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The

Promotive

health

services

are

not

the

responsibility of health sector only but require the participation of other sectors such as education, social welfare and clubs. Preventive health services are activities aim to prevent an action that could badly influence the health status. In this text we refer to the bad Preventive influence as a disease or injury. These events could be cured or lead to disability or death. health services are classified to primary prevention, secondary prevention or tertiary prevention. Primary prevention includes all measures to prevent occurrence of the undesired event (disease or injury). All the promotive services are considered as a primary prevention. A second example of primary prevention is immunization against infectious diseases. Health education for healthy people is a primary prevention, where public awareness is improved towards prevention of occurrence of a public health problem that could endanger the health. Other examples of primary prevention include safe water and food supply, safe working conditions and healthy housing.

2.

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these measures do not prevent the occurrence of the event but minimize its 3. manage acute or These services could be Care is given to Health problems. Tertiary Prevention aims to utilize the remaining body functions to compensate the functions that could not be maintained due to failure of primary and secondary prevention. 150 . Giving Oral Rehydration Solution (ORS) to children with diarrhea is a measure to prevent complications of that event and considered as a secondary prevention. chronic So. sequences. medical or surgical interventions. Curative Health Services: These services could be given in primary health care centers or inside hospital departments. Examples of tertiary prevention include rehabilitation of a patient with limb amputation or changing occupation in case of road accident.Secondary prevention includes measures taken to discover the events early and subsequently management is easier and complications are less. All screening programs such as routine physical examinations and screening for cancer breast and for cancer cervix are secondary health services.

Rehabilitation Health Services: Rehabilitation centers with specialized staff are responsible for provision of these services. Tertiary: Specialized health care. This meeting is the start point for the Slogan "Health for all by the year The major outcome of the meeting is Alma Ata Attached. Primary Health Care The concept of Primary Health Care is returned back the year 1978 when WHO called the World Countries to Participate in Alma Ata Conference. Ten years later during meeting the in Epidemiological 10 years Association DeclarationInternational presented Helsinki. Rehabilitation could be integrated with the primary health care activities or inside The modern trend is to conduct these activities within community based programs.professions including doctors and nurses are only authorized to provide these services. Secondary: Hospital care 3. Primary: Primary Health Care 2. hospital. Mahler achievement after Ala-Ata 151 . 2000". Finland the Director General WHO Dr. Levels of Health services 1. 4.

deceleration. Primary Health Care approach is adopted by the world countries and proved to be cost effective. mainly Education. 152 . Youth. North Karelia project in Finland is a good example of community involvement to over come the major health problems. In Palestine the approach starts to be gradually implemented since 1982 until the birth of National Health Plan – 1994 where primary health care is considered the vertebral column of the health care system in Palestine. Industry. Mahler concluded that we are far from achieving health for all by the year 2000 and phrased the Slogan as: "Health for all and All for Health by the year 2000". Agriculture. In this project mortality and morbidity due to cardio vascular and Cerebro-vascular disease reduced sharply when community was oriented and contributed to the organized program to overcome these problems. Dr. Now it is clear that health is not the responsibility of Ministries of Health but it is the outcome of community participation and involvement of other sectors. and Social Well fair.

Components of Primary Health Care: 1. An adequate supply of safe water and basic sanitation. and not merely the absence of disease or infirmity. Alma-Ata. meeting in Alma-Ata this twelfth day of September in the year Nineteen hundred and seventy-eight. including family planning. Declaration of Alma-Ata International Conference on Primary Health Care. 3. hereby makes the following Declaration: I The Conference strongly reaffirms that health. 5. 6. mental and social wellbeing. immunization against the major infectious diseases. 2. and the world community to protect and promote the health of all the people of the world. is a fundamental human right and that the attainment of the highest possible level of health is a most important world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector. all health and development workers. 4. appropriate treatment of common diseases and injuries. Prevention and control of locally endemic diseases. 153 . which is a state of complete physical. 612 September 1978 The International Conference on Primary Health Care. expressing the need for urgent action by all governments. Maternal and child health care. USSR. Education concerning prevailing health problems and the methods of preventing and controlling them. Promotion of food supply and proper nutrition. 7. provision of essential drugs.

It is the first level of contact of individuals. A main social target of governments. international organizations and the whole world community in the coming decades should be the attainment by all peoples of the world by the year 2000 of a level of health that will permit them to lead a socially and economically productive life. based on a New International Economic Order. of common concern to all countries. of which it is the central function and main focus. Primary health care is the key to attaining this target as part of development in the spirit of social justice. VI Primary health care is essential health care based on practical. the family and community with the national health system bringing health care as close as possible to where people live 154 . It forms an integral part both of the country's health system. therefore. and of the overall social and economic development of the community. V Governments have a responsibility for the health of their people which can be fulfilled only by the provision of adequate health and social measures. The promotion and protection of the health of the people is essential to sustained economic and social development and contributes to a better quality of life and to world peace.II The existing gross inequality in the health status of the people particularly between developed and developing countries as well as within countries is politically. socially and economically unacceptable and is. IV The people have the right and duty to participate individually and collectively in the planning and implementation of their health care. is of basic importance to the fullest attainment of health for all and to the reduction of the gap between the health status of the developing and developed countries. scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self reliance and self-determination. III Economic and social development.

including family planning. relies. and demands the coordinated efforts of all those sectors. to 155 . education. preventive. reflects and evolves from the economic conditions and sociocultural and political characteristics of the country and its communities and is based on the application of the relevant results of social.and work. at local and referral levels. on health workers. functional and mutually supportive referral systems. involves. 5. communications and other sectors. requires and promotes maximum community and individual selfreliance and participation in the planning. should be sustained by integrated. strategies and plans of action to launch and sustain primary health care as part of a comprehensive national health system and in coordination with other sectors. 7. industry. animal husbandry. prevention and control of locally endemic diseases. promotion of food supply and proper nutrition. housing. To this end. public works. operation and control of primary health care. food. maternal and child health care. an adequate supply of safe water and basic sanitation. making fullest use of local. providing promotive. 6. midwives. all related sectors and aspects of national and community development. it will be necessary to exercise political will. curative and rehabilitative services accordingly. in particular agriculture. and giving priority to those most in need. national and other available resources. and constitutes the first element of a continuing health care process. immunization against the major infectious diseases. in addition to the health sector. VII Primary health care: 1. organization. including physicians. and provision of essential drugs. suitably trained socially and technically to work as a health team and to respond to the expressed health needs of the community. biomedical and health services research and public health experience. 3. as well as traditional practitioners as needed. and to this end develops through appropriate education the ability of communities to participate. includes at least: education concerning prevailing health problems and the methods of preventing and controlling them. VIII All governments should formulate national policies. addresses the main health problems in the community. appropriate treatment of common diseases and injuries. 2. leading to the progressive improvement of comprehensive health care for all. auxiliaries and community workers as applicable. 4. nurses.

The Conference calls on all the aforementioned to collaborate in introducing. X An acceptable level of health for all the people of the world by the year 2000 can be attained through a fuller and better use of the world's resources. détente and disarmament could and should release additional resources that could well be devoted to peaceful aims and in particular to the acceleration of social and economic development of which primary health care. A genuine policy of independence. should be allotted its proper share. WHO and UNICEF. developing and maintaining primary health care in accordance with the spirit and content of this Declaration. PHC Mission Statement in Palestine The Palestinians adopted PHC as a vertebral column for service provision in Palestine and stated this concept in the Palestinian Strategic Plan as follow: 156 . It urges governments. The International Conference on Primary Health Care calls for urgent and effective national and international action to develop and implement primary health care throughout the world and particularly in developing countries in a spirit of technical cooperation and in keeping with a New International Economic Order. all health workers and the whole world community to support national and international commitment to primary health care and to channel increased technical and financial support to it. a considerable part of which is now spent on armaments and military conflicts. nongovernmental organizations. funding agencies. particularly in developing countries.mobilize the country's resources and to use available external resources rationally. as well as multilateral and bilateral agencies. peace. II. IX All countries should cooperate in a spirit of partnership and service to ensure primary health care for all people since the attainment of health by people in any one country directly concerns and benefits every other country. and other international organizations. as an essential part. In this context the joint WHO/UNICEF report on primary health care constitutes a solid basis for the further development and operation of primary health care throughout the world.

" Primary Health Care Activities: These activities are the core PHC services provided. mainly by the MOH and UNRWA. 157 . acute respiratory infections. particularly. affordable. in allocating resources to maximize and optimize the efficiency and to improve the quality of these services. high risk pregnancy. and immunization. • Women’s Health including prenatal care. promotion.“To provide preventive. family planning and reproductive health. including breast feeding. Thus. mortality and morbidity rates are decreased to the minimized possible level. and equitably distributed. curative and rehabilitative health care services to all individuals. available. attainable. These services should be universally accessible. • Nutrition and micronutrient deficiencies. The high risk approach is adopted in PHC. • Communicable and non-communicable disease control including control of diarrhea diseases. NGOs participate in providing some of these services much more in the West Bank than Gaza Strip: • Child’s Health including the care of child at birth. families and groups of the Palestinian population. brucellosis and others. socially acceptable.

• Health promotion and education. and • Diagnostic services including laboratory and X-Ray. • Oral preventive and curative health care. 158 . therefore it is difficult to find the same number of PHC centers in two different references. • Curative care for children and adults with provision of essential drugs in the PHC centers including medical emergency and chronic diseases.• School health. There is a rapid expansion of the PHC centers in all the districts in both West Bank and the Gaza Strip. The reader has to remember that the National Health plan is based mainly on the Primary Health care. Primary Health Care Centers in Palestine The following table shows the present available PHC centers in Palestine. • Environmental health.

Distribution of PHC centers in Gaza Strip and West Bank according to health providers. 1998 Governorate North Gaza Gaza City Mid-Zone Khan Younis Rafah Subtotal Jenin Tul Karem Nablus Qalqilia Salfit Ramalla Jerusalem Jericho Bethlehem Hebron Subtotal Grand Total Governme Health Providers UNRWA NGOs Total 19 38 20 22 6 105 68 40 57 24 21 60 6 23 30 147 476 581 nt 5 3 11 10 3 25 6 5 9 8 2 12 2 3 1 31 16 58 51 5 12 28 2 10 36 4 17 19 2 3 17 1 3 38 5 17 0 3 3 15 3 5 21 2 7 113 7 27 338 34 104 369 50 162 Maternal and Child Health MCH MCH services are the sites where women and children seek their preventive and curative services. It is a PHC 159 . MOH.

300 die before reaching their first birthdays.000. while the reported rate is 13. acute respiratory infections. For every 100.000 live births. Under – five Child mortality rate is 27 deaths per 1.000 live births.8 per 100. post neonatal at 8 per 1. hypothermia. Immunization coverage rate is over 95% for Polio 3 and DTP 3 among the 12-23 months old. To ensure antenatal care for all women during their reproductive life. and some basic services are 160 .000 live births.component where these services should be available. birth trauma. diarrhea. and accidents. congenital anomalies. 2.000 live births and maternal mortality rate is estimated about 70 to 80 per 100.000.000 born babies every year. the government heath services are the backbone of primary MCH services. affordable and accessible to all the population in their communities. These services are provided free of charge for children under age 3 (12% of population). Main causes of infant and child mortality reported are prematurity & low birth weight. The major aims of these activities are: To ensure complete health care for all children in the community. Together with UNRWA services for refugees. Infant mortality in the West Bank and Gaza is estimated at 23 deaths per 1. Neonatal mortality was estimated at 15 per 1.

Family planning services. 3. 4. 4. Health Education to ensure healthy children. Screening of all children for Phenylketoneurea and Hypothyroidism. MCH services are provided for those who are covered by the governmental health insurance scheme. Child Health 1. proper nutrition and self care. 3. Post natal follow up.provided free of charge for pregnant mothers. Immunization of all children against the vaccine preventable diseases. 2. Components of MCH activities: Childe Health: 1. 2. Early discovery of congenital abnormalities. Growth and development monitoring including proper nutrition with emphasis on breast feeding. Further. 5. Immunization. Physical and Development Assessment: 161 . Provision of safe delivery site. Provision of Antenatal Care including regular examination. Women Health: 1.

This examination aims to detect any congenital anomalies or birth associated injuries. These visits are scheduled with the immunization program.Every newborn is examined physically during the first visit to MCH center. • Community diagnosis: Somatic characteristics are one of the the direct health health status indices of for the measuring 162 . and Weight/Height. Height/Age. During each MCH visit each child is assessed for growth by taking weight and height. percentile of the are classified children malnourished children. individual observing change in their nutritional status either improving or deteriorating. For example a child shifting from the castigatory below 10 percentile to 10-50 percentile categories is improving. Subsequently regular physical and developmental check ups are conducted for children at each visit. Three indicators are used: Weight/Age. These measurements are plotted on specific charts for this purpose and serve three purposes: • Evaluation than • Follow 10 up of the current status of the Less as by individual child in term of percentile.

The discovered cases are followed up regularly. Communities with a low percentage of children less than 10 percentile are healthier than communities with higher percentage. The screening program has been in MOH since 1994 and expanded to UNRWA clinics in 2001. Incidence of (PKU) is 28 per 100. 2.000 for the year 2002. Screening Routine screening for phenylketoneurea (PKU) and hypothyroidism of newborns are conducted at the PHC-MCH clinics. Immunization: Childhood immunization in Gaza Strip and the West Bank has received major emphasis over many years. This has resulted in an expanded immunization program (EPI) which includes a broad range of vaccines with coverage of over 90% of infants and school age children. There have been no differences between the immunization programs 163 .000 and the reported incidence for Hypothyroidism is 33 per 100. The immunization program is under continuous review of international experts in this field. 3.communities.

Polio. Immunization is provided at MCH/PHC centers and with the help of mobile immunization team regularly visiting villages in addition to on-site services and UNRWA Health Center services. 1.Tuberculosis: BCG (Bacillus of Calmet and Gurin): BCG is the most widely used vaccine in the world and the immunization at birth will reduce the morbidity and mortality 164 . Vaccines are provided from different sources such as MOH. Hepatitis B. Tetanus. Pertussis. Measles and Tuberculosis as well as German measles and Mumps. Situation regarding the availability of vaccines to cover all population is generally good and immunization activities are regular in the MOH and UNRWA clinics. As recommended by WHO. the immunization program is conducted to cover the following infectious diseases: Diphtheria.implemented at governmental clinics in Gaza and the West Bank and at UNRWA clinics since 1995. The vaccine was also provided to UNRWA Health Services Centers and to all hospitals. UNICEF and WHO. During 1992/1993 routine immunization for hepatitis B for all newborns was instituted in Gaza and the West Bank.

BCG should continue to be given as soon after birth as possible in all populations at high risk of tuberculosis infection It is live attenuated Bacilli (Mycobacterium Bacilli).05-0.Oral Polio vaccine = Trivalent Oral Polio vaccine = Sabin vaccine=live attenuated vaccine… This vaccine developed by Sabin and it contains the three typed of Polio. type I. It is given in form of 2 drops per month in 3 doses with 4-8 weeks internal between the doses. 2-Polio vaccines: There are two types of Polio vaccines: A. It is not 165 . II.B.1 ml dose. The vaccine is given preferably directly after birth but due to logistic reason it is given during the first week after birth and not preferred after the 1st month of life. and III. A Fourth booster dose is given 6 months after the 3rd dose the most serious complication of this vaccine is the "vaccine associated poliomyelitis". The vaccine is given intradermally in a 0. The viruses are cultivated on Monkey Kidney tissue and pass process of attenuation to ensure weakening of the virus. The main complications of this vaccine are lymphadenitis and disseminate d T.from tuberculosis and disseminated disease among children.

3-Diphtheria – Pertussis – Tetanus (DTP) = Triple vaccine: This is a combination of toxins of Diphtheria Bacteria. Tetanus is caused by a potential neurotoxin produced by clostridium tetani and immunization is by tetanus toxoid. B. Pertussis killed bacteria and the toxins of Tetanus taxied. The vaccine is given for children under 3 years 166 .advised to give vaccine for children with immunodeficiency or children receiving immunosuppressive medication. This vaccine but more expansive and there is no chance for community dissemination losing the chance of passively immunizing other community members. an activated preparation of diphtheria toxin. A booster dose is given 6 month after the second dose. an inactivated preparation of the toxin. but prevent the systemic manifestations. It does not prevent the infection. Salk developed this vaccine and it is given Intramuscular in two doses with one month between.Killed Polio vaccine=Salk vaccine = Inactivated Polio – vaccine. Diphtheria immunization is by diphtheria toxoid. The third component is immunizations of Pertussis by inject of killed bacteria of Pertussis.

In Palestine this vaccine introduced to the health care centers in January 1993 and given routinely for all infants in 3 doses intramuscularly. 5. 4-Hepatitis B vaccine: Immunization with vaccine containing the hepatitis B surface antigen (HbsAg) is the recommended for all infants as soon possible after birth. A second dose of measles is recommended and usually it is given at age 15 months together with Rubella antigen and Mumps antigen in a vaccine called MMR (Measles.Mumps – Rubella). 167 . Tetanus taxied alone is recommended for pregnant women and for injured people who are not fully immunized or those older than 12 years old.Measles Vaccine: This is a live attenuated vaccine cultivated on egg yolk and given intramuscularly at age of 9 months. The dose is given in the 1st month of life and the 2nd dose in the 2nd month and a booster dose is given 6 moths after the second dose. A booster (4th) dose is given 6 months after the third dose. The given vaccine is an artificial DNA similar protein.but older children are given only DT where Pertussis is not recommended for older children. Triple vaccine is given in three doses with 4-8 weeks interval between each dose.

TOPV (3) Measles. DPT (1). Salk (IPV) (1) Hepatitis B (2). Hepatitis B (1). Hepatitis B (3) TOPV (4). IPV (2).Immunization schedule Palestine Age /months 1st month 2 nd Vaccine BCG. DPT (2) DPT (3). TOPV (1) TOPV (2). DPT (4) MMR month 3rd month 4th month 9 month 10-12 months 15th month th BCG: Bacillus of Calmet & Gurin DPT: Diphtheria Pertussis Tetanus TOPV: Trivalent Oral Polio Vaccine MMR: Measles Mumps Rubella IPV: Inactivated Polio Vaccine 168 .

stomach aches. coma.Relevant to Palestine Pulmonary Tuberculosis Description Symptoms A respiratory disease caused by Mycobacterium Bacilli. Cough.Summery for the vaccine preventable diseases A. and death if not treated Transmission Spread by coughing and sneezing Vaccine Diphtheria toxoid (contained in DTP. dyspnea. DT or Td vaccines) can prevent this disease. back. DTaP. and stiffness in the neck. nausea. and legs Complications Paralysis that can lead to permanent disability and death Transmission Contact with an infected person Vaccine Diphtheria Description Symptoms Polio vaccines (IPV & TOPV) can prevent this disease. headaches. A respiratory disease caused by bacteria Gradual onset of a sore throat and low-grade fever Complications Airway obstruction. Airway obstruction. sore throat. 169 . low-grade fever and loss of weight Complications Haemoptesis. and death if not treated Transmission Spread by coughing and sneezing Vaccine Polio Description Symptoms BCG (Bacillus of Calmet and Gurin) A disease of the lymphatic and nervous systems Fever. coma.

elevated blood pressure. drinking. Tetanus (lockjaw) Description Symptoms A disease of the nervous system caused by a bacteria (clostridium tetani) Early symptoms: lockjaw. especially people over age 50 Transmission Enters the body through a break in the skin Vaccine Tetanus toxoid (contained in DTP. and breathing Complications Pneumonia. and severe muscle spasms Complications Death in one third of the cases. Transmission Spread by coughing and sneezing (highly contagious) Vaccine Pertussis vaccine (contained in DTP and DTaP) can prevent this disease. Hepatitis B 170 . especially in infants. encephalitis (due to lack of oxygen). and death. DT.Pertussis (whooping cough) Description Symptoms A respiratory disease caused by bacteria Severe spasms of coughing that can interfere with eating. and difficulty swallowing Later symptoms: fever. stiffness in the neck and abdomen. DTaP & Td vaccines) can prevent this disease.

seizures. Measles Description Symptoms A respiratory disease caused by a virus Measles virus causes rash.Description Symptoms A disease of the liver caused by hepatitis B virus Potentially none when first infected (likelihood of early symptoms increases with the person's age) If present: yellow skin or eyes. stomach ache. loss of appetite. watery eyes. and red. lasting about a week. cough. nausea. 171 . Complications Diarrhea. runny nose. ear infections. encephalitis. tiredness. the greater the likelihood of staying infected and having lifelong liver problems. or joint pain Complications The younger the person. and death Transmission Spread by coughing and sneezing (highly contagious) Vaccine Measles vaccine (contained in MMR and measles vaccines) can prevent this disease. such as scarring of the liver and liver cancer Transmission Spread through contact with the blood of an infected person or by having sex with an infected person Vaccine Hepatitis B vaccine is will prevent this disease. pneumonia. high fever.

inflammation of the pancreas and deafness (usually permanent) Transmission Spread by coughing and sneezing Vaccine Mumps vaccine (contained in MMR) can prevent this disease. cataracts. and swelling of the lymph nodes close to the jaw Complications Meningitis. mental retardation.Mumps Description Symptoms A disease of the lymph nodes caused by a virus Fever. heart defects. and liver and spleen damage (at least a 20% chance of damage to the fetus if a woman is infected early in pregnancy) Transmission Spread by coughing and sneezing Vaccine Rubella vaccine (contained in MMR vaccine) can prevent this disease. Rubella (German measles) Description Symptoms A respiratory disease caused by a virus Rash and fever for two to three days ( mild disease in children and young adults) Complications Birth defects if acquired by a pregnant woman: deafness. inflammation of the testicles or ovaries. headache. muscle ache. B – Other vaccines: Haemophilus influenzae type b (Hib) 172 .

occurring primarily in infants Skin and throat infections.Description Symptoms A severe bacterial infection. Varicella (chickenpox) Description A virus of the herpes family 173 . sepsis. loss of appetite. Transmission Most often: spread by the fecal-oral route (An object contaminated with the stool of a person with hepatitis A is put into another person's mouth. but there is little risk of getting the disease after age 5) Complications Hib meningitis (death in one out of 20 children. and permanent brain damage in 10% . or nausea Complications Because young children might not have symptoms. meningitis.) Less often: spread by swallowing food or water that contains the virus Vaccine Hepatitis A vaccine will prevent this disease. A disease of the liver caused by hepatitis A virus Potentially none (likelihood of symptoms increases with the person's age) If present: yellow skin or eyes. stomach ache. tiredness. and arthritis (Can be serious in children under age 1.30% of the survivors) Transmission Spread by coughing and sneezing Vaccine Hepatitis A Description Symptoms Hib vaccine can prevent this disease. pneumonia. the disease is often not recognized until the child's caregiver becomes ill with hepatitis A.

Maternal Health • Antenatal Care 174 . or trunk Complications Bacterial infection of the skin.Symptoms A skin rash of blister-like lesions. swelling of the brain. usually on the face. scalp. and pneumonia (usually more severe in children 13 or older and adults) Transmission Spread by coughing and sneezing (highly contagious) Vaccine Varicella vaccine can prevent this disease.

Definition of antenatal care (ANC): Antenatal care is defined as: "The care that is given to an expectant mother from the time that conception is confirmed until the beginning of labor" (Bennett and Brown. 1999).• Natal Care • Post natal care • Family planning • Family Health Counseling 1. The outcome is referred to safe delivery and healthy newborn. In theory antenatal care should address both the psycho-social and medical needs of the women in the context of the health care delivery system and the surrounding culture "WHO. Other definition: ANC is "the monitoring of mother and fetus by trained health personal throughout the whole pregnancy 175 . Antenatal Care: Antenatal care is the health care given to the pregnant women since the first month till the delivery time to ensure safe pregnancy and safe outcome. WHO defined that Antenatal care as "the care referred to pregnancy related care provided by health worker either in medical facility or at home. 1996". Accordingly the main goal of ante-natal care programs is to ensure a healthy pregnancy and safe outcome for both the mother and the fetus.

1 Activities: Ante natal care activities focus on health supervision. follow up and surveillance of the pregnant woman through regular organized program. examination and laboratory A: Each lady is requested to provide information related to current pregnancy including: Demographic data. maternal immunization data. Also information related to past History is requested and include family history. During Antenatal care each pregnant women is served for: 1. postnatal examination data and maternal health education data.with necessary examinations and recommendations by regular intervals" (Ozvaris S and Akin A 2002). health history (medical and 176 . contain or manage any deviation from the normal pattern of pregnancy which could result in an adverse outcome for the mother and/or the child. 1. investigate and respond to the health care needs of the pregnant woman in order to prevent. Ante-natal care also provides the opportunity for the health care provider to undertake health promotional activities. These activities provide the opportunity to detect. antenatal assessment. social history. Assessment: history. share information with the pregnant woman and encourage her participation in her own health care and that of her unborn child and/or family.

32 weeks For Estimated Fetal weight (EFW) and for Placental localization. 16-22 weeks For Detailed Ultrasound. movements. personal hygiene. C: Laboratory tests: Each pregnant woman has to complete blood examination (CBC) including hemoglobin level. blood grouping and RH factor and Indirect Coombs for Rh negative mothers. B: Routine physical examination including general examination and Abdominal Examination. to confirm date (EDD). Ultrasound can provide information about fetal health including: Age of the fetus. 177 . Number of fetuses and Birth defects. Delivery data and Newborn data. fetal position. Additions to clinical examination: Ultrasound 3 times: During the 1st trimester. Health education: During pregnancy the health services have to provide all the women enough information about: nutrition. rate of growth of the fetus. care of the nipple. GTT for women at risk for Gestational Diabetes The urine is examined for the presence of Albumin and sugar (Refer MOH Guidelines) 2. blood sugar. Serological testing includes Australian Antigen (AA) and RBS Rubella titer.surgical History). Level of the uterus is defined each visit after the 12th week of pregnancy. dressings. Blood pressure and Weight are routine measurement during each visit. placement of placenta. Amount of amniotic fluid. Obstetric history.

Immunization: Tetanus Toxoid should be given for all pregnant women.Rest/sleep .Dental Care .Traveling .Nutritional advice . including breast-feeding and 1.Clothing .and awareness about the signs and symptoms associated with high risk pregnancy. 2.Smoking . Antenatal care is an opportunity where women should have Health promotion during antenatal period coverind these items: .Drugs .Counseling on newborn care.Planning for place of birth .Discomforts of pregnancy . the booster is two months later. and the third dose is offered six months after the second dose (postpartum) or to be postponed to the next pregnancy.Provision of supplements including ferrous tablets and folic acid tablets.Breast care .Hygiene .Exercise .Safer sex/sexual intercourse . If the interval between two pregnancies 178 . The first dose is usually given at the first visit (preferably after 4 months of pregnancy).Family planning Immunization .

Curative services where women are treated for acute illness including treatment of the Uro-genital tract infections.History of cesarean section 5.Edema 179 . These categories are considered as higher risky than others: 1. The aim of the health services would be to identify those "AT RISK" as early as possible and to intervene in order to reduce the risk.Short status 3. 4.2 High Risk Pregnancy: Although Pregnancy is a normal phenomenon.Hypertension – Albumin urea .Diabetes Mellitus 6. 3. Through the provision of effective ante-natal care individuals and groups with an increased chance of complications or disease are defined as being "AT RISK" or "High Risk".Prim-Para and Multi-gravida.is more than five years the woman should receive the toxoid again.Age below 18 and higher than 35 years old. 1. 2. During ante-natal care women are classified according to the risks associated with the pregnancy. problems can however occur.

Anemia 8. 2. During purperium each lady had to be check for signs of hemorrhage or infection. 3. Natal Care: Natal care is referred to the care given to a woman during delivery. or in the community either in the primary health care centers or separate maternity homes. due to presence of qualified health staff performing this task.7. Post natal care: This component is the weakest component in maternal health care. Delivery sites should be hygienic. Natal care should not be limited to the delivered women but care should be given to the newborn at the same time. Post natal care is either given in the health centers or during 180 . well These sites equipped and have qualified trained persons. The role of the traditional birth attendants (Daya) is limited during this time. where the percentage of women who receive this service is relatively low. could be in hospitals whether general hospitals or delivery hospitals.Mal presentation High risk pregnant women are advised for more frequent antenatal visits and they have to deliver in a hospital.

anxiety. infections especially genital infections 2. Counseling for family planning during post natal care visit is recommended in this stage. 4.Severe bacterial infection. Infant health challenges in the postnatal period 1. 7. Frequent Pelvic& headache pain. 3.Jaundice. Family planning: 181 .Hypothermia. 4. 6.Preterm birth and Smallness for gestational age. 8. Constipation.Neonatal tetanus.Congenital anomalies. 5. 6. 3. 2. Depression.Ophthalmia neonatorum. 7. Breast problems. Hemorrhoids and anemia.home visits. Bladder problems. 5. The most frequent reported health problems in the postpartum period are: 1. 4.Newborns suffering.

5.1 Methods: Intrauterine devices (IUDs) and pills are the most common methods used in family planning programs. safety and efficiently and more practical.Each family has to decide about the desirable size of the family and the health care providers have to help and advise for the most appropriate and the safe method to achieve this activity. Family planning is not family control and the best acceptable term is family spacing by giving enough time between the pregnancies to ensure healthy mother and healthy child 4. Women and children 182 . Other methods as vaginal diagram and spermicidal Recently injections are available and used Sterilization of gels are used. Condom and Natural methods as safe period and coitus interrupts are accepted by people and recommended when there is health problems contraindicated the use of pills or IUDs. socially. Counseling focuses on family planning and importance of breast feeding and the nutrition of the women and the child. Family Health Counseling: men or women is the most efficient way but not accepted Each family has the right to receive health counseling in the MCH centers and during the MCH visit.

with specific risk is in need for focus on their specific problems Counseling Steps “GATHER” Method: G A T H E R Greet the Client Ask the Client Tell the Client Help the Client Explain to the client Repeat Maternal Mortality 183 .

1992). methods of measurement and causes of maternal mortality. from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes" (WHO. The main determinant of the women health is the health status during reproductive age.Background: Women health is one of the major concerns of the public and the health policy makers all over the world. that is the maternal death. where women are exposed to risks associated with the pregnancy and the delivery. irrespective of the duration and site of the pregnancy. We are reviewing the concept and definitions. Definition of maternal mortality: Based on the tenth revision of the International classification of Diseases (ICD-10) the maternal death defines as: " the death of a woman while pregnant or within 42 days of termination of pregnancy. In this chapter we are intending to focus on undesirable event associated with the process of pregnancy and delivery. delivery or during the post partum period (42 days after delivery) is considered whether that is due to a disease. It is clear that this definition includes all women deaths during pregnancy. or due to intervention during delivery or abortion or surgical intervention as 184 . aggravation of a disease.

Most of deaths (95%) occur in developing and undeveloped countries.000 deaths maternal live births) death.000 94 Eastern Asia 55 11. 2000 Maternal Number of Lifetime Region Mortality ratio maternal risk of (per100.000 840 South-central Asia 520 207.400 DEVELOPING 440 527.600 210 Sub-Saharan Africa 920 247.000 74 DEVELOPED REGIONS 20 2500 2.800 120 Latin America and 190 22.000 61 REGIONS Africa 830 251. UNICEF and UNFPA.000 160 the Caribbean Oceania 240 530 83 Source: WHO (2004): Maternal Mortality in 2000: Estimates developed by WHO.800 Europe 24 1. The only excluded causes are those due to accidental or incidental causes such as car accident. Geneva Factors affecting maternal mortality: 185 .000 46 South-eastern Asia 210 25.000 16 Asia 330 253.000 140 Western Asia 190 9. Epidemiology: As shown in the table below: More than half million women in the world die each year due to complications of pregnancy and delivery.000 20 Northern Africa 130 4.cesarean sections. Department of Reproductive Health and Research World Health Organization.1 in: WORLD TOTAL 400 529.700 2. Maternal mortality estimates by United Nations MDG regions.

scared uterus. Ante Partum Hemorrhage (APH) or Post Partum Hemorrhage (PPH). Caesarian section delivery. Living far from the health care facilities whether hospitals or health primary health care centers. Smoking habits. Prolonged obstructed labor. Uterine fibroid. Short women. myomecotomy .Personal: These personal factors are affecting positively the maternal deaths where chances of death become more: 1. Pre-eclampsia. Previous Early Neonatal Death. Abortions: Two or more consecutive first trimester abortions or second trimester abortion. Multiple pregnancies. less than 150 cm Poor obstetric history: Recurrent stillbirths. Malpresentations. Uterine Abnormality. OR 6. Blood Disorders. Assisted Reproductive Techniques OR Previous infertility 186 . Obesity (Maternal pre pregnancy Weight more than 85 Kg). Age Less than 18 years or More than 35 years old. Intrauterine growth retardation. Previous gynecological operations such as prolapse. 4. 3. 2. Long duration of marriage with infertility and use of ovulatory drugs. Positive consanguinity. Premature labor Labour <24 weeks of gestation. 5. fistula. and third degree tears.

2. the community they serve. Birth attendants: 1. Neurological disorders. Anemia. 1. or refer obstetric complications. The fifth Millennium Development Goal (2000) calls for a reduction in maternal mortality and morbidity. Bronchial Asthma. nursing or medical studies. manage. Diabetes. Beside the study they should complete training to proficiency in the skills necessary to manage normal deliveries and diagnose. start treatment and supervise the referral of mother and baby for interventions that are beyond their competence or not possible in a particular setting. Cardiac disease. They must be able to manage normal labor and delivery.1 Skilled birth attendant: A skilled birth attendant is defined as a medically qualified provider with midwifery skills that could be gained through midwifery. Traditional birth attendant (TBA): A traditional birth attendant is a community-based provider of care during 187 .Presence of Major medical disorders: Hypertension. Ideally. Blood disorders or Hepatitis B carrier Availability of Health Services 1. and are part of. skilled attendants live in. One of the indicators used to track progress in meeting this goal is the proportion of women who deliver with the assistance of a skilled birth attendant. perform essential interventions.

human resources policies. supervision and management. including equipment and supplies. Although they are usually highly esteemed community members and are often the sole providers of delivery care for many women. electrical. water and communication systems. Skilled attendance is the site that operating within an enabling environment or health system capable of providing care for normal deliveries as well as appropriate emergency obstetric care for all women who develop complications during childbirth. The enabling environment describes a context that provides a skilled attendant with the backup support to perform routine deliveries and make sure that women with complications receive prompt emergency obstetric care. TBAs are not trained in all cases to proficiency in the skills necessary to manage or refer obstetric complications. It essentially means a well-functioning health system. accredited members of the health system. TBAs are not usually salaried. 188 . infrastructure and transport.pregnancy and childbirth. and clinical protocols and guidelines. 2. they should not be included in the definition of a skilled attendant for the calculation of the Millennium Development Goals indicator. Health care facilities: We refer to the facility providing delivery services and these facilities are called skilled attendance.

omissions. from interventions. Maternal causes could be direct or indirect. Obstructed labor 3.Causes of Maternal Mortality: The main direct causes of maternal mortality are: 1. Infection 6 There is a variation between causes of death in developed and in developing countries. Estimated average time from onset of complication to death Complication Hours Days 1. Hemorrhage 2. Complications from unsafe abortion The table below demonstrates variation of onset of death by different complications leading to death. where infection and hemorrhage are common complications in developing countries. resulting from obstetric complications of the pregnant state.Obstructed labour 3 4. Eclampsia (pregnancy-induced hypertension) 4. direct obstetric deaths. Infection 5. Hemorrhage Postpartum 2 Ante partum 12 2.Eclampsia 2 3. incorrect 189 .

X 100.000 Total live births This is the most commonly used measure where data availability and accuracy to calculate this measure is better than data required for other measures. Indirect obstetric deaths.treatment. It is calculated as the following: Maternal deaths MM Ratio =---------------------. is stated when they are resulting from previous existing disease or disease that developed during pregnancy and which was not due to direct obstetric causes but was aggravated by the physiological effects of pregnancy. Measurement of maternal mortality: Maternal mortality is measured by one of the three widespread measures (WHO. Maternal mortality ratio: Maternal mortality ratio is defined as the number of maternal deaths during a given time period per 100.000 live births during the same time period. Maternal mortality ratio 2.2004): 1. Maternal mortality rate 3. This measure 190 . Lifetime risk of maternal death 1.

Lifetime risk of maternal death: Lifetime risk of maternal death is a cumulative risk over the reproductive lifetime.X 100. 191 .000 Women of reproductive age This measure reflects the probability of women death during reproductive period.000 women of reproductive age during the same time period Maternal deaths MM Rate =--------------------------------. For each pregnancy the lady is exposed to the risk again. 3.reflects the probability of death once a woman becomes pregnant. 2. Maternal mortality rate: Maternal mortality rate is defined as the number of maternal deaths in a given period per 100. Each time the risk is higher. Approximately life time risk is calculated by multiplying the maternal mortality rate by the length of the reproductive period (around 35 years).

Reproductive Age Mortality Studies 6.xx 192 .000 (50% more). xx In Gaza Sali conducted assessment of maternal mortality and revealed underreporting and misclassification. Vital registration: To use the vital registration system in calculation of maternal mortality necessitates presence of a sufficient coverage and quality to enable the system to serve as the basis for the assessment of levels and trends in cause-specific mortality including maternal mortality. Registration systems are exposed to misclassification and underreporting. Indirect sisterhood method 5. Census 1. Direct household survey methods 3. where the reported maternal mortality ratio was 28 and the assessment figure came to be 42 per 100. therefore review of the evidence shows that registered maternal deaths should be adjusted upward by a factor of 50% on average. Verbal autopsy 7.Approaches for measuring maternal mortality: One or more of the following approaches are used to measure maternal mortality: 1. Direct sisterhood method 4. Vital registration 2.

3. Direct household survey methods: Maternal mortality could be calculated by the household surveys using direct estimation. The original indirect sisterhood method asks respondents four simple questions about how many of their sisters reached adulthood. During data collection the respondents are asked to provide detailed information about their sisters. These surveys are usually expensive and complex to implement because large sample sizes are needed to provide a statistically reliable estimate. the number who 193 . Sisterhood method: The sisterhood approach was designed to overcome the problem of large sample sizes and thus reduce the efforts and the costs of the household survey. and not appropriate for use in settings where fertility levels are low total fertility rate (TFR) less than 4 (Graham W. The indirect method depends on obtains information by interviewing respondents about the survival of all their adult sisters. There are two types of sisterhood approach: the direct and the indirect methods.2. The direct method . 1989). This indirect method is applicable for high fertility rate population.is used in Demographic and Health Surveys. including the numbers reaching adulthood. how many have died and whether those who died were pregnant around the time of death.

Rutenberg N. 1991) Attached the original used questions as stated in the WHO. THE ORIGINAL SISTERHOOD METHOD'S FOUR QUESTIONS: 1..1997. How many of these ever-married sisters are alive now? 3. the age at death. Is (NAME) still alive? 6. (WHO. How old in (NAME)? 7.1995. 1997 report: A. Was (NAME) pregnant when she died? 10. or during childbirth. In case of underreporting review of available records in the health care facilities and community 194 . In what year did (NAME) die? OR How many yeas ago did (NAME) die? 8. How many of these ever-married sisters are dead? 4. THE "DIRECT" SISTERHOOD METHOD'S QUESTIONS: 1.have died. the year in which the death occurred and the years since the death. How many sisters (born to the same mother) have you ever had who were ever-married (including those who are now dead)? 2. Reproductive Age Mortality Studies: Use of this approach enables us to identify and investigate the causes of all deaths of women of reproductive age. or during the six weeks after the end of pregnancy? B. Is (NAME) male or female? 5. Shahidullah M. Did (NAME) die within two months after the end of pregnancy or childbirth? 5. How many of these births did your mother have before you were born? 3. What was the name given to your oldest (next oldest) brother or sister? 4. This analysis could be completed through the vital registry if reporting is satisfactory. Did (NAME) die during childbirth? 11. How many of these dead sisters died while they were pregnant. How many children did your mother give birth to? 2. How old was (NAME) when she died? For dead sisters only: 9.

This method is used in absence of reliable death certificates. 6. In such studies misclassification of causes of death can be calculated. These general questions are followed detailed questions that would permit the identification of maternal deaths on the basis of time of death relative to pregnancy or delivery (Stanton. Abbreviations DHS: Demographic and Health Surveys GFR: general fertility rate MDG: Millennium Development Goal MMR: maternal mortality ratio RAMOS: reproductive age mortality study TFR total fertility rate UN: United Nations UNFPA: United Nations Population Fund UNICEF: United Nations Children’s Fund WHO: World Health Organization 195 . Verbal autopsy: Verbal autopsy means gathering information about the causes of maternal death retrospectively (WHO. Census: Among general questions census could include questions on deaths in the household. 7. 2001).could reveal more information. 1995).

World Health Organization. IRD/Macro International Inc. London. Studies in Family Planning. 1995. Charchil livingstone 196 . Brass W. Washington DC. UNICEF and UNFPA.79:657-64. World Health Organization. The sisterhood method of estimating maternal mortality: the Matlab experience. Geneva Ref: Bennett R. (1991) Direct and indirect estimates of maternal mortality from the sisterhood method. Studies in Family Planning. World Health Organization WHO (1997) The sisterhood method for estimating maternal mortality: guidance notes for potential users. Antenatal care 13th Ed..28. Department of Reproductive Health and Research. Shahidullah M. Geneva. WHO/RHT/97. Bulletin of the World Health Organization. Geneva. World Health Organization. Stanton C et al (2001) Every death counts: measurement of maternal mortality via a census..26:101-6.15. WHO/FHE/MSM/95.Reference: Graham W. WHO (2004) Maternal Mortality in 2000: Estimates developed by WHO. Tenth Revision. Sullivan JM.20:125-35. and brown L (1999) Myles text book for midwives. WHO (1995) Verbal autopsies for maternal deaths. (1989) Indirect estimation of maternal mortality: the sisterhood method. Snow RW. Rutenberg N. Geneva. WHO (1992 International Statistical Classification of Diseases and Related Health Problems.

Ozvaris S. Results of further analysis of the 1998 Turkish demographic and health survey 197 . (2002) contraception Abortion and maternal health services in Turkey. and Akin A.WHO (1996) Maternal and newborn health WHO antenatal care randomized trial.