Taha obaid

السلام علیكم و رحمة الله و بركاتھ

باللون الازرق ةكلام الدكتور السلایدات باللون الاسود

In this lecture we are going to discus the maternal and child health care services We mentioned in the primary health care services that one of the essential health care is maternal and child health . Its important to provide these two group with service in order to ascertain the child when grow in a normal environment , and he will develop as a normal adult So that its important for the mother in pregnancy to ensure the she will have a normal baby and then also going to provide the child with a good health care services . At the end of these lecture we must know this object : 1. To understand why mothers and child health are important? 2. To understand why child and mother health are one unit? 3. To understand main goals of maternal and child health services. 4. To discuss what is the Mother-Newborn Package? 5. To understand the components of MCH. (maternal and child health) 6. To describe family planning service. 7. To discuss the benefits of breastfeeding. 8. To discuss some obstetric complications.(what mother may facing during pregnancy) Why its important to have MCH??

1. Women at reproductive age and children under the age of 5 constitute 2/3rd of the total population in the world.

2. Women and children are vulnerable groups. (They are easily affective by certain factor which affect the health and the development of children)

3. Much of mortality and morbidity are modifiable or preventable (cause of death can be prevented by certain health program)

4. ¾ of the world population live in the developing countries.

5. Of a total of 16 million annual births around the world, 15 million take place in developing countries , mainly in the poorer areas. (so they are at risk of different type of problem)

6. Early interventions in children help them escape poverty. (lead to normal development for childe , such as vaccination , we vaccinat children early in life and ensure before the age of 5 year , they complete their schedule of vaccination and this will help in prevention of different type of communicable disease which the main cause of morbidity and mortality in previous century)

7. Age structure of the population in the Arab region is significantly younger than the global average….37.3% are less than 15 years.

In Jordan ( 2017), demographic indicators , nearly 37% of children they are under 5 year (so we have a good proportion of children they need good health services)

13% less than 5 years 12% 5-9 years 12% 10-14 years 10.9% 15-19 years

#Children (<5 yrs) are vulnerable fraction of population and they are may exposed to different adverse events e.g.:

1. the economic and educational level of the family it will affect the growth of children 2. culture and traditional practices which also affect development of the children e.g.(some

believes, values , practice ) 3. environmental hygiene (provision of proper water supply ,good hygiene , hygiene of the

house, lake of proper water supply may lead to high risk of gastrointestinal infection) 4. the availability and quality of health services (not only the availability it also quality)

In Jordan 2017-18 x Population =9,965,318 =10M x Under-five deaths =3,497 x under-five mortality rate =16 Deaths per 1000 live births x Infant mortality rate =14 Deaths per 1000 live births x Neonatal mortality rate =9 Deaths per 1000 live births x women in Jordan have an average of =2.7 children

x Fertility declined steadily from 1990 to 2002, stabilized from 2002 to 2012, and

decreased again between 2012 and 2017-18 x Mortality and morbidity rates of infants and children and the types of diseases they suffer

from ,show great variation in different parts of the world.

x Children are one of the vulnerable groups as they undergo physical & mental development, which calls for preventive care to meet the biological & psychological needs inherent in the process of growth & development. (so its important to have a healthy environment in order to develop physically, mentally and psychologically)

x Child health is also related to the health of the mother.

Fertility is high among women who live in poverty & who have low education. These women have:

1. frequent & excessive number of deliveries 2. pregnancy at an early or late age (these women in this country they married and get

pregnancy at early age group before age of 20)= teenage pregnant 3. lack of antenatal care 4. deliveries under undesirable conditions. (most of them they deliver at home in addition

they cut umbilical cord sometime by unsterile knife that may Couse = neonatal tetanus 5. They are liable to complications related to pregnancy and delivery leading to maternal

death or complications. Primary health care (PHC) services: for women and children are among selective services which should be given a priority in developing countries. These services comprise the provision of : 1) Child health service ( under 5 clinic) :

x Care of the newborn x Growth monitoring & development (measure of Wight an length because it the main

indicator of the child) x Early treatment of diarrhea (CDD). (by education the mother about feeding to prevent

dehydration) x Breast feeding x provision of adequate weaning food. x Immunization (EPI). Expanding program for immunization x Early diagnosis & treatment of respiratory infection (ARI).

Main goals of child health services are: a) Ultimate goals:

health promotion, every child should live & grow up in a family with love & security in a healthy environment, adequate nutrition, health supervision & efficient medical care→ adult with optimum physical, mental & social well-being.

b) specific goals 1. Prevention & control of morbidity (its important to prevent a larg number of disease

and its important early detection and treatment very important fot health problem in early in life Æ like diarrhea it’s important to prevent gastroenteritis )

2. Rehabilitation of the handicapped & disabled ( always follow of make developmental assist of the child we assist child mental growth and socially) they should be measured every visit and must make a curve to follow the ascending curve// if found any descending that mean there are problem and we should pic this problem and try to modify and manage this problem

3. Reducing childhood mortality

2) Maternal services:(service which provided by the mother) During pregnancy --} at pregnancy --} after pregnancy.

x Antenatal care (high risk pregnancy). (during pregnancy) x Natal care (Safe delivery) (during delivery) to ensure that will have safe delivery

so we always advice the mother to have their baby at hospital to ensure that if it have any complication may have management

x Postnatal care (care provided to mother after delivery in order to ensure that she have normal corporeal period and educate her to breast feeding

x Family planning x protection of mothers, babies and young children from deficiency states i.e. iodine,

or iron deficiency , folic acid .

Why the Mother-Newborn Package? 1) Jordan as a developing country is facing the challenge of maternal and neonatal deaths.

2) These deaths are the result of the same major complications of pregnancy : haemorrhage,

sepsis, hypertensive disorders of pregnancy, obstructed labor and abortion. It’s important to prevent any infection during pregnancy by early diagnose Abortion: is a expulsion of foetus before 12 week or during first 3 month After that it have another name

3) Women who survive such complications still suffer acute or chronic ill-health or lifelong disabilities. Some women develop anaemia during pregnancy or hypertension , some of women they persist have hypertension , some of them may develop Gestational diabetes

4) The goals of the Mother-Newborn Package are, by the year 2014 : to assist the public health sector achieve Jordan’s MDG4 for further reduction of neonatal mortality, and MDG5 for further reduction in maternal mortality

MDG: Millennium Development Goals

5) The complications which affect women during pregnancy and childbirth affect the fetus as well.

6) Many neonatal deaths are a direct consequence of poorly managed pregnancies and deliveries.

7) Infants who survive end up with a degree of damage that renders them physically or mentally disabled throughout their lives.

8) The causes are similar around the world as well as in Jordan newborn babies die or are damaged because of prematurity, birth asphyxia, trauma or infections

Prematurity: the women that delivered before 36 week of gestation and liable to larg number of defiction

Birth asphyxia: obstruction liable and decrease supply to brain and that will affect development of the brain

9) Pregnancy is not a disease, and pregnancy-related mortality and morbidity are preventable with attainable, simple and cost-effective interventions

#Most pregnancy-related complications can be effectively prevented or managed without recourse to sophisticated and expensive technologies or drugs #Maternal and neonatal mortality can be reduced when:

I. communities are informed about danger signs and symptoms II. quality health services are available and accessible, through primary healthcare

III. including a referral system to manage complications at a higher level in the healthcare system.

#This implies that safe motherhood interventions should be applied holistically within a general health context that promotes equity in access to and quality of care. Making motherhood safe requires action on four fronts simultaneously:

A. Reducing the numbers of high-risk and unwanted pregnancies. Many women don’t need use contraception and will have unwanted pregnancies and this women they are at risk of having abortion , illegal abortion and that will lead to many complication B. Reducing the numbers of obstetric complications. It’s important to advise the mother to delivery at hospital in order to be aware and early management C. Reducing case fatality rate in women with complications.

D. Proper management of high risk neonates.

Some of neonate of premature baby may be at high risk

E. Increasing the availability and accessibility of family planning information and services will substantially reduce the number of pregnancies – particularly high-risk and unwanted pregnancies – and will thus result in a reduction in maternal deaths.

The number and severity of obstetric complications may be reduced by: 1. ensuring that all women have access to quality antenatal we should ensure all women provided by antenatal health serves 2. delivery and postpartum care to provide information 3. prevention and management of diseases during pregnancy 4. early detection and management of complications.

#Special attention to the needs of the newborn resuscitation when necessary, immediate breastfeeding, warmth, clean delivery and cord care will also help ensure the survival and health of full-term (FT) newborn infants. #Special attention will be also needed with cases that need further interventions: LBW babies, premature , cases with asphyxia or sepsis If baby deliver <2.5 kg called LBW babies and need special care. LBW: low birth Weight

Basic maternity care comprises : 1. antenatal care 2. natal care ,a clean and safe delivery 3. postpartum care for mother and infant to detect and manage complications, such as

secondary postpartum hemorrhage, and sepsis, and to offer support for breastfeeding\

I. Antenatal care Antenatal care can help reduce the number and severity of pregnancy-related complications for both the mother and baby by careful monitoring and early treatment of diseases aggravated during pregnancy such as anemia and thyroid imbalance. It also provides the opportunity to offer prophylactic treatments such as iron and folate supplementation. Vit. D These days In addition, it facilitates the early detection and management or referral of pregnancy-related complications Mother-Newborn Package Interventions Before and During Pregnancy : Antenatal care

Information and services for family planning STD/HIV prevention and management (STD: sexual transmitted disease) Tetanus toxoid immunization (if the mother not sure about vaccination status we must

vaccinate the mother) 5 dose of tetanus vaccine

Antenatal registration and care Treatment of existing conditions Advice regarding nutrition and diet Iron/folate and Vit. D supplementation Recognition, early detection and management of complications – high risk pregnancy:

1. eclampsia/pre-eclampsia characterized by increase in BP & edema and proteinuria 2. bleeding 3. abortion 4. anemia 5. Rh- isoimmunization

II. During Delivery

Clean and safe (a traumatic) delivery (to ensure there no complication during delivery)

Recognition, early detection and management of complications at health centre and hospital (for example, hemorrhage, eclampsia, prolonged/obstructed labor)

III. After Delivery: Mother x Recognition, early detection and management of postpartum complications at

hospital (for example, hemorrhage, sepsis) x Postpartum care (promotion and support to breastfeeding and management of

breast complications) x Information and services for family planning x STD/HIV prevention and management x Tetanus toxoid immunization

IV. After Delivery: Newborn

1. Basic newborn care: x Resuscitation (some baby if they have complication in premature they

need Resuscitation) x Prevention and management of hypothermia (sometime baby they will

exposed to low temperature and will develop hypothermia or hypoglycemia sometime)

x Early and exclusive breastfeeding x Prevention and management of infections including ophthalmic

neonatorum (due to mother infection of Chlamydia trachomatis. Neisseria gonorrhea) and cord infections (it need special treatment because if not treated probably will lead to blindness of the baby)

2. Recognition, early detection and management of high risk neonates; x Low birth weight, asphyxia, sepsis and their associated complications.

Family planning

x Ensuring access to family planning information and services is a key element of the Mother-Newborn Package.

x Family planning can reduce maternal mortality in several ways: a. Family planning can lead to a reduction in the number of births and, since every

pregnancy is associated with some risk, this in itself helps reduce maternal deaths.

b. Family planning can help reduce mistimed pregnancies ; some are more risky than others – for example:

1) those among very young women 2) women of high parity 3) those of older women.

c. Family planning can help to reduce unwanted pregnancies, which is a threat to the

woman’s health, either because she may resort to unsafe abortion or she is less likely to take care of herself than if the pregnancy was wanted.

d. Some estimates indicate that access to family planning to prevent mistimed and unwanted pregnancies could reduce maternal mortality by up to one-third

Strategy

x A major information, education and communication (IEC) strategy should be developed, focusing on birth spacing and birth timing or limiting as important health measures for mother and child level.

1) Give the mother the information about how to space between birth(birth spacing) 2) birth timingÆ what time they want their children 3) limiting the number of the family x Training of health service providers should include not only the technical and managerial

aspects of contraception but also appropriate interpersonal communication and counseling skills.

x An optimal range of contraceptives should be made available to meet the needs of the widest possible range of users, following the principle of “free choice.”

x Overcome barriers to family planning, such as: social, cultural, financial, organizational, availability of FP methods etc….

BASIC MATERNITY CARE x This is of particular importance in parts of the world where most deliveries continue to

take place within communities and where many mothers deliver unaided or with the assistance of only relatives or traditional birth attendants ( TBA).

x Providing individuals and communities with the information they need to avoid harmful practices and promoting appropriate basic care including clean delivery can help prevent many pregnancy-related complications (neonatal tetanus).

x Furthermore, giving people information about the signs and symptoms which require

urgent assistance from a higher level of care helps mobilize communities to seek timely referral when complications arise.

x Encourage hospital delivery

x All pregnant women should have a minimum of four antenatal visits (at least 20 minutes

duration each) for prevention, early detection and management of complications.

x Antenatal care should comprise health promotion, assessment, management and/or referral through history taking, physical examination, and laboratory tests where necessary, tetanus toxoid immunization, and iron and folate supplementation.

If the mother lack immunity against tetanus and if the delivery occure in non-sterile condition So the baby will have neonatal tetany So it’s important to have prophylactic it the mother not sure if have tetanus immunization or not we will provid her 5 dose of tetanus toxoid

x Antenatal care sessions should be used as an opportunity to provide information to women and their families about danger signs and symptoms during pregnancy and delivery and to help them develop an appropriate delivery plan

x All women and service providers should be aware of the requirements for a clean

delivery: clean hands, clean delivery surface, clean cord cutting and care. All healthcare providers should be trained in and practice clean and safe delivery techniques and avoid unnecessary vaginal examinations and episiotomies.

)ما قرأتھم الدكتورة(x All women admitted in active labor should be monitored by service providers who are

using an appropriately to prevent prolonged labor.

x Information about signs and symptoms of infection and/or excessive bleeding, exclusive breast feeding and family planning counseling should be provided to all women in the post partum period

BREAST FEEDING One of the important element to provide the mother of information

� Breastfeeding is one of the most important contributors to neonatal, infant and child health, growth and development.

� The benefits are greatly enhanced if breastfeeding starts within one hour after birth, with demand feeding and no substitute feeds

� Exclusive breastfeeding for the first 6 months protect the child from many neonatal health problems such as:

1. Hypothermia 2. neonatal hypoglycemia 3. infections 4. neonatal jaundice associated with scheduled breastfeeding.

� Apart from the clear nutritional superiority of breast milk, breastfeeding protects against infant deaths and morbidities. Breastfeeding one of the most important prevention of death in addition of nutritional superiority

� Infants who are exclusively breastfed are less likely to suffer from episodes of diarrhea and respiratory infections as babies who are not breastfed.

Mothers benefit from breastfeeding: Not only baby take a benefit from breastfeeding also the mother benefit from this process

¾ It reduces the risk of postpartum hemorrhage ¾ Contribute in uterus involution (Slower involution continues over the next several weeks

until pre-pregnant size is attained). ¾ lowers the risk of breast and ovarian cancer. ¾ It contributes to child spacing and reduces fertility (lactating aminorial that give the

mother natural contraceptive )

Neonatal Tetanus o The total global estimate of deaths from neonatal tetanus is 560,000. o Tetanus is often associated with sepsis and substantial newborn deaths due to sepsis are

caused by unclean delivery and cord care.

o Pregnant women should have tetanus toxoid immunization. All pregnant women attending antenatal care should be assessed and given tetanus toxoid according to immunization status. The recommended 5 dose schedule is shown in (see box below). The 5 doses, once completed, will provide lifelong protection.

1. TT1: At first contact, or as early as possible during pregnancy. 2. TT2: At least 4 weeks after TT1. 3. TT3: At least 6 months after TT2 or during subsequent pregnancy. (or after

delivery) 4. TT4: At least 1 year after TT3 or during subsequent pregnancy. 5. TT5: At least 1 year after TT4 or during next pregnancy or during

subsequent pregnancy.

High risk pregnancy 1. Biological

a. Age: under 18 or above 35, or old primi. b. birth interval, short c. weight (<45kg, over wt) d. height, short stature – CS e. Primi gravida = first pregnancy ( she is may facing many complication) f. More than 6 pregnancies

2. Medical a. Diabetes b. Hypertention c. sickle cell anemia d. heart diseases e. maternal malnutrition, etc...

3. obstetric history complication, pre eclampsia , APH, PPH, CS, Rh-isoimmunization, previous fetal loss, abortion, grand multiparty can lead to transverse lie, LBW, placenta Previa, congenital malformation Prolapse of the cord , Previous caesarean section, vacuum, or forceps delivery , Previous perinatal death, stillbirth, Twins, etc APH: antepartum hemorrhage / PPH: postpartum hemorrhage / CS: cleavage cesarean section

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