TOWARDS A BETTER FUTURE MATERNAL AND CHILD HEALTH
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TOWARDS
A BETTER FUTURE
MATERNAL AND CHILD HEALTH - extracted text
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UNHCR Photo by S. Erringxon
The World Health Organization is a specialized agency of the United Nations with
primary responsibility for international health matters and public health. Through this
organization, which was created in 1948, the health professions of more than 150 countries
exchange their knowledge and experience with the aim of making possible the attainment
by all citizens of the world by the year 2000 of a level of health that will permit them to lead
a socially and economically productive life.
By means of direct technical cooperation with its Member States, and by stimulating
such cooperation among them, WHO promotes the development of comprehensive health
services, the prevention and control of diseases, the improvement of environmental
conditions, the development of health manpower, the coordination and development of bio
medical and health services research, and the planning and implementation of health
programmes.
These broad fields of endeavour encompass a wide variety of activities, such as devel
oping systems of primary health care that reach the whole population of Member
countries; promoting the health of mothers and children; combating malnutrition; control
ling malaria and other communicable diseases including tuberculosis and leprosy; having
achieved the eradication of smallpox, promoting mass immunization campaigns against a
number of other preventable diseases; improving mental health; providing safe water
supplies; and training health personnel of all categories.
Progress towards better health throughout the world also demands international cooper
ation in such matters as establishing international standards for biological substances,
pesticides and pharmaceuticals; formulating environmental health criteria; recommending
international nonproprietary names for drugs; administering the International Health
Regulations; revising the International Classification of Diseases, Injuries, and Causes of
Death; and collecting and disseminating health statistical information.
Further information on many aspects of WHO’s work is presented in the Organization’s
publications.
Community Health Cell
Library and Documentation Unit
BANGALORE
The financial contribution of the United Nations Fund for Population
Activities towards the preparation of this book is gratefully acknowledged.
TOWARDS
A BETTER FUTURE
MATERNAL AND CHILD HEALTH
World Health Organization
Geneva
1980
HEALTH: A DEFINITION
In order to understand the role and work of WHO in any field, it is
imperative to define the term '"health". Colloquially, health does not mean
much more than the absence of illness, and health care is taken to mean
merely measures and interventions designed to cure disease. The definition
of health embodied in the Constitution of WHO is much broader and much
more positive, namely “a state of complete physical, mental and social well
being and not merely the absence of disease or infirmity".
Such a definition, coupled with the growing realization that health and
development are interrelated, has significant implications for the work of
WHO. It means that health must also be considered in a non-medical
perspective and that behavioural and environmental factors must be taken
more and more into account This does not mean that medicine and medical
care are obsolete but that health must be viewed more broadly, with more
attention being paid to factors that enhance health and to action that can be
taken by the people themselves to preserve and promote their own health.
© World Health Organization 1980
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World Health Organization welcomes such applications.
The designations employed and the presentation of the material in this publication do
not imply the expression of any opinion whatsoever on the part of the Secretariat of the
World Health Organization concerning the legal status of any country, territory, city or
area or of its authorities, or concerning the delimitation of its frontiers or boundaries.
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Contents
Page
Mothers and children ........................................................................
5
Principles of maternal and child health care.......................................
9
Some factors affecting the health of mothers and children ................ 12
Health status of mothers and children ............................................. 15
Developments in maternal and child health: technologies
and knowledge ........................................................................... 25
Recent trends in maternal and child health care................................ 29
Action now ........................................................................................ 35
WHO’s role in the promotion of maternal and child health care......... 38
References ........................................................................................ 42
Mothers and children
Health cannot be attained where poverty and misery abound, where
food and safe water are scarce, where housing is inadequate, and where
public and community services are lacking or rudimentary. In such
conditions, faced by two-thirds of the world’s people, ill-health and
premature death are the rule rather than the exception. Most severely
affected by such risk factors are women of childbearing age and children,
who together make up the majority of the population in almost all parts
of the world today (Fig. 1). Mothers and children are especially at risk
because of the particular vulnerability of certain stages of the process of
growth and development. If family health is to be attained, the health
needs of mothers and children must be considered the first priority.
Fig. I
POPULATION BY AGE AND SEX (1975 AND 2000)
FEMALE
Developed Regions
1975 — 1 100 million
2000 — 1 300 million
(
| Population in 1975
[
] Increase 1975 to 2000
200
100
200
Millions
Millions
Source: Data from United States Bureau of the Census: published in Department of State Bulletin, October
1978.
5
Oi
Table I
VITAL STATISTICS BY GEOGRAPHICAL REGIONS, 1978
(in millions unless otherwise stated)
Annual number of deaths
of children aged
Population
Region
West Africa
Middle Africa
Life
expectancy
at birth (years)
Annual
number
of births
children aged
total
0-4 years
5-14 years
under
1 year
(thousands)
1-4
years
(thousands)
Deaths of children
under 5 years
as percentage
of all deaths
(8)
(1)
(2)
(3)
0)
(5)
(6)
(7)
42
128
24
34
6.3
1 010
564
55
381
215
61
60
42
50
9
13
2.2
East Africa
45
124
23
33
5.8
845
629
Mid South Asia
49
879
145
232
32.5
4 423
1 609
46
Southern Africa
52
31
5
7
1.2
150
65
44
South-East Asia
52
341
58
91
12.6
1 463
352
41
Northern Africa
52
103
18
28
4.4
580
399
68
South-West Asia
55
92
16
24
3.9
423
128
48
Tropical South America
61
188
31
50
7.0
689
163
50
Middle America
63
87
16
24
3.6
256
79
48
64
28
4
7
0.8
53
8
27
East Asia
66
1 122
131
236
24.7
1 431
631
23
Temperate South America
66
40
4
8
09
66
9
21
Oceania
68
22
3
4
0.5
13
2
8
USSR
69
261
22
45
4.7
132
12
6
Eastern Europe
70
108
9
16
1.9
49
8
5
Southern Europe
71
137
11
24
2.3
56
9
5
Western Europe
72
153
11
25
1.8
28
6
4
Northern Europe
72
82
6
13
l.l
14
3
2
North America
73
242
19
43
3.6
54
10
3
60
4 219
565
957
121.8
12 115
4 901
25
World
Sources: Cols (I), (2). (5)
Cols (3), (4)
Cols (6), (7)
Col. (8)
Notes:
— Population Reference Bureau Inc., Washington, DC; 1978 estimates.
— Population Reference Bureau and United Nations (Selected world demographic indicators. 1975).
— WHO (Division of Family Health) estimates based on data from various sources.
— Cols (6) and (7) and Population Reference Bureau Inc.
Totals were calculated before rounding, rounded figures may not add up to totals.
Col. (8) — Figure for northern Africa is greatly influenced by the estimated fall in the overall death rate (United Nations estimate).
n
Caribbean
8
Of the 122 million children born each year in the world, more than
12 million die before reaching their first birthday (Table 1); more than 10
million of these deaths occur in the developing world. Many of the risk
factors for infants also endanger the life of the mother, contributing to
high maternal mortality with consequent additional risks for orphaned
children. Unsafe obstetric practices, including clandestine abortions, also
increase maternal mortality.
Infant and maternal death rates may epitomize, more than any other
indicator, the gap between the rich and the poor. In many countries,
infant and maternal mortality rates have declined dramatically and the
health conditions of mothers and children have made impressive pro
gress, demonstrating clearly that the tragic waste of human life can be
prevented if proper action is taken.
Why then does the health situation of hundreds of millions of mothers
and children continue to be so poor? Why does maternal and child health
care not receive the priority it should in so many countries?
The answers to these questions are related to the overall health and
development situation. For example, the potential contribution of health
to development is too often overlooked or underestimated; many
countries face enormous constraints in terms of resources and the
environment; natural and man-made disasters result in tremendous hard
ships for many populations; the health system of many countries is too
weak or too inefficient to give proper support to action at the community
level. Other reasons include a lack of appreciation of the basic principles
of maternal and child health, its importance for health in general, and its
role in overall development and an improved quality of life.
The tragic situation of the mothers and children in the developing
world poses the greatest challenge to the achievement of the goal of
“health for all by the year 2000” that was set by the World Health
Assembly in 1977.
9
Principles of maternal and child health care
Knowledge acquired in the past few decades has clarified the biological
and social bases underlying the health and health care of mothers and
children. This knowledge has strengthened the scientific justification for
maternal and child health care.
The basic principle underlying maternal and child health care is that
there are specific biological and psychosocial needs inherent in the
process of human growth which must be met in order to ensure the
survival and healthy development of the child and future adult.
Maternal and child health care is not a form of service conveniently
“packaged” according to the age and sex characteristics of a population
group, nor is it a specific activity to deal with a given disease. It is,
rather, a type of service concerned with the overall process of growth and
development which is the foundation of human life. The very nature of
this process is crucial for health or ill-health, for life or death.
Each stage of growth and development builds on the one before and
influences the next. If the physiological and psychosocial requirements
are not fulfilled at each stage, it becomes increasingly difficult to catch
up or repair the damage; thus the body’s potential to adapt in a healthy
way throughout the process diminishes. The health of the child deter
mines the health of the adult; the growth and development of one gener
ation affects the next generation.
The process of healthy growth and development is in itself a normal
one, provided crucial elements in the environment are in balance. Certain
stages of this continuous process are more critical or rapid than others:
consequently, they are more vulnerable. Mothers and children are con
sidered vulnerable groups because of the special characteristics of
pregnancy or young age in relation to growth and development. The word
“vulnerability” refers to the potential for misdevelopment or danger.
The third trimester of gestation, the first year of extrauterine life, and
puberty are particularly critical stages because of the rapidity of growth
and development.
The concept of vulnerability has implications for any type of health
care. It calls for preventive care, continuity of care for all, individual
monitoring, and specific actions when deviations from normal progress
are detected. At any point in time, from a fifth to a third of the population
in most countries could be considered vulnerable. This fact is very
important from the point of view of social and health planning.
Understanding the biological reasons for the vulnerability of mothers
and children is not an academic exercise; it is essential in order to meet
the fundamental health needs of a whole lifetime.
Child spacing is an important means of bettering the health of mothers
and children. The positive impact of appropriate child spacing will be
reflected in national socioeconomic development.
The overall quality of life predetermines, to a large extent, the healthy
10
growth and development of an infant. Unwanted or unwise pregnancies
lessen the child’s chances of survival in that they impose a health risk for
the mother and, especially in underprivileged situations, decrease the
resources necessary to support the wellbeing of the child. Prevention of
unwanted or too closely spaced pregnancies is possible. Child spacing is
an alternative that should be available to everybody. Relevant sectors
and personnel should ensure the provision of information, technology and
resources for families who want and need to space their children. The
choice should be within the reach of all.
If preventive action is taken in pregnancy and early childhood, its effec
tiveness and impact on health are great.
The greatest part of the resources of health systems have traditionally
been allocated to action on behalf of the non-healthy; because of the
enormous and urgent demand from this part of the population, very little
has remained for the protection and promotion of health. This has been
particularly striking with maternal and child health care, which should be
essentially concerned with the promotion of healthy growth and develop
ment and the prevention of ill-health.
Preventing illness and promoting health entail very basic and concrete
measures which form part of a forward-looking orientation to life. Yet it
is only in the past few decades that the necessary conceptual, scientific
and practical foundations have been laid that have allowed families
throughout the world to plan for their own future or for that of their
children with any degree of certainty. The concepts involved in taking
action now for a better life tomorrow have only recently been defined
with any clarity.
New knowledge has also shown that many adult health conditions
result from problems in childhood (7). This growing understanding
demands a shift of priorities. National health authorities are increasingly
realizing that child care is not just the cure of disease in sick children, but
the prevention of potentially fatal diseases and incapacity in future
adults on whom national health and prosperity will depend, and that
greater investment in health care of children means reducing the need for
resources devoted to curative health services, hospitals, and facilities for
rehabilitation, now and in the future.
The healthy development of children is an investment in social develop
ment and productivity.
Underlying the preoccupation of development policy in the 1950s with
economic growth was the assumption that a healthy work force was
available. However, the prime necessity of maintaining a healthy popu
lation was often overlooked or grossly underestimated by the policy
makers, and the importance of ensuring child health as an investment for
the future was largely ignored. As a result, the development plans of
many countries—drafted in good faith in the 1940s and 1950s—have
yielded little but disillusionment and frustrated hopes.
In contrast, there are a number of examples of countries which in the
past few decades have made a concerted effort to promote the health of
11
their children as part of an overall priority investment in childhood; there
is no doubt that this investment has been beneficial for these children
(now adults), for their children in turn, and for the prosperity and devel
opment goals of the nation as a whole. The shift in the 1970s to a much
greater emphasis on social development—with a concern for social
justice, high levels of education and production, the organization of com
munities, and the participation of people in political and social pro
cesses—demands not only a physically healthy labour force but also a
population with a high level of energy. A productive and energetic popu
lation cannot grow from unhealthy children.
12
Some factors affecting the health
of mothers and children
Economics and the environment
The differences in health between rich and poor, which can be observed
in all age groups, are particularly striking among mothers and children.
Table 2 illustrates the relationship between crude fertility, infant
mortality and economic development, and shows how great these differ
ences are, but it does not show the pockets of high infant mortality in
wealthy countries or the uneven distribution within developing
countries.
Among the factors affecting maternal and child health are: agricultural
policy and land ownership, which have a direct influence on nutritional
status; an insanitary environment, including unsafe and insufficient
water and overcrowding; and transport and communication difficulties.
Moreover, urbanization, with its concomitant breakdowns of traditional
structures, causes new health problems, such as exposure to pollution,
the mental deprivation of children and the health consequences of their
social deprivation, increased risks of sexual exploitation and drug abuse
among the young, and so on. Cities are built for adults, and urban
planners all too rarely recognize the importance of the physical surround
ings for health and for accommodating children amid the concrete maze.
Table 2
INFANT MORTALITY. BIRTH RATES AND
ECONOMIC DEVELOPMENT
Countries
Average GNP
(USS per
capita)
Population
(million)
Crude birth rate
(per 1000
population)
Infant mortality
(per 1000
live births)
Industrialized
5 950
1 350
16.2
15
25
Developing:
High income
4 127
20
31.0
Upper middle income
1 498
108
23.8
35
Intermediate middle income
721
370
41.4
48
Lower middle income
384
215
45 0
88
Low income
151
554
46 6
129
2 1 12
1 480
17.8
25a
Centrally planned economies
a Excluding China
Source: World atlas of the child, Washington, DC. World Bank. 1979.
13
Social values and education
A society’s traditions, cultures, philosophies and religions all shape
and are shaped by people’s understanding and conception of health, sick
ness and death. Various harmful effects have been observed as a result of,
for instance, food taboos in the treatment of sickness in children and the
eating practices of pregnant women, child marriage, and discrimination
against female babies. On the other hand, there are positive aspects, such
as the traditional bonding or close contact of mother and infant, and the
value attached to cleanliness and personal hygiene in many religions.
While changes in traditional family life-styles are inevitable, valuable
practices such as breast-feeding should not be allowed to disappear.
There is sound sense in creating the new by grafting on to what was best
in the past.
The relationship between educational factors (formal and non-formal
schooling, literacy, and traditional forms of education) and health is
complex and not easily described. However, associations have often been
found between high levels of infant mortality and low levels of education.
The family
Health largely depends on the family’s social and physical environ
ment, and its life-style and behaviour. The role of the family in health
promotion and in prevention, early diagnosis and care of disease is of
crucial importance. The major part of health actions is carried out by
individuals and families before they come into contact with any health
worker. The mother is usually the family’s first health care worker. But
women often have no access to information and technology, to income
and education, and they are usually overburdened with work.
In more and more areas of the world today, man-made and natural
disasters, including war and other violence, political upheavals, changing
patterns of women’s employment, and migration of men have farreaching effects on the functioning of the family, especially with regard
to childbearing and child-rearing. The support mechanisms which the
family had provided for its members in the past are eroding because of
economic and social pressures, with implications for the health of
mothers and children.
In the past decade changes in patterns of socioeconomic development
and the adoption of family planning methods by an increasing number of
couples have had a significant impact on family structures and functions.
These changes have influenced both women’s and men’s economic and
social roles, as well as patterns of childbearing and child-rearing, and
hence family health. In some areas changes in traditional family struc
ture have led many more women to assume single-handedly the role of
head of the family, with implications for their own health and that of the
family as a whole.
14
Social support and health care
The many factors affecting the health status of mothers and children
also include community and social support measures, ranging from
neighbourhood-oriented day-care facilities to organized health care
systems. Whether these are available and how well they function has an
impact on the health of the family.
Table 3
WORLD POPULATION ESTIMATES
(1978)
World
(millions)
Developing
Areas
(millions)
Developed
Areas
(millions)
Women aged 1 5-49 years
1 005
727
278
Children aged 0-4 years
565
472
93
Children aged 5-14 years
957
778
179
sub-total
2 527
1 977
550
Total Population
4 219
3 105
1 1 14
60
64
49
Children 0-14 years and women
aged 15-49 years as percentage
of total population
Source. Population Reference Bureau Inc. & United Nations (Selected world demographic indicators)
15
Health status of mothers and children
Of the total world population, 24% are women of reproductive age and
36% are children below 15 years of age. While the proportion of women of
reproductive age is about the same in all parts of the world, children
under 15 years of age make up 24% of the population in the developed
areas and 40% in the developing areas. Thus, while the actual percentage
may vary from one country to another, these two groups together make
up the majority of the population in almost all parts of the world today.
The lack of reliable data is a severe obstacle to a global analysis of
health status. In addition, a drawback of existing data is that they are
mostly expressed as national averages, whereas it is known that there are
often large differences in health status between different population
groups within the same country.
It is also increasingly being questioned whether mortality and mor
bidity data fully reflect health status, particularly in respect of young
children for whom mere survival rates and specific disease rates are not
very clear expressions of child health. New, positive indicators of health
are emerging such as indices of human growth and development as well
as maturation during adolescence. Birth weight is an important example;
it reflects both the past and present health status of the mother and is
sensitive in predicting the chances of an infant’s survival and subsequent
health.
The inadequacy of data on mortality and morbidity is most serious in
those parts of the world where health problems are most widespread and
severe. The inadequacies of the information are particularly marked for
pregnant women and children, especially the newborn. These limitations
should be kept in mind when interpreting the data reviewed below.
Maternal mortality and morbidity
In countries with a well developed health care system and where the
maternal mortality rate is well documented, that rate is of the magnitude
of 5-30 per 100 000 live births and is continuously decreasing. In most
developing countries the information is only fragmentary but it is known
that the situation is worse—and in some cases much worse. Evidence
from special studies in a number of developing countries indicates that
maternal mortality rates in excess of 500 per 100 000 live births are by no
means exceptional. Rates of over 1000 per 100 000 have been reported in
parts of Africa (Table 4).
It can be estimated that in areas with the highest maternal mortality,
i.e., most of Africa and in West, South and East Asia, about half a million
women die from causes related to pregnancy and childbirth every year,
leaving behind at least one million motherless children. In Latin
America, the maternal mortality rates are much lower, but several
studies have shown serious under-reporting of maternal deaths; in some
countries up to half of such deaths were not reported accurately.
16
Table 4
COMPARISON OF EXTREME LEVELS OF NATIONAL MATERNAL
AND CHILD MORTALITY RATES
Highest levels
(1)
Lowest levels
(2)
Perinatal mortality*
120
12 - 15
8-10
Infant mortality*
200
8-10
20 - 25
Childhood mortality6
45
Maternal mortality*
1 000
0.4 - 1
5-10
Ratio of
(l)/(2)
45 - 75
100 - 200
° Per 1000 live births
b Per 1000 population.
c Per 100 000 live births.
Source: WHO (Division of Family Health) estimates based on a variety of sources.
Causes of maternal death
Post-partum haemorrhage, often with anaemia as an underlying or
associated cause, and sepsis are the most frequent causes of maternal
death, directly related to the absence or inadequacy of prenatal and
delivery care. In addition, hypertensive disorders of pregnancy are
important, not only in the developed countries where they account for
25-35% of all maternal deaths, but probably even more in the developing
countries. The etiology of toxaemia is not well known. It appears that the
condition is more frequently associated with the first pregnancy, very
young mothers and women over the age of 35, especially in women of
very high parity. Anaemia and hypertensive disorders of pregnancy, in
addition to their effect on maternal mortality, also cause high rates of
fetal death and of low birth weight. Large numbers of pregnancies, short
birth intervals, and pregnancies occurring at the extremes of reproduc
tive age are in close relationship with a greater-than-normal risk of
unfavourable outcome for both mother and child; this is manifested in,
among other ways, higher neonatal and infant mortality rates. Ina WHO
study in rural India (2), it was found that the mortality rates were more
than twice as high among infants born less than 2 years after the preced
ing pregnancy termination (abortion, fetal death or live birth) than
among those bom more than 4 years later (see Fig. 2).
Family planning can favourably influence the health, development, and
wellbeing of the family, in particular of mothers and children. The health
benefits of family planning result from (1) avoidance of unwanted preg
nancies and the occurrence of wanted births that might otherwise not
have taken place; (2) a change in the total number of children born to a
mother; (3) achievement of an optimum interval between pregnancies;
and (4) changes in the time at which births occur, particularly the first
and the last, in relation to the ages of the parents and especially that of
the mother.
17
Fig. 2
THE EFFECT OF PREGNANCY SPACING ON
NEONATAL AND INFANT MORTALITY
Note:
Preceding pregnancy interval = the interval between the termination of the preceding pregnancy
and the birth of the infant.
Source : Omran. A.R. & Standley. C.C., ed. Family formation patterns and health Geneva. World Health
Organization. 1976, (data from South India sample, 1971-1975,6541 women).
The role of illegally induced abortions as a cause of maternal death is
well recognized but difficult to estimate, even approximately, because of
the secrecy surrounding abortion as a cause of death. In Latin America,
where abortion is illegal in most countries, it has been estimated that
induced abortion is the cause of between one-fifth and one-half of all
maternal deaths (3).
Maternal morbidity
Reliable data on maternal morbidity are even more scarce than those
for maternal mortality, but some general observations can be made.
Chronic malnutrition and anaemia, closely interrelated with acute and
chronic infections such as malaria, infectious hepatitis, urinary tract
18
infections, and pulmonary tuberculosis, cause much suffering. Malaria in
particular is very widespread. Pregnant women lose part of thenacquired immunity, and malaria attacks are therefore often more severe
in pregnancy. Malaria of the placenta increases the risks of abortion and
low birth weight.
Anaemia is widespread among women of child-bearing age, both in
developed countries and in particular in developing countries. In the
latter the percentage of non-pregnant women with haemoglobin levels
indicative of anaemia ranges between 10% and 100%, and in developed
countries between 4% and 12% (4).
Almost all chronic diseases, such as hypertension, renal disease and
diabetes, are aggravated by pregnancy. Addictive drugs, alcohol and
smoking during pregnancy can lead to retardation of intrauterine growth
and even to malformation. Psychological stress factors are also of
increasing concern.
Involuntary infertility is a condition which causes great personal
distress and has important social implications. In most parts of the
world, about 2-10% of couples are affected, but in certain areas of Africa
the percentage of infertile couples may be as high as 40%. It is thought
that the causes of this high frequency include sexually transmitted
disease resulting in tubal obstruction, as well as sequelae from obstetric
conditions (5).
Fig. 3
PROBABILITY OF DYING BEFORE THE AGE OF 5 YEARS
IN MAJOR REGIONS
Source: WHO (Division of Family Health) estimates based on data from various sources.
19
Infant and childhood mortality (Table 4)
As mentioned earlier, of the some 122 million infants born each year,
roughly 10% will die before reaching their first birthday, and another 4%
before their fifth birthday. But the chances of survival are very unevenly
distributed in the world. While the risk of dying before reaching
adolescence is about 1 in 40 in developed countries, it is 1 in 4 in Africa as
a whole, and even as high as 1 in 2 in some countries. There are vast
differences between regions, in particular between Africa and South
Asia, where life expectancy is below 60 years, and the rest of the world.
In some of the former areas, nearly two-thirds of all deaths are those of
children below 5 years (see Fig. 3 and 4).
Fig. 4
DEATHS OF CHILDREN AGED UNDER 5 YEARS
AS A PERCENTAGE OF DEATHS AT ALL AGES
Source: WHO (Division of Family Health) estimates based on data from various sources.
20
Regardless of the level of infant and child mortality, the probability of
dying is at its peak at the time of birth and immediately before birth, and
except for a minor peak which marks the end of breast-feeding, it declines
thereafter. Both the probability of dying and the main causes of death
change rapidly during the early years of life. The conventional distinction
between perinatal (28th week of gestation to 7th day of life), neonatal
(first 28 days of life), post-neonatal (28th day to 1 year), infant (up to
1 year), and child (1-4 years) mortality is convenient from both the
analytical and the programmatic points of view. Of particular importance
is the different impact on mortality in each of these periods of adverse
environmental factors, especially nutrition. In countries where infant and
Fig. 5
DISTRIBUTION OF BIRTH WEIGHTS OF INFANTS
IN TWO CONTRASTING COMMUNITIES
Source: Based on data presented to a workshop on birth weight—A novel yardstick of development,
organized by the Swedish Agency for Research Cooperation with Developing Countries and
WHO. Sigtuna, Sweden, 16-18 June 1977 (see SAREC report No. R: 2, 1978).
21
child mortality have been reduced, mortality at the ages of 1-4 years has
fallen first and most rapidly, while perinatal mortality has declined much
more slowly.
Perinatal mortality now accounts for about 90% of all fetal and infant
mortality in the developed countries with the lowest infant mortality
rates, where more deaths occur in this short period (28th week of
gestation to 7 th day of life) than in the next 20 years of life. The under
lying causes of perinatal deaths are linked to those of maternal deaths,
i.e., poor health and nutritional status of the mother and complications of
pregnancy and childbirth.
Perinatal mortality is also closely associated with low birth weight,
defined as a birth weight below 2500 g; it affects mortality in the whole
first year of life and probably also in the following few years, and it has
adverse long-term effects on the development of the child. In a recent
WHO review of available information (6) it was estimated that nearly 21
million infants of low birth weight are bom each year. Globally, this
means that about 1 in every 6 infants has a low birth weight, but the inci
dence is not evenly spread about the globe. In some parts of Asia the
ratio is almost 1 in 2, while in parts of Europe it is only 1 in 17. Between
these extremes the incidence ranges, by geographic region, from 31% in
Mid-South Asia and 20% in Asia as a whole, to 15% in Africa, 11% in
Latin America and the Caribbean, to 8% in Europe and 7% in North
America. Of the 20.6 million low-birth-weight infants born in 1979, over
19 million, or 90%, were born in developing countries, mostly among the
least privileged populations. There are strong indications that these
babies contribute to a large proportion of deaths and childhood mor
bidity, the risk of mortality being up to 20 times higher than for other
babies, both in the neonatal period and later.
Late neonatal (after the first week of life) and post-neonatal deaths are
now uncommon in developed countries. In many developing countries,
however, they account for almost two-thirds of all infant mortality. In
many areas, tetanus may account for up to 10% of all neonatal mortality,
but diarrhoeal diseases, closely followed by respiratory infections, are the
leading causes of morbidity and mortality in the first year of life.
Malnutrition, as an underlying cause, is also important; it has been cited
as responsible for up to 57% of mortality at between 1 month and 1 year
of age in some countries (7).
The most effective measure for the prevention of malnutrition and for
protection against infection in infancy is breast-feeding. Evidence from
the developing countries indicates that infants breast-fed for less than
6 months, or not at all, have a mortality 5-10 times higher in the second
6 months of life than those breast-fed for 6 months or more. Despite the
marked advantages of breast-feeding, its popularity expressed in terms
of the number of women who practise it and how long they continue
breast-feeding has declined significantly in many parts of the world.
Historically, the decline has been particularly marked in highly devel
oped countries but there is evidence to suggest that in these areas the
trend is now changing and that the prevalence and duration of breastCH
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22
feeding may be increasing. In developing countries, where the value of
breast-feeding is most marked and where larger proportions of infants
are at risk of malnutrition and infection, data gathered by the WHO
Collaborative Study on Breast-feeding indicate that in some urban areas
relatively large proportions of mothers are not establishing breast
feeding. In the Philippines, for example, 33% of urban upper income and
15% of urban poor mothers who were interviewed had not breast-fed their
youngest child. Of those that do, many wean their infants before 6
months. The prevalence and duration of breast-feeding among rural
populations of developing countries, however, continue high although in
some cases problems of nutrition and health status in infancy appear to
be associated with the late introduction of appropriate and regular
supplementary feeding (8).
Mortality at the ages of 1-4 years is much lower in all populations than
infant mortality. In some areas with exceptionally high mortality levels,
the probability of surviving from age 1 to age 5 may, however, be as low
as 80%, mainly due to high death rates in the second year of life. During
this second year the main underlying causes of infant mortality continue
to be important. The infectious diseases of childhood, such as measles,
whooping cough, and pneumonia, begin to appear in the second half of
the first year or in the second year of life. Combined with malnutrition,
these diseases lead to high case-fatality rates. For example, during the
famine in the Sahel in 1973-1974, the case fatality from measles was esti
mated by WHO to be up to 50%. In other parts of tropical Africa the case
fatality is 7-10%, which is still very much higher than in most parts of
the world.
Childhood morbidity
For every childhood death there are many episodes of disease and illhealth. Many common childhood diseases and conditions do not usually
kill their victims but may cause serious chronic damage. Some of this is
already apparent in childhood (blindness, paralysis), while other sequelae
become manifest later in life (chronic heart disease, mental retardation).
In the developed world, accidents are the leading causes of death of
children aged 1-4 years, and they also result in a substantial amount of
disability. In the USA, for example, about 300 000 children are hospital
ized annually because of head injury and some 20 000 of these suffer from
some degree of permanent brain damage (7). There is every reason to
believe that accidents among children are frequent also in the developing
countries, especially burns and traumas as a result of home accidents
and, to an increasing degree, traffic accidents.
Behavioural disturbances Eire another child health problem the import
ance of which is increasingly recognized in most countries (9). In some
countries children abandoned by their families present severe social and
health problems; for example, the International Union for Child Welfare
has estimated that there are 2 million such children in Brazil and 1.5
million in India.
23
/
Fig. 6
DEATHS DUE TO ACUTE RESPIRATORY INFECTION
Note:
Data show deaths due to acute respiratory infection as a percentage of deaths from all causes in
the period 1970-1973.
Source: Bulla. A. & Hitze, K.L. Acute respiratory infections: a review. Bulletin of the World Health
Organization, 56: 481-495 (1978).
Malnutrition is the most widespread condition affecting the health of
children, particularly in the developing countries. Some 100 million
children under 5 years of age suffer from protein-energy malnutritionmore than 10 million of them from severe protein-energy malnutrition,
which is usually fatal if untreated. The prevalence is highest in Africa,
where it was estimated in 1974 that in some areas up to 23% of children
aged under 5 years suffered from severe, and up to 65% from moderate,
protein-energy malnutrition (10).
Other nutritional deficiencies include insufficiency of vitamins A
and D. The extent of blindness in children, primarily due to vitamin A
deficiency, is tragic. In spite of the abundance of sunshine, which pro
motes the synthesis of vitamin D in the body, children in parts of Africa
and Asia suffer from rickets mainly because of traditional beliefs about
child-rearing. This problem may also be found in migrant and other popu
lations in the industrialized countries.
24
. t .
A
Adolescence
Overall mortality is relatively low in adolescence, compared with other
phases of life, both in developing and developed countries, being gener
ally higher for males than for females. However secular trends may be
noted for some causes such as accidents and suicides which are increasing
(11), causing high death rates for males aged 15-19 years in a number of
developed countries.
For reasons that differ from country to country, and culture to culture,
there is widespread experimentation by adolescents with alcohol and
other drugs as well as with smoking. In many countries, about half the
adolescents indulge in such exploratory behaviour. As to smoking, there
have been some encouraging signs of a decline in recent years. In the
USA in 1975, for example, 34% of the boys and 35% of the girls in the
13-19-year age group who had ever smoked had given up doing so (12).
The sexual behaviour of adolescents is undergoing rapid changes in
many parts of the world, towards more and earlier sexual activity. In
most industrialized countries and in many areas of Africa, the incidence
of sexually transmitted disease among adolescents is more than twice as
high as it is among those aged 20-29 years. A striking increase in the
incidence of sexually transmitted diseases, especially gonorrhoea, has
been observed since the 1960s (13).
Information on the frequency of teenage pregnancies in developing
countries is limited. However, it is known that in some countries 50% of
first births occur to mothers aged less than 20 years, as do 25% of the
second births and 10% of third births.
Early teenage pregnancies pose special health risks not only for the
mother but also for the child. Evidence clearly shows that maternal
mortality rates are considerably higher for younger women, and that
teenage mothers also run a high risk of losing their babies in infancy.
25
Developments in maternal and child health:
Technologies and knowledge
Important advances in science and technology in the past few decades
have opened up new vistas for maternal and child health. Their potential
positive impact on the health status of mothers and children throughout
the world is very promising, especially from the point of view of prevent
ing deaths, disease and disorders. These developments, however, have
benefited mostly urban populations in industrialized countries. Vast
rural and peri-urban populations, mainly in developing countries, remain
untouched by them.
In the industrialized countries, the technological progress has been
rapid, with a trend towards increasingly sophisticated techniques and
the development of potent curative drugs. In obstetrics, the main devel
opments have been availability of life-saving oxygen, transfusion facili
ties and antibiotics, technology for fetal monitoring during labour, and
improved techniques for the induction of labour and for obstetrical anal
gesia. These have been coupled with such negative institutional practices
as separating the child from the mother after birth and inducing labour at
the convenience of the physician or hospital staff.
The technologies developed, although beneficial when used rationally,
have tended to interfere with a basically healthy, normal process.
Moreover, these advances have called forth new and costly mechanisms
and organizations to protect individuals and families against the illeffects accruing from abuse, misuse or over-use of the new technologies
and types of care. These ill-effects have been challenged both by the
public on the grounds of cost and the inhuman nature of the care, and by
clinicians on the grounds of their potential danger.
Prenatal and postnatal screening for metabolic, congenital or genetic
disorders in the fetus and newborn has been made possible by sophisti
cated biochemical and cytological techniques and devices; amniocentesis
is an example of such a technique.
Advances have also been made in the treatment of infertility. These
have centred on the development of drugs for the treatment of women
and men with impaired egg or sperm production, and highly sophisti
cated techniques for reconstructive surgery and embryo implantation.
This technology which is costly, both in terms of money and skilled
manpower, had had no impact in those areas of Africa where infertility is
a priority problem for maternal and child health.
The care of the newborn has progressed greatly through better know
ledge of the physiology of the kidney, gastrointestinal and lung function,
and heat regulation. This has led to improvement in techniques of
anaesthesia, intravenous nourishment, etc. Treatment of episodes of such
diseases as meningitis and pneumonia is now very successful; some
malignant diseases of the infant are controllable; and early surgical
corrections of malformations (including heart and eye defects) are very
effective.
26
Child psychology and psychiatry are becoming increasingly important
in general paediatric care. The care of children with chronic disorders is
more and more looked upon as part of family health. Likewise, insti
tutional care of handicapped children is being replaced by various social
support measures and services enabling families to assume a larger share
of rehabilitation within the family circle.
Preventive technologies
Preventive technologies in maternal and child health have had farreaching effects. Methods of fertility regulation have constituted an
important area of research over the past 15-20 years. New drugs, devices
and techniques have been developed but many problems related to side
effects are yet to be solved. Current research efforts are centred on
improving existing methods and developing new, safe and effective
methods which are simple to use or administer. Better technologies for
abortion, such as vacuum aspiration and the use of plastic cannulae
(small surgical tubes), have made the procedure safer and simpler.
Methods of fertility regulation are used by individuals numbering tens
of millions throughout the world; their implications for health—both
immediate and long-term—are numerous. The availability of effective
modem contraceptive technology has not only contributed to improve
ments in health but it has also brought about radical changes in the lives
of women.
Infectious childhood diseases can kill. In addition, many have after
effects that leave the survivors handicapped for life. The greatest success
in prevention of disease in childhood has been the development of
vaccines that protect children from common infectious diseases which
can cause severe health problems later in life. Effective, safe vaccines
have greatly reduced the incidence of diphtheria, whooping cough,
tetanus, tuberculosis, measles and poliomyelitis. Improved techniques of
immunization and of simple cold storage systems have also contributed
to the effectiveness of immunization efforts.
The prevention of diseases and disorders resulting from nutritional
deficiencies has been enhanced through the development of techniques
for the fortification of foods, e.g., the fortification of sugar with
vitamin A and of salt with iodine. These techniques have become wide
spread and have done much to reduce or even eliminate the incidence of
some deficiences.
The development of a simple method of oral rehydration for treatment
of diarrhoeal diseases in young children, although not a preventive
technology per se, has the potential for significantly reducing the great
number of deaths now caused by these diseases. With appropriate
instructions the method can easily and safely be used by the primary
health worker and family members.
Developments in knowledge
In recent years a better understanding of the process of growth and
27
development h^ejnerged and^pade possible the identification of critical
stages for normakbealtjiy patterns<It4jj jip^recognized that many of the
foundations of later health rest in those all-important first 40 weeks of
life, starting at conception. Increasing attention is paid to the intra
uterine environment, especially with regard to maternal nutrition, and
the crucial importance of the last trimester of pregnancy as the main
energy storage period of fetal life. It was less than 40 years ago that the
possibility was widely recognized that environmental factors during fetal
development, especially the first trimester, caused malformations in
humans. This was underlined, among other observations, by the dis
closures concerning the thalidomide tragedy, which drew attention to the
still under-researched area of perinatal pharmacology.
In the 1970s, results of research made it increasingly clear how events
in early life affect the health of the adult, and how many conditions can be
prevented through early action (1). For example, dental disease in adult
hood can be almost totally prevented by action in childhood. Early treat
ment of streptococcal infections in childhood can prevent rheumatic
heart disease. In spite of the evidence that genetic factors play a role in
essential hypertension, longitudinal studies suggest that the foundations
of hypertension in susceptible individuals may well be laid in early life.
The effects from one generation to the next of adverse environmental
conditions—especially undernutrition—are manifested, for example, in
delayed menarche in developing countries, as well as in the adverse
effects of small stature of the mother on outcome of pregnancy.
Studies carried out in recent years have irrefutably demonstrated
the synergistic effects of malnutrition and infection. These studies have
also shown that malnutrition, especially protein-energy malnutrition,
is a contributing or associated factor in more than half of childhood
deaths. In industrialized countries overnutrition has become a major
problem; because treatment generally fails, prevention becomes of prime
importance.
Evidence of the importance of breast-feeding is leading to attempts to
reverse the trend away from this practice in some areas, and to maintain
the present level of breast-feeding in others. Studies on breast-feeding
have conclusively shown that breast milk not only meets all the
nutritional needs of the baby safely and adequately, but also provides the
baby with defences (immunities) that protect against many of the
illnesses of early infancy. Recent studies have also demonstrated the
significance of early mother-infant contact, or “bonding”, for infant and
child development.
Research needs
Research in cell biology, immunology and pharmacology should yield
more knowledge during the coming years. Future research efforts in the
area of maternal and child health as part of the health care system should
take into account developments in the social sciences and lay more
emphasis on operational and health services research. A new balance has
28
to be struck so that research efforts are relevant to the health needs of
the people and take socioeconomic factors into account. The process of
socialization of the young child and the adolescent, for example, is not yet
well understood. This topic calls for the involvement of researchers from
many disciplines and it has great potential for improving the educational
system. The many roles that women are called upon to play in the family
and community must be better understood and supported for the benefit
of society as a whole. Much more needs to be known about the quality
and quantity of self-care in childbearing and child-rearing, and effective
social support systems need to be studied and developed. The efficiency
and effectiveness of the health care system should be studied at all levels
in various settings. This will call for the study of approaches to com
munity participation in decision-making, problem identification and pro
gramme implementation.
29
Recent trends in maternal and child health care
Maternal and child health care is no longer considered a separate entity
in health services. The content of care is more and more being adapted to
the priority health problems, sociocultural patterns, and child-rearing
and childbearing customs. Furthermore, in the past decade family plan
ning has increasingly been considered an integral part of maternal and
child health.
The components of maternal and child health care will vary from one
community to another as they are adapted to problems and solutions.
Nevertheless, they might include the following essential elements: care
during pregnancy and childbirth; promotion of breast-feeding and
appropriate infant and young child nutrition; supervision of growth and
development and prevention of infections, by immunization where appro
priate; the prevention and the management of infant and childhood diar
rhoea, which involves oral rehydration; family planning, including
prevention and treatment of infertility; family health education in
support of family self-reliance. In all countries the increasing dependence
on costly and complicated medical equipment and the over-dependence
on drugs are being questioned and more appropriate technologies are
being developed.
Organization of care
New planning methods are being developed to permit more effective
maternal and child health care; these include the “risk approach” being
promoted by WHO. This approach can be considered a managerial tool
for the flexible and rational distribution of existing resources, based on
measurements of individual and community risks, and for developing
local strategies and determining the appropriate content of maternal and
child health care, including family planning. Inherent in this approach is
the maximum utilization of all resources, including some human re
sources that are not conventionally involved in such care—traditional
birth attendants, teachers, women’s groups, and agricultural workers, for
example {14).
Conventional maternal and child health services tended to be frag
mented. The various components, immunization and family planning for
example, were dealt with separately by different staff. Nowadays there is
a general trend away from this fragmented approach towards “inte
grated”, comprehensive health care in which every contact of mother
and/or children with the health care system is seen as an opportunity to
deal with the health problems of all members of the family, and to see
each individual’s problems and needs in the context of the family and
community.
Manpower and training
The special category of “MCH worker” at the primary level is
gradually being phased out. A wide range of workers from various
30
sectors, both formal and informal, are being considered for maternal and
child health care. At the community level, these would include primary
health workers, crdche staff, extension workers, grandparents, members
of women’s organizations, schoolteachers and traditional birth attend
ants. However, training in maternal and child health care has not yet
been widely extended to workers in sectors other than health.
Availability and utilization of services
Much remains to be done in most countries to ensure universal access
to health services and to meet the health needs of populations. Despite
the efforts made by many developing countries to strengthen their health
services, the bulk of resources are still for urban specialist and hospital
care. For example, in a large Asian country only 32% of the rural popu
lation lived within a three-kilometre radius of any kind of health facility
at the end of 1975, while the corresponding percentage for the urban
population was 98%.
Services may also be underutilized for a variety of reasons, some of
which relate directly to the lives of women, who are the main users. In
many areas, women are overburdened: they spend their day working in
the field, fetching water, preparing meals and procuring food for the
family. They may have little energy and time left to seek health care,
especially when it is not easily accessible. Also, in some societies, women
prefer to consult or be examined by female health workers, who may not
be available.
Care during pregnancy and childbirth
Care during pregnancy and childbirth is provided in different forms,
with special clinics, outpatient and other services involved. Figures for
births attended by trained personnel in developing countries show a wide
range among regions: in Africa, the figures for countries range from 6%
to 67%; in Asia from 3% to 95%; and in Latin America from 12% to 97%.
These variations notwithstanding, the proportion of deliveries attended
by trained personnel is rising steadily in many countries. However, a
review by WHO of the most recent information suggests that in some
parts of the world at least 50%, and in a few instances as many as 85%, of
births are assisted by traditional birth attendants or relatives. In the
past traditional birth attendants were generally not recognized by the
health authorities. More and more countries are now devoting attention
to their training and utilization, and making provision for supervision
and referral.
Family planning
Recognizing the health and social benefits of family planning, more
countries are integrating family planning within national health pro
grammes. According to a recent worldwide survey, the percentage of
women of childbearing age who practise family planning nearly doubled
in some regions during the first half of the 1970s (15). In 1976, 34% of
31
couples in their reproductive years throughout the world were using
some form of contraception regularly. As can be expected, there are great
variations within and between countries; for example, over 50% of
eligible women practised family planning in the Western Pacific Region,
in Europe and in North America, whereas in West Africa the figure was
only 3%. Some 360 million women, however, remain unprotected. A
series of fertility surveys in all parts of the world showed a large pro
portion of women who did not want any more children, yet who did not
have the information or the means to practise contraception. In fact, only
half the couples of the world have sufficient knowledge to plan their
families, according to information compiled by the International Planned
Parenthood Federation.
Abortion
According to recent estimates, as of mid-1978, 9% of the world’s popu
lation lived in countries where abortion was prohibited without excep
tion, and 11 % lived in countries where it was permitted only to save the
life of pregnant women. Around 14% lived under statutes authorizing
abortion on broader medical grounds, that is, to avert a threat to the
woman’s health rather than to her life (with mental health specifically
mentioned in several countries), and sometimes on eugenic, or fetal, indi
cation (known genetic or other impairment of the fetus or increased risk
of such impairment) and/or juridical indication (rape, incest, etc.) as well.
Some 25% of the world’s population resided in countries in which social
factors—inadequate income, substandard housing, unmarried status,
and the like—could be taken into consideration in the evaluation of the
threat to the woman’s health or in which adverse social conditions alone,
without reference to health, could justify termination of pregnancy.
Countries allowing abortion on request without specifying reasons for at
least some categories of women—generally defined in terms of age,
number of children, and/or duration of pregnancy—accounted for 39%; in
these countries, abortions on medical grounds were generally permitted
beyond the gestational limit prescribed for elective abortion. No infor
mation is available for the remaining 2% of the world’s people; it would
appear, however, that most of them lived in areas with restrictive
abortion laws (16).
Infertility
Increasing attention is being paid to the social, public health and
service implications of infertility in developing countries. The frequency
of infertility is probably higher than the figures indicate, and its
treatment is too often a specialized service reserved for the privileged
few. Research is being conducted to achieve a better understanding of the
etiology of the problem and to indicate what conditions can be treated.
This research has important implications for the development both of
appropriate treatment and of services which can be made available to a
wider segment of the population.
32
Infant and child care
In developing countries, national data for infant and child services are
even more difficult to obtain than those for other components of maternal
and child health care; and the “content” of such services varies. In
general, however, it includes continuous supervision of the growth and
development of the child; prevention and management of common infec
tions and specific childhood diseases; and promotion of good nutrition.
At the present time, it is estimated that less than 10% of the children
born each year are immunized against the six common childhood diseases
(pertussis, tetanus, diphtheria, measles, tuberculosis and poliomyelitis).
It can be assumed that these 10%, at least, also receive appropriate pre
ventive health care in other respects. But in spite of a growing realization
of the importance of such care, the large majority of the world’s young
children come into contact with the health service only when they need
curative care.
While the role of the mother and father in the development of the
young child is recognized as a crucial one, adequate counselling in this
matter is rarely provided to expectant mothers, let alone to fathers.
Moreover, health services rarely provide for health education of families.
This is mainly due to such factors as pressure of time, inadequate
preparation of health workers, and lack of suitable educational materials.
Other relevant services and legislation
The health care of children is not limited to interventions through the
health care system; other related social services are closely involved.
Day-care services/facilities: The day-care of children is becoming a
pressing issue in some areas because of the growing trend towards work
outside the home, or far away from the home environment, for both
parents. This also entails a growing need for society to provide support
for child-rearing.
In developing countries, there are very few examples of governmental
efforts to implement day-care systems. Isolated efforts are made in the
private sector; however, they primarily benefit the privileged classes.
Nevertheless, in Africa there are examples of community-organized
group care of children, involving women’s groups or political organiz
ations, in newly developed urban areas and in agricultural areas. Depend
ing upon the sociocultural setting, other approaches are also being
developed. They include organized systems of day-care in factories or
industrial facilities, neighbourhood centres, cooperative self-help
women’s groups, and family-based day-care facilities for children of
working parents in which older members of the family take part. WHO is
currently studying these different approaches, their implications for
maternal and child health, their financing, as well as the degree of com
munity participation involved.
School health: While in the past the emphasis was on routine health
examinations of schoolchildren, school health now concentrates on motiv
33
ating children to develop healthy habits for their lifelong health. In addi
tion, schoolchildren join in learning about health problems of their
community as a whole, and in carrying out selected health activities for
themselves as well as for other children and their families. Schools can
effectively carry out specific activities such as updating of immunization,
nutrition education, accident prevention, and screening for hearing and
eyesight problems. The training of schoolteachers and other school
employees to give health guidance is being increasingly emphasized by
organized educational systems. WHO, in collaboration with Member
States, is exploring the role of the school in extending health care to the
community, and examining the potential role of education and health
personnel in preparing children for better family life.
On the other hand, in areas where school attendance is low, and where
the social environment is poor, the health needs of out-of-school children
may be overlooked. This problem is likely to become more acute since it is
estimated that by 1985 the number of children who receive no formal
schooling whatsoever will have increased considerably. WHO is, there
fore, exploring channels for reaching this group of young people.
Services for adolescents: Adolescents in most of the world are served
through normal health service channels, or through special services such
as school health services, though the latter do not exist in most areas for
this age group. Innovative types of services for adolescents have been
developed, mostly in urban centres in industrialized countries. They are
usually provided through nongovernmental or voluntary systems of care,
and have very limited coverage; they are also geared chiefly to special
problem groups, including adolescents with problems related to drug
addiction, juvenile delinquency, and teenage pregnancy.
Social legislation: During the past decade many countries, both
developed and developing, have enacted legislation that upholds the
right of individuals with respect to the availability of necessary services.
International labour conventions governing maternity leave, flexible
hours so that a mother may breast-feed her child, and the provision of
day-care facilities for young children have now been implemented in
almost all developed countries and some developing countries. In a few
countries in Europe, for example, social legislation adopted in recent
years enables mothers in outside employment to stay at home with full or
partial pay for a year or more in order to care for her child. Legislation in
one European country allows for the mother or father to stay at home for
the first eight months of the child’s life. Furthermore, legal developments
since 1967 reflect a change in attitudes towards abortion and family
planning.
Workers' health: Recent studies have shown that occupational con
ditions for women are often poor, with specific and serious effects on their
health, particularly in relation to complications in pregnancy. Several
types of industrial pollution have been shown to have deleterious effects
on fetal development.
34
In conclusion, for maternal and child health care to be effective, it must
be adapted to the life-style and socio-environmental conditions in each
area or country, and planned to meet the specific needs of the populations
concerned. The positive examples which are found on either a regional or
national scale are convincing enough to indicate that it is possible to pro
vide such care for many populations in the world which are now deprived
of such care.
Maternal and child health and primary health care
The past decade has witnessed mounting worldwide concern about the
rapidly changing family and population dynamics and their effects on
health everywhere. There are still millions of people without access to
any kind of health care who are eking out a meagre existence in adverse
and unstable socioeconomic and political conditions, including rapid
population growth.
The International Conference on Primary Health Care held in AlmaAta (USSR) provided a forum for all those concerned with this crucial
problem (17).
At Alma-Ata and in recent World Health Assemblies, the nations of
the world have set the target of attaining an acceptable level of health for
all by the year 2000, so that all peoples of the world can live socially and
economically productive lives. They also endorsed the principles and
approaches of primary health care as the key to achieving this goal.
Underlying primary health care is the conviction that health and develop
ment are closely interrelated.
At the Alma-Ata Conference, primary health care was defined as
“essential health care based on practical, scientifically sound and socially
acceptable methods and technology made universally accessible to
individuals and families in the community through their full partici
pation and at a cost that the community and country can afford to main
tain at every stage of their development in the spirit of self-reliance and
self-determination. It forms an integral part both of the country’s health
system, of which it is the central function and main focus, and of the
overall social and economic development of the community.”
The crucial importance of maternal and child health care within this
approach can hardly be over-emphasized. The basic principles underlying
the overall strategies and policies for primary health care are funda
mental to the concepts of maternal and child health care: the intersec
toral approach; the need for total coverage; the participation of individual
families and communities; the maximum use of existing resources such
as traditional birth attendants, women’s groups and schoolteachers.
As the major and essential action for maternal and child health takes
place within the family, the emphasis in the care afforded as part of
primary health care must be to support community and family selfreliance, especially regarding the family’s responsibilities in childrearing, childbearing and self-care.
35
Action now
The knowledge and technology required to reduce greatly the rates of
death of mothers and children, alleviate their suffering, and improve the
quality of life for all people throughout the world are available now.
Countries can set targets which can be measured, and the effectiveness of
maternal and child health actions can be monitored through the use of
suitable indicators. A large proportion of the major health problems of
mothers and children could be prevented through the application of tech
nologies already well-known.
What can be done: some examples
• Maternal deaths could be brought to within a range of 1-3 per
10 000 births in all parts of the world. Complications of
pregnancy and childbirth could be reduced through: prenatal
checks for every woman, to identify those who need extra
care; nutritional supplementation (including iron supple
mentation) when required; attendance during delivery by a
person appropriately trained.
• Births can be spaced and timed, with advantages for maternal
and infant health. The information, and many effective
methods, exist to regulate the timing and spacing of preg
nancies. These could be made available to all couples at low
cost. The means for choice could be within the reach of all.
• The rates of low-birth-weight babies could be reduced to not
more than 10% in all parts of the world. The third trimester of
pregnancy is of particular importance for the growth of the
fetus. Alleviating the high-energy consuming tasks of women,
increasing the energy intake, and controlling infections could
raise birth weights greatly, and contribute to reductions in
infant mortality. Families and communities could do much to
help and governmental support could be provided, through
such measures as maternity leave and child benefits. All
members of society must share these responsibilities.
• Neonatal tetanus could be controlled in all societies. Immu
nization of women twice before the birth of the baby is suf
ficient to prevent neonatal tetanus. This could become the
next worldwide success following the eradication of smallpox.
• Vitamin A and D deficiency diseases could be prevented. The
scientific basis for preventive action has been known for over
half a century. If all channels of communication were used to
convey the information and if nutritional supplementation
were provided where needed, the suffering caused by these
deficiencies—the blindness and deformities—could be elimi
nated. With a concerted effort, this goal could be achieved.
36
• Deaths due to diarrhoeal diseases could be reduced signifi
cantly. The immediate application of the oral rehydration
treatment could save millions of lives, giving young children a
chance to survive the crucial weaning period. The rehydration
can be performed within the family, thus greatly facilitating
its widespread use.
• Death and disabilities due to childhood diseases could be
avoided. Systematic immunization against diphtheria,
pertussis, tetanus, tuberculosis, measles and poliomyelitis
can effectively reduce the incidence of these diseases. Early
identification and treatment of acute respiratory infections in
the family and the community would significantly reduce
mortality.
The Member States of WHO have set the target of immunizing all
children of the world by the year 1990, while the United Nations Water
Conference (1977) set the goal of safe water supply and sanitation for all
by 1990. Exactly what impact these will have on infant mortality is not
known. However, it is clear that in order for the impact to be significant
they must be accompanied by other essential elements of maternal and
child health care, including a substantial improvement in nutrition.
Other components of care are more complex by the very nature of the
problems and solutions; they require time for people to absorb infor
mation and change behaviour. Some examples follow:
Prevention of accidents. Accidents are of concern to both developed
and developing countries. Because they are the dominant cause of death
of children over 4 years of age in many countries, a declining rate must
now be aimed at. The health care system can give the diagnosis but must
convince other sectors of their roles in preventing this “man-made
disease’’.
The promotion of infant and young child nutrition. The promotion of
breast-feeding is fundamental to preventing malnutrition in infancy, as is
the control of the introduction and use of breast milk substitutes. The use
of locally produced, nutritionally and culturally acceptable foods during
the weaning period is essential. Knowledge about the dietary needs of
children and about the timing of meals and the form (density) of foods can
be conveyed to people. Simple growth charts to record the growth of
children exist and can be kept by mothers.
Education. Knowledge about health and its determinants and prep
aration for parenthood should become part of general education, through
formal and informal educational programmes, the mass media, etc. Infor
mation on the behavioural and psychosocial aspects of child development
can help to prevent many mental health problems at later stages.
Increased knowledge and information are essential for people to improve
their own health. Education of the public in health costs little compared
to the high price of ill-health.
37
Social legislation. The fact that women have a unique role in the
creation of a new generation must not lead to the assumption that the
whole responsibility should lie with them. There is no reason why women
should carry the main burden, as well as pay the price of higher mor
tality, more ill-health, lesser opportunities in the labour market, or less
pay. Men are partners in more than a biological way, and the duties and
joy of caring for and being with children surely belong to both men and
women. The future generation is the responsibility of society as a whole—
men and women, parents or not. It is their duty to create the best
possible conditions for the growing generation.
Training strategies for maternal and child health care. Strategies
should be oriented to ensure that the training is socially relevant and
addresses itself to the three main groups involved: (a) families, com
munities and the public at large; (6) workers in various development
sectors, including policy-makers and planners; and (c) the different
categories of health workers at all levels, including primary health
workers, health auxiliaries, traditional birth attendants, and health
professionals and specialists working at supervisory and referral levels.
Health research. As already noted, certain areas require new
knowledge and appropriate technologies. In general, however, to meet
the priority needs of maternal and child health, much is already known.
In the years to come, the major research efforts will have to be geared to
the application of this knowledge, with emphasis on health service
research.
In summary, some of the major health problems of mothers and chil
dren could be solved “here and now” by the adoption of appropriate
measures; others would require more time since changes in attitude and
behaviour are called for. The attainment of all the goals enumerated
above presupposes several things: a firm political will on the part of
governments and supporting social organization; an increased budget for
health with an objective and rational allocation for maternal and child
health; a health care system that provides support to peripheral levels
and the “have nots”; measurement of the impact of the health services on
the health problems of the population.
38
WHO’s role in the promotion of maternal and
child health care
The Family Health Programme
The maternal and child health activities of WHO are carried out within
the Organization’s overall programme of family health. They are not only
a natural concern of the Organization; they are an obligation under its
Constitution, which states that one of WHO’s functions is “to promote
maternal and child health welfare and to foster the ability to live
harmoniously in a changing total environment”.
The objectives of that programme are:
• to promote family health, in particular to foster optimal
physical growth, the psychosocial development of the child,
improved reproductive health, and an enhanced quality of life;
• to support technical cooperation with and among Member
States in developing and strengthening the family health
component of the overall health system;
• to promote intersectoral development strategies for improv
ing the health and social wellbeing of women, children and the
family as a whole.
In pursuit of these objectives, WHO works in close collaboration with
the other bodies of the United Nations system, in particular UNICEF,
UNFPA, FAO, and UNESCO, and with bilateral agencies, nongovern
mental organizations and similar bodies, such as the International
Children’s Centre, the International Paediatric Association, and the
International Planned Parenthood Federation.
As part of the family health programme, the Organization’s maternal
and child health activities are carried out together with those more
specifically concerned with nutrition, health education and human repro
duction. They are also closely linked with other programmes such as
those dealing with diarrhoeal diseases control, immunization, mental
health, and health manpower development.
Through intercountry collaboration in all regions, WHO supports
activities to promote more efficient and effective methods for the inte
gration of maternal and child health care in all aspects of health develop
ment programmes; increased community participation in maternal and
child health/family planning activities; better approaches to multi
disciplinary and multisectoral programme development; and the
inclusion of traditional practitioners in health delivery systems. The
application of research findings, especially on new or adapted maternal
and child health/family planning technologies is stressed.
Health services research in maternal and child health/family planning
takes the primary health care approach. The collaborative programme on
“risk approach” in maternal and child health care, which started in 1974,
39
may be taken as one example. By using indicators of risk, studies first
establish the interrelationships between priority health problems and
communities and individuals. This epidemiological knowledge is used to
prepare new strategies, which are then tested in “real life” before being
proposed for local or national application. The “risk approach” is actionoriented and serves as a tool for change in the health care system. Partici
pation of health administrators, health staff and the community in this
type of health services research ensures maximum utilization of the
findings.
Training continues to be a major part of the maternal and child health
programme, as part of WHO’s support to national efforts in strengthen
ing national institutions and self-reliance in health manpower develop
ment. The Organization’s global and regional training activities in
comprehensive maternal and child health/family planning are being
oriented to reflect training more appropriate to the health problems and
needs of the vast majority of the population. Training takes place in
regional and national institutions in developing countries.
The programme of teacher-training in comprehensive maternal and
child health includes activities which are tailored to the specific needs of
national programmes. The focus in all regions is on health service needs,
and priority is given to the training of those involved in health service
delivery. Emphasis is placed on activities dealing with the synthesis of
knowledge and exchange of information on physical and psychosocial
development in childhood and adolescence, including nutritional aspects,
for use in the planning and formulation of practical strategies for timely
intervention programmes. There are six WHO collaborating centres
concerned with teacher-training in four regions.
Local adaptation of the WHO growth chart (18) to measure child
growth and development is also promoted. The chart is being used as a
practical tool in many areas by primary health care workers as well as
families. Studies are carried out on the epidemiology and social
implications of low birth weight; the results will be utilized for the
development of practical intervention strategies both during and before
pregnancy in order to reduce the frequency of low birth weight and
resulting morbidity and mortality. WHO also is studying the feasibility
at the local level of using birth weight as an indicator for assessing
maternal health and for predicting the future health of the child.
The WHO collaborative study on breast-feeding, mentioned earlier,
carried out in nine countries, has provided valuable knowledge on the
patterns of breast-feeding in various socioeconomic groups in different
regions of the world. The results of this study are used for the promotion
of appropriate infant feeding. The second phase of the WHO collabor
ative study, dealing with the quality and composition of breast milk, is in
process. This programme of breast-feeding is complementary to a
research programme in nutrition focusing on the weaning period.
40
In October 1979 a Joint WHO/UNICEF Meeting on Infant and Young
Child Feeding brought together representatives of governments,
numerous organizations of the United Nations system, nongovernmental
organizations, the infant-food industry and scientists. The objective of
this meeting was to discuss and summarize the current state of know
ledge concerning appropriate infant and young child nutrition; the social
health and environmental factors affecting it; contemporary trends in
feeding practices, the factors contributing to them and their implication
for action.
The statement and the recommendations formulated by the meeting
have been widely circulated and were endorsed by the Thirty-third World
Health Assembly; and follow-up activities have been undertaken or are
planned in the following areas:
(a) the encouragement and support of breast-feeding;
(b) the promotion and support of appropriate and timely comple
mentary feeding practices which make use of local food
resources;
(c) the strengthening of education, training and information on
infant and young child feeding;
(d) the development of support for improved health and social
status of women in relation to infant and young child feeding;
(e) the appropriate marketing and distribution of infant formulas
and weaning foods, including a code of marketing of infant
formulas and other products used as breast milk substitutes.
The new focus of the nutrition activities is the improvement of
nutrition and health through action at the community level, and as far as
possible with local resources. The major thrust is to develop new know
ledge and approaches and to translate them into operational activities
within the framework of primary health care. This is done at the local
level by national workers and institutions. The Organization is coop
erating with countries in four priority areas:
(a) extending the use of nutritional surveillance systems;
(b) integrating nutritional activities within primary health care;
(c) applying measures to control specific nutritional deficiencies;
(d) developing national multisectoral food and nutrition policies
and programmes within the framework of national development
plans, in collaboration with other agencies.
The development of appropriate technology and practical guidelines
relating to the management of the complications of pregnancy and
childbirth and of specific, prevalent diseases of childhood is also a focus
of activity. The findings of the WHO collaborative study on the
epidemiology of the hypertensive disorders of pregnancy will be followed
through intervention programmes, particularly as part of maternal and
child health activities within primary health care.
41
Since the majority of the world’s babies are born in developing
countries and delivery takes place at home, a programme of activities has
been initiated for the development of appropriate technology for
perinatal care to be applied in the home and small rural maternity units.
WHO is collaborating with 94 countries which are expanding their
immunization programmes in order to reduce significantly the incidence
of the common infectious diseases of childhood. Special efforts are being
made to train maternal and child health workers in immunization tech
niques in order to integrate these preventive measures in existing health
services systems.
Since 1978 the Organization has been steadily expanding its activities
for the control of diarrhoeal diseases. In the short term, the WHO
programme seeks to reduce diarrhoea-related morbidity, mortality and
malnutrition in children through the promotion of oral rehydration
therapy and improved child care practices, and to develop new tools and
techniques for better control through research.
Programmes on the health needs of adolescents are also being devel
oped in interested countries in all regions. In addition, studies on repro
ductive health of adolescents, patterns of ovulation and menstruation,
and use of fertility regulation methods are undertaken in countries in the
Western Pacific, Europe and the Americas.
Technical cooperation with and among countries is promoted for the
development of intersectoral programmes for children and youth; the
enhancement of the health and status of women and their equitable
participation in development; and social support measures for the family,
including organized systems of day-care in factories or industrial
facilities, neighbourhood centres, cooperative self-help women’s groups,
and family-based day-care facilities for children of working parents in
which older members of the family take part.
WHO pursues activities related to women and family health in col
laboration with countries and relevant United Nations bodies as part of
the United Nations Decade for Women (1975-1985). New approaches to
school health are being further developed to promote the integration of
appropriate health learning in all aspects of educational programmes,
including the participation of school-age children and teachers in health
activities. Also, the routine physical examinations in the health pro
grammes of many schools are being discouraged in their present form.
WHO continues to collaborate with national agencies and organizations
of the United Nations system in the health aspects of programmes for
youth, both as beneficiaries and particularly as participants in health and
development programmes.
42
References
Falkner, F., ed. Prevention in childhood of health problems in adult life, Geneva,
World Health Organization, 1980.
2. Omran, A. R. & Standley, C. C., ed. Family formation patterns and health, Geneva,
World Health Organization, 1976.
3. Puffer, R. R. & Griffith, G. W. Patterns of urban mortality, Washington, DC, Pan
American Health Organization, 1967 (Scientific Publication No. 151).
4. World Health Organization. The prevalence of nutritional anaemia in developing
countries (unpublished WHO document FHE/79.3; a limited number of copies is avail
able from the Division of Family Health, WHO).
5. Belsey, M. A. The epidemiology of infertility: a review with particular reference to
sub-Saharan Africa. Bulletin of the World Health Organization, 54: 319-341 (1976).
6. World health statistics quarterly. 33: 197-224 (1980).
7. Puffer, R. R. & Serrano, C. V. Patterns of mortality in childhood, Washington, DC,
Pan American Health Organization, 1973 (Scientific Publication No. 262).
8. World Health Organization. Contemporary patterns of breast-feeding, Geneva,
1981 (in press).
9. WHO Expert Committee on Mental Health. Child mental health and psychosocial
development, Geneva, 1977 (WHO Technical Report Series No. 613).
10. Bengoa, J. M. & Donoso, G. Prevalence of protein-calorie malnutrition, 1963 to 1973.
PAG bulletin, 4: 24 (1974).
11. WHO Expert Committee on Health Needs of Adolescents. Report, Geneva, 1977
(WHO Technical Report Series No. 609).
12. WHO Expert Committee on Smoking Control. Controlling the smoking epidemic,
Geneva, 1979 (WHO Technical Report Series No. 636).
13. Causse, G. The worm in the apple. World health. May 1975.
14. World Health Organization. Risk approach for maternal and child health care,
Geneva, 1978 (WHO Offset Publication No. 39).
15. International Planned Parenthood Federation. Unmet needs. People, 5: No. 3
(1978).
16. Tietze, C. Induced abortion, 3rd edition. New York, Population Council, 1979.
17. Alma-Ata 1978. Primary health care. Report of the International Conference on
Primary Health Care, Alma-Ata, USSR, 6-12 September 1978, Geneva, World Health
Organization, 1978.
18. World Health Organization. A growth chart for international use in maternal and
child health care, Geneva, 1978.
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