Professional Documents
Culture Documents
Anshu Mittal
Professor
Department of Community Medicine
Mother and children are priority ???
Constitute 71.4% of the population in developing
countries.
In India women of reproductive age group (15-50 yrs)
and children under 15 yrs constitute 57.5% of the
population (22.2% and 35.3% res).
Hence major consumers of any product and health
services are no exception.
They are the most VULNERABLE or SPECIAL RISK
group.
WHY vulnerable....
Menstruation, Child bearing among females
Dependent, growth and development among children
50% of all the deaths occurring in country are among
underfives, but not true for developed countries where
it is among old populations
Similarly maternal mortality is in range of 200-400 per
thousand live births against less than 20 per thousand
in developed countries.
Majority of these
deaths are
preventable
How???
Follow the principle of equity, intersectoral
coordination and community involvement
Same is followed in providing PRIMARY HEAILTH
CARE
It provides integrated package of health services to
mother and child considering them as ONE UNIT.
MOTHER and CHILD –One Unit
During antenatal period child is part of mother’s body
All the nutritional requirements of the foetus are met
through mother....so mother needs to be well nourished to
have healthy baby
Many diseases occurring during pregnancy also affect the
foetus
After birth also exclusive breast feeding and child care are
again mother’s responsibility
Postpartum care including advice regarding family
planning also affect the health of new born
This period of care makes mother the first teacher of the
child.
Linking Obstetrics, Paediatrics and
Preventive and Social Medicine
Though mother care is with obstetricians and child
care is with paediatricians but the principle of
prevention has led to various other terms
Social Obstetrics
Preventive Pediatrics
Social Pediatrics
Social Obstetrics
Study of interplay of social and environmental factors
and their effect on human reproduction.
Not only conception phase is important but also
preconception and even premarital period is equally
important.
Socio- environmental factors include: age at marriage,
age at child bearing, child spacing, family size, fertility
pattern, level of education, customs and beliefs and role
of women in society.
Preventive Paediatrics
Aims at providing efforts to avoid rather than curing
disease and disabilities among newborn and children.
So, divided into 2parts- antenatal paediatrics and
postnatal paediatrics.
Important activities include growth monitoring, oral
rehydration therapy, nutritional surveillance,
promotion of breast feeding, immunisation, regular
health check ups.
Social Paediatrics
Study the effect of social values and social policy on
child health.
It is the application of principles of social medicine to
paediatrics to obtain a more complete understanding
of the problems of children in order to prevent and
treat disease and promote their adequate growth and
development through an organised health structure.
Examples include giving prelacteal feeds, son
preference, restricting diet during illness etc.
How preventive medicine helps
Obstetricians and Paediatricians
Collection and interpretation of data of the population
to delineate at risk groups
Association of demographic characteristics with
various morbidity and mortality rates
Effect of cultural factors on utilisation of health
services
Evaluation of various programmes to see their impact
Maternity Cycle
Fertilisation
Antenatal period
Intranatal period
Postnatal period
Inter- conceptional period
MCH problems
Malnutrition
Infection
Uncontrolled reproduction
In developed countries congenital malformations, genetic
diseases and behavioural problems are issues of concern.
MATERNAL and CHILD HEALTH
It refers to promotive, preventive, curative and
rehabilitative healthcare for mothers and children.
It aims at
reduction of maternal, perinatal, infant and childhood
mortality and morbidity
Promotion of reproductive health
Promotion of physiological and physical and
psychological development of the child and adolescent
Components of Maternal Care
Antenatal Care
Intranatal Care
Postnatal Care
Antenatal Care
Pregnancy Detection- Urine Examination. Kits are
available with the health workers under the name
NISHCHAY pregnancy test kits. Also available in
market.
Antenatal visits- ideally pregnant female should visit
health care provider once a month till 7th month of
pregnancy, then twice a month during 8th and weekly
thereafter. But if not feasible at least 4 visits are
minimally required....
1st ....before 12 wks (whenever pregnancy suspected and
to be registered if confirmed)
2nd......between 14 and 26 weeks
3rd.......between 28 and 34 weeks
4th.......after 36 weeks till delivery
Purpose of 1st visit
Mainly provided by MPHW (female)/ANM
Facilitates proper planning for the care to be provided
to mother and foetus.
Calculate expected date of delivery from LMP.
Assess the health status of mother for any pre-existing
medical illness.
To know whether pregnancy is wanted or otherwise
referral for safe abortion to PHC/FRU.
Helps in rapport building for continued antenatal care.
Tasks to be carried out during
antenatal visits
Antenatal examination
Prenatal advice
Specific protection
Mental preparation
Family Planning
Paediatric component
ANTENATAL EXAMINATION
History taking: Any illness/ other problems, h/o drug
intake etc.
Physical Examination: Pallor, Pulse, Respiratory rate,
oedema, Blood pressure, Weight, breast examination.
Abdominal Examination: Fundal height, foetal heart
sounds, fetal movements, multiple pregnancies, fetal
lie and presentation, any scar (previous ceasarean) etc.
Assessment of gestation age
Laboratory Investigations
Laboratory investigations
Routine (at Sub- centre): Pregnancy detection, Hb
estimation, urine test for albumin and sugar, rapid
malaria test.
Screening (at PHC/CHC/FRU): Blood group and Rh
factor, VDRL/RPR for syphilis, HIV testing, Blood
glucose estimation, HBsAg for Hepatitis B.
Considering significant changes in mother
and child after 24 weeks, and also to perform screening
tests, it is preferred that 3rd visit should be at the PHC
to be examined by medical officer.
Identify high risk cases
Elderly primi (30 yrs and above)
Short statured primi (140 cm or less)
Malpresentations
Antepartum hemorrhage, threatened abortion
Pre-eclampsia and eclampsia
Anaemia
Twins
Bad obstetric history
Elderly grand multiparas
Prolonged pregnancy (>42 weeks)
Any medical illness
Previous caesarean
Treatment for infertility
Other benefits....
Maintenance of records: Number of pregnant females,
estimating requirement for manpower, infrastructure
and services, timely arrangements for emergency care.
Small-for-date (SFD) /
Preterm
intra uterine growth
retardation (IUGR)
Etiology of prematurity
Birth asphyxia
Meconium aspiration syndrome
Hypothermia
Hypoglycemia
Infections
Polycythemia
LBW: Issues in delivery
1.0 – 1.5 34 – 35
1.5 – 2.0 32 – 34
2.0 – 2.5 30 – 32
> 2.5 28 - 30
Convection
Evaporation
Radiation
Conduction
Skin-to-skin contact
Prevent heat losses
Definition of Kangaroo Mother Care
• Early, prolonged and continuous skin-to-
skin contact between a mother and her
newborn
• Could be in hospital or after early
discharge
Kangaroo Mother Care
How to Use Kangaroo Mother Care
• Newborn’s position:
– Held upright (or diagonally) and prone against skin of
mother, between her breasts
– Head is on its side under mother’s chin, and head,
neck and trunk are well extended to avoid obstruction
to airways
• Newborn’s clothing:
– Usually naked except for nappy and cap
– May be dressed in light clothing
– Mother covers newborn with her own clothes and
added blanket or shawl
……contd
How to Use Kangaroo Mother Care
• Newborn should be:
– Breastfed on demand
– Supervised closely and temperature monitored
regularly
• Mother needs lots of support because
kangaroo care:
– Is very tiring for her
– Restricts her freedom
– Requires commitment to continue
Benefits of Kangaroo Mother
Care (1)
• Is efficient way of keeping newborn warm
• Helps breathing of newborn to be more regular;
reduce frequency of apneic spells
• Promotes breastfeeding, growth and extra-uterine
adaptation
• Increases the mother’s confidence, ability and
involvement in the care of her small newborn
Benefits of Kangaroo Mother Care (2)
Seems to be acceptable in different cultures
and environments
Contributes to containment of cost— salaries,
running costs (electricity, etc.)
FEEDING
• Early and exclusive breastfeeding
– Breastmilk = best nourishment
– Already warm temperature
– Facilitated by kangaroo care
• If Breast milk is not availble, consider milk
formula : Preterm formula --- until 2000 gm
then change to After Discharged Formula
Guidelines for fluid requirements
Protein 11 33
Soluble Pro 7 5
Casein 4 28
Lipids 35 35
Linoleic acid 3.5 1
Carbohydrates 70 50
Calcium 0.33 1
Phosphorus 0.15 1
Iron 0.4-1.5 0.3-0.5
Vitamin C 60mg 20mg
Vitamin D 50IU 25IU
Energy 640-720kcal 650kcal
ADVANTAGES OF BREASTFEEDING
BABY
Bonding between mother and child
Rich in nutrients and antibodies
Easily digestible and supports growth and
development...better mental development too
Affordable
Sustainable: artificial feeding may not be provided
every time
Temperature is appropriate, also curtails cost of fuel
which is needed in topfeed.
MOTHER
Natural method of contraception...prolactin inhibits
ovulation
Involution of uterus is better
Help in weight loss gained during pregnancy
Lactating mothers, if diabetic, have shown lesser
insulin dependance
Seems to provide prevention against breast cancer
All Children 6-72 Calories 500 kcal Rs.4 per child Cooked Meal for
month age Proteins 12-15 gm 3-6 year old
children
Children 6-72 Calories 800 kcal Rs.6 per child
month age (severely Proteins 20-25 gm Take home
malnourished) Ration for < 3 year
aged kids and
Pregnant and Calories 600 kcal Rs.5 per eligible pregnant and
Nursing women Proteins 18-20 gm female lactating mothers
Nutrition and Health Education: Given to all females
of 15-45 years of age esp the pregnant and lactating
ones.
Immunisation: for all the kids and pregnant women
with help of Multipurpose Health Workers. Records
are maintained and available for any future reference.
Health Check up:
Antenatal care and postnatal care
Registration, Immunisation, IFA supplements
34 Hemorrhage
38 Sepsis
Hypertensive disorders
Obstructed labour
Abortions
Other Conditions
8
5 11
5
Determinants of Maternal Mortality
Medical Causes Social Factors
Obstetric Causes Age at child birth
Hemorrhage Parity
Infection Too close pregnancies
Toxemia of Pregnancy Family Size
Obstructed Labour Malnutrition
Unsafe Abortion Poverty
Non- Obstetric causes Illiteracy
Anemia Gender preference
Associated systemic diseases like cardiac, Women- weaker sex- often neglected and
renal, hepatic, metabolic etc. prone to domestic violence
Malignancy Poor Sanitation
Accidents Lack and underutilisation of MCH sevices
Delivery by untrained dais
Delay in availing expert services
Reasons for DELAY
Delay in identifying the danger signs
Delay in seeking care
Delay in transport to appropriate health facility
Delay in provision of adequate care
57
Causes
LBW
ARIs
ADDs
17 Congenital Malformations
Sepsis
Birth injury
4 Others
12 5
3 2
Factors affecting Infant mortality
1. BIOLOGICAL FACTORS
(a) Birth weight:
- babies of low birth weight
and high birth weight are at special risk.
- causes: poor nutrition during pregnancy..
(g) Illegitimacy
(j) Brutal habits and customs
-depriving the baby of the first milk or colostrum,
frequent purgation, branding the skin, application of
cow-dung to the cut end of umbilical cord, faulty
feeding practices and early weaning.
2. Prevention of infection
- eg. Neonatal tetanus, UIP- protect
against 8 vaccine preventable diseases.
3. Breast feeding
- prevents gastro-intestinal, respiratory infections and
PEM.
4. Growth monitoring
- all infants should be weighed periodically and their
growth charts maintained.
- these charts help to identify children at risk of
malnutrition early.
5. Family planning
- smaller sibship and longer spacing between
pregnancies are associated with improved infant and
child survival.
6. Sanitation
28 7 days 28 days
weeks of
gestation
Birth
Still Birth Rate
Death of a foetus beyond viability period i.e. If
separated from mother, it will be able to survive
with/without life support
This period has been marked at 22 weeks of
gestation globally but in our country it is at
28weeks
Hence, still birth is death of a foetus weighing
1000g(equivalent to 28 wks of gestation) or more
occurring during one year in every 1000 total
(live+still births).
Weight cut off is suggested to overcome the
difficulty to assess period of gestation in cases
where date of last menstrual period is not known.
Calculate Still BirthRate
Fetal deaths weighing over 1000g
at birth during the year
*1000
Total live+ stillbirths weighing over
1000g
Current at birth
still birthduring
rate intheIndia
sameisyear
5/1000
births/year.
It is same in urban and rural areas.
High in states where better services and literacy
status is high- high reporting
Low in states in which are poor in these
parameters –low reporting
Perinatal death rate
Perinatal period: The period which begins from the
twenty eight weeks of a pre-natal life of a fetus (at this
time body weight is 1000 g in norm or crown-heel
length of 35 cm atleast) and finishes after 7 full days
(168 hours) after a birth. Perinatal death rate
includes three periods:
India 41 12 53
Srilanka 8 2 10
Bangladesh 33 8 41
Pakistan 69 17 86
China 11 2 13
USA 6 1 7
UK 4 1 5
Japan 2 1 3
CHILD SURVIVAL INDEX
This parameters tells us the chance of a survival of new
born beyond age of 5 years
Calculated as
1000 - under-5 mortality rate
10
IDENTIFY
After classifying and planning the treatment
arrangements for the plan of action are to be made like
need for transportation if referral, drugs for specific
treatment, immunisation and supplementation (vit A in
measles). First dose preferably be given by the health
worker.
FLOW CHART FOR IMNCI
IF DANGER SIGN IS
THERE...urgent
referral along with
1. Check for danger signs..convulsions, pre-referral treatment
lethargy, inability to feed, vomiting
2. Assess main symptoms...cough,
difficulty breathing, diarrhoea, fever, No danger sign...but
ear problems antibiotics needed
3. Assess nutritional status and
immunisation status
4. Any other problem
Home based
treatment
INSTRUCTIONS to the care taker for compliance and
administration of treatment
COUNSELLING the parents for regular feeding of the
child as per age requirement, regarding immunization,
safe water, sanitation, vector control measures etc.
FOLLOW UP visit is must to assess the outcome and
accordingly modify the plan of action.
CONGENITAL DISORDERS
Defined as those diseases that are substantially
determined before or during birth which are in
principle recognizable in early life.
Their incidence worldwide has been reported as 1 in 33
newborns, responsible for more than 2,70,000 deaths
in neonates globally
Two substitutes are suggested by WHO
Malformations: structural defects
Anomaly: includes all biochemical, structural or functional
disorders
Causes of Congenital disoders
Genetic Factors: Includes
Chromosomal abnormalities: During meiotic divisions e.g. Down’s
Syndrome, Klinefelter’s syndrome, Turner’s syndrome
Inborn errors e.g. Phenylketonuria, galactossemia etc.
Inheritance of gene defects like thalassemia, sickle cell etc.
No specific aetiology: club foot, congenital dislocation of foot
Environmental Factors: Includes defects arising due to
exposure to external agent which could affect the growing
fetus:
Infection like rubella leading to congenital cataract, patent ductus
and auditory problems
Drugs like thalidimide causing limb deformity
Radiation exposure leading to metabolic anomalies
Dietary factors: Folic acid deficiency may lead to neural tube defect
RISK FACTORS
Maternal Age: Advancing age of mother has been
significantly associated with high incidence of down’s
syndrome
Consanguinity: Marriages in close relation especially
first cousins often lead to expression of recessive
disorders. Incidence of Mental retardation is also
relatively higher in kids born of such wedlocks.
PRENATAL DIAGNOSIS
Alpha feto proteins: neural tube defect
Avoiding drugs
Dietary supplements
• Referral services:
– Integrated Counselling and Testing Centre
– Prevention of Parent to Child Transmission
• Outreach services:
– Periodic health checkups and community camps
– Periodic health education activities
– Co-curricular activities
NRHM - ARSH
• Vision
– Improve availability of quality healthcare in rural areas
– Synergy between health and determinants of good
health
– Community ownership of health facilities
– Undertake architectural corrections of the health system
• Expected outcomes by 2012
– IMR -30/1000 live births
– MMR – 100/1000 live births
– TFR -2.1
Objective
Reducing teenage pregnancies
Meeting unmet contraceptive needs
Reducing number of teenage maternal deaths
Reducing incidence of STIs
Reducing proportion of HIV positive in 10 – 19 years
age group
We must Develop sensitivity towards adolescent
clients
NON JUDGMENTAL, FRIENDLY, COMPETENT
PROVIDER is required.
GERIATRIC
HEALTH
INDEX
INTRODUCTION
PHYSIOLOGICAL CHANGES DUE TO AGING
HEALTH PROBLEMS OF THE AGED
PSYCHOLOGICAL PROBLEMS
PREVENTION AND MANAGEMENT
a. PREVENTIVE HEALTH CARE
b. INTERVENTION IN REHABLITATION
SERVICES PROVIDED BY THE GOVT.
NON-GOVT. ORGANISATIONS
What is GERIATRICS ??????
The care of aged is called geriatrics or clinical
gerontology.
What is clinical gerontology???
Physical problem
Psychological problems
Social problem
Economical
Physical problems
Ailments % of occurrence
Visual complaints 88 %
Locomotor system 40 %
disorders
Neurological 18.7 %
complaints
Cardiovascular system 17.4 %
Respiratory system 16.1 %
Skin conditions 13.3 %
GI tract 9%
Psychiatric complaints 8.5 %
These are:
Peptic ulcer
Constipation
Ulcerative colitis
Carcinoma of GIT
Hearing loss
Hearing complaints form about 8.2% of the old age
complaints
These include
Nerve deafness
Conductive hearing loss
Genito-urinary complaints
These form about 3.5% of the old age complaints
They are:
Enlargement of prostate
Dysuria
Nocturia
Frequency and urgency of micturation
Psychiatric complaints
These form 8.5% of the old age complaints
These include
Alzheimer’s disease
Depression
Anxiety
Delirium
Schizophrenia
Personality disorder
Suicide and deliberate self harm
Psychological problems
Elderly patients less willing to talk about psychological
problems
Pay attention to:
anxiety
physical discomfort
adaptation to a new lifestyle
PSYCHOLOGICAL SYMPTOMS
Sleep
Interest
Guilt (“Are you a burden to others?”)
Energy
Concentration
Appetite
Psychomotor changes
Suicidality (“Do you wish you could die?”)
INCIDENCE IN ELDERLY
MAJOR DEPRESSION
3% community dwelling
14% two years after spouse dies
15% medically ill
25% long-term-care settings
Social problems
Abuse
Dependancy
Insecurity
Rehabilitation
PREVENTIVE HEALTH CARE
Preventive Health Care in Elderly
It includes-
Primary prevention.
Secondary prevention.
Tertiary prevention.
Primary prevention
Health habits-
Inadequate nutrition
Addiction to smoking & alcohol
Lack of exercise
Inadequate sleep
Predisposing factor for coronary heart disease
Modifiable-
smoking, obesity, HT, DM, hyperlipidemia, hypercholesterolemia,
etc.
Non-modifiable-
age, sex, genetic factors, etc.
Immunization-
Influenza
Pneumococcal
Tetanus.
Osteoporosis prevention-
Calcium and vit-d supplementation.
Hip protector devices.
Injury prevention
Burns accidents and falls should be prevented
by;-
Removal of obstacles
Keep the floor dry
Bright lighting
Flat shoes
Railing/holding bars in bathrooms
Low level switches
Easy and safe access to water.
Secondary prevention
Screening
Social attitude
Physicians support