BACKGROUND PAPER - 1 BACKGROUND PAPER - 1
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BACKGROUND PAPER - 1
1
MATERNAL
CHDLD HEALTH
(ISSUES & INTERVENTIONS)
MINISTRY OF HEALTH & FAMILY WELFARE
GOVERNMENT OF INDIA
■
COM Mi IN IT*
mpalTH
IlxTFRODlJCTION:
The Constitution of India eznvisaiges the establishment of a new social
order based on equality, justice and dignity of tte individual, ftnong
ottier things it directs the States to record improvenient in the public
Ixealth as one of its primary duties and aims at securing the health and
strength of workers, mtn and wznen, specially ensuring that children are
given opportunities and facilities to develop in a heal thy manner.
During LLie last three decades considerable procjress has been achieved in
tine improvement of health status of our people. Yet rmch ranains to be
done to fulfill tine cherished goals enshrined in our Constitution.
WTERNfl- njRTPL ITY
Defini Lions;
Maternal death
Intuitively one would expect the definition of a maternal death to be a
Childbirth is a memorable event and death in childbirth-'
In practice, however, matters are not that clear cut. If
tine definition of a maternal death is to include all deaths due to
pregnancy end childbirth it must include deaths taking place? before
childbirth (e.g. abortion, ectopic pregnancy), those taking place during
childbirth (e.g. antepartum, intraptartum and pce/tpartum haemorrhage), as
well as deaths taking place soire time after- the actual event of
childbirth (e.g. sepsis). Moreover, not all maternal deaths are directly
due to conditions resulting solely fro<m pregnancy. Some are caused by
pre-existing conditions which have been aggravated by pregnancy
(hepatitis). This latter distinction is not nevj. 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 (0587). This distinction is
reiterated in the Ninth Revision of the International Classification of
Diseases (ICD 9) which defines a maternal death as follows (CO3i):
simp1e matter.
even rriorc-? so-
"A maternal death is defined as the death of a woman while
pregnant or within 42 days of termination of pregnancy, fron
any cause related to or aggravated by the pregnancy or its
majiagement but not from accidental or inc iden ta1 causes.
Maternal deattis should be suLxjivided into two groups:
(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 re~•suiting
'
from previous
existing disease that developed duringj |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 tlie
definition is the notion of exclusion — "a maternal death is the
death of a ujomen while pregnant
but not from accidental or
incidental causes" •
• is
■
which
followed could significantly reduce
the bias inherent in most of the maternal mortality rates published
today. A UFO Working Group has suggested that the Tenth Revision
(ICD lo) 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 gees on to say — "this should be
the total definition. Me wish to have included in 'maternal
mortality' all kne^n dcatfis of women known to be pregnant.
In this
regard <.dl death certificates of women in tlo reproductive age
group, 12-bo, should have the certificate specially annotated if
the woman was known to be pregnant at the time of ter death or was
k-nowi 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
tkie condition causing the death was not obstetric or did not
aggravate the obstetric state.
It is realized that in m»any
situations it will not be possible to obtain all deathis in the
three categories bit certainly the principles should be
n^intaincxl." (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.
Ergggnt Status of Maternal Mortality in India:
Maternal morbidity and mortality rates in developing countries
including India is 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
g i vt .-i 'i as fol] ows:
- 3 -
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. Ma 1 presen ta t ion
28.1
7. Other causes
.84; 3
417,6
All causes:
Source: Model Registration Unit, Survey of Causes of Death 1972., R.G.I.
Percentage distribution of deaths by causes related to child birth and
pregnancy (maternal):
Specific causes
1990
1981
1982
1. Abortion
12.5
13.7
10.1
Toxaemia
12.4
8.0
12.5
3. Anaeimia
15.8
17.7
24.4
15.8
23.4
26.2
13.4
9.2
7.2
6. Puerperal sepsis
12.4
13.1
8.3
7. NcDt c 1 assi f iab 1 e
17.7
14.9
11.3
Total
100.0
100.0
1CX-J.0
4. Bleeding of pregnancy
and puerperium
5. Maiposition of child
leading to death of frother
Source:
R.G.I.
- 4 -
India ranks amongst countries with high maternal mortality. It is
essentially a rural country with 007. people living in villages with
unsatisfactory sanitation, poor economy and educational standards.
Female literacy rate (all ages) at all India level is 24.87.. Mean age at
marriage-females is 18.3. Total fertility rate 1981 (SRS) is 4.5.
Approximately 807. deliveries take place in houses. Majority are attended
by traditional birth attendants (dais), relatives of pregnant kxomen 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 cephal Opel vic
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 favour 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 will be 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, schem^as and programmes are being launched 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, intranatal and postnatal
care.
Some of the goals for Health and Family Welfare Programmes are? as follows:
5 Indicator
1.
Infant mortality rate
Current
Level
1990
2000
Rural: 105 (1985)
Urban: 57 (1985)
Total: 95 (1985)
E37
Fjelow
Perinatal mortality
Goals
67 (1976)
30-35
2.
Crude death rate
3
Pre-school child
(1-5 yrs) mortality)
24 (1976-77)
15-20
10
4.
Maternal mortality rate
4-5 (1976)
2-3
E<elow 2
5.
Life expectancy at birth
6.
11.7
10.4
Male 52.6 (1976-81)
Female 51.6 ( " )
Babies with birth
ujeight below 25.X) gms
(percentage)
30
9.0
57.6
57.1
M
IB
10
64
7.
Crude birth rate
32.7
27.0
21.0
B.
Effective couple protection
(percentage)
35.8
42.0
6C). 0
Net Reproduction Rate (bFR)
1.48 (1981)
1.17
1 JX)
10. Growth rate (annual)
2.24 (1971-81)
1.66
1.20
11. Family size
4.4 (1975)
12. Pregnant mothers receiving
antenatal care (7.)
40- 50
13. Deliveries by trained birth
attendant ("Z)
30-35
80
100
20
100
103
100
ICxj
100
100
9.
14. Immunization status
(7. coverage)
TT (for pregnant women)
TT (for school children)
10 years
16 years
2.3
60-75
103
DF'T (children below 3 years)
25
85
85
Folio (infants)
5
85
85
ECG (infants)
65
85
85
DT (na^j school entrants
5-6 years)
20
85
85
Typhoid (new school
entrants 5-6 years)
2
85
85
- 6 -
CHILD MORTALITY
DEFINITIONS
Infant Mortality Rate (IMR)
Number of infants dying under
one year of age in a year |:x?r
ICxX) live births of the same
year.
Neonatal mortality rate
Number of infants dying within
trie first month of life (under
28 years) in a
year- per lCx>."_)
live births of
ttie same year.
Postnatal mortality rate
Number of infants deatl’is at
28 days to one year of age per
lCx>j live births in a given year.
Perinatal mortality rate
Njmber of still bi.rtt(S plus
death within 1st week of
delivery per UXxj live births in
a year.
indicator of
The infant mortality rate (ItF) is considered to be an
The
socio-economic arid health conditions prevailing in the community.
IC-R in India was about 161 in 1R47 and it has
progressively
declining since then.
It was 104 in 19S3-84 and has dropped to 9a per
thousand live births in 1985.
Principle causes of High ItR in India:
According to the information available, the major causes of infant
mortality in the country are:
(a) prenvaturity
(b) respiratory infections
(c) complications at birth
(d) diarrhoea
(e) fevers, and
(f) tetanus
Trends in Infant Mortality Rate - Major States: (1976-B5)
■ 1985 has been estimated at 95 per
a significant fall of 9 points from 1984.
the period 1976-85, the Infant Mortality Rate at all India
level
I. .JI
--declined by 34 points. The
The State
State of
of Kerala
Kerala has
has recorded
i------ tie minimum IMR
of 32 in 1985. Excepting the State of Orissa, the Infant Mortali,ty Rate
.1976 and 1985.
has declined in all the major States between 1976
In Orissa,
the IMR increased by 20 points between 1976 and 1977, thereafter,
- 7 -
declined by 14 points between 1977 and 1978 and again increased by 16
points between 1978 and 1979. C'
‘
----After
1979,
however, the irF is
consistently on decline in the State (except for 1983). 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 14 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 (2.0),
Kerala (2.6)
3.0 - 4.0 points per year
- Bihar (3.2),
Haryana (3.0),
Andhra Pradesh (3.9),
Raj ast.han (3.7) ,
Tamil Nadu (3.3)
4.0 - 5.0 points per year
- A.P. (4.3),
Funj ab (4.1),
U.P. (4.2)
5.0 - 6.0 points per year
- Gujarat (5.3)
The latest available estimates for 1985 reveals that the Infant K
‘ '1ity
Horta
Rate has shown an increase in 1985 as compared to 1984 in the States of
Andhra Pradesh (5 points), Assam (12 points), Bihar (10 (joints), Kerala
(3 points), Madhya Pradesh (1 point) and Punjab
(5 points).
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 1976-1935, the IKR
Has i- egistered 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.
2.
Assam:
The Infant Mortality Rate during 1976-85 bias 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.
3.
Bihar:
1 Fie estimates lor 1976 to 198? are not available. Ttie II’T< bias
declined by 13 points (3.2 points per year) from 118 in 1981 to 105
in 1985. The maximum decline is observed during 1982-83 and the rate
lias showi an increase in 1985 as compared to 1984.
- 8 -
4.
Gujarat;
The State has reported the maximum decline of 40 points (5.3 fjoints
F3e?r year) among ilr? major States during 1976-1985. lie ll'l< 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 betv^een 1979 and 1980.
5.
Haryana;
The IM9 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
betv*JG?em 1984 and 1985. The rate also showed a significant increase
between
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.
7.
Kera1a:
The State has recorded the lowest Infant Mortality Rate of 32 per
tliousand live births among all the major States in 1985 and this is
reported to have declined by 24 points (2.6 points per year) between
1976-1985. The maximum decline of 9 points occurred between 1976
and 1977, folloujed by 7 points decline tetwaen 1981 and 1982. The
rate has, heaver , shown an increase in 1985 as compared to 1984.
8.
Madhya Pradesh:
The IhR in tho State has declined by 16 points (1.7 points peer 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.
9.
Maharashtra:
The IMR in the State has declined by 15 points (1.6 points per year)
from 83 in 1976 to 68 per thousand live births in 1985. The IhR
recorded a significant increase of 15 points between 1976 and 1977,
5 points between 1978 and 1979 and 9 points between 1982 and 1983.
I he maximum decline of 11 points occurred between 1979 and 1980,
followed by a decline of 8 points between 1984 and 1985.
10. Orissa:
He State of Orissa is the only State which has shown an increase of
points in ItR between 1976 and 1985. The IMR which was estimated
at 127 in 1976 went up to 130 per thousand live bi.rthe in 1985. The
IMF: increased by 20 points between 1976 and .1977, declined between
1977 and 1978 ar id again.
- 9 -
Estiiated Infant Mortality Rate - Major States (1976 - 1985)
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
(Provisional)
1.
Andhra Pradesh
122
125
117
106
92
86
79
77
78
83
2.
Assas
124
115
118
104
103
106
102
94
99
111
3.
Bihar
118
112
99
95
105
4.
Gujarat
146
138
122
123
113
116
111
106
106
98
5.
Haryana
112
113
109
100
103
101
93
91
101
85
6.
Karnataka
89
83
82
83
71
69
65
71
74
71
7.
Kerala
56
47
42
43
40
37
30
33
29
32
8.
Madhya Pradesh
138
148
143
143
142
142
134
125
121
122
9.
Maharashtra
83
108
81
86
75
79
70
79
76
68
10.
Orissa
127
147
133
149
143
135
132
126
131
130
11.
Punjab
108
105
117
92
89
91
75
80
66
71
12.
Rajasthan
142
142
140
108
105
108
97
109
122
108
13.
Tamil Nadu
110
103
105
100
93
91
83
87
78
80
14.
Uttar Pradesh
178
168
177
162
159
150
147
155
155
140
15.
Nest Bengal
91
86
84
82
77
110
105
105
104
95
All India
--- Not available ---
—- Not available —
129
130
127
120
114
Causes of High IMa :
Ttie interventions that are considered necessary to reduce
and I MR
are antenatal care, perinatal care, immunisation, control of diarrhoea
and CRT, breast feeding and infant nutrition, drinking water and better
sanitation, improved health care, health education, family planning and
f ema 1 e educ a ti.ci i.
10 -
FROGRATTE CCFFOhENTS OF MATEFJMAL & CHILD FEA_TH D^£ IN INDIA
LEVEL-1 CFKE
1.
Antenatal care - Prenatal care consists of an early detection of
pregnancy, identification of high risk mothers, invnunisation of thie
mother against tetanus, nutrient supplements with iron and folic
acid followed by an antenatal check up of pregnant mothers at 20th,
3oth, 34th and 38th weeks of pregnancy. This antenatal assessment
will aim at detection and management of anaemia, malnutrition,
pre-eclampsia, tieart disease and an early diagnosis of intra
uterine groujth retardation.
2.
Intranatal care - It consists of (a) conducting delivery in a well
lighted, clean room (either in the patient's own home or at tl~e
sub—centre) of normal cases with proper asepsis, (b) referring tfie
abnormal cases to the FH2, subdivisional or district level hospital.
3.
Postnatal care - It comprises (a) A check up of tlx-? newly delivered
mother once daily for ttie 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 advise regarding family planning methods.
LELEL-IICFFE
1.
Antenatal care - 7he prenatal care will be on the same line as in
level-I care. Since complicated, referred cases will have to be
dealt with, more frequent antenatal check up, as and when necessary
have to to dr*le, by the specia 1 ists, specialized equi piont,
instrument and facility of blood transfusion will be available for
dealing with such complicated cases.
F'ostnatal care - ‘Um? high risk casc?s delivering in tlr? level-Il
hospital will he kept as indoor patient for first seven to ten days
and later will be followed up io the postnatal clinics or by home
visits, with efnphasis on educating them regarding diet, personal
hygiene, exercise, breast feeding and later on advising them
regarding family planning.
LEVEL-III CAFE
1.
Antenatal care - The prenatal care should he given, in the
level-III hospitals through well established antenatal clinics
where specialists are available, alcnqwith 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.
2.
Intranatal care - Latour rooms should have a foetal monitoring
system, facility of blood transfusion arid a good operation theatre
near the labour room with specialists to deal with any abnormality
arising during labour.
11
3.
Postnatal care - This will be given for the first few days in tie
lospital by daily check up of the nether and baby and later on in
the postnatal clinic with particular emphasis on educating the
mottiers regarding diet during postnatal period, hygiene, breast
feeding, exercises and later on family planning methods.
I.
Prophylaxis against nutritional anaemia among mothers;
6
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 shion 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
mg elemental iron (180 mg of ferrous
sulphate) and G.b ng of folic acid is given daily. Ttie
administration of the tablets should lx? continued till the level of
haemoglobin is maintained at a satisfactory level, I tie
beneficiaries of the scheme are expectant and nursing mothers and
other women who have accepted Family Planning method.
TIk?? objective of the scheme is to prevent the development of overt
aruAemia anrong ttie mothers. It is suggested that an initial
estimation of haemoglobin should be done wherever possible to
decide whether a women is frankly anaemia and needs anti—anaemia
therapy or is fit to be kept co the prophylactic regimen. The
level of JiaeiTcglobin - 10 grre percent for women may be taken as
critical level for deciding on anti--anc^mic treatment or
prophylactic management. It is also suggested ttiat to enable
greater su.rvel1iance and follow up of the beneficiaries pat on the
prophylaxis programie. Iron
Folic Acid Tablets should not. toe
distributed tlxxigh the liospitals outdoor departments, but should be
.. given- thra igh the special clinics for frothers, antenatal clinics,
u postnatal clinics, etc. For convenience of rural mothers, it bias
also been suggested that they may he given the tablets for a
’^fortnight or a month and tie Abt! during the hone visits should
verify co the aptual intake by ncthers. Iron and folic acid
tablets are known to be issued in much larger quantities than
rexquirecl for a month. Closer scrutiny should be kept normally, not
more than the supply for a fortnight should be issued. Supplies
• for longer period are only to he given in exceptional cases. 1 lie
tablets are to tie taken continuously for a period of ICxj days.
COMMUNITY
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13 Liniversa 1 Immunisation Programme;
In order to improve? tie vaccine coverage of eligible papulation and
ensure high quality of service, a major shift in the strategy was
adopted in 1985 with the launching of Lhiversal Immunization Programre,
as a "living memorial to the memory of the late Prime Minister Smt.
Gandh1"- Lhder the programme, 30 districts ^re selected during
19du-tJ6 with the aim of a achieving 857. coverage of infants and jCx‘>7.
coverage of pregnant women during the year. He expect to cover the
entire cocmtry by 1990. The major tasks in the Universal Immunisation
Programme are expansion of vaccine coverage of the eligible population,
strengthening of cold drain 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 ICDA:
All 1C;I.)S blocks in tie country are covered under the expanded pr cxjr amu> •
of i.niTn..in i zation. thiversa1 immunization under UIP
. was
----- tain
_ ,:en up in 3(J
districts initially during 1985-86. Cut of 6-:.,8 blocks of ttiese
districts, 113 blocks are ICDS blocks. In ISrBS-RV, 62 districts with
1049 blocks were taken, Thus out of a total of 1677 blccl:s in 92
districts of UIP 356 ( 27.27.) have ICDS in operation. It is appropriate
that the scheduling of ICDS blocks and the UIP (districts
“
proceeds in a
synchronised and integrated manner tut due to the
- -o resources constraint
on the ICDS side, tb«e ICDS coverage of all blocks would t:e possible only
by 1995, hopefully.
Pre-requisite for success;
F or tfie successful implemeritaticn of this programme, we require careful
planning, effective monitoring and optimal use of available resources.
Fraining of nicdical and paramedical manpcc*jer bias 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 required.
Since these services are being delivered within the framework of the
existing health care delivery system, a close coordination is required
at all levels of implementation.
14 Volume of work:
I his is one of the largest immunization programnes under taken anyi^f^re
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 wompn and 82 million
infants. The magnitude of the tasks can be* wel1 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,- F fie
logistic support is not adequate, Field supervision and monitoring of
tie programme is not satisfactory. Higher priority given to some' other
programmes such
-- as family
---- 1 ,planning
-------- or malaria control for example, leads
to poorer performance under UIP* since the same health workers must do
all the activities.
Comnuni ty Invo1vement:
Community involvement is a pre-requisite for achieving success in this
programme and the major impediment in this sphere is tlx? lack: of
motivation in the community. Ministry of Health
Family Welfare is
developing publicity material to cover these gaps. In this programir?
vaccines are being given under a single roof so that people do not. f-^ve
to move from place to place for different vaccines. The programme
provides immunization services in areas which are not within easy reach
through outreach operations. Services of nongovernmental agencies,
prof€?ssional bodies and voluntary organizations are being encouraged in
this program-re, more particularly for demand generation, preparation of
lists of eligibles and undertaking health education activities and
reporting suspected case-s of Tetanus and Poliomyelitis.
II.
Prophylaxis against nutritional anaemia amongst children:
Nutritional anaemia of pre-school children is also a health problem
in India. Apart from affecting the health of the children, it
affects tlr?ir growth and development, Tie magnitude of the problem
is almost samie as is s-e?ori in wcmen. Linder this programme, children
in the age group of 1 to 5 years'are given 1. tablet of iron arid
folic acid containing 20 ml of elemental iron
ml of ferrous
sulphate) and 0.1 ml of folic acid is given daily for a period of
ICxj days to prevent dietary deficiency. The tablets are
sugar-quoted and shc-uld be given during or after meals, for smaller
children wlm cannot swallow tablets, limited quantity of liquid
preparation is also being given. The daily doses of liquid
preparation is 2ml which is equivalent to one smaller tablet, In
view of thx' limited stability of tlie preparation and thif?
side-effects associated with the preparation of iron in liquid from
this should be mainly used in children's clinics, hospitals or Post
Partum Centres attached to the institutions. The objective of the
scheme- is to prevent the developnent of overt-anaemia among
children. It is suggested that an initial estimation of
haemoglobin should be dene wherever possible to decide whether a
child is frankly anaemic and needs anaemic therapy or is fit to be
kept withi prophylactic management. A level of 8 gms percent of
haemoglobin may be taken as critical level to decide an
anti-anaemic treatment or prophylactic management. It is also
15 suggested that to enable greater surveillance and follow up of th?
beneficiaries to be on the prophylaxis progra/rvne the iron and folicacid tablets should not be distributed through hospital outdoor
deparbrnents, but stiould be given through special clinics for
children. For the convenience of the rural children, it has hjeen
suggested that tliey may be given the tablets for a fortnight or a
nonth and the AbM during the home visits should verily co the
actual intake by the children. Iron and folic tablets are knevo to
be issued in larger quantities than required for a month. Closer
scrutiny should be kept normally, not no re than, the supply for the
•fortnight should be issued, Supplied for longer periods are only
to be given in exceptional cases.
Prophylaxis against blindness (in children)
caused by Vitamin-^ deficiency;
Surveys carried out in the southern and eastern parts of the country
have revealed that
to 30 percent of thie children .in the pre—'schoo 1
age group fiave eye manifestations as a result of Vitamin-Pi def .icier icy.
It has also been estimated that not less than 1.2,0<X) to 14,OCxj children
go blind in the cc.intry every year as a result of Keratomalacia — the
most severe form of Vitamin-A deficiency coupled with malnutrition and
infecticn.
Investigations in India and other parts of the world tiave shcwi thiat if
Vitamin-A in a large dose is administered to children by ncu.th, tbie
concentration of Vitamin-A is maintained in the tody in such a manner
that the child is protected from Vitamin-A deficiency for almost one
year. Vitamin-A is readily stored in liver from where gradually it is
released for utilization in the body. The oral administration has been
equated with prophylactic vaccination against the disease.
Children living in tribal blocks chronically drought prone-? areas, other
backward areas, IC03 blocks, urban slums etc. are given priority.
In scelected areas efforts are made to cover all children in the age
group 1-5 years. 2.W 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. Coricentrated solution of synthetic Vitamin-A in arachis oil
containing one lakh I.U. in one ml. is kept in amber coloured bottles of
ICxj ml. This is orange flavoured. Enclosed with each bottles 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 should t«e
used before the expiry date, indicated on the bottles. It should be
administered to children in the herros or in children's clinics
personally by peripheral workers like: LHV, Ab-Ms, Male Multipurpose
Workers etc. However, in order to obtain maximum coverage of children
in tine regu.ired age group, children may be collected at appointed place,
sub-centresAnganwadis, Raiwadis. Day-care centres for administraticn
of the drug. The bottles of Vitamin-A solution should be carefully
stored at the primary health centres arid issued to the workers wlo
actually administer it to the children at the scheduled times.
16 -
The Anganwadi workers in ICDS blocks are also utilized for distribution
Iron Folic Acid tablets liquid and Vitamin—A solution for better
coverage of the eligible groups in these blocks.
IV.
*
Programme of Oral Rehydration Therapy;
Diarrhoeal diseases are 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
tie lower socio-economic segments of the ccwnunity. 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 carri.€?d
out in the different parts of the country indicate that a child may
suffer from as many as 3 episodes of diarrhoea per year. CJne
Kindred mil lien children below 5 years of age suffer ata.it 3(>j
million episodes of which 107. i.e.,’ 30 million may develop
dehydration and 17. i.e. , 3 mil lien may face death. By far the most
serious consequence is dehydration and repeated attacks of
diarrhoea may lead to malnutrition, stunted growth, disability and
death.
Linder this programme, the entire country is expected to be covered by
1990 A.D. A sujm of Rs. 25 crores has been allocated for tie Seven th
Flan and the details of implementation of this programme h$ve toee'n
worked out. The major components of this programme are:
1.
o
a.
Training of medical and paramedical workers.
Extensive health education of the population
Supply of Oral Rehydration Salts.
During the y^r 19o7--8H a slud of Rs.SCxj lai its l-tas be^n al located.
Steps taken by DJI for impletnenting the MCH programmes.
(a)
Training of manpower and adoption of risk approach:
One of the most important steps taken by GO in reducing tine
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.
Training is also given to medical paramedical personnel world ng in
the field with an accent on "risk" approach so that mothers at
"risk" are referred to appropriate referral institutions from
village to Taluka and district level hospital or medical colleges.
As on 31.3.87, 5.54 lakh dais (traditional birth attendant) 77960
female health vAorkers (AbM), 17401 female health assistants (LHV),
18669 FHJ medical officers have been trained. Inservice training
is also given to medical and paramedical personnel at all levels
both under EFI and LHP in the country.
17 -
(b)
Expansion of health infrastructure:
To provide better care of mothers during t.t»e pregnancy delivery <and
puerpcarium and children after birth, infrastructure of health
services in rural and urban areas have been developed and is being
extended during 7th Plan period. As on 31.3.87, 14145 FHCs and
subsidiary health centres, 98987 sub-centres, 954 post partum
centres were functioning in the country. It is envisaged to have a
to ta 1 20, CXX) FHCs and subs id iary hea 1th cen t res, 1.3 la k h
sub-centres and 1754 post-partum centres at the end of Seven th Five
Year Plan.
Specialized care to mothers and children are available? in (rrxJical
colleges, maternity liospitals, paediatric hospitals, district
sub-~divisional /taluka liospitals in urban areas and upgraded FHJs in
rural areas.
(c)
Health education:
Education of the ccxT¥n»jnity about diets of mothers during precjnancy
and after, minimum antenatal arid postnatal care and care of child
wh??n to repc?rt to the health worker etc is provided through
multimedia activities and also through inter-personnel efforts.
Special manuals, handbooks and pamphlets prepared for these
personnel give emphasis on MlH care including maternal and child
nutrition.
(d)
Tie details of the in^jnization programme, prophylaxis schemes and
the scheme of CRT for control of diarrhoea have already teen given
ear1ier.
(e)
Abortion:
Abortion also is an important cause of maternal mortality, lvhny of
these maternal deaths are due to abortion conducted by cuitrained
hemds in an illegal way. To avoid this HTF' act has been enacted
and termination of pregnancy has been liberalized. At present ITTP
facilities are available in 3336 government institutions and 1875
nongovernmental organizations. The facilities of HIP is being
gradually extended to all parts of the country.
(f)
Family Planning:
As pregnancy at early age arid frequent pregnancies adversely affect
matennal and child health, steps have been taken to raise tie age
at marriage and educate mothers to accept family planning mettxxis
to avoid frequent pregnancies.
!
i
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sauAueuboud (SaOI) saDTAuag quawdoxaAaa piTqg paqejbaqui
- 9T -
(B)
- 19 -
CHILD SURVIVAL SUMMARY CHART
MAJOR IMPEDIMENTS TO CHILD SURVIVAL
DIARRHOEAL DISEASE
SELECTED INGREDIENTS OF THE ROAD TO HEALTH
. Oral Rehydration Therapy (ORT)
- Administration of oral rehydration solution
- Continued feeding
- Referral when appropriate
. Breastfeeding
. Hygienic practices in household (e.g., handwashing, hygienic
handling and storage of food and water)
. Itproved water and sanitation supplies
. Iiwunization
VACCINE-PREVENTABLE DISEASES
Diphtheria, Measles, Pertussis
(Whooping Cough), Polio, Tuberculosis
Tetanus
. Immunization by age 1
. Adequate nutrition
. Less crowded living conditions
. Iinunization 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 RESPIRATORY INFECTION
. Immunization 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 treatment of acute
respiratory infections
- 20 -
MAJOR IMPEDIMENTS TO CHILD SURVIVAL
MALARIA
SELECTED INGREDIENTS OF THE ROAD TO HEALTH
. Environmental control of mosquito vector (e.g., limiting
breeding sites)
. Chemical control of mosquito vector (e.g., spraying with
insecticides)
. Limiting malaria transmission through preventive action
(e.g., use of screens and bed nets)
*
. Anti-ialarial drugs
. Possible vaccine in next decade
. Education on the patterns and prevention of malaria
MALNUTRITION
. Improved maternal health and nutrition 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 family
planning
- 21
Provisional
Estimated Annual Birth & Death Rates - 1985
(Rates are based on SRS data of continuous
enumeration and six monthly cross-check survey)
States/Un ion
Territories
Area
Birth rate
Death rate
STATES
1.
Andhra Pradesh
Combined
Rural
Urban
29.3
29.2
29.6
10.1
10.9
7.0
2.
Assam
Combined
Rural
Urban
34.3
35.0
25.0
13.1
13.5
8.4
3.
Bihar
Combined
Rural
Urban
37.6
38.3
30.9
14.9
15.5
8.2
4.
Gujarat
Combined
Rural
Urban
TO -J
33.5
31.1
10.7
11.7
8.2
•_'X_ ■ /
5.
Haryana
Combined
Rura 1
Urban
35.5
36.3
32.6
9.1
9.6
7.0
6,
Himachal Pradesh
Combined
Rural
Urban
30.2
30.7
10.5
10.8
6.5
OT
’7
J---1 ■ /
7.
Jammu ?/. kashmir
Combined
Rural
Urban
32.9
35.1
25.0
9.6
10.3
7.1
8.
Karnataka
Combined
Rura 1
Urban
29. (J
30.1
26.2
8.6
9.6
6.1
9.
Kerala
Combined
Rural
Urban
22.9
22.6
24.1
6.4
6.4
6.6
10.
Madhya Pradesh
Combined
Rural
Urban
38.8
40.3
32.8
13.9
15.1
9.3
11.
Maharashtra
Combined
Rura 1
Urban,
^B.9
..6
CH-IOl 8.4
9.4
r'
11
ft7
036^
*7//. (Hirst
6.7
t St 4
l?oad,
r
States/Uhicn
Territories
STATES
Area
12.
Manipur
13.
14.
Birth rate
Death rate
Combined
Rural
Urban
27.5
28.9
23.4
7.4
7.6
6.8
Meghalaya
Combined
Rural
Urban
39.1
42.4
24.1
12.7
14.3
5.6
Nagaland
Combined
Rural
Urban
24.8
27.7
11.2
h. (.)
6.7
3.0
15.
Orissa
Combined
Rural
Urban
30.3
•20.6
2 /. 7
13.9
.14.5
7.9
16.
FUn j ab
Combined
Rural
Urban
28.7
29.1
27.6
9. Cj
Combined
Rural
Urban
TO
O
7 ■ z.
40.7
32.9
12.9
13.8
9.2
S'
17.
Raj asthan
9.9
6.7
18.
Sikkim
Combined
Rural
Urban
33.1
35.1
24.2
10.7
11.7
6.2
19.
Tamil Nadu
Combined
Rura 1
Urban
24.8
23.8
9.5
10.9
6.9
“C.
“T
20.
Tripura
Combined
Rural
Urban
27.1
27.4
24.1
9.8
10.0
7.7
21.
Uttar Pradesh
Combined
Rural
Urban
37.6
39.0
31.6
15.8
17.2
9.6
West Bengal
Combined
Ri.iral
I Jr ban
28.6
32.1
19.9
9.1
10.2
6.4
- 23 -
e
States/Union
Territories
Area
Birth rate
Death rate
UNION TERRITORIES
1.
A & N Islands
Combined
Rura 1
Urban
28.3
30.6
20.9
6.8
7.9
3.4
2.
Arunachal Pradesh
Combined
Rural
Urban
34.1
34.4
30.5
13.0
13.8
3-
Chandigarh
Combined
Rural
Urban
24.5
32.3
23.9
4.0
6.1
3.8
4.
Dadra & Nagar
Haveli
Rural
36.9
11.8
5.
Delhi
Combined
Rura 1
Urban
32.5
35.6
32.2
7.8
9.8
7.7
6.
Goa, Daman <?< Din
Combined
Rura 1
Urban
19.1
19.0
19.4
7.8
8.7
6.0
7.
Lakshadweep
Combined
Rural
Urban
35.0
37.2
32.7
7.2
9.2
5.0
8.
Mizoram
9.
Pondicherry
Combined
Rural
Urban
22.2
26.3
18. £3
7.3
8.6
6.3
INDIA
COMBIhED
RURPL
URBW
32.7
34.0
28.0
11.7
12.9
7.6
*
>
z.. z.
- 24 THE rWIOh^L IMMUNIZATION SO€D(JL£
Beneficiaries
Infants
Children
Pregnant women
Age
Vaccine
No■ of doses
3-9 months
DPT
Polio
ECG
3
3
1
9-12 months
Measles
1**
18-24 men ths
DPT
Polio
1
1
5—6 years
DT
Typhoid
1*
2
10 years
TT
Typhoid
1*
1*
16 years
TT
Typhoid
1*
1*
16-36 weeks
TT
1*
W
*
**
Note:
two doses if not vaccinated previously
available only at selected places.
- Interval between doses should not be less than one month.
- Minor coughs, colds and mild fever are not a
contraindication to vaccination.
(document-Misc2)
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