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Section 7 : Family Health140 Maternal and Child Health A S Kushwaha 809

141 Risk Approach in MCH A S Kushwaha 811

142 Maternal Health Care AS Kushwaha 814

143 Care of Infants A S Kushwaha 826

144 Integrated Management of Neonatal and Childhood Illnesses (IMNCI) A S Kushwaha 835

145 Care of Under Five Children A S Kushwaha 848

146 School Health Services A S Kushwaha 853

147 Adolescent Health A S Kushwaha 856

148 Children’s Right to Health A S Kushwaha 865

149 Growth and Development of Children A S Kushwaha 869

150 Genetics and Public Health Amitava Datta 878

151 Preventive Health Care of the Elderly RajVir Bhalwar 887

152 Demography and Public Health Dashrath R. Basannar 891

153 Contraceptive Technology RajVir Bhalwar 895

• 809 •

140 Maternal and Child Health

A S Kushwaha

The health of women and children has always been an important social goal of all societies. Over the years, maternal and child health has evolved through various stages of conceptual approach, technological advances and social prioritization. The realization that, improved maternal and child health is the key to the ultimate objective of lifelong health in any society, has led to renewed interest and global focus towards this very important social health issue.

Mother and Child: A Single EntityMother and child are often spoken of in one breath for a number of reasons. Health of the child and the mother are so closely linked that each has the capacity to influence the other. The outcome of pregnancy in terms of a healthy newborn is dependent on the physical, physiological, mental and nutritional state of the mother during pregnancy. Some specific health interventions jointly protect pregnant women and their babies e.g. tetanus toxoid immunization and nutrition supplementation. At childbirth, both mother and child are at risk for complications which can endanger their lives. The postpartum care of the mother is inseparable from newborn care, immunization and family planning advice, and this provides not only operational convenience but offers continuity of care as well.

Important Sub Disciplines Related to MCH There are a number of sub disciplines that have developed over the years in the field of maternal and child health. It is in this endeavour that disciplines like social obstetrics, preventive pediatrics, community obstetrics, family health and family medicine have originated. Various initiatives in child health include essential newborn care, well baby clinics, under five clinics, Child guidance clinics and school health services.

Why So Much Attention to This Issue?Firstly, together, mothers (women 15-45 years of age) and children (under 15 years of age) constitute 70-80% of the population. They also belong to the most vulnerable section of society in terms of death, disease, disability and discrimination. Women and Children represent economically dependent and least empowered section of the society. The falling sex ratio (from 972 in 1901 to 933 in 2001) is a grim reminder of the social disadvantage faced by women in India(1). The issue also merits attention because of high morbidity and mortality faced by this group. Most of the deaths and illnesses in these groups are avoidable by cost effective interventions which are available to tackle them.

Scenario of Maternal and Child HealthGlobal Picture : Of the estimated 211 million pregnancies that occur each year, about 46 million end in induced abortion. Attending to all of the 136 million births every year is one of the major challenges that is now faced by the world’s health systems. Globally, huge toll on account of maternal deaths continues unabated. Often sudden, unpredicted deaths occur during pregnancy itself (as a consequence of unsafe abortion),

during childbirth, or after the baby has been born due to blood loss and infections. The 5,29,000 annual maternal deaths, including 68,000 deaths attributable to unsafe abortion, almost all of these are occurring in poor countries with only 1% in rich countries. Each year 3.3 million babies are stillborn, more than 4 million (neonatal deaths) are dying within 28 days of coming into the world, and a further 6.6 million young children die before their fifth birthday. Although an increasing number of countries have succeeded in improving the health and well-being of mothers, babies and children in recent years, in some countries the situation has actually worsened. Slow progress, stagnation and reversal are closely related to poverty, to humanitarian crises, and, particularly in sub-Saharan Africa, to the direct and indirect effects of HIV/AIDS. Over 300 million women in the world currently suffer from long-term or short-term illness brought about by pregnancy or childbirth. Programmes to tackle vaccine preventable diseases, malnutrition, diarrhoea, or respiratory infections still have a large unfinished agenda. India

Health of Women : The country has a falling low sex ratio of 933 female per thousand male. Early marriage in women and universality of marriage are important social issues. The median age at first marriage among women is 17.2 years. Almost half (46%) of women age 18-29 years got married before the legal minimum age of 18. Among young women age 15-19, 16 percent have already begun childbearing. Indians have poor knowledge about temporary contraceptive methods and this coupled with poor availability affects ‘delaying the first and spacing the second child’ doctrine adversely. Among the married women, 13 percent have unmet need for family planning. Less than half of women receive antenatal care during the first trimester of pregnancy, as is recommended. Three out of every five births in India take place at home; only two in five births take place in a health facility. Less than half of births took place with assistance from a health professional, and more than one third were delivered by a Traditional Birth Attendant. The remaining 16 percent were delivered by a relative or other untrained person. A Disposable Delivery Kit (DDK) is being used only in 20% of births taking place at home. Most women receive no postnatal care at all. Only 37 percent of mothers had a postnatal checkup within 2 days of birth. Every seven minutes an Indian woman dies from complications related to pregnancy and childbirth. The maternal mortality ratio in India stands at 300 per 100,000 live births. (Table - 1).

Child Health : Infant mortality is 77 per 1,000 for teenage mothers, compared with 50 for mothers age 20-29. Infant mortality in rural areas is 50 percent higher than in urban areas. Perinatal mortality, which includes stillbirths and very early infant deaths (in the first week of life), is estimated at 49 deaths per 1,000 pregnancies, that lasted 7 months or more. Less than half (44%) of children 12-23 months are fully vaccinated against the six major childhood illnesses: tuberculosis, diphtheria, pertussis, tetanus, polio, and measles. Although breast feeding is almost universal in India, only 46 percent of children under 6 months are exclusively breastfed. Many infants are deprived of the highly nutritious first milk (colostrum) as only 55 percent are put to the breast within the first day of life. Almost half

• 810 •

of children under age five are stunted or too short for their age. Anaemia is a major health problem in India, especially among women and children. Among children between the ages of 6 and 59 months, about 70 percent are anaemic including three percent who suffer from severe anaemia. More than half of women in India (55 percent) have anaemia with 17 percent of these have moderate to severe anaemia.

Table - 1: Important Mortality indicators of Maternal and Child Health (Source-NFHS 3)

Indicator 1994 2000 2001 2002 2003 2004 2005

IMR 74 68 65.9 64 60 58 58

NNMR 47.7 44 40.2 NA 37 37 37

PNMR 26 23 25.7 NA 23 21 22

PMR 42.5 40 26.2 NA 33 35 37

SBR 8.9 8 9.3 NA 9 10 9

MMR 327 301

IMR Infant Mortality rate

NNMR Neonatal Mortality rate

PNMR Post-Neonatal Mortality Rate

PMR Perinatal Mortality Rate

SBR Still Birth Rate

MMR Maternal Mortality Ratio

Challenges in MCH The look at statistics in Table - 1 gives a picture of many unfulfilled promises in the field of maternal and child health despite a family welfare programme running since 1950s. The challenges include lack of universalisation of services, rural urban differential, poor status of women in society and lack of political will and acceptance of the issue as a social priority. The main challenge to child survival no longer lies in determining the proximate causes of or solutions to child mortality but in ensuring that the services and education required for these solutions reach the most marginalized countries and communities.

Opportunities in MCHA new paradigm in MCH - Continuum of Care : The continuum consists of a focus on two dimensions in the provision of packages of essential primary-health-care services:

Time: There is a need to ensure essential services for mothers and children during pregnancy, childbirth, the postpartum period, infancy and early childhood. The focus on this element was engendered by the recognition that the birth period – before, during and after –is the time when mortality and morbidity

risks are highest for both mother and child.

Place: Linking the delivery of essential services in a dynamic primary-health-care system that integrates home, community, outreach and facility-based care. The impetus for this focus is the recognition that gaps in care are often most prevalent at the locations – the household and community – where care is most required.

The continuum of care concept has emerged in recognition of the fact that maternal, newborn and child deaths share a number of similar and interrelated structural causes with undernutrition. The continuum of care also reflects lessons learned from evidence and experience in maternal, newborn and child health during recent decades. In the past, safe motherhood and child survival programmes often operated separately, leaving disconnections in care that affected both mothers and newborns. It is now recognized that delivering specific interventions at pivotal points in the continuum has multiple benefits. Linking interventions in packages can also increase their efficiency and cost-effectiveness. The primary focus is on providing universal coverage of essential interventions throughout the life cycle in an integrated primary-health-care system.

Road AheadThe NRHM and RCH are aimed at meeting this challenge and have set out their targets as envisaged under various policies and MDGs. (See Table - 2)

Table - 2 : The Road Ahead (National targets for MCH)

Indicator10th Plan

goals (2002-07)

RCH -2 (2004-

09)

National Population

Policy 2000 (by

2010)

MDGs (by 2015)

Infant mortality

rate

45 per 1000 live

births

35 per 1000 live

births

30 per 1000 live

births-

Under 5 mortality

rate- - -

Reduce by 2/3rd

Maternal mortality

ratio

200 per 1 lakh live

births

150 per 1 lakh

live births

100 per 1 lakh live

births

Reduce by 3/4th

ReferencesNational Family Health Survey NFHS - 3 India 2005-06, International 1. Institute for Population Sciences, Mumbai, India. http://www.nfhsindia.org/nfhs3.html World Health Report 2005. Make Every Mother and Child count. WHO, 20052.

• 811 •

141 Risk Approach in MCH

A S Kushwaha

Risk as a Proxy for NeedIn every society there are communities, families and individuals whose chances of future illness, accident and untimely death are greater than others; they are said to be vulnerable owing to peculiar set of characteristics they share. These characteristics could be biological, genetic, environmental, psychosocial or economic. Similarly there are others who have a chance to enjoy better health. Thus as an example we can see that pregnant, poor, very young children and elderly are vulnerable and young and affluent are not. Risk however has come to be associated with the vulnerability to disease or illness or death. A pregnant woman with high blood pressure is at risk of complications like eclampsia and this measured risk to her and the child is an expression of her need for medical help and intervention. The risk strategy utilizes these risk estimates as guide for action, resource allocation, coverage and referral care. The hypothesis, on which risk strategy rests, therefore, is that more accurately the risk is measured, the better is the understanding of the need.

The risk approach is a managerial tool based on the strategy for efficient utilization of scarce resources with more care for those in need and proportionate to the need.

Tools of the Risk ApproachThe characters shared by a cohort making them vulnerable are referred to as risk factors. The measure of association with the outcome is known as the relative risk and estimation of the adverse outcome if these risk factors are present and calculation of effect if these risk factors are removed have made our decisions in public health prioritization. Risks, predictions and possible effects are therefore the tools of the risk approach. By quantifying the risks to the health of a population group and their associated risk factors, it focuses attention on the need for prevention.

Risk Approach Applied to MCHThe mothers and children are most susceptible to good or harmful influences that will permanently affect their health. The harm can be inflicted or the good can be promoted in a very short time. The preventive and promotive elements of primary health care will have greatest yield if applied by using risk approach in MCH.

DefinitionsRisk : It implies that the probability of adverse consequences is increased by the presence of one or more characteristics or factors. It is a measure of statistical chance of a future occurrence.

Relative Risk : It measures the strength of the association between risk factor and the outcome e.g. RR of an outcome due to a risk factor is 1.3, means a 30% excess risk in those with the risk factor.

Attributable Risk : This brings together three ideas - the frequency of the unwanted outcome when risk factor is present, frequency of the unwanted outcome when risk factor is absent, frequency of the occurrence of risk factor in the community. It indicates what might be expected to happen to the overall outcome in the community if the risk factor was removed.

Risk Factors : Risk factor is defined as any ascertainable characteristic or circumstance of a person or group of persons that is known to be associated with an abnormal risk of developing or being especially adversely affected by a morbid process. Risk factor is one link in a chain of association leading to an illness or an indicator of a link.

Risk factors can therefore be causes or signals but they are observable and identifiable. Risk factor could be related to individual, family, community or the environment. Examples include - first pregnancy, high parity, teenage pregnancies, malnutrition, rural area, birth attendance etc.

The significance of risk factors from the point of application and utility in practice of preventive community medicine can be judged by - (a) Degree of association with the outcome.(b) Frequency of the risk factor in the community.Combination of Risk FactorsThe combination of two or more risk factors increases the probability of the outcome. For example in a pregnancy, the hypertensive disease and poor antenatal care are independent risk factors for perinatal mortality but when both factors are present, the probability of perinatal mortality is much higher than expected. This is because the risk factors may have an additive or multiplicative effect.

Risk Factors and CausesNot all significant associations between the risk factor and the outcome are part of a chain of causality. Associations are usually described as ‘causal’ if they can be seen to be directly related to pathological processes, even if the pathways are not fully understood. e.g. Maternal malnutrition and low birth weight, placenta praevia and foetal death from anoxia, rubella in first trimester and congenital malformation. The important attributes in such association are ‘dose response relationship, specificity, consistency of association, time relationship and biological plausibility. The complex relationship between risk factor and outcome can be explained by an example of gastroenteritis in a child belonging to a poor family where the complex of poverty may include contributions to risk from large family size, crowding, early weaning, poor nutrition with infection of infant and neglect of early Diarrhoea for a variety of reasons. Thus it is more than clear that family poverty is a risk factor for gastroenteritis and death from gastroenteritis. The advantage of risk approach is the attention being given to all causes regardless of their medical, intersectoral, economic, political or social origins.

Methodology in Risk ApproachThe risk approach involves, first, decisions as to priority ‘targets’ or unwanted outcomes, measurement of association between risk factors and the outcome, and then intervention

• 812 •

planned. The risk approach has to be studied by research and then only applied over a wide population.

Outcome, Risk and Measurement : The risk approach seeks to use information about risk to prevent a variety of adverse outcome (illness, injury and death) through the application of a strategy at many levels of care.

Outcomes : This is the first information required. Collect details of morbidity and mortality rates which are our targets or priorities (prevalence and incidence, trends, distribution in geographical area and different groups).

Risk Factors : Collect information on the following : (a) Risk factors for each unwanted outcome.(b) Risk factors or combinations of risk factors for each group

of unwanted outcome.(c) For all risk factors - (i) Prevalence and incidence and trends in the

population (ii) Relative risk of unwanted outcomes associated with

each risk factors or combinations (iii) Attributable risk associated with each risk factors (iv) Predictive power of each risk factor (v) The ease, accuracy and acceptability of screening for the

presence of risk factor in communities and individuals.Priorities among Outcomes : This will depend upon many variables like - (a) Community priority and preference(b) Prevalence or frequency of occurrence(c) The seriousness of the problem (fatality rate)(d) Degree of preventability(e) Rising frequency or upward trend of the problem (emerging

issues)Steps1. Identifying the risk factors and the populations and the

individuals at risk2. Selection of risk factors (i) Optimum grouping (ii) Usefulness in terms of proposed intervention (iii) Strength of association / cause - effect relationship (iv) Ease of modification (intervention) (v) Ease and accuracy of identification (test)3. Who should do the screening? (Fig - 1)

Fig. - 1

TBA approaches allpregnant mothers

TBA examines

ANM examines

Senior Nurse/ DoctorexaminesHospital doctorexaminesSpecialist sees onlyvery high risk mothers

Referred Kept Returned

To give an example, if it was the Perinatal and maternal mortality (Outcome) then the identification of risk factors will involve screening at various levels for different risk factors depending upon the complexity of identification and infrastructure available and training of the health worker.

These decisions to refer or to keep are based on some form of risk scoring system. For example, while doing above exercise, suppose there is a risk scoring from 0 - 5, the scheme would look like (See Table - 1).

Table - 1 : Risk Scoring System

Health level

Func - tionary

Exam - ines

Keeps Refers Returns

I TBA 0, 1, 2, 3, 4, 5

0 1, 2, 3, 4, 5

-

II ANM 1, 2, 3, 4, 5

2 3, 4, 5 1

III Senior Nurse

3, 4, 5 3 4, 5 2

IV Doctor 4, 5 4 5 3

V Specialist 5 5 - 4

Issue of False Positives and False NegativesWhen screening populations, some of the difficulties faced are related to the issues of false positive and false negatives. The value of risk factors at predicting outcomes is gauged by proportion of the true association. There are examples where the cases of gastroenteritis deaths may be seen in breastfed infants (though less likely) while some of the bottle fed infants may not suffer from gastroenteritis (less likely). The issue of false positives and false negatives may make decisions for interpreting and introducing screening tests difficult.

Risk ScoringScores must accurately reflect the risk to the mother and children which in itself is a proxy for the need for care. Scoring attempts to provide simple, easy to use index of the urgency, seriousness and complexity, of the future threat to health. The risk scores are a good managerial tool. Sources of scores are - (a) Ad hoc - e.g. tall or short, poor or not poor, well fed or

malnourished(b) Points or score based on experience - For example, while

scoring for poor outcome of pregnancy, 3 points for poor obstetric history, 3 for high parity, 2 for maternal age, 1 for birth interval, family income, poor education etc.

(c) Absolute risk(d) Relative risk(e) Attributable riskMost scoring systems use the relative risk.

Trade off : While deciding the cut off for continuous risk factor there is a compromise between yield and resources by trade off between false positive and false negatives. This decision is arrived at by weighing how many more false positive can be afforded by the community for the desired reduction in the false negatives.

• 813 •

Basic information needed for planning the use of Risk Approach1. Age and sex distribution and geographical distribution by

community and household2. Mortality by age, sex and cause3. Local cultural factors, occupations, religion and attitude to

health and disease4. Services likely to have most impact from risk approach5. Information on environmental risk factors6. Local community organizations, groups7. Local health care services including personnel and

infrastructure8. Present way to deal with the MCH problems9. Information about traditional systems of medicine and

their acceptanceIntervention at different levels of care : This is used to define the main point of impact of an intervention within the health care system. Risk approach can be applied at all levels from self and home to intersectoral policy.Uses of the Risk Approach1. Self & Family(a) Improved ability to recognize health priorities and health

lifestyle and behavior.(b) Informed surveillance of self and family.(c) Earlier self and family referral.2. Local community - village groups, self help groups,

women’s group.3. Application within the health care system - resource

allocation.4. Increasing coverage - e.g. Universal immunization,

essential maternal and newborn care.5. Improved referral - better facilities, technology and skills.6. Regional and National level - for defining and planning

priorities, capacity and staffing, design referral chain, resource allocation and evaluation.

7. Intersectoral collaboration is the key to planning, designing and executing any health intervention.

Selecting Interventions : Steps involved are - (a) Potential for change in health care - managerial, avoid

authoritarian approach, no conflict with local, regional and national interest, local values and religious customs (MTP, Contraception).

(b) Criteria for selection - importance, feasibility, acceptability.

(c) Local priorities for action - Maternal mortality, Infant deaths, Perinatal mortality. Local priorities to be specific and well defined for application of risk approach.

(d) Local resources - people (trained and trainable), institutions, facilities and technology, managerial skills, health information systems, funds. Most important resources are time, commitment, enthusiasm and cooperation.

(e) National priorities(f) Decision pathwayModifying Risk Factors : Individual risk factors capable of modification are exemplified by some taboos and cultural practices (difficult to change), malnutrition, dwarfing, inadequate family planning services, lack of concern for environmental hazards, unsatisfactory personal hygiene,

negligent or dangerous work pattern and numerous intercurrent illnesses. Some can be modified without delay, some will have to wait till next pregnancy while yet others will only be changed in the next generation. Modification of the community risk factors is probably the most important potential achievement of the risk approach.

Selecting Target Health Problems : Among many health problems of mothers and children, it is usually a simple matter to choose the most important. This choice is often coloured by opinions. Most important health problems are not always the best targets for prevention. A method of rating scale which balances the factors like prevalence, seriousness, preventability, trends in time and local concern (Table - 2) is shown as an example.

Table - 2 : Selecting a health problem by Rating / Scoring

Health Problem

Criterion Max ratingRating

accorded

Maternal mortality

Extent 10 3

Seriousness 10 10

Preventability 10 8

Local concern 10 10

Time trend 10 2

Neonatal tetanus

Extent 10 8

Seriousness 10 10

Preventability 10 10

Local concern 10 4

Time trend 10 5

Childhood RTAs

Extent 10 3

Seriousness 10 10

Preventability 10 5

Local concern 10 7

Time trend 10 8

The relative importance of each criterion is also given its weight e.g. say on a five point scale, if we rate, extent and seriousness are given 5/5, preventability and local concern is given 3/5, time trend is given 2 out of 5. A simple matrix will set the health problems in the order of priority as seen in the Table - 3.

The order of priority in the above example is: first neonatal tetanus, second maternal mortality and third childhood RTAs.

Lessons from the Risk Approach - 1. Application to the whole field of Primary Health care is

limited due to shortage of support from evaluative research. Need to develop health system research.

2. Impediments and Barriers are related to Ethical (No research without service), Sociological (not in sync with local culture), Problems of human motivation, Political, managerial and technical problems and Shortage of skilled human resources.

The risk approach in MCH is a very useful tool and can help

• 814 •

in maximizing the output from the limited resources available especially in the developing countries. The risk approach helps to ease the pressure on the limited beds and facilities at the hospital level and also saving the expert human resources and sophisticated equipment for those who need it most. The risk approach also helps in developing health auxiliaries at the periphery providing the basic care in MCH close to home to the clientele within acceptable socio - cultural milieu. The policies and principles of care under NRHM using ASHA are an example of this approach.

Table - 3 : Selecting a problem by rating/scoring

Criteria and Relative weightage

Hea

lth

pro

blem

Ext

ent

(wei

ght

5)

Seri

ousn

ess

(wei

ght

5)

Pre

ven

tabi

lity

(w

eigh

t 3)

Loca

l co

nce

rn

(wei

ght

3)

Tim

e tr

end

(wei

ght

2)

Tota

l sc

ore

Maternal mortality

3x5 10x5 8x3 10x3 2x2 123

Neonatal tetanus

8x5 10x5 10x3 4x3 5x2 142

Childhood RTAs

3x5 10x5 5x3 7x3 8x2 117

SummaryThe risk strategy utilizes the risk estimates as guide for action, resource allocation, coverage, referral and care. Therefore the more accurately the risk is measured the better is the understanding of the need for efficient utilization of scarce resources with more care for those in need and proportionate to the need. Risk, predictions and possible effects are the tools

of the risk approach. The preventive and promotive elements of primary health care will have greatest yield if applied by using risk approach in MCH. Risk factors could be related to the individual, family, community and environment and their significance can be judged by their frequency and the degree of their association with the outcome. The risk approach involves prioritizing targets, measuring associations and the interventions to be applied. Info about the risk factors can be obtained through prevalence, incidence, trends, relative risk of unwanted outcomes and attributable risk associated with each risk factors and predictive power of risk factors. Prioritization will depend upon community priority, prevalence, fatality rates, degree of preventability and rising trend. Risk scoring (most of them use relative risk) if used must reflect the risk to the mother and the child.

Increased coverage, improved referral, risk factor modification, local, national and regional reorganization and training are the some of the uses of risk approach. The risk approach in MCH is a very useful tool maximizing the output with the limited number of tools available in addition to developing the health auxiliaries at the periphery.

Study ExercisesLong Question : Risk approach in MCH

Short Notes : (1) Basic information needed for planning the use of risk approach (2) Risk scoring (3) Uses of risk approach within and outside the health care system (4) Steps for selecting interventions.

ReferencesBackett E M, Davies A M, Petros - Barvazian A. Public Health Papers No 76: 1. The Risk approach in health care, with special reference to maternal and child health, including family planning, WHO Geneva, 1984Edwards L E et al. A simplified antepartum risk scoring system. Obstetrics 2. and Gynaecology, 54:237 - 240 (1979)Sogbanmu M. Perinatal mortality and maternal mortality in General hospital, 3. Ondo, Nigeria: Use of high risk pregnancy predictive scoring index. Nigerian Medical Journal, 9: 123 - 127 (1979)

142 Maternal Health Care

AS Kushwaha

All mothers and newborns, not just those considered to be at particular risk of developing complications, need skilled maternal and neonatal care. Maternal health care includes Antenatal, Intranatal care and Postnatal care, Quality intranatal care is critical to achieve the aim of a healthy mother and a healthy baby at the end of a pregnancy. This particular period (perinatal) though constitutes, only a small fraction in terms of its share (0.5 %) in the maternity cycle, but is probably, the most crucial.

DefinitionsMaternal Death : Maternal death is defined as death of a woman, while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of pregnancy, from any cause related to or aggravated by pregnancy or its management but not from accidental or incidental causes. (ICD-10)

Direct Obstetric Deaths : The deaths resulting from obstetric complications of the pregnant state (pregnancy, labour and the puerperium), from interventions, omissions, or incorrect treatment, or from a chain of events resulting from any of the above are called direct obstetric deaths.

Indirect Obstetric Deaths : Those resulting from previous existing disease or disease that developed during pregnancy and

• 815 •

that was not due to direct obstetric causes but was aggravated by the physiological effects of pregnancy.

Late Maternal Death : Late maternal death is death of a woman from direct or indirect obstetric causes, more than 42 days but less than one year, after termination of pregnancy.

Pregnancy Related Death : To facilitate the identification of maternal death in circumstances in which cause of death attribution is inadequate, ICD-10 introduced a new category, that of “pregnancy-related death” which is defined as : the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the cause of death.

Skilled Birth Attendant : Skilled Birth Attendants are people with midwifery skills (e.g. doctors, midwives, nurses) who have been trained to proficiency in the skills necessary to manage a normal delivery and diagnose and refer obstetric complications. This includes capacity to initiate the management of complications and obstetric emergencies, including life-saving measures where needed. Ideally skilled attendants live in, and are part of the community they serve.

Measurement of Maternal Mortality There are three main measures of maternal mortality- the maternal mortality ratio, the maternal mortality rate and the lifetime risk of maternal death.

Maternal Mortality Ratio : This represents the risk associated with each pregnancy, i.e. the obstetric risk. It is calculated as the number of maternal deaths during a given year per 100,000 live births during the same period. This is usually referred to as rate though it is a ratio.

The appropriate denominator for the Maternal Mortality Ratio would be the total number of pregnancies (live births, foetal deaths or stillbirths, induced and spontaneous abortions, ectopic and molar pregnancies). However, this figure is seldom available and thus number of live births is used as the denominator. In countries where maternal mortality is high denominator used is per 1000 live births but as this indicator is reduced with better services, the denominator used is per 1,00,000 live births to avoid figure in decimals.

Maternal Mortality Rate: It measures both the obstetric risk and the frequency with which women are exposed to this risk. It is calculated as the number of maternal deaths in a given period per 100,000 women of reproductive age (usually 15-49 years). From the year 2000, the SRS (Sample Registration System) has introduced this method of verbal autopsy called RHIME (Representative, Re-sampled, Routine Household Interview of Mortality with Medical Evaluation).Lifetime Risk of Maternal Death

This parameter takes into account both the probability of becoming pregnant and the probability of dying as a result of the pregnancy cumulated across a woman’s reproductive years. Lifetime risk can be estimated by multiplying the maternal mortality rate by the length of the reproductive period (around 35 years). This is also approximated by the product of the Total Fertility Rate and the Maternal Mortality Ratio.

Antenatal CareThe care of women during pregnancy is called antenatal care. This begins soon after conception. The ultimate objective is

to have a healthy mother and a healthy child at the end of pregnancy. Antenatal care includes visit to antenatal clinic, examination, investigations, immunization, supplements (Iron, Folic acid, Calcium, Nutritional) and interventions as required. This is a comprehensive approach to medical care and psychosocial support of the family that ideally begins prior to conception and ends with the onset of labour. Preconception care refers to physical and mental preparation of both parents for pregnancy and childbearing in order to improve the pregnancy outcome (Refer Box - 1). Antenatal (Prenatal) care formally begins with the diagnosis of pregnancy and includes ongoing assessment of risk, education and counselling and identifying and managing problems if they arise (Box - 2).

Box - 1 : Indications for Preconception Care

Advanced maternal (>35 years) or paternal (>55 years)age

History of neural tube defects in family or previous pregnancy

Congenital heart disease, hemophilia, thalassemia, sickle cell disease, Tay-sach’s disease, cystic fibrosis, Huntington chorea, muscular dystrophy, Down’s syndrome.

Maternal metabolic disorders

Recurrent pregnancy loss (>3)

Use of alcohol, recreational drugs or medications

Environmental or occupational exposures

Box - 2 : Objectives of Antenatal Care

To promote, protect and maintain health of the mother

To detect ‘at risk’ cases and provide necessary care

To provide advise on self care during pregnancy

To educate women on warning signals, child care, family planning

To prepare the woman for labour and lactation

To allay anxiety associated with pregnancy and childbirth

To provide early diagnosis and treatment of any medical condition/ complication of pregnancy

To plan for “Birth” and emergencies / complications (where, how, by whom, transport, blood)

To provide care to any child accompanying the mother

Frequency : Under optimal conditions a women should undergo regular antenatal health check once a month during first seven months, twice a month for 8th month and every week thereafter till delivery. However, a minimum of four visits are essential.

Essential Antenatal Care : Under CSSM program three antenatal visits have been recommended as minimum acceptable level of antenatal care. Early registration by 12-16 weeks followed by visits at 20, 32 and 36 weeks is recommended during any pregnancy. At least one home visit by health worker must be made. Essential Antenatal Care also includes immunization with tetanus toxoid and Iron Folic Acid supplements for 100 days. Deworming with mebendazole in areas endemic for hook

• 816 •

worm may be provided during 2nd/3rd trimester. Under RCH a minimum of three visits are to be made.

History Taking and Examination : During history taking important points to be covered are detailed medical, psychosocial and immunization history followed by careful physical examination and certain relevant laboratory tests.

Physical examination should include measurement of height, weight, pelvimetry (not very important). Important laboratory tests include hemoglobin, urinalysis, PAP smear, VDRL and any other test as warranted by the concerned physician. There is an opportunity for health promotion like cessation of tobacco, alcohol, manage pre-existing medical disorders, appropriate immunization and pregnancy planning.

First Visit : The patient is registered and antenatal card is initiated. First visit should be made at the earliest possible after pregnancy is suspected, ideally at 8 weeks of gestation but not later than 12-16 weeks. This is important for determining accurate EDD, evaluation of risk and to provide essential patient education. The functions of this visit are-(a) Confirmation of pregnancy(b) Screening for high risk pregnancy(c) Baseline investigations(d) Initiation of Iron and Folic Acid supplementation(e) Immunization with Tetanus toxoid (if visit in 2nd

trimester)(f) Education of the mother on pregnancy and childbirthIdentification of “High Risk” PregnanciesThe identification of high risk pregnancies involves meticulous history taking, careful examination and relevant investigations. The identification of these high risk pregnancies should follow needful referral and care. History should cover all aspects as outlined for preconception care. The ‘at risk’ pregnancies can be identified as under-Maternal Factors(i) Age- <18 years or > 35 years (especially in primigravida)(ii) Multiparity (> 4)(iii) Short stature ( < 140 cms )(iv) Weight < 40 Kg / weight gain < 5 Kg(v) Rh negativeBad Obstetric History(i) Recurrent abortions ( 2 x1st trimester or 1 mid-trimester)(ii) Intrauterine death or intrapartum death/ stillbirth(iii) Prolonged labour, birth asphyxia , early neonatal death(iv) Previous caesarean section / scar dehiscence(v) Postpartum haemorrhage, manual removal of placenta(vi) Baby which is LBW, SFD or large for date, congenitally

malformed(vii) Malpresentation, instrumental delivery, ectopic pregnancy(viii) Twins, hydramnios, pre-eclampsiaMedical Disorders(i) Cardiac (RHD, CHD, Valve defects), Renal, Endocrine

(Thyroid) or Gastrointestinal disease.(ii) Infections - TB, Leprosy, Malaria etc.(iii) Hypertension, Diabetes, IHD and Seizures(iv) AnaemiaBesides the above, the pregnancy at any stage can be classified as high risk if any of the following conditions/ complications

appear -(a) Bleeding PV at any point ( Antepartum haemorrhage)(b) Excessive vomiting ( Hyperemesis gravidarum)(c) Hypertension, proteinuria(d) Severe anaemia(e) Abnormal weight gain(f) Multiple pregnancy, hydramnios, oligohydramnios(g) Abnormal presentation in 9th month(h) Preterm Labour, PROM(i) Pre-eclampsia, eclampsiaHealth EducationThis is one of the most important and often neglected functions of antenatal care. This is also called prenatal advice. The communication between the mother and the service provider should be free and encompass the issues concerning not only pregnancy but should spillover to childbirth and childcare. The family planning issues like spacing and sterilization are better received at this time. Important issues that need to be deliberated are given below.(a) Diet & Rest(b) Personal Hygiene and Habits(c) Sexual intercourse(d) Drugs(e) Exercise(f) Travel(g ) Care of Breasts(h) Weight GainWarning signs : Besides education on common symptoms and their management, the woman should be educated on warning signs during pregnancy which should not be ignored. She should report to health facility in case she has any of the warning signs. The warning signs are-(i) Swelling of feet(ii) Convulsions/ unconsciousness(iii) Severe headache(iv) Blurring of vision(v) Bleeding or discharge per vaginum(vi) Severe abdominal pain(vii) Other unusual symptomPregnancy & HIV InfectionThis situation is likely to be encountered in states where HIV prevalence amongst antenatal cases is high. This will require special handling. The urgency of preventing mother-to-child transmission (PMTCT) of HIV is clear. Without treatment, half of the infants born with the virus will die before age two. Significant reductions in mother-to-child transmission, however, can occur through implementation of basic but critical actions, such as identifying HIV-infected pregnant women by offering routine HIV testing, enrolling them in PMTCT programmes, ensuring that health systems are fully able to deliver effective antiretroviral regimens both for prophylaxis and for treatment, and supporting women in adhering to optimal and safe infant feeding. The counselling of women early in pregnancy on risk of transmission to the baby and testing of spouse is mandatory. AZT 300 mg every 12 hours is given from 36 weeks of pregnancy till onset of labour and thereafter 300mg every 3 hours. Alternatively, Nevirapine 200 mg single dose as early

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as possible in labour and 50 mg in oral solution form to the newborn within 72 hours is recommended to prevent mother to child transmission. After delivery, this also helps to make required adaptations in infant feeding. Replacement feeding using principles of AFASS (acceptable, feasible, affordable, safe and sustainable) is a viable solution to prevent transmission of infection through breast feeding.

Planning for Birth (Birth Plan)This is an important function of the prenatal care. The planning for birth and emergencies is very important as it can take care of many unforeseen complications which may endanger life of both mother and the child and may arise at any point of time without any prior warning in an otherwise normal pregnancy. Plans made early for emergencies during pregnancy and labour will result in favourable outcomes. The birth plan helps to tide over the uncertain and sudden nature of complications of labour. The delivery will take place at hospital or home must be decided (See Box - 3).

Box - 3 : Institutional delivery is a must if there is-

Mild pre-eclampsia

PPH in the previous pregnancy

More than 5 previous births or a primi

Previous assisted delivery

Maternal age less than 16 years

H/o third-degree tear in the previous pregnancy

Severe anaemia

Severe pre-eclampsia/eclampsia

APH

Transverse foetal lie or any other Malpresentation

Caesarean section in the previous pregnancy

Multiple pregnancies

Premature or pre-labour rupture of membranes (PROM)

Medical illnesses such as diabetes mellitus, heart disease, asthma, etc.

In case of delivery at home what arrangements are there to overcome any unanticipated complication? The arrangement

for vehicle, money and blood can be difficult to make if not already planned and can be crucial for the life of both mother and child. Institutional delivery should be encouraged. Institutional delivery should be advocated as it is the right of every pregnant woman.

Intranatal Care and Postnatal CareObjectives of Intranatal Care - (AMC-N)1. Thorough Asepsis (“The Five Cleans” - clean hands,

surface, blade, cord, tie)2. Minimum injury to mother and child3. To deal with any Complications during labour4. Care of the NewbornThe Postpartum CareThe Postpartum Care is aimed at achieving a Puerperium which is free of any complications and to ensure a healthy newborn. (Box - 4)

Box - 4 : Objectives of Postpartum care

1. Restoration of mother to optimum health

2. To prevent complications of puerperium

3. Provide basic postpartum care & services to mother and child

4. Motivate, educate and provide family planning services

5. To check adequacy of breast feeding

The Postpartum Visits : The first 48 hours following delivery are the most important. The next most critical period is the first week following delivery. The mother is asked to pay another visit on day 3rd and day 7th, or the ANM in charge of that area should pay a home visit during this period. The second postpartum visit should be planned within 7-10 days after delivery. A visit at 6 weeks is mandatory to see that involution of uterus is complete. Further visits can be once a month for 6 month and thereafter every 2-3 months till the end of one year. Efforts to organize 3 - 6 visits must be made. If the woman misses her postpartum visits, she should be informed regarding the danger signs which if appear she should report back (Box - 5).Complications of the Puerperium : The postpartum period is often neglected after having a successful parturition. Sadly,

Box - 5 : Danger Signs in Puerperium

Advise the woman and her family to go to an FRU immediately, day or night, WITHOUT WAITING

Advise the woman that she should visit the PHC as soon as possible, if . . .

(i) Excessive vaginal bleeding, i.e. soaking more than 2 or 3 pads in 20-30 minutes after delivery, or bleeding increases rather than decreases after the delivery

(i) Fever

(ii) Abdominal pain

(iii) The woman feels ill

(ii) Convulsions (iv) Swollen, red or tender breasts, or sore nipples

(iii) Fast or difficult breathing (v) Dribbling of urine or painful micturition

(iv) Fever and weakness; inability to get out of bed (vi) Pain in the perineum or pus draining from the perineal area

(v) Severe abdominal pain (vii) Foul-smelling lochia

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neglected postnatal period can be the cause of significant mortality in mother and the newborn. The infections and haemorrhage are two serious dangers of Puerperium. Besides these UTIs, thrombophlebitis and psychiatric disorders are also seen (Box - 6).

Box - 6 : Common Complications of the Puerperium

1. Puerperal sepsis

2. Urinary tract infections

3. Breast infections

4. Venous thrombosis

5. Pulmonary thromboembolism

6. Puerperal haemorrhage

7. Incontinence of urine

8. Psychiatric disorders

Maternal MortalityGlobal BurdenMaternal mortality is currently estimated at 5,29,000 deaths per year, a global ratio of 400 maternal deaths per 100,000 live births (1). There are immense variations in maternal death rates in different parts of the world (See Table - 1). Only a small fraction (1%) of these deaths occurs in the developed world. Maternal mortality ratios range from as high as 830 per 100,000 births in some African countries to as low as 24 per 100,000 births in European countries. Of the 20 countries with the highest maternal mortality ratios, 19 are in sub-Saharan Africa. In sub-Saharan Africa, the lifetime risk of maternal death is 1 in 16, (See Table 1) compared with 1 in 2800 in rich countries (2). Rural populations suffer higher mortality than urban dwellers, rates can vary widely by ethnicity or by socio-economic status, and remote areas bear a heavy burden of deaths. Such deaths often occur suddenly and unpredictably. Between 11% and 17% of maternal deaths happen during childbirth itself and between 50% and 71% in the postpartum period (3-7). The fact that a high level of risk is concentrated during childbirth itself, and that many postpartum deaths are also a result of what happened during birth, focuses attention on the hours and sometimes days that are spent in labour and giving birth. The postpartum period - despite its heavy toll of deaths - is often neglected. Within this period, the first week is the most prone to risk. About 45% of postpartum maternal deaths occur during the first 24 hours, and more than two thirds during the first week (3).

Table - 1 : Life Time Risk of a Woman

Continents Losing a Neonate

Of dying due to Maternal cause

Africa 1 in 5 1 in 16

Asia 1 in 11 1 in 132

Latin America 1 in 21 1 in 188

Developed countries 1 in 125 1 in 2976

Breakdowns of access to skilled care due to war, strife and HIV may rapidly result in an increase of unfavourable outcomes, as in Malawi or Iraq. Malawi is one country that experienced a significant reversal in maternal mortality: from 752 maternal deaths per 100,000 live births in 1992 to 1120 in 2000 due to rise in HIV prevalence. Fewer mothers gave birth in health facilities: the proportion dropped from 55% to 43% between 2000 and 2001. The quality of care within health facilities deteriorated in Iraq as sanctions during the 1990s severely disrupted previously well-functioning health care services, and maternal mortality ratios increased from 50 per 100,000 in 1989 to 117 per 100,000 in 1997 (12).

Scenario in IndiaEvery seven minutes an Indian woman dies from complications related to pregnancy and childbirth. The maternal mortality ratio in India stands at 300 per 100,000 live births. It has some high performing states like Kerala with MMR of 110 and poorly doing states like Uttar Pradesh with MMR of 517 (13). The highlight is that most of the states recording unfavourable maternal mortality rates are the ones with the highest number of birth rates and huge population bases with poor health infrastructure. There are a number of reasons India has such a high maternal mortality ratio. Marriage and childbirth at an early age, lack of adequate health care facilities, inadequate nutrition and absence of skilled personnel, all contribute to pregnancies proving fatal. The common causes of maternal mortality in India are anaemia, haemorrhage, sepsis, obstructed labour, abortion and toxaemia. Maternal morbidities are the anaemias, chronic malnutrition, pelvic inflammations, liver and kidney diseases. In addition, the pathological processes of some preexisting diseases, such as chronic heart diseases, hypertension, kidney diseases and pulmonary tuberculosis are aggravated by pregnancy and childbirth.

‘Delay’ Model Leading to Maternal DeathThe maternal deaths can be explained by this model of delay which is due to:(a) Delay in seeking care(b) Delay in transport to appropriate health facility(c) Delay in provision of adequate careCauses of Maternal MortalityMaternal deaths result from a wide range of indirect and direct causes (See Fig. 1 & 2). Maternal deaths due to indirect causes represent 20% of the global total. They are caused by diseases (pre-existing or concurrent) that are not complications of pregnancy, but complicate pregnancy or are aggravated by it. These include malaria, anaemia, HIV/AIDS and cardiovascular disease. Their role in maternal mortality varies from country to country, according to the epidemiological context and the health system’s effectiveness in responding.

The lion’s share of maternal deaths is attributable to direct causes. Direct maternal deaths follow complications of pregnancy & childbirth or are caused by any interventions, omissions, incorrect treatment or events that result from these complications, including complications from unsafe abortion.

The four major direct causes of maternal loss are-(a) Haemorrhage

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(b) Infection (sepsis)(c) Eclampsia(d) Obstructed Labour

Fig. - 1 : World - Causes of Maternal Mortality

Indirect causes20%

Other Direct causes8%

Unsafe abortion13%

ObstructedLabour20%

Eclampsia12%

Infections15%

Severe bleeding(Haemorrhage)

25%

Note : Total is more than 100% due to rounding off

Fig. - 2 : India - Causes of Maternal Mortality

Anaemia24%

Haemorrhage23%

Abortion12%

Toxemia10%

Puerperal10%

Malposition7%

Others14%

Source : Registrar General India.Causes of Maternal Mortality in Rural India

Haemorrhage : The most common cause of maternal death is severe bleeding, a major cause of death in both developing and developed countries (14,15). Postpartum bleeding can kill even a healthy woman within two hours, if unattended. It is the quickest of maternal killers. An injection of oxytocin or ergometrine given immediately after childbirth is very effective in reducing the risk of bleeding. In some cases a fairly simple - but urgent - intervention such as massage of the uterus, removal of clot or manual removal of the placenta may solve the problem. Other women may need a surgical intervention or a blood transfusion, both of which require hospitalization with appropriate staff, equipment and supplies. The proportion

needing hospital care depends, to some extent, on the quality of the first-level care provided to women; for example, active management of the third stage of labour reduces postpartum bleeding. The proportion that dies depends on whether appropriate care is provided rapidly and with the degree of skill with which it is provided.

Infection : The second most frequent direct cause of death is sepsis, responsible for most late postpartum deaths. This is often a consequence of poor hygiene during delivery. The introduction of aseptic (clean delivery) techniques brought a spectacular reduction of its importance in the developed world. However, sepsis is still a significant threat in many developing countries.

Eclampsia : Classic complications of pregnancy include pre-eclampsia and eclampsia which affect 2.8% of pregnancies in developing countries and 0.4% in developed countries leading to many life-threatening cases and over 63 000 maternal deaths worldwide every year accounting for 12 % of the maternal deaths (17).

Obstructed Labour : The prolonged or obstructed labour accounts for about 8% of maternal deaths. This is often caused by fetoopelvic disproportion or by malpresentation (transverse lie, mentoposterior, brow presentation). Disproportion is more common where malnutrition is endemic, especially among populations with various traditions and taboos regarding the diets of girls and women. It is worse where girls marry young and are expected to prove their fertility, often before they are fully grown.

Abortions : More than 18 million induced abortions each year are performed by people lacking the necessary skills or in an environment lacking the minimal medical standards, or both, and are therefore unsafe resulting in 68000 deaths (18, 19). Almost all take place in the developing world. With 34 unsafe abortions per 1000 women, South America has the highest ratio (19). Unsafe abortion is particularly an issue for younger women. Around 2.5 million, or almost 14% of all unsafe abortions in developing countries, are among women under 20 years of age. The proportion of women aged 15-19 years in Africa who have had an unsafe abortion is higher than in any other region.

Others : Haemorrhage following placental abruption or placenta praevia affects about 4% of pregnant women. Less common, but very serious complications include ectopic pregnancy and molar pregnancy. Maternal malnutrition is a huge global problem, both as protein-calorie deficiency and as micronutrient deficiency. Anaemia is an important indirect cause of maternal death due to cardiovascular deaths but also is an important underlying factor in many direct causes like haemorrhage and sepsis.

Factors underlying the medical causesSocio-Economic : The factors underlying the direct causes of maternal deaths operate at several levels. The low social and economic status of girls and women is a fundamental determinant of maternal mortality in many developing countries including India. Low status limits the access of girls and women to education and good nutrition as well as to the economic resources to pay for health care or family planning services.

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Lack of decision making power in terms of family planning puts them to repeated childbearing. Excessive physical work coupled with poor diet leads to poor maternal outcomes. Many deliveries in rural areas are either conducted by relatives or traditional birth attendant or at times none. In India three out of every five births take place at home; only two in five births take place in a health facility. However, the percentage of births in a health facility has increased steadily.

Nutritional : Poor nutrition before and during pregnancy contributes in a variety of ways to poor maternal health, obstetric problems and poor pregnancy outcomes. Stunting predisposes to cephalopelvic disproportion and obstructed labour. Anaemia may predispose to infection during pregnancy and childbirth, obstetric haemorrhage and are poor operative risks in the event if surgery is required. Severe vitamin A deficiency make women more vulnerable to obstetric complications. Iodine deficiency increases the risk of stillbirths and spontaneous abortions. Lack of dietary calcium appears to increase the risk of pre-eclampsia and eclampsia during pregnancy.

Impact of Maternal Deaths (India)Maternal death has implications for the whole family and an impact that rebounds across generations. The complications that cause the deaths and disabilities of mothers also damage the infants they are carrying. The impact is summarized as under-(a) Children who lost their mothers are more likely to die

within two years of maternal death.(b) 10 times the chance of death for the neonate.(c) 7 times the chance of death for infants older than one

month.(d) 3 times the chance of death for children 1 to 5 years.(e) Enrolment in school for younger children is delayed and

older children often leave school to support their family.Significant reduction in infant mortality can be achieved by improving the access to care during labour, birth and the critical hours immediately afterwards.

Measures to Reduce Maternal MortalityWhat is known about Reducing Maternal Mortality?

The countries that have successfully managed to make motherhood safer have three things in common.(a) First, policy-makers and managers were informed: they

were aware that they had a problem, knew that it could be tackled, and decided to act upon that information.

(b) Second, they chose a common-sense strategy that proved to be the right one: not just antenatal care, but also professional care at and after childbirth for all mothers, by skilled midwives, nurse-midwives or doctors, backed up by hospital care.

(c) Third, they made sure that access to these services - financial and geographical - would be guaranteed for the entire population.

Where strategies other than that of professionalization of delivery care are chosen or where universal access is not achieved, positive results are delayed. This explains why many developing countries today still have high levels of maternal mortality. To provide skilled care at and after childbirth and to deal with complications is a matter of common sense - it is

also what mothers and their families ask for. Putting it into practice is a challenge that many countries have not yet been able to meet.Training of Traditional Birth Attendant - A Failed Experiment! : In the 1970s, training of traditional birth attendants (TBAs) to improve obstetric services became widespread in settings where there was a lack of professional health personnel to provide maternity care, and where there were not enough beds or staff at hospital level to give all women access to hospital for their confinement. TBAs already existed and performed deliveries (for the most part in rural areas), they were accessible and culturally acceptable and they influenced women’s decisions on using health services. While WHO continued to encourage this strategy until the mid-1980s but evidence emerged that training TBAs has had little impact on maternal mortality.

Actions for Safe Motherhood : Countries vary widely in terms of the situations and challenges they face and their capacity to address these. However, it is seen that to reduce maternal mortality requires coordinated, long term efforts. Actions are needed within families and communities, in society as a whole, in health systems, and at the level of national legislation and policy.

Legislative & Policy actions : Long term political commitment is an essential prerequisite. This leads to adequate resource allocation and policy decisions are taken. A supportive social, economic and legislative environment allows women to access the healthcare. (transport, money, social barriers limit the access)

(a) Family planning : To avoid pregnancies that are too early, too late or too frequent.

(b) Adolescents : To encourage late marriage and childbearing by increasing educational opportunities. To improve their nutritional status by supplementary nutrition (e.g. ICDS- Kishori Shakti Yojna). Education of adolescents on reproductive health and empowerment of women to control fertility and reproduction.

(c) Barriers to access : Provision of skilled health worker at village level health facility to overcome problems of distance and transport. These workers to be adequately trained in midwifery and paid adequately and to be provided with adequate supplies and at minimal cost.

(d) Develop protocols : Aimed at providing both routine maternal care and referral facilities for obstetric complications. (e.g. IMNCI, 2005-Guidelines on pregnancy by MCH Division of Ministry of Health & Family Welfare)

(e) Decentralization and delegation : Decentralized facilities available close to people’s homes together with written policies and protocols to allow delegation of certain functions at lower levels.

(f) Abortion : Availability of safe abortion services and policy to discourage illegal and unsafe abortions.

Society and Community Interventions : The long term commitment of politicians, planners and decision makers to programmes on safe motherhood depends on popular support from community and religious leaders, women’s groups, youth

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groups etc. National, regional and district safe motherhood committees can be set up. Health facility and community committee can investigate maternal deaths and implement strategies for improvement in areas such as referral, emergency transport, deployment and support of health care providers and cost sharing.

Health Sector Actions : The role of health sector is to ensure availability of good quality essential services to all women during pregnancy and childbirth. It is clear that certain pregnancy complications can be prevented but large number of these which occur around the time of childbirth/labour can neither be prevented nor predicted. Therefore, presence of a skilled birth attendant is crucial for early detection and management of such complications.

First Level Maternal and Newborn Care : First-level care does save lives and manage emergencies. It does so by controlling conditions before they become life threatening (e.g. treating anaemia) by avoiding complications (e.g. active management of the third stage of labour). A midwife or other professional with midwifery skills also actually deals with a range of emergencies on the spot, such as by administering vacuum extraction in case of foetal distress or by arranging emergency referral for caesarean section or other back-up care.

First-level maternal and newborn care should preferably be organized in midwife led birthing centres, combining cultural proximity in a non-medicalized setting, with professional skilled care, the necessary equipment, and the potential for emergency evacuation. Decentralization for easy access obviously has to be balanced by the need to concentrate the staff and equipment necessary to be available 24 hours a day, something more easily done in birthing centres with a team of several skilled attendants than in solo practices.

Health workers who provide first-level care need back-up when a problem occurs that they are unable to deal with as it goes beyond their competence or beyond the means they have at their disposal.

Back-up maternal and newborn care encompasses emergencies (such as a LSCS, hysterectomy or treatment of neonatal tetanus or meningitis) as well as non-emergency interventions (such as treatment of congenital syphilis). Back-up is ideally provided in a hospital where doctors - specialists, skilled general practitioners or mid-level technicians with the appropriate skills - can deal with mothers whose problems are too complex for first-level providers. To make the difference between life and death, the required staff and equipment must be available 24 hours a day, and the links between the two levels of care should be strong.Rolling out Services Simultaneously : First-level maternal and newborn care and the referral hospital services that should provide back-up have to be rolled out in parallel.. The challenge of simultaneous roll-out has striking similarities to the one that led the primary health care movement to opt for the health districts, with both health centres and a district hospital, linked by referral mechanisms, and organized to ensure a continuum of care.

Initiatives in IndiaIndia has a history of starting Family planning programme

since 1952 which focused mainly on limiting family size. This was later made more client oriented and allowed voluntary acceptance of these services and came to be called as family welfare from 1977 onwards. The focus on maternal and child services was program centric without involving client. It was in 1992, that a comprehensive approach to ensure survival of children and safe motherhood was implemented in the form of CSSM programme. It was later realized, that the overall improvement in the reproductive health was the key to achieve the overall aim of lifelong health and thus, the approach was changed and RCH program was launched. Various initiatives that have been taken are spelt out in the succeeding paragraph. The MDGs and launching of NRHM have provided the necessary impetus to the issue of safe motherhood which is the right of every woman.

All India Hospital Postpartum Programme : The Post Partum Programme, a maternity centered hospital based approach to Family Welfare Programme was begun in 1969 with 54 participating hospitals, the program had 122 hospitals by 1971-1972. 90% of these were attached to medical colleges. With a view to provide maternal, child health and family welfare services in semi-urban/ rural areas, the Post Partum Programme has been extended to sub-district level hospitals also by covering 50 institutions during 1980-81. Subsequently the programme was extended in a phased manner and by the end of 1988-89, 1075 Sub-district Level Hospitals were covered. The training of medical students and graduates in the techniques of birth control is an important aspect of the program. The major purpose of the program is to convince maternity and abortion patients to adopt birth control practices while they are in the hospital and also to interest others who hear about the program by word of mouth. Contraceptive services, including sterilization, are available to all friends, relatives, and neighbors of the confined women. Rural areas are reached through the medical colleges and attached hospitals which have responsibility for the area. Educational programs are a significant part of the program and are carried out in many parts of the hospitals and clinics.

Essential Obstetric Care (EOC) : This is the minimum obstetric care that must be made available to all pregnant women.(a) Registration of pregnancy in the first 12-16 wks of

pregnancy.(b) At least 3 prenatal check ups by ANM or in dispensary.(c) Assistance during delivery. (Skilled Birth Attendant)(d) At least 3 postnatal check ups.Emergency Obstetric Care (EmOC) : This is the service provided to cater for any unforeseen complication that may arise in any pregnancy at any stage. EmOC is an intervention for preventing maternal morbidity and mortality. Early detection and management of complications such as anaemia, haemorrhage, obstructed labour and sepsis can substantially reduce maternal mortality & morbidity. This requires competent supervision and check ups by ANM during antenatal, intranatal & post natal period. ANM should refer all cases having complications during pregnancy or at the time of delivery to PHCs / FRUs.

Inputs : A total of 1748 FRUs have been identified & equipped under CSSM programme. Some of the FRUs are lacking in manpower or infrastructure. Under RCH programme, a

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provision has been kept for strengthening these FRUs through provisioning of drug kits, laparoscope, blood transfusion and employing contractual staff like PHN/ANM/Lab Asst and anaesthesiologist.

24 Hour Delivery Services at PHCs/CHCs : Under RCH program, arrangements have been made that a doctor on call duty, a nurse and cleaning staff are available beyond normal working hours to encourage people to seek deliveries in PHCs/CHCs. For this doctor could be paid Rs 200/- per delivery & other staff could be hired on contractual basis.Referral Transport to Indigent Families through Panchayats : In category C districts of eight weakly performing states, communication infrastructure is weak and economic status of families in remote villages is poor. Because of this, even if there is a complication identified during pregnancy or delivery, the women have the delivery conducted in the village and frequently through untrained Dais. This is one of the causes of high maternal mortality and morbidity. This has been addressed by providing financial assistance to Panchayats through District Family Welfare Officers.

Blood Supply to FRUs/PHCs : Dept of family welfare will be taking up pilot projects with the assistance of European Commission under the RCH programme for setting up of regular and reliable supply of blood to PHCs/CHCs by linking them with the nearest blood bank

MTP services : MTP by untrained or experienced persons is responsible for high maternal mortality and morbidity. Therefore, increasing and improving facilities for MTP is an important component of the RCH programme at PHC level.

Inputs(a) Need based training in MTP by NIHFW.(b) Supply of MTP equipment to District Hospitals, CHCs &

PHCs where trained staff is available.(c) Assistance for engaging doctors trained in MTP to the

PHCs once a week on fixed days for performing MTP (Pay Rs 500/- day). These doctors will also provide ANC and PNC services to patients during their visit.

(d) Supply of MTP equipment to Private clinics if they have OT & trained doctors.

Janani Suraksha Yojna (Maternal Safety Scheme)Janani Suraksha Yojana (JSY) is a safe motherhood intervention under the National Rural Health Mission (NRHM) being implemented with the objective of reducing maternal and neo-natal mortality by promoting institutional delivery among the poor pregnant women. The Yojana, launched on 12th April 2005, is being implemented in all states and UTs with special focus on low performing states. JSY is a 100 % centrally sponsored scheme and it integrates cash assistance

with delivery and post-delivery care. The success of the scheme would be determined by the increase in institutional delivery among the poor families

The Yojana has identified ASHA, the accredited social health activist as an effective link between the Government and the poor pregnant women in l0 low performing states, namely the 8 EAG states and Assam and J&K and the remaining NE States. In other eligible states and UTs, wherever, AWW and TBAs or ASHA like activist has been engaged in this purpose, she can be associated with this Yojana for providing the services.

Role of ASHA or other link health worker associated with JSY would be to: (a) Identify pregnant woman as a beneficiary of the scheme

and report or facilitate registration for ANC,(b) Assist the pregnant woman to obtain necessary

certifications wherever necessary,(c) Provide and / or help the women in receiving at least three

ANC checkups including TT injections, IFA tablets,(d) Identify a functional Government health centre or an

accredited private health institution for referral and delivery,

(e) Counsell for institutional delivery,(f) Escort the beneficiary women to the pre-determined health

center and stay with her till the woman is discharged,(g) Arrange to immunize the newborn till the age of 14

weeks,(h) Inform about the birth or death of the child or mother to

the ANM/MO,(i) Post natal visit within 7 days of delivery to track mother’s

health after delivery and facilitate in obtaining care, wherever necessary,

(j) Counsell for initiation of breast feeding to the newborn within one-hour of delivery and its continuance till 3-6 months and promote family planning

The scheme focuses on the poor pregnant woman with special dispensation for states having low institutional delivery rates namely the states of Uttar Pradesh, Uttaranchal, Bihar, Jharkhand, Madhya Pradesh, Chhattisgarh, Assam, Rajasthan, Orissa and Jammu and Kashmir. While these states have been named as Low Performing States (LPS), the remaining states have been named as High performing States (HPS). Tracking Each Pregnancy : Each beneficiary registered under this Yojana should have a JSY card along with a MCH card. ASHA/AWW/ any other identified link worker under the overall supervision of the ANM and the MO, PHC should mandatorily prepare a micro-birth plan. This will effectively help in monitoring Antenatal Check-up, and the post delivery care.

Disbursement of Cash Assistance : As the cash assistance to the mother is mainly to meet the cost of delivery, it should be

Eligibility for Cash Assistance

LPS States All pregnant women delivering in Government health centres like Sub-centre, PHC/CHC/ FRU / general wards of District and state Hospitals or accredited private institutions

HPS States BPL pregnant women, aged 19 years and above

LPS & HPS All SC and ST women delivering in a government health centre like Sub-centre, PHC/CHC/ FRU / general ward of District and state Hospitals or accredited private institutions

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disbursed effectively at the institution itself.

Scale of Cash Assistance for Institutional Delivery

Cate-gory

Rural AreaTotal Rs.

Urban AreaTotal

Rs.Mother’s Package

ASHA’s Package

Mother’s Package

ASHA’s Package

LPS 1400 600 2000 1000 200 1200

HPS 700 700 600 600

Cash assistance for Referral transport : This assistance is given to go to the nearest health centre for delivery. The state will determine the amount of assistance (should not less than Rs.250/- per delivery) depending on the topography and the infrastructure available in their state. It would, however, be the duty of the ASHA and the ANM to organize or facilitate in organizing referral the transport, in conjunction with gram pradhan, Gram Sabha etc.

Note : This assistance is over and above the Mother’s package.

Cash Incentive to ASHA : This should not be less than Rs.200/- per delivery in lieu of her work relating to facilitating institutional delivery. Generally, ASHA should get this money after her postnatal visit to the beneficiary and that the child has been immunized for BCG.

Transactional cost (Balance out of Rs.600/-) : It is to be paid to ASHA in lieu of her stay with the pregnant woman in the health centre for delivery to meet her cost of boarding and lodging etc. Therefore, this payment should be made at the hospital/ heath institution itself.

All payments to ASHA would be done by the ANM only. In this case too, a voucher scheme be introduced in such a manner that for every pregnant woman she registers under JSY, ANM would give two vouchers to ASHA, which she would be able to encash on certification by ANM.

Special Dispensation for LPS StatesAge restriction removed ●Restricting benefits of JSY up to 2 births removed ●No need for any marriage or BPL certification ●

Subsidizing cost of Caesarean Section or management of Obstetric complications : Generally PHCs/ FRUs / CHCs etc. would provide emergency obstetric services free of cost. Where Government specialists are not available in the Govt’s health institution to manage complications or for Caesarean Section, assistance up to Rs. 1500/- per delivery could be utilized by the health institution for hiring services of specialists from the private sector. If a specialist is not available.

Assistance for Home Delivery: In LPS and HPS States, BPL pregnant women, aged 19 years and above, preferring to deliver at home is entitled to cash assistance of Rs. 500/- per delivery. Such cash assistance would be available only upto 2 live births and the disbursement would be done at the time of delivery or around 7 days before the delivery by ANM/ASHA/ any other link worker.

Strategy : While the scheme would create demand for institutional delivery, it would be necessary to have adequate number of 24X7 delivery services centre, doctors, mid-wives,

drugs etc. at appropriate places. Mainly, this will entail - (a) Linking each habitation (village or a ward in an urban

area) to a functional health centre- public or accredited private institution where 24x7 delivery service would be available,

(b) Associate an ASHA or a health link worker to each of these functional health centre,

(c) It should be ensured that ASHA keeps track of all expectant mothers and newborn. All expectant mother and newborn should avail ANC and immunization services, if not in health centres, at least on the monthly health & nutrition day, to be organised in the Anganwadi or sub-centre:

Micro-Birth Plan for JSY Beneficiaries : Inform the mother and the family about 4 Is, namely(a) Inform dates of 3 ANC & TT Injection(s) & ensure these are

provided(b) Identify the health centre for all referral(c) Identify the Place of Delivery(d) Inform expected date of delivery

Vande Mataram SchemeThe scheme is continuing under Public Private Partnership with the involvement of Federation of Obstetric and Gynaecological Society of India and Private Clinics. The aim of the scheme is to reduce the maternal mortality and morbidity of the pregnant and expectant mothers by involving and utilizing the vast resources of specialists/trained work force available in the private sector. The scheme intends to provide free antenatal and postnatal check, counselling on nutrition, breast feeding, spacing of birth etc. through public private partnership.

This is a voluntary scheme wherein any Obstetric and Gynaecologist, maternity home, nursing home can volunteer themselves in joining the scheme. Any lady doctor/MBBS doctor providing safe motherhood services can also volunteer to join this scheme. The enrolled ‘Vandemataram’ doctors will display ‘Vandemataram’ logo in their clinic. Iron and Folic Acid Tablets, oral pills, TT injections etc. will be provided by the respective District Medical Officers to the ‘Vandemataram’ doctors/clinics for free distributions to beneficiaries. The cases needing special care and treatment can be referred to the Government Hospitals and institutes, who have been advised to take due care to the patients coming with Vandemataram cards.

Challenges in Maternal Health(a) Establishing data base on maternal mortality : The maternal mortality continues to be a problem in rural, remote, inaccessible and tribal areas where there is hardly any health service available and even if available it is inadequate and in this setting the deaths in childbirth are either not recorded or recorded incorrectly due to causes other than pregnancy or childbirth. There is a need to record each and every maternal death to ascertain the correct magnitude of this public health problem.(b) High Risk Pregnancy Behaviour - Too Early, Too Many, Too Close : The social customs like universality of marriage, early marriage, social pressure for early childbearing, son preference, lack of education and poor social status of women in decision making, all lead to consequences of pregnancies that are early, repeated and frequent leading to maternal

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depletion and debility and even death.

(c) Urban-Rural Divide : The rural urban divide is a major social issue and a challenge for the public health administrators as most of the women who need the most care continue to be deprived of the same. The rural urban divide is marked not only by unequal distribution of health services but all the social and cultural factors which add up to the negative milieu for maternal health and survival.

(d) Poor Rate of Institutional Deliveries : Even after the facilities are made available, the uptake of these services continue to be poor because of various factors like lack of adequate manpower, infrastructure and facilities in the PHC/CHC, preference to deliver at home due to cultural reasons and inability to afford the cost of maternity in a civil or private health care setting.

(e) Lack of Skilled Care at Birth : The care available to mothers at birth continues to be by TBAs or midwives who are neither trained nor adequately equipped to handle complicated situations and thus either there is delay in diagnosing, transportation and referral to a FRU.

(f) Lack of Women Empowerment : This social aspect of women empowerment for a lady to take decisions for her own safety and health is still lacking where her in laws are making these decisions for her. The women are still not having the right to decide their age at marriage, pregnancy, spacing and contraception and even their maternity care.

(g) Poor Implementation of Programs : There has been a family welfare programme running in the country since last six decades but the services available for maternal health and survival at primary level is still inadequate with poor results. The reasons are many. The core intervention of providing a skilled care at birth by a midwife and backed by a referral service has still not materialized. There is a proposal for such services under NRHM as part of RCH programme.

Ten Action Messages for Safe MotherhoodThese ten action messages were identified at the Sri Lanka Technical Consultation on Safe Motherhood in 1999, which marked the tenth anniversary of the Safe Motherhood Initiative.(1) Advance Safe Motherhood Through Human Rights(2) Empower Women: Ensure Choices(3) Safe Motherhood is a Vital Economic and Social

Investment(4) Delay Marriage and First Birth(5) Every Pregnancy Faces Risks(6) Ensure Skilled Attendance at Delivery(7) Improve Access to Quality Reproductive Health Services(8) Prevent Unwanted Pregnancy and Address Unsafe

Abortion(9) Measure Progress(10) The Power of PartnershipTo provide skilled care at and after childbirth and to deal with complications is a matter of common sense - it is also what mothers and their families ask for. Putting it into practice is a challenge that many countries have not yet been able to meet. It is time to ensure that each pregnancy receives its due care with a view to prevent loss of lives in the form of maternal

deaths which are preventable to a large extent. India has an enormous task ahead to make assured services available at its health institutions and universalize the coverage of all women including those marginalized & underserved sections of society to realize the goal of safe motherhood. RCH and NRHM provide the necessary direction and opportunity to achieve this goal.

SummaryMaternal health includes Antenatal care, Intranatal care and Postnatal care. The Intranatal period constitutes only 0.5% of maternal cycle and but it is probably the most crucial.

Maternal death is defined as death of a women while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of pregnancy, from any cause related to or aggravated by pregnancy or its management but not from accidental or incidental cause. There are three main measures of Maternal mortality which are maternal mortality ratio, maternal mortality rate and life time risk of maternal death.

Antenatal care is the care of women during pregnancy. Its ultimate objective is to have a healthy mother and healthy child at the end of pregnancy. Antenatal care includes visit antenatal clinic, examination, investigations, immunization, supplements and interventions as required. Pre-conceptional care is indicated in some cases like maternal age more than 35 yrs and paternal age more than 55 years, history of congenital defects in family, recurrent pregnancy loss and use of alcohol.

Prenatal care should start as early as 8 weeks but not later than 12-16 weeks with registration of patient and initiation of antenatal card. This is important for determining exact EDD, evaluation of risk and essential health education of the patient. The at risk pregnancies are age less than 18 or more than 35, multiparity, short stature, Rh negative, bad obstetric history, medical disorders for eg IHD, Diabetes, seizures, hypertension, tuberculosis, anaemia etc. Health education or prenatal advice includes issues like diet, rest, personal hygiene, sexual intercourse, drugs, exercise, travel and care of breasts. Women should also be educated about the warning signs which should not be ignored like convulsions, severe headache, blurring of vision and bleeding or discharge per vaginum.

Birth planning is an important function of prenatal care. It takes care of complications which may arise suddenly and can be dangerous to the life of both mother and the child. Institutional delivery should be advocated but it is a must in many conditions which should be identified.

Objectives of Intanatal care are asepsis (The five cleans- clean hands, surface, blade, cord, tie), minimum injury to mother and child, to deal with complications during labour and the care of newborn.

The first 48 hours following delivery are the most important followed by first week following delivery. The mother should give postpartum visit at 3rd, 7th day and 6 weeks after delivery to see that involution of uterus is complete. Mother should be educated about danger signs and advised to report to hospital if they appear. Infections, haemorrhage, UTI, thrombophlebitis, and psychiatric disorders are common complications of puerperium.

The global burden of maternal mortality is 400 maternal deaths per 100000 live births. The burden is very high in developing countries as compared to developed countries where it is low.

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Rural population, low socio-economic status and remote areas bear a heavy burden of deaths. About 45% of maternal deaths occur in occur during the first 24 hours and more than two-thirds during first week. The maternal mortality ratio in India is 300 per 100,000 live births. The common causes in India are Anaemia, Haemmorhage, Sepsis, Obstructed labour, Abortion and Toxaemia. The 4 major direct causes of Maternal mortality are Haemmorhage, Infection, Eclampsia & Obstructed labour.

Actions for safe motherhood include legislative and policy decisions, society and community interventions, and health sector actions. Initiatives in India started since 1952 as Family planning programme. This was made more client oriented and voluntary since 1977 and called as Family welfare. In 1992 comprehensive approach was started in the form of CSSM programme. It was later realized, that the overall improvement in the reproductive health was the key to achieve the overall aim of lifelong health and thus, the approach was changed and RCH program was launched. Other programmes are All-India Hospital post-partum programme, Janani Suraksha Yojana (Maternal Safety Scheme) and Vande Matram Scheme.

The main challenges in Maternal Health are establishing data base on maternal mortality, high risk behavior, urban-rural divide, poor rate of institutional deliveries, lack of skilled care at birth, lack of women empowerment and poor implementation of programmes.

Study ExercisesLong Question : Describe in details the Programmes in India directed towards Maternal Health Care.

Short Notes : (1) Causes of Maternal mortality (2) Maternal Mortality Rate (3) All India Hospital Post-Partum Programme (4) Janani Suraksha Yojana

MCQs :1. Which of the following is not included in ‘Cleans’ in conduct

of delivery : (a) Clean hands (b) Clean Perineum (c) Clean cutting and care of the cord (d) Clean surface of delivery

2. In India, majority of deliveries take place at: (a) Hospital (b) Primary Health Centre (c) Private clinics (d) Home

3. Ante-natal care includes: (a) Genetic counselling for prospective parents (b) Spacing of births (c) Ensuring adequate maternal nutrition (d) All of the above

4. Janani Suraksha Yojana has been started under: (a) CSSM (b) NRHM (c) MCH (d) ICDS

5. Iron/Folic acid tablets are distributed to private doctors for free distribution under which scheme: (a) NRHM (b) CSSM (c) Janani Suraksha Yojana (d) Vande Mataram Scheme

6. Following are high risk ante-natal cases except: (a) Elderly Primi (b) Pre-eclampsia (c) Twin pregnancy (d) None

7. Minimum number of Antenatal visits during pregnancy is: (a) Two (b) Three (c) Five (d) Six

8. MMR in India is: (a) 300 per lakh (b) 400 per lakh (c) 200 per lakh (d) 500 per lakh

Answers : (1) b; (2) d; (3) d; (4) b; (5) d; (6) d; (7) b; (8) a.

ReferencesWHO/UNICEF. Antenatal care in developing countries. Promises, 1. achievements, & missed opportunities. An analysis of trends, levels, & differentials 1990-2001. Geneva, WHO, 2003.Carroli G, Villar J, Piaggio G, Khan-Neelofur D, Gulmezoglu M, Mugford M 2. et al. WHO systematic review of randomised controlled trials of routine antenatal care. Lancet, 2001,357:1565-1570

Make Every Mother & Child Count. The World Health Report 2005, WHO, 3. GenevaPregnancy, childbirth, postpartum, & newborn care (PCPNC). A guide for 4. essential practice. Geneva, WHO, 2004.Managing complications in pregnancy & childbirth. Geneva, WHO, 2003.5. National Family Health Survey NFHS - 3 India 2005-06, International 6. Institute for Population Sciences, Mumbai, India. http://www.nfhsindia.org/nfhs3.html Pasinlioglu T. Health education for pregnant women: the role of background 7. characteristics. Patient Education & Counselling, 2004, 53:101-106.Villar J, Bergsjo P. Scientific basis for the content of routine antenatal care. 8. I. Philosophy, recent studies, & power to eliminate or alleviate adverse maternal outcomes. ActaObstetricia et Gynecologica Scandinavica, 1997, 76:1-14.Maternal mortality in 2000: estimates developed by WHO, UNICEF & UNFPA. 9. Geneva, WHO, 2004.Attending to 136 million births every year. In chapter 4 of World Health 10. Report 2005, Make Every Mother & Child Count. WHO, Geneva 2005.Li XF, Fortney JA, Kotelchuck M, Glover LH. The postpartum period: the key 11. to maternal mortality. International Journal of Gynecology & Obstetrics, 1996, 54:1-10.Alauddin M. Maternal mortality in rural Bangladesh: the Tangail District. 12. Studies in Family Planning, 1986, 17:13-21.Bhatia JC. Levels & causes of maternal mortality in southern India. Studies 13. in Family Planning, 1993, 24:310-318.Koenig MA, Fauveau V, Chowdhury AI, Chakraborty J, Khan MA. Maternal 14. mortality in Matlab, Bangladesh: 1976-85. Studies in Family Planning, 1988, 19:69-80.MacLeod J, Rhode R. Retrospective follow-up of maternal deaths & their 15. associated risk factors in a rural district of Tanzania. Tropical Medicine & International Health, 1998, 3:130-137.Pathmanathan I, Liljestrand J, Martins JM, Rajapaksa LC, Lissner C, de Silva 16. A et al. Investing in maternal health: learning from Malaysia & Sri Lanka. Washington, DC,World Bank, 2003.Koblinsky MA, Campbell O, Heichelheim J. Organizing delivery care: what 17. works for safe motherhood? Bulletin of the WHO, 1999, 77:399-406.Suleiman AB, Mathews A, Jegasothy R, Ali R, Kandiah N. A strategy for 18. reducing maternal mortality. Bulletin of the WHO, 1999, 77:190-193.Maternal Mortality Study 2000. Cairo, Min. of Health & Population. 2001.19. Situation analysis of children & women in Iraq. New York, NY, United 20. Nations Children’s Fund, 1998.AbouZahr C. Antepartum & postpartum haemorrhage. In: Murray CJL, Lopez 21. AD, eds. Health dimensions of sex & reproduction: the global burden of sexually transmitted diseases, HIV, maternal conditions, perinatal disorders, & congenital anomalies. Cambridge, MA, Harvard School of Public Health on behalf of the WHO & the World Bank, 1998 (Global Burden of Disease & Injury Series, No. III):165-189.AbouZahr C. Global burden of maternal death & disability. In: Rodeck C, 22. ed. Reducing maternal death & disability in pregnancy. Oxford, Oxford University Press, 2003:1-11.AbouZahr C, Aahman E, Guidotti R. Puerperal sepsis & other puerperal 23. infections. In : Murray CJL, Lopez AD, eds. Health dimensions of sex & reproduction: the global burden of sexually transmitted diseases, HIV, maternal conditions, perinatal disorders, & congenital anomalies. Cambridge, MA, Harvard School of Public Health on behalf of the WHO & the World Bank, 1998 (Global Burden of Disease & Injury Series, No. III):191-217.AbouZahr C, Guidotti R. Hypertensive disorders of pregnancy. In: Murray 24. CJL, Lopez AD, eds. Health dimensions of sex & reproduction: the global burden of sexually transmitted diseases, HIV, maternal conditions, perinatal disorders, & congenital anomalies. Cambridge, MA, Harvard School of Public Health on behalf of the WHO & the World Bank, 1998 (Global Burden of Disease & Injury Series, No. III):219-241.Unsafe abortion: global & regional estimates of the incidence of unsafe 25. abortion & associated mortality in 2000, 4th ed. Geneva, WHO, 2004.The prevention and management of unsafe abortion. Report of a Technical 26. Working Group. Geneva, World Health Organization, 1992.Loudon I. Death in childbirth: an international study of maternal care and 27. maternal mortality, 1800-1950. Oxford, Clarendon Press, 1992.

Further Suggested readingPregnancy, childbirth, postpartum and newborn care: A Guide for essential 1. practice. Geneva, World Health Organization, 2003.Postpartum care of the mother and the newborn: a practical guide. Geneva, 2. World Health Organization, 1998.Managing complications in pregnancy and childbirth. Geneva, World Health 3. Organization, 2003.

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143 Care of Infants

A S Kushwaha

Infancy is the first year of life and this is marked by the greatest threat to survival and therefore is a good measure of the progress in the fields of socio-economic, medical and healthcare development in a country. It is customary to divide infancy into various time periods for convenience of planning service. The determinants of health are also different in these phases.

Infancy is sub-divided into following four distinct phases or periods

Perinatal period ●Early neonatal period ●Late neonatal period ●Post-neonatal period ●

DefinitionsPerinatal Period : Perinatal period extends from 28th weeks of gestation to less than 7 days of life, after birth.

Neonate : A child in 1st month [under 4 weeks of age (<28 days)]. Early Neonatal Period- First week of life (<7days or <168 hours). Late Neonatal period extends from 7th to 28th day.

Post-Neonatal period : Period of infancy from 28 days to under 365 days (<1 year)

Live born : A live born neonate is a product of conception, irrespective of weight or gestational age, that after separation from the mother, shows any evidence of life such as breathing, heart beat, pulsation of umbilical cord or definite movement of the voluntary muscle.

Still birth : A foetal death is a product of conception that after separation from the mother does not show any evidence of life. The WHO has recommended that within any country the term stillbirth be applied to a foetus born dead and weighing >500gm which is associated with a gestation of 22 weeks. For international comparisons a weight of 1000gm is to be used which frequently measures to 28 weeks of gestation. Still birth rate is the number of foetal deaths (>1000gm weight at birth) occurring in a year per 1000 total births (live births + stillbirths).

Pre-term Baby : Any neonate born before 37 completed weeks (<259 days) of gestation irrespective of the birth weight.

Term baby : A neonate born between 37 and 42 weeks of pregnancies (259-294 days) irrespective of the birth weight.

Low Birth Weight (LBW) : Any neonate weighing less than 2500 gm at birth irrespective of gestational age.

Very Low Birth Weight baby (VLBW) : Any neonate weighing less than 1500 gm at birth irrespective of gestational age.

Extremely Low Birth Weight baby (ELBW) : Any neonate weighing less than 1000 gm at birth irrespective of gestational age.

Perinatal Mortality Rate : This includes both late foetal deaths

(stillbirths) and early neonatal deaths. The important thing to consider is the weight 1000gm and more at birth or a gestation of 28 weeks if birth weight is not available and if both weight and gestation are not available, body length (Crown to heel) of at least 35 cm should be used.

The preferred criterion is birth weight. The denominator used in calculation of perinatal mortality is 1000 live births (suits nations with poor recording of still births) but for more precise comparison the denominator includes all live births weighing 1000 gm or more. Perinatal mortality is a sensitive indicator of essential maternal and newborn care provided at childbirth. The factors responsible for stillbirths and early neonatal deaths are often similar. This indicator also assumes importance in view of the fact that many of the early neonatal deaths are recorded as stillbirth in developing nations thereby inflating figures for stillbirths but showing figures for early neonatal deaths lower than the factual. This anomaly is taken care of by Perinatal Mortality Rate. The Perinatal period comprises just 0.5 % of the average lifespan but has more deaths in this period than next 30-40 years of life.

Babies continue to be very vulnerable throughout their first week of life, after which their chances of survival improve markedly. The conditions causing newborn deaths can also result in severe and lifelong disability in babies who survive.

Infant Mortality Rate : The ratio of infant deaths registered in a given year to the total number of live births registered in the same year, usually expressed per 1000 live births.

The infants who survive early neonatal period then face the dangers of Malnutrition, Diarrhoea and ARI and certain vaccine preventable diseases like measles.

Infant mortality has a special significance as -Single category with largest age specific mortality. ●Measure of health status and level of living of a ●communityDeaths are due to specific causes different from those that ●affect adults.Indicates social measures directed towards mother and ●child in a country. The importance of IMR can be gauged from the fact that it is one of the parameters for calculating Physical Quality of Life Index (PQLI). Various programs and policies have included reduction of Infant mortality as an important objective in the progress towards health for all.

Global Scenario : Each year, about four million newborns die during neonatal period across the world. Almost all (98%) of these deaths occur in developing countries. Newborn deaths now contribute to about 40% of all deaths in children under five years of age globally, and more than half of infant mortality. Rates are highest in sub-Saharan Africa and Asia. Two thirds of newborn deaths occur in the two WHO Regions (Fig. - 1), Africa (28%) and South-East Asia (36%). The average IMR for world is 54 per 1000 live births (2004). The lowest infant mortality rates in developed nations are under 10 with Japan recording an IMR of 3 per 1000 live births. The figures of IMR in underdeveloped nations are as high as 90 and above. The highest rates of IMR are recorded in Sierra Leone (165), Afghanistan (165), Mali (121) and Mozambique (104).

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Fig. - 1 : Region wise and cause wise neonatal deaths

Source : Make Every Mother and Child count. World Health Report, 2005

Progress : Consecutive household surveys from developing countries show that most have experienced a decline in neonatal mortality in recent decades. Much of the progress in survival has been made in the late neonatal period, with little improvement in the first week of life. Reductions in infant and child mortality in many countries are at least partly driven by socioeconomic development: improvements in women’s education and literacy, household income, environmental conditions (safe water supply, sanitation and housing), along with improvements in health services and child nutrition

Scenario in India : The infant mortality has been declining steadily over the years but the decline has been slower than desirable (Table - 1). The progress over the last decade is given in Fig. - 2.

Table-1 : Mortality indicators of infancy: India (1994-2006)

Indicator 1994 2000 2006

Infant Mortality Rate 74 68 57

Neonatal mortality rate 48 44 37

Post-neonatal mortality rate 26 23 22

Still birth rate 9 8 9

Fig.-2:Trend of IMR in India from 1994 to 2006 (NFHS-3)

74 7472

7172

7068

66

6360

58 5857

7573716967656361595755 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

IMR

Infant Mortality Rate

YearSource : SRS Bulletin - October 2007, Registrar General of India.

The deaths in the 1st year of life account for 18.7 % of total deaths in the country. Of these infant deaths, >60% occur during the 1st month of life (Neonatal deaths). Of this 40% of

neonatal deaths occur in the 1st week of life (Perinatal deaths). Risk of death is highest during first 24-48 hours of life.

Girls in India face a higher mortality risk than boys. Children born to mothers under age 20 or over age 40 are more likely to die in infancy than children born to mothers in the prime childbearing ages. Infant mortality is 77 per 1,000 for teenage mothers, compared with 50 for mothers aged 20-29 yrs. Infant mortality in rural areas is 50 percent higher than in urban areas. Children whose mothers have no education are more than twice as likely to die before their first birthday as children whose mothers have completed at least 10 years of school. In addition, children from scheduled castes and scheduled tribes are at greater risk of dying than other children. Infant mortality rates are highest in Uttar Pradesh, Chhattisgarh and Madhya Pradesh, where about 70 children in 1,000 die in their first year of life, and lowest in Kerala and Goa, with 15 infant deaths per 1,000 live births.

CausesInfant mortality is due to combination of various factors operating at different stages and are related to issues which may range from maternal, foetal, environmental and social. The causes differ during the neonatal and post neonatal phases of infancy. The factors operating in perinatal period do not have much relative impact in late neonatal part of infancy. Low birth weight (57%), respiratory infections (17%), diarrhoeal diseases (4%), congenital malformations (5%), Birth injury (3%) are the major causes of infant mortality in India. A list of causes is given in the Table - 2.

Table - 2 : Causes of Infant Mortality

Neonatal Mortality Post neonatal Mortality (1-12 months)

Low birth weight & prematurity Diarrhoeal diseases

Birth injury & difficult labour Acute respiratory infectionSepsis

Congenital anomalies Other communicable diseases-measles, malariaHaemolytic diseases of newborn

Conditions of placenta & cord Malnutrition

Diarrhoeal diseases Congenital anomalies

Acute respiratory infections Accidents

Neonatal tetanus

Factors Underlying Infant Mortality : The factors as discussed earlier vary in the Perinatal, neonatal and post neonatal phases of infancy. Perinatal mortality and neonatal mortality in particular accounts for nearly half of the infant mortality. Perinatal mortality is linked to a gamut of factors operating in the prenatal, intranatal and postnatal period.

(a) PrenatalMaternal factors-age (teenage, elderly), diseases like ●hypertension (toxemia), cardiovascular, diabetes, anaemia etc.Anatomical - uterine and cervical defects ●Blood incompatibilities ●

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Malnutrition, anaemia ●Antepartum haemorrhage ●Foetal- congenital defects ●

(b) IntranatalBirth trauma ●Birth asphyxia ●Prolonged or difficult labour ●Obstetric complications ●

(c) PostnatalPreterm baby/ Low birth weight ●Respiratory distress syndrome ●Congenital anomalies ●Infections ●

The causes operating in perinatal period are related to the maternal, foetal factors and care during delivery to the mother and the newborn. Factors like birth trauma, sepsis, asphyxia, prolonged labour and obstructed labour arise and operate due to lack of skilled care during delivery. The factors in the neonatal period are mainly ‘endogenous’ like prematurity, low birth weight and gestational age and congenital anomalies. This part of the infant mortality is the most difficult to tackle. Factors causing Post neonatal mortality are mainly social and environmental related. In developed countries the congenital anomalies is the main cause.

PreventionThe preventive strategy will be based on some direct and indirect measures as under -

Direct : These measures if taken can modify the problem of Infant mortality pretty quickly. These measures act both at primary and secondary prevention levels.

Safe and clean delivery with skilled birth attendant ●Essential Care of the newborn at birth ●Newborn resuscitation ●Infection control measures ●Exclusive Breast feeding ●Early diagnosis and management of complications ●Special care for the preterm and premature infants ●ORT and antibiotics for Diarrhoea and ARI respectively ●Immunization ●

Indirect : These factors though intangible but have a role of immense importance and operate at the level of family, community, health care and society at large. These factors are mostly acting at promotion and primary prevention levels.

Family planning - timing, spacing births, limiting family ●sizePrenatal nutrition of mothers ●Education of the mother on pregnancy and child care ●Antenatal care ●Growth monitoring of child ●Prevention of malnutrition- weaning practices ●Breast feeding ●Vit A prophylaxis ●Improved Sanitation and safe water ●Access to primary health care ●Overall socio-economic development ●

Essential Newborn CareCare of the newborn at birth is primarily aimed at helping the newborn to adapt to the extra-uterine environment. Physiological adaptation includes initiation of respiration and oxygenation of the arterial blood, temperature adaptation and initiation of breast feeding. Box - 1 shows the actions at birth.

Box - 1 : Actions at birth

Note timing of birth

Note sex of the baby and show to mother

Cleaning the airway

Cleaning and drying the baby

Put a identification mark / tag

Transfer the baby

APGAR score at 1 and 5 minutes

Take birth weight, length

Rule out any major congenital anomaly, birth injury

Routine Care at BirthOver 90% of newborns do not require any active resuscitation at birth. Efforts are directed to maintain asepsis, prevent infection and hypothermia, and to keep the airway patent.

Advise the mother to return immediately if the young Infant has any of these signs

Breast feeding or drinking poorly

Becomes sicker

Develops a fever or feels cold to touch

Fast breathing

Difficult breathing

Blood in stool

Examination of the NewbornA complete physical examination is an important part of newborn care. Each body system is carefully examined for signs of health and normal function. The physician also looks for any signs of illness or birth defects. The newborn baby at birth is 50 cm long & weighs >2.5 kg with a head circumference of 34 cm.

Risk Identification in the NewbornAn important task of the attending MO in the labour room is the identification of newborns at high risk for morbidity and mortality. These newborns would need special care, either at the PHC where the delivery took place (if the facilities and trained personnel exist) or at the FRU where these babies should be referred to.

Guidelines to detect these newborns at risk :

Danger Signs in a NewbornConvulsions ●Fast breathing (60 breaths per minute or more) ●Severe chest indrawing ●

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Nasal flaring ●Grunting ●Bulging fontanelle ●10 or more skin pustules or a big boil ●Severe Jaundice ●Axillary temperature 37.5°C or above (or feels hot to touch) ●or temperature less than 35.5°C (or feels cold to touch)Lethargic or unconscious ●Less than normal movements ●Blood in the stools ●Not able to feed ●Not sucking at all ●No attachment at all ●

Referring the Newborn to an FRUCheck on the arrangement for referral. A newborn will benefit from referral to a higher centre only if it is properly ventilated and kept warm during transport. Two people are needed to escort a newborn who requires ventilation: one person will continue to ventilate the baby while the other will assist with other tasks. If possible, transfer for the mother should also be arranged alongside.

Stopping ResuscitationDespite complete and adequate resuscitation efforts, some newborns may undergo brain death if the heart rate is absent at 15 minutes. Therefore, an absent heart sound, even after 15 minutes, is an absolute indication to stop resuscitation. If there is no gasping or breathing at all even after 20 minutes of effective ventilation (and cardiac massage, if required), stop ventilation.

JaundiceIn mild or moderate levels of jaundice, by 5 to 7 days of age the baby will take care of the excess bilirubin on its own. If high levels of jaundice do not clear up, phototherapy may be prescribed. The other modalities like exchange transfusion and suspension of breast feeding temporarily may be used if required depending on the cause.

Common Birth InjuriesA difficult birth or injury to the baby can occur because of the baby’s size or the position of the baby during labour and delivery.

Breast feedingFeeding of the Newborn : After birth, breast feeding should be initiated as early as possible (within 1 hour) unless there is a contraindication. The benefits of early and exclusive breast feeding must be explained to the mother. The baby should be fed on demand, both day and night. The mother should be advised that she SHOULD NOT-

Force the baby to feed. ●Interrupt a feed before the baby is done ●Use the artificial teats or pacifiers ●Give the baby any other food or drink for the 1 ● st six months of life.

Colostrum : During the first few days after delivery a woman produces special milk that is thick, sticky and yellowish or clear in colour. This special milk is called colostrum.

Colostrum contains large quantities of protective ●

substances and growth factors and has more protein and Vitamins A and K than mature milk.It enhances the development and maturation of the baby’s ●gastro-intestinal tract.The anti-infective proteins and white cells provide the first ●immunization against the diseases that a baby encounters after delivery.Although colostrum is secreted in small quantities ●(30-90 ml), it is sufficient to meet the caloric needs of a normal newborn in the first few days of life.Colostrum also has a mild purgative effect, which helps to ●clear baby’s gut of meconium (the first, very dark stools) and helps to prevent jaundice by clearing the bilirubin from the gut.It stimulates the baby’s immature intestine to develop ●in order to digest and absorb milk and to prevent the absorption of undigested protein.

Initiate breast feeding as soon as the baby is ready to suckle or as soon as the mother’s condition permits. If breast feeding has to be delayed due to maternal or newborn problems, teach the mother to express breast milk as soon as possible and ensure that this milk is given to the newborn. The BFHI promotes, protects, and supports breast feeding through The Ten Steps to Successful Breast feeding for Hospitals, as outlined by UNICEF/WHO are given in Box - 2.

Box - 2 : BFHI : Ten steps to successful breast feeding

1Maintain a written breast feeding policy that is routinely communicated to all health care staff

2Train all health care staff in skills necessary to implement this policy.

3Inform all pregnant women about the benefits and management of breast feeding

4Help mothers initiate breast feeding within 1 hour of birth.

5Show mothers how to breast feed and how to maintain lactation, even if they are separated from their infants.

6Give infants no food or drink other than breast milk, unless medically indicated

7Practice “rooming in”-- allow mothers and infants to remain together 24 hours a day.

8 Encourage unrestricted breast feeding

9Give no pacifiers or artificial nipples to breast feeding infants

10Foster the establishment of breast feeding support groups and refer mothers to them on discharge from the hospital or clinic

Objective of Breast feeding is “Exclusive breast feeding of the first six months of life” to be propagated as it has the following benefits:

It is the ideal method of infant feeding. ●It is the single most cost effective intervention for reduction ●of infant mortality.Delays return to fertility in the mother and hence acts as a ●natural contraceptive.

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The Infant Milk Substitute (IMS) Act is being implemented and following initiatives have been taken-(a) Baby Friendly Hospital Initiative(b) Lactation Clinics(c) Peer CounsellingWeaning (Complementary Feeding) : The complementary feeding means giving the child other nutritious foods in addition to breast milk. Weaning literally meant taking the child away from the breast and nourishment by other means. Breast feeding alone is sufficient to take care of the requirements in 1st six months. Thereafter, concentrated energy dense complementary foods are essential to maintain adequate velocity of growth for the infant. Weaning if not carried out properly, may lead to malnutrition and illness.

Small Babies (LBW)Neonates weighing <2500 gm at birth are classified as low birth weight. One third of the births in India are estimated to be LBWs. These LBWs can be of two broad groups- Preterm and SFA (small for gestational age) term infants. Most of these LBWs are SFA in developing countries while they are mostly pre-term in developed world. These LBWs face many risks at birth and are prone to many conditions like infections, respiratory difficulty and metabolic disturbances. Problems of each category are summarized in the Table - 3.

Table - 3 : Hazards of Low Birth Weight (LBW) Infant

Preterm (<37 weeks) Small for Age (SFA)

Birth asphyxia Birth asphyxia

Hypothermia Hypothermia

Infections Infections

Metabolic acidosis Meconium aspiration

Hyperbilirubinemia Hypoglycemia

Apneic spells Polycythemia

Respiratory distress ( Hyaline membrane disease)

Health Risk of being LBW : The low birth weight child begins with a disadvantage at birth and this may even have long term implications. The hazards of being born low birth weight are-

Survival : The mortality in infancy is much higher amongst those born with weight <2500 gm. This is due to several factors like physiological immaturity of respiratory, CNS system, liver; predisposition to hypoglycemia, hypothermia and infections, malnutrition etc.

Growth and development : Since LBWs are starting poorly at birth, they are likely to lag behind those born with normal weight. They have delayed milestones and grow poorly. The so called ‘catch up growth’ is seen more in preterm babies who are otherwise appropriate for their age.

Syndrome X : This metabolic syndrome is more common amongst those born with a poor weight at birth. Due to genetic programming (thrifty gene hypothesis) they develop tendency for accumulation of fat when nutrition is adequate and suffer the ill effects of this condition with increased likelihood of IHD, hypertension and diabetes.

The Causes of LBW : The causes of the LBW have been studied and they have inter-related multiple factors acting simultaneously in the setting of poverty (Table - 4). The famous triad of ‘Malnutrition, Infection and Unregulated fertility’ operates to produce this unfavourable outcome.

Table - 4 : Causes of Preterm and SFA infants

Preterm infants SFA Infants

Maternal

Incompetent cervix

Short stature

Medical diseases Undernutrition

InfectionsPrimi, grand multipara

Smoking, tobacco

PlacentalPlacenta previa, APH

Abruptio placentae, infarction, anomalies

Foetal

Multiple pregnancy

IUGR, multiple pregnancy

Congenital malformation

congenital malformation, intrauterine infections

Medical Conditions / complications

Uncontrolled diabetes

Hypertension, toxemia

Hypertension, toxemia

Cardiac illness

Cardiac illness Foetal distress

Foetal distress Rh isoimmunisation

Rh isoimmunisation

Anaemia

Severe IUGR Malaria

IatrogenicImproper assessment of maturity

-

Principles of Management of LBWsCare at Birth - All ‘at risk’ pregnancies for LBW babies must ●take place at a place where optimal facilities exist. Being prone to hypothermia, adequate precautions must be taken by maintaining a ‘Warm chain’. All arrangements for resuscitation of newborn should be available.Appropriate place of care - Depending on the birth weight ●the LBW can be cared for at home (>1800 gm) and if <1800, at the hospital till the child gains weight and if <1500 gm, these babies will need tertiary level care.Thermal protection - As outlined elsewhere by delaying ●bathing, maternal contact by Kangaroo mother care and external heat source if required.Fluids and feeds - Breast feeding, expressed breast milk, ●nasogastric feeding and IV fluids if required.Monitoring for early detection and management of ●complications like respiratory difficulty, metabolic disturbances, infections etc.Kangaroo Mother Care ●

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Kangaroo Mother Care (KMC) : This concept was first presented by Rey and Martinez in Colombia. It has been particularly advised in small, preterm and LBW babies but applies well in all babies. In this the key features are as under :

Early, continuous and prolonged skin-to-skin contact ●between the mother and the babyExclusive breast feeding ●It is initiated in hospital and continued at home ●Small babies can be discharged early ●Mothers at home require adequate support and follow up ●

It was developed as an alternative to inadequate and insufficient incubator care for those preterm newborn infants who had overcome initial problems and required only to feed and grow. It has been shown to be effective for thermal control, breast feeding and bonding in all newborn infants. The support binder is the only special item required for KMC. The baby is placed between the mother’s breasts in an upright position, chest to chest. The position allows mother with both hands free and ability to move around.Preventive Strategies to Tackle the Problem of LBW

DirectMaternal nutrition- by improving the pre-pregnancy weight ●and maternal nutrition during pregnancy, birth weight of the infant can be improved.Good antenatal care ●Prevention of infection in the mother ●Early diagnosis and management of maternal factors like ●anaemia, malaria, hypertension etc.

IndirectDelayed marriage and childbearing ●Adequate spacing ●Family planning ●Improved socio-economic status ●Women empowerment ●

Infection Prevention in the Newborn : This is an important component of every sphere of newborn care. Newborns are more susceptible to infection because of immature immune system. This is still more relevant to preterm and low birth weight infants.

General PrinciplesConsider every person (including staff and the baby) as ●potentially infectiousWash hands or use hand rub (alcohol based) before ●handling a baby and afterWear protective clothing like gown, mask, gloves ●Observe aseptic techniques in all procedures ●Routine cleaning of the ward and all equipment ●Isolation of babies with infections ●Routine care of newborn ●

Early ChildhoodChildren are more likely to survive, to grow in a healthy way, to have less disease and fewer illnesses, and to fully develop thinking, language, emotional and social skills when well nurtured and cared for in their earliest years. Frequent illness, unsanitary environments and poor nutrition steal a child’s potential.

It is a child’s right to have every chance to survive and thrive. Moreover, ensuring optimal conditions for a child’s early years is one of the best investments that a country can make if it is to compete in a global economy based on the strength of its human capital. The growth monitoring, correct feeding practices, immunization, responsive health care system, legal provisions, sensitive society, management during sickness and providing protection to these children can help in improving the lot of this important group of vulnerable population. The concept of well baby clinic, under five clinic and mother and child clinics are steps in this direction. The growth and development (Growth and Development) and care of sick children (IMNCI) are described in different chapters.

Community Based Health Care InterventionsUNICEF and WHO, have agreed on 12 key household practices for neonates and infants that can help to promote child survival, health and nutrition in communities:(1) Exclusive breast feeding from birth to six months.(2) Complementary feeding : Starting at about six months old,

feeding children energy - and nutrient-rich complementary foods while continuing to breast feed for at least two years could prevent more than 10 per cent of deaths from diarrhoea and acute respiratory infections, particularly pneumonia; and increase resistance to measles and other illnesses.

(3) Micronutrient Supplementation : Improving the intake of vitamin A through diet or supplements in communities where it is deficient could reduce mortality among children aged 6 months to five years by 20 per cent.

(4) Hygiene : Better hygiene practices, particularly hand washing with soap (or ashes) and the safe disposal of excreta could reduce the incidence of diarrhoea by 35%.

(5) Immunization : Vaccination against measles for children under age one could prevent most of the measles - related deaths each year. Caregivers should make sure children complete a full course of immunization (Bacille Calmette-Guérin; diphtheria, pertussis and tetanus vaccine; oral polio vaccine; and measles vaccine) before their first birthday.

(6) Malaria prevention : The use of insecticide-treated mosquito nets in households in malaria-endemic areas could lower malaria-related child deaths by as much as 23 per cent.

(7) Psychosocial care and development: Promote mental and social development by responding to a child’s need for care and by talking, playing and providing a stimulating environment.

(8) Feeding and fluids for sick children: Continue to feed and offer more fluids, including breast milk, to children when they are sick.

(9) Home treatment: Give sick children appropriate home treatment for infections.

(10) Care seeking: Recognize when sick children need treatment outside the home, and seek care from appropriate providers.

(11) Appropriate practices: Follow the health worker’s advice about treatment, follow-up and referral.

(12) Antenatal care: Every pregnant woman should have adequate antenatal care.

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Further important practices that protect children include - providing appropriate care for those who are affected by HIV and AIDS, especially orphans and vulnerable children; protecting children from injury and accident, abuse and neglect; and involving fathers in the care of their children. Many of these practices can be undertaken by community health workers or by community members themselves, given the appropriate support and distribution of products and services. The direct involvement of the community is perhaps most appropriate for those aspects of health care and nutrition that most closely affect members on a daily basis. These include infant and young child feeding, other caring practices, and water and sanitation.

Special Child Survival Initiatives in IndiaCSSM : The Child Survival and Safe Motherhood Programme jointly funded by World Bank and UNICEF was started in 1992-93 for implementation up to 1997-98. The Child Survival and Safe Motherhood Programme was implemented in a phased manner covering all the districts of the country by the year 1996-97. The objectives of the programmes were to improve the health status of infants, child and maternal morbidity and mortality. The programmes seek to sustain high coverage levels achieved under the Universal Immunisation Programme (UIP) in good performance areas and strengthen the immunisation services of poor performing areas. The programme also provides for augmenting various activities under the Oral Rehydration Therapy (ORT) Programme, universalising prophylaxis schemes for control of anaemia in pregnant women & control of blindness in children and initiating a programme for control of Acute Respiratory Infection (ARI) in children. The Programme yielded notable success in improving the health status of pregnant women, infants and children & also making a dent in IMR, MMR and incidence of vaccine preventable diseases.

UIP : Universal Immunization Programme against six preventable diseases, namely, diphtheria, pertussis, childhood tuberculosis, poliomyelitis, measles and neonatal tetanus was introduced in the country in a phased manner in 1985, which covered the whole of India by 1990. Significant progress was made under the Programme in the initial period when more than 90% coverage for all the six antigens was achieved. The UIP was taken up in 1986 as National Technology Mission and became operational in all districts in the country during 1989-90. UIP become a part of the Child Survival and Safe Motherhood (CSSM) Programme in 1992 and Reproductive and Child Health (RCH) Programme in 1997. Under the Immunization Programme, infants are immunized against tuberculosis, diphtheria, pertussis, poliomyelitis, measles and tetanus.

ORT : The diarrhoeal disease control programme was started in the country in 1978. The main objective of the programme was to prevent death due to dehydration caused by diarrhoeal diseases among children under 5 years of age due to dehydration. Health education aimed at rapid recognition and appropriate management of Diarrhoea has been a major component of the CSSM. Under the RCH programme ORS is supplied in the kits to all sub-centres in the country every year.

RCH : The initiatives under RCH for newborn and infant care

are as under-

Infant & Child Health(a) Reduction of new-born deaths, infant deaths and

child deaths by providing continuous health care and strengthening of new-born care infrastructure facilities.

(b) Organizing counselling sessions for the mothers.(c) Implementing integrated management of neonatal and

childhood illness as a pilot initiative in selected districts.(d) Operationalising infant death/stillbirth verbal autopsy.(e) Addressing the issue of female infanticide and foeticideIMNCI : Integrated Management of Neonatal and Childhood Illness (IMNCI)

Integrated Management of Childhood Illness (IMCI) strategy, which has already been implemented in more than 100 countries all over the globe, encompasses a range of interventions to prevent and manage five major childhood illnesses i.e. Acute Respiratory Infections, Diarrhoea, Measles, Malaria and Malnutrition. It focuses on preventive, promotive and curative aspects, i.e. it gives a holistic outlook to the programme. The details on the care of sick children are given in the chapter on IMNCI.Home Based Care of Newborns and Mothers - (SEARCH) A Project : In the Gadchiroli district of India, Drs. Abhay and Rani Bang and colleagues at the Society for Education, Action & Research in Community Health (SEARCH) have developed a remarkable approach to home-based health care that benefits both newborns and their mothers. It had to be home-based because 83 percent of births in rural India occur at home, and these villagers have virtually no access to health facilities. After two years of research, SEARCH introduced neonatal care through trained village health workers and trained birth attendants, who provide health education to new mothers, support breast feeding and maintenance of body temperature, and recognize danger signs in mothers and babies. By the third year of the program, which tracked results in 39 intervention villages and 47 control villages, SEARCH had recorded a 62 percent reduction in the neonatal mortality rate for the intervention areas as well as a significant reduction in various neonatal and maternal morbidities. This strategy has been recognized as a valuable option for the districts with high infant mortality.

Tackling infant mortality is largely an issue of addressing the perinatal mortality. Perinatal mortality improves by universal coverage of all deliveries with skilled attendance at birth and essential maternal and newborn care coupled with effective referral mechanism and back up FRU facilities. Post neonatal mortality is amenable to known interventions and is easiest to tackle by launching child survival methods like ORT, treating pneumonia, breast feeding, supplementary feeding, weaning practices and immunization. The infant survival is related largely to clean delivery practices, correct feeding practices, immunization and availability, adequacy and timely health care during sickness especially due to Diarrhoea, ARI and measles. The malnutrition is one single factor which touches all of these and determines the survival of the infant. The core interventions for child survival are given in Box - 3.

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Box - 3 : Core Interventions to Improve Child Survival

Skilled attendance during pregnancy Child birth and the immediate postpartum period : Nurturing newborns and their mothers.

Infant feeding : Exclusive breast feeding during the first six months of a child’s life, with appropriate complementary feeding from six months and continued breast feeding for two years or beyond, with supplementation with vitamin A and other micronutrients as needed.

Vital vaccines : Increased coverage of measles and tetanus vaccines, as well as immunization against common vaccine-preventable diseases.

Combating diarrhoea : Case management of diarrhoea, including therapeutic zinc supplementation and antibiotics for dysentery.

Combating pneumonia and sepsis : Case management of childhood pneumonia and neonatal sepsis with antibiotics.

Combating malaria : Use of insecticide-treated bednets, intermittent preventive malaria treatment in pregnancy, and prompt treatment of malaria.

Prevention and care for HIV : Treatment, care, infant feeding counselling and support for HIV-infected women and their infants.

SummaryInfancy is the first year of life and is marked by greatest threat to survival and therefore is a good measure of the progress of a country. It is sub-divided into Perinatal, Early neonatal, Late neonatal and Post neonatal period. Babies are very vulnerable during their first week of life and also when they are weaned. Infant Mortality Rate (IMR) has special significance because it is a single category with highest age-specific mortality, measure of PQLI. Deaths are due to causes different from adults and hence IMR indicates measures directed to mother and child in a country.

Each year, 4 million children die during neonatal period worldwide. Neonatal deaths contribute to 40% of deaths in Under-5 children and more than half of infant mortality worldwide. Rates are highest in Sub-saharan Africa and Asia. The average IMR is 54 per 1000 for the world (2004). The highest rates of IMR are in Sierra Leone and Afghanistan and lowest in Japan. Consecutive household surveys in developing countries have shown a reduction in neonatal mortality rates of which maximum reduction is in late neonatal period.

In India the infant mortality rate is declining steadily over the years but the decline has been slower than desirable. IMR in 2006 for India was 57. The deaths in the first year of life account for 18.7% of total deaths in the country. Of these Infant deaths more than 60% occur in neonatal period. Of these neonatal deaths 40% occur in first week of life (Early neonatal period). The greater mortality risk is associated with girl child, children of mothers aged less than 20 and more than 40, children born in rural areas, children of mothers with no formal education, children of scheduled castes and tribes. In India IMR is highest in Uttar Pradesh, Chattisgarh and Madhya Pradesh and lowest

in Kerala and Goa. Major causes of Infant mortality in India are Low birth weight(57%), Respiratory infections(17%), Congenital malformations(5%), Diarrhoeal diseases(4%) and Birth injury(3%).

Infant mortality can be due to prenatal, intranatal and postnatal causes. Prenatal causes are Maternal age (teenage and elderly), Maternal diseases like hypertension, cardiovascular, diabetes and anaemia, Uterine and cervical defects, Blood incompatibilities, Malnutrition, Ante-partum haemmorhage and Feto-congenital defects. Intranatal causes are Birth trauma, Birth asphyxia, Prolonged or difficult labour and Obstetric complications. Postnatal causes are Preterm or low birth weight baby, Respiratory distress syndrome, congenital anomalies and Infections.

Preventive strategies for reducing Infant mortality are divided into direct and indirect methods. Direct methods are Safe and clean delivery by skilled birth attendant, Essential care of newborn, Newborn resuscitation, Infection control measures, Exclusive breast feeding, Early diagnosis and management of complications, Special care for preterm and premature infants, ORT and antibiotics for Diarrhoea and ARI respectively and Immunization. Indirect methods are Family planning, Prenatal nutrition of mothers, Education, Antenatal care, Growth monitoring of child, Prevention of malnutrition, Vit A prophylaxis, Improved water and sanitation, Access to primary health care and overall socio-economic development.

Care of newborn at birth is primarily aimed at helping the newborn to adjust to extra-uterine environment. Physiological adaptations include initiation of respiration and oxygenation of the arterial blood, temperature adaptation and initiation of breast feeding. The Baby Friendly Hospital Initiative (BFHI) promotes, protects and supports breast feeding through the ten steps to successful breast feeding for hospitals as outlined by UNICEF/WHO. Objective of breast feeding is Exclusive breast feeding for the first six months of life. The Infant Milk Substitute (IMS) act is being implemented and the initiatives are Baby friendly hospital initiative, Lactation clinics and Peer counselling.

Over 90% of newborns do not require active resuscitation at birth. In these cases the mother is advised to return to hospital immediately if infant is breast feeding or drinking poorly, becomes sicker, develops fever or feels cold to touch, difficult breathing and blood in stools. In case of Jaundice the child is taken to hospital if Jaundice is noted during first 24 hours or baby develops a fever over 100°F or colour deepens after day 7 or Jaundice does not disappear after day 15 or baby is not gaining sufficient weight.

Complementary feeding or weaning means giving the child other nutritious foods in addition to breast milk and is done after 6 months. In this, complementary energy dense foods, which are locally available and are inexpensive, easily digestible and culturally acceptable are given.

Neonates weighing less than 2500 grams at birth are classified as low birth weight. They can be divided into Pre-term babies and Small for Gestational Age (SFA) babies. The health risks of being low birth weight are decreased survival, delayed milestones, poor growth and development and increased

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chances of Syndrome X later in life. The famous triad causing LBW babies include Malnutrition, Infection and Unregulated fertility. Principles of management of LBW babies include care at birth, appropriate place of care, thermal protection, fluids and feed, monitoring for early detection and management of complications and Kangaroo Mother Care (KMC).

The preventive strategies to tackle the problem of LBW are improving maternal nutrition, good ante-natal care, prevention of infection of the mother, early diagnosis and treatment of anaemia or hypertension or malaria etc., delayed marriage or childbearing, adequate spacing, family planning, improved socio-economic status and women empowerment.

UNICEF and WHO has agreed on 12 key household practices for neonates and infants that can help promote child survival, health and nutrition in communities. These are Exclusive breast feeding for six months, complementary feeding, micronutrient supplementation, hygiene, immunization, malaria prevention, psychosocial care and development, feeding and fluids for sick children, home treatment, care seeking appropriate practices and ante-natal care.

The important special child survival initiatives in India include CSSM (Child Survival and Safe Motherhood Programme), UIP (Universal Immunization Programme), RCH, IMNCI (Integrated Management of Neonatal and Childhood Illness).

Initiatives under RCH for newborn and infant care include reduction of newborn deaths, infant deaths and child deaths by providing continuous health care and strengthening of newborn care infrastructure facilities, organizing counselling sessions for the mothers, implementing IMNCI as a pilot project in selected districts, operationalising infant death/still birth verbal autopsy and addressing the issue of female infanticide and foeticide.

IMNCI straregy encompasses a range of interventions to prevent and manage five childhood illnesses i.e. ARI, Diarrhoea, Measles, Malaria and Malnutrition. It promotes on preventive, promotive and curative aspects i.e. it gives a holistic attitude to the programme.

Study ExercisesLong question : Discuss various causes of high IMR in developing countries and strategies to prevent it.

Short notes : (1) BFHI (2) IMR and its trend in India (3) Causes of Infant mortality (4) Essential newborn care (5) Breast feeding (6) Weaning (7) LBW (8) Kangaroo mother care

MCQs :1. Premature infant is one which is born: (a) Before 40 weeks

(b) Before 38 weeks (c) Between 28-37 weeks (d) Between 28-42 weeks

2. All are true of colostrum except: (a) Rich in proteins and minerals (b) Rich in anti-infective factors (c) Rich in fats (d) Secreted for first few days

3. Breast feeding should be started _____ hours after birth: (a) Within 1 hour (b) 2 hours (c) 24 hours (d) 48 hours

4. LBW baby is one whose weight is below: (a) 2200 grams (b) 2000 grams (c) 1500 grams (d) 2500 grams

5. Exclusive breast feeding is sufficient for ____ months after birth: (a) 1 month (b) 2 months (c) 6 months (d) 9 months

6. Low birth weight child is due to all except: (a) Maternal malnutrition (b) Infections (c) Unregulated fertility (d) Previous caesarean section

7. Single most important factor determining survival chances of newborn is: (a) Birth order (b) Multiple gestation (c) Intrauterine infection (d) Low birth weight

8. Adverse factor for child health is : (a) Birth order 5 or more (b) Maternal malnutrition (c) Teenage mother (d) All of the above

9. Perinatal period is: (a) 20-32 weeks of gestation (b) 37-42 weeks of gestation (c) 28 weeks of gestation to 1 week postnatal period (d) 28 weeks of gestation to 1 week postnatal period (d) 32 weeks of gestation to 2 week postnatal period

10. Perinatal mortality includes: (a) Stillbirths (b) Neonatal deaths (c) Stillbirths and Early neonatal deaths (d) Stillbirths and Neonatal deaths

11. Infant mortality rate in India in 2006 was: (a) 64 (b) 67 (c) 54 (d) 57

12. The denominator in IMR is: (a) Total no of live births (b) Total no of live and still births (c) Total no of still births (d) Total population

Answers : (1) a; (2) c; (3) a; (4) d; (5) c; (6) d; (7) d; (8) d; (9) c; (10) c; (11) d; (12) a.

ReferencesConcept and strategy Framework- Integrated Management of Neonatal and 1. Child Illnesses (IMNCI) - Government of India, State Governments, UNICEF and WHO) - February, 2004.Ministry of Health and Family Welfare. RCH II Document.2. MCH Division. Ministry of Health and Family Welfare. National Child Survival 3. and Safe Motherhood program. New Delhi: 1994.Registrar General of India. www.censusindia.net (Census of India, 2001).4. WHO. 1997. Hypothermia in the newborn. In: Thermal protection of the 5. newborn: a practical guide. Geneva, WHO press, 1997WHO and UNICEF, 2003. Integrated management of neonatal and childhood 6. illness. Assess and classify the sick young infant age up to 2 months. Ministry of health and Family Welfare, Government of India, New-Delhi, 2003WHO. Essential Newborn Care. Proceedings of Report of a technical working 7. group Trieste, 25-29 April 1994. Geneva, WHO press, 1994

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144Integrated Management of Neonatal and Childhood Illnesses (IMNCI)

A S Kushwaha

Accumulated evidence has suggested that an integrated and syndromic approach is needed for efficient management of sick children to improve outcomes. On analysis of the major causes of mortality in childhood and evidence based data, an approach called IMCI (Integrated Management of Childhood Illnesses) was developed by WHO. This encompasses a range of interventions to prevent and manage five major childhood illnesses i.e. Acute Respiratory Infections, Diarrhoea, Measles, Malaria and Malnutrition. It focuses on the preventive, promotive and curative aspects of the disease management with participation of the mother also in the process, i.e. it gives a comprehensive and holistic outlook to the programme.

As part of Millennium Development Goals (MDGs), Goal 4 and Target 5 are to reduce by two third, the mortality in the children under five. India is a signatory to the MDGs adopted in 2000 as part of the Millennium Declaration. A Core Group was constituted which included representatives from Indian Academy of Pediatrics (IAP), National Neonatology Forum of India (NNF), National Anti Malaria Program (NAMP), Department of Women

and Child Development (DWCD), Child-in-Need Institute (CINI), WHO, UNICEF, eminent Paediatricians and Neonatologists, and the representatives from Ministry of Health and Family Welfare, Government of India. The Adaptation Group developed Indian version of IMCI guidelines and renamed it as Integrated Management of Neonatal and Childhood Illness (IMNCI).

ApproachThe IMNCI approach has some distinct features which are given as under-

(a) Syndromic Approach : Mostly the children suffer from a constellation of symptoms and need to be treated as a whole. Many sick children present with overlapping signs and symptoms of illnesses, and a single diagnosis may not be feasible or appropriate, especially in a primary care level with scarce resources. The Syndromic approach gives the advantage of not missing out on co-existing conditions while presenting with a particular condition.

(b) Holistic Approach : This means that taking care of all the factors that determine the health of the child. While treating for diarrhoea, the immunization and nutritional factors are also addressed.

(c) Triage : Management is planned after triage of the patient into those needing emergent, early treatment, referral or care at home.

Fig. - 1 : IMNCI Approach

OUT PATIENT HEALTH FACILITYCheck for DANGER SIGNS

(Convulsions, Lethargy/Unconsciousness, lnability to drink/breastfeed, Vomiting)

Assess MAIN SYMPTOMS(Cough/Difficulty in breathing, Diarrhoea, Fever, Ear problems)

Assess Nutrition and immunisation status and potential feeding problems

Check for other problems

Classify CONDITIONS AND IDENTIFY TREATMENT ACTIONS

URGENT REFERRALOUT PATIENT HEALTH FACILITY(prereferral treatments. Advice

Parents, Refer child)

TREATMENT AT OUT PATIENTHEALTH FACILITY

OUT PATIENT HEALTH FACILITY(Treat Local Infection, Give Oral

Drugs, Advise and teach caretaker,Follow up)

HOME MANAGEMENTHOME

(Caretaker is counselled on HomeTreatments, Feeding and fluids,

When to return immediately,Follow up)

Emergency Triage and Treatment, Diagnosis, Treatment, Monitoring and FollowupREFERRAL FACILITY

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(d) Standardized Case Management : Standardized case management based on the classification / severity of illness(e) Primary Health Care Model : Based on primary health care model and referral to a facility when required.

(f) Community Participation : The IMNCI approach gives due importance to the role of the mother in the whole process of prevention, early diagnosis and management of the case at home by providing counselling to the caretaker.

Components of IMNCIThe major components of this strategy are:(a) Strengthening the skills of the health care workers(b) Strengthening the health care infrastructure(c) Involvement of the communityThe first two components are the facility based IMNCI and the third is the community based IMNCI in which mother is actively involved in the care of child in health and disease.

Steps in Management (ACT- assess, classify and treat) (See Fig. - 1)

The basic steps in the management of the sick children are as under-(a) Assess the child for group of symptoms(b) Classify the severity of disease(c) Treat as per the laid out plan(d) Counsell the mother(e) Follow up careAge CategoriesDepending on the age of the child, various clinical signs and symptoms differ in their degree of reliability, diagnostic value and importance and even the principles of management also differ. The IMNCI guidelines therefore recommend case management procedures based on two age categories:(a) Young infants (age up to 2 months) (b) Children (2 months up to 5 years) Young Infants (Age Up to 2 Months) : Neonates and infants below 2 months of age are considered as a special group for several reasons. They become sick rapidly and can die quickly due to serious bacterial infections. Certain general signs in these infants such as low body temperature, fever or less body movements may be the only manifestation of illness. On the other hand, a finding such as mild chest in-drawing is normal in them due to a soft chest wall. Therefore the assessment and classification process is different from that in an older infant or child.Assessment (Assess for BCD IF Hypothermic) (a) For serious Bacterial infection or local infection(b) For jaundice (Colour of skin) (c) For Diarrhoea(d) Checking the Immunization status(e) For Feeding problem or malnutrition and breast feeding(f) For low body temperature (Hypothermic) 1. Serious Bacterial Infection : Suspect possible serious bacterial infection if there is - (remember STING BALL CM) (a) Skin pustules (10 or more) (b) Tachypnoea (60 breaths per minute or more) (c) Severe chest In-drawing

(d) Nasal flaring(e) Grunting(f) Bulging Fontanelle(g) Abnormal Axillary temperature (more than 37.5°C or less

than 35.5°C) (h) Large Boil on the skin(j) Lethargy or Unconsciousness(k) History of Convulsions(l) Less than normal MovementsIf any one of these criteria is present, the infant is classified as having possible serious bacterial infection. Infant is to be referred to hospital urgently for admission. The pre-referral treatment consists of administering first dose of antibiotics (intramuscular ampicillin 100 mg/Kg and gentamicin 5mg/Kg) ; giving expressed breast milk (or appropriate animal milk orally or by nasogastric tube) to prevent hypoglycemia and providing warmth by skin to skin contact (kangaroo care) to avoid hypothermia.

2. Local Infection : The infant has local bacterial infection if there is redness of umbilicus, pus discharge from ear or less than 10 skin pustules. All such cases are given oral antibiotic - (cotrimoxazole 6 mg/kg/day of trimethoprim or amoxicillin 30 mg/kg/day) for 5 days. The mother is taught to apply gentian violet and dry the ear by wicking. Ear is dried at least 3 times daily. Clean absorbent cloth or soft, strong tissue paper is rolled into a wick and placed in the young infant’s ear. It is removed when wet. Replace the wick with a clean one and repeat these steps until the ear is dry. To treat skin pustules or umbilical infection, gentian violet paint is applied twice daily. The mother should gently wash off pus and crusts with soap and water. Dry the area and paint with gentian violet 0.5%. To treat thrush (ulcers or white patches in mouth) the mother should wash hands and then wash mouth of the child with clean soft cloth wet with salt water wrapped around the finger. After cleaning, the mouth is painted with gentian violet 0.25%. The infant is followed up after 2 days.

3. Jaundice : (a) Jaundice in a neonate appearing at less than 24 hrs or after 14 days or associated with yellow discolouration of palms and soles is classified as severe jaundice. Infant requires urgent referral to the hospital after giving pre-referral treatment which includes oral expressed breast milk, skin to skin contact and advising mother to keep the infant warm en route to hospital.

(b) If the infant has jaundice but palms and soles are not yellow, mother is reassured and the infant is reviewed after 2 days. It is important to advice the mother to return immediately if the infant develops any signs of serious bacterial infection or jaundice on palms and soles.

4. Low Body Temperature : In every sick young infant, Axillary temperature should be recorded. If it is 35.5 - 36.4°C, the infant is said to have low body temperature. Such an infant is warmed by skin to skin contact for one hour and reassessed. If there is no improvement, he is referred to hospital, while feeding expressed breast milk to prevent hypoglycemia.

5. Diarrhoea : If the stools have changed from the usual pattern and have increased in number and watery (more water then fecal matter), infant is said to have Diarrhoea. The normally

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frequent or loose stools of a breast fed baby are not considered as Diarrhoea. Duration of Diarrhoea and history of blood in the stool are important questions in the history. Assess for presence and severity of dehydration.

Severe dehydration : If the young infant has two of the following three signs, the dehydration is severe :(a) Lethargic or unconscious(b) Sunken eyes(c) Skin pinch goes back very slowly (> 2 seconds) If such an infant has low weight or any other severe classification, he is referred urgently to hospital. The pre-referral treatment includes first dose of IM antibiotics (ampicillin and gentamicin), giving frequent sips of ORS on the way, continuing breast feeding and keeping the infant warm. If the infant does not have low weight or another severe classification, fluids are administered for severe dehydration as per plan C and he is then referred to hospital after rehydration. The ORS should be continued. If IV fluids cannot be given, fluids by nasogastric tube could be given. If none of this is feasible refer to a hospital.

Some dehydration : If the young infant has two of the following three signs he is classified to have some dehydration. Oral rehydration is the mainstay.(a) Restless, irritable(b) Sunken eyes(c) Skin pinch goes back slowly.If the infant has low weight or another severe classification, first dose of IM antibiotics (ampicillin and gentamicin) are given and urgent referral to hospital is done, with mother giving frequent sips of ORS on the way, continuing breast feeding and keeping the infant warm. If the infant does not have low weight or another severe classification; fluids are administered for some dehydration as per plan B. The mother is told to give more if child asks. If the child vomits wait for 10 minutes and then resume. Reassess after 4 hours and re-classify. Breast feeding should be continued. The mother is counselled to return immediately if not improving, not accepting fluids and has blood in stools. Follow up visit in 2 days is recommended or earlier if danger signs develop.

No dehydration : If there are not enough signs to classify as some or severe dehydration, the infant has no dehydration and is given fluids to treat Diarrhoea at home as per plan A. The follow up is done in 5 days and mother is also advised when to return immediately.

Severe persistent diarrhoea : Severe persistent Diarrhoea is Diarrhoea lasting 14 days or more and the infant with this classification is referred to hospital. Give inj Ampicillin or gentamicin if the child has low weight, Diarrhoea or any other severe classification, keep the child warm and treat to prevent hypoglycemia as part of pre-referral treatment.

Severe Dysentery : If there is blood in the stool, the young infant has severe dysentery and is similarly referred to hospital. Administer same pre-referral treatment as above before sending to hospital in the presence of any criteria of severe classification.

6. Feeding Problems and Malnutrition

(a) Weight : The present weight and birth weight should be noted. Using the reference growth charts, the infant is classified as very low weight for age, low weight for age or not low weight for age.

(b) Feeding : Feeding should be assessed immediately if the infant feeds less than 8 times in 24 hours, receives no other foods or drinks, or is low weight for age and has no indications to refer urgently to hospital. The infant should be put to the breast and observed for attachment and effective suckling. Blocked nose, oral thrush and breast or nipple problems (flat or inverted nipples, sore nipples, engorged breasts or breast abscess) should be looked for. If the young infant is not able to feed, has no attachment at all, is not sucking at all or is very low weight for age, he has a life threatening problem and needs urgent admission to hospital after administering pre-referral treatment. If there are other feeding problems or the infant is low weight for age, counselling of the mother is done about correct position during breast feeding, increasing frequency of feeds, treatment of breast and nipple problems and treatment of thrush. The infant is followed up after 2 days for feeding problem and after 14 days for low weight for age.

7. Checking the Young Infant’s Immunization Status : Check whether OPV, BCG, DPT-1 and Hep B-1 vaccines have been administered in every sick young infant. An infant who is not sick enough to be referred to hospital should be given the necessary immunization before being sent home.

2 Months to 5 YearsA sick child aged 2 months to 5 years may present to the primary health care facility with common ailments like pneumonia, Diarrhoea, fever or an ear infection. The child in addition may also have malnutrition and anaemia. Irrespective of the presenting complaints the child is assessed in a comprehensive manner as under-Steps of Initial Assessment(a) Ask the mother about the child’s problem.(b) Check for general danger signs.(c) Ask the mother about the four main symptoms: (CDEF) (i) Cough or difficult breathing (ii) Diarrhoea (iii) Ear problem (iv) Fever.(d) If one of the four above mentioned symptoms is present: (i) Assess the child further for signs related to the main

symptom (ii) Classify the illness according to the signs which are

present or absent.(e) Check for signs of malnutrition and anaemia(f) Check the child’s immunization status(g) Assessing for any other problems.Look for General Danger Signs : A sick child brought to the primary health care facility may have signs that point towards a specific problem. However, some children may present with serious, non-specific signs called “General Danger Signs” that may not point to a particular diagnosis. For example, a child who is having convulsions or is unconscious may be suffering from any of the diseases like meningitis, epilepsy or cerebral

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malaria. It may be simply febrile convulsions. Presence of these general danger signs suggest that a child is severely ill and needs urgent attention. The following general danger signs are routinely checked in all children : (V ICU) (a) Repeated Vomiting(b) Inability to drink or breast feed(c) Convulsions(d) Lethargy or UnconsciousnessIf a child has any one or more of these signs, he is considered seriously ill and should be referred. In order to start treatment for severe illnesses without delay, the child should be quickly assessed for the most important causes of serious illness and death - acute respiratory infection (ARI), Diarrhoea, and fever (especially associated with malaria and measles). A rapid assessment of nutritional status is also essential.

Check for Four Major Symptoms (Remember CDEF) : After checking for general danger signs, the health care provider must check for the following main symptoms:(a) Cough or difficult breathing(b) Diarrhoea(c) Ear problems(d) FeverDiagnosis & Management

(A) Cough or Difficult Breathing : Any child with cough or difficult breathing is assessed by respiratory rate, chest in-drawing and presence of stridor.(a) Respiratory rate: A child’s age cut-off rate for fast breathing

that suggests pneumonia is:(i) 2 months up to 12 months: 50 breaths per minute or

more(ii) >12 months up to 5 years : 40 breaths per minute or

more(b) Lower chest wall in-drawing(c) StridorBased on the above clinical signs, children presenting with cough or difficult breathing are classified in to one of the three categories:(a) Severe pneumonia or very severe disease(b) Pneumonia(c) No pneumonia (i.e. cough or cold). Severe Pneumonia / Very severe disease : The child is classified as severe pneumonia /very severe disease if any general danger sign or chest in-drawing or stridor in an otherwise calm child is present. This child needs urgent attention and should be referred to a hospital by quickest means available, after administering the first dose of injectable antibiotic (IM Chloramphenicol 40mg/kg/dose) or if not possible, give oral amoxicillin 15mg/kg/dose.

Pneumonia : If only fast breathing is present without any stridor or chest in-drawing and there are no general danger signs, the child is classified as having pneumonia and is managed by oral antibiotics, cotrimoxazole (trimethoprim 8 mg/kg/day) for 5 days. Additional symptomatic treatment to soothe the throat and a safe cough remedy for children older than 6 months may be given. The mother is advised to return for follow up after 2 days. However if danger signs develop or the child becomes sicker, the mother should be asked to return

immediately.

No Pneumonia - Cough or Cold : If there are no signs of pneumonia, the classification is no pneumonia. The child is suffering from minor bout of cough or cold which can be managed symptomatically at home and does not warrant antibiotics. Such a child is followed up after 5 days if not improving, or immediately if any of the danger signs develop or the child deteriorates.

(B) Diarrhoea : A child presenting with Diarrhoea should first be assessed for general danger signs and the child’s caretaker should also be asked if the child has cough or difficult breathing.

A child with Diarrhoea may have three potentially lethal conditions:(a) Acute watery Diarrhoea (including cholera) (b) Dysentery (bloody Diarrhoea) (c) Persistent Diarrhoea (Diarrhoea that lasts 14 days or

more). All children with Diarrhoea should be checked to determine the duration of Diarrhoea, if blood is present in the stool and if dehydration is present.

Check Dehydration : Based on a combination of the following clinical signs, children presenting with Diarrhoea are classified into the three categories of severe dehydration, some dehydration and no dehydration and appropriate treatment is to be given. Main clinical signs are used to determine the level of dehydration

Severe Dehydration (Plan C) : Presence of at least two of the following signs classifies the child as having severe dehydration.(a) Lethargic or unconscious(b) Sunken eyes(c) Not able to drink or drinking poorly(d) Skin pinch goes back very slowlyChild should be managed in the primary health care facility with fluids. Re-assess every 1-2 hours and if required, fluid can be repeated once. The ORS should be continued. If IV fluids cannot be given, fluids by nasogastric tube could be given. If none of this is feasible refer to a hospital. However if the child has any other severe classification, he should be urgently referred to hospital. Oral doxycycline (5 mg/kg/day) should be administered if cholera is prevalent in the area.

Some dehydration : Look for the signs of dehydration-

If two or more of the signs are present the, classification is some dehydration. The child should be treated as per Plan B.

Such a child is followed up after 5 days if not improving. Mother is counselled to return immediately if child has any of the following signs:1. Not able to drink or breast feed2. Becomes sicker3. Develops fever4. Passes blood in stoolNo dehydration : The child is classified as if there are not enough signs to classify into some or severe dehydration. Treatment is given at home with fluids and feeds as per Plan A. The mother is advised to return after 5 days or immediately

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if above danger signs develop like not able to drink or breast feed, becomes sicker, develops fever or passes blood in stool.

Dysentery : A child is classified as having dysentery if the mother or caretaker reports blood in the child’s stool. This should be treated with oral cotrimoxazole (8mg/kg/day of trimethoprim in 2 divided doses) for 5 days. The child is followed up after 2 days.

Persistent Diarrhoea : All children with Diarrhoea lasting for 14 days or more are said to have persistent Diarrhoea. If dehydration is present, the child is classified as severe persistent Diarrhoea and should immediately be sent to hospital. If dehydration is not present, the child is given a single dose of vitamin A and oral zinc sulphate 20 mg daily for 14 days and the mother or caretaker is given counselling on feeding of the child. If still breast feeding, give more frequent, longer breast feeds, day and night. If taking other milk replace with increased breast feeding OR replace with fermented milk products, such as yoghurt OR replace half the milk with nutrient-rich semisolid food. Add cereals to milk (Rice, Wheat, Semolina). The child is followed up after 5 days.

(C) Fever : Children are considered to have fever if the body temperature is above 37.5°C axillary (38°C rectal). In the absence of a thermometer, children are considered to have fever if they feel hot or there is a history of fever. Body temperature should be checked in all sick children brought to an outpatient clinic. A child presenting with fever should be assessed for common serious causes like malaria, meningitis and measles. The following information is important:(a) Risk of malaria based on the geographic area endemic for

it(b) Presence of bulging fontanelle or stiff neck suggesting very

severe febrile illness such as meningitis(c) Presence of running nose, conjunctival congestion or

generalized rash suggestive of measlesSerious Febrile Illness : A child with fever is classified as having serious febrile illness if there is any general danger sign or stiff neck or bulging fontanel. He requires urgent referral to hospital. Pre- referral required to be given to the child is a dose of IM quinine (10 mg/kg/dose) after making a blood smear; first dose of IV or IM chloramphenicol (40 mg/kg/dose or if not possible oral amoxicillin 15 mg/kg/dose), feeding to prevent hypoglycemia and one dose of paracetamol (15 mg/kg) for high fever (temp. 38.5°C or above).

High Malaria Risk area : Children with fever but without any danger sign or stiff neck or bulging fontanel are classified as Malaria and should be treated with antimalarials after making a blood smear. The antimalarials given are as follows:

Presumptive treatment -(i) Oral chloroquine 10 mg/kg single dose on Day 1, 10 mg/kg

single dose on Day 2 and 5 mg/kg single dose on Day 3.(ii) In areas of high chloroquine resistance, give oral

sulphadoxine (25 mg/kg) plus pyrimethamine (1.25 mg/kg) single dose.

Radical treatment : if P. vivax is positive on blood smear - Oral primaquine 0.25 mg/kg daily for 5 days.

Low Malaria Risk Area : Children with fever but without any danger sign / stiff neck / bulging fontanella are classified as

Malaria there are no symptoms of runny nose, measles or any other cause of fever. The antimalarials given after making a blood smear are as follows:

Presumptive treatment(i) Oral chloroquine 10 mg/kg single dose on Day 1(ii) In areas of high chloroquine resistance, give oral

sulphadoxine (25 mg/kg) plus pyrimethamine (1.25 mg/kg)

Radical treatment in Smear positive Pf case(i) Oral chloroquine 10 mg/kg single dose(ii) Oral primaquin 0.75 mg/kg single doseRadical treatment in Smear positive Pv case(i) Oral chloroquin 10 mg/kg single dose(ii) Oral primaquin 0.25 mg/kg daily for 5 daysIn a child being treated for malaria, the mother should be advised to return immediately if the child becomes sicker or is unable to drink or breast feed. The child should be followed up after 2 days if fever persists or recurs within 14 days. If fever persists every day for 7 days the child should be referred for assessment.

Measles : A child with fever is assessed for signs of measles such as generalized rash with cough, runny nose and red eyes.

If the child has measles or has had measles within the ●last 3 months, and there is any general danger sign or clouding of cornea or deep / extensive mouth ulcers, the classification is Severe complicated measles. This child should be urgently referred to hospital after giving first dose of oral vitamin A, chloramphenicol IM and tetracycline eye ointment application.If the child has measles now or has had measles within the ●last 3 months, and there is pus draining from eye or mouth ulcers are present, he is classified to have measles with eye or mouth complications, and given first dose of vitamin A, tetracycline eye ointment and gentian violet for mouth ulcers. Follow up is done after 2 days.If the child has measles now or has had measles within the ●last 3 months, with none of the above signs, only first dose of vitamin A is given.

(D) Ear Infections : Any sick child should be assessed for ear problems such as ear pain or ear discharge. If there is a tender swelling behind the ear, the child has mastoiditis. He should be given first dose of IM chloramphenicol and urgently referred to hospital. If there is pus discharge or ear pain, the classification is acute ear infection and oral antibiotic (cotrimoxazole) should be given for 5 days. Dry the ear at least 3 times daily. Roll clean absorbent cloth or soft, strong tissue paper into a wick. Place the wick in the young infant’s ear. Remove the wick when wet. Replace the wick with a clean one and repeat these steps until the ear is dry.

(E) Malnutrition : Every sick child should be weighed and assessed for visible severe wasting and oedema of both feet.

If there is visible severe wasting or oedema, the child is ●said to have severe malnutrition and given a single dose of vitamin A, kept warm and urgently referred to hospital.If the child has very low weight (malnutrition grade II, ●III or IV), the mother is counselled for feeding. The child

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is followed up in 5 days if there is a feeding problem or otherwise after 30 days.

(F) Anaemia : Palmar pallor is looked for in every sick child presenting to primary health care.

If there is severe palmar pallor, the child has severe ●anaemia and should be urgently referred to hospital.If some palmar pallor is present, the child has anaemia ●and should be given iron and folic acid therapy in a single dose daily for 14 days (elemental iron 3-6 mg/kg/day and folic acid 100-200 mcg/day). All other sick children older than 6 months should be given ●prophylactic iron and folic acid (20 mg elemental iron + 100 mcg folic acid) for a total of 100 days in a year after the child has recovered from the acute illness.

Immunization

Immunization status of every sick child should be checked. Those being referred to hospital should not be immunized. All other children should be immunized as per schedule on the same day.Assess Other Problems

Although the IMNCI guidelines focus on the main symptoms as enumerated above, every sick child should be assessed for other complaints, which can lead to severe or acute illness. In addition, the health of the caretaker should be also be addressed. Case recording form for management of the sick child age 2 months up to 5 years is given on subsequent pages.Counselling of the Mother(a) Advise mother on home care for infant-The mother should

be counselled on breast feeding the child and keeping the baby warm.

(b) Advise mother when to return- To return immediately if the infant is

(i) Breast feeding or drinking poorly(ii) Becomes sicker(iii) Develops a fever or feels cold to touch(iv) Fast breathing(v) Difficult breathing(vi) Yellow palms and soles ( if infant has jaundice) (vii) Diarrhoea with blood in stool

(c) Counsell the Mother about her own healthIf the mother is sick, provide care for her, or refer her for ●help.If she has a breast problem (such as engorgement, sore ●nipples, breast infection), provide care for her or refer her for help.Advise her to eat well to keep up her own strength and ●health.Give iron folic acid tablets for a total of 100 days. ●Make sure she has access to: ●

- Family planning, Counselling on STD and AIDS prevention

SummaryWHO developed an approach called IMCI (Integrated Management of Childhood Illnesses) which encompasses a range of interventions to combat 5 major childhood illnesses i.e.

Acute Respiratory Infections, Diarrhoea, Measles, Malaria and Malnutrition. The Adaptation group developed Indian version of IMCI guidelines and renamed it as Integrated Management of Neonatal and Childhood Illnesses (IMNCI).

IMNCI approach has some distinct features i.e. It is based on syndromic and holistic approach, involves Triage and it works on Standardized case management and Primary health care model with community participation. The major components are strengthening the health care infrastructure, strengthening the skills of health care workers and community participation in which mother is actively involved. The basic steps in management are assess, classify, treat and follow up care of the child and counselling of the mother. The IMNCI guidelines recommend case management procedures separately for age up to 2 months and 2 months to 5 years.

For young infants aged up to 2 months the assessment and classification process is different from older infants and children. Assessment in young infants includes Serious bacterial infections or local infections, Jaundice, Diarrhoea, Low body temperature, Feeding problems or malnutrition and Immunization status. In case any sign of severe bacterial infection is present the child is given first dose of parenteral antibiotic and referred to hospital. If local infection present the infant is given oral antibiotics and advised home care. Jaundice in a neonate appearing in less than 24 hours or after 14 days or associated with yellow discolouration of palms and soles is classified as severe jaundice and urgent referral after initial treatment is done. Every sick young infant should be examined for low body temperature and managed accordingly. If Diarrhoea is present then assessment of dehydration should be done. If dehydration is present with low weight or any other severe classification, child is referred after giving first dose of IM antibiotics and frequent sips of ORS. If dehydration is present without low weight or any other severe classification, child is treated based on severity of dehydration. if Diarrhoea is present without signs of dehydration then child is treated at home with oral fluids. Weight and feeding of infant should also be assessed. Immunization status should also be checked and if feasible immunization should be carried out before discharging to home.

A sick child aged 2 months to 5 years may present with common ailments like Pneumonia, Diarrhoea, Fever, Ear infection, Malnutrition and Anaemia. Firstly the general danger signs should be looked for i.e. Lethargy or unconsciousness, Convulsions, Repeated vomiting and Inability to drink or breast feed. If a child has any one of these signs he is considered seriously ill and immediately referred. After examining for danger signs four major symptoms are looked for. These are Cough or difficult breathing, Diarrhoea, Fever and Ear problems. Any child with cough or difficult breathing is assessed by Respiratory rate, Chest-indrawing and Presence of stridor. Based on these signs children are classified into Severe pneumonia, Pneumonia and No pneumonia and treated accordingly. A child with severe pneumonia is referred to a hospital by quickest means after administering first dose of injectable antibiotics. A child classified as having pneumonia is treated with oral antibiotics at home for 5 days after giving necessary instructions to mother. A child with no pneumonia is treated

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without antibiotics at home. A child presenting with Diarrhoea should be first assessed for danger signs and then assessed for dehydration. Based on dehydration status child is classified into Diarrhoea with severe dehydration, some dehydration or no dehydration. A child with severe dehydration is treated with intravenous fluids and reassessed every 1-2 hours. If signs of severe classification are present child is immediately referred to hospital. If a child has some dehydration treat with ORS and reassess after 4 hours. If a child has no dehydration treat at home with oral fluids. A sick child should be checked for fever and if present should be assessed for common serious causes like Malaria, Meningitis and Measles. A child with fever is classified as having serious febrile illness if there is any danger sign or stiff neck or bulging fontanellae and requires parenteral antibiotics and quinine and urgent referral to hospital. If a child is classified as having Malaria than appropriate treatment is given. A child with fever is also assessed for signs of Measles. Any sick child should also be assessed for Ear infections, Malnutrition and Anaemia. Immunization status of every sick child should be checked. Mother should also be counselled for child care and her own health.

Study ExercisesLong Question : Describe in detail the IMNCI guidelines for management of Neonatal and Childhood illnesses.

Short Notes: (1) Components of IMNCI (2) IMNCI guidelines for Management of Pneumonia (3) IMNCI guidelines for Management of Diarrhoea (4) General danger signs in a sick child

MCQs1. General danger signs in a sick child include all except:

(a) Convulsions (b) Unconsciousness (c) Inability to Breast feed (d) Vomiting

2. Which of the following is not true of dehydration: (a) Mild to moderate dehydration can be corrected at home by ORS (b) ORS Solution should be made fresh daily (c) Breast feeding should be delayed till dehydration is corrected (d) Patient should be given as much ORS as he wants

3. Young infants in IMNCI guidelines are up to the age of: (a) 6 months (b) 1 year (c) 2 months (d) 3 months

4. For young infants assessment is basically done for all except: (a) Jaundice (b) Hypothermia (c) Diarrhoea (d) Measles

5. IMNCI recommendations are up to the age of: (a) 10 years (b) 8 years (c) 7 years (d) 5 years

6. Severe Jaundice in a neonate are all except: (a) Less than 24 hours (b) More than 7 days (c) More than 14 days (d) Yellow discolouration of palms and soles

7. In a 6 month old child breathing rate ___________ or more suggests pneumonia: (a) 40 per minute (b) 50 per minute (c) 60 per minute (d) 70 per minute

8. Signs for classifying a child as having severe dehydration are all except: (a) Dry tongue (b) Sunken eyes (c) Not able to drink (d) Lethargic or unconscious

9. A case of Simple Pneumonia is treated with: (a) Parenteral antibiotics (b) Oral antibiotics (c) Referred to hospital (d) Parenteral antibiotics and Referral

10. IMCI approach developed by WHO encompasses following childhood illnesses except: (a) Measles (b) Malaria (c) Diarrhoea (d) Chickenpox

Answers : (1) d; (2) c; (3) c; (4) d; (5) d; (6) b; (7) b; (8) a; (9) b; (10) d

ReferencesConcept and strategy Framework- Integrated Management of Neonatal and 1. Child Illnesses (IMNCI) - Government of India, State Governments, UNICEF and WHO) - February, 2004.WHO and UNICEF, 2003. Integrated management of neonatal and childhood 2. illness. Assess and classify the sick young infant age up to 2 months. Ministry of health and Family Welfare, Government of India, New-Delhi, 2003

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Case recording form (Up to 2 Months) Side - 1

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Case recording form (Up to 2 Months) Side - 2

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Case recording form (2 months to 5 years) Side - 1

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Case recording form (2 months to 5 years) Side - 2

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Plan A : Treat Diarrhoea at Home

Counsel themother on the three rules of home treatment: Give extra fluids, continue feeding, return if childworsens

If exclusively breast fed, breast feed frequently and for longer at each feed. If passing frequentwatery stools: For less than6 months age, give ORS and clean water in addition to breast milk. If 6 months or older, give one or more of the homefluids in addition to breastmilk.If the child is not exclusively breast fed: give one or more of the following home fluids: ORS solution, yoghurt drink, milk,lemondrink, rice or pulse based drink, vegetable soup, green coconutwater or plain cleanwater.

The child has been treatedwith plan B or Plan Cduring the visitThe child cannot return to a clinic if the diarrhea getsworse

Up to 2 years: 50 to 100ml after each loose stool2 years ormore: 100 to 200ml after each loose stool

Give frequent small sips froma cupIf the child vomits,wait for 10minutes. Then continue, butmore slowly.Continue giving extra fluids until the diarrhea stops

Give extra fluids ( asmuch as the childwill take)Tell themother :

It is especially important to giveORS at homewhen :

Teach themother how tomix andgiveORS.Give themother 2 packets ofORS to use at home.Show themother howmuch fluid to give in addition to the usual fluid intake:

Tell themother to :

Plan B : Treat Some Dehydration with ORS

Give recommendedamount ofORSover a 4 hour period

Show themother how togiveORS:

After 4 hours

If themothermust leave before completing the treatment

Explain the 3 rules of home treatment:

Determine the amount of ORS to give during next 4 hours as follows:

The approximate amount of ORS required (in ml) can also be calculated by multiplying the child’s weight (in kg) times 75

If a child wants more ORS than shown, give more.

For infants who are not breast fed, also give 100-200 ml clean water during this period

Give frequent small sips from a cup

If the child vomits, wait for 10 minutes. Then continue, but more slowly

Continue breast feeding whenever the child wants

Reassess the child and classify for dehydration

Select the appropriate plan and continue treatment

Begin feeding the child in the clinic

Show her how to prepare ORS solution at home

Show her how much ORS to give to finish 4 hour treatment at home

Give her enough ORS packets to complete rehydration. Also give her two packets as recommended in plan A.

Give extra fluids

Continue feeding

Return if child worsens, does not pass urine or refuses to drink

Age Up to 4months 4months to 12months 12months up to 2years 2 years up top5 yearsWeightInml

< 6kg 6<10 kg 10 - <12 kg 12-19 kg

200-400 400-700 700-900 900-1400

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Plan C : Treatment of Severe Dehydration

If you can give IV fluid immediately

If you cannot give IV fluids immediately and IV treatment is available nearby (within 30 min)

If IV treatment is not available immediately and you are trained to use nasogastric tube for rehydration

If IV treatment is not available immediately ( within 30 min), you are not trained to use nasogastric tube and the childcannot drink

If the child can drink, give ORS by mouth while drip is set up.

Give 100 ml/kg Ringers lactate solution or Normal saline as follows

Reassess child every 1-2 hours. If hydration status is not improving, give the IV fluid more rapidly.

Also give ORS (about 5 ml/kg/hour) as soon as the child can drink, usually after 3-4 hours(infants) or 1-2 hours(children)

Reassess an infant after 6 hours and a child after 3 hours. Classify dehydration. Then choose the appropriateplan(A,B, or C) to continue

Refer urgently to hospital for IV treatment

If the child can drink, provide the mother with ORS solution and show her how to give frequent sips during the trip \

Start rehydration by tube (or mouth) with ORS solution: 20 ml/kg/hour for 6 hours (total of 120 ml/kg)

Reassess the child every 1-2 hours

- If there is repeated vomiting or increasing abdominal distension, give the fluid more slowly

- If the hydration status is not improving after 3 hours, send the child for IV therapy

After 6 hours, reassess the child. Classify dehydration. Then choose the appropriate plan (A, B, C) to continue treatment.

Refer urgently to hospital for IV or Nasogastric tube treatment

Age First give 30 ml/kg in : Then give 70 ml/kg in:Infants( up to 12 months) 1 hour ( repeat once if radial pulse is still very weak or not detectable) 5 hours

Children (12 months – 5 years) 30 minutes( repeat once if radial pulse is still very weak or not detectable) 2 ½ hours

Feeding recommendations during sickness and health

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145 Care of Under Five Children

A S Kushwaha

Global ScenarioIn 2006, for the first time since mortality data have been gathered, annual deaths among children under five dipped below 10 million to 9.7 million. This represents a 60 per cent drop in the rate of child mortality since 1960. Most deaths among children under five years are still attributable to just a handful of conditions and are avoidable through existing interventions (Fig. - 1). Six conditions account for 70% to over 90% of all these deaths. These are acute lower respiratory infections, mostly pneumonia (19%), diarrhoea (18%), malaria (8%), measles (4%), HIV/AIDS (3%), and neonatal conditions, mainly preterm birth, birth asphyxia, and infections (37%).

India

Table - 1 : Child Health - India

1 IMR 57 / 1000 live births

2 Under Five Mortality 74 / 1000 live births

3 Children <3 yrs who are underweight 42.5 %

4 Breast feeding initiation in 1 hour 24.5 %

5 ORS given to children with diarrhoea 26 %

6 Children (12-23 months) with completed immunization

43.5%

7 % of newborn babies LBW 30 %

DefinitionsChild Death rate (1-4 Year Mortality Rate) : Child death rate is the number of deaths of children aged 1 to 4 years per 1000 children in the same age group in a given year. It therefore excludes infant mortality. This is a more refined indicator of the social situation in a country than infant mortality rate. It reflects the adverse environmental health hazards faced by the children including factors like malnutrition, poor hygiene and sanitation, infections and accidents caused due to social, economic, cultural characteristics of the community. This measure of child health excludes the perinatal and endogenous factors operating in the infancy. The second year of life is the one which poses greatest risk to life and accounts for nearly half of all deaths in the 1-4 years age children. The infectious diseases like measles, diphtheria, ARI, diarrhoea affect this age most. The 1-4 years child mortality rate in developed countries is negligible and quite high in the developing and underdeveloped nations. The countries also show a great interstate variation. The developed countries have home accidents as the leading cause in developed countries while infections predominate in the developing nations.

Under Five Mortality Rate (U5MR) (Child Mortality Rate): This is defined as the number of deaths in children under five

years of age expressed as rate per 1000 live births. This rate measures the probability of dying between birth and exactly five years of age. This indicator is considered as the single best indicator of social development and well being. The global figure stands at 72 while India has a rate of under five mortality at 74 per 1000 live births. There has been a declining trend in under five mortality but still continues to be very high in African countries especially Sub-Saharan countries. Child mortality is a sensitive indicator of a country’s development and telling evidence of its priorities and values. It has several advantages as a barometer of child well-being in general and child health in particular. First, it measures an ‘outcome’ of the development process rather than an ‘input’, such as per capita calorie availability or the number of doctors per 1,000 population - all of which are means to an end. Second, the U5MR is known to be the result of a wide variety of inputs: the nutritional status and the health knowledge of mothers; the level of immunization and oral rehydration therapy; the availability of maternal and child health services (including prenatal care); income and food availability in the family; the availability of safe drinking water and basic sanitation; and the overall safety of the child’s environment, among other factors. Third, the U5MR is less susceptible to the fallacy of the average than, for example, per capita gross national income (GNI per capita). This is because the natural scale does not allow the children of the rich to be 1,000 times as likely to survive, even if the human made scale does permit them to have 1,000 times as much income. In other words, it is much more difficult for a wealthy minority to affect a nation’s U5MR, and it therefore presents a more accurate, if far from perfect, picture of the health status of the majority of children (and of society as a whole).

Child Survival Index : This indicator is calculated by subtracting the under five mortality rate from 1000 and dividing this figure by 10. The child survival is a measure of social development and the attention given to the care of under five children. The child survival index of developed countries is 99 and above approaching 100 and developing countries like India have a much lower survival index but it is improving steadily.

Evolution of Under Five Child Health Services1. Primary Health Care Model : During the 1970s, socioeconomic development and improved basic living conditions like clean water, sanitation and nutrition were seen as the keys to improving child health. Primary health care stood for universal access to care and coverage on the basis of need. Along with intersectoral action for health, community involvement and self-reliance, much of the primary health care strategy was designed with the health of children as the priority of priorities.

2. Vertical Programmes-Model : At the end of the 1970s, the economic recession did not allow for such a development of primary health care system. Child health and particularly child survival was such an obvious emergency that by the early 1980s, many countries shifted their focus from primary health care systems to vertical, “single-issue”, programmes that promised cheaper and faster results. Child health continued to constitute a ‘silent’ emergency, as close to 15 million children were still dying annually before their fifth birthday.

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In the late 1970s, two scientists, Julia Walsh and Kenneth Warren, published ‘Selective Primary Health Care : An interim strategy for disease control in developing countries’ - a milestone paper that proposed an alternative strategy for rapidly reducing infant and child mortality at a reasonable cost. After breaking down the relative role of each major cause of child mortality and listing the existing interventions proved to be effective in addressing them, they concluded that a small number of causes (diarrhoea, malaria, respiratory diseases and measles, among others) were responsible for the vast majority of under-five deaths and that these deaths could be easily prevented by immunization oral rehydration therapy, breast feeding and antimalarial drugs(1). The Child Survival Revolution of the 1980s, spearheaded by the United Nations Children’s Fund (UNICEF), and built around a package of interventions grouped under the acronym GOBI (growth monitoring, oral rehydration therapy for diarrhoea, breast feeding, and immunization) soon gained currency.

3. Preventive Model (EPI) : Expanded Programme on Immunization of the mid-1970s, and programmes for Control of Diarrhoeal Disease and Acute Respiratory Infections became the successful strategy in which at country level, these vertical programmes successfully tackled a number of priority diseases. The Expanded Programme on Immunization started in 1974 and widened the range of vaccines routinely provided, from smallpox, BCG and DTP to include polio and measles. It set out to increase coverage in line with the international commitment to achieve the universal child immunization goal of 80% coverage in every country.

4. Breast feeding initiatives (BFHI) : Baby-Friendly Hospital initiative to support promotion of breast feeding in maternities was launched in 1992. In 1990, less than one fifth of mothers gave exclusive breast feeding for four months; by 2002 that figure had doubled to 38%.5. Integrated and Syndromic Approach to a Sick Child (IMCI): A feverish and irritable child that has difficulty eating can be suffering from a single illness, such as dysentery, or from a combination of diseases, such as malaria and pneumonia. Single-issue programmes were not designed to provide guidance on how to deal with such situations. There was clearly a need for a more comprehensive view of the needs of the child, one that would correspond to problems as they were encountered in the field (4) and would offer a wider range of responses than the existing programmes. The response to this new situation was to package a set of simple, affordable and effective interventions for the combined management of the major childhood illnesses and malnutrition, under the label of “Integrated Management of Childhood Illness” (IMCI). Details are covered in chapter on IMNCI, the Indian adapted version of IMCI.

6. Child Health - An issue of Rights for the Children : The MDGs have made it binding on all countries to move forward on issues of child health focusing on survival, growth, development and protection. The children of the world are subjected to many violations of their rights like child labour, abuse and exploitation, neglect, early marriage and even sexual abuse and violence against them. The UNICEF with many NGOs are focusing on these issues.

Under Five’s ClinicHistoryDr. Morley while working in rural areas of Nigeria developed the concept of growth chart popularly known as ‘Road to Health’ chart (2-6). He highlighted the problem facing child health services throughout the developing world and especially malnutrition which was at the core of all other childhood problems. He emphasized the role of growth monitoring through under-fives ‘clinic to quickly identify and combat malnutrition. These two measures have subsequently been adopted by many developing countries. Careful emphasis was placed on the social, economic, cultural and ethical considerations which were ignored by most doctors but also nurses and other health workers. Morley emphasized low-cost health services, within the means of the people involved, and the need to make extensive use of auxiliaries and villagers themselves. The concept of ‘Well Baby clinics’ is being practised with emphasis on preventive services mainly immunization and promotive growth monitoring.

Under Fives - A special group1. They constitute about 15 % of the total population.2. They suffer high rates of mortality and morbidity.3. The effects of malnutrition and other diseases have a role

in later life.4. The majority of the deaths are preventable through

available interventions.5. This is a period of growth and development.6. Brain growth is completed during 1st five years.7. Most causes of morbidity are preventable by

immunization.8. Health of children under five years and family health are

inter-related.9. Likely to be neglected in the face of poverty and unregulated

fertility.Cause of Death in ChildrenThe various causes of death in children are shown in Fig. - 1.

1. Pneumonia : Pneumonia kills more children than any other disease (19%), more than AIDS, malaria and measles combined. It is a major cause of child deaths in every region. Undernourished children, particularly those who are not exclusively breastfed or have inadequate zinc intake, or those with compromised immune systems, run a higher risk of developing pneumonia. Child suffering from other illnesses, such as measles, or those living with HIV, is more likely to develop pneumonia. Environmental factors, such as living in crowded homes and being exposed to parental smoking or indoor air pollution, may also play a role in increasing children’s susceptibility to pneumonia and its consequences.

2. Diarrhoea : Diarrhoea is most common in children between 6 months and 2 years with highest incidence in the 6-11 months age when weaning occurs. The mortality is estimated at 4.9 children per 1000 per annum due to Diarrhoea in children under five in the developing regions. The ORS has reduced the burden of childhood mortality to a great extent.

3. Malaria : This is a major cause of death in Sub-Saharan Africa where it causes 25% of childhood mortality. It kills

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about 1 million children accounting for 80% of all deaths due to malaria. It also contributes indirectly to deaths from ARI, anaemia, diarrhoea and malnutrition.

4. Measles : In India, measles is a major cause of morbidity and a major contributor to child mortality. It affects children between 6 months and 3 years. It tends to be severe in malnourished children. It weakens children’s immunity to other life-threatening diseases and conditions, including pneumonia, diarrhoea and acute encephalitis, and remains one of the leading causes of vaccine preventable deaths among children.

5. HIV/AIDS : This is an emerging cause of childhood deaths especially in Sub-Saharan Africa. This accounts for 3% of all under five deaths.

Fig. - 1 : Causes of death in Under Five Children

GoalThe overall goal of the Under-Fives Clinic is to provide comprehensive health care to young children in a separate specialized facility.

The under five clinic is represented by traditional logo of a triangle with four internal triangles and an outer enveloping triangle as shown in the Fig. - 2.

Objectives1. Care in illness2. Growth monitoring3. Preventive care4. Family Planning5. Health educationFeaturesUnder Five Clinics are specifically designed to serve children under the age of five in developing nations. It is important for the clinics to be as close to the residential areas as possible and for home visits to be a part of the services provided. Clinic visits also need to be kept as short as possible. The majority of the staff should be locally trained health care workers, nurses and auxiliary staff, who provide most of the care. The doctors on staff should be primarily responsible for training, diagnosis, and treatment of more complex conditions. When consultation with a senior staff person is necessary, the nurse

or auxiliary worker should be present and treated as an equal colleague. This procedure will encourage mothers to have more confidence in the skills of the locally trained worker. Mothers need education and support to institute practices that will minimize illness and promote health. Oral rehydration, breast feeding, and growth monitoring are all effective practices. Community health workers can also provide services, such as weighing, right in the residential areas. These workers should try to communicate with the key decision-makers in the child’s family - mother, father and grandparents, to inform them of the child’s nutritional needs.

Fig. - 2 : Under Five’s Clinic

Care in illness

Family Planning

Monitor Growth Preventive Care

Health Education

Functions(a) Care in Illness : This is the felt need of the mother and child for which any child is brought to the clinic. The usual illnesses encountered in children under five are fever, diarrhoea, ARI, infections of the skin and helminthiasis. The facility should provide for essential laboratory investigations and X-ray facilities. The Clinic should be backed by an effective referral mechanism.

(b) Growth Monitoring : This is one of the most important functions of the clinic. The child is weighed periodically - every month during the first year, every 2 monthly from 1 to 3 years of age and every 3 monthly in 4th and 5th years. Besides weighing, measuring height, mid arm circumference can also be carried out depending upon the availability of trained manpower and equipments. The growth is plotted on the growth chart and any faltering in the growth is detected and suitable action initiated. The milestones are also recorded and any delay in achieving milestone is evaluated.

(c) Preventive Care : This involves primarily the immunization services during the 1st five years of life and vitamin A supplementation (1 lac IU at 18 months, 2 lac IU at 6 month interval thereafter upto 3 years of age) and administration of Iron supplementation and antihelminthic treatment to prevent anaemia. The preventive care also provides for regular health

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check up, nutritional surveillance and use of ORS during Diarrhoea to prevent dehydration from developing.

(d) Family Planning : Family planning is central to any program directed towards women and children. The mothers are more receptive to family planning during early Puerperium and lactation. Mother is counselled on the various options available, their merits and de-merits so that she can make an informed choice.

(e) Health Education : The opportunity should be made use to educate the mother on issues of child care, breast feeding, nutrition, growth monitoring, immunization and hygiene of safe water and food preparation.

Child Health Programmes in IndiaIn 1951, India was the first country in the world to launch a family planning programme. Since then approaches aimed at reducing population growth have taken a variety of forms. Till 1977, the major health activity was family planning which was changed into Family welfare programme with Maternal and Child Health becoming an integral part of family planning programme with the vision that reduction in birth rate has a direct relationship with reduction in infant and child mortality.

(a) The Diarrhoeal Disease Control ProgrammeThis programme was started in the country in 1978. The main objective of the programme was to prevent death due to dehydration caused by diarrhoeal diseases among children under 5 years of age due to dehydration. Health education aimed at rapid recognition and appropriate management of Diarrhoea has been a major component of the CSSM. Under the RCH programme ORS is supplied in the kits to all sub-centres in the country every year.

(b) ICDS ( Integrated Child Development Scheme)The ICDS scheme was initiated by the then Ministry of Social and Women’s Welfare on 02 Oct 1975, in pursuance of the National Policy for children. The Ninth Five Year Plan aimed to universalise ICDS, i.e. cover the whole country.The beneficiaries of ICDS are -(i) Children below 6 years(ii) Pregnant and lactating women(iii) Women in the age group of 15-44 years(iv) Adolescent girls in selected blocksThe ICDS seeks to lay a solid foundation for the development of the nation’s human resource by providing an integrated package of early childhood services. These consist of

Supplementary nutrition ●Immunization ●Health check-up ●Medical referral services ●Nutrition and health education for women ●Non-formal education for children up to the age of 6 years ●Care of pregnant and nursing mothers ●

(c) Universal Immunization ProgrammeUIP against six preventable diseases, namely, diphtheria, pertussis, childhood tuberculosis, poliomyelitis, measles and neonatal tetanus was introduced in the country in a phased

manner in 1985, which covered the whole of India by 1990. Significant progress was made under the Programme in the initial period when more than 90% coverage for all the six antigens was achieved. The UIP was taken up in 1986 as National Technology Mission and became operational in all districts in the country during 1989-90. UIP became a part of the Child Survival and Safe Motherhood (CSSM) Programme in 1992 and Reproductive and Child Health (RCH) Programme in 1997. Under the Immunization Programme, infants are immunized against tuberculosis, diphtheria, pertussis, poliomyelitis, measles and tetanus. Universal immunisation against six Vaccine Preventable Diseases (VPD) by 2000 was one of the goals set in the National Health Policy (1983).

(d) The ARI Control ProgrammeARI control programme was started in India in 1990. It sought to introduce scientific protocols for case management of pneumonia with co-trimoxazole. A review of the health facility done in 1992 revealed that although 87% of personnel were trained and the drug supply was regular yet there were problems in correct case classification and treatment. Since 1992 the Programme was implemented as part of CSSM and later with RCH. Cotrimoxazole tablets are supplied as part of drug kit for use by different category of workers for managing cases of Pneumonia. Under RCH-II activities are proposed to be implemented in an integrated way with other child health interventions.

(e) The Child Survival and Safe Motherhood (CSSM) Programme This Programme jointly funded by World Bank and UNICEF, was started in 1992-93 for implementation up to 1997-98. The Child Survival and Safe Motherhood Programme was implemented in a phased manner covering all the districts of the country by the year 1996-97. The objectives of the programmes were to improve the health status of infants, child and maternal morbidity and mortality. The programme provided for augmenting various activities under the Oral Rehydration Therapy (ORT) Programme, universalising prophylaxis schemes for control of anaemia in pregnant women & control of blindness in children and initiating a programme for control of acute respiratory infection (ARI) in children. Under the safe motherhood component, training of traditional birth attendants (TBA), provision of aseptic delivery kits and strengthening of first referral units to deal with high risk and obstetric emergencies were taken up. Programme yielded notable success in improving the health status of pregnant women, infants and children & also making a dent in IMR, MMR and incidence of vaccine preventable diseases.

(f) Reproductive Child Health (RCH) ProgrammeGovernment of India during 1997-98 launched the RCH Programme for implementation during the 9th plan period by integrating Child Survival and Safe Motherhood (CSSM) Programme with other reproductive and child health (RCH) services. In addition, a new component for management of Reproductive Tract Infection (RTI) and Sexually Transmitted Infection (STI) has also been incorporated. The RCH Programme is partly funded by World Bank, UNICEF, UNFPA and European Commission. The program follows a differential strategy with

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inputs under the program linked to the needs of the area coupled with the capacity for implementation. The details on the RCH are covered under separate chapter on RCH.

(g) IMNCI (Integrated Management of Neonatal and Childhood Illnesses)This programme has been introduced on the principles of integrating all the services for management of sick children under 5 years of age. This is based on the fact that children have to be assessed as a whole for the entire important symptom complex and to be provided care and treatment involving the caregiver. Integration has different meanings at different levels. At the patient level it means case management. At the point of delivery it means that multiple interventions are provided through one delivery channel - for example where vaccination is used as an opportunity to provide vitamin A and insecticide-treated bednets during “EPI-plus” activities, boosting efficiency and coverage. At the system level integration means bringing together the management and support functions of different sub-programmes, and ensuring complementarity between different levels of care.

Childhood is the foundation of World’s future. There has been a definite progress in improving the child survival, development and protection. The World must make more sustained, collective and focused efforts to realize the dream of ‘World Fit for Children’ and fulfill the promise of safe and healthy childhood for every child. The Millennium Development Goals, ratified by all UN member states, provide the world’s governments with clear and tangible targets to combat poverty and raise the standard of living for the world’s people by 2015. Early Childhood Development contributes to the achievement of the goals. Seven of the eight goals directly relate to child survival, growth and development. Research has shown that the most effective interventions to improve human development and break the cycle of poverty occur most in children’s earliest years. Prevention is more cost-effective than treating a problem later. The important issues are ensuring positive gender socialization, supporting parents and families and developing standards and indicators for effective planning, monitoring and documentation of the progress in Early Childhood development.

SummaryChildhood is the foundation of world’s future. Only six conditions account for 70% to over 90% of the total deaths in under 5 age group. Child death rate excludes infant mortality rate and is a better indicator of social situation in a country than the IMR where as under 5 mortality rate is considered to be the single best indicator of social development and well being. It measures the outcome of the development process and is a result of various inputs. Child survival index is calculated by subtracting under 5 mortality rate from 1000 and dividing this figure by 10. Its a measure of the social development and the attention given to the care of under 5 children. Evolution of the under 5 child health services passes through various models like primary health care model, vertical programmes model,

preventive model, breast feeding initiative, IMCI. Under fives is a special group with pneumonia, diarrhoea, malaria, measles and HIV/AIDS being attributed as the major killers in this age group. For this reason the under five clinics were established in developing nations with five major objectives of care in illness, growth monitoring, preventive care, family planning, health education. In 1951 India was the first country in the world to launch a family planning programme and in 1977 it was changed to family welfare programme with maternal and child health becoming an integral part of it. Various child health programmes have been launched namely the diarrhoeal disease control programme (1978), ICDS (2 Oct 1975), Universal Immunization Programme (1985), the ARI control programme(1990), the child survival and safe motherhood programme (1992-93), Reproductive child health programme(1997-98), IMNCI which has been incorporated in RCH programme. Seven of the eight Millennium Development Goals directly relate to child survival, growth and development.

Study ExercicesLong Question : Discuss various child health programmes.

Short Notes : (1) Child death rate (2) Under 5 mortality rate (3) Child survival index (4) Under 5 clinics

Fill in the blanks1) Child death rate involves _________________ age group2) Child mortality rate involves _______________ age group3) CSSM was launched in year _________________4) Maximum number of children die because of ___________

among the five major causes of mortality in under 55) IMR in India is ____________ and Under 5 mortality in

India is ________________6) The single best indicator of social development of a country

is ________________Answers : (1) 1-4 yrs; (2) Less than equal to 5 yrs; (3) 1992; (4) Pneumonia; (5) 57/1000,74/1000 live births; (6) Under 5 mortality rate.

ReferencesWorld Health Report, 2005. Make every mother and Child Count, WHO1. Integrated Management of Pregnancy and Childbirth. Managing complications 2. in Pregnancy and Childbirth: A guide for midwives and doctors. Department of Reproductive Health and Research, Family and Community Health, WHO, Geneva, 2003The State of the World’s Children, 2005. Childhood Under Threat, UNICEF, 3. New YorkMorley D. A medical service for children under five years of age in West 4. Africa. Trans Roy Soc Trop Med Hyg. 1963;57:79-94.Morley D. The spread of comprehensive care through under-fives’ clinics. 5. Trans Roy Soc Trop Med Hyg. 1973;67(2):155-170.Morley DC. Paediatric priorities in developing world. London: Butterworths, 6. 1973.Sources : Committing to action: Achieving the MDGs, Background note by the 7. Secretary-General for the High-level Event on the Millennium Development Goals, United Nations, New York, 25 September 2008; The Millennium Devel opment Goals Report 2008, United Nations; The State of World’s Children 2008, UNICEF; MDG Monitor Website http://www.mdgmonitor.org/, UNDP; WHO re leases new guidance on insecticide-treated mosquito nets, WHO press release, on http://www.who.int/mediacentre/news/releases/2007/pr43/en/index.htmlUnited Nations Children’s Fund, Accelerated Child Survival and Development 8. in Ghana, UNICEF, March 2005, pp. 1-2.

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146 School Health Services

A S Kushwaha

School is a setting that plays an important role in the physical, emotional, social and mental development of children. Schools present an extraordinary opportunity to help millions of young people to acquire health supportive knowledge, values, attitudes and behavior. They can influence health behavior of other children, their families and community. School health services provide an opportunity to improve health of the students and promote healthful behavior through health education.

HistoryIn India, the history of school health service can be traced back to 1909, when medical examination of school children was started in Baroda. This important issue of social value has been raised repeatedly in various forums but continues to be a neglected aspect of Community Health service till date. Bhore committee in 1948 emphasized the need to put in place an organized system of school health service but this is still an unfulfilled dream. In 1953, Secondary Education Committee recommended medical examination and feeding of all school children to promote positive health early in the life as key to a healthy nation. The “National School Health Council” has been established since 1963 to plan and organize school children’s health care. Provisions have been made in the municipal, cantonment and state regulations for organization and maintenance of a school health service.

The concept of school health service has undergone change from mere health check up to become a comprehensive service with elements of preventive, promotive, curative and rehabilitative services.

Global School Health Initiative (GSHI)WHO’s Global School Health Initiative was launched in 1995. The initiative is designed to improve the health of students, school personnel, families and other members of the community through schools.

GoalThe goal of GSHI is to increase the number of schools that can truly be called “Health-Promoting Schools”.

Health Promoting SchoolWHO defines a health promoting school as one that is constantly strengthening its capacity as a healthy setting for living, learning and working.

Components of Comprehensive School Health Policy(a) School environment that is safe and promotes health(b) A sequential health education curriculum(c) A sequential physical education curriculum(d) Nutrition services programme(e) School Health Service programme(f) A counselling, psychological & social service programme(g) Integrated family and community involvement activities(h) Staff health promotion policy

School Health ServiceThe objectives of the school health care are as follows:(a) Help children in this critical period of their physical and

mental growth.(b) Maintaining working efficiency at a high level and

improving mental assimilating power by: (i) Ensuring congenial working conditions. (ii) Keeping them physically and mentally fit at all times. (iii) Improving the general nutrition of the children. (iv) Reducing absenteeism and thus increasing average

study hours/days. (v) Prevent spread of infections, reduce and detect minor

ailments. (vi) Imparting health education and physical training to

children. (vii) Providing special arrangement for the education of

handicapped children.Healthful School EnvironmentThe environment at the school has an important influence on the health of the school children. The following points should be kept in mind as regards school premises.1. School premises(a) The school should be located in areas free from crowded

surroundings, away from market, butcheries, factories, disposal grounds for waste matters, public sanitary areas or enclaves, and such other places which may create a health nuisance.

(b) There should be sufficient open space around the buildings.

(c) Enough playgrounds should be provided. Free muscular activity reduces mental boredom and strain and provides a stimulus for growth.

(d) There should not be any water collections for mosquito or fly breeding places around the school area.

(e) Traffic should be restricted to the minimum so as to avoid noise, smoke and dust nuisance and mainly accidents.

(f) Accidents should be prevented not only on roads around school but also on the playgrounds and in class rooms. First aid should be taught to all.

2. Seating Arrangement : These should be such as to allow adequate space, permitting freedom of movement for children on the bench so as to enable them to work without strain.

3. Drinking Water : It should be procured from an authorized clean source. Arrangements for central storage and safety must be provided. Ladles should be provided to take out water if taps are not possible.

4. Sanitary arrangements : A minimum of one urinal for 60 students and one latrine per 100 students should be provided. These should be maintained regularly and kept clean at all times. Adequate water supply should be arranged for sanitary block. Toilet facilities should be separate for boys and girls.

5. Nutrition services (Mid-day meal) : These should provide about one third of the total daily requirements of calories, proteins, vitamins ‘A’ and ‘B’ complex and calcium. They should provide about 20-30 g of fat, 20 g of protein of which one third should be of animal origin. Inclusion of milk in the

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meals will ensure this requirement. The school meals not only aim at supplementing the nutritional requirement but also at inculcating healthy food and eating habits.

6. Canteen Facility : All schools have some facilities which provide eatables. This canteen must observe cleanliness and hygiene of food preparation. Selling of junk food items at canteen must be prohibited.

7. Vaccination : School settings provide suitable conditions for spread of communicable diseases droplet infections and gastrointestinal diseases. All diseases amenable to prevention by vaccination should be covered. Children should be immunized against typhoid group of fevers, diphtheria and tetanus as a routine. If and when facilities exist, immunization against poliomyelitis and tuberculosis by BCG should be carried out.

8. Health Check up : All children should be thoroughly examined at least once a year or three times during the curriculum in addition to the one carried out at the time of entry. Results are recorded in the health record card and parents should be advised regarding remedial action. There should be a permanent register and health cards with column for remarks against examination of each system. The card is meant to be transferred to the institution the child may go after leaving one institution. A monthly, quarterly and annual report must be sent to the coordinating authority and medical authorities. The special points, to look for during any check up, are given below:(a) Eyes for trachoma and vision (including tests for acuity of

vision).(b) Ears for perforated drums, otitis media & hearing acuity.(c) Teeth for caries, non-alignment, mottling, gingivitis and so

on.(d) Nose & throat for adenoids and enlarged/infected tonsils.(e) Chest for lungs, cardiac anomalies (congenital).(f) Abdomen for enlarged spleen, liver and any palpable lymph

nodes.(g) Genitalia for phimosis, undescended testis or patent

inguinal canal.(h) Lower limbs for skeletal & muscular defects/deformities.(i) Spine for any deformity.(j) Skin for ring worm, scabies & any de-pigmented patches.(k) Hair for pediculosis, dandruff.(l) Weight and height for age and sex and nutritional profile

(anthropometry).(m) Any abnormal curvatures/postures, delicate health,

nutrition etc.9. Sick Reporting Facility : This should be provided and children are encouraged to report sick whenever they feel unwell. It not only helps to reduce minor ailments from developing into major ailments or disabilities but also helps to detect any other major ailments or disabilities undetected in the incipient or early stages. A trained staff is designated to provide necessary assistance whenever required. Availability of commonly required medications must be ensured at all times.

10. Referral Facilities : Facilities for reference of children to a specialist for investigation of ailments and their treatment/ hospitalization should be ensured. There should be arrangements for emergency transport and referral in case of

an emergency. The telephone number of the clinic or hospital should be known to the staff.

11. Physical Training : It is a major item of a school curriculum and should be insisted upon. Physical Training Instructors (PTI) should be appointed. Besides this if possible yoga trained teacher may also be appointed.

12. Health Education : This should be part of the curriculum. It can be imparted either as an integrated part of curriculum or otherwise. Health education is also incidentally acquired by children through the experiences and observation of healthy school life as described above.

13. School Health Committee : All schools must have a school health committee. It should consist of the Headmaster or Principal as the Chairman and class teacher, health educator, school nurse, physical training instructor and the school medical officer as its members. They should meet once a month or at least once in a quarter. A few parents should also be invited to attend these health committee meetings.

Management of Children with “Scholastic backwardness”Once a child starts struggling with his studies, the school environment turns ‘hostile’ to him. He gets punished by the teachers and friends make fun of him. The young child is clueless as to why he cannot score like his classmates, in spite of effort. He reacts to all these the way children do - either, turn defiant and fight back, or swallow the insults and give up. A sensitive Teacher, sensitized to the various causes of poor school performance can turn out to be his saviour and guardian angel. She can identify the cause of this particular child’s failure and institute an appropriate remedial strategy. After ruling out visual impairment and hearing problems and mental and psychological deficiency, the child should be considered to be evaluated for learning disorders. It may first appear as behaviour problems : Attention deficit, Hyperactivity, naughtiness, defiance, aggression, addiction to TV or computer, forging progress reports, Tics, Obsessive disorders, Anxiety, Depression, School phobia etc. A Schematic algorithm for evaluation of a child with poor scholastic performance is given in Fig. - 1.

Notes :1. Many normal children display some of these symptoms.2. Not all LD children display all pointers.3. Severe problems need multidisciplinary assessment.4. LD - Learning Disorder; ADHD - Attention Deficit

Hyperactive Disorder.Educating ‘Special’ children Categories of Disabilities1. Physical Disability2. Mental Disability3. Developmental Disability4. Learning Disability5. Hearing Disability6. Visual Impairment7. Emotional DisabilityCommon disabilities1. ADD/ADHD

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2. Autism3. Cerebral Palsy4. Down Syndrome5. Multiple Sclerosis6. Muscular Dystrophy7. Seizure Disorders

Fig. - 1 : A Schematic algorithm for evaluation of a child with poor scholastic performance

Special Schools in India : Along with other parts of the world, India too, witnessed the emergence of special schools for people with disabilities. The first school for the deaf was set up in Bombay in 1883, and the first school for the blind at Amritsar in 1887. There was rapid expansion in the number of such institutions. Today, there are more than 3200 special schools throughout India. However, these special schools have certain disadvantages which became evident as the number of these schools increased. These institutions reached out to a very limited number of children, largely urban, and they were not cost effective. But most important of all, these special schools segregated CWSN from the mainstream, thus developing a specific disability culture.

Integrated EducationThe emergence of the concept of integrated education in India during the mid 1950s began by the Royal Commonwealth Society for the Blind, and the Christopher Blind Mission. The Ministry of Education, too, launched a comprehensive scholarship scheme in 1952, a rudimentary beginning of the integrated education initiative by the Government.

Integrated Education for Disabled Children (IEDC) : Consequent to the success of international experiments in

placing children with disabilities in regular schools, the Planning Commission, in 1971, included in its plan a programme for integrated education. The Government launched the IEDC scheme in December 1974.

The aim of IEDC is to :Provide educational opportunities to CWSN in regular ●schools.Facilitate their retention in the school system. ●Place children from special schools in common schools. ●

The scope of the scheme includes pre-school training, counselling for the parents, and special training in skills for all kinds of disabilities. The scheme provides facilities in the form of books, stationery, uniforms, and allowances for transport, reader, escort etc. Similar Scheme in US is known as 504 Plan, which is a legal document falling under the provisions of the Rehabilitation Act of 1973, designed to plan a program of instructional services to assist students with special needs who are in a regular education setting.

Project Integrated Education for the Disabled (PIED): Under PIED, there has been a significant increase in the number of not only mildly disabled, but also severely disabled children, with the number of orthopaedically handicapped children far outstripping other disabled children. All these perform at par with non - disabled children; in fact their retention rate is higher than that of non - disabled children and absenteeism is low. PIED has also had a positive impact on the attitudes of the teachers, the heads of schools, as well as parents and the community in general. Also, the interaction between the disabled and the non - disabled children is good.

DPEP estimates clearly showed that there were a large number of disabled children in the relevant age group. Gradually realization dawned that UPE could not be achieved unless children with special needs were also brought under the ambit of primary education. This led to more concrete planning and strategization of providing resource support and remedial assistance to children with special needs. As the programme progressed, many models of service delivery evolved with the sole aim of providing supportive learning environment to children with special needs. The thrust was on imparting quality education to all disabled children.

The steps needed for implementation of IED under SSA (Sarva Shiksha Abhiyan) are classified under three headings:1. Direct Services to Children.2. Support Services.3. Monitoring and Evaluation.This is an important aspect for assessing progress and providing improvement in the process.

SummarySchool plays an important role in the physical, emotional, social and mental development of children. The medical examination of school children was started in Baroda in 1909. The “National School Health Council” has been established since 1963 to plan and organize school children’s health care. WHO’s Global School Health Initiative (GSHI) was launched in 1995. The goal of GSHI is to increase the number of schools that can truly be called “Health-Promoting Schools”. The

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concept of school health service has undergone change from mere health check up to become a comprehensive service with elements of preventive, promotive, curative and rehabilitative services that must include elements of safety, health education, physical education, nutrition and counselling and social service programme. A healthful school environment should be provided with due consideration to premises, seating arrangement, drinking water, sanitary arrangement, mid day meal, canteen, vaccination, sick reporting with referral facilities, physical education and health education which are to be monitored and supervised by a school health committee. Management of the children with scholastic backwardness should be proper as per algorithm for the evaluation of a child with poor scholastic performance. The Planning Commission, in 1971, included in its plan a programme for integrated education of disabled children in regular schools. The Government launched the IEDC scheme in December 1974. The steps needed for implementation of IED under SSA (Sarva Shiksha Abhiyan) are classified under three headings namely direct services to children, support services, monitoring and evaluation. School health services can influence health behaviour of other children, their families and community.

Study ExercisesLong Question : School health services in India

Short Notes: (1) GSHI (2) Healthful school environment (3) Causes of poor scholastic performance in school children (4) IEDC

MCQs & Fill in the blanks1) National School Health Council was established in _____2) Global School Health Initiative was launched in ________3) The first school of deaf in India was setup in (a) Bombay

(b) Calcutta (c) Delhi (d) Bangalore4) The first school of blind in India was setup in (a) Bombay

(b) Calcutta (c) Delhi (d) none5) IEDC scheme was launched in India in the year ________6) The medical examination of school children was started in

__________ In the year __________Answers : (1) 1963; (2) 1995; (3) a; (4) d; (5) December 1974; (6) Baroda,1909.

ReferencesGovt of India (1946). Report of the health survey and development committee; 1. Govt of India press, Shimla.Govt of India (1961), Report of school health committee, part I, Central 2. Health Education Bureau, New DelhiCentral Health Education Bureau (1965), Report of seminar on school health 3. services, New DelhiIdem (1965), Report of workshop for the development of criteria for healthful 4. aspects of a school programme, New DelhiTurner, C.E. et al (1957). School health and health education, CV Mosby5.

147 Adolescent Health

A S Kushwaha

Adolescence is a critical period of life marked by biological, social and psychological changes for an individual. These are formative years for behaviour patterns and activities relevant to health. It is a period of major transition during which adolescents learn to become adults. They can benefit from guidance in respect of vital issues of human biology, health, disease and behavioural adaptation. Recent discoveries in biological, behavioural, clinical and epidemiological research have clarified the concepts of this transition. The lifestyle and behaviour developed during adolescence has an impact on the health not only during adolescence but even in later life. In fact, the bulk of morbidity and mortality in adulthood is due to the health related behaviours (smoking, alcohol, exercise and diet) developed during the adolescence. The major issues concerning adolescents are growth and development, STDs and RTIs, drug, alcohol and tobacco abuse, teenage pregnancy, abortion, RTAs, suicide, homicide and issues of behavioural problems. HIV is

the latest addition to the multiple dimensions of adolescent health with huge implications on their health. Unfortunately, the special needs of adolescents’ have not been addressed by the educational, health, and family welfare programs in India so far.

Definition of AdolescenceThe word ‘Adolescent’ has been derived from Latin word ‘Adolescere’ which means ‘to grow to maturity’. Adolescent is considered to be, no longer a child, and not yet an adult. The definitions vary as to the exact range of age for this period. Most cultures relate the beginning of adolescence to the onset of puberty, but differ on specifying the end of adolescence. Different cultures define the roles, responsibilities and prerogatives of adults differently and thus the above variation. Thus in certain societies, an individual may have attained biological maturity but may not have attained full adult status. The chronological definition of adolescence has been kept broad so that it can be used in a variety of socio-cultural and health settings. WHO defines Adolescence as 10-19 years old, ‘Youth’ as 15-24 years old and ‘Young People’ as 10-24 years old. The adolescence has been divided into two phases: ‘early’ (10-14 years) and ‘late’ (15-19 years).

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The need to focus on Adolescent Health is because(a) Adolescents face serious health challenges(b) Adolescent health and development affect economic

prosperity(c) Investing in youth helps to break cycle of poverty(d) Health is a key element of overall youth development(e) Young people have a right to healthAdolescents : A special group with special needsThe need to focus on adolescent health exists for a number of reasons. (See Box 1)

Box - 1 : Why Adolescents are a special group?

Because of their number: they constitute more than 22% of the population.

Adolescence is the period of rapid physical growth, sexual and psychological changes.

Habits and behaviour picked up during adolescence (risk taking behaviour, Substance abuse, eating habits, conflict resolution) have lifelong impact.

Adolescence is the last chance to correct the growth lag and malnutrition.

Many adolescent boys and girls are sexually active but lack information and skill for Self- protection.

They have simple but wide pervading crucial reproductive health needs - Menstrual hygiene, contraception (including emergency contraception) safety from STI and HIV.

Communication gap exists with parents and other adults.

Some Basic Physiological & Psychological Needs1. Growth and Development : The early part of adolescence is characterized by rapid physical growth, changes in psychological functions and organ systems of the body and completion of sexual development. During adolescence marked morphological changes occur and hypothalamic-pituitary-gonadal system becomes mature. The ovaries and testes produce enough steroid hormones which result in the growth of genital organs and appearance of secondary sex characters. The body composition changes and there is increased strength and efficiency of body energy production. In adolescence these variations are exceedingly large within the same individual and between different individuals. This aspect needs to be understood by the adolescents, their families, health professionals in particular and society in general. The puberty in females is earlier as compared to males. Many adolescent boys and girls are sexually active but lack information and skills for self-protection (low level of information on Family Planning, low contraception use). They have simple but wide ranging crucial reproductive health needs- menstrual hygiene, contraception (including emergency contraception) safety from STI and HIV.

2. Nutritional and Psychosocial Needs : The adolescents in developing countries may suffer from malnutrition and dietary imbalance while those in developed countries may have problems of obesity. Adolescents have greater nutritional requirements because of rapid growth and physical activity

level. During this period that adolescents gain up to 50% of their adult weight, more than 20% of their adult height and 50% of their adult skeletal mass. In under-nourished children rapid growth during adolescence may increase the severity of under-nutrition. Iron is deficient in almost all age groups. Naturally the shortfalls create more vulnerability for adolescent girls. The factors that may interfere with nutrition are inadequate food supplies in quantity and quality, psychological factors affecting appetite, food fads and cultural attitudes and infections and parasitosis.

Adolescence is a period of change and, consequently, one of stress, characterized by uncertainties in regard to identity and position in the peer group, in the family, in the society at large and in the context of one’s own responsibilities as an adult. The compulsions of parental approval often encounter the emerging aspirations for independence. Their behaviour is guided by an intense desire for independence and identity. In the process, adolescents undergo intense psychological stress and personality change.

3. Socio-Cultural Factors Affecting the Development : In most parts of the world, especially developing world, girls are deprived of nutrition, access to health care, and opportunities for education and employment. They are taken out of schools when they reach menarche. In most traditional societies, from the very beginning of life, girls are groomed to accommodate the male-dominated, patriarchal society. With the rising proportion of children attending school and ever increasing functions of education, opportunity to facilitate healthy development of adolescents has opened up in many developing countries. Increasing urbanization, globalization, cosmopolitan type of population, explosion of information technology, pervasive scientific attitude and changing social and cultural values in the evolving society affect the psychological development of an adolescent.

Health Problems of AdolescenceThough adolescence is a relatively healthy period in the life of an individual with lowest age specific mortality (NFHS-3); however, it has certain characteristics that put them at risk to health hazards specific to this age group. The health problems of the adolescents relate to a large extent to their growth and development, sexual maturation, psychological changes. These issues are not discussed with the parents and health professionals due to lack of privacy and confidentiality and thus remain either unresolved or attempts are made through peers and available media which may not always be helpful and appropriate. The adolescent, because of rapid biological-psychosocial changes, is prone to impulsivity, emotional and risk taking type of behaviour putting them at risk to problems like STDs/RTIs, accidents, drug and substance abuse and psychological and mental health disorders.

The health care system have provided for health of the children and adults but adolescents have been left out, without any specific health programmes directed towards them especially in developing nations where resources are scarce. However, of late this special group of population has been given some attention in the post HIV period as the adolescents constitute highly vulnerable group

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Behaviour Related Health Problems

Alcohol, Smoking and Drugs : The adolescents tend to experiment with alcohol, smoking and other drugs. The use of tobacco and alcohol is widespread in both developing and developed nations. 30-50% of high school students in USA consider use of marijuana as an accepted way of life. In Sweden, drug dependence reaches its peak in the age group 12-20 years. The factors responsible for smoking in young people are peer pressure, following example of sibling and parents and employment outside the home.

Dietary Habits : Inappropriate dietary habits in adolescence are also commonplace. They tend to consume junk food and imbalanced diet more than any other age group. They may also develop habit of compulsive eating at one end and anorexia nervosa at the other end of spectrum.

Sexual Behaviour : Sexual indiscretion, lack of education on skills of responsible sexual behaviour and urge for experimentation can lead to myriad of problems ranging from unplanned pregnancy, STDs, HIV, unwed mothers, illegal abortions, psychological breakdowns and complex social problems.

Risk Taking Behaviour : Adolescent males tend to challenge difficulties without taking the danger into account to the extent that most adults would. This impulsive risk taking behaviour has implications for health of the adolescents, whether the activity is driving a vehicle, sports, any work or various health related behaviours like drugs, alcohol or sexual urge.

Adolescence - A Stressful Transition PeriodThe world in which adolescents of today live is marked by vastness as far as mobility is concerned and rapid technical and social changes. This demands a great degree of adjustments and adaptation by the adolescents who are undergoing rapid biological-social-psychological transition. The adolescents tend to explore actively in seeking information on new situations, new roles and future difficulties.

Adolescent Health : Global ScenarioThe health of the adolescents can be measured by studying age specific morbidity, mortality, prevalence of behavioural disorders and DALYs. This relatively healthy phase of life must also be seen in the light of barriers to health seeking behaviour and under-reporting of adolescent related data in the developing countries. However, DALYs has been found to be most suitable indicator for the purpose of international comparison. More than 33 percent of the disease burden and almost 60 percent of premature deaths among adults can be associated with behaviours or conditions that began or occurred during adolescence - for example, tobacco and alcohol use, poor eating habits, sexual abuse and risky sexual behaviour (WHO 2002). Adolescence-related risk factors are a greater problem in wealthier countries, largely because of the relatively greater impact of smoking and diet-related risks in those countries, though the prevalence of these risks is expanding rapidly in many low - and middle-income countries.

Indian Scenario Awareness on Common Health Issues : There is a lack of knowledge and awareness amongst adolescents about

important health issues and problems that affect them. An Indian Council of Medical Research (ICMR) study showed that knowledge and awareness about puberty, menstruation, physical changes in the body, reproduction, contraception, pregnancy, childbearing, reproductive tract infections, Sexually Transmitted Infections (STIs), and HIV was low among boys and girls, especially in younger adolescents (ages 10-14). The study reported, however, that older adolescents (ages 15-19) had better knowledge. About 80 percent had knowledge of STIs, including HIV.

Education : Only 83 percent of primary-school age children (6-10 years) attend school. School attendance drops to 75 percent for children aged 11-14 years and is only 41 percent for children age 15-17 years. Education is linked to delayed marriage and childbearing and better outcomes besides decreased fertility.

Marriage, Sex & Reproductive health : The importance of reproductive health of adolescents is receiving increased attention due to multiple factors- they are almost ¼ of the population, they are going to be parents of the next generation and HIV has provided the necessary impetus to this important issue. The fall in age at menarche and increased age at marriage coupled with changing social-cultural values and attitudes has increased the potential of pre-marital sexual activity. The effect of increased urbanization, migration, economic independence and declining family influence has provided suitable conditions for increased exposure of the young people to risky sexual behaviour.

High fertility rates, high rates of teenage pregnancy, high risk of STI/HIV and poor nutritional status are the main health problems among the adolescent population in India (4,5). The median age at first marriage among women is 17.2 years. Among young women aged 15-19 years, 16 percent have already begun childbearing. Of those who seek medical termination of pregnancy, 8-10% are teenage mothers and unmarried girls.

Public Health ImplicationsThe public health implications of adolescent health are far reaching and have intergenerational effects as well. (See Box - 2)

Box - 2 : Public Health Implications of Adolescent Health

Mortality in Adulthood : The 70% of the mortality in adulthood is linked to habits picked up during adolescence (risk-taking behaviour, substance abuse, eating habit and conflict resolution.)

Intergenerational Effects : Prevailing malnutrition, anaemia, stunting and lack of immunization have adverse impact on MMR, IMR and morbidity.

Adolescent Sexuality : Leads to adolescent pregnancy, unsafe abortion, RTI, STI/HIV and social problems.

Adolescent Pregnancy : In this the risk of adverse outcome (IMR, MMR LBW babies) is higher.

Risk Taking Behaviour : Lack of “connectedness” with parents and other adults prevents transmission of health messages and crucial skills leading to adoption of risky behaviour, substance abuse, early sexual debut and STI, HIV etc.

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InterventionsImproving the health of young people is a complex and difficult issue. Programs will have to seek multi-sectoral solutions that link health sector interventions with other types of interventions delivered through other sectors, either at the program level or at the policy level. Research has created international consensus over a multi-pronged intervention approach based on the following principles (Box - 3).

Box - 3 : Principles of Health Programming for Adolescents

Recognize the diversity of the youth age group.

Involve young people.

Design comprehensive programs

Make health services Youth Friendly.

Address gender inequality of Women.

Address the needs of boys.

Address non-health factors that influence health

Address underlying risk and protective factors.

(a) Life-Skills and Health & Sexuality Education in Schools: Well designed, well-implemented sexuality and reproductive health education can provide young people with a solid foundation of knowledge and skills to enable them to engage in safe and responsible sexual behaviour.

(b) Peer Education : Peer education programs are especially appropriate for young people who are not in school and for hard-to-reach, at-risk subsets of the youth population including, sex workers and street children.

(c) Mass Media and Community Mobilization : Mass media and community mobilization efforts that engage influential adults, such as parents, teachers, community and religious leaders, and music and sports stars, can help normalize positive adolescent behaviours and gender roles as well as direct young people to appropriate health services.

(d) Youth Development Programs : Youth development programs typically address a range of key adolescent needs, including life skills, education, jobs, and psychosocial needs. Programs with a voluntary community service component have successfully improved key reproductive health behaviours, but no evidence is available for developing countries.

(e) Clinical Health Services : Although some young people seek care through the formal health system, many others are deterred by the often judgmental attitudes of health workers, particularly when seeking care and advice on matters related to sexuality.

(f) Social Marketing : This approach involves the use of public health messages to promote healthy behaviours and the use of condoms and other health products and services. Effective programs bring products and services to places in the community that young people frequent, such as shops, kiosks and pharmacies.

(g) Workplace and Private Sector Programs : Programs that reach young people do so at their places of work and through

private channels, such as pharmacies and for-profit medical services, where many young people prefer to seek care.

Initiatives in India for Health and Development of AdolescentsThe Government of India has identified “Survival, Protection, and Development” as a major theme, focusing on gender-specific needs. This was a conscious effort to ensure equitable rights, opportunities, benefits, and status to girl children as part of National Plan for the SAARC decade of the Girl child.

Realizing for the first time, the importance of this population sub group, the Planning Commission has set up a Working Group for the Welfare and Development of Adolescents, to provide inputs into the Tenth Five Year Plan. Most importantly, policies and programmes need to cover the entire range of health and related problems of adolescents and not confined to education and service delivery for reproductive health alone. The Working Group proposed an allocation of at least Rs.112 crore for the Tenth Five Year Plan for the schemes for adolescents to be implemented by the nodal Ministry (Ministry of Youth Affairs & Sports). The adolescents have been recognized as valuable human resource with certain rights.

The initiatives taken under inter-related issues concerning adolescents under various schemes are given as under-

1. National Policy on Education (1986 modified in 1992): The main emphasis in the National Education Policy is on the eradication of illiteracy and universalization of primary education. Education helps to develop adolescent health by delaying marriage, childbearing while generating positive health behaviour.

2. National Population Policy : They are specifically referred to in the sections on information, nutrition, contraceptive use, STDs and other population-related issues. There is a special mention about developing a health package for adolescents and enforcing the legal age at marriage.

3. National AIDS Prevention and Control Policy : Since unprotected sex is a major source of AIDS and adolescents form a significant portion of the sexually active population, they should form a special focus group under the Policy. While the policy talks about programmes for adolescents like University Talk AIDS and NYKs, surprisingly, the policy does not specifically mention adolescents. One can say that even without specifically mentioning adolescents, the policy is crucially relevant to them and aims at addressing their needs.

4. National Nutrition Policy (1983) : The National Nutrition Policy has focused on adolescent girls and that too only in relation to the importance of their role as mothers and housewives. Adolescent boys do not find any mention in the policy. The need for the well being of adolescents, as a group has not been recognized. ICDS is providing supplementary nutrition to adolescent girls (Kishori Shakti yojna) but the coverage is abysmally low (3%). The 10th Five Year Plan and Nutritional Policy proposed a nutritional program for girls weighing less than 35 Kg and for pregnant women weighing less than 45 Kg and below poverty line, who would get ration of Rs 6/- per month in the form of wheat or rice, through the Public Distribution System. The adolescent girls need

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appropriate nutrition, education, health education, training for adulthood, training for acquiring skills as the base for earning an independent livelihood, training for motherhood, etc. Similarly on the other side their potential to be a good community leader has to be realized. A scheme for adolescent girls in ICDS was launched by the department of Women and Child Development, Ministry of Human Resource Development in 1991.

All adolescent girls in the age group of 11-18 years receive the following common services:(a) Immunization(b) General health check up once in every six months(c) Training for minor ailments(d) Deworming(e) Prophylactic measures against anaemia, goiter, vitamin

deficiency, etc.(f) Referral to PHC/District hospital in case of acute need (g) Watch over menarche5. National Policy for the Empowerment of Women (2001) : The policy has recognized the girl child as a separate category and adolescent girls seem to be covered there under. The policy relates to their nutrition, education, holistic approach to health, violence against them, sexual abuse of them and the rights of the girl child.

6. Reproductive & Child Health : The special package of interventions for adolescents under RCH are- (a) One booster dose of TT at the age of 16 & immunization of

girls against Rubella.(b) Sex education to promote responsible and healthy

reproductive & sexual behaviour.(c) Prevention of STD/HIV and AIDS.(d) Adult Literacy especially among women.(e) Vocational training.(f) Pre marital counselling.(g) Gender equality.(h) Family life education. It will be seen from the above that the present policies address specific sectors like education, health, family welfare, nutrition, HIV/AIDS, sports etc. or address certain population groups like women, children and youth. None of the policies however take an integrated and holistic view of adolescents. Adolescents in difficult circumstances like adolescents with disabilities, learning disorders, adolescent sex workers or children of sex workers and street children need much more visibility in policies.

Specific Programs on AdolescentsBrief of some specific programs initiated by governmental and non-governmental organization directed towards adolescents in India is given below-

1.Kishori Shakti Yojana : To improve the health and nutritional status of girls by supplementary nutrition, anaemia prophylaxis under ICDS. Poor coverage of the target population is the limitation of this programme.

2.Balika Samridhi Yojana, 1997: This scheme works to raise the status of girl children born in families below the poverty line by providing financial help to these families. Some specific

criteria have been laid down to provide financial assistance to the mother of a newborn girl child in the form of grants and investments through a postal financial instrument to be applied toward the education and economic independence of that child. The deposit will mature and be paid to the girl if she remains unmarried until she reaches 18 years of age. This helps to delay the age of marriage.

3.National Service Scheme (NSS) : NSS was launched in 1969 with a primary focus on students’ personality development and community service. NSS involved more than 1.6 million student volunteers from more than 175 universities and 22 senior secondary councils. The scheme’s programs include “regular activities” and “special campaign programs.”

4.Bharat Scouts and Guides : It is the third largest youth organization in the world. Scouting and guiding movements aim to develop boys’ and girls’ characters with the goal of making them good citizens of India. It inculcates in them a spirit of patriotism and promotes balanced physical and mental development.

5. Child Labour Projects : The Ministry of Labour is running 76 national Child Labour Projects in the country.

6. Integrated Program for “Street Children” : The Ministry of Social Justice and Empowerment has been implementing this program since 1992-93. One of the important initiatives under the program’s revision in 1998 was the establishment of the Child Help Line Services in a number of cities. The Child Help Line provides emergency assistance to children.

7. Population Council : The Population Council has supported initiatives on adolescent transition in different states in colLabouration with several NGOs. The Population Council supported programs on adolescence run by Mahila Samakhya in Karnataka and Andhra Pradesh and in the state of Haryana, Apni Beti Aapna Dhan and services in the areas of personality development, education, health, reproductive health, economic participation, and life skills training.

8. International Centre for Research on Women (ICRW): ICRW is coordinating a multi-site intervention and research program to develop effective programs for adolescent sexual and reproductive health and development in India. The studies confirmed that a lack of power, decision making opportunity, autonomy, and access to resources underlie the reproductive health risks faced by adolescents, particularly adolescent females, and those who are unmarried.9. Centre for Development and Population Activities (CEDPA) : CEDPA, An international NGO with operations in Delhi, in collaboration with local NGOs, UNFPA, UNESCO and USAID, has adapted “Choose a Future: Issues and Options for Adolescent Boys” to the Indian cultural context and is currently implementing programs in 11 states.

10. Planned Parenthood Federation : Planned Parenthood has promoted four major projects with the help of local NGOs:

(a) Improving the Reproductive Health of Young Women and Men : The goal of the project is to improve the lives of adolescents and youth by providing contraceptive services and sexuality education in 20 rural villages in a district in West Bengal with a local NGO.

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(b) Couple to Couple : The project employs peer couples to work with groups of newlyweds and other young couples to motivate them to increase gender awareness, encourage supportive relationships, and plan for their new families together.

(c) Improving the Reproductive Health of Adolescents and Youth : Located in Jharkhand state, the project aims to increase young people’s knowledge and understanding about sexuality and reproductive health and help them develop communication and decision-making skills so that they may lead healthy reproductive lives.

(d) Reproductive Health Through Advocacy and Services: The project is a part of a larger program to improve the reproductive health and rights of adolescents and youth in the Indian states of Bihar and West Bengal.

National Youth Policy, 2003 The National Youth Policy, 2003 reiterates the commitment of the entire nation to the composite and all-round development of the young sons and daughters of India. This Policy covers all the young people in the country in the age group of 13 to 35 years. The age group is, therefore divided into two broad sub-groups viz. 13-19 years and 20-35 years. Strategy

1. Youth empowerment(a) Attainment of higher educational levels and expertise by

the youth, as per their abilities and aptitudes, and access to employment opportunities accordingly.

(b) Adequate nutrition for the full development of physical and mental potential and the creation of an environment which promotes good health.

(c) Protection from disease agents and unwholesome habits.(d) Development of youth leadership.(e) Equality of opportunity.2. Gender Justice : The Policy recognizes that prevailing gender bias is the main factor responsible for the poor status of health and economic well-being of women in our society. The Policy enunciates that: (a) Every girl child and young woman will have access to

education and would also be a primary target of efforts to spread literacy.

(b) Women will have access to adequate health services and will have full say in defining the size of the family.

(c) Domestic violence will be viewed not only as violation of women’s freedom but also as that of human rights.

(d) All necessary steps should be taken for women’s access to decision-making process, to professional positions and to productive resources and economic opportunities.

(e) Young men, particularly the male adolescents shall be properly oriented, through education and counselling to respect the status and rights of women.

3. Inter-Sectoral Approach : The Policy recognizes that an inter-sectoral approach is a pre-requisite for dealing with youth-related issues.

4. Information & Research Network : The Rajiv Gandhi National Institute of Youth Development (RGNIYD) will serve as the apex Information and Research Centre on youth development issues. There is a crying need to have valid data

on health of adolescents in India. Priority Target Groups under the policy are given in Box - 4.

Box - 4 : Priority Target Groups

Rural and Tribal Youth ●Out-of-school Youth ●Adolescents particularly female ●Youth with disabilities ●Adolescents under special circumstances like victims of ●trafficking; orphans and street children.

Implementation Mechanism : The Union Ministry of Youth Affairs & Sports (with the guidance of this Committee) will be the Nodal Ministry for all such programmes and schemes and will oversee the implementation of the provisions of this Policy. A National Youth Development Fund will be created through contributions, including from Non-Governmental Organizations, which would be utilized for youth development activities.

Life Skills EducationLife skills have been defined by World Health Organization as ‘the abilities for adaptive and positive behaviour that enable individuals to deal effectively with the demand and changes of everyday life’. Life skills are abilities that help to promote mental well being and competency of young people to face the challenges of life. Effective acquisition of life skills can influence the way one feels about oneself and others and can enhance one’s productivity, efficacy, self-esteem and self-confidence. Life skills can also provide the tools and techniques to improve interpersonal relations.

There are three kinds of life skills : Thinking skills, social skills and negotiating skills. Thinking Skills include problem solving, thinking critically, processing information and exercising choice, making informed decisions and setting goals. Social skills include appreciating/validating others; building positive relationship with peer groups and family; listening and communicating effectively; taking responsibility; and coping with stress. Negotiating skills include self realization that enables an individual to understand ones values, goals, strengths and weaknesses. Thus, negotiating skills need to be enhanced at two levels - within oneself and with others. Adolescents need to learn to be assertive, including learning to say “no” to adopt risky and harmful behaviour like drug use or casual sex before marriage. During adolescence, life skills development is an active process. Despite superior intellectual abilities, the adolescent’s behaviour is occasionally influenced by emotions rather than by rational thinking. Frequently the adolescent is in an emotional dilemma of wanting to be guided by parents, yet wishing to be free from them, and more aligned to their peers. They also have the need to exercise skills to indicate and establish their individuality and independence. This becomes complex, as an adolescent has multiple situations to deal with. Many critical issues arise during adolescence like - puberty, dealing with sexuality and gender issues, tackling emotional upheaval, finishing education, need to make future career choices, facing responsibilities as an adult, etc. Hence, Life Skills Development is of immense value to the adolescents

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in managing their lives. It is recommended that 30 to 45 day ‘Life Skills Development Programmes’ be organized by NGOs/NYKs/other community groups for both school going and out of school adolescents. Adolescents who go through such a training programmes could thereafter be used as peer educators. Education of adolescents on family life is an important exercise as they are the parents of tomorrow. It is defined as “an educational process designed to assist young people in their physical, social, emotional and moral development as they prepare for adulthood, marriage, parenthood, ageing as well as their social relationship in their socio cultural context of the family and society” (UNESCO).

CounsellingCounselling is a process of enabling and empowerment to help a person in problem solving and crisis management. This may be required at different stages of life. One of these stages is the period of adolescence when adolescents are usually either in school or college or out of school as ‘drop-outs’ and ‘left-outs’), and therefore the need and importance of counselling is highest during this period and for these groups.

Adolescents in Difficult CircumstancesAdolescents in difficult circumstances are those who belong to special groups like drug addicts, adolescents with AIDS and adolescents with parents afflicted by AIDS, adolescent prostitutes and children of the same, juvenile delinquents and adolescent victims of crime, street adolescents, neglected juveniles and adolescents who are physically and mentally challenged. Any intervention to address adolescents must also keep in mind the environment in which adolescents live - their families and society. It is equally essential for any intervention aimed at adolescents in difficult circumstances, to address the parents and families of these adolescents. Needless to say a holistic and integrated approach has to be adopted.

Juvenile DelinquencyIt refers to a large variety of behaviour of children and adolescents which the society does not approve of and for which some kind of admonishment, punishment or preventive and corrective measures are justified in public interest.

Juvenile- ‘ ● Juvenis’- young - boy who has not attained 16 yrs, girl aged less than 18 Delinquent - “ ● delinquere”

- A child who has committed an offence - All deviations from normal youthful behaviourThis includes all children who are incorrigible, ungovernable and habitually disobedient and who desert their homes, with behavioural problems and anti-social practice. The term ‘juvenile’ has been defined in clause (h) of Section 2 of the Juvenile Justice Act, 1986, as a boy who has not attained the age of sixteen years or a girl who has not attained the age of eighteen years. Offence under clause (n) of Section 2 of the above Act means an offence punishable under any law for the time being in force which includes the Narcotics Drugs and Psychotropic Substances Act, 1985 and the Terrorist and Disruptive Activities (Prevention) Act, 1987.

A child becomes a criminal through the interaction of many causes, social and individual, familial, psychological and economic. In order to rehabilitate the juvenile delinquent as

a healthy member of society, it is necessary to understand all these causes and remove them through improving family life, proper schooling, reducing harmful peer influences, and social welfare services. Under the Juvenile Justice Act, 1986, separate provisions have been laid down for the neglected and uncontrollable juveniles. They are dealt with by the Juvenile Welfare Boards and not by Juvenile Courts. Common Problems seen in Juvenile Delinquents1. Behavioural problems e.g. lying, stealing, gambling

aggressiveness, destructiveness, disobedience, over activity.

2. Learning disabilities.3. Emotional problem e.g. depression, school refusal, fears,

timidity, shyness.4. Adjustment reactions e.g. school related problem, grief.5. Development disorder e.g. autism, bedwetting & soiling.6. Intellectual deficit.7. Psychosomatic disorders. 8. Bizarre and abnormal behaviours.9. Relationship (including parent-child, sibling and marital)

problem. 10. Socio-legal issues and problem e.g. child custody

assessment, sexual offences, child abuse and head injuries.

11. Other e.g. eating and sleep disorders, sexual problems in adolescence, tics (movement disorder) & stress reaction.

Prevention & Management of Juvenile DelinquencyImprovement of family life ●Life Skills development ●Schooling ●Social welfare services - Child guidance clinics, juvenile ●court, Child placement (Orphanages, Foster homes, Borstals, Remand home)

Child Guidance Clinic (CGC)The concept originated in USA when Child Guidance Clinic was started in 1909 in Chicago. These were originally intended to deal with juvenile delinquency. Now the concept has been widened to also deal with those children who are not adjusted with their environment. The basic objective of these clinics is to prevent children from becoming neurotics, psychotics, criminals in later life by offering a gamut of services provided by a team which may include-

Psychiatrist ●Clinical psychologist ●Educational psychologist ●Psychiatric social worker ●Public health nurse ●Pediatrician ●Speech therapist ●Neurologist ●

The composition of the team is variable depending on the need and the resources available.

The clinic offers a number of services for these children. Psychotherapy is central to all other services provided.Services

Psychotherapy- core of services ●Physical health ●

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Children’s One-Stop Psycho-Educational Services (COPES) ●Treatment

Medical treatment ●Individual psychotherapy ●Family and marital therapy ●Behavioural / Cognitive therapy ●Occupational therapy ●Group therapy ●Play therapy ●Social case work ●

Prevention : The preventive measures are based on the belief that juvenile delinquents are shaped by the socio-economic-cultural influences on a vulnerable child. A stable, emotionally fulfilling and healthy family environment is the best vaccine against this disorder. School plays an important role in shaping the behaviour of a child and healthy interaction with teachers and peers will result in a child who is emotionally balanced and mentally healthy. The role of developing life skills and family life education cannot be overemphasized.

Juvenile Justice (Care and Protection of Children) Act (2000)Background1. The constitution in Articles 15, 39, 45 & 47 has imposed

on the state a primary responsibility of ensuring that all the needs of children are met and that their basic human rights are fully protected.

2. Convention on the rights of the Children adopted by UN general assembly in 1989.

3. Government of India ratified the convention in 1992.4. United Nations Standard Minimum Rules for the

administration of Juvenile Justice,1985 (Beijing rules) and UN rules for the protection of Juveniles deprived of their liberty (1990).

5. Juvenile Justice Act 1986.Earlier the Children Act, 1960 amended in 1977 laid down that delinquent children needed to be provided with care, education, maintenance, training and rehabilitation. This covered victimized, uncontrollable, ungovernable, destitute and delinquent children. The Juvenile justice Act 2000 has removed all the inadequacies of the children act and has made the care more comprehensive and encompassing. The Act has been published in “The Gazette of India” No.70: The Juvenile Justice (Care & Protection of Children) Act 2000 (No. 56 of 2000) published by the Legislative Department of Ministry of Law, Justice and Company Affairs after receiving the assent of the President of India on 30 December 2000.The salient features of the Act are given below

(a) Child Welfare Committee : The State Government may, by notification in Official Gazette, constitute for every district or group of districts, specified in the notification, one or more Child Welfare Committees for exercising the powers and discharge the duties conferred on such Committees in relation to child in need of care and protection under this Act. The Committee shall consist of a Chairperson and four other members as the State Government may think fit to appoint, of whom at least one shall be a woman and another, an expert on matters concerning children. The Committee shall have

the final authority to dispose of cases for the care, protection, treatment, development and rehabilitation of the children as well as to provide for their basic needs and protection of human rights. Where a Committee has been constituted for any area, such Committee shall, notwithstanding anything contained in any other law for the time being in force but save as otherwise expressly provided in this Act, have the power to deal exclusively with all proceedings under this Act relating to children in need of care and protection.

(b) Juvenile Justice Board : State Government may, by notification in the Official Gazette, constitute for a district or a group of districts specified in the notification, one or more Juvenile Justice Boards for exercising the powers and discharging the duties conferred or imposed on such Boards in relation to juveniles in conflict with law under this act. A Board shall consist of a Metropolitan Magistrate or a Judicial Magistrate of the first class, as the case may be, and two social workers of whom at least one shall be a woman, forming a Bench and every such Bench shall have the powers conferred by the Code of Criminal Procedure, 1973 (2 of 1974), on a Metropolitan Magistrate or, as the case may be, a Judicial Magistrate of the first class and the Magistrate on the Board shall be designated as the principal Magistrate. No Magistrate shall be appointed as a member of the Board unless he has special knowledge or training in child psychology or child welfare and no social worker shall be appointed as a member of the Board unless he has been actively involved in health, education, or welfare activities pertaining to children for at least seven years.

(c) Children Homes : The State Government may establish and maintain either by itself or in association with voluntary organizations, children’s homes, in every district or group of districts, as the case may be, for the reception of child in need of care and protection during the investigation of any pending inquiry and subsequently for their care, treatment, education, training, development and rehabilitation. The State Government may, by rules made under this Act, provide for the management of children’s homes including the standards and the nature of services to be provided by them, and the circumstances under which, and the manner in which, the certification of a children’s home or recognition to a voluntary organization may be granted or withdrawn.

(d) Rehabilitation : The rehabilitation and social reintegration of a child shall begin during the stay of the child in a children’s home or special home and the rehabilitation and social reintegration of children shall be carried out alternatively by-(i) Adoption(ii) Foster care(iii) Sponsorship(iv) Sending the child to an aftercare organization(e) Special Juvenile Police Unit : Special juvenile police unit, to handle juveniles or children may be created in every district and city to co-ordinate and to upgrade the police treatment of the juveniles and the children.Child Placement

1. Orphanages : These are for the children who have no home, no parents or single parents or parents too poor to care for them. The concept is not very favourable to the overall wellbeing of

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the child as it does not provide emotional and social warmth required for their development.

2. Foster Home : This is a setting which provides all that is available in a family setting but a home other than their original family.

3. Borstals : These are institutions somewhere between a certified school and an adult prison for the children 16 years and above who have some social adjustment pathology.

4. Remand Homes : This is for those children who have been arrested by the police in some situation which warrants them to be taken care of like immoral trafficking, prostitution etc.

SummaryWHO defines Adolescence as 10-19 years old, Youth as 15-24 years old and Young people as 10-24 years old. The adolescence has been divided into two phases: early (10-14 years) and late (15-19 years). The need to focus on adolescent health exists for many reasons. They constitute 23.1% of Indian population. It is the period of rapid physical growth, sexual maturation and psychological changes. Habits and behaviours picked up during this period (risk taking behaviour, substance abuse, eating habits and conflict resolution) have long lasting impact. Adolescence provides the last chance to correct the growth lag and malnutrition of childhood.

There are various health problems related to the period of adolescence. The adolescent because of rapid biological and psychosocial changes, is prone to impulsivity, emotional and risk taking type of behaviour putting them at risk to problems like STDs/RTIs, accidents, drug and substance abuse and psychological and mental health disorders. Inappropriate sexual behaviour may lead to unplanned pregnancy, STDs, HIV, unwed mothers, illegal abortions, psychological breakdowns and complex social problems. An unfavourable family environment in the form of poverty, marital discord between parents, and alcoholic parent puts the adolescent at risk of Delinquency and prone to psychological problems. Adolescence is also a stressful transitional period. The transitions include educational, occupational, marriage, pregnancy/parenthood and migration related to education and employment.

The health of the adolescents can be measured by studying age specific morbidity, mortality, prevalence of behavioural disorders and DALYs. DALYs have been found to be the most suitable indicator for international comparisons..

In India there is lack of knowledge and awareness among adolescents about important health issue problems that affect them according to an ICMR study. High fertility rates, high rates of teenage pregnancy, high risk of STI/HIV, and poor nutritional status are important problems in adolescents in India. The median age at first marriage in India is 17.2 years.

Improving the health of young people is a complex problem. A multi-pronged intervention approach which should include life-skills and health and sexuality education in schools, peer education, mass media and community mobilization, youth development programs, clinical health services, social marketing and work place and private health sector programs.

The Government of India has identified Survival, Protection and Development as a major theme, focusing on gender

specific needs. The initiatives have been taken under inter-related issues concerning adolescents under various schemes. The notable ones are National policy on education (1986 modified in 1992), National population policy, National AIDS prevention and control policy, National nutrition policy (1983), National policy for empowerment of women and Reproductive and child health policy. These policies address specific sectors like education, health, family welfare, nutrition, HIV/AIDS, sports etc. or address certain population groups like women, children and youth. There are specific programs initiated by governmental and non-governmental organization directed towards adolescents. National Youth Policy, 2003 reiterates the commitment of the entire nation to the composite and all-round development of the young sons and daughters of India. This policy covers all young people in the country in the age group of 13 to 35 years. The strategies are Youth empowerment, Gender Justice, Inter-sectoral approach and Information and research network. The areas of focus are General health, Mental health, Spiritual health, AIDS and STDs, Population education/Family life education/Reproductive health and Tobacco/Substance abuse. The implementation is by Union Ministry of Youth Affairs and Sports.

Life-skills has been defined by WHO as ‘the abilities for adaptive and positive behaviour that enable individuals to deal effectively with the demands and changes of everyday life’. Effective acquisition of life skills can influence the way one feels about oneself and others and can enhance one’s productivity, efficacy self esteem and self confidence. There are three kinds of life skills- Thinking skills, Social skills and negotiating skills. Adolescents need to be assertive, including learning to say “no” to adopt risky and harmful behaviour like drug use or casual sex before marriage.

Juvenile Delinquency refers to a large variety of behaviour of children and adolescents which the society does not approve of and for which some kind of admonishment, punishment or preventive and corrective measures are justified in public interest. Juvenile is a boy who has not attained the age of 16 years or a girl less than 18 years. The common problems seen in Juvenile delinquents are Behavioural problems like stealing or lying or gambling or aggressiveness or destructiveness or disobedience, Learning disabilities, Emotional problems, Adjustment problems, Development disorder, Intellectual deficit, Psychosomatic disorders, Bizarre and abnormal behaviours, Relationship problems and Socio-legal issues and problems. Prevention and management of Juvenile delinquency includes improvement in family life, life skill development, schooling and social welfare services (child guidance clinics, juvenile courts, orphanages, foster homes, borstals and remand homes).

Child Guidance Clinics (CGC) started in USA in 1909, deals with children who are delinquents and also those who are not adjusted to their environment. The Juvenile Justice (Care and Protection of Children) Act 2000 (No. 56 of 2000) was published by the Legislative Department of The Ministry of Law, Justice and Company Affairs on 30 December 2000. The salient features of the Act include Child welfare committee, Juvenile Justice Board, Children homes, Rehabilitation and Special Juvenile Police Unit. The various Child placement institutions are Orphanages, Foster homes, Borstals and Remand homes.

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Study ExercisesLong Question: Describe various adolescent health problems in India and Programs directed against them.

Short Notes: (1) Specific programs on adolescents in India (2) National Youth Policy 2003 (3) Life skills education (4) Juvenile Delinquency (5) Child Guidance Clinic (6) Children Homes

MCQs 1. The concept of Child Guidance Clinic was started in

(a) India (b) USA (c) Russia (d) France2. Median age at first marriage among women in India is

(a) 18.5 years (b) 17.2 years (c) 16.2 years (d) 19.5 years3. The Population Council supported program on adolescents

‘Apni Beti Aapna Dhan’ is running in (a) Punjab (b) Haryana (c) Himachal Pradesh (d) Uttar Pradesh

4. A Juvenile boy is one who is under _________ years of age (a) 17 years (b) 18 years (c) 16 years (d) 15 years

5. Child Guidance Clinics deals with (a) Juvenile Delinquents (b) Children who are not adjusted to their environment (c) Both (d) None

6. A 13 year old with no father, runs from school and caught in a theft should be kept in (a) Foster home (b) Prison (c) Orphanage (d) Remand home

7. Which of the following closely resembles Juvenile Delinquency (a) Bedwetting (b) School failure (c) Speech problem (d) Destructiveness

8. The main service of Child guidance Clinic is (a) Career counselling (b) Management of Orphans (c) Psychotherapy (d) Recreation facilities

9. Children with parental disharmony are more prone to: (a) Mental retardation (b) Epilepsy (c) Delinquency (d) Accidents

10. All of the following are problems antisocial in nature except (a) Lying (b) Gambling (c) Unsociability (d) Destructiveness

11. The percentage of adolescents among total population in India is (a) 27.3% (b) 18.7% (c) 21.2% (d) 23.1%

12. According to WHO adolescents are ________ years of age (a) 10-19 (b) 11-18 (c) 10-17 (d) 12-21

Answers : (1) b; (2) b; (3) b; (4) c; (5) c; (6) d; (7) d; (8) c; (9) c; (10) c; (11) d; (12) a

References:Towards adulthood- WHO 2003 ( Exploring adolescent sexual and 1. reproductive health in south Asia)The reproductive health of adolescents- A strategy for action : A joint WHO/2. UNFPA/UNICEF statementHealth needs of adolescents. Report of a WHO Expert committee, TRS 609, 3. WHO Geneva, 1977 Gupta S D. In. Adolescent and Youth Reproductive Health in India: Status, 4. Issues, Policies and programs- Dir-Indian institute of Health Mgt Research, Jaipur- 2003National Youth Policy, 5. Elizabeth Lule, James E. Rosen, Susheela Singh, James C. Knowles, and 6. Jere R. Behrman. Adolescent Health Programs. Chapter 59. In: Disease Control Priorities in Developing Countries. Kirby, D. 2001. Emerging Answers: Research Findings on Programs to 7. Reduce Teen Pregnancy. Washington, DC: National Campaign to Prevent

Teen Pregnancy.

Further Suggested ReadingJames E rosen. Adolescent Health and Development- A resource book for 1. World bank Operations staff and Government counterparts. 2004, World bank, Washington DCHealth needs of adolescents. Report of a WHO Expert committee, TRS 609, 2. WHO Geneva, 1977 Adolescence - The Critical Phase, The Challenges & Potential, WHO 1997 3. National Youth Policy-20034.

148 Children’s Right to Health

A S Kushwaha

“We are guilty of many errors and many faults, but our worst crime is abandoning the children, neglecting the foundation of life. Many of the things we need, can wait. The child cannot. Right now is the time his bones are being formed, his blood is being made and his senses are being developed. To him we cannot answer “Tomorrow”. His name is “Today”.”

- Gabriela Mistral, 1948

The early years of life are crucial. When well nurtured and cared for in their earliest years, children are more likely to survive, to grow in a healthy way, to have less disease and fewer illnesses, and to develop thinking, language, emotional and social skills.

State of Children in IndiaUNICEF 2005 Report on the state of the world’s children was published under the title “Childhood under Threat”. Speaking about India, the report states that millions of Indian children are equally deprived of their rights to survival, health, nutrition, education and safe drinking water. A girl child is the worst victim as she is often neglected and is discriminated against because of the preference for a boy child. In India, children’s vulnerabilities and exposure to violations of their protection rights remain spread and multiple in nature. The manifestations of these violations are various, ranging from child labour, child trafficking, to commercial sexual exploitation and many other forms of violence and abuse. With an estimated 12.6 million children engaged in hazardous occupations (2001 Census); for instance, India has the largest number of child labourers under the age of 14 in the world. The lack of available services, as well as the gaps persisting in law enforcement and in rehabilitation schemes also constitute a major cause of concern.

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Child Protection Against ExploitationAn estimated 300 million children worldwide are subjected to violence, exploitation and abuse including the worst forms of child labour in communities, schools and institutions; during armed conflict; and to harmful practices such as female genital mutilation/cutting and child marriage. Millions more, not yet victims, also remain without adequate protection.

Protecting children from violence, exploitation and abuse is an integral component of protecting their rights to survival, growth and development. UNICEF advocates and supports the creation of a protective environment for children in partnership with governments, national and international partners including the private sector, and civil society. National child protection systems, protective social practices and children’s own empowerment coupled with good oversight and monitoring are among the elements of a protective environment and enable countries, communities and families to prevent and respond to violence, exploitation and abuse.

The UN Convention on the Rights of the Child states that all children are entitled to the same rights, regardless of the child’s, or their parent’s or legal guardian’s race, colour, sex, language, religion, political or other opinion, national, ethnic or social origin, property, disability, birth or other status. However, discrimination is a daily reality for millions of the world’s children. There are numerous forms of discrimination. The most common include:(a) Gender(b) Disability(c) Ethnicity and race(d) Caste(e) HIV/ AIDS(f) Birth status

Actions to Provide Protective Environment to ChildrenBuilding a protective environment for children that will help prevent and respond to violence, abuse and exploitation involves the following essential components as defined by UNICEF:1. Strengthening government commitment and capacity to

fulfill children’s right to protection.2. Promoting the establishment and enforcement of adequate

legislation addressing harmful attitudes, customs and practices.

3. Encouraging open discussion of child protection issues that includes media and civil society partners.

4. Developing children’s life skills, knowledge and participation.

5. Building capacity of families and communities.6. Providing essential services for prevention, recovery

and reintegration, including basic health, education and protection.

7. Establishing and implementing ongoing and effective monitoring, reporting and oversight.

UNGASS (UN General Assembly Special Session on Children): The UN held its 27th special session on children in May 2002. This was to review the progress made since 1990 when World Summit for Children (Convention on the Rights of

the Child) was held. The commitment to promote and protect rights of children was reaffirmed. The aim is to create a ‘World Fit for Children’ through following principles (See Box-1).

Box - 1 : World Fit for Children

Put children first

Eradicate poverty: Invest in children

Leave no child behind

Care for every child

Educate every child

Protect children from harm and exploitation

Protect children from war

Combat HIV/ AIDS

Listen to children and ensure their participation

Protect the Earth for children

Initiatives on Child Rights(a) National Policy on Children, 1974 : India is a party to the UN declaration on the Rights of the Child 1959. In 1974, the Government of India adopted a National Policy for Children, declaring the nation’s children as ‘supremely important assets’. The policy reaffirmed the constitutional provisions for adequate services to children, both before and after birth and through the period of growth to ensure their full physical, mental and social development. This policy lays down recommendations for a comprehensive health programme, supplementary nutrition for mothers and children, nutrition education for mothers, free and compulsory education for all children up to the age of 14, non-formal preschool education, promotion of physical education and recreational activities, special consideration for the children of weaker sections of the population like the scheduled castes and the schedule tribes, prevention of exploitation of children and special facilities for children with handicaps. The policy provided for a National Children’s Board to act as a forum to plan, review and coordinate the various services directed toward children. The Board was first set up in 1974.

(b) The Department of Women and Child Development : This was set up in the Ministry of Human Resource Development in 1985. The Department, besides ICDS, implements several other programmes, undertakes advocacy and inter-sectoral monitoring catering to the needs of women and children.

(c) Convention on the Rights of the Child (CRC), 1990 : The Government of India ratified the CRC on 12 November 1992. By ratifying the Convention on the Rights of the Child, the Government is obliged “to review National and State legislation and bring it in line with provisions of the Convention”. The Convention re-validates the rights guaranteed to children by the Constitution of India. The Ministry of Women and Child Development has the nodal responsibility of coordinating the implementation of the Convention. Since subjects covered under the Articles of the Convention fall within the purview of various departments/ ministries of the Government, the Inter-Ministerial Committee set up in the Ministry with representatives from the concerned sections monitor the implementation of the

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Convention. In pursuance of this, the Department formulated a National Plan of Action for Children in 1992.

(d) National Plan of Action for Children, 1992 : India is a signatory to the World Declaration on the Survival, Protection and Development of Children. In pursuance of the commitment made at the World Summit, the Department of Women and Child Development under the Ministry of Human Resource Development has formulated a National Plan of Action for Children. Most of the recommendations of the World Summit Action Plan are reflected in India’s National Plan of Action- keeping in mind the needs, rights and aspirations of children in the country. The priority areas in the Plan are health, nutrition, education, water, sanitation and environment. The Plan gives special consideration to children in difficult circumstances and aims at providing a framework, for actualization of the objectives of the Convention in the Indian context.

(e) Education - Right of every Child, 2002 : The Constitution (86th Amendment) Act was notified on 13th December 2002, making free and compulsory education a Fundamental Right for all children in the age group of 6-14 years.

(f) National Charter for Children, 2004 : The National Charter for Children, adopted on 9th February 2004, emphasizes Government’s commitment to children’s rights to survival, development and protection. It also stipulates the duties for the State and the community towards children and emphasizes the duties of children towards family, society and the Nation.

(g) National Action Plan for Children, 2005 : In recognition of the fact that 41% of India’s population is below 18, constituting a significant national asset, The National Plan of Action for Children, 2005 re-affirms the Nation’s commitment to wisely, effectively and efficiently invest its national resources to fulfill its commitments to children. This plan commits itself to ensure all rights to all children up to the age of 18 years. The guiding principles of the action plan are given in the Box - 2.

Box - 2 : The Guiding Principles of the National Plan of Action for Children, 2005

To regard the child as an asset and a person with human rights.

To address issues of discrimination emanating from biases of gender, class, caste, race, religion and legal status in order to ensure equality.

To accord utmost priority to the most disadvantaged, poorest of the poor and least served child in all policy and programmatic interventions.

To recognize the diverse stages and settings of childhood, and address the needs of each.

The National Plan of Action for Children, 2005 is divided into following four sections; and all categories of rights apply to all age groups, including before birth.(i) Child Survival(ii) Child Development(iii) Child Protection(iv) Child ParticipationThe Plan has identified twelve key areas keeping in mind

priorities and the intensity of the challenges that require utmost and sustained attention in terms of outreach, programme interventions and resource allocation, so as to achieve the necessary targets and ensure the rights and entitlements of children at each stage of childhood. Key result areas of the action plan are given in the Box - 3.

Box - 3 : Key Result Areas of the National Action Plan for Children 2005

Reducing Infant Mortality Rate.

Reducing Maternal Mortality Rate.

Reducing Malnutrition among children.

Achieving 100% civil registration of births.

Universalization of early childhood care and development and quality education.

Complete abolition of female feticide, female infanticide and child marriage.

Improving Water and Sanitation coverage both in rural and urban areas.

Addressing and upholding the rights of Children in Difficult Circumstances.

Legal and social protection from all kinds of abuse, exploitation and neglect.

Complete abolition of child labour

Monitoring, Review and Reform of policies, programmes and laws

Ensuring child participation and choice

(h) National Commission for Protection of Child Rights, 2006 : In order to ensure child rights practices and in response to India’s commitment to UN declaration to this effect, the Government of India set up a National Commission for Protection of Child Rights. The Commission is a statutory body notified under an Act of the Parliament on December 29, 2006. Besides the chairperson, it will have six members from the fields of child health, education, childcare and development, juvenile justice, children with disabilities, elimination of child labour, child psychology or sociology and laws relating to children. The Commission has the power to inquire into complaints and take suo motu notice of matters relating to deprivation of child’s rights and non-implementation of laws providing for protection and development of children among other things.

(j) Constitutional Provisions : India’s commitment to children is clearly manifested in its Constitution wherein several articles are dedicated to children (See Box - 4).

National Plan of Action for Children, 2005 : GOALS The National Plan of Action for Children 2005 has set out goals related to various fields of child welfare, exploitation, abuse and their right to health. The salient goals are laid out in Box - 5 to 9.

The ultimate objective of the entire international, regional, national and sub-national effort is to create a society where children will get the most favourable conditions to survive,

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grow and develop into healthy adults. This in other words can happen only in a Child Friendly Society that promotes survival, protection, development of children ensuring their protection against all forms of exploitation with their participation.

There has been a lot of progress in the field of child health in terms of not only improved child health indices but also with respect to global focus towards this very vital social issue. The Convention on the Rights of Children to a healthy childhood is a milestone in this endeavor. However, it is disturbing to note uneven progress not only in different regions and countries but also country to country variation and rural urban differential not only continue to exist but widening as well. The global pledge to address these child health issues by adopting MDGs is a ray of hope for the children of the world. The society has a moral duty to give every child a right to survival, growth, development and protection so that they can achieve their full potential. The ultimate aim of all initiatives towards rights and protection of children is to develop a child friendly society.

Box - 4 : Constitutional Provisions to Children

Article 14 : Equality before the law or the equal protection of laws

Article 15 : The State shall not discriminate against any citizen. Nothing in this Article shall prevent the State from making any special provisions for women and children.

Article 21 A : The State shall provide free and compulsory education to all children of the age of 6-14 years in such manner as the State may, by law, determine.

Article 23 : Traffic in human beings and beggar and other forms of forced labour are prohibited and any contravention of this provision shall be an offence punishable in accordance with the law.

Article 24 : No child below the age of 14 years shall be employed to work in any factory or mine or engaged in any other hazardous employment.

Article 45 : The State shall endeavour to provide early childhood care and education for all children until they complete the age of six years.

Article 243 G read with Schedule 11 : Provide for institutionalization of child care by seeking to entrust programmes of Women and Child Development to Panchayat (Item 25 of Schedule 11)

Box - 5 : Child Health Goals (NAP 2005)

To reduce Infant Mortality Rate to below 30 per 1000 live births by 2010.

To reduce Child Mortality Rate to below 31 per 1000 live births by 2010.

To reduce Neonatal Mortality Rate to below 18 per 1000 live births by 2010.

To explore possibilities of covering all children with plan for health insurance.

Box - 6 : Care and Education Goals (NAP 2005)

To universalize early childhood services to ensure children’s physical, social, emotional and cognitive development.

To ensure that care, protection and development opportunities are available to all children below 3 years.

To ensure integrated care and development and pre-school learning opportunities for all children aged 3 to 6 years.

To provide day care and crèche facilities to parents in rural and urban areas.

Box - 7 : Children in Difficult Circumstances Goals (NAP 2005)

To ensure that best interest of the child is upheld in all policies, plans, programmes, interventions and in strategies for children in difficult circumstances.

To create and uphold a safe, supportive and protective environment for all children within and outside the home.

Box - 8 : Protection Against Sexual Exploitation And Child Pornography Goal (NAP 2005)

To protect all children, both girls and boys, from all forms of sexual abuse and exploitation.

To prevent use of children for all forms of sexual exploitation, including child pornography.

To develop new and strengthen existing legal instruments to prevent sexual abuse and exploitation of children.

Box - 9 : Combating Child Labour Goals (NAP 2005)

To eliminate child labour from hazardous occupations by 2007, and progressively move towards complete eradication of all forms of child labour.

To protect children from all kinds of economic exploitation

SummaryThe early years of life are the most crucial years. Violations of the basic rights of children ranging from child labour, child trafficking, to commercial sexual exploitation may lead to various problems in the future. An estimated 300 million children worldwide are subjected to violence and many others remain without adequate protection. The lack of available services with India having the largest number of under 14 child labourers in the world is a major cause of concern especially with India being a signatory to UN declaration on the Rights of the Child, 1959. UNGASS in its 27th special session in May 2002 aims to create a ‘World Fit for Children’ through certain laid out principles. As a initiative to child rights, India adopted National Policy on Children in 1974 and a number of conventions and departments were setup followed by National Action Plan for Children, 2005 as a recognition of the fact that 41% of India’s population is below 18. It has set out various goals related to various fields of child welfare, exploitation, abuse and their right to health. India’s commitment to children is clearly manifested in its several articles which are dedicated

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to children. The ultimate aim is to develop a Child Friendly Society.

Study ExercisesLong Questions: India’s initiatives on Child Rights.

Short Notes : (1) National Action Plan for Children, 2005 (2) Constitutional provisions relating to child’s rights

MCQs and Fill in the blanks :1) UNGASS stands for __________2) India adopted the National Policy on Children in the year

__________3) Free and compulsory education is a fundamental right

of the children in the age group (a) 7-12 yr (b) 6-8 yr (c) 6-12yr (d) 6-14 yr

4) National action plan for children was launched in ______5) At present _____ % of population is under 18 years of age6) Free and compulsory education is a fundamental right of

the children according to the article (a) 14 (b) 15 (c) 24 (d) 21A

7) No child will be employed in any factory or mines according to Article __________

8) Infant mortality rate should be brought down to below __________ by 2010 according to child health goals

9) Child labour from all hazardous occupations should be eliminated by __________ according to child health goals

10) The department of women and child development was set up under the Ministry of __________

Answers: (1) United Nations General Assembly Special Session; (2)1974; (3) d; (4) 2005; (5) 41; (6) d; (7) 24; (8) 30/1000 live births; (9) 2007; (10) HRD

ReferencesPaediatric priorities in the developing World. D Morley1. World Health Report, 2005. Make every mother and Child Count, WHO2. Integrated Management of Pregnancy and Childbirth. Managing complications 3. in Pregnancy and Childbirth: A guide for midwives and doctors. Department of Reproductive Health and Research, Family and Community Health, WHO, Geneva, 2003The State of the World’s Children, 2005. Childhood Under Threat, UNICEF, 4. New YorkGOI, National Action Plan for Children 2005.5.

149 Growth and Development of Children

A S Kushwaha

Early ChildhoodWhen well nurtured and cared for in their earliest years, children are more likely to survive, to grow in a healthy way, to have less disease and fewer illnesses, and to fully develop thinking, language, emotional and social skills. Although it is never too late to improve the quality of a child’s life, the first three years are the most crucial for their survival and thriving. Frequent illness, unsanitary environments and poor nutrition steal a child’s potential.

When they enter school, their prospects for performing well are improved, and as adolescents, they are likely to have greater self-esteem. Later in life, they have a greater chance of becoming creative and productive members of society. It is a child’s right to have every chance to survive and thrive. Moreover, ensuring optimal conditions for a child’s early years is one of the best investments that a country can make if it is to compete in a global economy based on the strength of its human capital. The growth monitoring, correct feeding practices, immunization, responsive health care system, legal

provisions, sensitive society, management during sickness and providing protection to these children can help in improving the lot of this important group of vulnerable population. The concept of well baby clinic, under five clinic and mother and child clinics are steps in this direction.

DefinitionsGrowth and Development : Growth is the progressive increase in the size of a child. Development is progressive acquisition of various skills (abilities) such as head support, speaking, learning, expressing the feelings and relating with other people. Growth and development go together but at different rates.

Importance : The assessment of growth and development is very helpful in finding out the state of health and nutrition of a child. Continuous normal growth and development indicate a good state of health and nutrition of a child. Abnormal growth or failure to thrive (growth failure) is a symptom of disease. Hence, measurement of growth is an essential component of the physical examination.

Factors affecting growth and development : Each child’s pattern of growth and development is determined by its genetic and environmental influences. The genetic factors determine the potential and limitations of growth and development. If favourable, the environmental factors, such as adequate nutrition, facilitate the achievement of the genetic potential of growth and development. Unfavourable factors, acting singly or

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in combination, slow down or stop the growth and development. Some of the unfavourable factors are malnutrition, infections (prenatal and postnatal), congenital malformations, hormonal disturbances, disability, lack of emotional support, lack of play, and lack of language training. To promote optimum growth, these environmental factors can be removed or minimized. Once they are removed, infant follows a period of catch up growth. During this period the growth rate is greater than normal. This growth rate continues until the previous growth pattern is reached. Then the growth rate is reduced to the normal rate determined by the individual’s genetic factors.

A child genetically determined to be tall grows slightly more rapidly than a child genetically determined to be short. Socio-economic factors, emotional and cultural factors too exert their influence on the growth and development of children.

Laws of growth : Growth and development is a continuous and orderly process and follows a particular pattern over a period of time termed as sigmoid curve. There are periods of rapid growth and slower growth. Growth pattern of each child is unique. Each organ system and body part also has its characteristic pattern of growth. The body, brain and gonads grow in a different manner in different phases of childhood. The children grow in 3 different types of physical patterns of growth, ectomorphs, endomorphs and the mesomorphs.

1. Somatic growth (Body size) : This is rapid during foetal life, 1st 2 years of life and after onset of puberty. This follows a sigmoid curve pattern.

2. Brain growth : The brain enlarges rapidly during latter months of foetal life and early months of postnatal life. At birth head size is 65-70% of the expected head size of the adult. It reaches 90% by the age of two years.

3. Gonadal growth : Gonadal growth is dormant in childhood with rapid growth during puberty. The growth spurt during puberty is attributed to neuro-hormonal stimulation of the hypophysis by the hypothalamus.

4. Lymphoid growth : This is most notable in mid-childhood and may be even larger than in an adult.

Weight : Body weight represents the sum of protein, fat, water, and bone mineral mass, and does not provide any information on relative changes in these four chemical components.

Weight for age in children from 6 months to 7 years of age is an index of acute malnutrition, and is widely used to assess protein energy malnutrition and over nutrition, especially in infancy when the measurement of length is difficult. A major limitation of it as an index of PEM is that it does not take into account height differences. As a result children with low weight for age are not necessarily wasted. To interpret a single measurement of weight in relation to the reference data, the exact age of the child must be known. The average birth weight in Indian children is around 2.6 Kg and 3 kg in developed countries. After losing 10% weight in 1st week, the infants regain their weight by the second week. They gain weight at an approximate rate of 25-30 gm per day for 3 months. The gain in weight in next 9 months is @ 400 gm per month. An infant doubles weight by 5 months and triples by one year of age and becomes 4 times his birth weight by end of 2 years. At 3 years

the weight becomes 5 times the birth weight. On an average child gains 2 kg per year in 3-7 years age and 3 kg after that till puberty.

Head Circumference (HC) : HC is important because it is closely related to brain size. It can be used as an index of chronic protein energy nutritional status during the first two years of life. Chronic malnutrition during the first few months of life, or intrauterine growth retardation, may decrease the number of brain cells and result in an abnormally low head circumference.

Beyond the age of two years, growth in HC is slow and its measurement is no longer useful.

The head circumference is measured by encircling the head with an unstretchable tape measure, or a piece of string in the absence of a tape measure. This is passed over the most prominent part of the occiput posteriorly and just above the supra-orbital ridges anteriorly to obtain the greatest distance around the head. At birth HC is 35 cm, at 3 months 40 cm, 45 cm at 1 year and reaches 48 cm by second year and 52 by 3rd year. Crown rump length (CRL) is always <HC in 1st year of life.

Mid Upper Arm Circumference (MUAC) : Arm contains subcutaneous fat and muscle. A decrease in MUAC may therefore reflect a reduction in muscle mass, a reduction in subcutaneous tissue or both. In developing countries, where the amount of subcutaneous fat is frequently small, a change in MUAC tend to parallel changes in muscle mass and hence is particularly useful in the diagnosis of PEM or starvation. Changes in MUAC can also be used to see progress during nutritional therapy. MUAC changes are easy to detect and require a minimal amount of time and equipment. Some investigators claim that MUAC can differentiate normal children from those of PEM as reliably as weight for age. MUAC changes very little from 1-5 years of age and it can be used as an age-independent measurement.

Low MUAC has been shown to be a sensitive indicator of risk of death in children.

The mid upper arm circumference is measured using a tape or string in the absence of a tape. The tape or string is placed around the upper arm, midway between the olecranon and acromion processes. Care is taken not to pull the tape or string too tightly. The mid upper arm circumference increases fairly rapidly to about 16 cm by the age of one year. In the period 1 to 5 years, the mid upper arm circumference increases by only 1 cm. So, irrespective of age, the mid upper arm circumference of well nourished children ranges 16 -17 cm in the period 1-5 years. Conversely, if the mid upper arm circumference of a child of 1 to 5 years of age is less than 16 cm, that child has malnutrition and corrective intervention should be carried out.

Length / Height : The length of a child is measured in the first 3 years and the height is measured after 3 years of age. The length is measured using a horizontal measuring board put on the ground or on a table. The child is laid on his back with the head against the fixed head board. A helper holds the child’s head so that the eye angle- external ear canal line is vertical and also keeps the body straight. With one hand of the health worker, the child’s knees are pressed down to straighten the child’s legs fully while, with the other hand, the sliding foot

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board is placed to touch the child’s heels firmly. With the foot board in place, the child’s length is read on the metre scale. To measure the height, a bare foot child stands with the feet together. The heels, the buttocks and the occiput lightly touch the measuring device. The head is aligned so that that the external eye angle- external ear canal plane is horizontal. The child is told to stand tall and is gently stretched upward by pressure on the mastoid processes with the shoulders relaxed. The sliding head piece is lowered to rest firmly on the head. The height is read and recorded. An average term baby is 50 cm long. The length increases by 50% in the first year. In the second year, the average height growth is about 12 cm. The birth length doubles by 4 years of age. After the second year of age, the annual height growth averages 5-6 cm until the beginning of the adolescent growth spurt. Height growth stops at about the age of 18 years in girls and at the age of about 20 years in boys. After plotting the child’s height or length on a height chart, you should determine whether the growth pattern is normal. A normal growth pattern is parallel to the printed percentile lines.

Chest circumference : The chest circumference is 3 cm less than the head circumference at birth. They become equal by end of 1st year and thereafter chest circumference exceeds the head circumference.

Tooth eruption : Tooth eruption is an important part of growth. In general, teething in infants usually starts at about 6 months of age, but some start later than 6 months. A new tooth appears approximately every month so that by 2 - 2½ years of age the baby will have 20 primary teeth. This makes the number of teeth roughly equal to age in months minus 6.

A parent should only start to worry about tooth eruption if a child has not yet started teething by 13 months. This is because at this age the child should be eating solid foods. Teething may cause excessive salivation, irritability, disturbed sleep and some pain. Sometimes it also causes Diarrhoea. At the age of about 6 years, the shedding of the primary teeth starts and continues through to the age of 12 years. Eruption of permanent teeth starts at about 6 years of age.

DevelopmentDevelopment is defined as the progressive acquisition of various skills (abilities) such as head support, speaking, learning, expressing the feelings and relating with other people. Each child follows a unique path in growth and development that is laid down from the beginning of life by what he has inherited from both parents. Unfortunately, many factors may change the genetically determined path of growth and development. These things include, for example, infections, lack of care, psychological trauma, bad education, and malnutrition, to mention just a few. The normal well-fed infant who is protected from infections develops quickly, particularly during the first 3 months. It is very important to know the age ranges when most children acquire certain skills. The various skills the baby and a young child learn are called milestones (Table - 1). In monitoring development, we notice at what age the child achieves various milestones, such as smiling at the mother, sitting without support, grasping objects with his/her hands, standing, walking and talking. You should record at what

age the child has achieved the various milestones. Still, it is important to remember that every child develops at his/her own rate or pace. Some walk early, others late.

Infant development occurs in an orderly and predictable manner that is determined intrinsically. It proceeds from cephalic to caudal and proximal to distal as well as from generalized reactions to stimuli to specific, goal-directed reactions that become increasingly precise. Extrinsic forces can modulate the velocity and quality of developmental progress.

Table - 1 : Important Developmental Milestones

Age range

Motor Development Language and social development

Birth When prone turns head to one side to avoid suffocation

Cries

3-6 Months

Good head control Can follow an object with eyes, plays with hands

6-9 Months

Can sit unsupported Grasps actively, makes loud noises

9-12 Months

Able to stand Understands a few words, tries to use them

9-18 Months

Able to walk Grasps small objects with thumb and index finger

15-30 Months

Able to run around as much as he wants

Can say several words or even some sentences

3 Years Plays actively, is able to jump and climb

Starts talking a lot, is curious and asks many questions

Each developmental domain must be assessed during ongoing developmental surveillance within the context of health supervision. Generalizations about development cannot be based on the assessment of skills in a single developmental domain (i.e. one cannot describe infant cognition based on gross motor milestones). However, skills in one developmental domain do influence the acquisition and assessment of skills in other domains.

Speech delays are the most common developmental concern. A sound understanding of the distinction between an isolated speech delay (usually environmental and often can be alleviated) and a true language delay (a combined expressive and receptive problem that implies more significant pathology) will help the clinician refer appropriately for precise diagnosis and appropriate management.

It is essential to understand normal development and acceptable variations in normal developmental patterns to recognize early patterns that are pathologic and that may indicate a possible developmental disability. Assessment of the quality of skills and monitoring the attainment of developmental milestones are essential to early diagnosis of developmental disabilities and expedient referral to early intervention programs.Theories of Development : Developmental theory has been shaped by the persistent debate of whether nature (intrinsic forces) or nurture (extrinsic forces) is the predominant

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influence. Earlier theories centered on the role of nature. By mid 20th century, theories that stressed the importance of nurture began to prevail. Pavlov (1930s), Watson (1950s), and Skinner (1960s) promoted the view that development was a function of learning. Operant conditioning (positive and negative reinforcements through social interactions or environmental changes) promoted learning and shaped the child’s development. During the second half of the century, the name of Piaget became almost synonymous with child development. Piaget was the first to describe the infant as having intelligence. Piaget revealed that infants were, indeed, capable of thinking, analyzing & assimilating. He viewed development as stage-like cognitive changes. The child actively explores objects in an effort to understand his or her environment.

Fields of Development : Gross motor; Fine motor; Social; Cognitive; Psychological; Emotional; Problem solving; Adaptive; Language development.

Developmental Quotient : Developmental Quotient (DQ) is the developmental age divided by chronologic age times 100 (see Example in Box - 1). This provides a simple expression of deviation from the norm. A quotient above 85 in any domain is considered within normal limits; a quotient below 70 is considered abnormal. A quotient between 70 and 85 represents a gray area that warrants close follow-up. Values in the upper limit of normal do not particularly indicate supernormal abilities. The concept of windows of achieving milestones (Fig. - 1) becomes relevant as proposed by the WHO.

Box - 1 : Example - Motor Quotient

A 12-month-old boy is seen for health supervision. He is not walking alone, but he pulls up to stand (9 months), cruises around furniture (10 months), and walks fairly well when his mother holds both hands (10 months). This child has a gross motor age of 10 months at a chronologic age of 12 months. Should this 2-month discrepancy is a concern? To decide, one should calculate the DQ by using these gross motor milestones : DQ =motor age/chronologic age X 100 = 10 X100/12 months= 83

Fig. - 1 : Windows of Development

g

Source : WHO Child Growth Standards

The motor age and the developmental quotient are good summary descriptors of the child and have more meaning than plotting each milestone. Because the lower limit is 70, this boy’s DQ falls within the “suspect” or gray zone. In reality, infants falling into the gray zone of motor domains usually do quite well and rarely require referral to an early intervention program. This is in contrast to those falling in the gray zones of the cognitive domains.

Factors in Development : The factors that promote development include good nutrition, emotional support, play and language training.

1. Good Nutrition : Good nutrition is essential for normal growth and development. Unlike most other organs in the body, the brain is not fully developed at birth. Good nutrition in the first 6 months of life is extremely important. Malnutrition in this period may impair the growth of the brain. As a result of impaired brain growth, the child may suffer for the rest of life. A malnourished child is often tired, apathetic and not interested in learning new things that will promote normal development. Nutrition is discussed in detail elsewhere.

2. Emotional Support : The first 5 years of life are critical for the foundation of the skills. A newborn starts with no knowledge and learns a great deal during his/her first year of life. It is very important to realize that a child is a growing and developing human being right from birth. He ought to be treated very carefully, with love and affection, so that he can develop normally. He needs full emotional support.

3. Play : Play is a source of information, stimulation for the brain, stimulation for the muscles and a lot of fun. All these activities are necessary for physical, mental and social development. All normal children like to play.

4. Language Training : Another factor that promotes development is language training. Children should be offered opportunities to meet, use, and play with words in conversation and in reading books.

Growth MonitoringGrowth Monitoring was popularized by David Morley in 1960s’ and 70s’ (1-5). This strategy proved that growth monitoring could improve nutritional status. His “road to health” chart was a tool which possessed a number of precise functions-(a) Provide a health record of the child which included weight

but also relevant information on immunization, disease episodes, family planning, etc.

(b) Emphasize integration of curative and preventive care.(c) Increase proportion of “care” as opposed to the prevailing

“cure”.(d) Help the family to take care of its own health.(e) Provide a support for the less qualified rural health

worker.In 1982, growth monitoring i.e. the regular weighing of children and charting their weight on a chart was taken up by UNICEF as part of the GOBI program. G= growth promotion, O= ORT (oral rehydration therapy), B = breast feeding, I= immunization. This programme was later extended with the three Fs of Family Planning, Food and activities for Females to GOBIFFF.

Growth monitoring is the process of maintaining regular

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observation of a child’s growth. It starts with measurements of weight daily, weekly, monthly, bimonthly etc. The successive weights are plotted on the growth chart of the child health card. A curve deviating downwards indicates a situation that the child is losing weight. The child needs extra care immediately. The baby may be suffering from malnutrition, tuberculosis, AIDS or other medical conditions. The mother is advised to take the baby to hospital for investigations and treatment. Any infant who does not gain weight for one month or a child who does not gain weight for two months should receive urgent attention. Such an infant or child is becoming malnourished.Importance of Growth Monitoring : Health workers and parents should monitor the growth of children for the following reasons -(a) For early detection of abnormal growth and development.(b) To facilitate the early treatment or correction of any

conditions that may be causing abnormal growth and development.

(c) To provide an opportunity for giving health education and advice for the prevention of malnutrition.

Growth monitoring is one of the basic activities of the Under Five clinics where the child is weighed periodically at monthly intervals during the 1st year, every 2 months during the 2nd year and every 3 months thereafter up to the age of 5 to 6 years. The Anganwadi under ICDS is also based on Growth monitoring and supplementary feeding for children under six years of age.

IAP Guidelines on Growth Monitoring : Growth Monitoring Guidelines Consensus Meeting of the IAP recommended that-

(i) Birth to 3 years : Immunization contacts at birth, 6, 10 and 14 weeks, 9 months, 15-18 months may be conveniently used for growth monitoring. An additional monitoring visit at 6 months with opportunistic monitoring at other contacts (illness) is recommended. Normally growing babies should not be weighed more than once per fortnight under 6 months and no more than monthly thereafter, as this increases anxiety. After 18 months measurements are to be taken every 6 monthly. It is recommended that the height, weight and head circumference be measured up to 3 years of age.

(ii) 4 to 8 years : It is recommended that height and weight be measured 6 monthly during this period and BMI should be assessed yearly from 6 years of age.

(iii) 9 to 18 years : It is recommended that height, weight and BMI be assessed yearly during this period.

AnthropometryAnthropometry means “body measurements”. Anthropometry is very useful for measuring overall health status, not just nutritional status.The advantages of anthropometry1. Simple, safe, non-invasive procedure2. Applicable to large sample sizes3. Requires inexpensive, portable and durable equipment,

which can be made or purchased locally4. Methods are precise and accurate if standardized techniques

are used5. Information on past long term nutritional history can be

obtained

6. Helps in identification of mild, moderate or severe degree of malnutrition

7. Helps in evaluation of nutritional status over time and from one generation to the next (secular trend)

8. May be used in nutritional screening to identify individuals at high risk of malnutrition

Limitations of anthropometric assessment1. Relatively insensitive method and can not detect change of

nutritional status over short period of time.2. Anthropometric information is non-specific and does not

identify the cause of growth failure.3. In poor communities, dietary inadequacies and infection

are often major environmental determinants of growth failure. While anthropometry may index the problem, it does not, by itself, identify the specific cause or indicate the specific solution.

4. Certain non-nutritional factors, viz. disease, genetics, diurnal variation, reduced energy expenditure, etc. can reduce specificity and sensitivity of anthropometric methods.

5. Appropriate sampling or experimental design can largely exclude such limitations.

Uses of Anthropometry1. Population assessment2. Identification of target groups3. Nutritional surveillance4. Monitoring of nutritional status5. Evaluation of program impact6. Growth monitoring of individualsReference Vs Standard : Height and weight measurements mean little unless compared to a growth reference.

Instead of the term “standard”, which originated from the “Harvard Standard” that was developed in 1955, the preferred term today is “growth reference”, which is used to compare measurements. The characteristics of a reference population as defined by WHO, include measurements taken from a well-nourished population with at least 200 children/age and sex group, and from a cross-sectional sample. There have been several growth references developed. The first was the “Harvard Standard”, also known as the “Boston Standard,” the “Stuart-Meredith Standard” or the “Jelliffe Standard”. A “Reference” is defined as a tool for grouping and analyzing data and provides a common basis for comparing populations; no inferences should be drawn about the meaning of observed differences.

Deciding Cut-off Points : Environment plays a more important role than genetics in determining preschool age child nutritional status using anthropometry, given an adequate environment, preschool-age children around the world should have similar growth curves. There are three different types of cut-off points that can be used to identify stunting, wasting, and underweight. Percentiles are useful but are problematic in classifying children who fall outside the extreme centiles of the growth reference (i.e. below the 3rd and above the 97th percentiles) since they cannot be accurately classified. The percent of median is very useful since it provides a more precise estimate of the HFA, WFH and WFA of a population, particularly where stunting, wasting, and underweight are expected, which is common in developing countries. The median of the NCHS

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growth reference is used since it is the best comparison point in distributions of HFA, WFH and WFA. For example, with HFA, in any population there will be a few tall children, a few short children, and the rest in-between. Since the few very tall or few very short children do not adequately represent the group, the median is selected as the comparison point. The cut-off points of <90%, <80% and <70% of reference median for HFA, WFH and WFA to define stunting, wasting and underweight respectively, were selected because studies have shown that significant increases occur approximately at these three cut-off points for various functional parameters, such as mortality. Therefore, these cut-off points are really not as arbitrary as it may appear. The preferred method of cutoff points is Z-score, which is the number of standard deviation units (SD) from the reference median, which is “0” Z-score. The Z-score gives a much more precise measurement of stunting, wasting, and underweight than percentiles or percent of median.Measuring Growth

Measurements : There are various measurements that are used to measure growth.1. Weight2. Head circumference3. Mid Upper Arm Circumference (MUAC)4. Height / length5. Chest circumferenceIndices : Anthropometric indices are combinations of the measurements. They are important since mere measurements provide little useful information. For example, mere body weight has little utility unless it is related to age or height. An example of such combination of two measurements is BMI (weight in kg / height2). Ponderal index is weight/ height3. In children three common indices used are WFH (weight for height), HFA (height for age) and WFA (weight for age). These indices could be expressed in the form of Z-scores, percentiles and % of median which can then be used to compare a child to a reference population. To be useful, these measurements must be taken accurately using reliable equipment and correct measuring techniques.

(a) Z score : The deviation of the value for an individual from the median value of the reference population, divided by the standard deviation for the reference population.

(b) Percentile : The rank position of an individual on a given reference distribution, stated in terms of what percentage of the group the individual equal or exceeds. For example, a child whose weight falls in the 10th percentile weighs the same or more than 10% of the reference population of children of the same age. Percentiles are easy to use and thus preferred in clinical settings. The percentile is interpreted by the percent of individuals above and below specified percentile value. For example 35th percentile is described by 35% of the individuals lying below the value and 65% above. However, the same interval of percentile values corresponds to different changes in absolute height or weight according to which part of the distribution is concerned. Another disadvantage being that

(observed value) – (median reference value)Standard deviation of the reference population

Z score =

towards the extremes of the reference distribution there is little change in the percentile values for significant changes in height or weight.

For example : Consider a child of age 2 years having a weight of 10.5 kgs. When the child is tracked on the growth chart we first locate the age of 2 years i.e. 24 months on the Age axis and weight of 10.5 kgs on the weight axis. The intersection of these two is the point shown by coloured circle (Fig. - 2). We observe that the individual falls in between 50th percentile and 3rd percentile.

(c) Percent of Median : The ratio of a measured value in the individual, for example weight, to the median value of the reference data for the same age or height, expressed as percentage. The disadvantage is that this does not correspond to a fixed point of the distribution across age or height status.

For example consider a child who is 18 months of age and weighs around 7.5 kgs. Again while tracking the child on the growth chart we first locate the intersection point at the specified age and corresponding weight of the child. The coloured point denotes the intersection on the growth chart (Fig. - 3). We observe that the child falls in Grade II of malnutrition. Hence intervention is needed in this child.

Why use ‘Z score’? : One of the problems with percent of median is that although 90% of reference median is the cut-off point for HFA where a child who has a HFA below the cut-off point is classified as stunted, each age group of children actually has a different cut-off point when using percent of median. For example, the cut-off point at -2 Z-score of boys 2 years 4 months is 92.2%; for boys 3 years 5 months, it is 91.1%; for boys 4 years 4 months, it is 91.7%. Therefore, using a cut-off point of 90% for all children may create problems in properly classifying children’s nutritional status - using Z-score eliminates this problem.

Advantages of using Z score over percentage of median1. Z-score cut-off point always at -2 Z-score2. Different cut-off points for % of median for different ages of

children3. Z-score and percentage of median can yield different

results - can cause misclassification4. Clearer interpretation of Z-score5. Misleading interpretation of % of median

IndicatorsAn indicator refers to the use or application of indices. Example, proportion of children below a certain level of weight for age (say -3SD) can be used as an indicator of undernourished children in a given community. These indicators could be used as indicators of body size, health or nutrition or a combination of these. The use of these indicators should be clearly defined as incorrect interpretation and its usage may lead to formation of unscientific interventions.

Growth ChartsIn Haiti, in the mid sixties, Beghin with Fougère and King designed a growth chart based on Gomez classification of degrees of malnutrition, to select children for referral to nutritional rehabilitation centers (1). In Colombia, Rueda Williamson adapted a chart developed earlier by Tony, which

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combined weight and height. As the Director of National Institute of Nutrition, he actively promoted his “auxogramme” which, interestingly enough, was also used for counselling the child’s mother. While working on malnourished children, Dr David Morley introduced the concept of growth monitoring and developed the earliest growth charts. These have come to be known as ‘Road to Health’ charts. The growth chart shows progressive changes in the height and weight of a child in a graphic form. They depict average and permissible range of variation for the particular age and attribute.

The Indian Council for Medical Research (ICMR) undertook a nationwide cross sectional study during 1956 and 1965 to establish Indian reference charts. The measurements were made on children of the lower socio-economic class and hence cannot be used as a reference standard. There are a number of different types of growth charts in use in India. The commonly used and approved by the Government had four reference curves depicting three different grades of malnutrition. The topmost curve represented 80 % of the median of WHO reference standards which is approximately equivalent to 2 SD below the median which is the conventional lower limit of normal range. The three lines below this curve represent 1st to 3rd degree of malnutrition. The prototype WHO chart (home based) had two reference curves. The upper curve represented the median for

boys (50th percentile) and the lower curve represented the 3rd percentile for girls. This chart had an advantage of application to both the sexes.

NCHS (National Center for Health Statistics) developed the growth charts in 1977 and were adopted by the WHO as a clinical tool to monitor growth of children. CDC (Center for Disease Control) in 2000 brought out growth charts and they represent the revised and improved version of NCHS charts. The CDC has introduced two BMI charts besides 16 (8 for boys and 8 for girls) charts. In 1993, the World Health Organization (WHO) undertook a comprehensive review of the uses and interpretation of anthropometric references. The review concluded that the NCHS/WHO growth reference, which had been recommended for international use since the late 1970s, did not adequately represent early childhood growth and that new growth curves were necessary. In response, WHO undertook the Multi-centre Growth Reference Study (MGRS) between 1997 and 2003 to generate new curves for assessing the growth and development of the children which could be applicable the world over.WHO Multi-centre Growth Reference Study (MGRS) Charts: The MGRS combined a longitudinal follow-up from birth to 24 months and a cross-sectional survey of children aged 18 to 71 months. Primary growth data and related information were gathered from 8440 healthy breastfed infants and young

Fig. - 2

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children from widely diverse ethnic backgrounds and cultural settings (Brazil, Ghana, India, Norway, Oman and USA). The MGRS is unique in that it was purposely designed to produce a standard by selecting(a) Healthy children living under conditions likely to favour

the achievement of their full genetic growth potential.(b) The mothers of the children selected for the construction of

the standards engaged in fundamental health-promoting practices, namely breast feeding and not smoking.

The growth standards provide a technically robust tool that represents the best description of physiological growth for children under five years of age. The standards depict normal early childhood growth under optimal environmental conditions and can be used to assess children everywhere, regardless of ethnicity, socioeconomic status and type of feeding. The new growth curves are expected to provide a single international standard that represents the best description of physiological growth for all children from birth to five years of age and to establish the breastfed infant as the normative model for growth and development.

Epidemiological Aspects of the Standards : As expected, there are notable differences with the NCHS/WHO reference that vary by age, sex, anthropometric measure and specific percentile or z-score curve.1. Differences are particularly important in infancy.2. Stunting will be greater throughout childhood when

assessed using the new WHO standards compared to the NCHS/WHO reference.

3. The growth pattern of breastfed infants will result in a substantial increase in rates of underweight during the first half of infancy and a decrease thereafter.

4. For wasting, the main difference is during infancy when wasting rates will be substantially higher using the new WHO standards.

5. With respect to overweight, use of the new WHO standards will result in a greater prevalence that will vary by age, sex

and nutritional status of the index population.

SummaryEnsuring an optimal condition for a child’s early years is one of the best investments that a country can make and it is a child’s right to have every chance to survive and thrive. Environment plays a more important role than genetics in determining preschool age child nutritional status. Growth is the progressive increase in the size and development is progressive acquisition of various skills. Measurement of growth is an essential component of the physical examination in finding out the state of health and nutrition of a child. It follows a particular pattern over a period of time termed as sigmoid curve and the body, brain and gonads grow in a different manner in different phases of childhood. There are various measurements that are used to measure growth like Weight, Head circumference, Mid Upper Arm Circumference (MUAC), Height / length, Chest circumference. Weight for age in children from 6 months to 7 years of age is an index of acute malnutrition, and is widely used to assess protein energy malnutrition and over nutrition. HC is important because it is closely related to brain size. It can be used as an index of chronic protein energy nutritional status during the first two years of life. Arm contains subcutaneous fat and muscle. A decrease in MUAC may therefore reflect either a reduction in muscle mass, a reduction in subcutaneous issue, or both and it changes very little from 1-5 years of age and it can be used as an age-independent measurement. The length of a child is measured in the first 3 years and the height is measured after 3 years of age. On a height chart, you should determine whether the growth pattern is normal. A normal growth pattern is parallel to the printed percentile lines. The various skills the baby and a young child learn are called milestones and that’s why we notice at what age the child achieves various milestones, such as smiling at the mother, sitting without support, grasping objects with his/her hands, standing, walking and talking. Infant development occurs in an orderly and predictable

Fig. - 3

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manner that is determined intrinsically. Speech delays are the most common developmental concern. Piaget was the first to describe the infant as having intelligence. Developmental quotient (DQ) is the developmental age divided by chronologic age times 100. This provides a simple expression of deviation from the norm. A quotient above 85 in any domain is considered within normal limits. The factors that promote development include good nutrition, emotional support, play and language training. Growth Monitoring was popularized by David Morley in 1960s’ and 70s’ (1-5). This strategy proved that growth monitoring could improve nutritional status. In 1982 growth monitoring, i.e. the regular weighing of children and charting their weight on a chart was taken up by UNICEF as part of the GOBI program. Anthropometry is very useful for measuring overall health status, not just nutritional status. IAP has laid down various guidelines for growth monitoring according to different age groups. Height and weight measurements mean little unless compared to a growth reference. Anthropometric indices are combinations of the measurements. They are important since mere measurements provide little useful information; for example Ponderal index, WFH (weight for height), HFA (height for age) and WFA (weight for age). These indices could be expressed in the form of Z-scores, percentiles and % of median. The prototype WHO chart (home based) had two reference curves. The upper curve represented the median for boys (50th percentile) and the lower curve represented the 3rd percentile for girls. The growth standards provide a technically robust tool that represents the best description of physiological growth for children under five years of age.

Study ExercisesLong Question : “Growth and development is very helpful in finding out the state of health and nutrition of a child”. Explain in detail.

Short Notes : (1) Mid upper arm circumference (2) Development quotient (3) Growth monitoring (4) Anthropometry (5) Growth charts (6) IAP guidelines for growth monitoring

MCQs and fill in the blanks1) At birth head size is ________ % of the expected head size

of the adult.2) Weight for age in children from ________ years to ________

years of age is an index of acute malnutrition3) Head circumference at birth is ________ cm4) The length of a child is measured in the first _____ years.5) By 2 - 2½ years of age the baby will have _________

primary teeth.6) A developmental quotient below ___________ is considered

abnormal7) Growth Monitoring was popularised by ________8) Weight / height3 represents a) Brocas index b) Ponderal

index, c) Quetelet index, d) none9) Z score = ___________Answers: (1) 65 to 70; (2) 0.5 yrs to 7 yrs; (3) 35; (4) 3; (5) 20; (6) 70; (7) David Morley; (8) b;

(9) (observed value) – (median reference value)Standard deviation of the reference population

Z score =

ReferencesBeghin I, Fougère W, King KW. L’alimentation et la nutrition en Haïti. Paris: 1. Presses Universitaires de France,1970. 248 pagesMorley D. A medical service for children under five years of age in West 2. Africa. Trans Roy Soc Trop Med Hyg. 1963;57:79-94.Morley D. The spread of comprehensive care through under-fives’ clinics. 3. Trans Roy Soc Trop Med Hyg. 1973;67(2):155-170.Morley DC. Paediatric priorities in developing world. London: Butterworths, 4. 1973.Morley D. The design and use of weight charts in surveillance of the 5. individual. In: Beaton GH and Bengoa JM (Eds.): “Nutrition in preventive medicine”. Geneva: WHO, 1976; 520-529.Morley D, Woodland M. See how they grow: monitoring child growth for 6. appropriate health care in developing countries. London: Mc. Millan, 1979.The World Health Organization. Expert Committee on Physical Status. The 7. Use and Interpretation of Anthropometry. Physical Status: Report of a WHO Expert Committee: WHO Technical Report Series 854, WHO, Geneva, 1996.MGRS- 2006.8.

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150 Genetics and Public Health

Amitava Datta

Historical AspectsHomosapiens first appeared on this planet approximately 50,000 years ago. Early man seemed to be as curious as in the present day on matters of inheritance. Engravings in Chaldea in Babylonia (now Iraq) dating back at least 6000 years show pedigrees documenting the transmission of certain characteristics of the mane in horses. Early Greek philosophers and physicians such as Aristotle and Hippocrates concluded with typical masculine modesty that important human characteristics were determined by semen utilizing menstrual blood as a culture medium and the uterus as an incubator. Our present understanding of human genetics owes much to the work of the Austrian monk, Gregor Mendel, who in 1865 presented the results of his breeding experiments on garden peas. The importance of these findings were however only realized in 1900. It was a Danish botanist, Johannsen who coined the term “gene” for the hereditary factors postulated by Mendel. Credit for first recognition of a single gene trait is shared by William Bateson and Archibald Garrod who proposed that alkaptonuria was a rare recessive disorder. During the twentieth century, it gradually became clear that hereditary factors are implicated in many conditions and that different genetic mechanisms are involved. The study of genetics and its role in the causation of human disease has in modern times been at the forefront of medical research. Francis Crick, James Watson and Maurice Wilkins in 1962 gained acclaim for their elucidation of the structure of DNA. In the next 30 years or so the Nobel prize was awarded on twelve occasions to scientists working in the field of human and molecular genetics. Dramatic advances in technology lead to better and more complete understanding of the way we inherit different characteristics, why diseases occur and human biology. Increasing globalization and the internet enabled the gigantic “Human Genome Project” started in 1991, mainly with funding by United States Government, to map the complete human genome. Thus throwing up tremendous potential for diagnosis and management of human disease. Gene therapy, which till recently was considered in the realms of science fiction, suddenly became eminently possible although its routine use in the management of disease is still several years away.

Increasing control world wide on communicable diseases, ethical considerations of gene manipulation and better understanding of genetic basis of disease has pushed genetics into the realm of public health. A comprehensive knowledge of elementary genetics is now therefore inescapable for a potential public health specialist.

Cellular basis of InheritanceThe structure of a cell as evident on light microscopy is shown in Fig 1.

The transmission of hereditary characteristics is controlled by chromosomes located inside the nucleus and containing genes which are made up of DNA. The double helical structure of DNA

was proposed by Watson and Crick to explain the versatility of the transmission mechanism. The chromosome structure is however more complex. DNA sequences make up genes which code for different proteins necessary for life. It is estimated that there are upto 1,00,000 genes in the nuclear genome, which code for specific proteins in humans. Many human genes are single copy genes coding for polypeptides which carry out a variety of cellular functions. These include enzymes, hormones, receptors and structural and regulatory proteins.

Fig - 1 : Structure of Cell

Ribosome

Endoplasmicreticulum

Nucleolus

Nuclearmembrane

Chromosomes

CellmembraneCytoplasm

Mitochondria

The original concept of a gene as a contiguous sequence of DNA coding for a protein was turned on its head in the early 1970s by detailed analysis of the structure of the β-globin gene which revealed it to be much longer than the length necessary to code for the β-globin protein. The gene was found to be containing non-coding intervening sequences or “introns” separating the coding sequences or “exons”. The number and size of introns in various human genes is extremely variable although the general trend is that larger the gene, the greater the number of exons.

Fig. - 2 : Structure of Gene

TranscriptionInitiation

TranscriptionTermination

Promoterregion

TranslationInitiation

Codon(ATG)

TranslationTermination

Codon(TAA)

PolyadenylationSignal

Exon1 Exon2 Exon3

Intron2Intron1

5’ 3’

‘CAT’Box

‘TATA’Box

The process whereby genetic information is transmitted from DNA to RNA is called “transcription”. The information stored in the genetic code is transmitted from DNA to messenger RNA (mRNA) which is single stranded. The mRNA leaves the

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nucleus after undergoing “post-transcription processing”. The transmission of the genetic information from mRNA to protein is called “translation”. mRNA migrates out of the nucleus into the cytoplasm where it becomes associated with the ribosomes, which are the site of protein synthesis. In the ribosomes, the mRNA forms the template for producing a particular sequence of amino acids (See Fig. - 3a & b).

Fig. - 3a : Process of TranscriptionTRANSCRIPTION

INITIATIONTRANSCRIPTIONTERMINATION

TATA BOX

Exon1 Exon2 Exon3

Poly (A)Signal

Translation stopTranslation start

Primary RNA

TranscriptionPolyadenylationCapping

Splicing

TranslationPost-transitionalprocessingProtein

Poly (A) tall1’ Cap

mRNA

3’

5’

Intron2Intron13’

5’

Fig. - 3b : Process of Translation

A A A C T C C A C T T C T T CU U U G A G G U G A A G A A G

U U U G A G G U G A A G A A GC U C C A C

U U CA A A

DNA

m-RNA

Nuclearmembrane

m-RNA(template)

t-RNA

Ribosome

ValineLysinePeptide

Glutamic AcidPhenylalanine

Genetic information is stored with the DNA molecule in the form of a triplet code, that is a sequence of three bases determines one amino acid. Only 20 different amino acids are found in proteins. By experimentation with various refinements, triplet codes have been assigned to all 20 amino acids. The triplet of nucleotide bases in mRNA which codes for a particular amino acid is called “codon”. In addition to “Structural genes” ( which are concerned with the synthesis of specific proteins), there are “control genes” which regulate the activity of structural genes. It was initially believed that genetic information was transferred from DNA to RNA and thence translated into protein. However, at times genetic information can occasionally flow from RNA to DNA (as in the case of retro virus). This is referred to as “RNA directed DNA synthesis”.

MutationsA mutation is defined as an alteration or change in the genetic material. Mutations are usually harmful and can arise due to exposure to mutagenic agents but may occur in a vast number of cases spontaneously through errors in DNA replication and repair. Although mutations can occur in “coding” or “non-

coding” sequences, it is only in the former that some disease or condition arises. A mutation occurring in a somatic cell cannot be transmitted to future generations. It is estimated that each individual carries upto six lethal or semi-lethal recessive mutant alleles which in the homozygous state would have very serious effects. Occurrence of mutations in DNA, if left unrepaired, would have serious consequences both for the individual and subsequent generations. The stability of DNA is dependent on “DNA repair”. Defects in this mechanism can lead to chromosomal breakage syndromes.

ChromosomesChromosomes are thread like structures and can be considered to be made up of genes. The centromere divides the chromosome into short and long arms designated ‘p’ = petit and ‘q’ = grand respectively. The tip of each end is referred as telomere, which plays an essential role in sealing the ends of the chromosome. In human cells, there are 22 pairs of autosomes and a pair of sex chromosomes - XX in female and XY in male. One member of each chromosome is derived from each parent. Somatic cells have a diploid component consisting of 46 chromosomes whereas gametes (ova or sperm) have haploid complement of 23 chromosomes. Recent developments have allowed the study of chromosomes to detect regions of allele loss and gene amplification. The process of cell division ensures that the human zygote which is a single cell at conception undergoes rapid division leading to approximately 1014 cells in an adult. In some organs and tissues, the process of cell division continues throughout life. In mitosis (somatic cell division) the chromosome divides longitudinally and after separation forms two daughter cells. In meiosis (gamete formation) the chromosome number is halved during Meiosis I while Meiosis II is like ordinary mitotic division. Meiosis facilitates halving of the diploid number of chromosomes so that each child receives half of its chromosome complement from each parent. It also provides an extraordinary potential for generating genetic diversity as DNA derived from both parents are present in each chromatid. The process of gametogenesis is different in male and female.

In oogenesis, oogonia derived from primordial germ cells start undergoing meiosis by 3 months of intra uterine life. At birth all the primary oocytes enter a phase of maturation arrest known as dictyotene in which they remain suspended until meiosis I is completed at the time of ovulation when a single secondary oocyte is formed. The lengthy interval between onset of meiosis and its eventual completion upto 50 years later has been suggested as the reason for the well documented increase in chromosomal abnormalities in offspring of older mothers.

In spermatogenesis, spermatogonia mature into primary spermatocytes at puberty. Spermatogenesis is a continuous process involving many mitotic divisions so that spermatozoa produced by a man of 50 years or older could well have undergone several hundred mitotic divisions. DNA copy errors may lead to mutations in offspring of older parents.

Chromosomal AbnormalitiesA large number of disorders are due to chromosomal abnormalities which can be due to either numerical or structural abnormality of chromosomes. Numerical abnormalities

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involve the gain or loss of one or more chromosomes- aneuploidy or addition of one or more complete haploid complement of chromosomes - polyploidy. The common examples are Trisomy 21 (Down’s syndrome), Trisomy 13 (Patau’s syndrome), Trisomy 18 (Edward’s syndrome), Monosomy X (Turner’s syndrome), Super males (XYY) or Super females (XXX). The commonest cause is non-disjunction during meiosis (Fig.-4). Polyploidy is found relatively often in spontaneous miscarriage and is usually not commensurate with life. It is usually due to failure of a maturation meiotic division in ovum or sperm or fertilization of an ovum by two sperms.

Structural chromosomal abnormalities result from chromosome breakage with subsequent reunion in a different configuration (Fig. - 5). This may be due to translocation (transfer of genetic material from one chromosome to another), deletions (loss of part of a chromosome), insertions (segment of one chromosome becomes inserted into another chromosome), inversions (two break rearrangement involving a single chromosome in which a segment is reversed in position), ring chromosome (break on each arm of a chromosome leaving two “sticky” ends which reunite as a ring) and Isochromosomes (loss of one arm of a chromosome with duplication of the other arm). In all the structural abnormalities, when there is loss or gain of genetic material called balanced rearrangement, the effect is mild. When there is incorrect amount of genetic material due to loss or gain, it is called unbalanced arrangement and the clinical effects are usually very severe.

Fig. - 5 : Chromosomal Abnormalities : Inversion

AB

C

D

E

A

B

C

D

E

A

B

C

D

A

B

C

D

Incidence and Prevalence of Genetic diseaseGenetic disease may manifest at birth or may remain without manifesting till several decades later. Besides the disorders which are clearly genetic in origin, several disorders like

Diabetes mellitus, cancers etc. are multi- factorial in origin. The genetic predisposition with suitable environmental conditions can lead to the occurrence of these diseases. The very process of aging is now considered to be genetically determined as are some of the diseases which have a rising incidence with age - “acquired somatic genetic disease”.

Certain predictions have been made based on the assumption that heritability of disease declines with increasing age :

Persons with early onset of symptoms are more likely to ●have severe disease and also to have affected first degree relatives.Age specific age at onset should reach a peak and then ●decline.Multi-genic diseases do not require a specific environment ●for their occurrence.Migration, socio-economic status and other environmental ●change may affect the age of onset and the likelihood of the clustering of the disease in families.If one sex is less often affected, early onset, severity and ●increased incidence in affected relatives should characterize it.Concordance in monozygotic twins should be greatest ●when disease onset is early.Patients with late onset of the disease have milder forms ●of the disease which are more amenable to prevention and treatment.

Burden of Genetic DiseaseThe burden of diseases of genetic etiology in a community is determined by the “Gene pool”, customs regarding marriage (breeding patterns) and migrations. The social and demographic structures of populations play a very significant role in the distribution patterns of specific inherited disorders. In countries with recent industrialization and urbanization, widespread population movement from the countryside (rural areas) to rapidly expanding towns and cities (urban areas) have resulted in dissolution of historical, local, regional and national boundaries. This has helped to exert a partial homogenizing effect on national gene pools. This is similar to the effect that large scale migration from Europe to Americas and Australia had in the previous centuries which resulted in significant mixing of previously distinct populations.

Fig. - 4 : Chromosomal Non-dysjunction

A B C

Meiosis I Non dysjunction

Non dysjunctionMeiosis II

Normal MonosomicGametes

DisomicGametes

NullisomicGametes

NormalMonosomic

Gametes

DisomicGamete

NullisomicGamete

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In most developing countries, local and regional clan, tribal and ethnic grouping have largely remained intact. In India, Pakistan and Bangladesh which collectively account for more than 20% of the world’s population, marriage continues to be arranged within caste and biraderi boundaries that probably date back some 3000 years. In India, it is estimated that there are 50,000 to 60,000 separate endogamous communities. 25 percent of the population of more than 1 billion are members of the scheduled castes and scheduled tribes which number more than 1600. Muslims account for 130 million of India’s population. Each of these groupings forms separate breeding pools - Hindus (divided into castes & regions), Muslims, Sikhs, Christians Jains, Buddhists, Parsis etc.

Therefore diseases caused due to mutations of ancient origin are likely to be distributed throughout the population. However diseases due to mutation which have arisen more recently may be restricted or even unique to individual ethnic groups, sub-castes, tribes or clans.

Although adequate statistics are not available in India of the incidence and prevalence of genetic disorders, certain studies have attempted to estimate the burden due to genetic diseases in India. The large population, high birth rate and favouring of consanguineous marriage by significant numbers of communicates, should lead to high prevalence of genetic disorders in the country. According to a study it is estimated that every year 4,95,000 infants with congenital malformations, 3,90,000 with G-6 PD deficiency, 21,400 with Downs Syndrome, 9,000 with thalassaemia, 5,200 with sickle cell disease and 9,760 with amino acid disorders are born each year. Studies on haemoglobinopathies indicate that they represent a significant national health burden in India. Distribution of specific disorders varies geographically and by community. Heterozygote frequencies of thalassaemia range from 1 to 15 percent resulting in an estimated 20 million carriers. Sickle cell anaemia is mainly present in tribal communities with carrier presence as high as 40 percent in some cases. It is estimated that there are 50,000 affected Hemophilia patients nation wide with an additional 1,500 new cases born each year. The prevalence of late onset multifactorial disorders including coronary artery disease, hypertension and psychiatric disorders is also large. Genetic eye disorders have been reported in large numbers. Shankar Nethralaya, the premier institute for ophthalmology in South India has reported 2,335 patients with genetic eye disorders over a five year period. 673 (28.8 percent) of these patients reported a family history of consanguinity. Retinitis pigmentosa was detected in a large proportion (63.9 percent) of those reporting family history of consanguinity.

The seriousness of the burden of genetic disorders in India is thus clearly appreciable inspite of lack of population based studies. Determining the role of genetics in disease will require better methods of classifying disease and processing health data. Computerized record keeping will become very important not only to build longitudinal health histories on individuals but also to link these into sibships and family groupings. Administrative and other health data sets that already exist can be combined to evaluate if familial clustering occurs. If familial clustering is detected, then various methodologies may be used to untangle whether this is due to genetic or shared

environmental factors or more likely to be an interaction between the two.

Categories of Genetic DiseaseThe broad classification of various categories of genetic disease has evolved with the availability of sophisticated diagnostic tools which has enabled identification of genetic and molecular basis of these disorders.

Chromosomal DisordersSince the demonstration in 1959 that the presence of an additional number 21 chromosome (Trisomy 21) results in Down’s syndrome, more than 1,000 chromosomal syndromes have been reported. They have a major contribution to morbidity and mortality in infants and account for a large proportion of spontaneous abortions. Chromosomal abnormalities have been detected in 10 percent of spermatozoa and 25 percent of mature oocytes. It is estimated that 15-20 percent of pregnancies do not survive beyond a few weeks due to presence of chromosomal abnormalities and also that more than 50 percent of all spontaneous abortions are having chromosomal abnormalities. The common abnormalities are :

Trisomy (50 percent) ●Monosomy X (20 percent) ●Triploidy (15 percent) ●Tetraploidy (5 percent) ●Others (10 percent) ●

The presence of chromosomal abnormality in newborns ranges up to 90 per 10,000 births. The common abnormalities are Autosomal (20 per 10,000) & Sex chromosome (30 per 10,000). The presence of chromosomal abnormality reduces from conception to birth. The presence in still births is about 5 percent. It is known that spontaneous pregnancy loss occurs commonly in the presence of chromosomal abnormalities, with as high as 80%-98% pregnancies being lost among foetus having Monosomy or various forms of Trisomy. The common chromosomal disorders are :Autosomal Disorders (Gain of entire chromosome)

Down syndrome (Trisomy 21) ●Patau syndrome (Trisomy 13) ●Edward’s syndrome (Trisomy 18) ●

Chromosomal Deletion Syndromes (Deletion of part of chromosome)

Wolf Hirschhorn syndrome (Chromosome 4) ●Cri-du-chat syndrome (Chromosome 5) ●Retinoblastoma (Chromosome 13) ●Wilm’s tumour (Chromosome 11) ●

Sex Chromosomal Disorders (Gain or loss of entire chromosome or part)

Klinefelter’s syndrome (47, XXY) ●Turner’s syndrome (45, X) ●Super females (47, XXX) ●Super males (47, XYY) ●Fragile X Syndrome (46, XX*) ●

The chromosomal disorders are all potentially detectable by pre natal diagnosis. Since only those subgroups of women identified as being at higher risk (due to family history or age) are screened pre-natally, there is an opportunity to avoid only a proportion of these conditions at present.

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Single Gene or Mendelian Disorders Credit for the first recognition of a single gene trait is shared by William Bateson and Archibald Garrod who together proposed that alkaptonuria was a rare recessive disorder. Since then many more disorders have been identified - by 1966 almost 1500 single gene disorders or traits had been identified which follow the mendelian rules of inheritance. An American physician, Victor Mckusick published a catalogue of all known single gene disorders. An online version of Mckusick’s catalogue has been created which is known as “Online Mendelian Inheritance in Man” (OMIM) which can be accessed on the World Wide Web. As on 07 July 2008, there were 18,811 single gene traits or disorders which were included in this catalogue. There are mainly four categories into which single gene disorders are grouped, based on patterns of inheritance as indicated below :

Autosomal Dominant Disorders (AD)An autosomal dominant trait is one which manifests in the heterozygous state i.e. in a person possessing both the abnormal or mutant allele and the normal allele. It is often possible to trace a dominantly inherited trait or disorder through many generations of a family. The disorder is transmitted to both sexes of the progeny. Any child born to a person affected with a dominant trait has a one in two (50%) chance of inheriting it and being similarly affected. Autosomal dominant traits can involve only one organ or part of the body e.g. Polydactyly. The clinical features can show striking variation from person to person and in some cases the findings can be undetected - “reduced penetrance” possibly due to the modifying influence of other genes. Examples of autosomal dominant traits or disorders are Huntington’s chorea, Neurofibromatosis, Polyposis coli. There may be also some cases due to new mutations. In these cases it will not be possible to trace the trait in the family and hence pose problems in genetic counselling.

Autosomal Recessive Disorders (AR)Most recessive disorders are individually rare, each with a birth prevalence of 1 in 15,000 to 1 in 1,00,000. However, since there are so many, they have a considerable impact with 1 in 500 live born individuals being identified as having one of these disorders before age 25 yrs. The recessive traits and disorders are only manifest when the mutant allele is present in a double dose i.e. homozygosity. Individuals who are heterozygous for a recessive mutant allele show no features of the disorders and are perfectly healthy i.e. they are carriers. It is usually not possible to trace an autosomal trait or disorder through the family tree. However, consanguinity can be detected in the ancestors. Generally speaking, the rarer a recessive trait or disorder, the greater the frequency of consanguinity among the parents of the affected persons. Autosomal recessive traits are transmitted both to sons and daughters equally and both are capable of transmitting it to their sons and daughters. The progeny may however, not manifest unless they are in homozygous state. The chance of having an affected child inheriting the recessive trait is 1 in 4. Common examples of autosomal recessive traits or disorders are : cystic fibrosis, albinism, alkaptonuria, and haemoglobinopathies.

Sex Linked Inheritance It refers to the pattern of inheritance shown by genes which are located on either of the sex chromosomes. Genes carried on the X chromosome are referred to as X-linked, while genes carried on the Y chromosome are referred to as exhibiting Y - linked or “Holoandric inheritance”.

X-linked Recessive disorders (XR) : An X linked recessive trait is one determined by a gene carried on the X chromosome and usually only manifests in males. These disorders are transmitted by healthy heterozygous female carriers to affected males, as well as by affected males to their obligate carrier daughters. The mode of inheritance whereby only males were affected by a disease which is transmitted by normal females was appreciated by the Jews nearly 2000 years ago. They were excused from circumcision, the son of all sisters of a mother who had sons with the “bleeding disease” i.e. Haemophilia. The sons of the father’s sibs were not excused. A male transmits his X chromosome to each of his daughters and his Y chromosome to each of his sons. If a male affected with Haemophilia has children with a normal female, then all his daughters will be obligate “carriers”, but none of his sons will be affected. A male can not transmit his X-linked disorder to his son except in very rare circumstances. For a carrier female having children with a normal male, each son has a 1 in 2 (50%) chance of being affected and each daughter has a 1 in 2 (50%) chance of being a carrier. Duchenne muscular dystrophy and Haemophilia are common examples of X-linked recessive disorders.

X-linked Dominant Disorders (XD) : There are few disorders in this category like familial Hypophosphataemia with rickets, Alport’s syndrome etc. It superficially resembles autosomal dominant inheritance. Both sons and daughters of an affected female have a 1 in 2 (50%) chance of being affected. However, an affected male transmits only to his daughters and not to his sons. Affected females are more common than males but are less severely affected as compared to males.

Y-linked Inheritance : Y-linked or holandric inheritance implies that only males are affected. An affected male transmits Y-linked traits to all his sons but not his daughters. Hairy ears, H-Y histocompatibilty antigens and genes involved in spermatogenesis are carried on Y chromosome and therefore transmitted accordingly.

Mitochondrial Genetic DisordersGenes coding for proteins involved in oxidative phosphorylation are located in mitochondria in human cells. These are always inherited from the mother. Disorders involving these genes therefore do not behave like other mendelian disorders. Some examples of mitochondrial genetic disorders are Leber’s optic atrophy, infantile bilateral striatal neurosis and Kearns-Sayre syndrome.

Multifactorial DisordersMany disorders demonstrate familial clustering which does not conform to any recognized pattern of mendelian inheritance. Francis Galton, a cousin of Charles Darwin, had carried out research on human characteristics like stature, physique and intelligence based on studying identical twins. The differences among twins in these parameters could only be

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due to environmental influences. He introduced to genetics the concept of “Regression co-efficient” as a means of estimating the degree of resemblance between various relatives. This model, polygenic inheritance, of quantitative inheritance in which many genes play a role in the phenotypic expression is now widely accepted to explain the pattern of inheritance of many relatively common conditions including cleft lip and palate, hypertension and diabetes mellitus. The underlying genetic mechanisms are however, still not well understood.

The liability / threshold model to explain multi-factorial inheritance of disorders proposes that a threshold exists above which the abnormal phenotype is expressed. This hypothesis (rather than proven fact) helps to explain the observed system of inheritance of certain multi-factorial diseases like cleft lip/palate, pyloric stenosis and spina bifida as follows :

The incidence of the condition is greatest amongst relatives ●of the most severely affected patients.The risk is greatest amongst close relatives of the index ●case and decreases rapidly in more distant relatives.If there is more than one affected close relative then the ●risks for other relatives are increased.If the condition is more common in individuals of one ●particular sex, than relatives of an affected individual of the less frequently affected sex will be at higher risk than relatives of an affected individual of the more affected sex. The risk of recurrence for first degree relatives (siblings ●and offsprings) approximates to the square root of the general population incidence, for e.g. if the incidence in the general population of a disease is 1 : 1000, the risk for first degree relatives of an affected person will equal approximately 1 in 32 or 3%.

The inheritance patterns in insulin dependent diabetes mellitus or type - I diabetes mellitus lends a good example of the above elucidated multi-factorial inheritance. The concordance rate in monozygotic and dizygotic twins is 50% and 12% respectively. The sibling recurrence risk is 6%. These observations point to contributions both by environmental and genetic factors. Known environmental factors include diet, viral exposure in early childhood and certain drugs. The disease produces irreversible destruction of insulin producing beta cells in the pancreas by the body’s own immune system probably as a result of an interaction between infection and an abnormal genetically programmed immune response. The polygenic susceptibility consists of one major locus (IDDM-1, which is in the HLA locus on chromosome 6p21), and up to 20 minor loci. The product of these gene loci are believed to interact in a complex and poorly understood manner to confer susceptibility to environmental triggers of auto immune pancreatic beta cell destruction.

Acquired Somatic Genetic Disease Not all genetic errors are present from conception. During the billions of cell division (mitosis), which occur during the life time, the opportunity for occurrence of mutations due to DNA copy errors and numerical chromosomal errors exist. Accumulating somatic mutations and chromosomal abnormalities are now known to account for a large proportion

of malignancies and possibly explain the rising incidence with increasing age of many serious illnesses including the ageing process itself.

Public Health Issues in Genetic DiseasesEpidemiological studies have helped us understand how genetic diseases are distributed in a population. Genetic methods are increasingly allowing us to identify genetically susceptible individuals. New molecular genetic techniques now allow particular DNA sequences to be evaluated in patients and compare with control subjects and hold out the hope for future progress in early detection and even management (gene therapy). Various considerations in prevention of genetic diseases, thus needs detailed analysis.

Primary PreventionEugenics : It is science of improvement of genetic endowment through breeding. It has long attracted the attention of mankind. The term was first coined by Francis Galton. “Positive Eugenics” seeks to improve the genetic endowment in the population of “favourable traits” by encouraging persons with these traits to intermarry. However, as we now know, the inheritance of most of these traits like appearance, skin colour, height, intelligence etc. are inherited in a complicated manner and are difficult to control. “Negative Eugenics” in which people suffering from serious disorders which are genetic in origin are debarred from producing children is practiced in most communities. Many countries do not allow migration of people who are known to have serious genetic diseases. However, as new mutations continue to occur negative eugenics can not be an effective public health tool to reduce the burden of genetic diseases.

Genetic Counselling : More than 40 years ago genetic counselling services to cater for the needs of persons seeking information regarding genetic diseases were first introduced. Genetic counselling caters for the concerns of individuals /families who have a family history of serious diseases. Their concern may be whether they can develop the disease or whether they can transmit the disease.

Genetic counselling has been defined as a process of communication and education which addresses concerns relating to the development and / or transmission of a hereditary disorder. The person who seeks genetic counselling is known as “consultand”. During genetic counselling, the counsellor tries to provide the consultand with information which enables him/ her to understand :

The medical diagnosis and its implications in terms of ●prognosis and possible treatmentMode of inheritance of the disorder and the risk of ●developing and / or transmitting itChoices or options available for dealing with the risks ●

Genetic counselling is non directive, with no attempt to lead the consultand in any particular direction. The process presents medical scientific facts / risks so that the “consultand” can make their own decisions. Commonly, people seek counselling after the occurrence of a hereditary disorder in the family. Rarely, individuals / couples may seek pre-marital advice. Usually , for diseases like mental retardation, congenital abnormalities, etc., there is occasional seeking of such counselling which is thus

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“retrospective” in nature. In certain occasions there may be an attempt to identify heterozygous individuals for a disease and explaining the risks of marrying another heterozygote for the same disease - “prospective” counselling. In both prospective as well as retrospective counselling, the outcomes sought would range from contraception, pregnancy termination or even adoption of a child.

Steps in Genetic Counselling

Establishment of diagnosis : It is the most crucial step in any genetic counselling. Misleading advice may be given based on incorrect diagnosis which may lead to tragic consequences. A correct clinical diagnosis will require proper history taking, detailed clinical examination and appropriate investigations. The family history may need to be obtained by a properly trained genetics nurse or counsellor. Chromosomal and molecular studies will also be needed to establish the inheritability and genetic basis of the disease. At times, for example in hearing loss, etiological heterogenosity may affect the ability to correctly calculate the “recurrence risk”. Other disorders like congenital cataract (AD, AR, XR), ichthyosis (AD, AR, XR), retinitis pigmentosa (AD, AR, XR) and polycystic kidney disease(AD, AR) can also show “genetic heterogenosity”.

Calculating and presenting the risk : This is the next step based on the genetic diagnosis and calculation of risk based on well established norms like use of Bayes Theorem or use of “empirical risks”. The recurrence risks need to be quantified, qualified and placed in context. A risk statement “1 in 4“ can be misunderstood that once it has occurred it will recur only after 3 normal children. Inheritance does not have any “memory” and applies for each offspring. For a risk of recurrence of “1 in 25”, it must also be explained that “24 out of 25” chance is for a normal baby. The risk needs to be qualified by aspects like long term burden rather than its precise numerical value. For a trivial disorder like polydactyly even a risk of “1 in 2” may not deter having more children. Whether a disease can be successfully treated, associated with pain and suffering and whether pre-natal advice is available can be relevant to the decision making process. Placing the risk in context is equally important . For a disease with a population risk of 1 in 40 , an additional risk of 1 in 50 may in fact be considered low. As an arbitrary guide, risk of 1 in 10 or greater can be regarded as high while 1 in 20 or less can be regarded as low.

Discussing the options : It is a natural follow up after making the diagnosis and presenting the “risks”. All the choices should be provided with no attempt made to guide the consultand to select one of them. The issues need to be broached with care and sensitivity as the realization of the disease, its risks and the likely outcomes may be cause of great emotional shock to the consultand.

Communication and support: It is provided by most genetic counselling clinics. The setting of the counselling must be agreeable, private and quiet with ample time for discussion and questions. As far as possible, technical terms must be avoided but no attempt must be made to hide facts and questions answered honestly and openly. It is necessary to reiterate the aspects covered specially the aspects of risk in written communication as all aspects may not have been clearly

understood by the Consultand during the limited duration of the counselling session. A letter summarizing the topics discussed is then sent to the Consultand. Informal contact through a network of genetic associates or nurse specialist are also an added features of genetic counselling clinics.

Other Health Promotional Measures : Problems of increased genetic diseases in late marriages and advancing age of mother are now common knowledge. Appropriate counselling is required to restrict pregnancies arising from late marriages or in women past 35 years.

Consanguineous marriages are another cause for concern. Community involvement will be needed to overcome this social occurrence. A consanguineous marriage is defined as one in between blood relatives with at least one common relative no more remote than great-great-grand parents. Hearing loss, mental retardation, alkaptonuria are common among offsprings of consanguineous marriages.

Specific Protection : Radiation, chemicals and drugs are known to produce mutations and teratogenic effect. Adequate protection is needed to be ensured for persons in the reproductive age group. X-Ray and other ionizing radiations produce mutations which are proportional to the dose of radiation. There is no threshold. Genetic effects are known to be cumulative and protection is routinely provided to all those who are likely to be occupationally exposed to radiation.

Chemicals like mustard gas, benzene, formaldehyde, caffeine, etc. are known mutagens in animals. Caution is therefore required to prevent exposure to these and basic dyes by human specially those in the reproductive age groups. A large number of drugs have been known to be teratogenic and need to be avoided in pregnancy.

Early Diagnosis : Increasing awareness of the role of genetics in the etiology of disease and its overall impact on the burden imposed on individuals, families and society has lead to introduction of several population genetic screening programs. The primary objective is to enable individuals to be better informed about genetic risks and reproductive options. A secondary objective is the prevention of morbidity due to genetic diseases and alleviation of the suffering. The scope of early diagnosis thus covers apparently healthy persons who may wish to be made aware of genetic disease in themselves or their offspring, diagnosis of the presence of genetic abnormalities in utero as well as the new born and for diagnosis of genetic disease or carrier state in the siblings of a person (adult or child) diagnosed with a genetic disease.

A number of tests of different types are available to detect carriers for Autosomal and X-linked recessive disorders and for pre-symptomatic diagnosis of heterozygotes for Autosomal dominant disorders. Biochemical or hematological techniques can be used to detect carriers of Autosomal recessive disorders like Tay-sachs disease (reduced hexoseaminidase A levels in serum), sickle cell disease / trait ( sickling of RBCs in deoxygenated condition), Duchenne muscular dystrophy (elevated serum creatinine kinase level) and G-6PD deficiency (reduced erythrocyte - G6PD activity). However these tests are reliable only in those cases where the gene involved is directly involved in the biochemical activity.

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Table - 1 : Pre-natal diagnostic techniques

Technique Test & Result Foetal age Genetic conditions diagnosed

Chorionic villus sampling

(2-3% risk of miscarriage)

Chromosome analysis10-11 wks

Chromosomal abnormalities

Biochemical assay Metabolic disorders, Molecular defects

Amniocentesis

(0.5-1%risk of miscarriage)

α -fetoprotein raised

16 wks

Neural tube defects

Chromosome analysis Chromosomal abnormalities

Biochemical assay Metabolic disorders, Molecular defects

Ultrasound ( also indirect evidence of chromosomal disorders)

18 wksStructural abnormalities (heart, kidney, limbs, CVS)

Fetoscopy (3-5% risk of miscarriage)2nd

trimesterStructural abnormalities & others

Radiography (now rarely used) 10 wks Skeletal dysplasias

Maternal serum screening

(usually standard screening for “at risk” mothers)

Fetoprotein raised

16 wks

Neural tube defects

Quad test

- α-fetoprotein reduced

- Unconjugated oestriol reduced

- HCG increased

- Inhibin A increased

Down’s syndrome

Table - 2 : Treatment modalities in genetic diseases

Treatment Disorder

Enzyme induction by drugs : Phenobarbitone Congenital Non-haemolytic Jaundice

Replacement of deficient enzyme / protein :

Blood transfusion

a-glucosidase

Factor VIII

SCID

Gaucher’s disease

Haemophilia A

Replacement of deficient vitamin / co-enzyme :

B6

D

Homocystinuria

Vit D resistant rickets

Substrate reduction in diet :

Phenylalanine

Leucine/isoleucine/valine

Galactose

Cholesterol

Phenylketonuria

Maple syrup disease

Galactosaemia

Fam. hypercholesterolaemia

Drug therapy :

Pancreatic enzymes

Penicillamine

Cystic fibrosis

Wilson’s disease

Replacement of diseased tissue :

Kidney transplant

BM transplant

Polycystic kidney disease

X-linked SCID

Removal of diseased tissue:

Colectomy

Splenectomy

Polyposis coli

Hereditary spherocytosis

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Until the recent past, couples at high risk of having a child with a genetic disorder had to choose between taking the risk or considering other reproductive options. In the recent past reliable pre-natal diagnosis of abnormalities in an unborn child have been widely used to assist decision making by such couples. The ethical issues are however very complex. The techniques used are amniocentesis, chorionic villus sampling, ultrasonography, fetoscopy, foetal blood sampling, radiography and maternal serum screening. A summary of the techniques is indicated in Table - 1.

Treatment : A large number of genetic diseases are “treatable” and the disablement reduced provided the defect has been diagnosed in time. Some of these treatable conditions are enumerated in Table - 2. Although still in the realm of research, gene therapy to correct the genetic abnormality is a distinct possibility and needs serious consideration.

Strategy for public health action The volume of new knowledge and technologies from genetic and genomic research is such that a concerted effort is needed to ensure the effective translation of these scientific advances into benefits for population health. International consensus has been achieved on a public health strategy for achieving this goal. This strategy recognizes the importance of knowledge integration. This integrated and interdisciplinary knowledge base is used for informing public policy, developing new health services (both preventive and clinical), communication and stakeholder engagement, and education and training of health professionals. A new initiative GRAPH Int (Genome-based Research And Population Health International) has been established to promote this strategy for public health action in the genomics era. It facilitates the responsible and effective integration of genome-based knowledge and technologies into public policies, programme and services for improving the health of populations. Practitioners of public health are expected to contribute to this endeavour by remaining aware of the growing importance of the understanding of genetic mechanisms in disease & of the potential to utilize the new genetic knowledge for the benefit of both individuals & society.

SummaryOur present understanding of human genetics owes much to the work of Sir Gregor Mendel in 1865 on breeding experiments on garden peas. In 1962, James Watson and Maurice Wilkins discovered the structure of DNA. The gigantic “Human Genome Project” started in 1991 by US Govt to map the complete human genome to tap its tremendous potential for diagnosis and management of human disease through ‘gene therapy’. Genetic disease may manifest at birth or later or may remain without manifesting. Broadly genetic diseases are classified as Chromosomal disorders - numerical chromosomal abnormalities arising due to non-disjunction during meiosis while structural chromosomal abnormalities results from chromosomal breakage syndrome; Single gene / Mendelian disorders-includes autosomal dominant, autosomal recessive & sex linked disorders; Mitochondrial disorders; Multifactorial disorders-viz spina bifida, diabetes mellitus, cleft lip & cleft palate etc; and Acquired somatic genetic disease-due to accumulation of somatic mutations & aging process itself.

Newer molecular genetic techniques allows to detect particular DNA sequence responsible for causation of disease and therefore escalating importance of prevention of genetic diseases by ethically utilizing preventive approaches viz Eugenics, Genetic counselling, avoidance of consanguineous & late marriages and avoiding exposure to radiation, mutagenic/ teratogenic chemicals and drugs. Besides, myriad of population genetic screening tests and prenatal diagnostic tests are also available for early detection and timely intervention. A new initiative GRAPH Int - Genome based research and population health international has been established to promote the strategy for public health action in this genomic era.

Study Exercises1. The Austrian monk who presented the results of his

breeding experiments on garden peas in 1865 was (a) James Watson (b) Gregor Mendel (c) William Bateson (d) Johannsen

2. The term ‘Gene’ was coined by (a) James Watson (b) Gregor Mendel (c) William Bateson (d) Johannsen

3. The double helical structure of DNA was proposed by (a) Watson & Crick (b) Mendel & Wilkins (c) Bateson & Garrod (d) Johannsen & Maurice

4. How many genes are estimated to be in the human genome (a) 50,000 (b) 1,00,000 (c) 1,50,000 (d) 2,00,000

5. The process where genetic information is transmitted from DNA to RNA is called (a) Processing (b) Transcription (c) Translation (d) Sequencing

6. The site for protein synthesis in the cell is the (a) Mitochondria (b) Nucleus (c) Cytoplasm (d) Ribosome

7. How many amino acids are involved in formation of proteins (a) 10 (b) 15 (c) 20 (d) 25

8. The triplet of nucleotide bases in mRNA which codes for a particular amino acid is called (a) Structural genes (b) Codon (c) Control genes (d) Genome

9. The stability of DNA is based on (a) Coding (b) Non-coding (c) Mutation (d) DNA repair

10. The process of cell division ensures that the human zygote which is a single cell at conception undergoes rapid division leading to cells in an adult (a) 104 (b) 1010 (c) 1014 (d) 1020

11. Edward’s syndrome is (a) Trisomy 21 (b) Trisomy 13 (c) Trisomy 18 (d) Trisomy 22

12. Patau’s syndrome is (a) Trisomy 21 (b) Trisomy 13 (c) Trisomy 18 (d) Trisomy 22

13. Concordance in monozygotic twins should be greatest when disease onset is early: True/False

14. Multigenic diseases require a specific environment for their occurrence. True/False

15. The burden of diseases of genetic etiology in a community is determined by all except (a) Gene pool (b) Breeding pattern (c) Migration (d) None

16. Chromosomal deletion disorder associated with Chromosome 4 is called (a) Wolf Hirschhorn syndrome (b) Cri-du-chat sydrome (c) Retinoblastoma (d) Wilm’s tumour

17. Chromosomal deletion disorder associated with Chromosome 13 is called (a)Wolf Hirschhorn syndrome (b) Cri-du-chat sydrome (c) Retinoblastoma (d) Wilm’s tumour

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151 Preventive Health Care of the Elderly

RajVir Bhalwar

In general, “elderly” age group is defined as persons aged 65 years and above. With improvements in health care, there have been resultant increases in life expectancy and increase in the percentage of “elderly population”. For instance, the current estimates are that in our country the percentage of population who are aged 65 years and above, which was 3% a few decades back, is now 5% and is likely to increase to 10% by 2025 AD and 18% by 2050 AD. These demographic changes will require shifting our focus to cater to geriatrics. i.e. special preventive health care needs as well as medical care needs of the elderly population.

Peculiarities of elderly population in context of health needsThe peculiarities of health needs of elderly people are that their health problems cannot be seen in isolation. There is a wide gamut of social, psycho-emotional and physical correlates which determine the medical problems and this entire gamut of factors (and not simply the treatment of concerned condition) needs to be addressed. The important ones of these factors are as follows :

Social Aspects : As industrialization progresses, it will be difficult for the children to stay on with their parents and carry on with the conventional family occupations. As children move out and take up the vocation in other places, the problems

of isolation and lack of physical support of the old parents, left behind at ancestral places, will come up. Even day to day requirement of life like going out to pay the electricity / telephone bills, buying fresh fruits and vegetables and even cooking a proper nutritious meal would become difficult.

Psycho-Emotional Aspects : With loneliness at home, isolation will occur which would get aggravated if one of the spouses passes away. Friend circle will also get restricted because friends would also get old. The problem of isolation would get worse because of retirement when the old persons would find it difficult to keep them occupied. This complex interplay will not only increase the risk of mental stress and its consequences but also aggravate the impact of stress related diseases as IHD and hypertension.

Financial Issues : Unless backed up by adequate financial savings or pension plans, or else financially assisted by children, there will be definite reduction in income, to the extent that it may interfere with bare needs of life as adequate nutrition, clothing and shelter.

Issues Related to Health care System : At present we do not have a very effective health insurance system in our country, which coupled with the inadequacies of public / Govt. funded general health care system and inadequate training of medical, paramedical personnel in geriatric medicine would adversely affect the health care of the elderly.

Medical Problems of the Elderly A description of medical problems of the elderly is given in this chapter. However, as said earlier, these problems should not be seen as isolated medical issues but should be viewed in the larger context of socio-economic-emotive determinants as

18. As on 07 July 2008, there were _____ single gene disorders included in Mckusick’s catalogue (a)16,811 (b) 17,811 (c) 18,811 (d) 19,811

19. The genes coding for proteins involved in oxidative phosphorylation are located in (a) Mitochondria (b) Nucleus (c) Cytoplasm (d) Ribosome

20. The concept of “regression coefficient” as a means of estimating the degree of resemblance between relatives was given by (a) James Watson (b) Gregor Mendel (c) William Bateson (d) Francis Galton

21. In multifactorial diseases, the incidence of a condition is greatest among relatives of the most severely affected patients : True/False

22. The science of improvement of genetic endowment through breeding is (a) Eugenics (b) Euthenics (c) Genetic counselling (d) None

23. The term ‘Eugenics’ was coined by (a) James Watson (b) Gregor Mendel (c) Francis Galton (d) Johannsen

24. The person who seeks Genetic counselling is called ______

25. GRAPH Int stands for ___________26. Chorionic Villous Sampling is ideally done at (a) 8 -10wks

(b) 10 -12wks (c) 12 -14wks (d) 14 -16wksAnswers : (1) b; (2) d; (3) a; (4) b; (5) b; (6) d; (7) c; (8) b; (9) d; (10) c; (11) c; (12) b; (13) True; (14) False; (15) d; (16) a; (17) c; (18) c; (19) a; (20) d; (21) True; (22) a; (23) c; (24) Consultand; (25) Genome-based Research & Population Health International; (26) b.

Further Suggested ReadingGenetics in disease prevention. Ron Zimmern and Alison Stewart in Oxford 1. Handbook of Public Health Practice. 2nd ed, 2007. 276-281Genetics and the Public Health. Patricia A. Baird and Charles R Scriver in 2. Maxcy-Rosenau-Last. Public Health & Preventive Mediicne. Appleton & Lange. 14th ed, 1998. 1069-1080Human and medical genetics. Friedrich Vogel and Arno G. Motulsky in Oxford 3. Textbook of Public Health. 4th ed, 2002. 131-148.

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an overall health issue. For example, organizing an eye camp for the elderly would have little benefit if the transportation system, traffic control and street / domestic lighting is not improved.

Medical officers and public health programme managers should make special efforts to understand both the preventive as well as curative aspects of health care of the elderly since a significant proportion of our clientele would belong to this age group, and the proportion is likely to further increase, given the steady increases in life expectancy that are occurring in our population.

The health problems of elderly can be divided into 3 groups :(a) Problems which are important for both genders.(b) Problems which mainly concern the elderly males.(c) Problems which mainly concern the elderly females.Problems which are Important for Both the Genders

Ocular Diseases : Age related diminution of vision and cataracts are major issues among elderly and significantly compromise the quality of life as well as Activities of Daily Living (ADL). Glaucoma also is an important cause of suffering among elderly.

Hearing Defects : Reduction in acuity of hearing not only compromises the quality of life but even drives an old person into emotional isolation because they find it difficult to communicate.

Reduced Muscular Strength and Coordination : Reduction in muscular strength due to reduction in lean mass coupled with reduced flexibility and neuromuscular coordination occurs with age and results in increased proneness to accidents and injuries.

Accidents and Injuries : There is marked increase in risk of accidents and injuries among the aged. The major physio-pathological factors which contribute to such increased proneness are diminution of vision and hearing, reduced muscular strength and neuro-muscular coordination, and various environmental factors, notably wet, slippery floors and poor lighting. The commonest areas of accidents are the toilet (due to wet floor, and a large number of fixtures in a small space), kitchen (mainly due to open flames), staircases and roads.

Nutritional Deficiencies : Both macro and micronutrient deficiencies are common among elderly. They result due to interplay of four major reasons, viz., lack of financial resources to buy nutritious food items; reduced ability to go out to the market and buy nutritious raw items; reduced physical abilities with resultant reduced ability to cook nutritious meals; and physical ailments especially oro-dental problems causing difficulty in mastication and reduced sense of taste.

Dental Problems : Reduction in number of teeth / edentulousness interferes with mastication, digestive process and also with the desire to eat. Ill-fitting dentures further aggravate the problem.

Cardiovascular Diseases : The end result of atherosclerotic process becomes most evident in the elderly age group. The incidence (as well as mortality due to) of IHD, Stroke and Hypertension is significantly increased in this age group.

Increased Susceptibility to Adverse Effects of Physical Environment : People aged >65 years are more susceptible to adverse effects of heat (heat stroke and heat exhaustion) as well as environmental cold (generalized hypothermia and local adverse effects of cold).

Increased Susceptibility to Infections : Age >65 years increases the susceptibility to nearly all infections due to decline in immunologic defenses. More particularly, lower respiratory tract infections (pneumonia) and urinary tract infections are an important cause of morbidity and mortality among elderly.

Degenerative Neurological Diseases : Alzheimer’s disease and Parkinsonism are almost exclusively encountered among elderly. Besides morbidity, these diseases substantially reduce the quality of life.

Complication of Diabetes : The micro vascular as well as macro vascular complications are more prominent during advanced age.

Cancers : Oral, gastric, lung and colorectal cancers are more common in elderly age group.Problems which mainly affect the Elderly Male

Benign Prostatic Hypertrophy (BPH) : This is one of the commonest diseases affecting males >50 years, particularly >60 years age.

Prostatic Cancer : The incidence shows a steep climb after 50 years age. Yearly Digital Rectal Examination (DRE) is a good screening tool for both BPH and prostate cancer. In addition, Prostate Specific Antigen (PSA) could be useful screening test for prostate cancer after 50 years of age. Levels of < 4 ng/ml can be considered as normal, 4 to 10 ng/ml as suspicious and >10 ng/ml as strongly suspicious and need to be followed up with a biopsy.

Male Sexual Dysfunction : Male sexual dysfunction among elderly may manifest as either libido, erectile or ejaculation problems.Problems which mainly concern with Elderly Females

Menopausal Problems : There are five areas which are predominantly affected by menopause - increased risk of cardiovascular diseases; genitourinary atrophy; skeletal bone loss; skin and hair changes; and neuroendocrine and vasomotor changes. Skin changes include loss of elasticity (apparent as lagging and wrinkled skin), dryness of mucosal surface, minor facial hirsutism and voice changes. Uro-genital changes include atrophic vaginitis, dysparuenia, pruritis vulvae and irritable bladder. Neuroendocrine changes include hot flushes (which may sometimes interfere with quality of life) and psychological/ mood problems.

Urinary Incontinence : The impact is considerable both from medical as well as psychological point of view.

Cancers and Other Disease of Female Genital Tract : The 3 major cancers of genital tract affecting the elderly women are uterine (endometrial), ovarian and cervical cancers. Prolapse of uterus is another debilitating problem among elderly females.

Osteoporosis : Osteoporosis occurs in both sexes (Type-II Osteoporosis) but the incidence as well as the impact is much higher among females especially after menopause (Type-I

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osteoporosis). Osteoporosis represents only a small proportion of the problem, in any community, for every case of osteoporosis there would be additional 3-4 cases of osteopenia. Osteoporosis results in a large number of low-trauma fractures. The major fracture sites are hip, spine, wrist and pelvis. Risk factors for primary osteoporosis include low body weight, history of prior fracture, family history of maternal hip fracture, lack of dietary calcium and vitamin D, menopause, lack of weight bearing exercise, smoking and excessive alcohol use, tall and thin stature and white-race. Weight of <58 kg may indicate risk. In fact, a rough guide is to calculate an index as {0.2 X (Body weight in Kg - Age in years)}; if the result is less than 2, the same indicates increased risk.

Prevention & ControlPrevention and control of health problems of elderly would need multifaceted approach. A well coordinated approach from health, social welfare, rural / urban development and legal sectors is desirable.

Developing a Policy and Programme : A community based geriatric health care programme should start with development of a policy, which should be comprehensive so as to include not only medical aspects but the large gamut of social, economic and emotive aspects of geriatric problems as well. Strong political commitment and social action is imperative for the enunciation and implementation of such a policy. There is also a need to translate such policy into a comprehensive geriatric health care programme, to be delivered at the grass root level by the general health services, but coordinated at the district / state level by specialized personnel.

Social Measures : Developing social ethos wherein children voluntarily take the responsibility of looking after their aged parents is important. In fact, young people need to be educated and motivated to utilize the experience and support of their parents / grandparents in day to day household matters to facilitate passing on the cultural heritage to the children. There is also a need to develop regulatory mechanisms which make it obligatory for the members of society to look after their aged parents.

Developing a Health Insurance Scheme : A large majority of the elderly are those who are not covered by any formal public sector health care support, unlike retired govt. servants. The need is to develop an affordable health insurance scheme in which people contribute, along with the employer and the government, to cater to subsequent expenses on medical care during old age.

Pensionary Benefits : Similar to the health insurance schemes suggested above, there is need to develop pension schemes based on contribution from employee, employer and government, so that old people can feed for themselves during old age, even if not supported by their children.Proper Construction of Roads, Walkways, Stair cases and Houses : Accidents and injuries are an important cause of morbidity and mortality among the elderly. Proper designing of roads / walkways, and stair cases, along with adequate enforcement of traffic rules is a clear need. In addition, construction of “elderly friendly houses”, giving particular attention to construction of toilets, kitchens, bedrooms and

common galleries is important. In general, the principles of construction and maintenance are that the floor should not be slippery / wet; that the fixtures and furniture should be adequately separated giving enough space for movement; lighting should be adequate; staircases should have side-supports, made of non-slippery material and be well lighted; open flames should be restricted to the minimum and, preferably, enclosed.

Health Measures: These include the following :

Need to Initiate Primary Preventive Measures in Early Adulthood : While a number of diseases finally manifest in elderly age (as cardiovascular disease, osteoporosis, cancers), the basic pathologic processes start during early adulthood, even during adolescence. Therefore, it would be wise for children / young people to start prevention at young age itself through healthy lifestyle (adequate and regular physical exercise, healthy diet, avoidance of tobacco and alcohol use). The details are discussed in the section on healthy lifestyle.

Information, Education & Communication Strategies : Health education should focus towards three broad groups - firstly, the elderly persons, secondly, the middle aged who would move into elderly age group in near future and thirdly the younger people who are the potential care providers for their elderly parents / relatives. The major areas of education should address the issues of hygiene, nutrition, physical exercise, avoidance of tobacco and alcohol, accident prevention measures, awareness about recognition of early signs / symptoms of common geriatric problems and motivation to seek treatment, and education regarding periodic health check-up.

Training and Re-training of Medical and Paramedical Personnel : This should be undertaken regarding the special health needs of the elderly and updating their knowledge regarding prevention and treatment of common geriatric diseases.

Immunization : Vaccines which have a potential for use among elderly include those against streptococcal pneumonia, influenza and tetanus.

Periodic Health Assessment : Ideally, all people, males & females, should undergo a detailed health assessment once they are 45-50 years of age. Subsequently, a thorough health evaluation should be done once in every 5 years till 65 years age and thereafter every year or at least once in 2 years. Assessment should include general clinical examination, assessment of hearing & vision, assessment of Dental and oral health, nutritional status including obesity, cardiovascular status, musculoskeletal system including spine, per-rectal examination for males and gynecological and breast examination for females. Depending on availability, important investigation would include Hb%, GBP, urine routine and microscopic, stool routine and microscopy and test for occult blood, blood sugar estimation, lipid profile, renal function parameters and an ECG if required. Depending on the requirement, bone densitometry, PSA, Colonoscopy, USG studies and histo-pathological studies may be undertaken as indicated.

Provision of Prostheses and Other Medical Aids : Elderly persons will often need devices as spectacles, hearing aids, walking aids, dentures, cervical collars, wheel chairs and

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so on. The preventive health care for elderly should cater to provide these implements to all those who are in need, ensuring availability, accessibility and affordability.

Development of Gerontology Units : There is a felt need to develop specialized units which would take care of the special and wide health related needs of the elderly as well as train health care workers in these issues. It would be worthwhile if a coordinated approach between departments of community medicine, internal medicine, general surgery, gynaecology, orthopaedics, ENT and ophthalmology be developed to initiate such comprehensive care through gerontology units, for the population of three PHCs which is to be providing health care by various medical colleges. Subsequently, such units may be developed at the level of district hospitals.

Ensure Effective Communication : Elderly people need special efforts for communication. Hence, medical personnel dealing with elderly should very effectively communicate their findings and advise to this group and ensure a system of feedback to verify that their communication has been correctly understood by the elderly subjects.

SummaryElderly age is defined as persons aged 65 years or more. In our country, proportion of elderly is consistently increasing and there is need to focus on their health needs. Health problems of elderly should not be seen as isolated medical issues but should be viewed in the larger context of socio-economic-emotive determinants as an overall health issue. Due to children moving out of home for employment, elderly face problems of isolation and lack of physical support. This isolation may be worsened by retirements or death of spouse, and predispose them to variety of lifestyle diseases. Financial crisis because of lack of income sources may compound the problem. Moreover the present health care system in our country is not very well geared up to cater to the health needs of elderly. The health problems of elderly can be divided into 3 groups, i.e. problems which are important for both genders, problems which mainly concern the elderly males and problems which mainly concern the elderly females.

Problems which are important for both the genders include- ocular diseases like age related diminution of vision, cataract and glaucoma; hearing defects; reduced muscular strength and coordination resulting in increased proneness to accidents and injuries; nutritional deficiencies; dental problems like reduction in number of teeth or edentulousness; cardiovascular diseases like IHD, stroke and hypertension; increased susceptibility to effects of heat and cold; increased susceptibility to infections, particularly lower respiratory tract infections (pneumonia) and urinary tract infections; degenerative neurological diseases like Alzheimer’s disease and Parkinsonism; micro and macrovascular complications of diabetes and cancers like oral, gastric, lung, uterus, ovaries and colorectal cancers are more common in elderly age group. Problems which mainly affect the elderly males include benign prostatic hypertrophy (BPH); prostate cancer and male sexual dysfunction. Problems which mainly concern with elderly females include Menopausal Problems like increased risk of cardiovascular diseases, genitourinary atrophy; skeletal bone loss, skin and hair

changes, and neuroendocrine and vasomotor changes; Urinary incontinence; Osteoporosis; Cancers of female genital tract mainly uterine (endometrial), ovarian and cervical cancers.

Prevention and control of these problems need multifaceted approach. There is need to develop social ethos wherein children voluntarily take the responsibility of looking after their aged parents. The need is to develop an affordable health insurance scheme and pension schemes. There should be proper designing of roads / walkways, and stair cases, along with adequate enforcement of traffic rules. Houses should be constructed in such a manner that these are “elderly friendly houses”. Primary preventive measures should start in early adulthood through life style modification. IEC about health problems of elderly should be targeted to elderly, adults who are likely to move in elderly group and also to younger people who are care provider to elderly. Training and retraining of health staff, so as to efficiently address health needs of elderly is required. Periodic health examination should be done at least every 5 years starting with age of 45 - 50 years till the age of 65, and thereafter it should be done at least once in every two years. All these measures should be communicated to elderly in an effective manner.

Study ExercisesLong Question : Describe your plan of providing comprehensive health care to the elderly persons in your district, in your capacity as the district health officer.

Short Notes : (1) Osteoporosis (2) Benign Prostatic Hypertrophy (3) Health problems of the elderly

MCQs1) Elderly is defined as the person aged above: (a) 60 yrs

(b) 65 yrs (c) 70 yrs (d) 75 yrs2) The proportion of elderly in our country is: (a) 1% (b) 2%

(c) 4% (d) 5%3) Which of the following is not the primary disease of elderly

age group: (a) Parkinsonism (b) Alzheimer’s (c) Multiple sclerosis (d) Cerebrovascular disease

4) Which of the following malignancy is not commonly seen in elderly age group: (a) Stomach (b) Colorectal (c) Prostate (d) Testis

5) IEC strategies for prevention and control of health problems of elderly should be targeted to: (a) Elderly (b) People in late adulthood (c) Younger people (d) All of the above

6) Characteristics of “elderly friendly houses” does not include: (a) Furnitures should be adequately separated (b) Lighting should be adequate (c) Floor should not be slippery (d) Electrical appliances should not be used to avoid threat of electrocution

7) Periodic Health Assessment for elderly should ideally be done once in every: (a) 5 yrs (b) 4 yrs (c) 3 yrs (d) 1 yr

8) Routine Periodic Health Assessment for elderly should include all except: (a) Stool test for occult blood (b) blood sugar estimation (c) Renal function parameters (d) Pulmonary function tests

9) Risk factors for primary osteoporosis does not include: (a) High BMI (b) History of prior fracture (c) Family history of maternal hip fracture (d) Lack of weight bearing

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exercise.10) Which of the following is not a postmenopausal problem:

(a) increased risk of cardiovascular diseases (b) Genitourinary atrophy (c) Skeletal bone loss (d) Atrophy of ovary

11) Major physio-pathological factors which contribute to increased proneness to accidents among elderly are all except: (a) Reduced muscular strength (b) Poor neuro-muscular coordination (c) Restlessness (d) Diminution of vision and hearing

12) Elderly are at risk of nutritional deficiencies because of: (a) Lack of financial resources to buy nutritious food items (b) Reduced physical abilities with resultant reduced ability to cook nutritious meals (c) Oro-dental problems (d) All of the above

13) Hot flushes occurring in postmenopausal women are mainly due to: (a) Psychological response (b) Neuroendocrine disturbance (c) Macrovascular changes (d) Microvascular changes

14) A rough guide to calculate an index of risk of osteoporosis based on body weight is { 0.2 X (Body weight in Kg - Age in years) } the value of index which indicates increased risk if it is: (a) >1 (b) <1 (c) >2 (d) <2

15) Normal level of PSA (Prostate specific antigen) is (in ng/dl) : (a) <2 (b) <6 (c) <4 (d) <8

16) Presbyopia occurs in elderly because of: (a) Cataract change in ocular lens (b) Retinal degeneration (c) Insufficiency of power of accommodation (d) Corneal degeneration

17) Hearing loss among elderly is mainly because of: (a) Sensorineural deafness (b) Conductive deafness (c) Degenerative changes in temporal cortex (d) None of the above

Fill In the Blanks1. The proportion of elderly in India is like to reach _________

by year 2050 AD.2. Prostate Specific Antigen (PSA) of the level higher than

_____________ indicates strong suspicion of Ca prostate.3. Females are at much higher risk of developing osteoporosis

Type ______________ especially after menopause.4. Common fracture sites among elderly are ______________5. Hearing loss commonly occurring among elderly because

of sensori-neural deafness is called as ______________Answers : MCQs : (1) b; (2) d; (3) c; (4) d; (5) d; (6) d; (7) d; (8) d; (9) a; (10) d; (11) c; (12) d; (13) b; (14) d; (15) c; (16) c; (17) a. Fill In the Blanks : (1) 18%; (2)10 ng/ ml; (3) Type - I; (4) Hip, wrist, spine and pelvis; (5) Presbyacusis

152 Demography and Public Health

Dashrath R. Basannar

Demography is the scientific study of human populations. It is mainly concerned with

Size : It refers to the total number of persons in the given population.

Distribution : It refers to the arrangement of entire population with respect to the geographical areas at a given point of time.

Structure : It refers to the distribution of the given population with respect to age and sex.

Change : It refers to the increase or decrease in the size of the given population due to fertility, mortality and migration.

Development : It refers to the development of the given population with respect to socio economic aspects.

Other characteristic like genetic inheritance, intelligence and health.

Role of Demography in Public Health Administration : For effective planning, designing, evaluation and execution of health and health care needs for the entire population for the present as well as for the future, the knowledge about population with respect to its size, structure, change in its size

and their developments is essential. The following are number of the applications of demography in health related fields.

The knowledge in demography is helpful to public health administrators for various purposes :i) Mortality rates by age-sex and its geographical distribution

with respect to various diseases are helpful in locating and identifying diseases of public health importance with respect to age-sex-location, for planning remedial measures to control these diseases, future planning for prevention of these diseases, for determining leading causes of mortality, for planning drugs/medicines/equipment/manpower/other medical facilities requirements etc.

ii) Percentage distribution of population by age-sex-location are helpful in understanding health and health care needs of various age groups by sex by location, for planning, designing, evaluation and effective implementation of various public health programs. For example : Vaccination and immunization program for children under 5 years of age, Mother and Child Health program for mother and new born, Family planning program, old age program, nutritional program etc.

iii) Determining the success or failure of health programs.iv) To describe the level of community health.v) To determine the leading causes of mortality and

morbidity.vi) To determine the relative importance of different fatal

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diseases with respective to age and sex. vii) To discover solution to health problems and find clues for

public health administration.Sources of Demographic Data : The following are the sources of demographic data. The details of these sources have already been dealt with in detail in an exclusive chapter in the section on epidemiology : 1. Census 2. Vital Events Registers3. Surveys 4. Sample Registration System Measures of Population Projection : By “Population projections”, we mean estimating and forecasting the population of a country or a region for a given time. There are mainly three types of population estimates namely inter-censal (during any two consecutive census period), post-censal (any period following latest census up to the present moment of time) and future (any period time after the present moment). Generally the data on population are available for census year only hence population estimates (inter-censal estimates) are required for calculating fertility rates, mortality rates etc. during the inter-censal period. Future population projections (future estimates) are very essential basically for understanding and planning future needs of the population for various purposes such as health, education, economic, social, employment, irrigation, food, housing, etc. The following measures of population estimates are commonly used.

i) Mathematical Methods : Some of the mathematical models which are commonly used for estimating inter-censal and post-censal population estimates are :

Arithmetic Growth Method ●Geometric Growth Method ●Exponential Growth Method ●Component Projection Method ●

a) Arithmetic Growth Method : In this method it is assumed that there is an equal addition every year to the population during the inter censal period and this addition is taken to be average increase per year. Arithmetic Growth Method for estimating population is where P0 population at time t is, P0 and P1 are populations at two consecutive censuses. a = P0 and b = ((P1 - P0 ) ÷ 10) and inter census period = 10years. For example populations of a town A at censuses 1st Mar 1981 and 1st Mar 1991 were 50,000 and 90,000. Estimate population of the town on 1st Mar 1985. Here a = 50,000, inter-censal period = 10 years, b =4,000 per year and t =4,

= 66,000

b) Geometric Growth Method : This method assumes the population begets population at a constant rate of increase on the compound interest law. Geometric Growth Method for estimating population is where r is growth rate

and . In the above example,

=0.0605.

= 63,252.69

c) Exponential Growth Method : In this method it is assumed that there is an exponential growth. Exponential Growth

Method for estimating population is

where r is exponential growth rate

In the above example =0.05878 and

= 63,252.69

d) Component Projection Method : This method is mainly used for future population projections (future estimates) using following model.

Here 0 stands for base year from which population projected is made, t denotes the period of projection from the base year.

represents number of births, number of deaths, number of immigration and number of emigration during the period 0-t respectively. P0 Represents population at the base year 0.

This method makes assumptions about fertility, mortality and migration for the projection period based. This method requires information regarding age-sex distribution, age-sex specific mortality, fertility and migration distribution by age-sex for the base year 0 and estimates for the period t.

Demographic Transition : In 1929 the American demographer Warren Thompson, observed changes in birth and death rates in industrialized societies over the past two hundred years or so and then formulated a model called “Demographic Transition” that describes population change over time in fully developed country today, such as The United States or Canada, the countries of Europe, or similar societies elsewhere (e.g. Japan, Australia etc.). The model is a generalization that applies to these countries as a group and may not accurately describe to less developed societies. As shown in the Fig. - 1, Demographic Transition model recognises five demographic stages namely high stationary, early expanding, late expanding, low stationary and declining.

High stationary (first stage) ● : The first stage is associated with pre Modern times, and is characterized by very high birth rates and very high death rate (30-50 per 1000) balance between them results in only very slow population growth that is referred to as the “High Stationary Stage” of population growth. This situation was true of all human populations up until the late 18th century. Early expanding (second stage) ● : The second stage is characterized by a rise in population caused by a decline in the death rate while the birth rate remains unchanged, or perhaps even rises slightly. The decline in the death rate in Europe began in the late 18th century. Late expanding (third stage) ● : The third stage is characterized by further decline in the death rate while birth rate tends to fall that results in increase in the population

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growth. In general the decline in birth rates in developed countries began towards the end of the 19th century.Low stationary (fourth stage) ● : The fourth stage is characterized by a low birth rate and low death rate; the balance between them results in no population growth that is referred to as the “low Stationary Stage” of population growth.Declining (fifth stage) ● : The fifth stage is characterized by a birth rate lower than death rate the balance between them results in decline in population growth that is referred to as the “Declining Stage” of population growth.

Demographic transition in national Context : As shown in the Table - 1 and Fig. - 1 & Fig. - 2, India’s population growth during the twentieth century can be classified into four distinct phases as follows : 1901-1921, this period was characterised by a high birth rate and high death rate (46-49 per 1000) and growth rate was slow, close to zero and it was negative during 1911-21and the year 1921 is called the year of great divide. There after growth rate steadily increased till 1991.

During 1921-1951, birth rate steadily declined from 48.1 in 1921 to 39.9 in 1951 and death rate also declined from 47.2 in 1921 to 39.9 in 1951 while growth rate steadily increased during this period which was more than 1 but less than 2. During this period India experienced rapid growth.

During 1951-1981, birth rate little further increased and then declined and death rate further declined and growth rate further increased and it crossed over 2 during this period. During this period India experienced explosive rapid growth.

During 1981-2001, birth rate further declined and came down to 26.1 and death rate further declined while growth rate started slowing down during this period. Growth rate during 1971 to 1991 was more than 2, first time after 40 years fall down below 2, still it characterises as very rapid growth.

From the Table - 1, it is evident that there is declining trend in CDR, it declined from 46.2 in 1911 to less than 10 i.e. 8.7 in 2001 and it was less than 7 in 2007 and it is close to some of

the developed countries like United States and Canada. During this period life expectancy at birth increased from 23.63 years for male and 23.96 years for female in 1901 to 62.30 years for male and 65.27 years for female in 2001. Similarly CBR declined from 49.2 in 1911 to almost half i.e. 26.1 in 2001.

India with 238.4 million population in 1901 almost doubled in 1961 in 60 years while it took just 30 years to double the population from 439.2 million in 1961 to 844.0 million in 1991. The population of India has increased nearly five times from 238 million to 1 billion during this century period.

In 2001 census India’s population was 1,028,737, i.e. about 16 percent of the world’s population on 2.4 percent of the globe’s land area. It is the second largest populous country in the world. If current trends of fertility and mortality continue, India may overtake China in 2045, to become the most populous country in the world. As per census 2001 report, state with highest population was Uttar Pradesh (166,197,921) and state with lowest population was Sikkim (540,851); union territories with highest population was Delhi (13,850,507) and union territories with lowest population was Lakshadweep (60,650) ; district with highest population was Medinipur (West Bengal) (9,610,788) and district with lowest population was Yanam (Pondicherry) ( 31,394 ).

National Policies to Control Population Growth : India was the first country in the world to launch a national family planning to control birth rates to stabilize the population in 1952. The role of family planning programme was mainly to deliver contraceptive methods and creating facilities for abortion. After 1952, sharp declines in death rates were observed, however, not accompanied by a similar drop in birth rates. The Government has passed Child Marriage Act in 1978 and this Act specified the minimum age at marriage for females and males to be 18 and 21 years respectively. The National Health Policy, 1983 stated that replacement levels of Total Fertility Rate (TFR) should be achieved by the year 2000. Half a century after formulating the national family welfare programme, reduced Crude Birth

Table - 1: Birth Rate, Death Rate and Growth Rate in India (1901-2001)

Census yearTotal

population (million)

Decadal Growth (%)

Average annual exponential

growth rate (%)

Growth rate over 1901 (percent)

Birth Rate/1000 live births

Death Rate/1000 population

1901 238.4

1911 252.1 5.75 0.56 5.75 49.2 46.2

1921 251.3 -0.31 -0.03 5.42 48.1 47.2

1931 279 11 1.04 17.02 46.4 36.3

1941 318.7 14.22 1.33 33.67 45.2 31.2

1951 361.1 13.31 1.25 51.47 39.9 27.4

1961 439.2 21.64 1.96 84.25 41.7 22.8

1971 548.2 24.8 2.2 129.94 41.2 19

1981 683.3 24.66 2.22 186.64 37.2 15

1991 844 23.86 2.14 255.03 29.5 9.8

2001 1027 21.34 1.93 330.8 26.1 8.7Source: SRS data 1999 and Census of India 2001

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Rate (CBR) from 40.8 (1951) to 26.4 (1998, SRS) ; the Infant Mortality Rate (IMR) from 146 per 1000 live births (1951) to 72 per 1000 live births (1998, SRS) ; Crude Death Rate (CDR) from 25 (1951) to 9.0 (1998) ; Total Fertility Rate from 6.0 (1951) to 3.3 (1997). The National Population Policy (NPP), 2000, recently adopted by the Government of India states that ‘the long-term objective is to achieve a stable population by 2045, at a level consistent with the requirements of sustainable economic growth, social development, and environment protection’. It has been assumed in the policy document that the medium-term objective of bringing down the Total Fertility Rate (TFR) to replacement level of 2.1 by 2010 will be achieved. It is envisaged that if the NPP is fully implemented, the population of India should be 1013 million by 2002 and 1107 million by 2010.

SummaryDemography is the scientific study of human populations and it is mainly concerned with size, distribution, structure, change, development and other characteristics like genetic inheritance, intelligence and health. Demography plays an important role in public health administration for effective planning, designing, evaluation and execution of health and health care needs for the entire population for the present as well as for the future.

The important sources of demographic data are Census, Vital Events, Registers, Surveys, and Sample Registration System. There are mainly three types of population estimates namely inter-census (during any two consecutive census period), post census (any period following latest census up to the present moment of time) and future (any period time after the present moment). The measures of population estimates commonly used are Mathematical Methods - Arithmetic Growth Method, Geometric Growth Method, Exponential Growth Method, and Component Projection Method.

Demographic Transition model recognises five demographic stages namely high stationary, early expanding, late expanding, low stationary and declining. High stationary is characterized by very high birth rates and very high death rate. Early expanding is characterized by a rise in population caused by a decline in the death rate while the birth rate remains unchanged, or perhaps even rises slightly. Late expanding is characterized by further decline in the death rate while birth rate tends to fall that results in increase in the population growth. Low stationary is characterized by a low birth rate and low death rate the balance between them results in no population growth. Declining is characterized by a birth rate lower than death rate the balance between them results in decline in population growth.

In 2001 census India’s population was 1,028,737, i.e. about 16 percent of the world’s population on 2.4 percent of the globe’s land area. It is the second largest populous country in the world. If current trends of fertility and mortality continue, India may overtake China in 2045, to become the most populous country in the world. As per census 2001 report, state with highest population was Uttar Pradesh (166,197,921) and state with lowest population was Sikkim (540,851).

National policies to control population growth : India was the first country in the world to launch a national family planning to control birth rates to stabilize the population in 1952. The Government has passed Child Marriage Act in 1978, the National Health Policy in 1983, and the National Population Policy (NPP) in 2000. It has been assumed in the policy document that the medium-term objective of bringing down the Total Fertility Rate (TFR) to replacement level of 2.1 by 2010 will be achieved. It is envisaged that if the NPP is fully implemented, the population of India should be 1013 million by 2002 and 1107 million by 2010.

Fig. - 1 Fig. - 2

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Study ExercisesShort Notes : (1) Important sources of Demographic Data (2) Demographic Transition (3) Role of Demography in Public Health

MCQs 1. According to the demographic cycle, India is in the

following phase (a) High Stationary (b) Early Expanding (c) Late Expanding (d) Low Stationary

2. According to Central Registration Act of 1969, birth is to be reported within : (a) 7 days (b) 14 days (c) 10 days (d) 21 days

3. Annual growth rate is between (a) Crude birth rate - Crude death rate (b) Crude birth rate - IMR (c) Total Fertility rate - Death rate (d) Crude birth rate - Total Fertility rate

4. Census in India is done every (a) 05years (b) 10years (c) 15 years (d) 20 years

5. The most cost effective family planning method is (a) Vasectomy (b) Barrier method (c) IUCD (d) Oral pills

6. The year of “Big Divide” is (a) 1900 (b) 1901 (c) 1920 (d) 1921

7. As per Census 2001 Average annual growth rate of India is (in %) (a) 2.01 (b) 1.93 (c) 1.80 (d) 1.86

8. As per Census 2001 Decadal growth rate of India is (in %) (a) 21.34 (b) 31.93 (c) 11.80 (d) 9.86

9. As per Census 2001, the % of world’s population from India is (a) 26 (b) 16 (c) 10 (d) 06

10. As per Census 2001, lowest populated state of India is (a) Kerala (b) Sikkim (c) Goa (d) Nagaland

11. The annual growth rate of India presently characterized as (a) slow (b) rapid (c) very rapid (d) explosive

Answers : (1) c; (2) b; (3) a; (4) b; (5) a; (6) d; (7) b; (8) a; (9) b; (10) b; (11) c.

153 Contraceptive Technology

RajVir Bhalwar

As per the National population policy - 2000 and the RCH program in our country, the couples should be given a choice out of various contraceptive methods. Promotion of contraception purely on a voluntary basis, without any coercion, and with provision of due information about the various contraceptive alternatives is the central ethos of our national family welfare programme. The strategies and operational details of the programme and the various contraception facilities being provided to the community are dealt with in the chapter on RCH program. The technical details of various methods of contraception are being dealt with in this chapter.

Broadly, methods of contraception would fall into two groups, viz. “Natural Methods” and “Artificial Methods”. Artificial methods are further grouped into Temporary and Permanent methods.

Efficacy of Contraceptive Methods : Efficacy of a given contraceptive procedure is evaluated in terms of the “Pearl Index” which measures the number of failures (i.e. pregnancies occurring despite continuous usage of the particular method) per 100 woman years (HWY), or for every 1200 woman - months.

Total failures (pregnanciesdespite use of the contraceptive)Total months of continuoususe of the contraceptive

Pearl Index(Failure rate per HWY) X 1200=

The numerator (total failures) should include all pregnancies which occur during the period of observation, irrespective of their outcome (i.e. whether the pregnancy terminated in live birth, still birth or abortion etc.). The denominator is taken in months and hence the numerator is multiplied by 1200, to make it equal to 100 years. In the denominator, for every pregnancy which is continued till full term, 10 months are deducted, while for every pregnancy that terminates in abortion, 4 months are deducted, from the total period of follow up for each woman. When studying the effectiveness of contraceptives, it is recommended that at least 600 woman-months (50 woman-years), preferably more, of follow up should be done. A failure rate of 3.33 per HWY means that, given the fertile period of a woman is 30 years (usually 15 to 44 years age) and if a woman uses that contraceptive continuously for her entire fertile period, she is likely to have one pregnancy due to failure of the contraceptive. (Calculated as 3.33 failures in 100 years for 1 woman, hence (30 X 3.33) / 100 = 1 failure in 30 years of usage. It also means that if 100 women use the contraceptive for 10 years continuously, thus giving 1000 woman years, then about 33 accidental pregnancies are likely to occur, in all, among these 100 women over the 10 years of use.

Natural Methods of ContraceptionThese methods utilize either total avoidance of sexual intercourse (Abstinence) or by discharging the semen outside female genitalia (Coitus interruptus or withdrawal method) or else by utilizing methods which observe the naturally occurring signs / symptoms of fertile versus non-fertile periods of the menstrual cycle and avoiding sexual intercourse during the fertile period. These methods, which are also sometimes referred as the “Standard Day Methods” (SDM) work on the principle that during one menstrual cycle, one ovum is

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discharged; very rarely, a second ovum can be discharged after 24 hours. Secondly, after intercourse, sperms stay alive upto 5 days (rarely 7 days) but can actually fertilize the ovum for at most 4 days. With this background the most fertile period of women is from 10th day to the 18th day, provided the cycle is of 28 days. Natural methods are based on detecting the fertile period and avoiding intercourse during the period. These are :

(a) Rhythm Method : For women who have a regular 28 days cycle, the fertile period would be generally from day 7 to day 21 (the day of onset of menstrual bleeding is taken as the first day). Sexual intercourse is avoided during this period.

(b) Basal Body Temperature Method : The woman should record her oral temperature first thing on getting up in the morning, daily, and plot it on a graph paper with the days of menstrual cycle along horizontal axis and temperature along vertical axis. Immediately following ovulation there is increase in oral temperature by 0.5 to 0.8°F (0.2 to 0.4°C). Couples should avoid intercourse for 3 days, once the rise in temperature is noted.

(c) Cervical Mucous Method : The woman notices daily, the quality of vaginal mucus discharge, by putting a finger into the vagina. Following cessation of menstrual flow, no mucus is felt in the vagina for couple of days. These are called the “dry days”. Following the dry days, cloudy, white or cream coloured mucus of sticky consistency with little moisture appears. This indicates that ovulation is approaching. Thereafter, just before and at time of ovulation the mucus becomes copious, clear and slippery, resembling the white of an egg and can be stretched into a thread if the thumb and finger on which the mucus is stuck, are gently moved apart. This persists for 3 days and is called the “wet days”. Following this wet period, the mucus again becomes scanty, sticky and cloudy indicating the post ovulation phase, which persists till onset of next menstrual flow. The couple should abstain as soon as the first sign of mucus appears in the pre-ovulatory phase, during the wet days in ovulatory phase and for 3 days after the completion of wet period.

(d) Symptothermal Method : This is based on combined observation of changes in BBT, mucus changes and also by palpating the cervix with a finger high up in the vagina. The cervix becomes softer and cervical os becomes more open during the fertile period.

Natural methods are reasonable efficacious; however, the problem is mainly the difficulty in maintaining compliance. If consistently and properly used, the failure rates per 100 women per year (HWY) (indicating the number of women who will become pregnant during one year out of 100 women who are using these method are : (i) Calendar Method - 9 / 100 HWY (9%)(ii) BBT Method - 1 - 2 / 100 HWY (1-2%)(iii) Cervical mucus Method - 3 / 100 HWY (3%)(iv) Symptothermal Method - 2 / 100 HWY (2%)(e) Lactational Amenorrhoea Method : Full or nearly full breast feeding means that at least 85% of the baby’s food requirement is being provided by breast milk. For women who are fully breast feeding their infants, chances of pregnancy are very less for 6 months or when menstrual flow returns,

whichever is earlier. If used correctly and consistently, the failure rate is 1 to 1. 5%. Chances of pregnancy are, however, more if the woman is not having full lactation or if not fully breast feeding the infant.

Artificial MethodsArtificial, Temporary Methods : The broad categories of contraceptives included in artificial (temporary) methods are Barrier methods, Spermicides, Intrauterine devices (IUDs), Oral contraceptives and Non-oral hormonal contraceptives.

Barrier Contraceptives

Condoms : Condoms are made of latex and are available as nonlubricated (Nirodh, Kohinoor), lubricated (Nirodh - Lubricated, Kamasutra, Kohinoor - Pink and Sawan) and more lately, coated with spermicidal jelly which is usually nonoxynol-9 (Share, Rakshak). The average shelf life is 5 years from date of manufacture and they should be stored in cool and dry place. If further lubrication is required then glycerin, K-Y jelly or a spermicidal jelly can be applied, but not Vaseline, oils or butter. Some couples may complain of initial reduction in pleasure due to slight decrease in sensations and interruption in sexual play (since the man has to put on the condom just before insertion). However, it should be explained to them that this is only a transient phenomena, and most couples will adapt well with passage of time. Besides contraceptive effect, condoms are also very effective in preventing transmission of HIV, STDs, HPV infection (and amnionitic fluid infections while having sex during pregnancy).

The total “slippage” and “breakage” rate is 4% to 9%. The average failure rate is 12% to 14%, but if correctly used, it may be as low as 3%. Concurrent use of spermicidal jelly will further reduce the failure rate. Condoms are very good choice as temporary method, especially for couples in whom use of hormonal contraceptives and IUDs is not indicated among the female partner. The only contra-indication to condom use is allergy to latex rubber in which case condom made of polyurethane or silicon rubber may be used.

Diaphragm, Cervical Cap (Check Pessary), Vault Cap and Vimule : These are barrier methods to be used by the females but not much used now due to wide availability of other contraceptives.

Female Condoms : Available under trade name of “Femindon” and “Reality”. The device is inserted like a vaginal diaphragm. At present it is not much used as contraceptive but has potential in prevention of HIV transmission.

Spermicides : Most commonly used spermicide is nonoxynol- 9. They are available as vaginal pessaries which are inserted high up in the vagina, 10 to 15mts before sex or as creams / jelly, as Delfen cream, Orthogynol jelly etc.

Foam Tablets : These are very commonly used. It is marketed in our country as “Today” as a vaginal foam suppository containing nonoxynol-9. The tablet is to be inserted high in the vagina (may be moistened slightly with water if vagina is dry), 10 minutes before sex act and the action lasts for 1 hour after sex. If properly used, failure rates are as low as only 0. 5%.

Intra Uterine Devices (IUDs) : IUDs have been in use as contraceptives for many decades. However, their exact mode of

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action is still not clear. In all probabilities, they act by inducing mild inflammatory changes and foreign body reaction in the endometrium, which combined with alterations in prostaglandin levels, incapacitate the sperms and ovum, prevent sperm from fertilizing the ovum, and even if fertilization occurs, makes the uterine environment inhospitable for the blastocyst to be implanted. The earliest IUDs, namely lippies loop, have now been almost phased out by copper-T and its subsequent variants. Copper - T 200 (Gynae-T) is made of propylene impregnated with BaSO4 and carries 120mg of 0. 25mm diameter copper wire wound around the vertical limb. The tail limb has a pair of threads (some variants have only one thread) which comes out of cervical os, into vaginal canal after the Copper-T has been inserted and can be felt with a finger to check that the Copper-T is in place. The copper has an exposed area of 200 sq. mm and hence the name Cu-T- 200. The US-FDA approved Cu-T-200 has an effective life of 4 years. Some additional variants available commercially in our country are Multiload ML Cu-T-250, ML Cu-T-375 and Nova Cu-T-200 (Nova T) which has a silver core added to the copper wire. The conventional Cu-T-200 has failure rate of 2%, while the newer variants have lower failure rate of 1-2%. In general Cu-T-200 is referred to a Group-I IUD; ML-250 and 375 as Group-II; while Nova-T and Cu-T-386A are referred to as Group-III IUDs. The advantages of IUDs is the ease of insertion (can be inserted at Sub centre level by paramedical workers), the semi-permanency (Cu-T-200 can be left in place and remains effective for 3 years) and the ease of removal. However, before advising IUD, proper history should be taken from the couple and correct advice given as per details given in succeeding paragraphs.

Conditions which are absolute contra - indications to IUD insertion / continuation(a) Pregnancy(b) Puerperal or Post abortal sepsis(c) Unexplained vaginal bleeding(d) Pelvic inflammatory disease within last 3 months(e) Known pelvic TB(f) STD during the past 3 months(g) Suspected neoplasia of genital tract(f) Uterine abnormalitiesConditions which increase the risk due to IUD, and alternative contraceptive may be considered, if possible(a) Post partum 48 hours to 4 weeks (more chances of

perforation)(b) Women having increased chances of STD / HIV transmission

(prefer condom)(c) Age <20 years(d) Nulliparity(e) Endometriosis(e) Menstrual irregularities with increased bleeding or

dysmenorrhoeaWomen who are best suited for IUD include those aged >20 years, who have given birth to at least one child, have diseases or conditions like Obesity, Tobacco use, Headache, IHD, RHD, Diabetes, Thyroid disease, Benign breast disease and Irregular menstruation but without heavy bleeding and those who are breast feeding.

Timing of Insertion(a) The best time to insert is during or soon after menstrual

periods, post partum within 48 hours of delivery and after abortion.

(b) However, after delivery or abortion it is preferable to insert IUD 6 weeks after the delivery / abortion and the couple may be advised to use another method, as condom, for that period.

(c) It may be noted that as for as possible insertion should not be delayed just because of timing. In fact, the best timing is the one which is most convenient to the potential user, if it can be reasonably ascertained that she is not pregnant.

(d) It can also be inserted post coitus, even up to 5 days after coitus to prevent pregnancy

Instructions to be given to the lady, after insertion(a) For the next few periods (at least for next 3 periods) she

should watch her pads for any expelled IUD and, after the periods, should feel for the threads (tails) coming out of the cervical os, to ensure that the device is in place. She should report if she cannot feel the threads or sees the device on her pads, or feels the device to be in the vagina

(b) She should come for a routine health check up after the next menstrual period

(c) She should report in case of persistent, irregular or heavy bleeding, severe pain in lower abdomen or abnormal vaginal discharge, or amenorrhoea (in which case pregnancy should be excluded)

(d) She should also report if she feels that she has been exposed to STD or HIV

Indications for Removal(a) Abnormal or excessive bleeding(b) Persistent pelvic pain or cramping(c) Expiry of effective life span (3 to 4 years from date of

manufacture, for Cu-T-200)(d) Pregnancy(e) Acute pelvic infection or neoplasm of genital tract(f) Displacement of IUD either inside the uterus or outside it(g) Personal reasons(h) After menopause (within one year)Routine problems after insertion

The lady should be advised that she may face certain routine problems following insertion as follows, and she should not unduly worry about them : (a) Some cramping abdominal pain for a few days(b) Some vaginal discharge for a few weeks(c) Heavier menstrual bleeding and possibly inter-menstrual

bleeding for a few weeksComplications of IUD(a) Increased menstrual bleeding and sometimes inter-

menstrual spotting(b) Cramping lower abdominal pain(c) Explusion : The overall expulsion rate is 2 - 8% in first year.

It is commonest in first 3 months, especially after the 1st period following insertion

(d) Leucorrhoeic vaginal discharge(e) Perforation of uterus (occurs in approximately 1 per 1000

insertion)

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(f) Infection, especially during first month(g) Pregnancy, due to failure (1 to 2%)(h) Ectopic pregnancy (Rare, approximately 1 per 1000 women

years. However, if pregnancy occurs with IUD in situ, then chances of its beings ectopic are very high, almost 30%)

Oral ContraceptivesHormonal Contraceptives have revolutionized the implementation of Planned Parenthood Programmes all over the world. Broadly, hormonal contraceptives could be either oral or parenterally administered. Oral contraceptives (OCs) can be further divided into two broad groups, viz. “Combined pills” (Containing both Estrogen & Progestogen) and “Progestogen only pills” (mini pills).

(a) Combined Pills : These can be of two types, viz, Monophasic pill in which every pill has same amount of Oestrogen as well as Progestogen, and the multiphasic pill in which, in a given pack for one menstrual cycle, the pills will have variable amount of Oestrogen & Progestogen. An example is “Triquila” available in our country. Monophasic pills can be, in turn, low dose pills which contain less than 0.05 mg of ethinyl estradiol (EE) in each pill along with progestogen. The other variety, i. e. high dose pills containing > 0.05mg EE per pill have been discontinued by now. Similarly, the earlier used sequential pills, which used only oestrogen in the tablets for first 14 days followed by combined Oestrogen & Progestogen for next 7 days have also been abandoned by now.

(b) Progestogen only (Mini pill) : These contain small amount of only a progestogen but no oestrogen. They are indicated for women >40 years age or who are lactating and have not completed 6 months from delivery. They are available under trade names of Microval or Femulen; they are generally not available in our country.

Choice of pill : Any of the low dose combined pill or else a triphasic pill (Triquilar) can be used. The choice will mainly depend on cost, since the triphasic pills are costly.

Commonly Available Pills : In our country, the following pills are commonly available :

Common low dose pills(a) Ovral-L or Mala-D - This contains L-norgesterol (LNGL)

0.15 mg and EE 0.03 mg per pill. Mala-D is available at subsidized rates in our country under the FW program.

(b) Mala-N - This contains dl-NGL 0.30mg and EE 0.03mg per pill. This is available free of cost under the FW program in our country.

Triphasic pills : Triquilar contains L-NGL 0.05mg and EE 0.03mg for first 6 days, 0.75mg and 0.04 mg respectively for next 5 days and 0.125mg L-NGL with 0.03 mg EE for the next 10 days.

Mechanism of Action : Combined OCs produce contraceptive effect in different ways, viz. and inhibition of ovulation by bringing about changes in FSH & LH secretion, by altering the endometrium and by bringing about changes in cervical mucus.

Mode of Administration : The day on which menstrual flow starts is taken as day-1. The first pill is taken on Day-6, one pill every day for next 21 days. Thereafter the pill is stopped

and restarted after a gap of 7 days, irrespective of the onset or stoppage of menstruation during these pill free periods.

Very often the packet has 28 pills. In such cases, the last 7 tablets are actually iron tablets. In this scenario the next packet should be started on the very next day after the previous packet is finished, without any gap. Secondly, care should be taken to take the actual (hormonal) tablets on first 21 days and iron tablets on days 22 to 28.

Action to be taken when a Pill is Missed : If a pill is missed on a day, two pills should be taken on the next day, as soon as the woman remembers (preferably within 12 hours of last missed dose) and the other at bedtime; or else, if not remembered earlier, 2 tablets at bedtime on the next day. If 2 or 3 tablets are missed, the woman should take 2 tablets on each of the consecutive 2 or 3 nights and continue with rest of the packet as usual. In all such cases, when the pills have been missed the next packet should be started as usual after a gap of 7 days from the time last 21 days packet is finished. In such cases where this prompt initiation immediately after 7 days is delayed by 1 or 2 days, the women should use additional barrier method till the time of starting the next normal course of 1 pill a day (from the 7th or 8th day). These rules apply to all OC users, whether using combined or triphasic pills.

Effectiveness : Combined OC are very effective, with an overall failure rate of 0.1% (1 per 1000 women year). Failures are maximum during first year of use and are mainly due to missed pills, delay in starting the next course exactly after 7 days of finishing the last 21 days pack, and due to stopping the pill abruptly due to side effects without taking any other appropriate contraceptive measure.

Side Effects : These are of two categories, viz, minor side effects which are often temporary and the subject should therefore be properly counselled so that she does not unnecessarily discontinue the pills. The second category is the major side effects.

Minor Side Effects : These include nausea, vomiting and decrease in appetite for the initial 2 or 3 months; breakthrough bleeding usually during first few months; menorrhagia, irregular bleeding or oligomenorrhoea; breast heaviness and tenderness; headache; weight gain; acne and oily skin; and, rarely, depression and decline in libido.

Major Side Effects : These include increased risk of IHD, and stroke especially if the woman is also a smoker or hypertensive or diabetic or has history of venous thromboembolism. There is also risk of raised blood pressure especially if age is >35 years; slightly increased risk of breast cancer and possibly cervical cancer; interference with insulin action in diabetics; exacerbation of existing hepatic conditions and reduction in lactation.

Who Should Avoid OCs : The following women should avoid OCs and try to use some other contraceptive device : (a) Smokers, especially if age >35 years.(b) Women who are breast feeding their children, up to 6

months post partum.(c) Hypertensives.(d) Past H/o breast cancer.(e) Unexplained vaginal bleeding.

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(f) H/o stroke, thromboembolism or IHD(g) Cirrhosis of liver or active hepatitis or liver tumors(h) Using Rifampicin or anti-epileptics.(j) Undergoing major surgery or prolonged immobilization.(k) Diabetes with >20 years duration or with vascular

complications.(l) Hyperlipidaemia.Warning Features : Women should be educated to watch out for following features and seek medical attention should they occur : (a) Chest pain(b) Shortness of breath(c) Headaches which are severe or throbbing or occur on one

side.(d) Blurred or diminished vision.(e) Swelling or severe pain in a leg(f) Missed periods, especially if 2 periods are missed.(g) Post coital or persistent irregular vaginal bleeding after

3 months of pill usage or excessive, white discharge especially if mixed with blood.

(h) Yellowness of eyes or urine.Advantages of OC use(a) Very effective, require minimal effort.(b) Return of fertility on stopping the pills is very prompt.(c) Can bring about relief in certain menstrual disorders as

dysmenorrhoea.(d) May be protective against endometrial cancer and ovarian

cancer.(e) May be protective against benign diseases of breast and

ovaries.(f) Likely to be protective against ectopic pregnancy,

PID, hirsutism, acne, osteoporosis and progression of rheumatoid arthritis.

(g) At times, the increase in weight is quite welcome to women.

Non-Oral Hormonal ContraceptivesThese are of 3 broad categories :

(a) Injectable : These include the progesterone only (Depot Medroxy Progesterone Acetate - DMPA and Norethesterone Enanthanate - NETEN) or the combined ones (DMPA 25mg Plus oestradiol 5mg or NETEN plus oestradiol 5mg)

(b) Contraceptive Implants : These include Norplant (6 capsules of levo-norgesterol) and Implanon (single rod of 3-keto desogesterol).

(c) Contraceptive Impregnated Devices : as progesterone releasing IUD (progestinsert, LNG-20, Levonova); or contraceptive vaginal rings.

Of the above, DMPA (Depot provera) and NET-EN are often used and available in India. DMPA is given 150mg i. m. inj and remains effective for 3 months; NETEN is given 200mg as an oil based i. m. inj and remains effective for 2 months. These are most effective when given within first 1-5 days of menstrual cycle. The failure rate is only 0.1 to 0.4%.

Absolute contra-indications for their use are pregnancy, unexplained vaginal bleeding and current breast cancer. Relative contraindications include less than 6 weeks postpartum among breast feeding women, history of breast cancer, jaundice,

cirrhosis, liver tumor, severe headache, undiagnosed breast disease, previous OC related liver diseases, and H/o IHD, hypertension or stroke. Fertility may take 6 to 12 months to return after discontinuation of this injection.

Emergency (post-coital; morning-after) contraceptionEmergency contraception pills (ECPs) are a very good method of preventing pregnancy likely to occur due to unprotected sex or else due to suspected failure, as rupture of a condom. The following are the salient features of ECPs : (a) ECPs are hormonal oral contraceptives having the same

hormones as used in OCs but in a higher concentration.(b) ECPs come in a pack of two pills. The first should be taken

as soon as possible, but certainly within 72 hours of an unprotected sex. The second should be taken 12 hours after the first pill.

(c) One ECP packet can protect only against one episode of unprotected sex.

(d) ECPs are available free of cost at PHCs and with ANMs at subcentres, under the name of “E-Pill”. They are also commercially available under brand names like Ecee-2, Norlevo, E-P-72 and Pill72.

(e) ECPs are safe for all women including those who are breast feeding.

(f) If the lady vomits within 1 hours of taking the pill, the dose should be repeated after taking an antiemetic as Meclizine HCL (Pregnidoxin)

(g) Some women may have minor side effects as breast tenderness, headache, nausea, vomiting, spotting, fatigue, and dizziness which may last for maximum of 24 hours.

(h) It should be clearly conveyed to the clientele that ECP is not an abortion pill since it cannot dislodge an implanted ovum.

(j) ECP is quite effective in that they may prevent up to 75% pregnancy which would have otherwise occurred following unprotected sex.

(k) After taking ECP, if onset of next menstrual cycle is delayed by more than 1 week of expected date, a pregnancy test should be done. She should also report if the period starts on time but the flow is scanty or is unusually foul smelling.

(l) ECP should not be used as a regular contraceptive method.

(m) In case E-pill or such ECP preparation is not available, the women can take 4 tabs of Mala-D at the earliest but within 72 hours of unprotected sex, followed by 4 Tablets of Mala-D after 12 hours of first dose.

(n) Reassure the women that her next period will start on the expected date or sometime 2-3 days earlier or later than expected date.

Non-Hormonal Oral Contraceptives : CentchromanThis is a new form of oral contraceptive pill that does not contain any steroidal hormones, developed by the Central Drug Research Laboratory, Lucknow. It appears to be safe and economical and is sold under the brand names “Saheli” and “Centron”. It is taken once a week and is very convenient. It is very effective and can increase client privacy. There are no known side effects, except that in about 8% of users there is a delay in menses.

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Permanent MethodsPermanent methods include male sterilization (Vasectomy) and female sterilization (Tubectomy). Any couple who has at least one child and is voluntarily motivated can be offered sterilization procedure. Medical officers should emphasize on the clientele that these procedures are perfectly safe and do not carry adverse effects like decline in libido, low backache, obesity and so on, as are commonly thought of. In fact the sexual performance and pleasure may improve since the fear of unwanted pregnancy is removed.

Vasectomy : In the conventional procedure, an incision is given on the scrotal skin and a piece of vas deferens 1 to 1. 5 cm long is removed. In the more recent technique of “No Scalpel Vasectomy” a puncture is made in scrotal skin using a reverse scissor and a hole of approx half a cm is created through which vas is ligated after removing a piece 1 cm long. The advantage of this method is that no stitches need to be given on the scrotal skin. It must be emphasized on the acceptor that it will take 3 months for him to become completely sterile. For this duration, he or his wife should use an alternative temporary method. After 3 months, seminal analysis should be done to confirm azoospermia. The following advice should be given for implementation during post operative period :

He or his partner should use some other contraceptive ●procedure till such time the semen exam indicates definite azoospermia, which is generally after 3 months.To keep the local area clean and dry. ●To wear a T-bandage for 2 weeks ●To avoid cycling or lifting heavy weights for 2 weeks ●To get the stitches removed as advised by the surgeon. ●

There are very few complications of vasectomy and even these are minor. Some persons may get pain, local infection and haematoma which last for a few days and respond well to antibiotics and analgesics. Local granuloma formation may occur in a very few patients and subsides over time. The most important complications are, in fact, psychological, as feeling of low backache, development of abdominal obesity and reduced sexual drive. Subjects should be adequately educated and counselled about these psychological problems.

Overall failure rate of vasectomy is between 1 to 2 per 1000 person years (0.1 to 0.2 per 100 person years). The two important causes of its occurrence are firstly, mistakenly removing some other anatomical structure (as a local vein or spermatic chord) instead of vas. This problem is negligible in expert hands. The second reason is spontaneous recanalisation of the vas, the potential of which always exists to the tune of 0 to as high as 6%. Therefore, all persons undergoing vasectomy should be explained of this unforeseen complication and advised regular follow up for at least 3 years. In addition, another cause of pregnancy could be unprotected intercourse before complete azoospermia, which usually takes 3 months, but may be more in some subjects. It is therefore important to advise the subjects on these various aspects, since misconceptions and lack of knowledge may lead to serious domestic conflicts.

Tubectomy : In the conventional method (Pomeroy’s method), a piece of the loop of Fallopian tubes about 1 cm long on both sides is removed. The same is done in minilaparotomy.

In Laparoscopic tubectomy the tubes are either blocked by electrocoagulation or sealed with a silastic band. The ideal time for tubectomy is soon after menstrual flow is over or in the post partum period. However, it can be done anytime in between the menstrual period but the woman should continue to use alternative contraceptive till her next menstrual flow.

Recanalisation : For couples who have undergone sterilization operation but now need children, recanalisation operations are available. The success of recanalisation depends on many factors, the most important being the fertility state of both the partners. In case of tubal recanalisation it also depends on the original method by which tubectomy was done - if the original method was spring loaded clip, the pregnancy rate following recanalisation may be as high as 88%, while for Pomeroy method it is about 60%. As regards recanalisation of vas, in expert hands, the patency rate may be as high as 80% but actual pregnancy rate may be lower due to various other factors as fertility status of the husband and wife.

SummaryAs per present policy in the country, people are given choice to adopt contraceptive methods voluntarily out of various choices available. The various methods of contraception are divided broadly into artificial and natural methods. The natural methods include Rhythm method, Basal body temperature method, cervical mucous method, Symptothermal method and Lactational amenorrhoea method.

Artificial methods are further subdivided into temporary and permanent methods. Temporary methods include barrier contraceptives, spermicides, IUDs, oral & non-oral hormonal contraceptives. Most commonly used barrier contraceptive is condom which has the additional advantage of providing protection against STDs and HIV. It has average failure rate of 12-14 HWY, mainly because of incorrect technique of use.

IUDs act mainly by inducing inflammatory changes in endometrium, incapacitating the sperm & ovum and preventing implantation. IUDs are divided into Gp I, II & III. Before its insertion, various contraindications should be ruled out. It should be inserted soon after menstruation upto 10th day of cycle. It can also be inserted in immediate postpartum or ideally 6 weeks after delivery/abortion. It can be used as a postcoital contraceptive. After its insertion woman should be instructed regarding regular checking of IUD in place, and regular health checkups. Important complications include menorrhagia, dysmenorrhoea, expulsion, perforation, Infection & ectopic pregnancy. Average failure rate is 1-2 HWY.

OCPs are divided into combined pills and progesterone only pills. Progesterone only pills can be used in women >40 yrs. or lactating period upto 6 months of postpartum. Combined pills act by inhibiting ovulation, altering endothelium and changing cervical mucus. Combined pills can be monophasic or triphasic. Commonly used monophasic pills now come with low amount of estrogen i.e. < 0.05mg ethinyl estradiol. The first pill is taken on 6th day of period and is continued for 21 days, and after stopping for 7 days it is restarted. Failure rate is as low as 0.1 HWY. Major side effects are increased risk of IHD, CVA and venous thromboembolism.

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Non-oral hormonal contraceptives include Injectable (DMPA, NETEN), Contraceptive Implants (Norplant, Implanon), Contraceptive Impregnated Devices (Progestinsert, LNG-20). Emergency contraception pills (ECPs) have the same hormones as combined pills but in higher dose, the 1st dose should be taken as soon as possible after unprotected sex (max 72 hr) and 2nd dose 12hr after the 1st dose.

Permanent methods include vasectomy and tubectomy. Vasectomy can be conventional or No scalpel vasectomy. An alternative temporary method should be used till azoospermia is achieved after vasectomy (usually 3 months). Tubectomy can be done by Pomeroy’s method using conventional, laparoscopic or minilap procedure. In laparoscopic tubectomy, electrocoagulation or sialistic rings are used. Recanalisation after permanent methods is possible with varying degree of success results.

Study ExercisesLong Question : How will you educate a group of approximately 150 adult, married men and women aged 20 to 50 years, belonging to a rural background and most of them educated between 4th to 8th class, as regards the various available contraceptive procedures.

Short Notes : (1) Pearl Index (2) Compare and contrast OCs and IUDs (3) Emergency contraception.

MCQs & Exercises1) In Rhythm method for contraception, intercourse is avoided

during : (a) 3-14 days (b) 5-25 days (c) 10-28 days (d) 7-21 days

2) In Basal Body Temperature Method for contraception, increase in body temperature occurs : (a) Just before the ovulation (b) Ovulation period itself (c) Immediately after ovulation (d) Menstruation

3) The failure rate of cervical mucus method if used correctly is : (a) 1 per HWY (b) 2 per HWY (c) 3 per HWY (d) 4 per HWY

4) The failure rate of Condom is : (a) 12-14 HWY (b) 14-17 HWY (c) 17-20 HWY (d) 20-25 HWY

5) The active agent in spermicidal jelly is : (a) 9- Xylenolol (b) 9- Xylene (c) 9- Nonoxynol (d) 9- Nonxylenol

6) In Cu T-200, 200 signifies : (a) Weight of Cu in mg (b) Surface area of Cu in sqmm (c) Length of Cu wire in mm (d) Diameter of Cu wire in µm

7) The mechanism of action of IUD does not include (a) Inducing mild inflammatory changes and foreign body reaction in the endometrium (b) Incapacitate the sperms and ovum, prevent sperm from fertilizing the ovum (c) Makes the uterine environment inhospitable for the blastocyst to be implanted (d) Increases the reverse peristalsis of uterus

8) Which of the following IUDs belong to Gp II IUDs : (a) Cu T- 200 (b) Lippe’s loop (c) Cu T-380A (d) ML-250

9) The presence of Cu-T in place is checked routinely by (a) Feeling the thread coming out of cervical os (b) Absence of menstruation (c) Feeling the metal tip in upper part of vagina (d) None of the above only X-ray can check it

10) Which one is not an absolute contraindication for IUD insertion : (a) Pregnancy (b) Puerperal sepsis (c) Anaemia

(d) Bleeding P/V of unknown etiology11) Which of the following is not the likely adverse effect of

IUD : (a) Menorrhagia (b) Metrorrhagia (Intermenstrual bleeding) (c) Polymenorrhoea (d) Anaemia

12) Single pill of MALA-D contains : (a) L-norgesterol (LNGL) 0.15mg and EE 0.03mg (b) L-norgesterol (LNGL) 0.03mg and EE 0.15mg (c) D-norgesterol (LNGL) 0.15mg and EE 0.03mg (d) D-norgesterol (LNGL) 0. 03mg and EE 0.15 mg

13) Which of the following is not the likely mechanism of action of OCPs : (a) Inhibition of ovulation by bringing about changes in FSH & LH secretion (b) By altering the endometrium (c) By bringing about changes in cervical mucus (d) Incapacitates sperm

14) Which of the following is not the likely adverse effect of OCP : (a) Menorrhagia (b) Breast Heaviness (c) Oligomenorrhoea (d) Dysmenorrhoea

15) The failure rate of OCP is : (a) 1 HWY (b) 2-3 HWY (c) 0.1 HWY (d) 10 HWY

16) Which is not the containdiaction for OCP use (a) Hyperlipidaemia (b) Cirrhosis of liver (c) Unexplained vaginal bleeding (d) Anaemia

17) Which of the follwing is most cost effective method for permanent sterilization : (a) Vasectomy (b) Pomeroy’s tubectomy (c) Laparoscopic tubectomy (d) No scalpel vasectomy

18) After vasectomy/ no scalpel vasectomy, for at least how many months should the couple use alternative temporary method of contraception : (a) 3 weeks (b) 3 months (c) 2 weeks (d) 2 months

19) Emergency contraceptive pill should be used within a max period of : (a) 24 hr (a) 48 hr (c) 72 hr (d) 96 hr

20) What is a mini pill : (a) Pill containing lesser amount of estrogen and progesterone (b) Once a month pill (c) Progesterone only pill (d) Emergency pill

Match the Following :

1. Cervical mucus Method a. 12 to 14 / HWY

2. Condoms b. 3 / HWY

3. IUDs c. 1 per 1000 women year

4. Combined OC d. 1 to 2/ HWY

Fill in the Blanks 1. Emergency Contraceptive Pills (Hormonal) come in a pack

of _____ Pills, The first should be taken as soon as possible, but certainly within ____ hours of an unprotected sex. The second should be taken ______ hours after the first pill.

2. The first pill is taken on Day _________, one pill every day for next ___ days. Thereafter the pill is stopped & restarted after a gap of ______ days, irrespective of the onset or stoppage of menstruation during these pill free periods.

3. _________ Oral contraceptive pill is available free of cost under the FW program in our country. This contains _____ dl-NGL and __________ Ethinyl estradiol (EE) per pill.

4. Oral Contraceptives produce contraceptive effect by __________ and __________ and __________

5. The best time to insert Copper-T is_________________

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Answers : MCQs : (1) d; (2) c; (3) c; (4) a; (5) c; (6) b; (7) d; (8) d; (9) a; (10) c; (11) c; (12) a; (13) d; (14) d; (15) c; (16) d; (17) d; (18) b; (19) c; (20) c; Match the Following : (1) b; (2) a; (3) d; (4) c; Fill in the Blanks : (1) 2, 72, 12 (2) 1, 21, 7; (3) Mala-N, 0.30mg, 0.03mg (4) Inhibition of ovulation by bringing about changes in FSH & LH secretion, by altering the endometrium and by bringing about changes in cervical

mucus (5) During or soon after menstrual period.

Further Suggested ReadingHatcher RA, Rinechant W, Blackburn R, Galler JS. The essentials of 1. contraceptive technology. John Hopkins School of Public Health, Baltimore, USA. First edition 1997.Chaudhari SK. Practice of fertility control : A comprehensive text book. BI 2. Chuchil Livingstone, New Delhi, 5th Edition 2001.