MATERNAL AND CHILD HEALTH ISSUES & INTERVENTIONS
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MATERNAL AND CHILD HEALTH
ISSUES & INTERVENTIONS
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MATERNAL AND CHILD HEALTH
ISSUES & INTERVENTIONS
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Compiled by:
Dr. K.P.M. Prabhu
Asst Commissioner (MCH)
MINISTRY OF HEALTH & FAMILY WELFARE
GOVERNMENT OF INDIA
1987
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COM**11 mi*’
INTRODUCTION:
The.Constitution of India envisages the establishment of a new
social order based on equality, justice and dignity of the
individual. /Among other things it directs the States to record
improvement in the public health
--- 1 as one of its primary duties
and aims at securing the health and strength
o_, of workers, men
and women, specially ensuring that childreni are given
opportunities and facilities to develop in ;a healthy manner,
During the last three decades considerable progress has been
achieved in the improvement of health status of our people.
Yet much remains to be done to fulfill the cherished goals
enshrined in our Constitution.
MATERNAL MORTALITY
Definitions:
Maternal death
Intuitively one would expect the definition of a maternal
death to be a simple matter. Childbirth is a memorable event
and death in childbirth even more so. In practice, however
matters are not that clear cut. If the definition of a
■"aierna! death is to include all deaths due to pregnancy and
childbirth it must include deaths taking place before
childbirth (e.g. abortion, ectopic pregnancy), those taking
place during childbirth (e.g. antepartum, intrapartum and
postpartum haemorrhage), as well as deaths taking place some
time after the actual event of childbirth (e.g. sepsis).
Moreover, not all maternal deaths are directly due to
conditions resulting solely from pregnancy. Some are caused by
pre existing conditions which have been aggravated by pregnancy
(hepatitis). This latter distinction is not new.
Traditionally maternal deaths have been classified as ’’true
maternal” deaths when the pregnancy was directly responsible
for the sequence of events that lead to the death, and
associated or indirect causes where the condition that lead to
the death was unrelated to the pregnancy
pregnancy (0587).
(0587). This
distinction is reiterated in 1the
’ "'.I
Ninth Revision of the
International Classification of Diseases (ICD 9) which defines
a maternal death as follows (0881):
”A maternal death is defined as the death of a woman while
pregnant or within 42 days of termination of pregnancy, from
any cause related to or aggravated by the pregnancy or its
management but not from accidental or incidental causes.
i
2
Maternal deaths should be subdivided into two groups:
e
(1) Direct obstetric deaths: those resulting from obstetric
complications of the pregnant state (pregnancy, labour and
puerperium), from interventions, omissions, incorrect
treatment, or from a chain of events resulting from any of
the above.
(2) Indirect obstetric deaths: those resulting from previous
existing disease that developed during pregnancy and which
was not due to direct causes, but which was aggravated by
physiologic effects of pregnancy."
A significant feature of this definition is that implicit in
the definition is the notion of exclusion — "a maternal death
is the death of a women while pregnant ... but not from
accidental or incidental causes” — which if followed could
significantly reduce the bias inherent in most of the maternal
mortality rates published today. A WHO Working Group has
suggested that the Tenth Revision (ICD 10) should go even
further and define a maternal death as ’’the death of a women
while pregnant or within 42 days of termination of pregnancy
irrespective of the duration of or the site of the pregnancy".
The recommendation goes on to say — "this should be the total
definition. We wish to have included in ’maternal mortality'
all known deaths of women known to be pregnant. In this regard
all death certificates of women in the reproductive age group,
12-50, should have the certificate specially annotated if the
woman was known to be pregnant at the time of her death or was
known to have been pregnant at any time within the previous
42 days. Maternal death should then be subdivided into three
groups: firstly, direct obstetric death, secondly, indirect
obstetric death and, thirdly, the fortuitous or coincidental
death of a woman where the condition causing the death was not
obstetric or did not aggravate the obstetric state. It is
realized that in many situations it will not be possible to
obtain all deaths in the three categories but certainly the
principles should be maintained." (0882) Maternal mortality
is thus being defined as a 'time of death' measure, analogous
to infant mortality which can, where such information is
available, also be analyzed by cause.
Present Status of Maternal Mortality in India:
Maternal morbidity and mortality rates in dev^loping countries
including India are quite high. As the majority of child
births in India take place in houses and deaths are not always
reported, correct information on maternal mortality rate also
is not available. The cause-wise rate available for the year
1972 is given as follows:
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Maternal Deaths in rural India (1972) per 100,000 live births:
Cause
Rate
1. Haemorrhage
96.3
2. Abortion
56.2
3. Toxaemia
56.2
4. Anaemia
50.2
5. Puerperal sepsis
46.2
6. Malpresentation
28.1
7. Other causes
84.3
All causes:
e
417.6
Source: Model Registration Unit, Survey of Causes of Death
1W2, R.G.I.
Percentage distribution of deaths by causes related to child
birth and pregnancy (maternal):
Specific causes
1980
1981
1982
1. Abortion
12.5
13.7
10.1
2. Toxaemia
12.4
8.0
12.5
3. Anaemia
15.8
17.7
24.4
15.8
23.4
26.2
13.4
9.2
7.2
6. Puerperal sepsis
12.4
8.3
7. Not classifiable
17.7
13.1
f
14.9
11.3
Total
100.0
100.0
100.0
4. Bleeding of pregnancy
and puerperium
5. Malposition of child
leading to death of mother
Source: R.G.I.
4 -
India ranks amongst countries with high maternal mortality, It
is essentially a rural country with 8OZ people living in
villages with inadequate sanitation, weak economy and low
educational standards. Female literacy rate (all ages) at all
India level is 24.8%. Mean age at marriage-females is 18.3.
Total fertility rate 1981 (SRS) is 4.5. Approximately
80% deliveries take place in houses. Majority are attended by
traditional birth attendants (dais), relatives of pregnant
women or female health worker (auxiliary nurse midwife). In
case of abnormal or difficult labour it becomes difficult to
transport the patient to the nearest health facility. Early
marriage and early pregnancy and repeated pregnancies make
women prone to higher risk due to cephalopelvic disproportion,
toxaemia, intrauterine inertia, etc. Anaemia of mothers which
is an important cause of maternal mortality is of nutritional
origin. Poverty, illiteracy, ignorance, superstition, all
aided by lack of proper antenatal, intranatal and postnatal
care result in a high maternal death rate.
Strategies to improve women's and children's health and steps
taken:
The National Health Policy provides highest priority for the
improvement of maternal and child health with a special focus
on the less privileged section of the society. While efforts
are continuing at providing refresher training and orientation
to the traditional birth attendants, schemes and programmes are
being intensified to ensure that progressively all deliveries
are conducted by competently trained persons so that
complicated cases receive timely and expert attention within a
comprehensive programme providing antenatal, intra- atal and
postnatal care.
Some of the goals for Health and Family Welfare Programmes are
as follows:
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Indicator
1.
Current
Level
Infant mortality rate
Rural:
Urban:
Total:
107 (1985)
59 (1985)
97 (1985)
Perinatal mortality
67 (1976)
Goals
1990 ~ 2000
87
Below 60
30-35
11.8
10.4
9.0
(0-4 yrs) mortality)
41.2 (1984)
15-20
10
4.
Maternal mortality rate
4-5 (1976)
2-3
Below 2
5.
Life expectancy at birth
Male
Female
54.1 (1980)
54.7 ( ” )
57.6
57.1
64
64
18
10
27.0
21.0
2.
Crude death rate
3.
Pre-school child
6.
Babies with birth
weight below 2500 gms
(percentage)
30
32.9 (1985)
7.
Crude birth rate
8.
Effective couple protection
(percentage)
35.8
42.0
60.0
Net Reproduction Rate
(NRR)
1.48 (1981)
1.17
1.00
10. Growth rate (annual)
2.25 (1971-81)
1.66
1.20
11. Family size
4.4 (1975)
9.
2.3
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Indicator
e
Current
Level
Goals
1990
2000
12. Pregnant mothers receiving
antenatal care (%)
40-50
60-75
100
13. Deliveries by trained birth
attendant (%)
30-35
80
100
20
100
100
100
100
100
100
14. Immunization status
(Z coverage)
TT (for pregnant women)
TT (for school children)
10 years
16 years
DPT (children
below 1 year)
25
85
85
Polio (infants)
5
85
85
BCG (infants)
65
85
85
DT (new school entrants
5-6 years)
20
85
85
Typhoid (new school
entrants 5-6 years)
2
85
85
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e
CHILD MORTALITY
DEFINITIONS
*
Infant Mortality Rate (IMR)
Number of infants dying
under one year of age in a
year per 1000 live births
of the same year.
Neonatal mortality rate
Number of infants dying
within the first month of
life (under 28 years) in a
year per 1000 live births
of the same year.
Postnatal mortality rate
Number of infants deaths at
28 days to one year of age
per 1000 live births in a
given year.
Perinatal mortality rate
Number of still births plus
death within 1st week of
delivery per 1000 live
births in a year.
The infant mortality rate (IMR) is considered to be an
indicator of socio-economic and health conditions prevailing in
the community. The IMR in India was about 161 in 1947 and it
has been progressively declining since then. It was 104 in
1983-84 and has dropped to 97 per thousand live births in 1985.
Principle causes of High IMR in India:
According to the information available, the major causes of
infant mortality in the country are:
(a) prematurity
(b) respiratory infections
(c) complications at birth
(d) diarrhoea
(e) fevers, and
(f) tetanus
*
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Trends in Infant Mortality Rate - Major States: (1976-85)
The Infant Mortality Rate for 1985 has been estimated at 97
per 1000 live births which represents a significant fall of
7 points from 1984. During the period 1976-85, the Infant
Mortality Rate at all India level has declined by 32 points.
The State of Kerala has recorded the minimum IMR of 31 in
1985. Excepting the State of Orissa, the Infant Mortality Rate
has declined in all the major States between 1976 and 1985. In
Orissa, the IMR increased by 20 points between 1976 and 1977,
thereafter.
declined by 14 points between 1977 and 1978 and again increased
by 16 points between 1978 and 1979. After 1979, however, the
IMR is consistently on the decline in the State (except for
1984-85). The average decline between 1976 and 1985 varied
between 1-4 points per year in Assam to 5.3 points per year in
Gujarat. The extent of decline in 15 major States is given as
follows:
0-1.0 points per year
- Nil
1.0 - 2.0 points per year
- Assam (1.4)
Madhya Pradesh (1.7)
Maharashtra (1.6)
2.0 - 3.0 points per year
- Karnataka (2.2)
Kerala (2.8)
3.0 - 4.0 points per year
- Bihar (4.0)
Haryana (3.0)
Andhra Pradesh (3.9)
Rajasthan (3.7)
Tamil Nadu (3.2)
4.0 - 5.0 points per year
- A.P. (4.3)
Punjab (4.1)
U.P. (4.0)
West Bengal (4.25)
5.0 - 6.0 points per year
- Gujarat (5.3)
The estimate for 1985 reveals that the Infant Mortality Rate
has shown an increase in 1985 as compared to 1984 in the States
of Andhra Pradesh (5 points), Assam (12 points), Bihar
(10 points), Kerala (2 points), Madhya Pradesh (1 point),
Punjab (5 points), Orissa (1 point) and Tamil Nadu (3 points).
9 -
The Statewise position is given below:
1. Andhra Pradesh:
The Infant Mortality Rate was estimated at 83 per thousand
live births in 1985 as compared to 122 in 1976. During
1976-1985, the IMR has registered a decline of 39 points
(4.3 points per year) and the most significant decline of
25 points has occurred between 1978 and 1980. The rate is
observed to be increasing since 1983.
Assam:
The Infant Mortality Rate during 1976-85 has declined by
13 points (1.4 points per year) to 111 per thousand live
births in 1985 as compared to 124 in 1976. The maximum
decline of 14 points occurred between 1978 and 1979. The
rate is observed to be increasing since 1983.
Bihar:
The estimates for 1976 to 1980 are not available. The IMR
has declined by 12 points (4.0 points per year) from 118 in
1981 to 106 in 1985. The maximum decline is observed
during 1982-83 and the rate has shown an increase in 1985
as compared to 1984.
4, Gujarat:
The State has reported the maximum decline of 48 points
(5.3 points per year) among the major States during
1976-1985. The IMR was estimated at 98 per thousand live
births in 1985 as compared to 146 per thousand live births
in 1976. The maximum decline by 16 points was observed
between 1977 and 1978, followed by a decline of 10 points
between 1979 and 1980.
5. Haryana:
The IMR has declined by 27 points (3 points per year) from
112 in 1976 to 85 in 1985. The maximum decline of
16 points is observed between 1984 and 1985. The rate also
showed a significant increase of 10 points between 1983 and
1984.
6, Karnataka:
The Infant Mortality Rate in the State declined by 18 points
(2 points per year) from 89 in 1976 to 71 per thousand live
births in 1985. The maximum decline of 12 points occurred
between 1979 and 1980.
4
a
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7. Kerala:
The State has recorded the lowest Infant Mortality Rate of
31 per thousand live births among all the major States in
1985 and this is reported to have declined by 25 points
(2.8 points per year) between 1976-1985. The maximum
decline of 9 points occurred between 1976 and 1977,
followed by 7 points decline between 1981 and 1982. The
rate has, however, shown an increase in 1985 as compared
to 1984.
8. Madhya Pradesh:
The IMR in the State has declined by 16 points (1.7 points
per year) from 138 in 1976 to 122 in 1985. The IMR
increased by 10 points between 1976 and 1977 but
consistently declined thereafter upto 1984 and recorded an
increase of 1 point in 1985.
Maharashtra:
TKe IMR in the State has declined by 15 points (1.6 points
e
per year) from 83 in 1976 to 68 per thousand live births
in 1985. The IMR recorded a significant increase of
15 points between 1976 and 1977, 5 points between 1978 and
1979 and 9 points between 1982 and 1983. The maximum
decline of 11 points occurred between 1979 and 1980,
followed by a decline of 8 points between 1984 and 1985.
10. Orissa:
a
The State of Orissa is the only State which has shown an
increase of 5 points in IMR between 1976 and 1985. The
IMR which was estimated at 127 in 1976 went up to 132 per
thousand live births in 1985. The IMR increased by
20 points between 1976 and 1977, declined between 1977 and
1978 and again between 1980 and 1981 and thereafter there
was a downward trend till 1983 but it has shown an
increase in 1984 and 1985.
11. Punjab:
the^IMR in this State has declined by 37 points
(4.1 points per year) from 108 in 1976 to 71 in 1985.
However, there was an increase of 12 points between 1977
and 1978, 2 points increase between 1980 and 1981,
5 points increase between 1982 and 1983 and 5 points
increase between 1984 and 1985.
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12. Rajasthan:
The IMR in this State has declined by 34 points
(3.7 points per year) from 142 in 1976 to 108 in 1985.
However, there was an increase of 3 points between 1980
and 1981, 12 points between 1982 and 1983, and 13 points
between 1983 and 1984.
13. Tamil Nadu;'
The IMR in this State has declined by 29 points
(3.2 points per year) from 110 in 1976 to 81 in 1985.
However, there was an increase of 2 points between 1977
and 1978, 4 points between 1982 and 1983, and 3 points
between 1984 and 1985.
14. Uttar Pradesh:
This State has been having the highest IMR in the
country. Even in this State there has been a declining
trend. The IMR in this State has declined by 36 points
(4.0 points per year) from 178 in 1976 to 142 in 1985.
However, there was an increase of 9 points between 1977-78
and 8 points between 1982 and 1983.
15. West Bengal:
For this State the figures of IMR are available only from
1981. In the 4 years, upto 1985, there has been a decline
of 17 points (4.25 points per year). The decline in this
State has been consistent so far.
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12 Estimated Infant Mortality Rate - Major States (1976 - 1985)
1976
1977
1978
1979
1980
1981
1982
86
79
106
102
118
1983
1984
1985
78
83
82
94
99
111
109
112
99
95
106
99
1986
Provisional
1.
Andhra Pradesh
122
125
117
106
2.
Assam
124
115
118
104
3.
Bihar
4.
Gujarat
146
138
122
123
113
116
111
106
106
98
107
5.
Haryana
112
113
109
100
103
101
93
91
101
85
85
6.
Himachal Pradesh
-- Not available --
84
88
7.
J & K
-- Not available --
87
81
8.
Karnataka
89
83
82
83
71
69
65
71
74
71
74
9.
Kerala
56
47
42
43
40
37
30
33
29
31
27
10.
Madhya Pradesh
138
148
143
143
142
142
134
125
121
122
117
11.
Maharashtra
83
108
81
86
75
79
70
79
76
68
63
12.
Orissa
127
147
133
149
143
135
132
131
132
123
13.
Punjab
108
105
117
92
89
91
75
80
66
71
67
14.
Rajasthan
142
142
140
108
105
108
97
109
108
104
15.
Tamil htedu
HO
103
105
1OO
93
91
83
87
78
81
80
16.
Uttar Pradesh
178
168
177
162
159
150
147
155
155
142
132
17.
West Bengal
91
86
84
82
74
71
110
105
105
104
97
96
Al 1 India
103
-- Not available --
-- Not available --
129
130
127
120
114
The interventions that are considered necessary to reduce MMR and
are antenatal care, perinatal care, immunisation, control of deaths due
to dehydration in diarrhoeal diseases through ORT, breast feeding and
infant nutrition, drinking water and better sanitation, improved health
care, health education, family planning and female ec.1ucatic.ri.
*
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PROGRAMME COMPONENTS OF MATERNAL & CHILD HEALTH CARE IN INDIA
CAREOF PREGNANT WOMEN & NURSING MOTHERS:
LEVEL-I CARE (Sub-centre and Primary Health Centre)
1. Antenatal care “ Prenatal care consists of an early
detection of pregnancy, identification of high risk
mothers, immunisation of the mother against tetanus,
nutrient supplements with iron and folic acid followed by
an antenatal check up of pregnant mothers at 20th, 30th,
34th and 38th weeks of pregnancy. This antenatal
assessment is aimed at detection and management of anaemia,
malnutrition, pre-eclampsia, heart disease and an early
diagnosis of intra uterine growth retardation and
prevention of neonatal tetanus.
2.
IntrHUdtnl csre
It consists of (a) conducting delivery
in a well lighted, clean room (either in the patient's own
home or at the sub-centre) of normal cases with proper
asepsis, (b) referring the abnormal cases to the PHC,
subdivisional or district level hospital as the case may be.
Postnatal care -
It comprises (a) a check up of the newly
delivered mother once daily for the first 7 days and twice
weekly for the next three weeks, (b) encouraging breast
feeding, (c) educating the mother regarding personal
hygiene, proper diet, and (d) at a later date suitable
advice regarding family planning methods.
LEVEL-II CARE (Selected Taluk/Sub-divisional/Dist.
Hospitals)
1. Antenatal
____ _ care -Th6 prenatal care is given on the same
line as in level-I care. Since complicated and referred
cases are dealt with, at these centres, more frequent
antenatal check up, as and when necessary is done by the
specialists. Specialized equipment, instruments and
facility of blood transfusion is available for dealing with
such complicated cases.
2* Postnatal care " The high risk cases delivering in the
level-II hospital are kept as indoor patients for the first
seven to ten days and later, followed up in the postnatal
clinics or by home visits, with emphasis on educating them
regarding diet, personal hygiene, exercise, breast feeding
and later on;
advising them regarding
family planning
through the post partum
centres
..
- - — — established
— — ——~
J at these
levels.
14 -
*
LEVEL-III CARE (Medical Colleges and selected
District-level hospitals)
care " The prenatal care is given, in the
1. Antenatal
level-III hospitals through well established antenatal
clinics where specialists are available, alongwith the
special equipments such as ultra-sound, colposcope etc. and
facilities for sophisticated biochemical tests required for
ensuring the well being of the foetus in utero.
Intranatal care -
Labour rooms at these centres have a
foetal monitoring system, facility for blood transfusion,
and a good operation theatre near the labour room, with
specialists to deal with any abnormality arising during
labour.
Postnatal care “ This is given for the first few days in
the hospital by daily check up of the mother and baby and
later on in the postnatal clinic with particular emphasis
on educating the mothers regarding diet during postnatal
period, hygiene, breast feeding, exercises and later on
family planning methods through the post-partum centres
available at all these centres.
I. Prophylaxis against nutritional anaemia among mothers:
Anaemia is one of the health problems affecting women of
child bearing age in the country. Anaemia in pregnant
mothers is an important cause of maternal morbidity and
mortality. Apart from affecting the health of the pregnant
mother, it also affects the newborn adversely. Studies
have shown that the great majority of cases of anaemia in
mothers are of nutritional origin. In order to prevent
nutritional anaemia among mothers, one tablet of Iron &
Folic Acid containing 60 mg elemental iron (180 mg of
ferrous sulphate) and 0.5 mg of folic acid is given daily.
The administration of the tablets is continued till the
level of haemoglobin is maintained at a satisfactory
level. The beneficiaries of the scheme are expectant and
nursing mothers and other women who have accepted Family
Planning method (sterilisation and I.U.D. insertions).
♦
15
a
The objective of the scheme is to prevent the development
of overt anaemia among the mothers. An initial estimation
of haemoglobin should be done wherever possible to decide
whether a woman is frankly anaemic and needs anti-anaemic
therapy or is fit to be kept on the prophylactic regimen.
The level of haemoglobin - 10 gms percent for women is
taken as critical level for deciding on anti-anemic
treatment or prophylactic management. To enable greater
surveillance and follow up of the beneficiaries put on the
prophylaxis programme. Iron & Folic Acid Tablets are not
being distributed through the hospitals outdoor
departments, but are given through the special clinics for
mothers, antenatal clinics, postnatal clinics, etc. For
the convenience of rural mothers, they are given the
tablets for a fortnight or a month and the ANN during the
home visits verifies the actual intake by mothers. Iron
and folic acid tablets are known to be issued in much
larger quantities than required for a month. Closer
scrutiny is kept normally, and not more than the supply for
a fortnight is issued. Supplies for longer periods are
only given in exceptional cases. The tablets are to be
taken continuously for a period of 100 days. Anganwadi
workers are actively involved in this programme.
The target population for this scheme is estimated to be
50% of pregnant women, 50% of the nursing mothers and
25% of the women acceptors of terminal methods and I.U.D.
In 1987-88, 80% of this target group is expected to be
covered. By the year 1990, the entire target population is
expected to be covered. This will be about 30 million
women.
Care of the children:
1. Immunization programme:
e
Immunization can help in reducing the IMR directly by
controlling morbidity and mortality amongst children due to
vaccine preventable diseases and indirectly, by preventing
secondary infection and malnutrition which follows
occurences of these diseases. Sample surveys have
indicated that 0.28 million children die annually due to
neonatal tetanus alone within the first month of birth, if
there is no TT immunization for the pregnant women.
4
<
)
- 16 -
Benefits of Immunization:
*
The immunization programme has a definite role to play in the
reduction of IMR besides significantly reducing the incidence
of diseases in children. It is estimated that 0.2 million
children suffer from paralytic poliomyelitis and
18 to 20 million children get whooping cough and measles
annually. Other diseases which are controlled as a result of
immunization are diphtheria, tetanus and childhood tuberculosis.
Immunization programme was started in the IV Five Year Plan in
a modest way and was expanded later with greater coverage and
inclusion of more vaccines.
EPI:
The expanded programme on immunization was started in 1978
with the objective of reducing the morbidity and mortality due
to diphtheria, pertussis, tetanus and tuberculosis by making
vaccination services progressively available to all eligible
children and pregnant women.
Oral polio vaccine was introduced in the National Programme in
1979-80 and measles vaccine was introduced in 1985.
Some of the vaccines such as DPT, OPV and TT are required to be
given in repeated doses for protection. The coverage is
monitored in terms of beneficiaries with completed schedule.
Coverage during Sixth Plan & Proposed Seventh Plan:
9
9
It is estimated that about 22 million children are born in the
country every year. During the Sixth Plan period 37.5 million
pregnant women received TT vaccine, 50.2 million children
received DPT vaccine,
26.8 million children received polio vaccine and 66.8 million
children received BCG vaccine. During the Seventh Plan, it is
proposed to immunise 92 million pregnant women and 82 million
infants.
17 -
Universal Immunisation Programme:
In order to accelerate the vaccine coverage of eligible
population and ensure high quality of service, a major shift in
the strategy was adopted in 1985 with the launching of
Universal Immunization Programme, as a ’’living memorial to the
memory of the late Prime Minister Smt. Indira Gandhi”. Under
the programme, 30 districts were selected during 1985-86 with
the aim of achieving 85% coverage of infants and 100% coverage
of pregnant women during the year. It is expected to cover the
entire country by 1990. The major tasks in the Universal
Immunisation Programme are expansion of vaccine coverage of the
eligible population, strengthening of cold chain of vaccines,
procurement and distribution of essential equipment, training
of health personnel, preparation of health education material,
promotion of community participation, development of
surveillance system operational research, monitoring and
evaluation.
Integration with ICDS:
All ICDS blocks in the country are covered under the expanded
programme of immunization. Universal immunization was taken up
in 30 districts initially during 1985-86. Out of 628 blocks of
these districts, 113 blocks were ICDS blocks. In 1986-87,
62 districts with 1049 blocks were taken. Thus out of a total
of 1677 blocks in 92 districts of UIP 356 (27.2%) have ICDS in
operation. It is appropriate that the scheduling of ICDS
blocks and the UIP districts proceeds in a synchronised and
integrated manner but due to the resources constraint and
different selection criteria on the ICDS side, the ICDS
coverage of all blocks would be possible only by 1995,
hopefully.
Pre-requisite for success:
For the successful implementation of this programme, careful
planning, effective monitoring and optimal use of available
resources are required. Training of medical and paramedical
manpower has been given a high priority. Modern techniques of
mass media are being used for generating public demand for
these services. Close monitoring of cold chain equipment used
for storage, and distribution of vaccine is done. Since these
services are being delivered within the framework of the
existing health care delivery system, a close coordination is
solicited and ensured at all levels of implementation possible,
both at Central and State level.
- 18 -
Volume of work:
This is one of the largest immunization programmes undertaken
anywhere in the world. By 1990, we aim to provide services to
23 million pregnant women and over 18 million infants
annually. During the Seventh Plan period, we expect to cover
92 million pregnant women and 82 million infants. The
magnitude of the tasks can be well imagined from the fact that
funds sanctioned under UIP are not released in time. The
training programmes are not satisfactory specially at the lower
levels. The logistic support is not adequate. Field
supervision and monitoring of the programme is not
satisfactory. Higher priority given to some other programmes
such as family planning or malaria control for example, leads
to poorer performance under UIP since the same health workers
must do all the activities. Hence it is essential that these
activities have to be planned carefully at the grass root level.
Community Involvement:
Community involvement is a pre-requisite for achieving success
in these programmes and the major impediment in this sphere is
the lack of motivation in the community. Ministry of Health &
Family Welfare is developing publicity material to cover these
gaps. In these programmes, drugs and vaccines are being given,
under a single roof, so that people do not have to move from
place to place for different vaccines and drugs. The programme
provides immunization services in areas which are not within
easy reach through outreach operations. Services of
nongovernmental agencies, professional bodies and voluntary
organizations are encouraged in this programme, particularly
for demand generation, preparation of lists of eligibles and
undertaking health education activities and reporting suspected
cases of Tetanus and Poliomyelitis etc.
II. Prophylaxis against nutritional anaemia amongst children:
Nutritional anaemia among pre-school children is also a
health problem in India. Apart from affecting the health
of the children, it affects their growth and development.
- 19 -
The magnitude of the problem is almost the same as is seen in
women. Under this programme, children in the age group of 1 to
5 years are given 1 tablet of Iron and Folic Acid containing
20 mgm of elemental iron (60 mgm of ferrous sulphate) and
0.1 mgm of folic acid is given daily for a period of 100 days
to prevent dietary deficiency, The tablets are sugar-coated
and taken during or after meals, for smaller children who
cannot swallow tablets, a limited quantity of liquid
preparation is also being given, The daily dose of liquid
preparation is 2 ml which is equivalent to one small tablet.
In view of the limited stability of the preparation and the
side-effects associated with the preparation of iron in liquid
form this is mainly used in children's clinics, hospitals or
Post Partum Centres attached to the institutions. The
objective of the scheme is to prevent the development of
overt-anaemia among children. An initial estimation of
haemoglobin is done wherever possible to decide whether a child
is frankly anaemic and needs anti-anaemic therapy or is fit to
be on prophylactic management. A level of 8 gms percent of
haemoglobin is taken as critical level to decide on
anti-anaemic treatment or prophylactic management.
To enable greater surveillance and follow up of the
beneficiaries to be on the prophylaxis programme the iron and
folic acid tablets are not distributed through hospital outdoor
departments, but are given through special clinics for
children. For the convenience of the rural children, the
tablets are given for a fortnight or a month and the ANN during
the home visits verifies the actual intake by the children.
Iron and folic tablets are known to be issued in larger
quantities than required for a month. Closer scrutiny is kept
and not more than the supply for a fortnight is issued.
Supplies for longer periods are only given in exceptional
cases. Anganwadi workers are actively involved in this
programme in the ICDS projects.
The target population for this scheme is estimated to be 50Z of
the children in the age group 1-5 yrs. In 1987-88, 44Z of the
target population is expected to be covered. By the year 1990,
50 million children are expected to be covered which
constitutes the entire target group.
- 20 -
Prophylaxis against blindness (in children) caused by
Vitamin-A deficiency:
Surveys carried out in the southern and eastern parts of the
country in late 1970’s, have revealed that 20 to 30 percent of
the children in the pre-school age group have eye
manifestations as a result of Vitamin-A deficiency, It has
also been estimated that not less than 12,000 to 14,000
children go blind in the country every year as a result of
Keratomalacia — the most severe form of Vitamin-A deficiency
coupled with malnutrition and infection.
Investigations in India and other parts of the world have shown
that if Vitamin-A in a large dose is administered to children
by mouth, the concentration of Vitamin-A is maintained in the
body in such a manner that the child is protected from
Vitamin-A deficiency for almost one year. Vitamin-A is readily
stored in the liver from where it is gradually released for
utilization in the body. The oral administration has been
equated with prophylactic vaccination against the disease.
Coverage of children living in tribal blocks, chronically
drought prone areas, other backward areas, ICDS blocks, urban
slums etc. are given priority in the implementation of this
programme.
In selected areas efforts are made to cover all children in the
age group 1-5 years. 2.00 lakhs I.U. of Vitamin-A solution is
given orally every six months to this group of children till
they cross five years of age. Concentrated solution of
synthetic Vitamin-A in arachis oil containing one lakh I.U. in
one ml. is kept in amber coloured bottles of 100 ml. This is
orange flavoured. Enclosed with each bottle of Vitamin-A
solution is a plastic spoon to measure 2 ml. (2 lakhs I.U. of
the solution. Vitamin-A solution has a short shelf life and
has to be used before the expiry date, indicated on the
bottles. It is administered to children in the homes or in
children’s clinics personally by peripheral workers like: LHV,
ANMs, Male Multipurpose Workers etc. However, in order to
obtain maximum coverage of children in the required age group,
children may be collected at appointed places, sub-centres,
Anganwadis, Balwadis, Day-care centres for administration of
the drug. The bottles of Vitamin-A solution are carefully
stored at the primary health centres and issued to the workers
who actually administer it to the children at the scheduled
times.
21
The Anganwadi workers in ICDS blocks are also utilized for
distributing Iron Folic Acid tablets liquid and Vitamin-A
solution for better coverage of the eligible groups in these
blocks.
The target group for this scheme is estimated to be 50% of the
children in the age group 1-5 years. In the year 1987-88,
60% of the target population is expected to be covered. By the
year 1990, 50 million children are expected to be covered.
This constitutes the entire target group. Wherever, the
incidence of Vitamin-A deficiency is a public health problem,
as revealed by surveys, coverage could be increased in such
areas only.
IV, Programme of Oral Rehydration Therapy;
Diarrhoeal diseases are also a major health problem in
the country, especially amongst children below 5 years of
age. Diarrhoea is associated with multiple
socio-economic factors such as lack of clean water
supply, low environmental sanitation, lack of knowledge
of personal hygiene, etc. The incidence of the disease
is more in the lower socio-economic segments of the
community. Except cholera, diarrhoeal diseases caused by
other organisms are not notifiable. As such, it is not
possible to assess the exact magnitude of the problem.
However, longitudinal surveys carried out in the
different parts of the country indicate that a child may
suffer from as many as 3 episodes of diarrhoea per year.
One hundred million children below 5 years of age suffer
about 300 million episodes of which 10% i.e., 30 million
may develop dehydration and 1% i.e.,
3 million may face death. By far the most serious
consequence is dehydration and repeated attacks of
diarrhoea (chronic diarrhoea) may lead to malnutrition,
stunted growth, disability and death.
Under this programme, the entire country is expected to be
covered by 1990 A.D. A sum of Rs. 25 crores has been allocated
during the Seventh Plan and the details of implementation of
this programme have been worked out. The major components of
this programme are:
1.
2.
3.
Training of medical and paramedical workers at all levels.
Extensive health education of the population - especially
the mothers
Supply of Oral Rehydration Salts.
During the year 1987-88 a sum of Rs.500 lakhs has been
allocated.
- 22 -
Steps taken by GOI for implementing the MCH programmes.
(a) Expansion of health infrastructure:
To provide better care to mothers during the pregnancy,
delivery and puerperium and children after birth,
infrastructure of health services in rural and urban areas
have been developed and is being extended during Seventh
Plan Period.
The programme of establishing primary health centres with
3 subcentres and 4-6 beds per primary health centre (PHC)
in Community Development Block, having a population of
60,000 to 80,000 was launched as an integral part of the
Community Development Programme in October 1952.
Consequently, over the past 3 decades the health services
organization and infrastructure have undergone extensive
changes and expansion in stages following review by a
number of expert committees, namely the Mudaliar Committee
(1974) and Srivastava Committee (1975). Progressive
changes have been introduced into the programme during
successive Five Year Plan periods.
The delivery of Primary Health Care including Maternal and
Child Health Services is the foundation of rural health
care system and forms an integral part of the national
health care system, to develop the country's vast human
resources and accelerate the socio-economic development
and attain improved quality of life.
In the rural area, services are provided through a network
of integrated health care and family welfare delivery
system. Priority has been accorded to extension,
expansion and consolidation of the rural health
infrastructure viz., sub-centres, primary health centres
and community health centres.
(i)
Subcentres:
Subcentres are being established on
the basis of one sub-centre for every 5000
population in general and for every 3000 in hilly,
tribal and backward areas. Each subcentre is manned
by a trained female health worker (ANM) and a
trained male health worker. All the subcentres
required in the country would be established by
31.3390.
23 -
(ii)
Primary Health Centre: Primary health centres are
established for an average of every 30,000 rural
population in hilly, tribal and backward areas. This
primary health centre is manned by a Medical Officer, and
other paramedical staff. All the primary health centres
required in the country are expected to be established by
31.3.90. Each PHC provides supportive supervision to
6 subcentres and serves as a referral institution for
these subcentres.
dii) Community Health Centre: There would be one community
health centre for every 1 to 1.20 lakh of population so
as to serve as a referral institution having a minimum of
30 beds and 4 specialists, for 4 primary health centres.
By 31.3.90, it is expected to have 50% of the total
required community health centres in position in the
country.
The present status of subcentres, primary health centres
and community health centres is given below:
! Institution
i
Subcentres
Primary Health Centres
Community Health Centre
(iv)
I No. in
! position as
’ on 30.9.87
1,02,160
14,409
1,293
i
i
No. required!
by 31.3.90 I
1,30,000
21,666
2,708
Training Facilities: A large number of training
centres7schools have been established in the country to
train ANMs, LHVs and multipurpose workers (M). Regional
Teachers Training Institutions have also been established
in order to meet the shortage of nursing teachers/nurses
in the Female Multi-purpose Worker and Health Assistants
Schools in the country. Training programmes have also
been initiated for the training of lab-technicians,
community health officers (CHO), pharmacists and
specialists working at primary health centres and
community health centres.
There are 47 Health and Family Welfare Training Centres
in the country. 441 ANN training schools with an annual
admission capacity of 22,989 students. There are
44 promotional training schools for LHVs with an annual
admission capacity of 3221.
24
LEVEL OF ACHIEVEMENT OF SOME NORMS
ALL INDIA POSITION AS ON 30.9.1987
I
Parameters/Indicators
I
I
I
«
i
! National Norms ! Norms
i
i achieved/
i
I
I
established I
I
I
(approximate) I
i
I
1.
Population covered by a
subcentre
2.
Population covered by a
PHC
I
I
3000-5000
5648
20,000-30,000
40041
3.
Population covered by a
Community Health Centre
4.
No. of subcentres for
each PHC
5.
No. of primary health
centres for each
community health centre
4 PHCs
11.1 PHCs
6.
Trained Village Health
Guide
1 for each
village/1000
population
1.49 villages/
1298 population
7.
Trained Dai
Guide
Atleast one
for each
village
1.07 villages/
1031 population
8.
Population served by
Health Workers (Male
and Female)
M: 3000-5000
F: 3000-5000
9.
Ratio of HA(M) : HW(M)
1 : 6
1 : 3.4
10. Ratio of HA(F) : HW(F)
1 : 6
1 : 6.2
(b) Training of manpower:
About
1 lakh
6 sub-centres
4.45 lakhs
7 sub-centres
6777
5364
One of the most important steps taken by GOI in reducing
the maternal and infant mortality rate is training of the
Traditional Birth Attendants (Dais). This was being done
at a very slow pace till 1976. This was intensified by
reducing the period of training to one month for various
reasons.
- 25
Training is also given to medical and paramedical
personnel working in the field with an accent on ’’risk’*
approach so that mothers at "risk" are referred to
appropriate referral institutions colleges.
As on 30.9.87, 5.59 lakhs Traditional Birth Attendants
(Dais) 1,07,593 Female Health Workers (ANMs), 17,272
Female Health Assistants (LHVs) and 19,169 PHC Medical
Officers have been trained. Inservice training is also
given to medical and paramedical personnel at all levels
under immunization programme and the programme of oral
rehydration therapy.
(c) Health Education:
Education of the community about diets of mothers during
pregnancy and after, minimum antenatal and postnatal care
and care of child when to report to the health worker etc.
is provided through multi-media activities and also
through inter-personnel efforts. Special manuals,
handbooks and pamphlets prepared for these personnel give
emphasis on MCH care including maternal and child
nutrition.
details of the immunization programme, prophylaxis
(d) The
schemes and the scheme of ORT for control of diarrhoea
have already been given earlier.
(e) Abortion:
Abortion also is an important cause of maternal
mortality. Many of these maternal deaths are due to
abortion conducted by untrained hands in an illegal way.
To avoid this MTP act has been enacted and termination of
pregnancy has been liberalized. At present MTP facilities
are available in 3336 government institutions and 1875
nongovernmental organizations. The facilities of MTP are
being gradually extended to all parts of the country.
Family Planning:
(f) As
pregnancy at early age and frequent pregnancies
adversely affect maternal and child health, steps have
been taken to raise the age at marriage and educate
mothers to accept family planning methods to avoid
frequent pregnaneies.
e
- 26
(g) Integrated Child Development Services (ICDS) Programme:
The Ministry of Human Resource Development through its ICDS
projects is providing an integrated package of services
comprising :
- supplementary nutrition
- immunization
- health check-up and referral services
- nutrition and health education and nonformal education.
The beneficiaries are pregnant mothers and children. As
per latest information available 1605 projects have been
sanctioned in the country and most of them are
functioning. The projects are in tribal, backward rural
areas and urban slums. The programme is gradually being
extended throughout the country.
t
CHILD SURVIMOL StTWRY CH^T
!
MftJOR irFEDIMENTS TO CHILD SURVIVAL
DIARRFCEAL DISEASE
SEl-ECIED IN
■IENTS CF THE ROAD TO FCPLTO
. (Vai Rehydration Therapy (ORT)
- Administration of oral rehydration solution
— Continued feeding
— Referral when appropriat
. Breastfeeding
. Hygienic practices in household (e.g., handwashing, hygienic
handling and storage of food and water)
. Improved water and sanitation supplies
. Immunization
V^¥XIhE-FREX>ENTABLE DISEASES
Diphtheria, Measles, Pertussis
(Whooping Cough), Polio, Tuberculosis
. Immunization by age 1
. Adequate nutrition
• Less crowded living conditions
Tetanus
. Immunization by age 1
. Hygienic treatment of wounds and injuries
Neonatal Tetanus
. Immunization of women of childbearing age
. Hygienic conditions and practices at birth (especially
sterile treatment of umbilical cord)
. Assistance at birth by trained birth attendants
ACUTE H±i-,IRA ILHY IM-ELI IChl
. Immjnization for vaccine preventable diseases
. Curative drug therapy
. Adequate nutrition
. Improved housing conditions (e.g. less crowding)
- Health education for parents and other caregivers to
recognize and seek treatment for severe respiratory
infection
- Expanded availability of services for the treatmmt of anite
respiratory infections
- 28 -
J
tWCR irFEDIfENTS TO CHILD 9LFVIMQL
MALARIA
SELECTED IhEREDIENTS OF Tl-E ROAD TO hO^_TH
. Environmental control of mmca-y n tn vector (e.g., 1 imi ting
breeding sites)
. Chemical control of mosquito vector (e.g., spraying with
insecticides)
. Limiting malaria transmission through preventive artim
(e.g., use of screens and bed nets)
. Anti-malarial drugs
. Education on the patterns and prevention of malaria
**
MQLMJTRITICN
. Improved maternal health and nutriticn during pregnancy
. Breastfeeding
. Improved weaning practices (e.g., timely initiation, adequate
duration and maintenance of a balanced diet through weaning)
. Improved child feeding practices (e.g., meeting the protein,
energy, and micro-nutrient needs of a growing child)
. Feeding during illness
. Growth monitoring
HIGH-RISK FERTILITY
. Lengthening birth intervals
• Shifting childbearing away from very young and very old
reproductive ages
. Avoiding very high parity
. Breastfeeding
. Provision of family planning services:
- Wide and reliable distribution of contraceptive methods
- Information and education on use and benefits of fanily
planning
- 29 -
Provisional
Estimated Annual Birth & Death Rates - 1985
(Rates are based on SRS data of continuous
enumeration and six monthly cross-check survey)
! States/Union
! Territories
! Area
i
! Birth rate I Death rate !
i
i
i
•
•
I
STATES
1. Andhra Pradesh
2. Assam
Bihar
4. Gujarat
5. Haryana
6. Himachal Pradesh
7. Jammu & Kashmir
Combined
Rural
Urban
29.9
29.8
30.2
10.3
11.1
7.3
Combined
Rural
Urban
34.3
35.0
25.0
13.2
13.5
8.4
Combined
Rural
Urban
37.8
38.5
31.1
15.0
15.6
9.0
Combined
Rural
Urban
33.0
33.8
31.2
10.8
11.8
8.7
Combined
Rural
Urban
35.7
36.5
32.9
9.1
9.7
7.1
Combined
Rural
Urban
30.2
30.7
23.8
10.5
10.8
6.5
Combined
Rural
Urban
33.6
35.9
25.4
9.8
10.5
7.2
- 30 -
*
! States/Union
.' Territories
! Area
I
! Birth rate ! Death rate !
i
i
i
»
•
STATES
8. Karnataka
Kerala
10. Madhya Pradesh
11. Maharashtra
12. Manipur
13. Meghalaya
14. Nagaland
15. Orissa
16. Punjab
Combined
Rural
Urban
29.6
30.9
26.2
8.8
9.8
6.1
Combined
Rural
Urban
23.3
23.1
24.1
6.5
6.5
6.6
Combined
Rural
Urban
39.4
41.0
33.0
14.2
15.3
9.4
Combined
Rural
Urban
29.0
29.8
27.7
8.4
9.4
6.7
Combined
Rural
Urban
28.5
29.8
24.4
7.7
7.9
7.1
Combined
Rural
Urban
39.1
42.4
24.1
12.7
14.3
5.6
Combined
Rural
Urban
25.3
28.4
11.2
6.3
7.0
3.0
Combined
Rural
Urban
30.7
30.9
28.3
14.0
14.6
8.1
Combined
Rural
Urban
28.5
28.8
27.6
8.9
9.7
6.7
a
31 -
! States/Union
! Territories
! Area
! Birth rate ! Death rate !
I
I
i
•
•
STATES
17. Rajasthan
18. Sikkim
19. Tamil Nadu
20. Tripura
21. Uttar Pradesh
22. West Bengal
Combined
Rural
Urban
39.7
41.1
33.6
13.2
14.0
9.6
Combined
Rural
Urban
33.1
35.1
4.2
10.7
11.7
6.2
Combined
Rural
Urban
24.7
25.2
23.8
9.5
10.9
6.9
Combined
Rural
Urban
27.3
27.6
24.5
9.9
10.1
8.0
Combined
Rural
Urban
37.6
39.0
31.6
15.8
17.2
9.6
Combined
Rural
Urban
29.4
33.0
20.5
9.6
10.7
6.8
i
32 -
c
! States/Union
! Territories
I Area
I
! Birth rate ! Death rate !
i
i
I
•
•
UNION TERRITORIES
*
1. A & N Islands
Combined
Rural
Urban
28.3
30.6
20.9
6.8
7.9
3.4
Rural
Urban
35.5
35.9
30.5
14.3
15.2
2.2
Combined
Rural
Urban
24.5
32.3
23.9
4.0
6.1
3.8
Rural
36.9
11.9
Combined
Rural
Urban
32.8
35.8
32.6
8.1
10.1
7.9
Combined
Rural
Urban
19.5
19.6
19.4
8.0
9.0
6.0
Combined
Rural
Urban
35.0
37.2
32.7
7.2
9.2
5.0
Combined
Rural
Urban
22.1
26.1
18.8
7.2
8.3
6.3
COMBINED
RURAL
URBAN
32.9
34.0
28.1
11.8
13.0
7.8
2. Arunachal Pradesh Combined
Chandigarh
4. Dadra & Nagar
Haveli
5. Delhi
6. Goa, Daman & Diu
7. Lakshadweep
It
8. Mizoram
Pondicherry
INDIA
*
*
e
- 33 -
I
THE NATIONAL IMMUNIZATION SCHEDULE
*
€
Vaccine
No. of doses
1 /2 ■” 9 months
DPT
Polio
3
3
0-12 months
BCG
1
9-12 months
Measles
1**
18-24 months
DPT
Polio
1
1
5-6 years
DT
Typhoid
1*
2
10 years
TT
Typhoid
1*
1*
16 years
TT
Typhoid
1*
1*
Beneficiaries
1
Infants
Children
*
*
Pregnant women 16-36 weeks
TT
.
1*
two doses if not vaccinated previously
**
available only at selected places.
*
Or
e
c
a
r
Note: - Interval between doses should not be less than one
month.
” Minor coughs, colds and mild fever are not a
contraindication to vaccination.
(document-EPI(2)ls)
ls:8.4.88
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