Pinki Sah Nursing Lecturer

1. MAGNITUDE OF MATERNAL AND
CHILD HEALTH PROBLEMS

2. INTRODUCTION
MATERNAL AND CHILD
HEALTH
• Maternal and child health is
recognized as one of the
significant components of
family welfare.
• It is being observed that the
deaths of mothers and children
are the major contributions to
mortality in any community in
Nepal.

4. NDHS DATA 2016

5. CHILDHOOD MORTALITY
• The neonatal mortality rate is
21 deaths per 1000live
births.
• The infant mortality rate is 32
deaths per1000 live births.
• The under-5 mortality rate is
39 deaths per 1000 live
births.

6. MATERNAL MORTALITY
• Perinatal mortality rate is 31 deaths per 1000
pregnancies.
• Maternal mortality ratio is 239 deaths per 100000 live
births during the 7 years preceding the survey.
• Life time risk of maternal mortality in Nepal is 1 women
in 167 can expected to have a maternal mortality death
while age 15-49.

7. ANTENATAL CARE (ANC)
• 84% of women who gave
birth in the 5 years only 69%
of women had at least 4 ANC
care visits.
• 84% women received ANC
from skilled provider. Doctors
were the major service
providers (43%), followed
closely by nurses or Auxiliary
Nurse Midwives (41%).

8. INSTITUTION DELIVERY
• 57% of birth in 5 years were delivered in health
facilities.
• 43% of deliveries took place in government facilities and
10% in private facilities.

9. POSTNATAL CARE (PNC)
• 57% of women reported having received a postnatal
check-up in the first 2 days after the birth, with most
check-up within 4 hours of delivery.
• 42% of women does not receive any postnatal care.
• The proportion of women with a postnatal check within
2 days after delivery increased from 45% in 2011 to
57% in 2016.

11. ABORTION
• 71% of women who had an abortion in the 5 years went
to Doctor, Nurse or Auxiliary Nurse Midwife.
• 19% received service from a pharmacist or medical
shop, while 5% received services from a Health
Assistant or other health workers.

12. DEFINITION OF MATERNAL HEALTH
• Maternal Health is now referred as "Reproductive
Health” (RH).According to WHO it is defined as a state
of complete physical, mental and social wellbeing and
not merely the absence of disease or infirmity in all
matters relating to the reproductive system and its
functions and processes.

13. • Reproductive Health is defined as “People have the
ability to reproduce and regulate their fertility, women
are able to go through pregnancy and child birth safely,
the outcome of pregnancies is successful in terms of
maternal and infant survival and well being and couples
are able to have sexual relations free of fear of
pregnancy and of contracting diseases.”

14. MEANING OF MATERNAL AND CHILD
HEALTH
• Maternal and Child Health (MCH) refers to a package of
comprehensive health care services which are
developed to meet promotive, preventive, curative,
rehabilitative health care of mothers and children.
• It includes the sub areas of maternal health, child
health, family planning, school health and health
aspects of the adolescents, handicapped children in
special setting.

15. OBJECTIVES OF MATERNAL AND
CHILD HEALTH
• To reduce maternal, infant and childhood mortality and
morbidity.
• To reduce perinatal and neonatal mortality and morbidity.
• Promoting satisfying and safe sex life.
• Regulate fertility so as to have wanted and healthy children
when desired.
• Provide basic maternal and child Health Care to all mothers
and children.

16. • Promote and protect health of mothers.
• To promote reproductive health.
• To promote physical and psychological development of
children and adolescents with in the family

17. GOALS OF MATERNAL AND CHILD
HEALTH SERVICES
• To ensure the birth of a healthy infant to every
expectant mother.
• To provide services to promote the healthy growth and
development of children up to the age of under- five-
years.
• To identify health problems in mother and children at an
early stage and initiate proper treatment.
• To prevent malnutrition in mothers and children.

18. • To promote family planning services to improve the
health of mothers and children.
• To prevent communicable and non- communicable
diseases in mothers and children.
• To educate the mothers on improvement of their own
and their children’s health.

19. A. MATERNAL HEALTH PROBLEM
The maternal health problems are as follows:-
1. Nutritional problems
a. Malnutrition
b. Nutritional anemia
2. Infection problems
a. Reproductive Tract Infection (RTIs)/ Sexually
Transmitted Infection.

20. b. Infection in general.
c. Puerperal sepsis.
3. Disturbances in Menstruation
4. Adolescent Gravida
5. Abortion
6.Complication of deliveries
7. Infertility

21. 8. Uterine prolapse
9. Cervical cancer

22. B. CHILD HEALTH PROBLEMS
1. Nutritional deficiency problems.
a) Malnutrition
b) Vitamin A deficiency
c) Iron deficiency
d) Low birth weight
2. Infectious disease
a) Tuberculosis
b) Diptheria

23. c) Pertussis (whooping cough)
d) Tetanus
e) Poliomyelitis
f) Measles
g) Acute Respiratory Infection (ARI)
h) Diarrheal disease

24. 3. Problems of Neonatal Tetanus
a) Hyper bilirubinemia
b) Hyperthermia
c) Neonatal tetanus

25. MATERNAL HEALTH PROBLEMS

26. 1. NUTRITIONAL PROBLEMS

27. MALNUTRITION

28. • Over all, 11% of women are shorter than 145cm. A total
of 17% women are thin, with 11% mildly thin and 6%
moderately thin and 1% severely thin. Further 22% are
overweight and 5% obese.

29. • Malnutrition is a very common problem among women
who are discriminated and underprivileged.
• Pregnant and nursing mothers are especially prone to
the effects of malnutrition.
• Malnutrition can cause poor resistance, abortion,
anemia, miscarriage or premature delivery, low birth
weight baby (<2.5kg), eclampsia, postpartum
hemorrhage etc. These conditions can cause fatal
effects on mothers, unborn and new born babies.

31. • Malnutrition in women needs to be prevented and treate
d by some of the direct measures such as:
nutrition education, modification and improvement of
dietary intake before, during and after pregnancy,
supplementation of diet, distribution of iron and folic
acids tablet, subsidizing of food items and their
fortification and enrichment.

32. • Other measures which can help prevent malnutrition
include prevention and control of infections by
improvement of environmental sanitation, safe water
supply, food and personal hygiene, immunization
treatment of minor ailments, regulation of fertility
and practice of small family norm, and health education.

34. NUTRITIONAL ANEMIA
• Anemia is a major concern among women, which leads
to increase maternal morbidity and mortality and poor
birth outcomes, as well as reductions in work
productivity.
• 41% of women are anemia, with 34% mildly anemic, 7%
moderately anemic and less than 1% severely anemic.
• Prevalence of anemia decrease with increases age. For
example, 44% of women age 15-19 are anemic
compared with 36% among women age 40-49.

35. • Pregnant women and breast feeding women (each
46%) are more likely to be anemic than other women
(39%).
• A higher proportion of women in terai (52%) are anemic
compared with women from mountain (35%) and hill
(29%) ecological zones.

36. DETERMINANTS OF ANEMIA IN
PREGNANCY

37. PREVENTION OF ANEMIA

38. 2. INFECTION PROBLEMS

39. REPRODUCTIVE TRACT INFECTIONS (RTIs)/
SEXUALLY TRANSMITTED INFECTION(STI)
• RTIs include a variety of
bacterial, viral and protozoal
infections of the lower and
upper reproductive tract of
both sexes.
• RTIs pose a threat to women’s
lives and well being throughout
the world.

40. • A high incidence of infertility, tubal pregnancy and poor
reproductive outcome is an indirect reflection of high
prevalence of RTIs and STIs.

41. INFECTION IN GENERAL
• The women during pregnancy, especially in
underdeveloped areas and developing countries are at risk
of contraction infection.
• Many women get infected with herpes simplex virus,
cytomegalovirus, protozoon which causes toxoplasmosis,
E.Coli causing nephritis or cystitis.
• Infection during pregnancy can cause various harmful
effects e.g. retardation of fetal growth, abortion, low birth
weight and puerperal sepsis.

42. PUERPERAL SEPSIS
• It is mainly due to infection during labor and after
delivery of lack of personal hygiene, insanitary
conditions, septic procedures, etc.
• This may lead to inflammation of ovaries, fallopian
tubes, endometrium. cervix and vagina.
• Many a time leucorrhoea may persist for years.
• Sometimes secondary sterility may follow after acute or
chronic salpingitis.

43. • Chronic infections of cervix may predispose to cancer of
the cervix.
• It requires proper preparations for confinement by the
mother, conduct of deliveries by trained and skillful dais
, midwives etc. and availability of equipment and
supplies etc.

44. 3. DISTURBANCES AND MENSTRUATION
• Amenorrhea absence of menstrual flow, dysmenorrhea-
painful menstruation, abnormal uterine bleeding,
hypermenorrhea/ menorrhea, excessive bleeding
(amount and duration), metrorrhagia, bleeding between
menstrual periods.

45. 4. MATURE GRAVIDAS
• The pregnant woman over 35 years faces unique
problems.
• The primigravida in this age category has generally
decided to postpone child bearing until her career is
well established.
• Although the child may be wanted and anticipated, she
will often have much ambivalence and concern about
how motherhood will affect her lifestyles and how it will
affect her relationship with the father of the baby.

46. • For woman having first pregnancy later in life, fear
about the infant’s health and survival often becomes the
dominant feeling.
• This may be the last egg in the basket and this is
very much valued. As a result, cesarean birth is
chosen more often by obstetricians, and indicates an
overcautious approach to birth problems.

47. 4. ADOLESCENT GRAVIDA
• The adolescent mother and her family create a particularly
difficult problem. The need scan be so extensive that care
will be fragmented and ineffective unless and
interdisciplinary team approach coordinates the school,
social and health care services.
• According to UNFPA state of world population report,
Nov/08/2013, 7.3 million girls under 18 year gives birth in
developing countries. About 1 in 5 girls in Nepal are
mothers or pregnant.

48. • The scope of adolescent pregnancy is enormous. The mean
age of menarche is around12 years. 42% of girls and 64% of
young boys are sexually active by age 18.
• A family’s reaction to teen age pregnancy varies considerably.
In certain ethnic and cultural groups, teenage parenting is
common.
• Indeed the girl’s mother may have been a teenage parent
herself. In these cases, the situation is not a crisis. In other
families, major problems result.
• Sex education and family planning help to adolescent Gravida.

49. 5. ABORTION
• Large abortions are still done by quacks and unauthorized
persons in the rural areas. This is mainly due to lack of
access to safe abortions clinics in urban areas, lack of
information about the availability of safe abortions clinics.
• Only 71% of abortion was done by Doctor/Nurse/ANM
remaining was done by HA, AHW, FCHV, VHW,
Pharmacist/medical shop, relatives and friends.
• 40.6% 0f women think abortion is legal.
• 40.0% of women, who know a place for safe abortion.

50. • 10.3% abortion done due to health of mother.
• 4.3% abortion done because parent don’t have money to take
care of the baby.
• 11.7% abortion done because parent wanted delay child
bearing.
• 50.3% abortion done because parent did not want more
children.
• 9.3% abortion done because parent wanted to space birth.

51. • 6.5% abortion were done because fetus sex were not
desired by parents.
• 3.7% abortion done because husband/ partner did not
want a child.

52. 6. COMPLICATIONS OF DELIVERIES
• most of the deliveries take place at home under unhygienic
environment and mostly by untrained dais lacking obstetric skill.
• Often various health hazards results in such as perineal tears,
cervical damage, prolapse and displacement of uterus, fetal
distress, postpartum hemorrhage etc.
• Thus it is very important to have properly trained skillful and
qualified health workers, adequate facilities and well linked
referral units where skillful and efficient emergency care can be
given to save mother and baby.

53. 7. INFERTILITY
• Infertility is both medical and social problem Even if the
fault/defect is in the male partner, usually it is the woman
who is labeled as “Banjh” and is socially not treated
properly by the family and the society.
• Therefore this problem is to be considered medically as
well as socially. There is need to have empathetic attitude
towards childlessness of woman by society.

54. 8.UTERINE PROLAPSE
• Uterine prolapse is the major problem in women of hilly
region. Women working at construction sites, climbing
heights, or digging and ground or climbing 2-3 storey with
heavy weights are predisposed to prolapse uterus.
• Certain child birth practices such as pressing hard on the
abdomen during labor, pulling the baby etc., lead to prolapse
of the uterus, especially when the mother is weak and
malnourished..

55. • In 2007 study carried out by the center for Agro-Ecology
and Development found that over 1 million women in
Nepal suffer from the condition, Many of whom
require surgery and 40% of whom are the reproductive
age.
• Uterine prolapse may cause lot of inconvenience to
mother and predispose her to infection. Hence the need
for trained and skillful dais and midwives, improvement
of working conditions and education of women.

56. 9. Cancer of the cervix
• There are various factors which contribute to the
prevalence of cancer of cervix.
• These are early marriage and
early pregnancy, multiple child birth, poor hygiene by th
e partner, multiple partners, and repeated infections.
• Most of these factors are pertaining to sociocultural
aspects of a community and families are imply involving
attitudinal change in these practices to prevent the
occurrence of cancer of the cervix.

57. • Cervical cancer is the most preventable cancer in women. It
is biggest killer among all the cancer in Nepali women .
• All women that are sexually active are at risk of contracting
it.
• It is estimated that 20% of all female cancers linked to
cervical cancer, most of those being in advanced clinical
stage.
• Annually in Nepal, there are an estimated 1,100 deaths due
to cervical cancer.
- Cervical cancer in Nepali women 31, 2010

58. CHILD HEALTH PROBLEMS

59. 1. NUTRITIONAL DEFICIENCY PROBLEMS

60. MALNUTRITION
• Overall, 36% of children under
age 5 are stunted, with 12%
being severely stunted (too short
for their age).
• 10% are wasted with 2%
severely wasted (too thin for
their height); and 27% are
underweight, with 5% severely
underweight (too thin for their
age), while around 1% of the
children are overweight (heavy
for their height)

62. VITAMIN A DEFICIENCY
• The study shows that, in Nepal,
the Vitamin A deficiency has
significantly reduced among
children. In 1998, 20.8%
preschool children were Vitamin
‘A’ deficient as compared to
4%of children aged between six
and 59 months in 2016.- 29
August 2018, UNICEF Nepal

63. IRON DEFICIENCY ANEMIA
• Prevalence of anemia among
under 5 children, over the
past 5 years it has increased
by 7% points (from 46% in
2011 to 53% in 2016)
• Mild -26%, Moderate-26%,
Severe-1%

65. LOW BIRTH WEIGHT BABY
• 12% baby were of low birth
weight (<2.5kg). There was
no change in the
percentage of babies with a
low birth weight between
2011 and 2016.

66. 2. INFECTIOUS DISEASE

67. • In Nepal, tuberculosis in
children represents 5-15% of
all TB cases.
• Untreated adults pass the
disease on to 43% of
children under one and 16%
of children from 11-15years
old.

68. DIPTHEIA
• Diphtheria is a worldwide problem in most developed co
untries owing to routine children vaccination. In
developed countries like England and Wales there were
only
5cases of diphtheria in 1980 as against 46,281 cases, s
een among non-immunized children.

69. PERTUSIS (WHOOPING COUGH)
• Whooping cough is an acute infectious disease causing complications an
d high mortality in many parts of the world. It is caused by Bordetella
Pertussis.
• The source of infection is infected human being. These may be typical,
mild or missed cases. The infection is present in nasopharyngeal and
bronchial secretions.
• The disease is most
communicable during the later part of incubation period and inflammatory
stage(catarrhal stage).
• The period of infectivity usually extends from one week after exposure to
infection to about 3 weeks after the onset of typical whooping cough.

70. TETANUS
• It is one of the leading causes of infant mortality.
Tetanus can be prevented by active immunization by
tetanus toxoid of all antenatal mothers and children.

71. ACUTE RESPIRATORY INFECTION (ARI)
• The prevalence of symptoms of ARI among children under
age 5 in Nepal felt from 5% in 2011 to 2% in 2016.
• The prevalence of symptoms of ARI was highest among
children age 6-11 months and age 12-23 months
(4%each)followed by children age 24-35 months (2%)

72. DIARRHEAL DISEASE
• In Nepal, diarrhea is one of the most common illnesses
among children and continues to be a major cause of
childhood morbidity and mortality.

74. III. Problems of Neonatal
a) Hyperbilirubinemia
b) Hyperthermia
c) Neonatal tetanus: 2% of neonatal mortality occurs due
to tetanus

75. CAUSES OF MATERNAL MORTALITY
AND MORTALITY
• Every day, approximately 830 women die from
preventable causes related to pregnancy and child
birth.
• 99% of all maternal deaths occur in developing
countries.
• Maternal mortality is higher in women living in rural
areas and among poorer communities.

76. • Young adolescents face a higher risk a complications
and death as a result pregnancy than other women.
• Between 1990 and 2015, maternal mortality
worldwide dropped by about 44%.
• Between 2016 and 2030, as part of the Sustainable
Development Goals, the target is to reduce the global
maternal mortality ratio to less than 70 per 100000 live
births.

77. MATERNAL MORTALITY
• Maternal mortality is the death of a women while pregnant or
within 42 days of termination of pregnancy, irrespective of the
duration and site of the pregnancy or its management but not
from accidental or incidental causes.”
OR
• The maternal mortality rate (MMR) is the annual number of
female deaths per 100,000 live births from any cause related to
or aggravated by pregnancy or its management (excluding
accidental or incidental causes).

78. MATERNAL MORBIDITY
• WHO definition “any health condition attributed to and
/or aggravated by pregnancy and child birth that has a
negative impact on the women’s well being.
• Many women dies of pregnancy-related causes and
other experience acute or chronic morbidity, often with
permanent sequelae that undermine their normal
functioning.

79. • These sequelae can affect women’s physical, mental or
sexual health, their ability to function in certain domains
(e.g., cognitive, mobility, participation in society)
• Maternal morbidity is estimated to be highest in low-
and-middle income countries, especially among the
poorest women.

80. CAUSES OF MATERNAL MORTALITY:
• Direct causes:
 Haemorrhage (24%)
 Eclampsia (21%)
 Unsafe abortion (15%)
 Pre-eclampsia (10%)
 Infection (8%)
 Sepsis (5%)
 Prolonged and obstructed labour (6%)

81. • Underlying causes:
 Poverty
 High parity
 Nutritional status of mother
 Extreme of age
 Neglect of women’s right to equal status.
 Harmful cultural practice
 Low educational status of women

82. REFERENCES
• https://www.scribd.com/doc/27462253/Magnitude-of-
Maternal-and-Child-Health-Problem
• http://www.who.int/news-room/fact-sheets/detail/maternal-
mortality
• http://www.who.int/bulletin/volumes/91/10/13-117564/en/
• https://pre-empt.bcchr.ca/who-maternal-morbidity-working-
group