HISTORICAL AND

CONTEMPORARY
PERSPECTIVES,ISSUES OF
MATERNAL AND CHILD
HEALTH
Introduction
History
Midwifery and nursing
• A midwife is a person who having been regularly
admitted to a midwifery education,but recognized by
the country in which it is located,has successfully
completed the prescribed course of studies in
midwifery and has aquire the requisite to be
registered and or legally licenced to practice
midwifery.
In India
IN KERALA
• Ancient Times- Untrained Dais
• 1901-dais Given Skill Training For lyear

• 1939-jphn Course Of 1 ^ Year Duration Started ,Later

To 2year
• 1972-bsc.Nursing Started In Kerala At Govt.Hospital
Trivandrum
• 2011-1year Course Of Independent Nurse Midwifery
Practice/Training At Govt Hospital Trivandrum.
 ional programme
mother and child health
• MCHPROGRAMME
• ICDS PROGRAMME
• CHILD SURVIVAL AND SAFE MOTHERHOOD
PROGRAMME
• RCHPROGRAMME
• JANANI SURAKSHA YOJANA
• NRHM
Development of maternity
services and obg nursing
education...
In India

• 1854-midwifery Course Started In School Of

Nursing In Madras
• 1909-midwifery Programme Was Changed To 3yr

Programme
IN KERALA
• 1906-2yr Prog Started In Govt Hosp Trivandrum

• 1954-school Of Nursing Started In Govt Hospital

Trivandrum

• 1972-school Of Nursing Upgraded To Bsc.Nursing

• 1990-msc Nursing

• 1996-msc Nursing In Obstetric And Gynecologic

Nursing
NURSING
advancements
Obg nursing -global perspective
 Maternal
and Child
Health
 Maternal and child health.

Healthy children need healthy mothers

 aternal health

Health of women during pregnancy, childbirth and the postpartum

period.

Motherhood, for too many women it is associated with suffering, ill-

health and death.

Haemorrhage, infection, HBP, unsafe abortion and obstructed

labour still are major direct causes of maternal morbidity and

mortality.
Maternal health care
• Is a concept that encompasses family planning,
preconception, prenatal, and posnatal care.

• Goals of preconception care can include providing

education, health promotion, screening and
interventions for women of reproductive age to reduce
risk factors that might affect future pregnancies
 Child health.
• Child's health includes physical,
mental and social well-being too.

• Each year more than 10 million

children under the age of five die.

• At least 6.6 million child deaths can

be prevented each year if affordable
health interventions are made available
to the mothers and children who need
them.
 Maternal & child health.
• There are birth-related disabilities that
affect many more women and go
untreated like injuries to pelvic
muscles, organs or the spinal cord.

• At least 20% of the burden of disease

in children below the age of 5 is related
to poor maternal health and nutrition,
as well as quality of care at delivery
and during the newborn period.
 ISSUES OF MATERNAL
AND CHILD HEALTH
-GLOBAL PERSPECTIVE
 Maternal mortality ratio, by country, 2005

200-499 500-
999 > 1000
not Source: Maternal mortality in 2005. Estimates developed by WHO, UNICEF,
available UNFPA arid The World Bank. World Health Organization, 2007.
 Maternal mortality.
• Maternal deaths are clustered around
the intrapartum (labour, delivery and the
immediate postpartum); the most common
direct cause globally is obstetric
haemorrhage.

• Other major causes are: obstetric

haemorrhage; anaemia; sepsis/infection
obstructed labour; hypertensive disorders
and unsafe abortions.
Children < 5 years mortality (2008).
• Globally, 80 percent of all child
deaths to children under five are due to
only a handful of causes:
• pneumonia (19 %),
• diarrhea (18 %),
• malaria (8 %),
• neonatal pneumonia or sepsis (10 %),
• pre-term delivery (10 %),
• asphyxia at birth (8 %),
• measles (4 %),
• HIV/AIDS (3 %).
"CHILD ANDMATERNAL
HEALTH ISSUES IN INDIA
of Quality care
• Most people in the developing countries are
malnourished
• Malnutrition has a significant impact on the
vulnerable groups - pregnant women, lactating
women and children
• It can result in maternal complications such as
• anemia
• post partum haemorrhage
• toxemia of pregnancy
• low birth weight in baby
• Children are most affected in utreo and during
period of weaning
• Malnourished children are more susceptible to
infections
 erventions to prev rition
can be direct and indirect

• Direct measures
• Food supplementation
• Food fortification
• Iron and folic acid supplementation
• Nutritional education
• Indirect measures
• Food hygiene
• Education
• Environmental sanitation
• Vaccination to prevent disease
• Provision for clean drinking water
Infection
• Although infections have been controlled to a great
extend in developed countries, they continue to be a major
problem in developing countries
• Maternal infection can result in
• IUGR
• low birth weight
• abortions
• peurperal sepsis
• Upto 25 percent of pregnant women have urinary tract
infection
• Cytomegalovirus, herpes and toxoplasma infection are
also seen among mothers
• Children are at risk for diarrhoeal diseases, respiratory
tract diseases and skin conditions
• adequate nutrition
• sanitation
• immunization
• better primary health care
services
• Unregulated fertility has adverse effects
on both mother and children
• Decrease in birth spacing results in
inadequate care for the existing child and
risk of more complications during
pregnancy ( such as anemia, IUGR,
abortion)
• The risk increases greatly after the 4th
pregnancy
 erventions mainly i

• family planning services form an important

part of MCH programs
• Measures like Intrauterine contraceptive
device, oral contraceptive pills, long acting
injectable medroxy progesterone acetate,
female sterilisation and barrier methods
can be used.
 Core interventions to prevent
child deaths.
• Preventive interventions:
• Vaccination
• Folic acid supplementation
• Tetanus toxoid
• Syphilis screening and treatment
• Pre-eclampsia and eclampsia
prevention (calcium supplementation)
• Intermittent presumptive treatment for
malaria in pregnancy
 Core interventions to prevent
child deaths.
• Preventive interventions:

• Antibiotics for premature rupture of

membranes
• Detection and management of breech
(caesarian section)
• Labor surveillance
• Clean delivery practices
• Breastfeeding
 Core interventions to prevent
child deaths.
• Preventive interventions:

• Hib vaccine
• Water, sanitation, hygiene
• Antenatal steroids
• Vitamin A
• Nevirapine and replacement feeding to
prevent HIV transmission
• Measles vaccine
 Core interventions to prevent
child deaths.
• Preventive interventions:

• Prevention and management of

hypothermia
• Kangaroo mother care (skin-to-skin
contact) for low birth-weight newborns
• Newborn temperature management
• Insecticide-treated materials
• Complementary feeding
 Core interventions to prevent
child deaths.
• Treatment interventions:
• Detection and treatment of asymptomatic
bacteriuria.

• Corticosteroids for preterm labor.

• Newborn resuscitation

• Community-based pneumonia case management,

including antibiotics

Oral rehydration therapy

 Core interventions to prevent
child deaths.
• Antibiotics for dysentery, sepsis,
emerging and reemeging diseases.

• Zinc for diarrhea

Vitamin A in respiratory diseases.

PFemale Infanticide
Female Feticide
• Female Feticide is the act of aborting a baby because

it is of a female gender. Sex selective abortion is a

big problem in India. The number of abortions by

medical professionals have increased so much that

today it has become a industry even though it is

punishable by law.
• Female Infanticide is the act of killing a
female girl either new-born or within the first
few years of life. It could be actively,
murdering through suffocation, poisoning
etc. Such acts can also be passive, where
no interest is taken with regards to feeding
or towards her general health in affect total
neglect.
Trafficking, slavery
NDER EQUITY ISSUES
IN INDIA
HU MAM SEXUALITY
(
• Within the framework of the World Health

Organization's (WHO) definition of health as a state of

complete physical, mental and social well-being, and not

merely the absence of disease or infirmity. reproductive

health, or sexual health/hygiene, addresses the

reproductive processes, functions and system at all stages

of life.
• Reproductive health, therefore, implies that people are
able to have a responsible, satisfying and safer sex life
and that they have the capability to reproduce and the
freedom to decide if, when and how often to do so. One
interpretation of this implies that men and women ought
to be informed of and to have access to safe, effective,
affordable and acceptable methods of birth control; also
access to appropriate health care services of sexual,
reproductive medicine and implementation of health
education programs to stress the importance of women
to go safely through pregnancy and childbirth could
provide couples with the best chance of having a healthy
infant..
• According to the WHO, "Reproductive
and sexual ill-health accounts for 20%
of the global burden of ill-health for
women, and 14% for men."
An unofficial working definition for sexual health is that
"Sexual health is a state of physical, emotional, mental
and social well-being in relation to sexuality; it is not
merely the absence of disease, dysfunction or infirmity.
Sexual health requires a positive and respectful approach
to sexuality and sexual relationships, as well as the
possibility of having pleasurable and safe sexual
experiences, free of coercion, discrimination and
violence. For sexual health to be attained and
maintained, the sexual rights of all persons must be
respected, protected and fulfilled."
• Early childbearing and other behaviours can have health
risks for women and their infants. Waiting until a woman
is at least 18 years old before trying to have children
improves maternal and child health. If an additional child
is to be conceived, it is considered healthier for the
mother, as well as for the succeeding child, to wait at
least 2 years after the previous birth before attempting
to conception. After a fetal fatality, it is healthier to wait
at least 6 months.
• The WHO estimates that each year, 358 000 women die
due to complications related to pregnancy and
childbirth; 99% of these deaths occur within the most
disadvantaged population groups living in the poorest
countries of the world.Most of these deaths can be
avoided with improving women's access to quality care
from a skilled birth attendant before, during and after
pregnancy and childbirth.
International Conference on Population
and Development (ICPD), 1994
• The International Conference on Population and
Development (ICPD) was held in Cairo, Egypt, from 5 to
13 September 1994. Delegations from 179 States took
part in negotiations to finalize a Programme of Action on
population and development for the next 20 years. Some
20,000 delegates from various governments, UN
agencies, NGOs, and the media gathered for a
discussion of a variety of population issues, including
immigration, infant mortality, birth control, family
planning, and the education of women.
“a state of complete physical, mental and social well-being

and...not merely the absence of disease or infirmity, in all

matters relating to the reproductive system and its

functions and processes. Reproductive health therefore

implies that people are able to have a satisfying and safe

sex life and that they have the capability to reproduce and

the freedom to decide if, when and how often to do so.

• Implicit in this last condition are the right of men and
women to be informed [about] and to have access to
safe, effective, affordable and acceptable methods of
family planning of their choice, as well as other methods
of birth control which are not against the law, and the
right of access to appropriate health-care services that
will enable women to go safely through pregnancy and
childbirth and provide couples with the best chance of
having a healthy infant.”
The ICPD achieved consensus on four qualitative an
quantitative goals for the international community, the
final two of which have particular relevance for
reproductive health:

• Reduction of maternal mortality: A reduction of

maternal mortality rates and a narrowing of

disparities in maternal mortality within countries and

between geographical regions, socio-economic and

ethnic groups.
Access to reproductive and sexual health services
including family planning: Family planning counseling,
pre-natal care, safe delivery and post-natal care,
prevention and appropriate treatment of infertility,
prevention of abortion and the management of the
consequences of abortion, treatment of reproductive tract
infections, sexually transmitted diseases and other
reproductive health conditions; and education,
counseling, as appropriate, on human sexuality,
reproductive health and responsible parenthood.
• Services regarding HIV/AIDS, breast cancer,

infertility, delivery, hormone therapy, sex

reassignment therapy, and abortion should be made

available.
• Active discouragement of female genital mutilation
(FGM)
Millennium Development Goa

• Achieving universal access to reproductive health by

2015 is one of the two targets of Goal 5 - Improving
Maternal Health - of the eight Millennium Development
Goals. To monitor global progress towards the
achievement of this target, the United
Nations has agreed on the following indicators:

• 5.3: contraceptive prevalence rate

• 5.4: adolescent birth rate
• 5.5: antenatal care coverage
• 5.6: unmet need for family planning
statistics on all four indicators have either improved
or remained stable between the years 2000 and 2005.
However, progress has been slow in most developing
countries, particularly in Sub-saharan Africa, which
remains the region with the poorest indicators for
reproductive health. According to the WHO in 2005 an
estimated 55% of women do not have sufficient
antenatal care and 24% have no access to family
planning services.
 MDGs and maternal/child health
• Millennium Development Goal 4 aims
to reduce child deaths by two-thirds
between 1990 and 2015.

• Millennium Development Goal 5 has

the target of reducing maternal deaths
by three-quarters over the same
period.
 MDGs and maternal/child health

• Unfortunately, on present trends,

most countries are unlikely to achieve
either of these goals.

• A recent review of MDG progress,

show that the world have only 32% of
the way to achieving the child health
goal and less than 10% of the way to
achieving the goal for maternal health.
• An article from the World Health Organization calls safe,
legal abortion a "fundamental right of women,
irrespective of where they live" and unsafe abortion a
"silent pandemic".The article states "ending the silent
pandemic of unsafe abortion is an urgent public-health
and human-rights imperative.".
• It also states "access to safe abortion improves women’s
health, and vice-versa, as documented in Romania
during the regime of President Nicolae Ceausescu" and
"legalisation of abortion on request is a necessary but
insufficient step toward improving women’s health" citing
that in some countries, such as India where abortion has
been legal for decades, access to competent care
remains restricted because of other barriers
WHO’s Global Strategy on Reproductive Health, adopted
by the World Health Assembly in May 2004, noted: “As a
preventable cause of maternal mortality and morbidity,
unsafe abortion must be dealt with as part of the MDG
on improving maternal health and other international
development goals and targets." The WHO's
Development and Research Training in Human
Reproduction (HRP), whose research concerns people's
sexual and reproductive health and lives, has an overall
strategy to combat unsafe abortion that comprises four
inter-related activities:
 • to collate, synthesize and generate scientifically sound
evidence on unsafe abortion prevalence and practices;
• to develop improved technologies and implement
interventions to make abortion safer;
• to translate evidence into norms, tools and guidelines;

• and to assist in the development of programmes and

policies that reduce unsafe abortion and improve access
to safe abortion and high quality post-abortion care
• This strategy does not involve studying the possible
effects of abortion on aborted fetuses
• Burt defined sex education as “the study of the
characteristics of beings; a male and female. Such
characteristics make up the person's sexuality. Sexuality
is an important aspect of the life of a human being and
almost all the people including children want to know
about it. Sex education includes all the educational
measures which in any way may of life that have their
center on sex. He further said that sex education stands
for protection, presentation extension, improvement and
development of the family based on accepted ethical
ideas.”
• Leepson sees sex education “as instruction in
various physiological, psychological and sociological
aspects of sexual response and reproduction.”
• Kearney also defined sex education as “involving a
comprehensive course of action by the
school, calculated to bring about the socially desirable
attitudes, practices and personal conduct on the part
of children and adults, that will best protect the
individual as a human and the family as a social
institution
 ix education may also be described as "sexuality
education", which means that it encompasses education
about all aspects of sexuality, including information about
family planning, reproduction(fertilization, conception and
development of the embryo and fetus, through to
childbirth), plus information about all aspects of one's
sexuality including: body image, sexual orientation,
sexual pleasure, values, decision
making, communication, dating, relationships, sexually
transmitted infections (STIs) and how to avoid them,
and birth control methods. Various aspect of sex
education are to right in school depending on the age of
the students or what the children are able to
comprehend at a particular point in time.
• Rubin and Kindendall expressed that sex education is
not merely a unit in reproduction and teaching how
babies are conceived and born. It has a far richer scope
and goal of helping the youngster incorporate sex most
meaningfully into his present and future life, to provide
him with some basic understanding on virtually every
aspect of sex by the time he reaches full maturity.
• Sex education may be taught informally, such as when

someone receives information from a conversation with

a parent, friend, religious leader, or through the media.

It may also be delivered through sex self-help authors,

magazine advice columnists, sex columnists, or sex

education web sites. Formal sex education occurs

when schools or health care providers offer sex

education.
• Slyer stated that sex education teaches the young

person what he or she should know for his or her

personal conduct and relationship with others.

Gruenberg also stated that sex education is necessary

to prepare the young for the task ahead. According to

him, officials generally agree that some kind of

planned sex education is necessary.

Sometimes formal sex education is taught as a full

course as part of the curriculum in junior high school

or high school. Other times it is only one unit within a

more broad biology class, health class, home

economics class, or physical education class.

• Some schools offer no sex education, since it remains a
controversial issue in several countries, particularly the
United States (especially with regard to the age at
which children should start receiving such education,
the amount of detail that is revealed, and topics dealing
with human sexual behavior, e.g. safe sex practices,
masturbation, premarital sex, and sexual ethics).
The existence of AIDS has given a new sense of

urgency to the topic of sex education. In many

African nations, where AIDS is at epidemic levels

(see HIV/AIDS in Africa), sex education is seen by

most scientists as a vital public health strategy..

• Some International organizations such as Planned

Parenthood consider that broad sex education

programs have global benefits, such as controlling the

risk of overpopulation and the advancement of

women's rights (see also reproductive rights). The use

of mass media campaigns, however, has sometimes

resulted in high levels of "awareness" coupled with

essentially superficial knowledge of HIV transmission

According to SIECUS, the Sexuality Information and
Education Council of the United States, 93% of adults
they surveyed support sexuality education in high
school and 84% support it in junior high school. In fact,
88% of parents of junior high school students and 80%
of parents of high school students believe that sex
education in school makes it easier for them to talk to
their adolescents about sex. Also, 92% of adolescents
report that they want both to talk to their parents about
sex and to have comprehensive in-school sex education
• Sexual Education In India
In India, there are many programs promoting sex
education including information on AIDS in schools as
well public education and advertising. AIDS clinics
providing information and assistance are to be found in
most cities and many small villages.
• “India has a strong prevention program which goes
hand in hand with care, support and treatment. We
have been able to contain the epidemic with a
prevalence of just 0.31 %. We have also brought
about a decline of 50% in new infections annually.”
As per the words of Shri Gulam Nabi Azad, Hon’ble
Minister of Health and Family Welfare, 2011.
• Indonesia, Mongolia, South Korea have a systematic
policy framework for teaching about sex within
schools. Malaysia and Thailand have assessed
adolescent reproductive health needs with a view to
developing adolescent-specific training, messages and
materials.
• Bangladesh Myanmar, Nepal and Pakistan have no
coordinated sex education programs.
• In Japan, sex education is mandatory from age 10 or
11, mainly covering biological topics such as
menstruation and ejaculation.
In China and Sri Lanka, sex education traditionally consists
of reading the reproduction section of biology textbooks. In
Sri Lanka young people are taught when they are 17-18
years old. However, in 2000 a new five-year project was
introduced by the China Family Planning Association to
"promote reproductive health education among Chinese
teenagers and unmarried youth" in twelve urban districts
and three counties. This included discussion about sex
within human relationships as well as pregnancy and HIV
prevention.
• The International Planned Parenthood Federation
and the BBC World Service ran a 12-part series
known as Sexwise which discussed sex education,
family life education, contraception and parenting. It
was first launched in South Asia and then extended
worldwide
• Morality
Lesbian, gay, bisexual, and
transqender youth
HEALTH IN INDIA
• Reproductive health implies that people are able to
have a responsible, satisfying and safer sex life and that
they have the capability to reproduce and the freedom to
decide if, when and how often to do so. According to the
WHO, “Reproductive and sexual ill-health accounts for
20% of the global burden of ill-health for women and 14%
for men. The WHO estimates that each year, 3, 58, 000
women die due to complications related to pregnancy
and childbirth.
PChallenqes Facing '
Reproductive and Sexual Health in
India
In India, the problems related to reproductive and
sexual health among women is highest amongst the
rural population. Illiteracy is the leading cause of this
situation. Ensuring literacy of the girl child can help
delay the age at which a woman gets married and
thereby reduce other disparities.
Gender Inequality
Women in India for years have been exposed to gender
inequality that has been the root cause of sexual and
reproductive diseases. Optimum sexual and
reproductive health can be attained by health and social
interventions.
Nutrition

The lack of proper nutrition has a profound effect on

the health of a woman as she advances into
motherhood. “When it comes to reproductive health,
pregnancy care is very crucial. During pregnancy, the
nutritional deficiency has a negative impact on the
heath of both mother and the baby. In this period,
women are vulnerable to problems like anaemia, post-
delivery bleeding, low birth weight babies, etc
• . Also, in developing countries, Tetanus remains as a
leading cause of maternal and neonatal morbidity and
mortality,” said Dr Amita Shah, obstetrics &
gynaecologist, Columbia Asia Hospital, Gurgaon. She
adds that the Reproductive and Child health
programme mandated by the Ministry of Health and
Family Welfare that promotes the concept of health of
women from womb to tomb is taken seriously
rack of Decision-Making Power

The lack of power to decide how and when to have a child has
amounted to the increase in maternal mortality. “The women should
have the right to have safe sex, to decide on when she wants to get
pregnant or opt for a legal abortion. Women empowerment can be
successful only when societal norms enable the women to access
these rights and empowers them to take right decisions. There
should be an advanced health system in place to deal with
pregnancy related complications, which is also very important,”
adds Dr Shah.
Spread of STDs

Generally, women don’t have any access to

contraceptives, thereby increasing the number of
unwanted and unplanned pregnancies and severe
sexually transmitted diseases.
HEALTH SERVICES
• Family Planning Services
• Counseling to enable couples to make an informed
choice
• Prenatal care
• Safe delivery and post natal care
• Prevention and appropriate treatment of infertility
• Prevention of spontaneous abortion and management
of consequences of induced abortion
• Treatment of reproductive tract infections, sexually
transmitted diseases and other reproductive health
conditions
• Education on responsible parenthood
• Other Specific Health Services pertain to:
• HIV/AIDS
• Breast cancer
• Delivery
• Hormone therapy
• Sex reassignment therapy
• Abortion
Thank you...