AFMC WHO Textbook Community Medicine

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2. Section 7 : Family Health
140 Maternal and Child Health A S Kushwaha 809
141 Risk Approach in MCH A S Kushwaha 811
142 Maternal Health Care AS Kushwaha 814
143 Care of Infants A S Kushwaha 826
144 Integrated Management of Neonatal and Childhood Illnesses (IMNCI) A S Kushwaha 835
145 Care of Under Five Children A S Kushwaha 848
146 School Health Services A S Kushwaha 853
147 Adolescent Health A S Kushwaha 856
148 Children’s Right to Health A S Kushwaha 865
149 Growth and Development of Children A S Kushwaha 869
150 Genetics and Public Health Amitava Datta 878
151 Preventive Health Care of the Elderly RajVir Bhalwar 887
152 Demography and Public Health Dashrath R. Basannar 891
153 Contraceptive Technology RajVir Bhalwar 895

3. during childbirth, or after the baby has been born due to blood
140 Maternal and Child Health loss and infections. The 5,29,000 annual maternal deaths,
including 68,000 deaths attributable to unsafe abortion,
almost all of these are occurring in poor countries with only
A S Kushwaha
1% in rich countries. Each year 3.3 million babies are stillborn,
more than 4 million (neonatal deaths) are dying within 28
The health of women and children has always been an important days of coming into the world, and a further 6.6 million young
social goal of all societies. Over the years, maternal and child children die before their fifth birthday. Although an increasing
health has evolved through various stages of conceptual number of countries have succeeded in improving the health
approach, technological advances and social prioritization. and well-being of mothers, babies and children in recent
The realization that, improved maternal and child health is the years, in some countries the situation has actually worsened.
key to the ultimate objective of lifelong health in any society, Slow progress, stagnation and reversal are closely related
has led to renewed interest and global focus towards this very to poverty, to humanitarian crises, and, particularly in sub-
important social health issue. Saharan Africa, to the direct and indirect effects of HIV/AIDS.
Mother and Child: A Single Entity Over 300 million women in the world currently suffer from
Mother and child are often spoken of in one breath for a number of long-term or short-term illness brought about by pregnancy or
reasons. Health of the child and the mother are so closely linked childbirth. Programmes to tackle vaccine preventable diseases,
that each has the capacity to influence the other. The outcome malnutrition, diarrhoea, or respiratory infections still have a
of pregnancy in terms of a healthy newborn is dependent on large unfinished agenda.
the physical, physiological, mental and nutritional state of the India
mother during pregnancy. Some specific health interventions Health of Women : The country has a falling low sex ratio
jointly protect pregnant women and their babies e.g. tetanus of 933 female per thousand male. Early marriage in women
toxoid immunization and nutrition supplementation. At and universality of marriage are important social issues. The
childbirth, both mother and child are at risk for complications median age at first marriage among women is 17.2 years.
which can endanger their lives. The postpartum care of the Almost half (46%) of women age 18-29 years got married before
mother is inseparable from newborn care, immunization and the legal minimum age of 18. Among young women age 15-19,
family planning advice, and this provides not only operational 16 percent have already begun childbearing. Indians have poor
convenience but offers continuity of care as well. knowledge about temporary contraceptive methods and this
Important Sub Disciplines Related to MCH coupled with poor availability affects ‘delaying the first and
spacing the second child’ doctrine adversely. Among the married
There are a number of sub disciplines that have developed over
women, 13 percent have unmet need for family planning. Less
the years in the field of maternal and child health. It is in this
than half of women receive antenatal care during the first
endeavour that disciplines like social obstetrics, preventive
trimester of pregnancy, as is recommended. Three out of every
pediatrics, community obstetrics, family health and family
five births in India take place at home; only two in five births
medicine have originated. Various initiatives in child health
take place in a health facility. Less than half of births took
include essential newborn care, well baby clinics, under five
place with assistance from a health professional, and more
clinics, Child guidance clinics and school health services.
than one third were delivered by a Traditional Birth Attendant.
Why So Much Attention to This Issue? The remaining 16 percent were delivered by a relative or other
Firstly, together, mothers (women 15-45 years of age) and untrained person. A Disposable Delivery Kit (DDK) is being
children (under 15 years of age) constitute 70-80% of the used only in 20% of births taking place at home. Most women
population. They also belong to the most vulnerable section of receive no postnatal care at all. Only 37 percent of mothers
society in terms of death, disease, disability and discrimination. had a postnatal checkup within 2 days of birth. Every seven
Women and Children represent economically dependent and minutes an Indian woman dies from complications related to
least empowered section of the society. The falling sex ratio pregnancy and childbirth. The maternal mortality ratio in India
(from 972 in 1901 to 933 in 2001) is a grim reminder of the stands at 300 per 100,000 live births. (Table - 1).
social disadvantage faced by women in India(1). The issue Child Health : Infant mortality is 77 per 1,000 for teenage
also merits attention because of high morbidity and mortality mothers, compared with 50 for mothers age 20-29. Infant
faced by this group. Most of the deaths and illnesses in these mortality in rural areas is 50 percent higher than in urban areas.
groups are avoidable by cost effective interventions which are Perinatal mortality, which includes stillbirths and very early
available to tackle them. infant deaths (in the first week of life), is estimated at 49 deaths
Scenario of Maternal and Child Health per 1,000 pregnancies, that lasted 7 months or more. Less than
half (44%) of children 12-23 months are fully vaccinated against
Global Picture : Of the estimated 211 million pregnancies that
the six major childhood illnesses: tuberculosis, diphtheria,
occur each year, about 46 million end in induced abortion.
pertussis, tetanus, polio, and measles. Although breast feeding
Attending to all of the 136 million births every year is one of
is almost universal in India, only 46 percent of children under 6
the major challenges that is now faced by the world’s health
months are exclusively breastfed. Many infants are deprived of
systems. Globally, huge toll on account of maternal deaths
the highly nutritious first milk (colostrum) as only 55 percent
continues unabated. Often sudden, unpredicted deaths occur
are put to the breast within the first day of life. Almost half
during pregnancy itself (as a consequence of unsafe abortion),
• 809 •

4. of children under age five are stunted or too short for their risks are highest for both mother and child.
age. Anaemia is a major health problem in India, especially Place: Linking the delivery of essential services in a dynamic
among women and children. Among children between the ages primary-health-care system that integrates home, community,
of 6 and 59 months, about 70 percent are anaemic including outreach and facility-based care. The impetus for this focus is
three percent who suffer from severe anaemia. More than half the recognition that gaps in care are often most prevalent at
of women in India (55 percent) have anaemia with 17 percent the locations – the household and community – where care is
of these have moderate to severe anaemia. most required.
The continuum of care concept has emerged in recognition of the
Table - 1: Important Mortality indicators of Maternal and
fact that maternal, newborn and child deaths share a number of
Child Health (Source-NFHS 3)
similar and interrelated structural causes with undernutrition.
Indicator 1994 2000 2001 2002 2003 2004 2005 The continuum of care also reflects lessons learned from
IMR 74 68 65.9 64 60 58 58 evidence and experience in maternal, newborn and child
health during recent decades. In the past, safe motherhood and
NNMR 47.7 44 40.2 NA 37 37 37
child survival programmes often operated separately, leaving
PNMR 26 23 25.7 NA 23 21 22 disconnections in care that affected both mothers and newborns.
PMR 42.5 40 26.2 NA 33 35 37 It is now recognized that delivering specific interventions at
pivotal points in the continuum has multiple benefits. Linking
SBR 8.9 8 9.3 NA 9 10 9 interventions in packages can also increase their efficiency and
MMR 327 301 cost-effectiveness. The primary focus is on providing universal
coverage of essential interventions throughout the life cycle in
an integrated primary-health-care system.
IMR Infant Mortality rate
NNMR Neonatal Mortality rate
Road Ahead
The NRHM and RCH are aimed at meeting this challenge and
PNMR Post-Neonatal Mortality Rate
have set out their targets as envisaged under various policies
PMR Perinatal Mortality Rate and MDGs. (See Table - 2)
SBR Still Birth Rate
Table - 2 : The Road Ahead (National targets for MCH)
MMR Maternal Mortality Ratio
National
Challenges in MCH 10th Plan RCH -2 Population
MDGs (by
The look at statistics in Table - 1 gives a picture of many Indicator goals (2004- Policy
2015)
unfulfilled promises in the field of maternal and child health (2002-07) 09) 2000 (by
despite a family welfare programme running since 1950s. The 2010)
challenges include lack of universalisation of services, rural 35 per
urban differential, poor status of women in society and lack of Infant 45 per 30 per
1000
political will and acceptance of the issue as a social priority. The mortality 1000 live 1000 live -
live
main challenge to child survival no longer lies in determining rate births births
births
the proximate causes of or solutions to child mortality but
Under 5
in ensuring that the services and education required for Reduce
mortality - - -
these solutions reach the most marginalized countries and by 2/3rd
rate
communities.
150 per
Opportunities in MCH Maternal 200 per 1 100 per 1
1 lakh Reduce
A new paradigm in MCH - Continuum of Care : The continuum mortality lakh live lakh live
live by 3/4th
consists of a focus on two dimensions in the provision of ratio births births
births
packages of essential primary-health-care services:
Time: There is a need to ensure essential services for mothers References
and children during pregnancy, childbirth, the postpartum 1. National Family Health Survey NFHS - 3 India 2005-06, International
period, infancy and early childhood. The focus on this element Institute for Population Sciences, Mumbai, India. http://www.nfhsindia.org/
nfhs3.html
was engendered by the recognition that the birth period – before,
2. World Health Report 2005. Make Every Mother and Child count. WHO, 2005
during and after –is the time when mortality and morbidity
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5. Attributable Risk : This brings together three ideas - the
141 Risk Approach in MCH frequency of the unwanted outcome when risk factor is present,
frequency of the unwanted outcome when risk factor is absent,
frequency of the occurrence of risk factor in the community.
A S Kushwaha
It indicates what might be expected to happen to the overall
outcome in the community if the risk factor was removed.
Risk as a Proxy for Need
Risk Factors : Risk factor is defined as any ascertainable
In every society there are communities, families and individuals characteristic or circumstance of a person or group of persons
whose chances of future illness, accident and untimely death that is known to be associated with an abnormal risk of
are greater than others; they are said to be vulnerable owing to developing or being especially adversely affected by a morbid
peculiar set of characteristics they share. These characteristics process. Risk factor is one link in a chain of association leading
could be biological, genetic, environmental, psychosocial or to an illness or an indicator of a link.
economic. Similarly there are others who have a chance to enjoy
Risk factors can therefore be causes or signals but they are
better health. Thus as an example we can see that pregnant,
observable and identifiable. Risk factor could be related to
poor, very young children and elderly are vulnerable and young
individual, family, community or the environment. Examples
and affluent are not. Risk however has come to be associated
include - first pregnancy, high parity, teenage pregnancies,
with the vulnerability to disease or illness or death. A pregnant
malnutrition, rural area, birth attendance etc.
woman with high blood pressure is at risk of complications
like eclampsia and this measured risk to her and the child is an The significance of risk factors from the point of application
expression of her need for medical help and intervention. The and utility in practice of preventive community medicine can
risk strategy utilizes these risk estimates as guide for action, be judged by -
resource allocation, coverage and referral care. The hypothesis, (a) Degree of association with the outcome.
on which risk strategy rests, therefore, is that more accurately (b) Frequency of the risk factor in the community.
the risk is measured, the better is the understanding of the Combination of Risk Factors
need. The combination of two or more risk factors increases the
The risk approach is a managerial tool based on the strategy probability of the outcome. For example in a pregnancy, the
for efficient utilization of scarce resources with more care for hypertensive disease and poor antenatal care are independent
those in need and proportionate to the need. risk factors for perinatal mortality but when both factors are
Tools of the Risk Approach present, the probability of perinatal mortality is much higher
than expected. This is because the risk factors may have an
The characters shared by a cohort making them vulnerable
additive or multiplicative effect.
are referred to as risk factors. The measure of association
with the outcome is known as the relative risk and estimation Risk Factors and Causes
of the adverse outcome if these risk factors are present and Not all significant associations between the risk factor and
calculation of effect if these risk factors are removed have made the outcome are part of a chain of causality. Associations are
our decisions in public health prioritization. Risks, predictions usually described as ‘causal’ if they can be seen to be directly
and possible effects are therefore the tools of the risk approach. related to pathological processes, even if the pathways are not
By quantifying the risks to the health of a population group fully understood. e.g. Maternal malnutrition and low birth
and their associated risk factors, it focuses attention on the weight, placenta praevia and foetal death from anoxia, rubella
need for prevention. in first trimester and congenital malformation. The important
attributes in such association are ‘dose response relationship,
Risk Approach Applied to MCH specificity, consistency of association, time relationship and
The mothers and children are most susceptible to good or biological plausibility. The complex relationship between
harmful influences that will permanently affect their health. risk factor and outcome can be explained by an example of
The harm can be inflicted or the good can be promoted in a very gastroenteritis in a child belonging to a poor family where
short time. The preventive and promotive elements of primary the complex of poverty may include contributions to risk from
health care will have greatest yield if applied by using risk large family size, crowding, early weaning, poor nutrition with
approach in MCH. infection of infant and neglect of early Diarrhoea for a variety
Definitions of reasons. Thus it is more than clear that family poverty is a
risk factor for gastroenteritis and death from gastroenteritis.
Risk : It implies that the probability of adverse consequences
The advantage of risk approach is the attention being given to
is increased by the presence of one or more characteristics
all causes regardless of their medical, intersectoral, economic,
or factors. It is a measure of statistical chance of a future
political or social origins.
occurrence.
Relative Risk : It measures the strength of the association Methodology in Risk Approach
between risk factor and the outcome e.g. RR of an outcome due The risk approach involves, first, decisions as to priority
to a risk factor is 1.3, means a 30% excess risk in those with ‘targets’ or unwanted outcomes, measurement of association
the risk factor. between risk factors and the outcome, and then intervention
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6. planned. The risk approach has to be studied by research and To give an example, if it was the Perinatal and maternal
then only applied over a wide population. mortality (Outcome) then the identification of risk factors
Outcome, Risk and Measurement : The risk approach seeks will involve screening at various levels for different risk
to use information about risk to prevent a variety of adverse factors depending upon the complexity of identification and
outcome (illness, injury and death) through the application of infrastructure available and training of the health worker.
a strategy at many levels of care. These decisions to refer or to keep are based on some form of
Outcomes : This is the first information required. Collect risk scoring system. For example, while doing above exercise,
details of morbidity and mortality rates which are our targets suppose there is a risk scoring from 0 - 5, the scheme would
or priorities (prevalence and incidence, trends, distribution in look like (See Table - 1).
geographical area and different groups).
Table - 1 : Risk Scoring System
Risk Factors : Collect information on the following :
(a) Risk factors for each unwanted outcome. Health Func - Exam Keeps Refers Returns
(b) Risk factors or combinations of risk factors for each group level tionary - ines
of unwanted outcome. I TBA 0, 1, 2, 0 1, 2, 3, -
(c) For all risk factors - 3, 4, 5 4, 5
(i) Prevalence and incidence and trends in the
II ANM 1, 2, 3, 2 3, 4, 5 1
population
4, 5
(ii) Relative risk of unwanted outcomes associated with
each risk factors or combinations III Senior 3, 4, 5 3 4, 5 2
(iii) Attributable risk associated with each risk factors Nurse
(iv) Predictive power of each risk factor IV Doctor 4, 5 4 5 3
(v) The ease, accuracy and acceptability of screening for the
V Specialist 5 5 - 4
presence of risk factor in communities and individuals.
Priorities among Outcomes : This will depend upon many Issue of False Positives and False Negatives
variables like -
When screening populations, some of the difficulties faced
(a) Community priority and preference
are related to the issues of false positive and false negatives.
(b) Prevalence or frequency of occurrence
The value of risk factors at predicting outcomes is gauged by
(c) The seriousness of the problem (fatality rate)
proportion of the true association. There are examples where
(d) Degree of preventability
the cases of gastroenteritis deaths may be seen in breastfed
(e) Rising frequency or upward trend of the problem (emerging
infants (though less likely) while some of the bottle fed infants
issues)
may not suffer from gastroenteritis (less likely). The issue of
Steps
false positives and false negatives may make decisions for
1. Identifying the risk factors and the populations and the interpreting and introducing screening tests difficult.
individuals at risk
2. Selection of risk factors Risk Scoring
(i) Optimum grouping Scores must accurately reflect the risk to the mother and
(ii) Usefulness in terms of proposed intervention children which in itself is a proxy for the need for care. Scoring
(iii) Strength of association / cause - effect relationship attempts to provide simple, easy to use index of the urgency,
(iv) Ease of modification (intervention) seriousness and complexity, of the future threat to health. The
(v) Ease and accuracy of identification (test) risk scores are a good managerial tool. Sources of scores are -
3. Who should do the screening? (Fig - 1) (a) Ad hoc - e.g. tall or short, poor or not poor, well fed or
malnourished
Fig. - 1 (b) Points or score based on experience - For example, while
TBA approaches all scoring for poor outcome of pregnancy, 3 points for poor
pregnant mothers obstetric history, 3 for high parity, 2 for maternal age, 1 for
birth interval, family income, poor education etc.
TBA examines (c) Absolute risk
(d) Relative risk
ANM examines (e) Attributable risk
Most scoring systems use the relative risk.
Senior Nurse/ Doctor
examines Trade off : While deciding the cut off for continuous risk factor
there is a compromise between yield and resources by trade
Hospital doctor
off between false positive and false negatives. This decision
examines
is arrived at by weighing how many more false positive can
Specialist sees only be afforded by the community for the desired reduction in the
very high risk mothers
false negatives.
Referred Kept Returned
• 812 •

7. Basic information needed for planning the use of Risk negligent or dangerous work pattern and numerous intercurrent
Approach illnesses. Some can be modified without delay, some will have
1. Age and sex distribution and geographical distribution by to wait till next pregnancy while yet others will only be changed
community and household in the next generation. Modification of the community risk
2. Mortality by age, sex and cause factors is probably the most important potential achievement
3. Local cultural factors, occupations, religion and attitude to of the risk approach.
health and disease Selecting Target Health Problems : Among many health
4. Services likely to have most impact from risk approach problems of mothers and children, it is usually a simple matter
5. Information on environmental risk factors to choose the most important. This choice is often coloured
6. Local community organizations, groups by opinions. Most important health problems are not always
7. Local health care services including personnel and the best targets for prevention. A method of rating scale which
infrastructure balances the factors like prevalence, seriousness, preventability,
8. Present way to deal with the MCH problems trends in time and local concern (Table - 2) is shown as an
9. Information about traditional systems of medicine and example.
their acceptance
Intervention at different levels of care : This is used to define Table - 2 : Selecting a health problem by Rating / Scoring
the main point of impact of an intervention within the health
Health Rating
care system. Risk approach can be applied at all levels from self Criterion Max rating
Problem accorded
and home to intersectoral policy.
Uses of the Risk Approach Extent 10 3
1. Self & Family Seriousness 10 10
(a) Improved ability to recognize health priorities and health Maternal
Preventability 10 8
lifestyle and behavior. mortality
(b) Informed surveillance of self and family. Local concern 10 10
(c) Earlier self and family referral. Time trend 10 2
2. Local community - village groups, self help groups, Extent 10 8
women’s group.
3. Application within the health care system - resource Seriousness 10 10
Neonatal
allocation. Preventability 10 10
tetanus
4. Increasing coverage - e.g. Universal immunization, Local concern 10 4
essential maternal and newborn care.
5. Improved referral - better facilities, technology and skills. Time trend 10 5
6. Regional and National level - for defining and planning Extent 10 3
priorities, capacity and staffing, design referral chain, Seriousness 10 10
resource allocation and evaluation. Childhood
7. Intersectoral collaboration is the key to planning, designing Preventability 10 5
RTAs
and executing any health intervention. Local concern 10 7
Selecting Interventions : Steps involved are - Time trend 10 8
(a) Potential for change in health care - managerial, avoid
authoritarian approach, no conflict with local, regional The relative importance of each criterion is also given its
and national interest, local values and religious customs weight e.g. say on a five point scale, if we rate, extent and
(MTP Contraception).
, seriousness are given 5/5, preventability and local concern is
(b) Criteria for selection - importance, feasibility, given 3/5, time trend is given 2 out of 5. A simple matrix will
acceptability. set the health problems in the order of priority as seen in the
(c) Local priorities for action - Maternal mortality, Infant Table - 3.
deaths, Perinatal mortality. Local priorities to be specific The order of priority in the above example is: first neonatal
and well defined for application of risk approach. tetanus, second maternal mortality and third childhood RTAs.
(d) Local resources - people (trained and trainable), institutions,
facilities and technology, managerial skills, health Lessons from the Risk Approach -
information systems, funds. Most important resources are 1. Application to the whole field of Primary Health care is
time, commitment, enthusiasm and cooperation. limited due to shortage of support from evaluative research.
(e) National priorities Need to develop health system research.
(f) Decision pathway 2. Impediments and Barriers are related to Ethical (No
Modifying Risk Factors : Individual risk factors capable of research without service), Sociological (not in sync with
modification are exemplified by some taboos and cultural local culture), Problems of human motivation, Political,
practices (difficult to change), malnutrition, dwarfing, managerial and technical problems and Shortage of skilled
inadequate family planning services, lack of concern for human resources.
environmental hazards, unsatisfactory personal hygiene, The risk approach in MCH is a very useful tool and can help
• 813 •

8. in maximizing the output from the limited resources available of the risk approach. The preventive and promotive elements
especially in the developing countries. The risk approach helps of primary health care will have greatest yield if applied by
to ease the pressure on the limited beds and facilities at the using risk approach in MCH. Risk factors could be related to
hospital level and also saving the expert human resources and the individual, family, community and environment and their
sophisticated equipment for those who need it most. The risk significance can be judged by their frequency and the degree
approach also helps in developing health auxiliaries at the of their association with the outcome. The risk approach
periphery providing the basic care in MCH close to home to the involves prioritizing targets, measuring associations and the
clientele within acceptable socio - cultural milieu. The policies interventions to be applied. Info about the risk factors can be
and principles of care under NRHM using ASHA are an example obtained through prevalence, incidence, trends, relative risk of
of this approach. unwanted outcomes and attributable risk associated with each
risk factors and predictive power of risk factors. Prioritization
Table - 3 : Selecting a problem by rating/scoring will depend upon community priority, prevalence, fatality rates,
degree of preventability and rising trend. Risk scoring (most
Criteria and Relative weightage
of them use relative risk) if used must reflect the risk to the
mother and the child.
Health problem
Preventability
Local concern
Increased coverage, improved referral, risk factor modification,
Seriousness
Total score
Time trend
local, national and regional reorganization and training are the
(weight 5)
(weight 5)
(weight 3)
(weight 3)
(weight 2)
some of the uses of risk approach. The risk approach in MCH
Extent
is a very useful tool maximizing the output with the limited
number of tools available in addition to developing the health
auxiliaries at the periphery.
Maternal
3x5 10x5 8x3 10x3 2x2 123
mortality Study Exercises
Neonatal Long Question : Risk approach in MCH
8x5 10x5 10x3 4x3 5x2 142
tetanus Short Notes : (1) Basic information needed for planning the
Childhood use of risk approach (2) Risk scoring (3) Uses of risk approach
3x5 10x5 5x3 7x3 8x2 117
RTAs within and outside the health care system (4) Steps for selecting
interventions.
Summary References
The risk strategy utilizes the risk estimates as guide for action, 1. Backett E M, Davies A M, Petros - Barvazian A. Public Health Papers No 76:
The Risk approach in health care, with special reference to maternal and
resource allocation, coverage, referral and care. Therefore child health, including family planning, WHO Geneva, 1984
the more accurately the risk is measured the better is the 2. Edwards L E et al. A simplified antepartum risk scoring system. Obstetrics
understanding of the need for efficient utilization of scarce and Gynaecology, 54:237 - 240 (1979)
resources with more care for those in need and proportionate 3. Sogbanmu M. Perinatal mortality and maternal mortality in General hospital,
Ondo, Nigeria: Use of high risk pregnancy predictive scoring index. Nigerian
to the need. Risk, predictions and possible effects are the tools Medical Journal, 9: 123 - 127 (1979)
Definitions
142 Maternal Health Care Maternal Death : Maternal death is defined as death of a
woman, while pregnant or within 42 days of termination of
AS Kushwaha pregnancy, irrespective of the duration and site of pregnancy,
from any cause related to or aggravated by pregnancy or its
All mothers and newborns, not just those considered to be management but not from accidental or incidental causes.
at particular risk of developing complications, need skilled (ICD-10)
maternal and neonatal care. Maternal health care includes Direct Obstetric Deaths : The deaths resulting from obstetric
Antenatal, Intranatal care and Postnatal care, Quality intranatal complications of the pregnant state (pregnancy, labour and
care is critical to achieve the aim of a healthy mother and a the puerperium), from interventions, omissions, or incorrect
healthy baby at the end of a pregnancy. This particular period treatment, or from a chain of events resulting from any of the
(perinatal) though constitutes, only a small fraction in terms above are called direct obstetric deaths.
of its share (0.5 %) in the maternity cycle, but is probably, the Indirect Obstetric Deaths : Those resulting from previous
most crucial. existing disease or disease that developed during pregnancy and
• 814 •

9. that was not due to direct obstetric causes but was aggravated to have a healthy mother and a healthy child at the end of
by the physiological effects of pregnancy. pregnancy. Antenatal care includes visit to antenatal clinic,
Late Maternal Death : Late maternal death is death of a examination, investigations, immunization, supplements
woman from direct or indirect obstetric causes, more than 42 (Iron, Folic acid, Calcium, Nutritional) and interventions as
days but less than one year, after termination of pregnancy. required. This is a comprehensive approach to medical care and
psychosocial support of the family that ideally begins prior to
Pregnancy Related Death : To facilitate the identification
conception and ends with the onset of labour. Preconception care
of maternal death in circumstances in which cause of death
refers to physical and mental preparation of both parents for
attribution is inadequate, ICD-10 introduced a new category,
pregnancy and childbearing in order to improve the pregnancy
that of “pregnancy-related death” which is defined as : the death
outcome (Refer Box - 1). Antenatal (Prenatal) care formally
of a woman while pregnant or within 42 days of termination of
begins with the diagnosis of pregnancy and includes ongoing
pregnancy, irrespective of the cause of death.
assessment of risk, education and counselling and identifying
Skilled Birth Attendant : Skilled Birth Attendants are people and managing problems if they arise (Box - 2).
with midwifery skills (e.g. doctors, midwives, nurses) who have
been trained to proficiency in the skills necessary to manage a Box - 1 : Indications for Preconception Care
normal delivery and diagnose and refer obstetric complications.
This includes capacity to initiate the management of Advanced maternal (>35 years) or paternal (>55 years)age
complications and obstetric emergencies, including life-saving History of neural tube defects in family or previous
measures where needed. Ideally skilled attendants live in, and pregnancy
are part of the community they serve. Congenital heart disease, hemophilia, thalassemia, sickle
Measurement of Maternal Mortality cell disease, Tay-sach’s disease, cystic fibrosis, Huntington
There are three main measures of maternal mortality- the chorea, muscular dystrophy, Down’s syndrome.
maternal mortality ratio, the maternal mortality rate and the Maternal metabolic disorders
lifetime risk of maternal death.
Recurrent pregnancy loss (>3)
Maternal Mortality Ratio : This represents the risk associated
Use of alcohol, recreational drugs or medications
with each pregnancy, i.e. the obstetric risk. It is calculated as
the number of maternal deaths during a given year per 100,000 Environmental or occupational exposures
live births during the same period. This is usually referred to as
rate though it is a ratio. Box - 2 : Objectives of Antenatal Care
The appropriate denominator for the Maternal Mortality Ratio
To promote, protect and maintain health of the mother
would be the total number of pregnancies (live births, foetal
deaths or stillbirths, induced and spontaneous abortions, To detect ‘at risk’ cases and provide necessary care
ectopic and molar pregnancies). However, this figure is To provide advise on self care during pregnancy
seldom available and thus number of live births is used as the
To educate women on warning signals, child care, family
denominator. In countries where maternal mortality is high
planning
denominator used is per 1000 live births but as this indicator
is reduced with better services, the denominator used is per To prepare the woman for labour and lactation
1,00,000 live births to avoid figure in decimals. To allay anxiety associated with pregnancy and childbirth
Maternal Mortality Rate: It measures both the obstetric risk To provide early diagnosis and treatment of any medical
and the frequency with which women are exposed to this risk. condition/ complication of pregnancy
It is calculated as the number of maternal deaths in a given
period per 100,000 women of reproductive age (usually 15- To plan for “Birth” and emergencies / complications (where,
49 years). From the year 2000, the SRS (Sample Registration how, by whom, transport, blood)
System) has introduced this method of verbal autopsy called To provide care to any child accompanying the mother
RHIME (Representative, Re-sampled, Routine Household
Interview of Mortality with Medical Evaluation). Frequency : Under optimal conditions a women should
Lifetime Risk of Maternal Death undergo regular antenatal health check once a month during
first seven months, twice a month for 8th month and every
This parameter takes into account both the probability of
week thereafter till delivery. However, a minimum of four visits
becoming pregnant and the probability of dying as a result of
are essential.
the pregnancy cumulated across a woman’s reproductive years.
Lifetime risk can be estimated by multiplying the maternal Essential Antenatal Care : Under CSSM program three antenatal
mortality rate by the length of the reproductive period (around visits have been recommended as minimum acceptable level
35 years). This is also approximated by the product of the Total of antenatal care. Early registration by 12-16 weeks followed
Fertility Rate and the Maternal Mortality Ratio. by visits at 20, 32 and 36 weeks is recommended during any
pregnancy. At least one home visit by health worker must be
Antenatal Care made. Essential Antenatal Care also includes immunization
The care of women during pregnancy is called antenatal care. with tetanus toxoid and Iron Folic Acid supplements for 100
This begins soon after conception. The ultimate objective is days. Deworming with mebendazole in areas endemic for hook
• 815 •

10. worm may be provided during 2nd/3rd trimester. Under RCH a appear -
minimum of three visits are to be made. (a) Bleeding PV at any point ( Antepartum haemorrhage)
History Taking and Examination : During history taking (b) Excessive vomiting ( Hyperemesis gravidarum)
important points to be covered are detailed medical, (c) Hypertension, proteinuria
psychosocial and immunization history followed by careful (d) Severe anaemia
physical examination and certain relevant laboratory tests. (e) Abnormal weight gain
Physical examination should include measurement of height, (f) Multiple pregnancy, hydramnios, oligohydramnios
weight, pelvimetry (not very important). Important laboratory (g) Abnormal presentation in 9th month
tests include hemoglobin, urinalysis, PAP smear, VDRL and any (h) Preterm Labour, PROM
other test as warranted by the concerned physician. There is (i) Pre-eclampsia, eclampsia
an opportunity for health promotion like cessation of tobacco, Health Education
alcohol, manage pre-existing medical disorders, appropriate This is one of the most important and often neglected functions
immunization and pregnancy planning. of antenatal care. This is also called prenatal advice. The
First Visit : The patient is registered and antenatal card is communication between the mother and the service provider
initiated. First visit should be made at the earliest possible should be free and encompass the issues concerning not only
after pregnancy is suspected, ideally at 8 weeks of gestation but pregnancy but should spillover to childbirth and childcare.
not later than 12-16 weeks. This is important for determining The family planning issues like spacing and sterilization are
accurate EDD, evaluation of risk and to provide essential better received at this time. Important issues that need to be
patient education. The functions of this visit are- deliberated are given below.
(a) Confirmation of pregnancy (a) Diet & Rest
(b) Screening for high risk pregnancy (b) Personal Hygiene and Habits
(c) Baseline investigations (c) Sexual intercourse
(d) Initiation of Iron and Folic Acid supplementation (d) Drugs
(e) Immunization with Tetanus toxoid (if visit in 2nd (e) Exercise
trimester) (f) Travel
(f) Education of the mother on pregnancy and childbirth (g ) Care of Breasts
Identification of “High Risk” Pregnancies (h) Weight Gain
Warning signs : Besides education on common symptoms
The identification of high risk pregnancies involves meticulous
and their management, the woman should be educated on
history taking, careful examination and relevant investigations.
warning signs during pregnancy which should not be ignored.
The identification of these high risk pregnancies should follow
She should report to health facility in case she has any of the
needful referral and care. History should cover all aspects as
warning signs. The warning signs are-
outlined for preconception care. The ‘at risk’ pregnancies can
be identified as under- (i) Swelling of feet
(ii) Convulsions/ unconsciousness
Maternal Factors
(iii) Severe headache
(i) Age- <18 years or > 35 years (especially in primigravida) (iv) Blurring of vision
(ii) Multiparity (> 4) (v) Bleeding or discharge per vaginum
(iii) Short stature ( < 140 cms ) (vi) Severe abdominal pain
(iv) Weight < 40 Kg / weight gain < 5 Kg (vii) Other unusual symptom
(v) Rh negative
Pregnancy & HIV Infection
Bad Obstetric History
(i) Recurrent abortions ( 2 x1st trimester or 1 mid-trimester) This situation is likely to be encountered in states where HIV
(ii) Intrauterine death or intrapartum death/ stillbirth prevalence amongst antenatal cases is high. This will require
(iii) Prolonged labour, birth asphyxia , early neonatal death special handling. The urgency of preventing mother-to-child
(iv) Previous caesarean section / scar dehiscence transmission (PMTCT) of HIV is clear. Without treatment, half
(v) Postpartum haemorrhage, manual removal of placenta of the infants born with the virus will die before age two.
(vi) Baby which is LBW, SFD or large for date, congenitally Significant reductions in mother-to-child transmission, however,
malformed can occur through implementation of basic but critical actions,
(vii) Malpresentation, instrumental delivery, ectopic pregnancy such as identifying HIV-infected pregnant women by offering
(viii) Twins, hydramnios, pre-eclampsia routine HIV testing, enrolling them in PMTCT programmes,
Medical Disorders ensuring that health systems are fully able to deliver effective
antiretroviral regimens both for prophylaxis and for treatment,
(i) Cardiac (RHD, CHD, Valve defects), Renal, Endocrine
and supporting women in adhering to optimal and safe
(Thyroid) or Gastrointestinal disease.
infant feeding. The counselling of women early in pregnancy
(ii) Infections - TB, Leprosy, Malaria etc.
on risk of transmission to the baby and testing of spouse is
(iii) Hypertension, Diabetes, IHD and Seizures
mandatory. AZT 300 mg every 12 hours is given from 36 weeks
(iv) Anaemia
of pregnancy till onset of labour and thereafter 300mg every 3
Besides the above, the pregnancy at any stage can be classified hours. Alternatively, Nevirapine 200 mg single dose as early
as high risk if any of the following conditions/ complications
• 816 •

11. as possible in labour and 50 mg in oral solution form to the for vehicle, money and blood can be difficult to make if not
newborn within 72 hours is recommended to prevent mother already planned and can be crucial for the life of both mother
to child transmission. After delivery, this also helps to make and child. Institutional delivery should be encouraged.
required adaptations in infant feeding. Replacement feeding Institutional delivery should be advocated as it is the right of
using principles of AFASS (acceptable, feasible, affordable, safe every pregnant woman.
and sustainable) is a viable solution to prevent transmission of
infection through breast feeding. Intranatal Care and Postnatal Care
Planning for Birth (Birth Plan) Objectives of Intranatal Care - (AMC-N)
1. Thorough Asepsis (“The Five Cleans” - clean hands,
This is an important function of the prenatal care. The planning
surface, blade, cord, tie)
for birth and emergencies is very important as it can take care
2. Minimum injury to mother and child
of many unforeseen complications which may endanger life of
3. To deal with any Complications during labour
both mother and the child and may arise at any point of time
4. Care of the Newborn
without any prior warning in an otherwise normal pregnancy.
Plans made early for emergencies during pregnancy and labour The Postpartum Care
will result in favourable outcomes. The birth plan helps to The Postpartum Care is aimed at achieving a Puerperium which
tide over the uncertain and sudden nature of complications of is free of any complications and to ensure a healthy newborn.
labour. The delivery will take place at hospital or home must be (Box - 4)
decided (See Box - 3).
Box - 4 : Objectives of Postpartum care
Box - 3 : Institutional delivery is a must if there is- 1. Restoration of mother to optimum health
Mild pre-eclampsia 2. To prevent complications of puerperium
PPH in the previous pregnancy 3. Provide basic postpartum care & services to mother and
More than 5 previous births or a primi child
Previous assisted delivery 4. Motivate, educate and provide family planning services
Maternal age less than 16 years 5. To check adequacy of breast feeding
H/o third-degree tear in the previous pregnancy
The Postpartum Visits : The first 48 hours following delivery
Severe anaemia are the most important. The next most critical period is the first
Severe pre-eclampsia/eclampsia week following delivery. The mother is asked to pay another
visit on day 3rd and day 7th, or the ANM in charge of that
APH
area should pay a home visit during this period. The second
Transverse foetal lie or any other Malpresentation postpartum visit should be planned within 7-10 days after
Caesarean section in the previous pregnancy delivery. A visit at 6 weeks is mandatory to see that involution
of uterus is complete. Further visits can be once a month
Multiple pregnancies
for 6 month and thereafter every 2-3 months till the end of
Premature or pre-labour rupture of membranes (PROM) one year. Efforts to organize 3 - 6 visits must be made. If the
Medical illnesses such as diabetes mellitus, heart disease, woman misses her postpartum visits, she should be informed
asthma, etc. regarding the danger signs which if appear she should report
back (Box - 5).
In case of delivery at home what arrangements are there to Complications of the Puerperium : The postpartum period
overcome any unanticipated complication? The arrangement is often neglected after having a successful parturition. Sadly,
Box - 5 : Danger Signs in Puerperium
Advise the woman and her family to go to an FRU Advise the woman that she should visit
immediately, day or night, WITHOUT WAITING the PHC as soon as possible, if . . .
(i) Excessive vaginal bleeding, i.e. soaking more than 2 (i) Fever
or 3 pads in 20-30 minutes after delivery, or bleeding (ii) Abdominal pain
increases rather than decreases after the delivery
(iii) The woman feels ill
(ii) Convulsions (iv) Swollen, red or tender breasts, or sore nipples
(iii) Fast or difficult breathing (v) Dribbling of urine or painful micturition
(iv) Fever and weakness; inability to get out of bed (vi) Pain in the perineum or pus draining from the perineal
area
(v) Severe abdominal pain (vii) Foul-smelling lochia
• 817 •

12. neglected postnatal period can be the cause of significant Breakdowns of access to skilled care due to war, strife and HIV
mortality in mother and the newborn. The infections and may rapidly result in an increase of unfavourable outcomes,
haemorrhage are two serious dangers of Puerperium. Besides as in Malawi or Iraq. Malawi is one country that experienced a
these UTIs, thrombophlebitis and psychiatric disorders are also significant reversal in maternal mortality: from 752 maternal
seen (Box - 6). deaths per 100,000 live births in 1992 to 1120 in 2000 due
to rise in HIV prevalence. Fewer mothers gave birth in health
Box - 6 : Common Complications of the Puerperium facilities: the proportion dropped from 55% to 43% between
2000 and 2001. The quality of care within health facilities
1. Puerperal sepsis
deteriorated in Iraq as sanctions during the 1990s severely
2. Urinary tract infections disrupted previously well-functioning health care services, and
3. Breast infections maternal mortality ratios increased from 50 per 100,000 in
1989 to 117 per 100,000 in 1997 (12).
4. Venous thrombosis
Scenario in India
5. Pulmonary thromboembolism
Every seven minutes an Indian woman dies from complications
6. Puerperal haemorrhage related to pregnancy and childbirth. The maternal mortality
7. Incontinence of urine ratio in India stands at 300 per 100,000 live births. It has
8. Psychiatric disorders some high performing states like Kerala with MMR of 110 and
poorly doing states like Uttar Pradesh with MMR of 517 (13).
Maternal Mortality The highlight is that most of the states recording unfavourable
maternal mortality rates are the ones with the highest number
Global Burden of birth rates and huge population bases with poor health
Maternal mortality is currently estimated at 5,29,000 deaths infrastructure. There are a number of reasons India has such
per year, a global ratio of 400 maternal deaths per 100,000 a high maternal mortality ratio. Marriage and childbirth at an
live births (1). There are immense variations in maternal early age, lack of adequate health care facilities, inadequate
death rates in different parts of the world (See Table - 1). Only nutrition and absence of skilled personnel, all contribute to
a small fraction (1%) of these deaths occurs in the developed pregnancies proving fatal. The common causes of maternal
world. Maternal mortality ratios range from as high as 830 per mortality in India are anaemia, haemorrhage, sepsis, obstructed
100,000 births in some African countries to as low as 24 per labour, abortion and toxaemia. Maternal morbidities are the
100,000 births in European countries. Of the 20 countries with anaemias, chronic malnutrition, pelvic inflammations, liver
the highest maternal mortality ratios, 19 are in sub-Saharan and kidney diseases. In addition, the pathological processes
Africa. In sub-Saharan Africa, the lifetime risk of maternal of some preexisting diseases, such as chronic heart diseases,
death is 1 in 16, (See Table 1) compared with 1 in 2800 in hypertension, kidney diseases and pulmonary tuberculosis are
rich countries (2). Rural populations suffer higher mortality aggravated by pregnancy and childbirth.
than urban dwellers, rates can vary widely by ethnicity or by
‘Delay’ Model Leading to Maternal Death
socio-economic status, and remote areas bear a heavy burden
of deaths. Such deaths often occur suddenly and unpredictably. The maternal deaths can be explained by this model of delay
Between 11% and 17% of maternal deaths happen during which is due to:
childbirth itself and between 50% and 71% in the postpartum (a) Delay in seeking care
period (3-7). The fact that a high level of risk is concentrated (b) Delay in transport to appropriate health facility
during childbirth itself, and that many postpartum deaths are (c) Delay in provision of adequate care
also a result of what happened during birth, focuses attention Causes of Maternal Mortality
on the hours and sometimes days that are spent in labour and Maternal deaths result from a wide range of indirect and direct
giving birth. The postpartum period - despite its heavy toll of causes (See Fig. 1 & 2). Maternal deaths due to indirect causes
deaths - is often neglected. Within this period, the first week represent 20% of the global total. They are caused by diseases
is the most prone to risk. About 45% of postpartum maternal (pre-existing or concurrent) that are not complications of
deaths occur during the first 24 hours, and more than two pregnancy, but complicate pregnancy or are aggravated by it.
thirds during the first week (3). These include malaria, anaemia, HIV/AIDS and cardiovascular
disease. Their role in maternal mortality varies from country
Table - 1 : Life Time Risk of a Woman to country, according to the epidemiological context and the
health system’s effectiveness in responding.
Losing a Of dying due to
Continents The lion’s share of maternal deaths is attributable to direct
Neonate Maternal cause
causes. Direct maternal deaths follow complications of
Africa 1 in 5 1 in 16 pregnancy & childbirth or are caused by any interventions,
Asia 1 in 11 1 in 132 omissions, incorrect treatment or events that result from these
complications, including complications from unsafe abortion.
Latin America 1 in 21 1 in 188
The four major direct causes of maternal loss are-
Developed countries 1 in 125 1 in 2976 (a) Haemorrhage
• 818 •

13. (b) Infection (sepsis) needing hospital care depends, to some extent, on the quality
(c) Eclampsia of the first-level care provided to women; for example, active
(d) Obstructed Labour management of the third stage of labour reduces postpartum
bleeding. The proportion that dies depends on whether
Fig. - 1 : World - Causes of Maternal Mortality appropriate care is provided rapidly and with the degree of skill
with which it is provided.
Infection : The second most frequent direct cause of death
is sepsis, responsible for most late postpartum deaths. This
Indirect causes is often a consequence of poor hygiene during delivery. The
20% introduction of aseptic (clean delivery) techniques brought a
Severe bleeding
(Haemorrhage) spectacular reduction of its importance in the developed world.
25% However, sepsis is still a significant threat in many developing
countries.
Other Direct causes
8% Eclampsia : Classic complications of pregnancy include pre-
eclampsia and eclampsia which affect 2.8% of pregnancies in
Infections developing countries and 0.4% in developed countries leading
Unsafe abortion 15% to many life-threatening cases and over 63 000 maternal deaths
13%
worldwide every year accounting for 12 % of the maternal
Obstructed Eclampsia
deaths (17).
Labour 12% Obstructed Labour : The prolonged or obstructed labour
20% accounts for about 8% of maternal deaths. This is often caused
by fetoopelvic disproportion or by malpresentation (transverse
lie, mentoposterior, brow presentation). Disproportion is more
Note : Total is more than 100% due to rounding off
common where malnutrition is endemic, especially among
populations with various traditions and taboos regarding the
Fig. - 2 : India - Causes of Maternal Mortality diets of girls and women. It is worse where girls marry young
and are expected to prove their fertility, often before they are
fully grown.
Others Abortions : More than 18 million induced abortions each
14% year are performed by people lacking the necessary skills or
Anaemia in an environment lacking the minimal medical standards,
24%
Malposition or both, and are therefore unsafe resulting in 68000 deaths
7% (18, 19). Almost all take place in the developing world. With
34 unsafe abortions per 1000 women, South America has the
Puerperal highest ratio (19). Unsafe abortion is particularly an issue
10% for younger women. Around 2.5 million, or almost 14% of all
unsafe abortions in developing countries, are among women
Haemorrhage under 20 years of age. The proportion of women aged 15-19
23% Toxemia years in Africa who have had an unsafe abortion is higher than
10%
in any other region.
Abortion Others : Haemorrhage following placental abruption or
12%
placenta praevia affects about 4% of pregnant women. Less
common, but very serious complications include ectopic
Source : Registrar General India.Causes of Maternal Mortality in Rural India pregnancy and molar pregnancy. Maternal malnutrition is a
huge global problem, both as protein-calorie deficiency and
Haemorrhage : The most common cause of maternal death as micronutrient deficiency. Anaemia is an important indirect
is severe bleeding, a major cause of death in both developing cause of maternal death due to cardiovascular deaths but also
and developed countries (14,15). Postpartum bleeding can kill is an important underlying factor in many direct causes like
even a healthy woman within two hours, if unattended. It is haemorrhage and sepsis.
the quickest of maternal killers. An injection of oxytocin or Factors underlying the medical causes
ergometrine given immediately after childbirth is very effective
Socio-Economic : The factors underlying the direct causes
in reducing the risk of bleeding. In some cases a fairly simple
of maternal deaths operate at several levels. The low social
- but urgent - intervention such as massage of the uterus,
and economic status of girls and women is a fundamental
removal of clot or manual removal of the placenta may solve
determinant of maternal mortality in many developing countries
the problem. Other women may need a surgical intervention
including India. Low status limits the access of girls and women
or a blood transfusion, both of which require hospitalization
to education and good nutrition as well as to the economic
with appropriate staff, equipment and supplies. The proportion
resources to pay for health care or family planning services.
• 819 •

14. Lack of decision making power in terms of family planning also what mothers and their families ask for. Putting it into
puts them to repeated childbearing. Excessive physical work practice is a challenge that many countries have not yet been
coupled with poor diet leads to poor maternal outcomes. Many able to meet.
deliveries in rural areas are either conducted by relatives or Training of Traditional Birth Attendant - A Failed
traditional birth attendant or at times none. In India three out Experiment! : In the 1970s, training of traditional birth
of every five births take place at home; only two in five births attendants (TBAs) to improve obstetric services became
take place in a health facility. However, the percentage of births widespread in settings where there was a lack of professional
in a health facility has increased steadily. health personnel to provide maternity care, and where there
Nutritional : Poor nutrition before and during pregnancy were not enough beds or staff at hospital level to give all
contributes in a variety of ways to poor maternal health, obstetric women access to hospital for their confinement. TBAs already
problems and poor pregnancy outcomes. Stunting predisposes existed and performed deliveries (for the most part in rural
to cephalopelvic disproportion and obstructed labour. Anaemia areas), they were accessible and culturally acceptable and they
may predispose to infection during pregnancy and childbirth, influenced women’s decisions on using health services. While
obstetric haemorrhage and are poor operative risks in the event WHO continued to encourage this strategy until the mid-1980s
if surgery is required. Severe vitamin A deficiency make women but evidence emerged that training TBAs has had little impact
more vulnerable to obstetric complications. Iodine deficiency on maternal mortality.
increases the risk of stillbirths and spontaneous abortions. Actions for Safe Motherhood : Countries vary widely in terms
Lack of dietary calcium appears to increase the risk of pre- of the situations and challenges they face and their capacity
eclampsia and eclampsia during pregnancy. to address these. However, it is seen that to reduce maternal
Impact of Maternal Deaths (India) mortality requires coordinated, long term efforts. Actions are
needed within families and communities, in society as a whole,
Maternal death has implications for the whole family and an
in health systems, and at the level of national legislation and
impact that rebounds across generations. The complications
policy.
that cause the deaths and disabilities of mothers also damage
the infants they are carrying. The impact is summarized as Legislative & Policy actions : Long term political commitment
under- is an essential prerequisite. This leads to adequate resource
(a) Children who lost their mothers are more likely to die allocation and policy decisions are taken. A supportive social,
within two years of maternal death. economic and legislative environment allows women to access
(b) 10 times the chance of death for the neonate. the healthcare. (transport, money, social barriers limit the
(c) 7 times the chance of death for infants older than one access)
month. (a) Family planning : To avoid pregnancies that are too early,
(d) 3 times the chance of death for children 1 to 5 years. too late or too frequent.
(e) Enrolment in school for younger children is delayed and (b) Adolescents : To encourage late marriage and childbearing
older children often leave school to support their family. by increasing educational opportunities. To improve their
Significant reduction in infant mortality can be achieved by nutritional status by supplementary nutrition (e.g. ICDS-
improving the access to care during labour, birth and the critical Kishori Shakti Yojna). Education of adolescents on reproductive
hours immediately afterwards. health and empowerment of women to control fertility and
Measures to Reduce Maternal Mortality reproduction.
What is known about Reducing Maternal Mortality? (c) Barriers to access : Provision of skilled health worker at
village level health facility to overcome problems of distance and
The countries that have successfully managed to make
transport. These workers to be adequately trained in midwifery
motherhood safer have three things in common.
and paid adequately and to be provided with adequate supplies
(a) First, policy-makers and managers were informed: they
and at minimal cost.
were aware that they had a problem, knew that it could be
tackled, and decided to act upon that information. (d) Develop protocols : Aimed at providing both routine
(b) Second, they chose a common-sense strategy that proved maternal care and referral facilities for obstetric complications.
to be the right one: not just antenatal care, but also (e.g. IMNCI, 2005-Guidelines on pregnancy by MCH Division of
professional care at and after childbirth for all mothers, by Ministry of Health & Family Welfare)
skilled midwives, nurse-midwives or doctors, backed up by (e) Decentralization and delegation : Decentralized facilities
hospital care. available close to people’s homes together with written policies
(c) Third, they made sure that access to these services - and protocols to allow delegation of certain functions at lower
financial and geographical - would be guaranteed for the levels.
entire population. (f) Abortion : Availability of safe abortion services and policy
Where strategies other than that of professionalization of to discourage illegal and unsafe abortions.
delivery care are chosen or where universal access is not Society and Community Interventions : The long term
achieved, positive results are delayed. This explains why many commitment of politicians, planners and decision makers to
developing countries today still have high levels of maternal programmes on safe motherhood depends on popular support
mortality. To provide skilled care at and after childbirth and from community and religious leaders, women’s groups, youth
to deal with complications is a matter of common sense - it is
• 820 •