Maternal & Child Health (MCH)

Pakistan is one of the countries with a high maternal and infant mortality rates. Women, especially pregnant women suffer even at primary care level due to a lack of properly trained and skill health care worker in the community.To overcome this issue the Mother & Child Health Care Centre, training Institute has been established.

Mother and Child Health

It is a branch of Public Health which is planned for the supervision of health of mother and child not only Physical but also Mental, Social & Emotional Health.

Aims & Objectives

The main aims and objectives of MCH include,

1. Making available the best possible care during pregnancy, labour and puerperium.
2. Providing best possible care to the children while they are growing and are vulnerable.

Reasons for MCH Services

• Mother & children form 2/3 of the population
• Good health of mothers & children is future investment in social development & productivity
• They are vulnerable to diseases
• Combined widespread services enhance the interdependence of mother & child & provide continuity of care
• Prevention & intervention during childhood reduces morbidity & mortality disability & resulting social burden
•  Providing women with the choice of child spacing results in better health of mother & infant.

MCH Services

MCH services are key to achieve an acceptable level of health.

Basic Characteristics of MCH Services

1. Target oriented services – well defined objective.
2. To achieve the target special functions & activities are to be carried out.

Levels of Prevention in MCH

a)     Primary prevention

b)    Secondary prevention

c)     Tertiary prevention

a)   Primary Prevention

Activities designed to promote

• Optimum health.
• To provide protection against specific disease.

b)   Secondary Prevention

• Early & accurate diagnosis.
• Prompt & appropriate treatment of acute illness.
• Limit undesirable sequale & disability.

c)    Tertiary Prevention

• Acknowledge the reality of chronic illness.
• Attempt to limit resulting disability.
• Provide appropriate & well-integrated health care & supportive services.

Goals of MCH Services

• To decrease infant mortality rate (IMR).
• To decrease maternal mortality rate (MMR).
• To decrease Morbidity.
• To decrease crude birth rate (CBR)
• To decrease death rate (CDR).
• To increase CPR.

Aims / Objectives

• Promotion, protection & preservation of Health of Women & children
• Reduction of the risks associated with pregnancy & child birth
• Reduction of perinatal neonatal infant, child & maternal mortalities & morbidities
• Monitoring of growth & development of children
• Prevention of communicable diseases
• Nutritional education
• To educate health workers, mothers & families about child care & it importance

The Aims/Objectives are to be Achieved Through

• Active participation by community
• Keeping in view the local culture & tradition of the community
• Intersectoral coordination
• Use of simple & effective technologies

Components of MCH

Main components of the MCH are following,

1. Maternal Care
2. Child Care
3. Others (Miscellaneous)

1.     Maternal care

• Registration
• Antenatal care
• Natal care
• Postnatal care
• Family planning
• Immunization
• Nutrition Education
• Mother craft
• Referral
• Growth monitoring
• Nutrition Education

Child care

• Immunization
• Treatment of minor Ailments
• Health education
• Environmental Health

Others

• Sanitation
• Training of personals
• Data collection
• Research

Indicators

• Crude birth rate
• Crude death rate
• Maternal mortality ratio
• CPR
• Perinatal & neonatal mortality rate

2.     Child health

1. Infant mortality rate
2. Under five mortality rate

Maternity Cycle

There are following stages in maternal cycle.

1. Fertilization
2. Antenatal Care
3. Intra natal Care
4. Postnatal Care

Antenatal Care

Antenatal care is the care of woman during pregnancy.

Objectives

1.  To promote, protect and maintain the health of mother during pregnancy.
2. To detect “HIGH RISK” cases and give them special care.
3. To foresee complications and prevent them.
4. To remove anxiety and dread associated with delivery
5. To reduce maternal infant mortality and morbidity.
6. To teach the mother elements of child care nutrition, personal hygiene, and environmental sanitation.
7. Referral, in case of any risk factor associated.
8. Recommend hospital birth for high risk pregnancy.
9. To sensitize the mother to the need for FAMILY PLANNING ,including advice to cases seeking medical termination of pregnancy; and
10. To attend to the under -5 accompanying the mother

Antenatal Visits

• First visit as soon as possible
• Second visit after every four weeks till 28 weeks.
• After every two weeks till 36 weeks.
• Once a week till delivery.
• Home visits
• Backbone of MCH services.
• To give health education
• To observe home environment i.e. personal hygiene, sanitation nutrition.
• Routine at first visit.
• Confirm pregnancy.
• Information about base line health status.
• Complete general physical examination
• History of Mother.

History on First Visit

1. Name
2. Age
3. Address
4. Date of last menstrual period (LMP)
5. Calculate EDD
6. Gravidity (no. of pregnancies)
7. Ask about risk factors during pregnancy as
8. H/o spotting, bleeding
9. Burning micturition
10. Foul smelling vaginal discharge
11. Headache, vomiting
12. Previous injuries, especially to pelvis.
13. Any medical problem like hypertension diabetes TB.

Medications Currently Being Taken

• Any other problem associated with pregnancy.
• Immunization.
• History of previous pregnancies.
• Date of last delivery outcome of each pregnancy and mode of delivery.
• Complication during each pregnancy and labor.

Examination

1. General Physical Examination

• Record pulse
• Blood pressure
• Assess anemia by looking at conjunctiva, lips nails
• Examine neck for thyroid
• Examine edema by applying pressure on ankle
• Measure height
• Measure weight

2. P/A  Examination (according  To period of gestation)
3. Assess fundal height

Preventive Services for Mothers

Preventive services for mother includes,

1. Prenatal Services
2. Lab Investigations
3. Subsequent Visits

Prenatal Services

a)     Health  History

b)    Physical Examination

c)     Lab investigations

d)    Complete urine

e)     Stool examination

f)      C/B count, Hb

g)     Serological exam

Lab Investigations

• Blood grouping
• Chest X-ray  if needed
• Rh compatibility
• Pap test if facility exists

On subsequent visits

1. Physical examination

• Weight gain
• Blood pressure

2. Lab Tests

• Urine Examination
• Hb estimation

3. Iron folic acid supplements
4. Immunization against tetanus
5. Instructions on nutrition, family planning, self-care, delivery and parenthood.
6. Home visiting by female health worker or trained Dais.
7. Referral services where necessary

Risk Approaches

• The risk approach is a managerial tool for improved MCH care
• Purpose: better services for all but special care to those who need them the most
• Maximum utilization of all resources  —some human which are conventionally not used at all —as TBAs (Traditional Birth Attendants) community health workers ,women group

Risk Factors

1. Elderly primi less than18yrs (30 YRS)
2. Short stature primi (LESS THAN 140 CM)
3. Weight :underweight ,overweight ,when no weight gain
4. Gravida: multi gravida having 5 or more children
5. malpresentation
6. Ante partum Hemorrhage
7. Pre-eclampsia and eclampsia
8. Anemia
9. Twins hydromnios
10. Previous stillbirth, intra uterine death, manual removal of placenta
11. Prolonged pregnancy 14 days –EDD
12. H/O Previous C-Section or Instrumental Delivery
13. Pregnancy assessment with general diseases renal ,diabetes TB ,liver disease
14. Elderly grand multipara

Any other problem associated with current pregnancy

• H/O spotting, bleeding
• Foul smelling vaginal discharge
• Headache, vomiting, swelling
• Malpresentation, malposition
• Twin pregnancy
• Medication being currently being taken
• h/o convulsions
• B.P Over 140/90 mm Hg and albumin urea

E.O.C. (Essential Obstetric Care)

Eight essential obstetric functions are following,

1. Surgical functions.
2. Anesthetic function.
3. Medical treatment.
4. Blood replacement.
5. Manual removal of placenta.
6. Family planning functions.
7. Management of women at particular risk.
8. Neonatal special care.

Intranatal Care

• Clean safe delivery
• Trained staff & sterilized equipment for normal delivery.
• Intra natal care (during delivery)
• .Three ‘C’ to conduct aseptic delivery.
• ‘C’ Clean place.
• ‘C’ Clean Cut. (Umbilical cord)
• Referral service in case of complication.
• Post natal care (after delivery)
• Monitor new born vital signs.
• Monitor mother after delivery.
• Referral services in case of postpartum complications.
• Advice about

a)     Nutrition

b)    Child health

c)     Family

Routine Delivery Care

• Trained birth attendant present
• Review birth plan and undertake risk assessment
• Perform clean delivery
• Basic resuscitation of newborn
• Thermal control of newborn
• Start breastfeeding
• Referral community based emergency service

Danger Signals during Labour

• Sluggish pains or no pains after rupture of membranes
• Good pains for an hour after rupture of membrane but no progress
• Prolapse of cord and hand
• Meconium stained liquor or slow irregular or excessively fast fetal heart
• Excessive show or bleeding during labour
• Collapse during labour
• High grade fever during labor
• High B.P
• Immediate Referral

3’ Delay Model

• Ist Delay. Difficulty (delay) in deciding to take obstetric care.
• 2nd Delay in reaching the health facility.
• 3rd Delay in receiving care.
• Women face multiple delays in seeking and receiving lifesaving care when they need it.

a)                  They may not recognize the signs of life threatening complication (Delay one)

b)                They may postpone deciding to seek care (delay two)

c)                 It may postpone take too long to reach appropriate care (delay three) Women may receive substandard or slow care at health facilities (delay four)

Postnatal care

• Maternal
• Newborn
• Objectives
• To prevent complications of postnatal period.
• To provide care for the rapid restoration of the mother to optimum level.
• Care of mother & New born after Delivery.

Postnatal Visits

1^st Visit: within 12 hours

2^nd Visit: 3^rd Day

3^rd Visit: 7^th Day

After Delivery (Mothers)

• Recognition early detection and management of post-partum complications
• Post-partum care (promotion & support to breast-feeding)
• Information & services for family planning
• STDs / HIV prevention & management

After Delivery (Newborn)

• Resuscitation
• Prevention & management of hypothermia
• Eye care
• Early and exclusive breast-feeding
• Prevention and management of infections
• To check adequacy of breastfeeding
• To provide family planning services
• To provide basic health education to mother and family
• Complications of postnatal periods
• Puerperal sepsis
• Thrombophlebitis
• Secondary hemorrhage
• others

Care of the Infant

• Registration of all births
• 4 visits
• 1^st – mothers postnatal visit
• 2^nd – 3 – 4 months
• 3^rd 2^nd half of 1^st year
• 4^th – 2^nd half of
• Ensure EPI program
• Care of pre-schooling child
• Supervise the health of child years of age by regular visiting and examination
• Training
• Participate and arrange initial and refresher training of TBAs & LHWs
• Impact practical and theoretical training public health to Dias / Midwives/ LHWs

Immunization of Mother

• Tetanus Toxoid (TT)
• 2 doses of TT at least 4-weeks apart
• Last dose at least 2-weeks before delivery
• Routine 5Doses
• 1^st dose first  contact
• 2^nd  dose at least 4-weeks after 1^st
• 3^rd dose 6months after 2^nd
• 4^th dose after one year or subsequent pregnancy
• 5^th dose after one year or in successive pregnancy

Current Programs in MCH

• Early Childhood Development Program (ECD)
• Started during early 80s by
• (WHO, UNICEF, UNESCO)
• Network of services to improve child survival & attain optimum growth, development & cognitive capabilities
• Integrated Management of childhood illnesses (IMCI)
• Contents:
• ARI
• Malaria
• EPI
• Nutrition
• Maternal & Perinatal Health
• Education
• Safe Environment:
• Safe water
• Sanitation
• Early detection of disease & appropriate treatment
• National Programme Of Health

Health Personals providing MCH Services

1. Lady Health Visitors (LHVs)
2. Midwife
3. Trained Dai
4. Traditional Birth Attendants (TBAs)

Lady Health Visitor

• BPS: 9
• Qualification: Matric with science
• Training: two years
• Responsibilities

1. Incharge of MCH centre
2. Provides Static MCH services
3. Conducts Home visiting

Midwife

• Qualification:

a)     Matric

b)    One year Midwifery course form Midwifery school

c)     Nurse Midwife She is a qualified Nurse who receives one year Midwifery Training form Midwifery school

Trained Dai

A trained Dai is a trained person who receives one year training from MCH center. She is regular employ a health department.

Traditional birth attendant (TBA)

Person who has learnt the skill through practice or working with predecessor and assists in child birth, having no or little formal organizational training is called Trained TBA.TBAs receive training (15 days – 3 month ) on clean and safe delivery

Duties of LHV

• Job
• Static & outreach domiciliary midwifery
• Basic pay scale in Pakistan (BPS): 9
• Qualification:

1. Lady Health Visitor Course
2. Registered LHV with PNC

• Duties at least two days visits / week
• Scope Static & domiciliary activity
• Visit:70 – 80 expectant mothers / month
• 70 – 80 postnatal visits / month
• Attend 10 birth / month
• Daily routine: 5-7 session on Family Planning
• 9 infants & school children / day
• Work schedule: Mo Incharge / DDHO / AIHC

Prenatal Care

• Registration of expectant mothers
• Visit her at least once for antenatal examination
• Advice health, general health care intake of balanced diet and micronutrients
• To advise mothers on preparation for delivery
• To detect abnormalities arrange referral
• Ensure T.T
• Maintain adequate health record

Delivery Care

• 25% of all the deliveries in her catchment attended by LHV
• 1^st visit within 24 hours
• 2^nd visit within 3 days
• 3^rd visit within 7 days
• Postnatal Care

a)     Arrange referral postnatal complication

b)    Advise care of their health

c)     Advise mothers on family planning & child spacing

Care of the Infant

• Registration of all births
• 4 visits
• 1^st – mothers postnatal visit
• 2^nd – 3 – 4 months
• 3^rd 2^nd half of 1^st year
• 4^th – 2^nd half of
• Ensure EPI program
• Care of pre-school child
• Supervise the health of child years of age by regular visiting and examination
• Training
• Participate and arrange initial and refresher training of TBAs & LHWs
• Impact practical and theoretical training public health to Dias / Midwives/ LHWs

Supervision of Trained Dais / TBAs / LHWs

• TBA Training
• Dai
• Maintain and update register
• Supervise one confinement / year
• Check bags
• To arrange refresher for undersigned dai

Nutrition Advice

• List N/O trained / untrained Dai
• Women and lactating on their and the children’s nutritional
• Nutritional pregnant women and lactating mothers
• Prescribe micronutrients (Ferrous Sulphate etc.)
• Mothers on accurate methods of preparation and timing breastfeeding and good weaning practices
• Health education
• Health education especially to pregnant and lactating females
• Family planning
• 5-7 session
• Record

Notifications to Authorities

The LHV will report to the Assistant Director or Municipal Health Officer or concerned health authorities through prescribed channel on:

• Negligence of bad midwifery by Dais practicing in the area.
• Sanitary conditions of households and villages noted by her during her visit (at least once a month).
• All live and still births taking place in the area.
• Unregistered midwifery practice.
• All cases or suspects suffering from any notifiable disease.
• The number of vaccinations performed by her.