Magnitude of Maternal and Child Health Problems

(PlsNote: Not An Original Article)

By Ms.Hannah Ranjani, Msc N I year Con,SRIPMS,Coimbatore

Introduction:

Maternal, newborn, infant and child mortality are often viewed as barometers of overall
socio economic well being. For example maternal mortality is seen as an important measure of
whether a health system is well functioning because of many facets of the health care mechanism
that must function smoothly to ensure a safe outcome. The problems affecting the health of
mother and child are multi factorial; despite current efforts the health of mother and child still
constitutes one of the most serious health problems affecting the community, particularly in the
developing countries. The effort to meet the challenge is compromised by the hurdle of lack of
qualified professional care. The following passages will deal with the details of the maternal
health and child health problems and issues involved.

Terminologies:

Maternal health refers to the heath of women during pregnancy, child birth and in post partum
period. –World Health Organisation.

Child health refers to the health of the child from birth through adolescence, although the
specific range varies.

Newborn health captures the health of babies form birth through the first 28 days of life.

Statistical terms used to report maternal and child health

Birth rate: The number of births per 1000 population.
Fertility rate: The number of pregnancies per 1000 women of child bearing age.
Fetal death rate: The number of fetal deaths (over 500gm) per 1000 live births.
Neo natal death rate: the number of deaths per 1000 live births occurring at birth or in the first
28 days of life.
Perinatal death rate: the number of deaths occurring in fetuses more than 500 gm and in the
first 28 days of life per 1000 live births.
Maternal mortality: the number of maternal deaths per 100,000 live births that occur as a direct
result of the reproductive process.
Infant mortality: the number of deaths per 1000 live births occurring at birth or in the first 12
months of life.

Magnitude of the problem:

In any community, mothers and children constitute a priority group. In sheer numbers, they
comprise approximately 71.4% of the population of the developing countries. In India women of
the child bearing age (15-44 yrs) constitute and children under 15 yrs of age about 35.3% of the
total population. Together they constitute nearly 57.5% of the total population. By virtue of their
numbers, mothers and children are the major consumers of health services of whatever form.
Mothers and children not only constitute a large group but they are also a vulnerable of special
risk group. The risk is connected with the child bearing in the case of women and growth and
development and survival in case of infants and children whereas 50% of all deaths are occurring
among people over 70 in the developed countries .the same proportion of deaths are occurring
among children during the first five years of life in developing countries . global observations
show that in developing regions maternal mortality ratio averages at 13 per one lac live births
and in developing the figure is 440. From the commonly accepted indices, it is evident that infant
, child and maternal mortality rates are high in developing countries.
Most maternal, new born and child deaths occur in the developing world. With the Sub Saharan
Africa being the hardest hit region followed by South Asia. An estimated 82% of maternal,
newborn and child deaths take place in Sub Saharan Africa and South Asia within these regions ,
several countries have particularly high rates of maternal and child mortality.
One recent study concluded that in 2008 more than 50% of all maternal deaths occurred in six
countries: Afghanistan, The Democratic Republic of Congo, Ethiopia, India, Nigeria and
Pakistan. Similarly almost half of under five child deaths in 2008 occurred in five countries:
China, The Democratic Republic of Congo, Ethiopia, India, Nigeria and Pakistan

Top Ten
Sno Maternal mortality ration in 2005 Under five mortality ratio in 2008
1. Sierra Leone 2100 Afghanistan 257
2. Afghanistan 1800 Angole 220
3. Nigeria 1800 Chad 209
4. Chad 1500 Somalia 200
5. Angole 1400 Congo 199
6. Somalia 1400 Guinea Bissau 195
7. Rwanda 1300 Mali 194
8. Liberia 1200 Sierra leone 194
9. Burundi 1100 Nigeria 186
10. Malawi 1100 Central African Republic 173

Global status and role of India:

Globally each year almost 5,50,000 women die due to pregnancy related causes ,
approximately a death every minute and India accounts for one in five out of these deaths. 15 5%
of all pregnant women in India develop life threatening complications. 65% of deliveries take
place at home and only 41% have a skilled birth attendant at the time of delivery. 605 of
maternal deaths occur after delivery; only one in six receive post natal care: 60% of neonatal
deaths occur in first five days of their birth.
The WHO estimates that of 5.36,000 maternal deaths occurring globally each year 1,36,000
takes place in India. The global burden of the disease for 1990 also showed that India contributed
25% of disability adjusted life years lost due to maternal conditions.
Maternal mortality

Maternal death: Death of a woman while pregnant or within 42days of the termination of
pregnancy irrespective of the duration and the site of pregnancy from any cause related to or
aggravated by the pregnancy or its management but not from accidental or incidental causes.
Maternal mortality ratio (MMR) is expressed in terms of such maternal deaths per one lac live
births: In most of the developed countries the MMR varies from 4 to 40 per one lac live births. In
developing countries it varies from 100 to 700 with India having about 407 per one lac live births
Maternal mortality rate indicates the number of maternal deaths divided by the number of
women of reproductive age (15 to 49yrs).It is expresses per one lac women of reproductive age
per year. In India it is about 120 as compared to 0.5 to United States.
Reproductive mortality is used currently to include maternal mortality and mortality from use of
contraceptives.

Classification of maternal deaths:

The causes of maternal deaths may be classified into:

Direct Obstetric Deaths (75%) are those resulting from complication of pregnancy, delivery or
their management. Such conditions are abortion, ectopic gestation, pre eclampsia, eclampsia ante
partum and post partum hemorrhage and puerperal sepsis.
Indirect Deaths (25%) includes conditions present before or developed during pregnancy but
aggravated by the physiological effects of pregnancy and strain of labour. These are anemia,
cardiac disease, diabetes, thyroid disease etc of which anemia is the most important single cause
in the developing countries: viral hepatitis when endemic contributes significantly to maternal
deaths.
Non obstetric or fortuitous deaths: accidents, typhoid and other infectious diseases.

Important causes of maternal deaths

Sno Causes Percentage
1. Hemorrhage 25%
2. Indirect causes 20%
3. Sepsis 15
4. Unsafe abortion 13%
5. Eclampsia 12%
6. Obstructed labor 8%
7. Other direct causes 7%

Factors associated with maternal mortality:

1. Age: the optimum reproductive efficiency appears to be between 20 to 25 years. In the
young adolescent, pregnancy carries a higher risk due to pre eclampsia, cephalo pelvic
disproportion and uterine inertia. In women aged 35 years or above the risk is 3 to 4 times
higher.

2. Parity: The risk is slightly more in primi gravid but it is three times higher in para five or
above where post partum hemorrhage, mal presentation and rupture of uterus are more
common. The risk is lowest in the second pregnancy.
3. Socio economic strata: Mortality rates are higher in women belonging to low socio
economic strata as these women are likely to be less privileged in the field of nutrition,
housing, education and antenatal care.
 4. Antenatal care: Unfortunately the women who have the highest mortality, like grand
multi para or the patients of lower socio economic status are women who often do not
avail the benefits of the antenatal care.
5. Sub standard care: When care is provided is below the generally accepted level,
available at that circumstance. Shortage of resources (staffs) of back up facilities
(laboratory) is also included.

Important causes of Maternal Deaths and Interventions

Causes Percent Proven interventions
Hemorrhage 20 to 25 • Treat anemia in pregnancy .
Mostly due to post partum hemorrhage and other • Skilled birth attendant
causes are: • Prevent or treat hemorrhage.
• Ante partum hemorrhage(abruption placenta, • Use oxytocin in time.
placenta previa) • Replace fluid loss.
• Retained placenta • Blood transfusion, if severe
• Abortion complications and hemorrhage..
• Ectopic pregnancy.
• Hemorrhage is more dangerous when the
mother is anemic.
Infection : 15 to 20 • Skilled birth attendant
It is associated with labor and puerperium. • Clean practices during
Infections from pre mature rupture of membrane, delivery.
prolonged and obstructed labor are still frequent in • Antibiotics if infection is
the developing world. evident.
Hypertension during pregnancy: 12 to 15 • Early detection.
Pre eclampsia, eclampsia • Appropriate referral.
• Anti seizure prophylaxis or
treatment with Magnesium
Sulphate.
Unsafe abortion 10 to 13 • Skilled birth attendant
• Access to family planning
and safe abortion services.
• Antibiotics after evacuation.
• Post abortion care.
Obstructed labor: due to cephalo pelvic 8 • Use of partograph.
disproportion, abnormal lie and mal presentations. • Detection in time.
• Refer for operative delivery.
Anemia: An indirect cause. About 50% of 15 to 20 • Routine iron folic acid
pregnant women worldwide suffer from anemia. supplementation.
Anemia is commonly due to dietary deficiency • Treat hook worm, malaria,
(nutrition, iron, folic acid, iodine and other micro HIV etc.
nutrients) or infections. • Admit when Hemoglobin is
less than 7gm/dl.
Other direct causes: Viral Hepatitis is endemic in 5 to 10 • Safe drinking water
India with high mortality. Death is mostly in the
last trimester due to hepatic coma and coagulation • Immunization
failure and post partum hemorrhage. • Appropriate referral and
supportive care.

80% of these deaths can be prevented through actions that are effective and affordable in
developing country settings (WHO, UNICEF and UNFPA 2001).

Avoidable social factors:

In the developing countries avoidable social factors are probably evident. These are related to:
• Presence of social evils- illiteracy, early pregnancy and prejudice.
• Unregulated fertility an unsafe abortion.
• Poor socio economic conditions.
• Inadequate maternity services.
• Under utilization of the existing services.
• Lack of communication and referral facilities. These are most often inter related and
are responsible for increased number of avoidable deaths.

Indian context:
MCH problems cover a broad spectrum. At one extreme the most advanced countries
are concerned with the problems such as perinatal problems, congenital malformations, genetic
and certain behavioural problems. At the other extreme , in developing countries , the primary
concern is reduction of maternal and child mortality and morbidity, spacing of pregnancies,
limitation of family size, prevention of communicable diseases, improvement of nutrition and
promoting acceptance of health practices. Currently the main health problem affecting the health
of the mother and child in India, as in other developing countries, resolve round the triad of
malnutrition, infection and the consequences of unregulated fertility. Associated with these
problems is the scarcity of health and the social services in vast areas of the country together
with poor socio economic conditions.

Mal nutrition:
Malnutrition is like an iceberg. Pregnant women, nursing mothers and children are
particularly vulnerable to the effects of malnutrition. The adverse effects of maternal
malnutrition has been well documented.
The effects of mal nutrition are also frequently more serious during the formative years of
life. Previous it was thought that mal nutrition was largely concentrated in school age children
and in toddlers. Now it is realized that the intra uterine period of life is a very important period
from the nutritional stand point. Infants born with adequate birth weight have relatively low
mortality even under poor environmental conditions.
The next critical period of child hood is the period of weaning. Severe mal nutrition
coincides with the age at which babies are usually weaned. Susceptibility to infection and
severity of illness are significantly less in well nourished than in mal nourished children.
Nutrition protection and promotion is therefore an essential activity of MCH care.
Infection :
Maternal infections may cause a variety of adverse effects such as:
a. Fetalgrowth retardation
b. Low birth weight
 c. Embryopathy
d. Abortion and
e. Puerperal sepsis.
In industrial societies, the risk of the mother acquiring infections during pregnancy is
relatively low but in under developed areas, the mother is exposed to significantly higher risks.
Many women are infected with Cytomegalo virus, herpes simplex virus or toxoplasma during
pregnancy. Furthermore as many as 25% of the women in rural are suffer atleast one bout of
urinary infection.
As far as the baby is concerned, infection may begin with labor and delivery and increase as
the child grows older. Children may be ill with debilitating diarrheal, respiratory and skin
infections for as much as a third of their first year of life. In some regions, the situation is further
aggravated by such chronic infections as malaria and tuberculosis. The occurrence of multiple
and frequent infections may precipitate in the children a severe protein energy mal nutrition and
anemia. When the child becomes ill, traditions, beliefs and taboos enter into play; the indirect
effect of infections may be more important than the direct one in tradition societies.
Prevention and treatment of infections in mother and children is a major and important part of
normal MCH care. It is now widely recognized that children in developing areas need to be
immunized against six infections: tuberculosis, diphtheria, measles, whooping cough, tetanus and
polio. Many countries including India have adopted the WHO expanded programme on
immunization as a part of everyday MCH care. Tetanus toxoid application during pregnancy has
also taken up. Education of mothers in medical measures such as oral rehydration in diarrhea and
febrile diseases is being tires. In addition a good knowledge and practice of personal hygiene and
appropriate sanitation measures particularly in and around the home are essential pre requisites
for the control of the most common infections and parasitic diseases.

Uncontrolled reproduction:
The health hazards for the mother and the child resulting from unregulated fertility have
been well recognized –increases prevalence of low birth weight babies, severe anemia, abortion,
ante partum hemorrhage and a high maternal and perinatal mortality which have shown a sharp
rise after the fourth pregnancy. Statistics have shown that in almost every country in the world, a
high birth rate is associated with high infant mortality and under five mortality rates.

Sno Country Crude birth rate IMR (per 1000 Under five mortality
(per 1000 live births) rate(per 1000 live
population) births)
1. India 23 54 72

2. Pakistan 27 73 90

3. Bangladesh 25 47 61

4. Thailand 15 6 7

5. Sri lanka 15 17 21

6. China 13 19 22
 7. Switzerland 9 4 5

8. United Kingdom 12 5 6

a. United States of 14 7 8
America
9. Singapore 8 2 3

1 Japan 8 3 4
0.

Steps to reduce maternal mortality (actions for safe motherhood):

It is a co ordinate, long term effect within the families, communities and the health systems. It
also involves the national legislation and policy. Actions may vary in respect of an individual
country. The government must make maternal mortality a priority public health issue and
periodically evaluate the programmes in an effort to prevent or minimize maternal deaths.
Specific actions are discussed under the following groups:
Health sector actions: Basic antenatal, intra natal and post natal care.

Antenatal care
Early registration of
pregnancy
• A minimum of four
antenatal visits (first at 16
wks; second at 24 to 28 wks;
third at 32 wks; fourth at 36
wks) should be carried out.
• Risk approach to
identify high risk cases
during pregnancy, labor or
puerperium.
• Appropriate referral
to an equipped centre
through an efficient referral
system.
• Routine
immunization with tetanus
toxoid and supplementary
iron-folic acid therapy daily
for at least 100 days after the
first trimester
RCH interventions
Intra natal care Post natal care
• Institutional • Support to restore the
deliveries in 80% cases and health of mother and care of
100% deliveries by Skilled the new born.
Birth Attendants. • Breast feeding early
• Five cleans (clean and exclusive .
surface, hands, perineum, • Ten baby friendly
blade and cord ) initiatives.
• Family planning
services to prevent
unplanned pregnancy and
unsafe abortion.
Risk assessment is not once only but a
continued procedure throughout and the
women are referred to a higher level of care
when needed.
  A skilled birth attendant should be present at every birth. Functioning referral system is
essential for integration of domiciliary and institutional services.
 Emergency obstetric care(EmOC) is to be provided either by a field staff at the door step
of a pregnant woman or preferably at the first referral unit(FRU).
 Good quality obstetric services at the referral centers are to be ensured. Facilities for
blood transfusion, laparotomy and cesarean section must be available at the FRU level.
 Prevention of unwanted pregnancy and unsafe abortion. All couples and individuals
should have access to effective, client oriented and confidential family planning services.
 Frequent joint consultation amongst specialists in the management of medical disorders
in pregnancy particularly anemia, diabetes, viral hepatitis and hyper tension.
 Maternal mortality conferences to evaluate the causes of deaths and the avoidable factors.
 Periodic refresher causes for continuing education of obstetricians, general practitioners,
midwives and ancillary staff and to highlight the preventable factors.

Community, society and family actions:

These are essential to safe motherhood. Wide range of groups (women’s groups), health
care professionals, religious leaders and safe motherhood committees (regional, district) can help
the woman to obtain the essential obstetric care.
Health planners or policy makers actions
• To organize community education, motivation and formation of safe motherhood
committee at the local level.
• To strengthen the referral system for obstetric emergencies.
• To develop written management protocols for obstetric emergencies in the hospitals.
• T o improve the standard and quality of care by organizing refresher courses for the
health care professionals.
• Periodic audit of the existing health care delivery system and to implement changes as
needed.

Legislative and policy actions:

 Girl children and adolescents should have good nutrition, education and economic
opportunities.
 They should be educated about the age of sex and the risks of unprotected sex.
 Barrier to the access of health care facilities should be removed.
 Policies should increase women’s decision making power as regard to their own health
and reproduction.
 Decentralization of services to make them available to all the women.
 Safe abortion services and post abortion must be ensured by national policy.
 Social inequalities and discrimination on grounds of gender, age and marital status are to
be removed.
Maternal morbidity

It has been estimated that for one maternal death at least to suffer from severe morbidities. As
such about an optimistic 5 to 7 million women suffer a severely impaired quality of life as a
result of short term or long term disability.
Definition: Obstetric morbidity originates from any cause related to pregnancy or its
management any time during ante partum, intra partum and post partum period usually upto 42
days after confinement. The parameters are:
 Fever more than 100.4⁰F or 38⁰C continuing more than 24 hours.
 Blood pressure more than 140/90 mm of Hg.
 Recurrent vaginal bleeding.
 Hemoglobin less than 10.5 gm/dl irrespective of gestational period.
 Asymptomatic bacteriuria of pregnancy.

Classification :

Maternal morbidity

Direct Indirect
Previous conditions aggravated by
pregnancy
1. Tuberculosis 3. Malaria
2. Anemia 4. Hepatitis etc

Temporary Permanent
1. Antepartum hemorrhage 1. Recovaginal
2. Post partum hemorrhage fistula
3. Eclampsia 2. Dysparenuria
4. Obstructed labour 3. Prolapse
5. Rupture of uterus 4. Secondary
6. Sepsis infertility
7. Ectopic pregnancy 5. Obstetric palsy
6. Sheehan’s
8. Molar pregnancy etc.
syndrome

Reproductive morbidity is used in a broader sense to include:

 Obstetric morbidity
  Gynecological morbidity
 Contraceptive morbidity

Perinatal mortality

Definition: Perinatal mortality is defined as deaths among fetuses weighing 1000gm or more at
birth (28weeks of gestation) who die before or during delivery or within the first seven days of
delivery. The perinatal mortality rate is expressed in terms of such deaths per 1000 total births.

It reflects closely the standards of medical care and effectiveness of social and public
health measures. However for instructional acceptance, the limit of viability is brought down to a
fetus weighing 500 gm (gestational age of 22 weeks) or more. Worldwide nearly four million
new born die within the first week of life and another three million are born dead.
The perinatal mortality is less than ten per 1000 total births in the developed countries
while it is much higher in the developing countries (60/1000 in India). The national goal is
between30 to 35. The major health problems in the developing world arise from the synergistic
effect of mal nutrition, infection and unregulated fertility combined with lack of adequate
obstetric care.

Pre disposing factors of perinatal mortality

1. Epidemiological: Age over 30 years, parity above five, low socio economic condition,
poor maternal-nutritional status- all adversely affect the pregnancy outcome.
2. Medical disorders: Anemia (Hb less than 8 gm/dl), hypertensive disorders of pregnancy,
diabetes mellitus, syphilis, acute fever (Malaria) and infection (HIV) are often associated.
Perinatal deaths increase due to hypoxia, intra uterine growth retardation, prematurity and
infection.
3. Obstetric complications:
4. Ante partum hemorrhage: Abruptio placenta contributes to 10% of perinatal deaths due
to severe hypoxia.
5. Pre eclampsia and eclampsia are associated with high perinatal loss either due to
placental insufficiency or prematurity; spontaneous or induced.
6. Cervical incompetence: Premature effacement and dilatation of cervix between 24 to 36
weeks is responsible for significant perinatal deaths from pre maturity.
7. Complications of labor:
8. Dystocia from disproportion, mal presentation, abnormal uterine actions, pre mature
rupture of membranes may result in asphyxia, amnionitis and birth injuries contributing
to perinatal deaths.
9. Fetoplacental factors:
10. Multiple pregnancy most often leads to pre term delivery and usual complications
11. Congenital malformations are responsible for 8 to 10 % of perinatal deaths, the lethal
malformations are mostly related to nervous , cardio vascular and gastro intestinal
systems.
12. Intra uterine growth restriction and low birth weight babies : apart from pre term
delivery, intra uterine nutritional deficiency may be responsible for such low birth weight
babies which are more vulnerable to bio chemical, neurological and respiratory
 complications resulting in high perinatal deaths of about 50% when the birth weight is
less than 2 Kg.
13. Pre term labor and pre term rupture of membranes are known leading causes of pre
maturity.

Important causes of perinatal mortality and main interventions

Sno Causes Percent Proven interventions
1. Infections : 33 Maternal immunization against tetanus.
Sepsis, meningitis, Early and exclusive breast feeding.
pneumonia, neo Screening for infections
natal tetanus, Clean delivery
congenital syphilis Warmth
Early recognition and management of infections.
2. Birth asphyxia 28 Skilled birth attendant
and trauma Detection and management of obstetric
complications.
3. Pre term birth/ 24 Prevention of obstetric complication and
low birth weight management.
Infection control
Warmth
Breast feeding
Referral to special care unit.
4. Congenital 15 Prenatal diagnosis
malformations Genetic counseling
and others

Prevention:

• As every mother has the right to conclude her pregnancy safely so also has the baby got
right to be born alive safe and healthy. The following measures are helpful in reducing
the perinatal mortality.
• Pre pregnancy health care and counseling
 • Genetic counseling in high risk cases and pre natal diagnosis, to detect genetic,
chromosomal or structural abnormalities are essential step in. Termination of an affected
fetus is a positive step in reduction of deaths due to congenital mal formations.
• Regular ante natal care with advice regarding health care, diet and rest.
• Detection and correction of anemia and prevention of pre eclampsia and eclampsia.
Immunization against tetanus should be done as routine.
• Screening of high risk patients those of poor socio economic status or high parity,
extremes of age and twins etc and their mandatory hospital delivery; risk approach to
RCH is essential.
• Careful monitoring in labor and avoidance of traumatic vaginal delivery.
• Skilled birth attendant- to minimize sepsis and five cleans to be maintained.
• Provision of referral neonatal service specially to look after the pre term babies.
• Health care education of the mother about the care of the new born.
• Early and exclusive breast feeding; prevention of hypothermia.
• Educating the community to utilize family planning services and also to utilize the
available maternity and child health care services. Family planning services can prevent
unwanted pregnancies.
• Autopsy studies of all perinatal deaths.
• Continued study of perinatal mortality problem by demographic studies, regular clinically
allied inter departmental meetings and pathological research.
• Perinatal mortality: It implies major illness of the neonate from birth to first four weeks
of life. Important causes of morbidity are due to:
• prematurity and growth restriction
• Birth asphyxia and birth trauma
• Congenital malformations.

Still births
A still birth is the birth of a newborn after 28th completed week ( weighing 1000 gm or
more) when the baby does not breathe or show any sign of life after delivery. Such deaths
include ante partum deaths (macerated) and intra partum deaths (fresh still born). Still birth rate
is the number of such deaths per 1000 total births (live and still births).

Important causes of still births and main interventions

Sno Causes Percent Proven interventions

1. Birth asphyxia and trauma 30  Skilled birth attendant
 Effective management of obstetric
complications.
2. Pregnancy complications (placental 30  Pre – pregnancy care; effective
abruption; pre eclampsia and diabetes) management of pregnancy
complications
3. Fetal congenital malformations and 15  Pre conceptional genetic
chromosomal anomalies counselling; pre natal diagnosis.
4. Infection 5  Effective care during pregnancy,
 labor, clean delivery.
5. Cause unknown 20

Neonatal deaths:
Neonatal death is the death of the baby within 21 days after birth; neonatal mortality rate
is the number of such deaths per 1000 live births. Majority of the deaths occur within 48 hours of
birth.
The cause of death within seven days are almost always obstetrically related and as such
still births and neo natal deaths within seven days are grouped together as perinatal deaths. About
two thirds of the neo natal deaths are related to prematurity.

Role of nurse midwives:

The nurse midwives constituting the major part of the skilled birth attendants pool should
understand the magnitude of the problems and thereby should be responsible in their roles as
first level of health care providers.
They should be equipped with knowledge and skill and be able to provide sensitive care to the
women. The care of the midwives should be focused to be safe, skilled and sensitive.

Conclusion:
The contents discussed so far have given a bird’s eye view of the maternal and child health
problems and issues. The nurse midwives should have clear understanding of the sensitive
issues like sexual and reproductive health rights and act as nodal agencies of not only
information to the women in the community but also should posses skills and knowledge to stand
for the vulnerable section of the community- both mother and children.