1. Maternal and Child Health Interventions

2. Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 2012 2 Continuum of Care Home and Community First level Facility Referral Facility

3. Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 2012 3 Continua of Care Guiding principles for planning maternal and child health programmes  Continuum across Life-stages (which interventions?)  Continuum across Health System (at which level?)

4. Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 2012 4 Continuum of Care Across Life-stages Factors which help decide interventions across the life-cycle: –Causes and distribution of child deaths –Proven efficacy of interventions –Feasibility –Cost –Acceptability –Issues related to health services

5. Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 2012 5 Most effective interventions require implementation at each level Factors guiding levels at which interventions are implemented: –Community acceptability and demand –Availability of trained staff –Access to health services –Technical complexities –Equity issues Balance between implementation at different levels is important Continuum of Care Across Health Systems Home and Community First level Facility Referral Facility

6. Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 2012 6 Example: Interventions to improve Child Health Home and Community First-level facility Referral Facility Pregnancy At birth Newborn period Infancy and Childhood

7. Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 2012 7 Example: Interventions to improve Child Health Home and Community First-level facility Referral Facility Pregnancy Promote & support antenatal care Detection & management of complications of pregnancy Management of severe complications At birth Promote and support skilled care at birth Immediate newborn care Management of obstetric complications Newborn period Promote and support key newborn care practices Management of newborn illnesses Immunization Management of severe newborn illnesses Infancy and Childhood Community case management of diarrhea & ARI Standard case management during childhood illnesses Management of severe childhood illnesses

8. Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 2012 8 Packaging of Interventions A way of integrating and combining health interventions –Essential for making programmes feasible as it reduces programme costs and improves program effectiveness Several Maternal and Child Health intervention packages already exist. Sometimes, there might be need for adding a new package.

9. Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 2012 9 Intervention Packages Skilled obstetric and immediate newborn care including resuscitation Emergency obstetric care to manage complications such as obstructed labour and hemorrhage Antibiotics for preterm rupture of membranes # Corticosteroids for preterm labour # Emergency newborn care for illness, especially sepsis management and care of very low birth weight babies Clinical care Folic acid # Counseling and preparation for newborn care and breastfeeding, emergency preparedness Healthy home care including breastfeeding promotion, hygienic cord/skin care, thermal care, promoting demand for quality care Extra care of low birth weight babies Case management for pneumonia Family- community Clean home delivery Simple early newborn care 15 - 32% 4-visit antenatal package including tetanus immunisation, detection & management of syphilis, other infections, pre- eclampsia, etc Malaria intermittent presumptive therapy* Detection and treatment of bacteriuria # Outreach services Postnatal care to support healthy practices Early detection and referral of complications 6 - 9% 23 - 50% NMR effect Infancy Neonatal period Pre- pregnancy Pregnancy Birth Administering basic community-based intervention packages at full coverage can save ~ 37% of all newborn deaths!

10. Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 2012 10 Packaging of Interventions A way of integrating and combining health interventions –Essential for making programmes feasible as it reduces programme costs and improves program effectiveness Several Maternal and Child Health intervention packages already exist. Sometimes, there might be need for adding a new package.

11. Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 2012 11 Example: Intervention package for maternal and child health ANC Care – TT vaccination, Anemia prophylaxis, Detection of complications, Counseling Routine post-natal visits to mother and newborn - Exclusive breastfeeding, Thermal care, Hygienic cord care, Extra care of LBW infants, Prompt care- seeking for illness, Immunization, Management of newborn illness IMNCI – Algorithm-based management of diarrhea, pneumonia, malaria, malnutrition and newborn illnesses, Promotion of ORS and Zinc F-IMNCI – Management of inpatient children with severe illnesses

12. Introduction to Maternal and Child Health; MCH Lecture Class MGIMS, Sewagram;; 04 Jul 2012 12 Community based: IMNCI, Management of diarrhea and ARI, IYCF, Immunization, IFA and Vitamin A, HBNC, MCTS and MCP Card. Facility based: Facility based new born care- FBNC (SNCU, NBSU, NBCC), F-IMNCI, NRC, JSSK. Delivery strategies for the interventions

13. Malnutrition 34% Causes of under-five deaths in India: 2010

14. Malnutrition 34% Causes of under-five deaths in India: 2010 Infections (sepsis / pneumonia, diarrhoea, tetanus) Antibiotics for premature rupture of membranes Syphilis screening & treatment Clean delivery practices Hypothermia management Kangaroo mother care Breastfeeding Community based pneumonia management Tetanus toxoid immunization Preterm / low birth weight Detection & treatment of asymptomatic bacteriuria Syphylis screening & treatment (Pre) eclampsia prevention Corticosteroids for preterm labour Hypothermia management - Kangaroo mother care Skilled delivery practices Asphyxia Institutional delivery Skilled birth attendant Use of partograph for labour surveillance Resuscitation of newborn

15. Malnutrition 34% Causes of under-five deaths in India: 2010 Pneumonia: Breastfeeding counselling Complementary feeding counselling Hib vaccination Antibiotics Early detection and management Diarrhoea: Breastfeeding counselling Complementary feeding counselling Vitamin A supplementation Oral rehydration therapy Zinc adjuvant therapy Antibiotics for dysentery Measles: Measles vaccination Complementary feeding counselling Vitamin A supplementation Vitamin A therapy Malnutrition: Breastfeeding counselling Complementary feeding counselling Vitamin A supplementation Vitamin A therapy Measles vaccination Growth monitoring and promotion Community-based and Facility- based management of malnutrition Malaria and HIV: Insecticide treated nets Anti-malarial treatment PPTCT Complementary feeding counselling Vitamin A supplementation Niverapine and (replacement) feeding

16. Maternal and Child Health Interventions | RCH Program UG Class | 2012 16 Evidence-based interventions Child Health Antenatal care4%* Skilled care at birth13%* Postnatal care: routine care for all newborns, additional care for LBW, treatment of neonatal sepsis 13%* Exclusive breastfeeding13% Appropriate complementary feeding, including micronutrients 6% Immunization5% Insecticide-treated bed nets7% ORT and zinc for diarrhoea19% Treatment of suspected pneumonia6% Treatment of malaria5%

17. Maternal and Child Health Interventions | RCH Program UG Class | 2012 17 Evidence-based interventions for Child Health Preventive Breastfeeding13% Insecticide-treated materials7% Complementary feeding6% Zinc5% Clean delivery4% Hb vaccine4% Water, sanitation and hygiene3% Antenatal steroid3% Newborn temperature maintenance2% Vitamin A2% Nevirapine and replacement feeding2% Tetanus toxoid2% Antibiotics for premature rupture1% Measles vaccine1% Antimalarial intermittent preventive treatment in pregnancy<1%

18. Maternal and Child Health Interventions | RCH Program UG Class | 2012 18 Evidence-based interventions for Child Health Treatment Oral rehydration therapy15% Antibiotics for sepsis6% Antibiotics for pneumonia6% Antimalarials5% Zinc4% Newborn resuscitation 359 (0)* 4% (0%)*4% Antibiotics for dysentery 310 3%3% Vitamin A 8<1%

19. Maternal and Child Health Interventions | RCH Program UG Class | 2012 19 Summary: Child Health Interventions PREGNANCY Tetanus toxoid immunization Birth and emergency planning Detection and management of problems complicating pregnancy (e.g. hypertensive disorders, bleeding, mal- presentations, multiple pregnancies, anemia) Information and counseling on self-care, nutrition, breastfeeding, family planning Sleeping under an insecticide-treated bed net Prevention of mother-to-child transmission of HIV+

20. Maternal and Child Health Interventions | RCH Program UG Class | 2012 20 Summary: Child Health Interventions Labor, birth and 1-2 hours after birth Monitoring progress of labor, maternal and fetal well-being with partograph Social support (companion) during birth Immediate newborn care (resuscitation if required, thermal care, hygienic cord care, early initiation of breastfeeding) Emergency obstetric and newborn care for complications Antibiotics for preterm and/ or premature rupture of membranes* Antenatal corticosteroids for preterm labor Prevention of mother-to-child transmission of HIV+

21. Maternal and Child Health Interventions | RCH Program UG Class | 2012 21 Summary: Child Health Interventions Newborn period (after the first 1-2 hours after birth up to 1 month) Exclusive breastfeeding Thermal care Hygienic cord care Prompt care-seeking for illness Extra care of low-birth-weight (LBW) infants Immunization Management of newborn illness Prevention of mother-to-child transmission of HIV+

22. Maternal and Child Health Interventions | RCH Program UG Class | 2012 22 Summary: Child Health Interventions Older infants and children (1 month up to 5 years) Preventive Interventions Exclusive breastfeeding (up to age 6 months) Safe and appropriate complementary feeding starting at 6 months with continued breastfeeding (up to age 2 years and beyond) Prevention and management of malaria Immunization Vitamin A supplementation Hand washing and proper disposal of faeces Birth spacing of 24 months or more

23. Maternal and Child Health Interventions | RCH Program UG Class | 2012 23 Treatment interventions Oral rehydration therapy for diarrhoea Zinc for diarrhoea Antibiotics for dysentery Antibiotics for pneumonia Antimalarials Management of severe malnutrition Management of HIV-exposed and HIV-infected children Summary: Child Health Interventions Older infants and children (1 month up to 5 years)

24. Maternal and Child Health Interventions | RCH Program UG Class | 2012 24 Common causes of maternal deaths in India

25. Maternal and Child Health Interventions | RCH Program UG Class | 2012 25 Common causes of maternal deaths in India Hemorrhage Active management of 3rd stage of labour; Detect & Treat anaemia; Skilled attendant at birth Referral transport Blood transfusion Operative procedures Sepsis Clean delivery Post-natal care Early detection and referral Proper management at facility Hypertensive disorders ANC Care Early detection and referral Proper management Complications of abortion Access to family planning methods including emergency contraception Use of medical methods Safe abortion facility Ensuring good quality of care Obstructed labor Nutrition of girl child Detection of high risk pregnancy and institutional delivery Use of partograph Skilled care at birth

26. Maternal and Child Health Interventions | RCH Program UG Class | 2012 26 Direct causes of maternal deathCost – effective clinical interventions Bleeding after delivery (24%) Active management of 3 rd stage of labour; Detect & Treat anaemia in pregnancy; Skilled attendant at birth: prevent/treat bleeding with correct medicines, eg, oxytocin, replace fluid loss by IV drip and transfusion if severe Infection after childbirth (15%) Skilled attendant at birth: clean practices Antibiotic if infection arises Unsafe abortion (13%) Skilled attendant: give antibiotics, empty uterus, replace fluids if needed, counsel & provide family planning/ prevention. Access to safe abortion where not against law High blood pressure, most dangerous when severe (eclampsia) (12%) Detect high blood pressure in pregnancy; refer to doctor at hospital. Treat convulsions with appropriate anticonvulsive medicines (MgSO 4 ) Refer unconscious woman for expert urgent assistance Other direct obstetric causes (8%)Refer ectopic pregnancy for operation Key interventions to effectively prevent maternal deaths by cause

27. Maternal and Child Health Interventions | RCH Program UG Class | 2012 27 Three Delays Model Source: Operational Guidelines on Maternal and Newborn Health, NRHM, MoH & FW DELAY 1 Delay in recognizing the problem Delay in deciding to seek care DELAY 2 Delay in reaching the health facility DELAY 3 Delay in receiving adequate treatment once a woman has arrived at the health facility

28. Maternal and Child Health Interventions | RCH Program UG Class | 2012 28 Summary: Maternal Health Interventions PRE-PREGNANCY Family Planning Folic acid fortification and/or supplementation to prevent Neural Tube Defects Prevention of mother-to-child transmission of HIV+

29. Maternal and Child Health Interventions | RCH Program UG Class | 2012 29 Summary: Maternal Health Interventions PREGNANCY Iron and Folic Acid Supplementation Tetanus toxoid immunization Birth and emergency planning Management of unintended pregnancy Detection and management of problems complicating pregnancy (e.g. hypertensive disorders, bleeding, mal-presentations, multiple pregnancies, anemia) Information and counseling on self-care, nutrition, breastfeeding, family planning Prevention and management of malaria Prevention of mother-to-child transmission of HIV+

30. Maternal and Child Health Interventions | RCH Program UG Class | 2012 30 Summary: Maternal Health Interventions Labor, birth and 1-2 hours after birth Monitoring progress of labor, maternal and fetal well-being with partograph Social support (companion) during birth Prophylactic uterotonic and Active management of third stage of labor to prevent postpartum hemorrhage Emergency obstetric care for complications Management of Post-partum hemorrhage Induction of labor for prolonged pregnancy Caesarean section for maternal/foetal indication Antibiotics for preterm and/ or premature rupture of membranes

31. Maternal and Child Health Interventions | RCH Program UG Class | 2012 31 Summary: Maternal Health Interventions Post-partum period (after the first 1-2 hours after birth up to 6 weeks) Advice and provision of family planning Prevent, measure and treat maternal anemia Detection and management of postpartum sepsis Prevention of mother-to-child transmission of HIV+

32. Maternal and Child Health Interventions | RCH Program UG Class | 2012 32 Obstetric Care Essential Obstetric Care Emergency Obstetric Care

33. Maternal and Child Health Interventions | RCH Program UG Class | 2012 33 Current Approach to Reduction of Maternal Mortality Maternal Mortality Reduction Sri Lanka 1940–1985 85% births attended by trained personnel

34. Maternal and Child Health Interventions | RCH Program UG Class | 2012 34 Maternal Mortality: UK 1840–1960 Improvements in nutrition, sanitation Antibiotics, banked blood, surgical improvements Antenatal care

35. Maternal and Child Health Interventions | RCH Program UG Class | 2012 35 How can maternal deaths be prevented? Skilled birth attendance Prompt referral to an appropriately equipped facility if complications arise 24×7 hours availability of expert services – a team of specialists to perform surgery Well equipped hospital with operation theatre and blood transfusion services Keep the woman in the facility for at least 48 hours after delivery The facilities should be accessible within a radius of 35 km

36. Maternal and Child Health Interventions | RCH Program UG Class | 2012 36 Packages of interventions in different time frames related to pregnancy Focused antenatal Care (delivered through outpatient or outreach service) o Minimum four ANC check ups o At least 1 ANC by Medical Officer, (preferably 3 rd ) o Timing of visits – –1 st : within 12 weeks/ preferably as soon as pregnancy is suspected –2 nd : between 14 – 26 weeks –3 rd : between 28 – 34 weeks –4 th : between 36 weeks and term

37. Maternal and Child Health Interventions | RCH Program UG Class | 2012 37 Packages of interventions in different time frames related to pregnancy Focused antenatal Care (delivered through outpatient or outreach service) o Early registration o Two doses of injection Tetanus Toxoid o All pregnant women – 100 tabs IFA (200 for anemic) o Screening for treatment of disorders o Provision of preventive interventions o Counseling – diet, hygiene, HIV status, birth, emergency preparedness, care and feeding of babies

38. Maternal and Child Health Interventions | RCH Program UG Class | 2012 38 Packages of interventions in different time frames related to pregnancy Intranatal care (facility based clinical care package) o Promotion of institutional deliveries o Skilled attendance for normal child birth, eg, monitoring labor progress by partograph o Emergency obstetric care (basic & comprehensive) for complicated cases o Effective referral system

39. Maternal and Child Health Interventions | RCH Program UG Class | 2012 39 Packages of interventions in different time frames related to pregnancy Postnatal care (Institutional in the first 48 hours and thereafter delivered through outpatient or outreach service for a 42 day period) o Prevention and detection of complications o Information and counseling on self-care at home, nutrition, family welfare, breast feeding

40. Maternal and Child Health Interventions | RCH Program UG Class | 2012 40 Skilled Birth Attendant An accredited health professional (eg, midwife, doctor or nurse) Educated and trained to proficiency in the skills needed to manage – o Normal (uncomplicated) pregnancies o Childbirth o Immediate postnatal period Helps in identification, management and referral of complications in women and newborns