Introduction to Family Health

By: Gedife. A (MPH RH)

November, 2023
Learning Objectives
 At the end of this session the student is expected to:
 Define family and family health
 List and discuss the major components of family health
 Discuss the characteristics of health family
 Discuss the determinants of family health
 Definition of Family
 What is family?

 A group of two or more persons related by birth, marriage,

or adoption and residing together in a household

 It is a smallest social unit

 A basic structure of society centered about replacement

 Every family is unique and it is affected by every aspect

of community life
Types of family

 Nuclear family: a family consisting of a married couples

and their children; the children can be born or adopted

 Extended family: a nuclear family plus collateral kinship

 consisting of parents like father, mother, and their children,

nieces, nephews, aunts, uncles, cousins, grandparents etc.

 Joint family: a family consisting of two or more married

couples staying together with children

 Definition of Family Health
 Health : a state of complete physical, mental and social
well-being and not merely/only the absence of disease and
infirmity (WHO, 1958)
 Family Health: a state of positive interaction between family
members which enables each members of the family to enjoy
optimum physical, mental, and social well being
 Is part of community health
 Is a unit of health care
 Major components of family health
 Reproductive health
 Safe motherhood,(family planning, antenatal care,
obstetric care, post natal care, abortion care and control of
STI/HIV/AIDS)
 Nutritional deficiencies,
 LBW
 RTIs
 Infertility
 Adolescent health (suicide, depression, STIs)
Major components of family health …
 Child health
 Child bearing, rearing
 Child health services: nutrition, immunization, Growth
monitoring
 Mortality and mortality of children
 Social health problems of children: Child abuse , street
children, child labour , Juvenile delinquency, and battered
baby syndrome
 Major components of family health …
 Gender issues in family: Girls trafficking, Gender

mainstreaming, Female Genital Mutilation , female feticide

(sex-selective abortion)
 Aging: Problems of ageing, active ageing

 Mental health: situation of mental health, its causes and

prevention, National mental health policy

 Characteristics of health family
 A healthy family is a stress effective family in that such a family
is able to function at its fullest capacity, and is able to cope with
demands of daily life
 Commitment : A family is like an organism, with life and
vitality. It is made of many interdependent parts. For the family to
survive, those interdependent parts (different roles in the family)
must work together, coordinate, and be supportive of each other
 Togetherness: the family should spend time together in such
activities as playing games, taking family vacations, and
celebrating birthdays together
 Appreciation: high degree of mutual admiration and appreciation
between members of families for their job plays important role to
have healthy family
 Characteristics of health family…
 Good communication: Good communication creates a sense of
belonging, reduces frustration, reduce redundancy, and enhances
marital relationships
 Spiritual well-being: When family members share a common
faith, it reassures their mutual support, and tends to be more
patient, forgiving, and broadly accepting of each other
Our differences in faith create distance between us
 Coping with crisis and stress : Healthy families are able to face
reality and creatively, systematically, and rationally overcome
crises together, family members must depend on each other’s
mutual trust and interdependence
 The determinants of family health
Income and Social Status: Healthy families are those in societies
which are prosperous and have an equitable distribution of wealth
Education: Health status a family improves with level of
education , Effective education for children and lifelong learning
for adults are key contributors to health and prosperity of the
family
Employment and Working Conditions: unemployment, stressful
or unsafe work are associated with poorer health outcome
Social Support Networks: Support from families, friends and
communities helps families to solve problems, associated with
better health outcome
The determinants of family health…
 Social Factor : Availability of resources to meet daily
needs, Social norms and attitudes, such as
discrimination ,Exposure to crime, violence
 Physical Environments: an exposure to toxic substances
and other physical hazards and , contaminants of air, water,
food and soil can cause a variety of adverse health effects
 Health Services: Lack of access, or limited access, to
health services greatly impacts an individual’s health status
 Genetics: Hereditary disease such as sickle-cell anemia,
hemophilia, heart disease, and cystic fibrosis Carrying the
BRCA1 or BRCA2 gene, which increases risk for breast
and ovarian cancer
 The determinants of family health…
 Lifestyle/ individual behaviors: Dietary practice, physical
activity , Hygiene , alcohol consumption , cigarette smoking
, and other drug use plays a role in family health outcomes
 Gender: Gender based domestic violence, male dominating
societies, lack of women participation in health decision
making process will affect greatly on overall concept of
healthy family
 Culture: Marginalization, stigmatization, loss or
devaluation of language and culture and lack of access to
culturally appropriate health care and services badly affect
the family health
Introduction to Reproductive
Health(RH)
Learning Objectives

At the end of this session the learners will be able to:

Define RH
Discuss the concept of RH
Discuss the components of RH
Discuss youth friendly health services
Definition of RH
 RH is a “state of complete physical, mental & social
wellbeing & not merely the absence of disease or
infirmity, in all matters related to reproductive
systems & to its functions & process (ICPD,1994)
 RH encompasses three main points :
1. Sexual health
2. Reproductive freedom (access to information, methods
and services in reproductive health matters) and
3. Safe motherhood.(safe pregnancy, safe childbirth and
healthy children)
 Sexual Health
 A state of physical, emotional, mental, and social
wellbeing in relation to sexuality; it is not merely the
absence of disease, dysfunction, or infirmity
 It includes a positive and respectful approach to sexuality
and sexual relationships that are free of coercion,
discrimination, and violence
 Brain storm
 Sexuality?
 sensuality ?
 Sexualization?
 Sexuality
It is a central aspects of humanity which includes:
 Sex
 Gender identities and roles
 Sexual orientation
 Sexual pleasure
 Eroticism
 Sexual intimacy and Reproduction
 Sexuality is experienced and expressed in thoughts, fantasies, desires,
beliefs, attitudes, values, behaviors, practices, roles and relationships
Sensuality: Awareness and feeling with one’s own body and other
people’s bodies, especially the body of a sexual partner: – Sensuality
enables us to feel good about how our bodies look and feel and what they
can do
 Concept of RH

 Reproductive health implies

 A responsible, satisfying and safe sex life

 Successful maternal and infant survival

 Freedom to control reproduction

 Ability to minimize gynecological disease throughout life

 Women and men have the right:

 To be informed and have access to safe, effective,

affordable and acceptable Family Planning services

 To have access to appropriate health care services that

enable women to go safely through pregnancy and

childbirth and provide couples with the best chance of
having a healthy infant
 The concept of reproductive health is based on the
equality between men and women
 Human health, especially women’s right is central to
reproductive health
 Reproductive health service is a means to realize
reproductive health
 The definition of RH is not merely about reproduction
 It must be viewed as three interconnected domains:-
 Universal rights,
 Women’s empowerment, and
 Health service provision
 Components of RH care
 Quality family planning counseling, information,

education, communication (IEC) and services

 Prenatal, safe delivery and post natal care, including

breast feeding
 Prevention and treatment of infertility

 Prevention and management of complications of unsafe

abortion
 Safe abortion services, where not against the law
 Treatment of reproductive tract infections, sexually
transmitted diseases and other conditions of the
reproductive system
 Information and counseling on human sexuality, responsible

parenthood and reproductive health

 Active discouragement of harmful practices

 Referral for additional services related to: family planning,

pregnancy, devilry, abortion, infertility, RTI, SRD, cancer of

reproductive organ
 Maternal Health and Safe Motherhood
Learning objectives:
By the end of this session students will be able to discuss:

 Define Maternal Health

 Describe causes of Maternal Mortality and
Morbidity
 Discuss key intervention strategies for maternal
health
 Discuss major components of maternal health
services
 Introduction
• Maternal health according to (WHO) refers to the health of

women during pregnancy, childbirth and the postpartum period.

• It encompasses the health care dimensions of:

• family planning,

• preconception, In order to ensure a positive and

• prenatal, and fulfilling experience in most cases
and reduce maternal morbidity and
• postnatal care
mortality in other cases.
 Introduction
Women’s health needs differ from those of men because
of
 Biological differences
 Gender differentials in exposure to risk factors

Unlike men, women need health services even when they

are not ill to:-
 Prevent unwanted pregnancies,
 carry wanted pregnancies to term,
 Deliver safely
 Introduction
Every minute
 380 women become pregnant

 190 women face unplanned or unwanted pregnancy

 110 women experience a pregnancy related

complication
 40 women have an unsafe abortion

 1 woman dies from a pregnancy-related complication

 Maternal Morbidity and Mortality

Maternal Morbidity:
 Any departure, subjective or objective, from a state of
physiological or psychological well-being (during
pregnancy, childbirth and the postpartum period up to
42 days or 1 year)
 Maternal Mortality
A maternal death : the death of a woman while pregnant or Within 42

days of termination of pregnancy, irrespective of the duration and the

site of the pregnancy, from any cause related to or aggravated by the

pregnancy (WHO 1993)

 Pregnancy-related death: The death of a woman while pregnant or

within 42 days of termination of pregnancy, irrespective of the cause of

the death
 The difference is that pregnancy-related deaths include deaths from all,

including accidental and incidental causes

Maternal mortality…
Late maternal death
 The death of a woman from direct or indirect
obstetric causes more than 42 days but less than one
year after the termination of pregnancy
 Identifying late maternal deaths makes it possible to
count deaths in which a woman had problems that
began during pregnancy, even if she survived for more
than 42 days after its termination
Global situation in MM

 MMR of 216 per 100000 live births in 2016 as

compared to 385 per 100000 live births in 1990

 The number of women who died each year from

complications of pregnancy and childbirth declined

from 532,000 in 1990 to 303,000 in 2015

Trend of maternal mortality
Causes of MM
 DIRECT CAUSES (72%):
Those resulting from
 Obstetric complications (pregnancy, labor, & puerperium)
 Interventions omissions
 Incorrect treatment
 A chain of events resulting from any of the above.
Including, Hemorrhage (APH, PPH), Sepsis, Unsafe abortion,
Hypertensive disorders of pregnancy (Preeclampsia, eclampsia),
Obstructed labour
World wide causes of maternal mortality
 Causes of MM…

Indirect causes (28%):

Those resulting from
Previous existing diseases or
Diseases that developed during pregnancy
and which is not due to direct obstetric
causes but aggravated by physiologic effects
of pregnancy.
Existing cardiovascular diseases, malaria,
anemia, HIV/AIDS etc
The Road To Maternal Mortality
THE THREE DELAYS MODEL

Maternal death results as a result of the three delays.

Once the pregnancy occurred women experience the

classic three delays
THREE DELAYS…
The first delay
 Is the delay in deciding to seek care for an obstetric complication.

 Failure to recognize signs of complications

 Failure to perceive severity of illness

 Fear of the costs

 Previous negative experience with the health system

Usually caused by socio economic factors

 Women’s status, literacy, Income, employment, workload,
Culture, Values, Beliefs
THREE DELAYS…
The second delay
 Delay to go to health facility after the decision has been

made to seek care.

 This is a delay in physically reaching the care facility

 Usually caused by inaccessibility of service

Difficulty in finding or paying for transportation.

Lack of available transportation

Conditions of roads
THREE DELAYS…
The third delay
Is the delay in obtaining care once present at the facility.
Women wait for many hours at the referral centre because
of
 Poor skills of health providers
 Shortages of supplies and basic equipment
 Difficulties in obtaining blood supplies, equipment
or an operating theatre
 Non-availability of health personnel
THREE DELAYS…
Maternal Health services(safe
motherhood)
 It is a comprehensive care given before, during and
after pregnancy and delivery.
 Making motherhood safe requires action on three

fronts:
 Reducing the numbers of high-risk and
unwanted pregnancies
 Reducing the numbers of obstetric
complications
 Reducing the case fatality rate in women
with complications
 Key strategies to Safe Motherhood
• Achieving safe motherhood and reducing maternal
mortality requires a three-pronged strategy:

Prevention of
Prevention complication Prevention
of s of death
pregnancy (EOC)
(Maternity
(FP) care )
Pillars of safe
Motherhood
 Essential services of safe motherhood
1. Preconception care
2. Antenatal care
3. Delivery services
4. Postpartum care
5. Post-abortion care
6. Family planning
7. RH education and services for adolescents
8. Community education on safe motherhood
 ANTENATAL CARE (ANC)
 ANC is a care given to pregnant women with the aim of

improving the maternal and perinatal out come

 All pregnant women should have a minimum of 8

antenatal contacts (at least 20 minutes duration each) for:

- Prevention,

- Early detection and

- Management of complications.
 Benefits of Antenatal Care
 Used as an opportunity to provide information to women and their
families about:
 Danger signs and symptoms during pregnancy and delivery and
 Developing an appropriate delivery/birth plan, based on the
woman's history and health status
 Unique opportunity for early diagnosis and treatment of problems
like:
 Maternal problems: anemia, vaginal bleeding,
preeclampsia/eclampsia, infection
 Fetal problems: Abnormal fetal growth or movement, abnormal
fetal position
 HIV, syphilis, malaria, malnutrition
 What is Focused Antenatal Care (FANC)?

- Focused Antenatal Care is a care routinely provided

to all pregnant women from screening to intensive
life support provided to any woman while pregnant
and up to delivery
- “Having one or more visits with a trained person
during pregnancy” can detect early signs of disease or
risk factors and timely intervention (WHO).
 Approach of FANC
An approach of ANC that emphasizes:
 Individualized care
 Client- centered
 Fewer but comprehensive visits
 Disease detection, not risk
 Care by a skilled provider
 Goals of FANC

- Early detection and treatment of problems and

complications
- Prevention of complications and disease
- Birth preparedness & complication readiness
- Health promotion
WHO’s 2016 ANC Model

WHO recommends a minimum of eight contacts:

five contacts in the third trimester,
one contact in the first trimester, and
two contacts in the second trimester
Evidence-based ANC interventions
- Prevention, detection, investigation of anemia and
treatment of iron-deficiency anemia reduces maternal
anemia.
- Detection, investigation and treatment of Hypertensive
disease in pregnancy/pre-eclampsia, controls disease
(reduces case Fatality among women and newborns)
Evidence-based ANC interventions
- Treatment of Eclampsia reduces:

 Case fatality among women and

newborns,

 Recurrent convulsions (mgso4)

- Prevention of obstructed labor
 Reduces C-section and death
Evidence-based ANC interventions
- Breastfeeding counseling

 Increases rates of exclusive

breastfeeding
- Follate supplementation

 Reduces risk for neural tube defects

Evidence-based ANC interventions
- Immunization against tetanus and promotion of
 clean delivery
 Prevents maternal and newborn
tetanus
- Screening for infection: syphillis, gonorrhea
 Reduces fetal loss, LBW,
maternal/infant morbidity
- Screening for infection: bacteriuria
 Prevents preterm delivery and LBW
 Trends of ANC use in Ethiopia

EDHS, ANC use

In 2000 around 27%
In 2005 around 28%
In 2011 around 34%
In 2016 around 62%
 Intra-partum care

– Aims
 Clean and safe delivery
 Recognition, early detection and management of

 complications at health center or hospital (for example, hemorrhage,

eclampsia, prolonged/obstructed labour)
– Strategy
 All women and birth attendants should be aware of the requirements for
a clean delivery: clean hands, clean delivery surface, clean cord cutting and
care
Intra-partum care
– All health care providers should be trained in and practice clean
and safe delivery techniques and avoid unnecessary vaginal
examinations and episiotomies.
– All women and their birth attendants should be aware of the
need to refer cases of prolonged or obstructed labour to a higher
level of care.
– All institutional deliveries should be monitored using an
appropriately adapted version of a partograph in order to
prevent prolonged labour.
The five cleans in delivery care
– Clean hands

– Clean delivery
surface

– Clean perineum

– Clean cord cutting

– Clean environment
Intra-partum care
– Intra-partum care strategies are critical to reduce maternal
mortality

– The single most critical intervention for safe motherhood

is to ensure:
o A skilled health professional is present in every birth,
o Access to an emergency obstetric care in
case of complications
 Institutional delivery
 The proportion of births occurring in health facilities in
the area
 A key strategy to ensure skilled care during childbirth is
to that all births take place in health facilities in which
obstetric complications can be treated when they arise
 The situation in Ethiopia
EDHS 2005- 5
EDHS 2011- 10
EDHS 2016- 26
EDHS 2019- 48
Skilled birth attendance
o The skilled attendance is defined as a process through which a
woman is provided with adequate care during labor, delivery,
and the postpartum period
o Skilled attendance depends on;
– The presence of a skilled attendant
– The enabling environment
 Enabling
environment
1.Availability of drugs and supplies to
Availability of provide skilled care at different
skilled providers levels.
at different levels 2.Availability of functioning
referral system
3.Awareness and readiness of the
community for utilizing skilled
care
4.Supporting policy and political
commitment

Skilled
attendanc
e
Skilled attendant at birth
– Most maternal deaths are due to a failure to get skilled help in
time for delivery complications.
– Skilled attendant refers exclusively to people with midwifery
skills (for example midwives, doctors and nurses) who have been
trained to proficiency in the skills necessary to manage normal
deliveries and diagnose, manage or refer obstetric complications.
Minimum set of skills for the skilled attendant
– Take a detailed history, ask relevant questions, demonstrate
cultural sensitivity, and use good interpersonal skills.

– Perform a general examination, identify deviations from

normal, and screen for conditions that are prevalent or
endemic in the area.

– Take vital signs (temperature, pulse, respiration, blood

pressure)
Minimum set of skills for the skilled attendant
– Auscultate the foetal heart rate.

– Calculate the estimated date of delivery.

– Provide appropriate intervention (including referral) for

intrauterine foetal death, mal-presentations and
abnormal lies at term, multiple pregnancy, poor nutrition
and anaemia, pre-eclampsia, rupture of membranes prior
to term, severe vaginal bleeding
Minimum set of skills for the skilled attendant
– Perform an abdominal examination,
identifying abnormalities and factors that place the us
at risk

– Assess the effectiveness of uterine contractions

– Perform a vaginal examination

– Use the partograph

EDHSBirth
2005-attended
6 by a skilled
provider 2005-2019
EDHS 2011-10

EDHS 2016- 28

EDHS 2016- 28

EDHS 2019- 50
 Postpartum care
The main life threatening complications of
postnatal period include haemorrhag, anemia genital
trauma, hypertension, sepsis, urinary tract
infections and mastitis.
All women should receive a postpartum visit within
the first week of delivery in order to ensure early
detection and management of hypertension,
haemorrhage and sepsis.
– However, all women should be assessed within 24
hours after delivery.
 Postpartum care cont…
–Management of complications at health centre or
hospital (for example, haemorrhage, sepsis and
eclampsia)
–Promotion and support to breastfeeding and
management of breast complications)
–Information and services for family planning
–STD/HIV prevention and management
–Tetanus toxoid immunization
 Postpartum care: Newborn care
–Resuscitation
–Prevention and management of hypothermia
–Early and exclusive breastfeeding
–Prevention and management of infections
including ophthalmia neonatorum and cord
infections
–Recording of birth weight and referral of
newborn for immunizations and growth
monitoring
 Post-abortion care
Mortality due to unsafe abortion
– Worldwide, 20 million unsafe abortions occur each
year
– 70,000 women die each year as a result of
complications following abortion.
– 1 in 8 pregnancy related deaths are due to unsafe
abortion.
Comprehensive post-abortion care
 Emergency treatment of incomplete abortion
and potentially life threatening complications

 Post-abortion family planning counseling and

services
 Links between post-abortion emergency services
and the reproductive health care system.
 Emergency treatment for post-abortion
complications

– Initialassessment to confirm the presence of abortion

complications.
– Medical evaluation (brief history, limited physical and
pelvic examinations.
– Prompt referral and transfer if the woman requires
treatment beyond the capability of the facility.
– Stabilization of emergency conditions and treatment of any
complications.
– Uterineevacuation to removeretained products
of conception.
 Links to other reproductive health services
– Identify the reproductive health services
that each woman may need

– Offer as wide a range of services as possible

 Eg Treatment of STIs, Cervical Cancer

screening
FAMILY PLANNING
Introduction
Contraception?
Contraception is the intentional prevention of pregnancy

during sexual intercourse

It is the device and/or practice to decrease the risk of

conceiving, or bearing offspring

 Family planning:
The decision-making process by couples, together or

individually:
on the number of children that they would like to have

in their lifetime, and

the age interval between children.

This means that both halves of a couple have equal rights

to decide on their future fertility.

Objectives of family planning
 Limit family size
 Adequately space children
 Reduce maternal and child morbidity and mortality
related to complications of unwanted and high risk
pregnancies
 Help infertile couples to bear children
 Advantages of FP
 For women
Avoid unwanted and high risk pregnancies
Reduce morbidity and mortality
 Children
Avoid morbidity and mortality
Better feeding, Care, Clothing, Schooling
 Family
Improves family well-being
Better food, clothing, housing, and living
 Nations
Better Economic development •
People's economic situation move faster in countries where
women have fewer children.
Less unproductive force
FP reduces youth dependency ratio
 Conservation of Natural resources
 reduces the exploitation of natural resource by reducing
population growth
 World/Earth
Low demands on natural resources
Better opportunity for better life
 Family planning methods
Refers to methods or ways by which unwanted
pregnancy is prevented
 Not all these methods are equally effective, safe or
equally acceptable
Therefore, individualization of contraceptive choice is
important for successful prevention of pregnancy
Classifications
Hormonal Cotraceptive Methods
A. Oral contraceptives
Oral contraceptives are pills that a woman takes by

mouth to prevent pregnancy.

They contain two female hormones, estrogen and

progestin (combined oral contraceptives (COCs» or

progestin only.(progestin-only pills (POPs).
Combined Oral Contraceptives (COCs)
 Combined oral contraceptives are preparations of synthetic estrogen and

progesterone which are highly effective in preventing pregnancy.

 Pills that contain low doses of two hormones-a progestin and an estrogen.

 Instructions: Begin with:

 The onset of menses

 6 weeks after delivery if breast feeding

 After 3 weeks if not breast feeding

 Immediately or with in 7 days after abortion

 Packing of 28 tablets containing 21 hormonal tabs and 7 placebo or

iron
 The three forms of low-dose COCs:
 Monophasic– each active pill contains the same amount of
estrogen and progestin
 Biphasic– the active pills in the packet contain two different
dose-combinations of estrogen and progestin.
 For example in a cycle of 21 active pills, 10 may contain one

combination while 11 contain another

 Triphasic– the active pills contain three different dose

combinations of estrogen and progestin

 Out of a cycle of 21 active pills, 6 may contain one

combination, 5 another combination, while 10 pills contain

other combinations of the same two hormones
 COCs: Mechanisms of Action

Suppress ovulation

Reduce sperm transport

in upper genital tract
(fallopian tubes)

Change endometrium making

implantation less likely

Thicken cervical mucus

(preventing sperm
penetration)

90
Advantages
Contraceptive
Highly effective when taken correctly and consistently
Effective immediately (after 24 hours)
Do not interfere with intercourse
Convenient and easy to use
Client can stop use any time they want to get pregnant
can be provided by trained person
Non-contraceptive
 Decreased menstrual flow (lighter, shorter periods) and may
improve iron deficiency anemia
 Decreased menstrual cramps
 May lead to more regular menstrual cycles
 Protects against ovarian and endometrial cancer
 Decreases benign breast disease and ovarian cysts .
 Prevents ectopic pregnancy
 Protects against some causes of PID
Disadvantages

User-dependent (require continued motivation and daily

use)
Some nausea, dizziness, mild breast tenderness or

headaches as well as spotting or light bleeding (usually

disappear within 2 or 3 cycles)
Effectiveness may be lowered when certain drugs like

rifampin, phenytoin, and barbiturates are also taken

Cont…
Forgetfulness increases failure

Serious side effects (e.g., heart attack, stroke, blood clots

in lung or brain, liver tumors)

Resupply must be available

Does not protect against GTls or other STDs (e.g., HBV,

HIV/AIDS)
Contra-indications
• Pregnancy (known or suspected)
• Breast-feeding and fewer than 6-8 weeks postpartum
• Unexplained vaginal bleeding (until evaluated)
• Active liver disease (viral hepatitis)
• Age 35 and smoker
• History of heart disease, stroke or high blood pressure (> 180/110)
How to Take COCs:
Schedule and Missed Pills
Schedule: Quick start in COC
• Take one pill every day
• 21-day packs  7-day break
• 28-day packs  no break between packs

Missed pill:
• Take missed pill as soon as remembered
Missed 1 or 2
• Keep taking other pills on schedule
active pills
• No backup method needed

Source: WHO, 2004.

How to Take COCs:
Missed Pills
Miss 3 or more • Take first missed pill as soon as you remember
active pills or • Continue daily pill taking as usual and use
start pack 3 or backup method or abstain for next 7 days
more days late • Count number of active pills remaining in pack

7 or more active Fewer than 7 active

pills left in the pack pills left in the pack

• Finish active pills

• Finish active pills
• Discard inactive pills
• Take hormone-free break
• Start new pack immediately

Source: WHO, 2004.

Progestin Only Pills (POPs)
As the name indicates the pill only contains progestin, no

estrogen.
These pills may be used during breast-feeding period, as

they do not reduce milk flow.

The tablets must be taken at the same time each day

without interruption or contraceptive safety will be

reduced.
As there is no estrogen in the pills there is an increased

chance of spotting when used by menstruating women.

Mechanism of action
Thickens cervical mucus,

preventing sperm penetration.

Suppresses ovulation

Makes the endometrium less favorable for implantation

Reduces sperm transport in upper genital tract (fallopian

tube)
Advantages
Contraceptive
Effective when taken at the same time every day (0.5-10
pregnancies per 100 women during the first year of use)
Immediately effective (<24 hours)
Pelvic examination not required prior to use.
Does not interfere with intercourse
Does not affect breast-feeding
Immediate return of fertility when stopped.
Convenient and easy-to-use
Can be provided by trained nonmedical staff.
No estrogenic side effect
Non-contraceptive

May decrease menstrual cramps.

May decrease menstrual bleeding and may improve iron

deficiency anemia.
Protects against endometrial cancer

Decreases benign breast disease

Protects against some causes of PID

Disadvantages
Cause changes in menstrual bleeding pattern (irregular
bleeding/spotting initially) in most women
Some weight gain or loss may occur
User-dependent
Must be taken at the same time every day
Forgetfulness increases failure
Resupply must be available
Effectiveness may be lowered when certain drugs like
rifampin ,phenytoin and barbiturates are also taken
Do not protect against GTls or other STDs (e.g., HBV,
HIV/AIDS
Contra-indications

Pregnancy (known or suspected)

Known or suspected cancer of the reproductive tract and

breast.
Undiagnosed genital tract bleeding

Taking drugs like rifampin ,phenytoin, and barbiturates

 Contraception patches
 The patch releases a daily dose of hormones (estrogen and
progesten) through the skin, into the bloodstream. It works in
the same way as the combined pill.
 Used for 3 ws ,new patch each week ,and 1w off) patch free
week, withdrawal bleeding).
 Very sticky ,should not slip off even with bathing ,swimming,
or sauna .
B. Injectable contraceptives
 Injectable contraceptives are systemic progestin
preparations administered by intramuscular injection.
 The most common type of injectable contraceptive is
Depo-Provera/Medroxy-progesterone Acetate, which is a
progestin-only injectable contraceptive (PICs) given every
3 months.
 A second PIC is Noristerat which is given every 2 months.
 Combined injectables (CIC) contain both progestin and
estrogen. They are administered once a month. Given
every month
,

Mechanism of action
Thickens cervical mucus, preventing sperm penetration

Make the endometrium less favorable for implantation

Reduces sperm transport in upper genital tract (fallopian

tubes).
Suppresses ovulation (release of eggs from ovaries)
Advantages
 Contraceptive

Highly effective (0.3-1 pregnancies per 100 women

during the first year of use)

Rapidly effective (< 24 hours)

Intermediate-term method (2 or 3 months per injection)

Pelvic examination not required prior to use.

Does not interfere with intercourse

Cont….
Does not affect breast-feeding (except CIC)

No supplies needed by client

Can be provided by trained non-medical staff

No estrogenic side effects (except CIC)

No daily pill taking

long term pregnancy prevention but reversible

Side Effects
First 3 months:
Irregular bleeding
Prolonged bleeding
At one year:
No monthly bleeding
Infrequent bleeding
Irregular bleeding
Contraindication
Absolute contraindications to the use of monthly

injectables are
current or suspected pregnancy, and

estrogen-responsive tumors of the breast or

genital tract.
 Long acting FP methods

Implants
 Are matchstick sized flexible progestin-filled rods or capsules
that are placed just under the skin of the upper arm.
An excellent option for women at all phases of their
reproductive lives, to delay, space, or limit births.
Types
 Norplant: 6 capsules,
labeled for 5 years of use
 Currently not in use Norplant

 Jadelle: 2 rods, lasts 5

years
 75 mg of levonorgestrel
 Implanon: 1 rod, lasts 3 Jadelle
years
 68 mg of etonogestrel
 Sinoplant: 2 rods, each 75
mg of levonorgestrel, lasts 5
years Implanon
 Comparison
of Norplant®, Jadelle® and Implanon®
Norplant® Jadelle ® Implanon®
1 rod
6 capsules 2 rods
Effective for 7 yrs Effective for 3 yrs

Failure rate
Effective for 5 Failure rate

1st -yr : 0.05% years 1st -yr : 0.05%

Failure rate
Over 7-yrs : 2 % Over 3- yrs: 0.1
Insertion time: 4.3 min (0.8-18.0) 1st -yr : 0.05% %
Removal time: 10.2 min (1.3-50m) Over 5-yrs : 1% Available in Ethiopia

Cost: $27 Very short insertion and removal time

Available in Cost: comparable;
Ethiopia
Short insertion
and removal time
Mechanism of action
Implants continually release a small amount of
progestin steadily into the blood.
The primary mechanisms are:

Increased cervical mucus viscosity (within 48-72 hrs).

Inhibition of ovulation- in about 50% of menstrual

cycles.
Alters endometrium, making it less conducive for
implantation
Effectiveness of Implants
Are one of the most effective methods

<1 preg. per 100 women over the first year (5 per
10,000 women).
Start to lose effectiveness sooner for heavier women
 Drug interaction effect on implants
effectiveness
Contraceptive effectiveness may be reduced when co-
administered with some:-
Antibiotics ( Rifampin ),

Anti-fungals,

Anticonvulsants, and

Anti-HIV -Protease Inhibitors

Characteristics of Implants
Are safe
Easy to use/ Convenient
Highly effective
Not motivation dependent/ No need for user
compliance
Discreet, virtually invisible
Long acting
Rapidly reversible/No delay in return of fertility after
removal
Do not increase frequency of ectopic pregnancy.
Characteristics of Implants …
Stable hormone levels
Contain no estrogen
Safe for Breast feeding mother (after 6 wks PP),
May cause irregular bleeding
Does not protect from STIs
High initial cost
Require minor surgical procedure for insertion
/removal
Characteristics of Implants …
Non-contraceptive health benefits include:-
Help prevent ectopic pregnancy,
Help protect against pelvic inflammatory disease
Help prevent iron deficiency anaemia
May prevent endometrial cancer
May reduce sickle crises in women with sickle cell
anaemia.
 Who Can Use Implants?
Suitable for nearly all women; including women who:
Prefers a long-acting method
Cannot remember to take a pill every day.
Is breastfeeding (starting 6 wks after childbirth)
Cannot take estrogen-containing contraceptives
Is post-abortal
Has moderate to severe menstrual cramping
Smokes
Who can not use Implants ?
Implants may not be appropriate for some women
Use the WHO medical eligibility criteria
Generally avoid in case of
Serious liver disease
Current DVT
Unexplained vaginal bleeding
Breast cancer (current or history)
 Timing of insertion
 A woman can start using implants any time she wants if
it is reasonably certain she is not pregnant.
 Recommended times for insertion when changing from
another contraceptive
Natural FP or barrier method: before day 7 of cycle
COC: within 7 days of last active pill
Implant: when Implant is removed
Progestogen-only pill: on the day the last pill is taken
Injectable hormones: any time before next injection
IUD: any time
Insertion site
Intra-Uterine Contraceptive Devices
(IUCD)

126
IUCD
An intrauterine contraceptive device is a small piece
of flexible plastic with or without copper wound
around it
Modern IUCDs are highly effective, easily inserted
and removed
The IUCD is inserted into the uterus through the
vagina and cervix by a trained family planning
provider and is left in place with the strings hanging
down through the cervix into the vagina.
The client can check the strings to be sure that the
IUCD is in place
It provides continuous protection against pregnancy for a

minimum of 10 years for copper bearing and 5 year for

progestin releasing ones.
There are two broad types of IUCDs:­

• Copper-releasing: Copper T 380A, (currently distributed

in Ethiopia ), Nova T and Mutliload 375

• Progestin-releasing: Progestasert and LevoNova
 Mechanisms of Action
• Principal mechanism: Sterile
foreign body reaction  hostile
environment  prevent or
interfere fertilization by affecting
sperm motility.
• Effect of progesterone,
Thickening of cervical mucus,

• Not abortificant • Prevents fertilization by

Impairing the viability sperm
and interfering with
movement of the sperm

130
 Who Can Use IUCDs?
Most women can use the Copper T IUD safely, including
women who:
Have or have not had children
Are not married
Are of any age
Have just had an abortion or miscarriage (no
infection)
Are breastfeeding
Have had PID
Have vaginal infections
Are infected with HIV or have AIDS and on ARVs
131
 Who can not use IUCDs?
 Use the WHO medical eligibility criteria for IUCD use
 Generally not appropriate for women:-
With pregnancy (known or suspected)
With unexplained vaginal bleeding
Who is post partum between 48hrs-4wks
With current pelvic infection (puerperal, post abortal, TB &
STI)
With GTD or cervical/endometrial cancer
With uterine cavity distortion (myoma or congenital)
With AIDS cases (clinically not well)
Side effects
 Puncturing or perforation of the uterus(rare)
 May cause ectopic pregnancy(rare)
 Change in bleeding pattern including( lighter
bleeding , fewer days of bleeding, infrequent bleeding,
irregular bleeding, no monthly bleeding, prolonged
bleeding)
 Acne, headache, breast tenderness, weight gain,
nausea, mood change
Timing of insertion
 A woman can start using IUCDs any time she wants if it is
reasonably certain she is not pregnant.
 Optimal times for insertion are
Within 12 days from onset of menstrual bleeding
Immediately or within 12 days after abortion (if no infection is
present)
If <48 hours post partum or > 4 weeks

 Switching from another method

 For emergency contraception
Contraindication for IUCD use
Absolute contraindications for IUD use include the
following:
Pregnancy
Significantly distorted uterine anatomy
Unexplained vaginal bleeding concerning for
pregnancy or pelvic malignancy
Ongoing pelvic infection
Postpartum endometritis or septic abortion in
the past 3 months
Multiple sexual partner
Immunosuppression
Permanent methods
Surgical sterilization:
permanent, generally irreversible procedure.
It is advised only for individuals who are absolutely certain that they do not
want any or additional children
Surgical sterilization does not protect against HIV infection (AIDS) or any
other sexually transmitted infection (STIs)
Types of sterilization:
Tubal ligation is the most common procedure. In this procedure, the
physician inserts a laparoscope through a small incision made in the
abdomen. Each fallopian tube is then sealed or "tied," which prevents the
passage of an egg.
vasectomy. Through a small incision in the scrotum, the physician seals the
ducts (vas deferens) that carry sperm. A backup method of birth control
should be used until it has been confirmed that any remaining sperm in
the ducts have been completely ejaculated
Tualligiation and Vasectomy
How Effective is Surgical Sterilization?

Tubal ligations (female sterilization) are 99% effective

Vasectomy (male sterilization) is 99.9% effective
Sterilization is considered one of the safest
contraceptive methods, but it does involve a surgical
procedure.
There is always the possibility of complications such
as bleeding, infection, and possible damage to
surrounding organs
Emergency contraception
 Used as an emergency procedure to prevent unintended pregnancy
following an unprotected sexual intercourse
 If a woman had intercourse without using contraception or think her
method might have failed there are two emergency methods she can use.
 Prevents about 75% -85% of pregnancies
 Types:
 Emergency contraceptive pills (ECPs) –
 ECPs are sometimes referred to as “morning after” or “postcoital”
pills
 May be progestin only or Combined
 Copper releasing IUDs
 IUCDs are highly effective as ECs. After unprotected sexual
intercourse
 Menstrual cycle and safe period

 Ovulation usually happens 10–16 days before the start of

the next period

 Record the length of six of your menstrual cycles

 Subtract 18 from the total number of days in your shortest

cycle: represents the first fertile day of your cycle

 Subtract 11 from the total number of days in your longest

cycle: represents the last fertile day of your cycle

 Contraceptive use
 Contraceptive use is a practice that helps individuals or
couples to avoid unwanted pregnancy to attain their
desired children as their plan
 842 million are using contraceptive methods,
 270 million have an unmet need for contraception
 Only one contraceptive method, condoms, can prevent
both a pregnancy and the transmission of sexually
transmitted infections, including HIV.
MoH developed the health sector transformation plan of
2015, which aimed
To increase the CPR from 35 % in to 55 % by 2020
To reduce TFR from 4.6 in to 3 by 2020
Modern contraceptive use in Ethiopia
EDHS 2016- 35
EDHS 2019- 41
The most commonly used modern contraceptive methods
among currently married women in Ethiopia are
Injectables (27%), followed by implants (9%), and the pill
and IUD (2% each
Family planning counseling

Counseling is a type of client-provider interaction that

involves two-way communication b/n a health care staff
member & a client for the purpose of confirming or
facilitating a decision by the client or helping the client
address problems or concerns.
Effective counseling enables
 Enables clients to choose a method that suits their
needs
 Enables clients to use their chosen method correctly
 Enables the client to continue using a FP method with
satisfaction
 Informs and prepares clients for side effects
When providing counseling, health care
staff is responsible for:
 Helping clients to assess their own needs for services,
information, and emotional support
 Providing information appropriate to clients’ identified
problems and needs
 Assisting clients in making their own voluntary and
informed decisions by helping them weigh the options
 Helping clients explore possible barriers to the
implementation of their decisions and helping them
develop the strategies and skills to overcome those
barriers, and carry out their decisions
 Answering questions and addressing concerns, and
making sure the clients understand all the information
they have received
Frameworks of family planning counseling
Contraception related challenges in Ethiopia
 limited access to contraceptives
 spousal disapproval
 Availability
 perceived health risk/Lack of information
 Cost
 Effectiveness/Mistrust
 dependency on short-term FP methods
 Poor supply chain management system
 Fear of infertility
Child Health

BY Gedfie.A (MPH RH)

 Child health
 Child health is a state of physical, mental, intellectual,
social and emotional well-being and not merely the
absence of disease or infirmity
 Child’s health is the foundation of all growth and
development
 Healthy children live in families, environments, and
communities that provide them with the opportunity to
reach their fullest developmental potential.
Child health problems

 The global under-five mortality rate declined by 59

per cent, from 93 deaths per 1,000 live births in 1990
to 38 in 2021
 In 2021 alone, roughly 13,800 under-five deaths
occurred every day, an intolerably high number of
largely preventable child deaths
 A child's risk of dying is highest in the neonatal
period, the first 28 days of life
 44% of child deaths under the age of five take place
during the neonatal period
 Child health…
 Globally the leading causes of death in under-five
children are
preterm birth complications,(15%)
pneumonia, (15 %)
complications during birth eg, birth asphyxia, (10%)
diarrhea (9%)
Malaria (7%)
 About 45% of all child deaths are linked to
malnutrition/nutritional problem
 Five top causes of child mortality in Ethiopia

 80% of child mortality in Ethiopia can be attributed to

five conditions:
Neonatal causes (low birth weight, sepsis and asphyxia)
Pneumonia
Diarrhoea
Malaria
Measles
 Two underlying conditions:
Malnutrition
HIV/AIDS
 Child health services in Ethiopia
 child health service is basic to end preventable child
deaths and promote the healthy growth and development
of all children in the first decade of their life
 Ethiopia has made tremendous effort by
reducing Under-5 mortality declined from 123 deaths per
1,000 live births in 2005 to 59 deaths per 1,000 live births
in 2019
 Infant mortality declined from 77 to 47 deaths per 1,000
live births
 Neonatal mortality declined from 39 deaths per 1,000 live
births in 2005 to 29 deaths per 1,000 live births in 2016
before increasing to 33 deaths per 1,000 births in 2019
 Child health care service mainly includes

 Newborn care

 Immunization

 Monitoring growth and developments

 Early detection and treatment of health problem

 In Ethiopia Majority of facilities provide all basic child

health services
 New born cares
Step 1: Deliver baby on to mother’s abdomen or into her arms
Step 2: Dry baby’s body with dry towel. Wipe eyes. Wrap with
another dry one and cover head
Step 3: Assess breathing and color. If < 30 breaths per minute, blue
tongue, lips or trunk or if gasping then start resuscitating
Step 4: Tie the cord two fingers from abdomen and another tie two
fingers from the
1st one (if no clamp). Cut the cord between the 1st and 2nd tie
(clamp)
Step 5: Place the baby in skin-to-skin contact and on the breast to
initiate breastfeeding
Step 6: Apply Tetracycline eye ointment once
Step 7: Give Vitamin K,1mg IM on anterior mid thigh
Step 8: Weigh baby (if <1500 gm refer urgently)
 Parameters of growth assessment

 Weight for age “growth faltering” ---- Normal 80th percentile

 Height for age "stunting” ---- Normal >90th percentile

 Weight for Height "wasting’’ ---- Normal 5th to < 85th percentile

 Head circumference --- Average newborn HC is 35cms (range 32.6 –

37.2cms)

 Mid-upper arm circumference (1- 5 years) -Normal >12 cm

 Introduction to immunization services
 Immunization is the process whereby a person is made
immune or resistant to an infectious disease, typically by the
administration of weakened live attenuated and killed micro
organisms that cause diseases
 It is one of the cost-effective public health interventions, and
can be used to limit life threatening childhood illnesses like
diphtheria, pertussis, tetanus, hepatitis virus, measles, mumps,
pneumonia, polio virus and rotavirus
 Since the establishment of the Expanded Program on
Immunization (EPI) in 1974, millions of deaths and
disabilities due to the six targeted diseases (diphtheria,
measles, pertussis, poliomyelitis, tetanus and tuberculosis)
have been prevented
Historical background of immunization services in
Ethiopia
 The expanded program on immunization was launched in
1980 with the objective of achieving 100% immunization
coverage of all children under two years old by
 In 1986, the coverage target was reset to 75% and the target
age group was changed to less than one year old but progress
in increasing coverage has been slow.
 With the introduction of new approaches known as Reaching
Every Districts (RED) and Sustainable Outreach Services
(SOS) for immunization in 2003, As a result, the coverage
showed marked improvement
 Now, the Reaching every district strategic approach is recast
to reaching every children/community strategic approach in
order to deal with inequities within districts.
The government of Ethiopia introduced the pneumococcal
conjugate vaccine (PCV) and monovalent human rotavirus
vaccine (RV) into the national infant immunization program
in November 2011 and October 2012, respectively
Ethiopia intends to introduce new vaccines such as measles
second dose as Measles rubella, Men A, HPV and Yellow
Fever in the coming NIP (2016-2020)
Ethiopia launched HPV vaccine for the first time in 2018 for
all 14 year old girls through a school-based approach and in
health centers
Ethiopia introduced the second dose measles vaccine
(MCV2) in the routine immunization program in February
2019.
A yellow fever vaccination campaign was launched on
November 2020
 National immunization program of Ethiopia
 The Ethiopian immunization implementation guideline
has been revised in 2015.
 Children of under-one year of age and women of
reproductive age group (15-49 years age) are the targets
for the currently available EPI vaccines in Ethiopia
(BCG, Measles, DPT-HepB-Hib or penta- valent,
Rotavirus, Pneumococcus vaccine (PCV), OPV and TT
 The 2016-2020 NIP of Ethiopia aims at achieving five
major goals
 Goal 1: Achieve a country free of poliomyelitis by 2018
 Goal 2: Meet vaccination coverage targets in, district,
zone, region, and nationally by 2020
 Goal 3: Exceed the MDG 4 target for reducing child
mortality in the country (we can state like ‘To reduce
under-five mortality from 2013 level of 64/1,000 to
35/1,000, infant mortality rate from 44/1000 to 24/1000
and NMR from 28 to 14/1,000 by 2020”)
 Goal 4: Meet National elimination targets e.g. measles,
MNT
 Goal 5: Introduce New & Under-utilized Vaccines
Program Objectives
 Increase and sustain high vaccination coverage
 Maintain polio free status and fulfill the recommend
standard AFP surveillance at national and regional levels
for national certification
 Eliminate measles and advocate for the elimination of
rubella and congenital rubella syndrome
 Attain and maintain elimination/control of other vaccine-
preventable diseases
 To expand cold storage capacity in line with introduction

of new vaccines, population growth and coverage

expansion plan and campaigns at all levels by 2016
 Improve knowledge and practice Health workers on EPI

 Strengthen program Monitoring and Evaluation

 Increase government fund allocation to 10% for

traditional vaccines procurement and new vaccine co

financing by 2020
 Immunization and major vaccines provided in
Ethiopia
 The percentage of children age 12-23 months who
received all basic vaccinations increased from 20% in
2005 and 24% in 2011 to 39% in 2016 and 44% in 2019.
Also, the proportion of children with no vaccinations
decreased from 24% in 2005 to 19% in 2019
 In 2019 children age 12-23 months, 74% received the first
dose of PCV and 60% received the third dose (Table 8.2).
Seventy-three percent of children received the first dose
of RV, while 67% received the second dose
 A vaccination card, booklet, or other home-based record
was seen for 41% of children age 12-23 months and 26%
of children age 24-35 months
Types of vaccine Age When to give

BCG, OPV0 At birth

DTP-HepB1- 6 week
Hib1,OPV1,PCV1, Rota1

DTP-HepB2- 10 week
Hib2,OPV2,PCV2, Rota2

DTP-HepB3-Hb3, OPV3, 14 week

PCV3, IPV

Measles 1 9 month
Measles 2 12-15 month
HPV 9-13 year
MenA 1-29 year
 Vaccine management system
The cold chain
 Vaccines are biological substances that may lose their
effectiveness quickly if they become too hot or too cold,
especially during transport and storage
 Cold Chain system of EPI is the System that ensures
1.Potency
2.Quality and
3.Safety of Vaccines by maintaining the correct temperature
from Manufacturer to Children/Women
 The cold chain system is a means for storing and
transporting vaccines in a potent state from the
manufacturer to the person being immunized
Vaccine storage

 At the national level:

 keep your vaccines for a maximum of 6 months :

 Store OPV, Measles, and Mumps vaccines at -15 to -25

degree Celcious;
 Store Hepatitis B, DPT, DT , TT and BCG at 0 to +8

degree Celcious;
 Send vaccines to regions in insulated containers at 0 to

+8 degree Celcious
 At the regional level:

 keep your vaccines for a maximum of 3 months :

 Store OPV, Measles, and Mumps vaccines at -15 to -25

oC
Store Hepatitis B, DPT, DT, TT and BCG at 0 to +8o C;

Send vaccines to districts in insulated containers at 0 to

+8 o
 At the district level:

keep your vaccines for a maximum of 1 month :

store OPV, Measles, and Mumps vaccines at -15 to -25 o C, if

possible;
store Hepatitis B, DPT, DT, TT and BCG at 0 to +8 o C;

send vaccines to health facilities in insulated containers at 0 to

+8 o C
 At the health facility level:

keep all your vaccines for a maximum of 1 month:

store all vaccines at 0 to +8 o C

 The Cold Chain Equipment
 Cold boxes: Cold boxes are supplied to all peripheral
centers. These are used mainly for transportation of the
vaccines.
 Vaccine carriers: Vaccine carriers are used to carry small
quantities of vaccines (16-20 vials) for the out of reach
sessions. fully frozen ice packs are used for lining the
sides, and vials of DPT, DT, TT and diluents should not
be placed in direct contact with frozen ice packs. The
carriers should be closed tightly.
 Ice packs: The ice packs contain water and no salt should
be added to it. Every health Centre should have two sets
of ice packs, one being frozen while the other is in use
 Tools for monitoring the cold chain
Cold Chain Refrigerator Graph

 The vaccines are stored in refrigerators, they are

monitored twice a day and readings are recorded on a

chart to ensure a safe temperature is maintained
Cold Chain Monitor Card

 It is used to show cumulative exposure to Temp above

the safe range during storage& transportation

 Shake Test
By shaking two vials of cold sensitive vaccines side by-
side, for 10-15 seconds one that might have been frozen
and one that has never been frozen
Observe whether there is sedimentation or not after 30
minute
Don’t use the vaccine if granular sediment is observed
 Vaccine vial monitors
 VVM is a label containing a heat-sensitive material
which is placed on a vaccine vial to register cumulative
heat exposure over time
Reading a Vaccine Vial Monitor
 Vaccine preventable disease surveillance
 Monitoring vaccine effectiveness” Through:

 Randomized field trials

 Retrospective cohort studies

 Case-control studies

 Incidence density measures

Surveillance for VPD provides continuous, long-term

evidence-based information that allows for the timely

detection and response to VPD and the monitoring of
impact of national immunization programs
VPDs include all diseases for which vaccination is

recommended for use by national immunization

programme, as well as those diseases for which baseline
surveillance data are required to define disease burdens
before vaccine introduction
 To identify outbreaks quickly for immediate action, such
as reactive vaccination campaigns and other
interventions. Epidemic- and outbreak prone VPDs
include polio, measles, rubella, meningococcal, cholera,
typhoid, yellow fever, diphtheria, pertussis, and Ebola.
 To identify unreached and under immunized populations
through triangulation of surveillance, vaccine coverage,
vaccine supply, clinical administrative, and other
relevant data to inform targeted vaccine delivery
strategies and program improvement
 To monitor progress towards global and regional disease
elimination and eradication goals, namely for polio,
measles, rubella, and neonatal tetanus
 To determine disease burden and epidemiology to inform
decision-making about vaccine introductions (e.g.,
pneumococcus, rotavirus, and future vaccines such as
against RSV) and geographic usage for regional vaccines
(e.g., typhoid, Japanese encephalitis, and yellow fever)
 To identify circulating strains of vaccine-preventable
pathogens and changes in those circulating strains after
vaccines are introduced, to guide choice and development
of vaccines, such as for meningococcus, pneumococcus,
and influenza
 To generate evidence on vaccine impact, which
surveillance has shown for routine use of rotavirus and
meningococcal vaccines among other VPDs
 To guide optimal use of vaccines, such as defining high-

risk groups or modifying vaccine schedules for VPDs

including pertussis, meningococcus, pneumococcus,
diphtheria, tetanus, and influenza, especially as the
disease epidemiology changes with vaccine programme
implementation
 Priority activities for comprehensive VPD
surveillance
Workforce
Laboratory
Information systems
Applied research
Sustainable financing
 Common childhood diseases and preventions
methods
 Preterm delivery
 Insecticide treated materials
 Antenatal steroids
 Antimalarial intermittent Rx during pregnancy
 Birth asphyxia
 Follow labour promptly
 Timely intervene on prolonged labour
 Neonatal sepsis
 Breast feeding
 Clean delivery
Neonatal tetanus

 Tetanus toxoid

 Clean delivery

 Pneumonia

Breast feeding

Complementary feeding

PCV10 vaccine
Diarrhea
Breast feeding
Complementary feeding
Water sanitation
hygiene
Zinc
Vitamin A
Malaria
Insecticide-treated materials
 Complementary feeding
Malaria proplaxis
Measles

 Measles vaccine

Complementary feeding

 HIV/AIDS

• PMCT

• ARV prophylaxis

• replacement feeding
 Gender and Reproductive health
Sex is biological or reproductive differences based on
genitalia, chromosomes, hormones (Male or Female)
Gender refers to the economic, social and cultural attributes
and opportunities associated with being male or female in a
particular social setting at a particular point in time
Sex Gender
Biological Social
Born Not born
Natural learned
Universal Local
Unchangeable Changeable
Characteristics of gender
Relational Socially constructed
Hierarchical Power relations (unequal power
relationships due to the greater importance and value to
the characteristics and activities associated with what is
masculine)
Changes: Changes over time (potential for modification
through development interventions
Context specific Varies with ethnicity, class culture etc.
Institutional Systemic (a social system that is supported
by values, legislation, religion, etc.)
 Gender equality: Is equal treatment of women and men

in laws and policies and equal access to resources and

services within families, communities and society at
large
 Gender equity

Is fairness and justice in the distribution of benefits and

responsibilities between women and men.

It often requires women‐specific programs and policies

to end existing inequalities

 Gender discrimination - any distinction, exclusion or
restriction made on the basis of socially constructed
gender roles and norms which prevents a person from
enjoying full human rights
 Gender stereotypes: believing or thinking that gender
roles are natural and we don't question them.
 Gender mainstreaming: the incorporation of gender
issues into programs
 Gender analysis: a research tool that helps policy
makers and program managers appreciate the
importance of gender issues
STI AND SYNDROMIC APPROACH

By: G.A 12/09/2023

 Presentation Outline
 Introduction to STIs
 Ethiopian situation to STIs
 Definition of Sexually Transmitted Infections?
 Management approaches for STIs
 Public health impacts of STIs
 Strategies to prevention and control for STIs

By: G.A 12/09/2023

 Introduction to STI
STI: Infections caused by organisms that are passed through
sexual activity with an infected partner
 Endogenous infections : Infections that result from an
overgrowth of organisms normally present in the vagina
• are not usually sexually transmitted, and include bacterial
vaginosis and candidiasis
 Iatrogenic infections :Infections introduced into the
reproductive tract by a medical procedure such as menstrual
regulation, induced abortion, IUD insertion, or childbirth
STD: is diseases that are passed from one person to
another through sexual contact
By: G.A 12/09/2023
 Introduction
Sexually transmitted infections (STIs) are among the
most common causes of illness in the world and have
negative impact on health, social and economic
consequences
STIs represent a large burden of disease worldwide
with an annual incidence of about 333 million cases
each year in people under the age of 25 years
It affect 1 in 20 young peoples every year globally

By: G.A 12/09/2023

 Etiology of STI

 Sexually Transmitted Infections are:

caused by more than 30 different pathogens,
Commonly caused by bacteria, viruses, protozoa,
fungus and ecto-parasites.
The infections are caused by different organisms and
have a wide variety of symptoms

By: G.A 12/09/2023

Epidemiological Synergy Of STIs and HIV

Inflammatory STIs (e.g. GC) lead to 5 fold increased

HIV acquisition
Genital ulcers lead to 12 fold increased HIV
acquisition
STDS may be more resistant to Rx in HIV infected
individuals

By: G.A 12/09/2023

STIs increase HIV transmission through

 Reducing physical/mechanical barriers(disruption of

 epithelium)

 Increasing HIV in genital lesions, semen or both(Increase

viral shedding )
 Increasing the number of receptor cells or the density of

receptors per cell

By: G.A 12/09/2023

HIV infection affects STIs through:
 HIV alters susceptibility of STI pathogens to antibiotics

 Increased susceptibility to STIs among immune

suppressed individuals
 The clinical features of various types of STIs are

influenced when there is co-infection with HIV

 The treatment of conventional STIs is also affected when

infection with HIV coexist

By: G.A 12/09/2023

 Approaches STI Management.

A. Etiologic Approach
This is done by identifying the causative agent(s)

Using laboratory tests and

Giving treatment targeting to the pathogen
identified.

By: G.A 12/09/2023

 Dis/ Advantages
Advantages
Avoids over treatment.
Support to traditional
training.
Satisfies patients who feel
inadequate service.
 Can be used to screen
asymptomatic patients
By: G.A
Disadvantages
• Requires skilled personnel and
sophisticated lab equipment.
 Testing facilities usually not
available at PHC level.
 Lab tests are expensive, time
consuming and results may not be
reliable.
 Delay in Rx and reluctance of
patients to wait for lab results.
 Mixed infections often leads to
miss treatment
12/09/2023
 B. Clinical Approach
Uses clinical experience to identify symptoms which are typical
for a specific STI, then giving treatment targeted, to the
suspected pathogen(s).
Example: Gonorrhea

By: G.A 12/09/2023

 Dis/ Advantages
Advantage Disadvantage

 Saves time for patients  Requires high clinical skill

 Reduces lab expenses  Mixed infections often
overlooked
 Doesn’t identify
asymptomatic STIs

By: G.A 12/09/2023

C. Syndromic Approach

 Syndromic approach management is based on:

 The identification of a group of symptoms and easily
recognized signs associated with infection with well-
defined pathogens.
Treatment for each syndrome is directed against the main
organisms within that geographical setting responsible for
the syndrome.

By: G.A 12/09/2023

Syndromic Approach cont…
 Identification of clinical syndrome and giving
treatment targeting all the locally known pathogens
which can cause the syndrome.
 It is called “Comprehensive approach” because in
addition to the provision of treatment it includes:
Education of the patient, condom supply, counseling,
partner notification and
Management and HIV testing and counseling.

By: G.A 12/09/2023

Dis/ Advantages Syndromic Approach
Advantage
 Complete STI care offered at first
visit
 Simple, rapid and inexpensive
 Patients treated for possible mixed
infections
 Accessible to a broad range of health
workers
 Avoid unnecessary referral to
hospitals
 Highly effective for the Mx of
majority of the STI.
 Efficient case detection and
treatment By: G.A
Disadvantage
Risk of over-treatment
Requires prior research to
determine the common causes
of particular syndromes
Asymptomatic infections are
missed
Has low specificity and ppv
for detecting cervical and
vaginal discharge.
may cause drug resistance
12/09/2023
Syndromic management key features
 Problem oriented (responds to patient’s symptoms )

 Highly sensitive & does not miss mixed infections

 Treats the patient at first visit

 Can be implemented at primary health care level

 Use flow charts with logical steps

 Provides opportunity & time for education &counseling

By: G.A 12/09/2023

The four steps in Syndromic STI case management
History taking and examination

Syndromic diagnosis and treatment, using flow charts

Education and counseling on HIV testing and safer

sex, including condom promotion and provision

Management of sexual partners

By: G.A 12/09/2023

 Ethiopian context
 Ethiopia has been implementing syndromic approach
since 2001 by using flow chart for the mgt of STIs.
 In order to:

To solve Inadequate access to sophisticated laboratory for

etiological diagnosis.

To decrease duration of patients’ infectiousness.

By: G.A 12/09/2023

 What is Flow Chart
A flow chart (Algorithm) is a decision and action tree.
It is like a map that guides the health worker to go through
a series of decisions and actions.
Each decision or action is enclosed in a box, with one or
two routes leading out to another box, containing another
decision or action.
It be used at any time in all types of health facilities.
They suggest clear decisions.

By: G.A 12/09/2023

Flow Chart cont…
 Each flow-chart is made up of a series of three steps.
1. The clinical problem box:
 The patient’s presenting symptoms
2. The decision box that needs to be taken:
 This is the box, which requires further information, which
the health care provider finds out by taking a history or
examining the patient.
3. The action box that needs to be carried out.
 Each of the exit paths leads to an action or do box.
 This is the box that instructs the service provider on what
action to take.
By: G.A 12/09/2023
 Clinical Problem Decision Box

Enlarged and Painful Inguinal

Lymph nodes?

Take History & Examine

Ulcer (s) Use Genital

Yes Ulcer Flow Chart
Present?

No

By: G.A Action Box

Common STI Syndromes

 The commonly encountered STI syndromes are:

Urethral discharge in men
Genital ulcer
Vaginal discharge
Lower abdominal pain in women/PID
Inguinal bubo
Scrotal swelling
Neonatal conjunctivitis.

By: G.A 12/09/2023

Diagnosis Using Syndromic Approach
1. Urethral Discharge Syndrome
 It is the presence of abnormal secretions from the
distal part of the urethra.
 It is the characteristic manifestation of urethritis.
 Usually it is accompanied by burning sensations
(dysuria) during micturition.
 The appearance of the discharge can be:
 purulent or mucoid,
clear, white, or
yellowish-green.

By: G.A 12/09/2023

Causative agent for Urethritis

 The two most common causative agents of the syndrome

are
 Neisseria gonorrhea(81%) and
Chlamydia trachomatis ( 36.8%) (2014 EPHI).
 Some of the other causative micro-organisms are
mycoplasma genitalium,Trichomonas vaginalis, and
Ureaplasma urealyticum.
 Mostly it is mixed infection of Neisseria gonorrhea and
Chlamydia trachomatis.
By: G.A 12/09/2023
Urethral Discharge Syndrome cont…

The urethritis caused by N. gonorrhea has usually an

acute onset with profuse and purulent discharge.

By: G.A 12/09/2023

 Recurrent / Persistent Urethral
Discharge Syndrome

 Persistent or recurrent burning sensation on urination,

with or without discharge, due to:

Inadequate treatment or poor compliance

Re-infection (partner/s not managed)
Infection by drug-resistant organisms , Example
N.gonorrhea.

By: G.A 12/09/2023

By: G.A 12/09/2023
By: G.A 12/09/2023
 2. Genital Ulcer Syndrome
Genital ulcer is an open sore or a break in the
continuity of the skin or mucous membrane of the
genitalia.
 Commonly it is caused by bacteria and viruses.
It facilitates transmission of HIV more than other
STIs because it disrupts continuity of skins and
mucous membranes significantly.

By: G.A 12/09/2023

 Etiologic Genital Ulcer Syndrome

 Common etiologies of genital ulcer syndrome are:

Herpes simplex virus (HSV-1 and HSV-2)
Treponema pallidum
Haemophilius ducreyia
Chlamydia trachomatis
Klebsiella granulomatis (donovanosis)
Most cases of genital herpes are caused by HSV-2.

By: G.A 12/09/2023

 Clinical manifestation of
Genital clinical
Common Ulcer manifestations of genital ulcer
are:
Constitutional symptoms such as fever, headache,
malaise and muscular pain
Recurrent painful vesicles and irritations
Shallow and nonindurated tender ulcers
 Painless indurated ulcer(Chancre)
 Regional lymph adenopathy

By: G.A 12/09/2023

 manifestation Genital Ulcer cont…
common sites in women are
vulva, perineum, vagina Common sites in male are glance
penis, prepuce and penile shaft

By: G.A 12/09/2023

By: G.A 12/09/2023
By: G.A 12/09/2023
 3. Vaginal Discharge Syndrome

 Abnormal vaginal discharge is recognized:

 when a women notices a change in color, odor and
amount accompanied by pruritus.
 Etiology of Vaginal Discharge

Neisseria gonorrhea
Chlamydia trachomatis
Trichomonas vaginalis
Gardnerella vaginalis (Common in Ethiopia)
Candida albicans
By: G.A 12/09/2023
Vaginal Discharge Syndrome cont…

The classical manifestation of vaginal discharge is

discharge from the vagina.
The discharge can be thin, homogenous whitish discharge
with fishy odor.
Thick, profuse, malodorous, yellow-green, frothy itchy
Purulent exudate from the cervical Os
White , thick and curd like discharge coating the walls of
the vagina

By: G.A 12/09/2023

Vaginal Discharge Syndrome cont..

Clinical Manifestation

Vaginal discharge
syndrome can cause many
devastating complications if
left untreated.
Hence any woman with
vaginal discharge syndrome
must be treated promptly by
classifying either risk
assessment positive or
By: G.A negative. 12/09/2023
By: G.A 12/09/2023
By: G.A 12/09/2023
4. Lower Abdominal Pain (PID)
 PID refers to a clinical syndrome resulting from
ascending infection from the cervix and/or vagina.
 The commonest manifestations of PID include:
Lower abdominal pain
Abnormal vaginal discharge
Inter-menstrual or post coital bleeding
Dysuria
Backache
Fever, nausea and vomiting
Cervical excitation tenderness
Rebound tenderness

By: G.A 12/09/2023

 Etiology of PID

 PID is occurred due to frequently poly-microbial infection.

 The commonest pathogens are C. trachomatis and N.
gonorrhea.
 Other causes which may or may not be transmitted sexually
include:
Mycoplasma genitalium
Bacteroides species
E. coli
H. influenza
Streptococcus
By: G.A 12/09/2023
By: G.A 12/09/2023
By: G.A 12/09/2023
 5. Scrotal Swelling Syndrome
 Mostly the inflammation of the epididymis is caused
common etiologies which is transmitted by during sexual
contact.
 The commonest etiology are the following:
N. gonorrhea
 C. trachomatis
 T. pallidum
 M. tuberculosis
 Mumps virus
 Pseudomonas aeruginosa
Filarial diseases
By: G.A 12/09/2023
 Scrotal Swelling
Syndrome cont…
clinical manifestation
Swelling of the scrotum
Tender and hot scrotum
on palpation
Edema and erythema of
the scrotum
Sometimes urethral
discharge can be there

By: G.A 12/09/2023

By: G.A 12/09/2023
By: G.A 12/09/2023
6.Inguinal Bubo Syndrome
 Inguinal bubo is swelling of inguinal lymph nodes as a
result of infections.
 Etiology
 The common causes of inguinal and femoral bubo are:
Chlamydia trachomatis
Klebsiella granulomatis (donovanosis)
Treponema pallidum
Haemophilius ducreyia

By: G.A 12/09/2023

Swollen Glands cont...
clinical manifestation

Tender unilateral or
bilateral lymphadenopathy
forms a classical “groove
sign” in the inguinal area .
Fluctuant abscess
formation which form a
coalesce mass (bubo)
Some time concomitantly
occur with genital ulcer
By: G.A 12/09/2023
By: G.A 12/09/2023
By: G.A 12/09/2023
 7. Neonatal Conjunctivitis

 Neonatal conjunctivitis (ophthalmia neonatorum) is an

ocular redness, swelling and drainage due to pathogenic
agents occurring in infants less than 4 weeks of age.
 Some of the common etiologic causes of neonatal
conjunctivitis are:
N. gonorrhea
C. trachomatis
S. pneumoniae
H. influenzae
S. aureus

By: G.A 12/09/2023

 Neonatal Conjunctivitis cont…
clinical manifestation
Red and edematous
conjunctivae
Edematous eye lead
Discharge which may be
purulent
Orbital cellulitis in more
serious cases

By: G.A 12/09/2023

By: G.A 12/09/2023
By: G.A 12/09/2023
Types of Prevention
1.Primary Prevention
 Safer sexual behaviors
Abstinence from sexual activity altogether/
delaying the age of sexual practice.
Life-long mutual monogamy
Correct and consistent use of condoms .

By: G.A 12/09/2023

 Types of Prevention cont…
2.Secondary Prevention
Promoting STI care-seeking behaviour, through:
Public education campaigns on adherence.
Counseling for partner screening and Rx.
Ensuring a continuous supply of highly effective
drugs.

By: G.A 12/09/2023

 Population dynamics

 A population is defined as a group of individuals of the

same species living and interbreeding within a given

area
 Population dynamics: Variation among populations

due to birth and death rates, and by migration

Measures of fertility
and
Reproduction
 Definitions

Fecundity—Physiological capacity to conceive

Infecundity (sterility)—Lack of the capacity to conceive.

– Primary sterility—Never able to produce a child

– Secondary sterility—Sterility after one or more children have

been born
 Definitions

Fecundability—Probability that a woman will

conceive during a menstrual cycle
 Fertility (natality)—Manifestation of fecundity

 Infertility—Inability to bear a live birth

 Natural fertility—Fertility in the absence of

deliberate parity-specific control
 Definitions
• Reproductivity—Extent to which a group is replacing its
own numbers by natural processes.
• Gravidity—Number of pregnancies a woman has had

• Parity—Number of children born alive to a woman

• Birth interval—Time between successive live births

• Pregnancy interval—Time between successive

pregnancies of a woman
 Crude Birth Rate (CBR)
 Let B = Number of births
 Let P = Mid-year population
 Let W15-44= Number of women of reproductive ages

P15f  49
 Crude Birth Rate—Number of births per 1,000 population in
CBR 
B
* 1000 
B
* * 1000
P P15f  49 P
a given time period.

B
CBR  * 1000
P
 Based on CBR values Fertility
 High fertility Rate = > 30/1000

 Medium fertility rate = 20-30/1000

 Low fertility rate = < 20/1000

Limitations of CBR

Only a crude estimate of fertility.

All the population included in the denominator is not exposed to the risk of pregnancy.

 Not good for comparing fertility across populations

 General Fertility Rate (GFR)
General Fertility Rate—Number of births per 1,000
women of reproductive ages in a given time period.

B
GFR  f
*1000
P 15 49
• It eliminates distortions that might arise due to different age and sex
distributions among the total population.

 The major limitation of GFR is that not all women in the denominator are

exposed to the risk of child birth.

 Exercise
General Fertility Rate (GFR)
• Use the following data to calculate the GFR per 1,000
women aged 15–49:
• Island of Mauritius, 1985
• Age Group Women 15-
19 52 013 20-24
54 307 25-29
46 990 30-34
40 211 35-39
30 401 40-44
23 496
• 45-49 12000
• Total births: 18 500
• Source: U.N. Demographic Yearbook, 1986
Age-Specific Fertility Rate (ASFR[a]) and TFR

 ASFR(a)—Number of births per 1,000 women of a specific

age group a in a given time period.
Ba
ASFR( a )  * 1000
Where Ba=Number of births to women of ageWa(group) “a”
Wa= Number of women of age (group) “a”
a= age group 15-19, 20-24,… 44-49.
 Total Fertility Rate (TFR)
 Total Fertility Rate(TFR)—Number of children a woman
will have if she lives through all the reproductive ages and
follows the age-specific fertility rates of a given time period
(usually one year).
 For single-year age
49
Ba 49
TFR   * 1000   ASFR(a )
a 15 Wa a 15
 For five year age groups

45 49 45 49
Ba
TFR  5 *  * 1000  5 *  ASFR(a )
a 1519 Wa a 1519
 Total Fertility Rate (TFR)
• Example: ASFR and TFR—Country X, 2004
• Age group Birth #of Women ASFR
• 15-19 43807 1230396 35.60 20-
24 257872 1390077 185.51 25-29
236088 1653183 142.81 30-34
115566 1608925 71.83 35-39
38450 1241967 30.96 40-44
6627 941963 7.04
45-49 1600 841963 1.9
475.64
TFR=5*475.64/1000=2.38
It indicates on average a woman in country x will have 2.38 number of
children at the end of her reproductive life following the 2004 ASFR.
 Gross Reproduction Rate (GRR)

 Let B f =Number of female births

 = Number of male and female births, i.e., all births
t
B
 Gross Reproduction Rate (GRR)
• Gross Reproduction Rate—Number of
daughters expected to be born alive to a
hypothetical cohort of women (usually 1,000) if
no one dies during childbearing years and if the
same schedule of age-specific rates is applied
throughout the childbearing years.
• Note: In the gross reproduction rate mortality of
the mother's generation before the end of the
childbearing age is not taken into consideration.
 Gross Reproduction Rate (GRR)
45 49 f
B
GRR  5 * 
a 1519
ASFR(a ) * a

Ba
t

GRR  TFR * Proportion of female births

If the sex ratio at birth is assumed constant across ages of

women.
 Exercise Gross Reproduction Rate (GRR)

• Use the following data to calculate the GRR

• United States, 1990
Age Group of Births
Mothers #of Women Total Male
15-19 8 651 522 267
20-24 9 345 1094 560
25-29 10 617 1277 653
30-34 10 986 886 454
35-39 10 061 318 163
40-44 8 924 49 25
45-49 5600 28 13
Numbers are in 1000s
Check the correct answer is 1.07 daughters per woman.
Note that
 Age-specific fertility rates are per 1,000 women.

 TFR: Total fertility rate expressed per woman

 GFR: General fertility rate expressed per 1,000 women age 15-49

 CBR: Crude birth rate, expressed per 1,000 population

by Hanan Abdulkadir
 Measures of Mortality

by Hanan Abdulkadir
 Mortality (Death)
 Mortality refers to deaths that occur within a population

 Death is a unique and universal event, and as a final event, clearly

defined

 Mortality (Death) rates have three essential elements:

 A population group exposed to the risk of death

(denominator).
 The number of deaths occurring in that population group

(numerator)
 A time period.
by Hanan Abdulkadir
 Cont…
 Common measures of mortality includes:

A. Crude Death (Mortality) Rate (CDR)

 The crude death rate is the number of deaths per 1000

population in a given year.

CDR = Total number of deaths in a year X 1000

Mid-year population
 As its name implies the CDR is not a sensitive measure

(indicator) of health status of a population.

by Hanan Abdulkadir
 B. Age specific Death (Mortality) Rates

 Death Rates can be calculated for specific age groups, in

order to compare mortality at different ages.

ASMR = Number of deaths in a specific age group X 1000

Mid-year population of the same age group

by Hanan Abdulkadir
 C. Infant Mortality Rate (IMR)
 Infant Mortality Rate is the number of deaths of infants under

one year of age (0-11 months of age) per 1000 live births in a
given year.
 Infant (children under one year of age) are at highest risk of

death than any other age group

IMR = No of death of children < 1 year in a year X 1000

Total live births during that year

 In Ethiopia, IMR is 59 per 1000 live births (CSA, 2012).

by Hanan Abdulkadir
 IMR…
 The infant mortality rate is considered to be a sensitive

indicator(good indicator) of the health status of a

community, because it reflects the socio-economic condition
of the population; like:
level of education,

environmental sanitation,

adequate and safe water supply,

communicable diseases, provision of health services.

by Hanan Abdulkadir
 D. Under Five Mortality Rate (<5MR)
 It is the number of deaths of children under five years of age

in a year per 1000 children under five years of age .

 It is also a very good indicator of the health status of a

community.

<5MR = No of deaths of children <5 yrs in a year X 1000

Total number of children < 5 years of age

by Hanan Abdulkadir
 F. Neonatal Mortality Rate (NNMR)
 Neonatal period is the first month of age of an infant.

 Neonatal mortality (death) is the death of infants under one

month (<4 weeks) per 1000 live births.

NNMR = No of deaths of infants < 1 month in a yr X 1000

Total number of live births in the same year

 In Ethiopia, NNMR is 37 per 1000 live births (CSA, 2012).

by Hanan Abdulkadir
 NNMR…
 Neonatal mortality rate reflects mortality due to:

Maternal factors during pregnancy

Birth injuries

Neonatal infection, etc.

 It is an indicator of the level of prenatal and obstetric

components of maternal and child health care (MCH).

by Hanan Abdulkadir
 G. Post-Neonatal Mortality Rate (PNNMR)
 The post neonatal age is the period of time between one month

up to one year.
 Post – Neonatal mortality (death) is deaths of infants one month

(four weeks) of age up to one year (1 – 11 months age of) per

1000 live births.

PNNMR = No of deaths of infants 1 month to 1 yr in a yr X1000

Total Number of live births during the same year

 In Ethiopia, post neonatal death accounts for 22 per 1000 live births
by Hanan Abdulkadir
(CSA, 2012).
 PNNMR…
 The post-neonatal mortality rate reflects deaths due to

factors related to;

Environmental sanitation

Infections (communicable diseases)

Nutritional problems

Child care etc.

 It can be used as an indicator to evaluate Maternal and

Child Health Care services and socio-economic

development of a community or country.
by Hanan Abdulkadir
Maternal Mortality Ratio (MMR)

Definition:
‘Maternal Mortality’ is death of a woman while
pregnant ,or within 42 days of termination of
pregnancy irrespective of the duration or site of the
pregnancy from any cause related to, or aggravated by
the pregnancy or its management not from accidental
causes

by Hanan Abdulkadir
 Conti….
 Maternal mortality ratio is the number of maternal deaths

related to pregnancy, child birth and post natal (Puerperium)

complications per 100,000 live births.

MMR = Number of deaths of women related to pregnancy ,child birth

and Puerperium in a year X 100,000

Total number of live births in the same year

 It is a sensitive indicator of health status of a population.

 It reflects the socio- economic status of a community.

by Hanan Abdulkadir
Maternal Mortality Rate
• Number of deaths due to maternal causes per 1,000
women of reproductive ages

Note: Maternal mortality ratio is more widely used

•Represents both the obstetric risk and the frequency

with which women are exposed to this risk
by Hanan Abdulkadir
 Lifetime risk of Maternal Death
Women’s lifetime risk of Death: Is the risk of an individual woman
dying from pregnancy or childbirth during her lifetime
 Takes into account probability of becoming pregnant and
probability of dying as a result of that pregnancy cumulated across
a woman’s reproductive years.
 It can be approximated by multiplying the maternal mortality rate

by the length of the reproductive period.

1-(1-MMR)*35
Measurement of Migration

by Hanan Abdulkadir
 Migration
 It is a process of involving movement of people from one
geographical area to another.
 It involves change of residence and crossing of pre- defined
boundary.
 Like fertility and mortality, it is one component of population
change.
 Migration takes various forms across space and time.
 It has significant effect on the development of separate cultures and
diffusion of cultures.
by Hanan Abdulkadir
Definitions of term
 In-migrant—A person who moves in a political area within

the same country

 Immigrant—An international migrant who enters the area

from a place outside the country

 Out-migrant—A person who moves out of a political area

within the same country

 Emigrant—An international migrant departing to another

country by crossing the international boundary

by Hanan Abdulkadir
 Migration…

 In broad terms migration can be classified in to two internal

and International migration

1. Internal migration

 It affects only the distribution of population.

 Is a movement with in the boundary of a country

 Involves crossing of political boundaries

by Hanan Abdulkadir
2. International migration

 It entails movement of people across national

boundaries.
 Affects all parts of the globe in terms of distribution,
gain or loss of population
 It is referred to as emigration with respect to the sending
nation and immigration with respect to the receiving
nation

by Hanan Abdulkadir
 International…

 Movements across national boundary may be classified in to

short term or long term, temporary or permanent, voluntary
or forced, legal or illegal etc.

 Data on international migration could be obtained from.

 Frontier control
 From population register
 Population census and surveys

by Hanan Abdulkadir
 Cont…
 Net Internal migration=In-migrants - Out-migrants

 Net International migration=Immigrants – Emigrants

Note: Net migration for an area often includes both international

and internal migration

 Gross Internal migration= In-migrants + Out migrants =

Migration turnover
by Hanan Abdulkadir
 Cont…
 Migration stream—A group of migrants having a

common origin and destination in a given migration

period.

 Migration counter stream—In opposite direction of

stream.

by Hanan Abdulkadir
 Migration…

Immigration rate

 The number of immigrants arriving at a destination per

1,000 population at that destination in a given year.

IMR = No. of immigrants X1000

total population at destination

by Hanan Abdulkadir
 Migration measures…
Emigration rate
 The number of emigrants departing an area of origin per 1,000

population at that area of origin in a given year

EMR = No. of emigrants X1000

total population at origin

 NInternationalMR =No. of immigrants–No. of emigrants X1000

Total mid year population

by Hanan Abdulkadir