Faculty of Medicine Introduction - PowerPoint Presentation

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Faculty of Medicine Introduction to Community Medicine Course (31505201) Primary Health Care-PHC Maternal & Child Health- MCH

By Hatim JaberMD MPH JBCM PhD1- 11- 2017

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Presentation outlineTimeIntroduction and Definitions08:15 to 08:25Maternal Health08:25 to 08:40Child Health08:40 to 09:00

Prevention of Maternal and Child Health problems09:00 to 09:15Family Planning

09:15 to 09:30

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Introduction to course 31505201 Course ContentWeek 1 Unit 1: Introduction to Health and Community Health Week 2 Unit 2 Nutrition and Nutrition Assessment and Diet    Week 3 Unit 2 (cont.) Nutrition and Nutrition Assessment and Diet  Week 4 Unit 2 (con..): Infant and Breast Milk Characteristics  Week 5 Unit 3: Public Health/Environmental Health  Week 6 Public Health/Environmental Health Week 7

Unit 5: Primary Health careWeek 8 Unit 6: :

Epidemiology .Epidemiology

Demography

, Data and

Biostatics

Week

9  Midterm assessment (Exams.)15-11-2017Week 10 Unit 8 Public Health SurveillanceWeek 11 Unit 9: Prevention and Control of DiseasesWeek 12 Unit 10: Health Education and CommunicationWeek 13 Unit 11: ScreeningWeek 14 Unit 12: Health Administration and healthcare managementWeek 15 Unit 13: Revision and Health ResearchWeek 16 Final assessment (Exams.)

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Week 7 Unit 5: Primary Health Care- PHCPrinciples and elements of PHC 30-10-20172. Maternal and Child Health- MCH 1-11-20175Slide6

PHC Definition PHC is an essential health care that is a socially appropriate, universally accessible, scientifically sound first level care provided by a suitably trained workforce supported by integrated referral systems and in a way that gives priority to those most in need, maximises community and individual self-reliance and participation and involves collaboration with other sectors.6Slide7

Declaration of the Alma AtaReleased in 1978 and consisted of ten fundamental principles for effective comprehensive primary health care service deliveryPrinciples were in response to the broader community and social issues leading to poor population health7Slide8

Core Activities for PHC There is a set of CORE ACTIVITIES, which were normally defined nationally or locally. According to the 1978 Declaration of Alma-Ata proposed that these activities should include:Education concerning prevailing health problems and the methods of preventing and controlling them Promotion of food supply and proper nutritionAn adequate supply of safe water and basic sanitationMaternal and child health care, including family planningImmunization against the major infectious diseasesPrevention and control of locally endemic diseasesAppropriate treatment of common diseases and injuriesBasic laboratory services and provision of essential drugs.

Training of health guides, health workers and health assistants. Referral services

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The Four Pillars of Primary Health CareCommunity Participation Appropriate Technology Inter-Sectoral Coordination Equitable Distribution 9Slide10

Primary Health CarePreventive servicesCurative servicesGeneral servicesCare of vulnerable groups

Outpatient clinic (referral)

Laboratory services

Dispensary

First aid and emergency

services

Health education

Monitoring of

environment

Prev.&control of endemic diseases

Health office services

Maternal &

child health .

School health services

Geriatric health

services

Occupational

health services

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Levels of Care Primary health careSecondary health careTertiary health care11Slide12

Core Activities for PHC There is a set of CORE ACTIVITIES, which were normally defined nationally or locally. According to the 1978 Declaration of Alma-Ata proposed that these activities should include:Education concerning prevailing health problems and the methods of preventing and controlling them Promotion of food supply and proper nutritionAn adequate supply of safe water and basic sanitationMaternal and child health care, including family planningImmunization against the major infectious diseasesPrevention and control of locally endemic diseasesAppropriate treatment of common diseases and injuriesBasic laboratory services and provision of essential drugs.

Training of health guides, health workers and health assistants. Referral services

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Historical Development of MCH Services:The term maternal and child health refers to promotive, preventive, curative and rehabilitative health care for mothers and children. It includes the sub-areas of maternal health, child health, family planning, school health and adolescent health.The specific objectives of MCH are:Reduction of maternal, prenatal, infant and child mortality; 13Slide14

Objective of MCHTo improve the health status of the largest and most vulnerable sector of the population by providing the best health care available.14Slide15

Major Targets of MCH Services Women of reproductive age group (15-49 yr) Pregnant women Children < 15yr Children <5yr Children <1yr 15Slide16

Major component of MCH services Provision of quality ANC, delivery care, PNC, and FP services Prevention of STIs/HIV/AIDS Immunization Growth monitoring Well baby clinic Sick baby clinic Nutrition Rehabilitation Clinic (NRC) Nutrition counseling and health education School health education Adolescent health services 16Slide17

Connecting care throughout the crucial time periods in the lifecycle17Slide18

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Maternal and child health.HEALTH

MOTHERCHILD

SOCIETY

Heal

thy children need healthy mothers

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Maternal and Child HealthMothers and children are both vulnerable groups of the community. Women in the childbearing period (15-49 years) constitute about 25% of the population. Children on the other hand constitute about 40% to 45% of the population in developing countries. In Jordan ?????This group is characterized by relative high mortality and morbidity rates.20Slide21

Maternal and child health and diseaseMaternal and child health and disease has multi-factor origin and can exist of sequential and continuous form. Bad maternal conditions account for the fourth leading cause of death for women after HIV/AIDS, malaria, and tuberculosis21Slide22

Reproductive health universe.Socialdeterminantsof health Health services Genetics factor Promotion&

Prevention Reproductive health

Maternal

&

Child health

Morbidity

&

Mortality

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Age Structure of Jordan’s Population (2015)Source: Jordan in Numbers, Department of Statistics, 2015.Slide26

Maternal health. Health of women during pregnancy, childbirth and the postpartum period. Motherhood, for too many women it is associated with suffering, ill-health and death. Haemorrhage, infection, HBP, unsafe abortion and obstructed labour still are major direct causes of maternal morbidity and mortality.26Slide27

Some emerging and reemerging problems to M & Ch Health.HIV/AIDS and TB plus Multirresistant TB.Dengue. Others viral haemorragic fever.Old neglected diseases with new burden. Cholera outbreaks in Africa and Asia.Avian and swyne flu.Conflicts, war and infraestructure destruction.Bad governance and uneffective polices.27Slide28

Maternal health care.Is a concept that encompasses family planning, preconception, prenatal, and posnatal care. Goals of preconception care can include providing education, health promotion, screening and interventions for women of reproductive age to reduce risk factors that might affect future pregnancies. 28Slide29

According to 2015 WHO estimations it was concluded that:Maternal mortality is unacceptably high. About 830 women die from pregnancy- or childbirth-related complications around the world every day. It was estimated that in 2015, roughly 303 000 women died during and following pregnancy and childbirth. Almost all of these deaths occurred in low-resource settings, and most could have been prevented29Slide30

Maternal HealthEvery day, approximately 830 women die from preventable causes related to pregnancy and childbirth.99% of all maternal deaths occur in developing countries.Maternal mortality is higher in women living in rural areas and among poorer communities.Young adolescents face a higher risk of complications and death as a result of pregnancy than other women.Skilled care before, during and after childbirth can save the lives of women and newborn babies.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 100 000 live births.30Slide31

The major cause of MM includesDirect cause – are these disease or complications occur only during pregnancy and child birth e.g., Hemorrhage – 25% Sepsis – 15% Unsafe abortion – 13% Hypertensive disorder – 12% Obstructed labor – 8% Other – 8% Indirect cause – are these which are pre-existing disease but aggravated by pregnancy. 31Slide32

Ex- AnemiaHeart disease - Essential HTN / 20% MMDM Kidney disease Coincidental causes – are not related to pregnancy Ex – Death from traffic accident32Slide33

Maternal MortalityThe other 1/3rd of maternal deaths worldwide results from indirect causes or an existing medical condition made worse by pregnancy or delivery: MalariaAnemiaHepatitisAIDS TuberculosisMalnutrition

Nearly 2/3rds of maternal deaths worldwide results from five causes: Hemorrhage (24%)Obstructed labor (8%)

Eclampsia (pregnancy induced hypertension) (12%)

Sepsis (15%)

Unsafe abortion (13%)

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Why do women die?Women die as a result of complications during and following pregnancy and childbirth. Most of these complications develop during pregnancy and most are preventable or treatable. Other complications may exist before pregnancy but are worsened during pregnancy, especially if not managed as part of the woman’s care. The major complications that account for nearly 75% of all maternal deaths are:severe bleeding (mostly bleeding after childbirth)infections (usually after childbirth)high blood pressure during pregnancy (pre-eclampsia and eclampsia)complications from deliveryunsafe abortion.34Slide35

Some Factors that Contribute to Maternal Mortality and MorbidityThe 4 “too”s of pregnancy:Too youngToo oldToo manyToo soonIn other words: young or old age of pregnancy, short intervals between pregnancies, and high parity. Other factors include low socio-economic status and inadequate maternal care.35Slide36

Maternal Health CareMHCMHCPreconceptionalCare

Postnatal Care Intra-natal Care

Antenatal

Care

Including

Premarital

Care

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Preconception Care It is a care of female before conception.It is continued care from birth, through stages of growth and development, and until the time of conception and pregnancy, so as to prepare the female for normal child bearing and delivery in the future.37Slide38

Components of Preconceptional Care:Health promotion and prevention of health hazards specially those of particular risk to pregnancy.Regular health appraisal for early case detection and management, and prevention of sequelae or complications.Health education of young girls e.g. determinants and requirement of health, family health, family planning…..Premarital care (for both partners).38Slide39

Premarital CareIt includes:Premarital counselingPremarital immunizationPremarital examination:History takingGenetic counselingSystemic medical examinationInvestigations 39Slide40

Antenatal (Prenatal) CareGeneral objective:“ The general objective of antenatal (prenatal) care is to prepare the mother both physically and psychologically to give birth to a healthy newborn (favorable outcome of pregnancy) and to be able to care for it.”40Slide41

Components Antenatal (Prenatal) CareRegistration: During the booking visit, and record keepingMedical examination and investigations; for both the booking visit and continuing visits.Health educationImmunizationSupplementations Clinical servicesSocial services (outreach services).41Slide42

Antenatal care in Jordan (according to mother’s age ) in 2012 JPFHS 42Slide43

Intra-natal Care “Normal delivery is defined as a process of delivery of a single fetus and other products of conception within 24 hours, through the normal birth canal and without complications.”Objectives of intra-natal care: safety of mother and fetus, by helping the pregnant to have a normal delivery, and providing emergency services when needed.Determination of place of birth, with a well-organized back up system. 43Slide44

High Risk DeliveriesMother Delivery

Fetus

Toxemia of pregnancy

Prolonged labor

Prematurity

Diabetes mellitus

Breech presentation

LBW

Age < 20 yrs

Cord prolapsed

Fetal distress

Age > 35 yrs

Multiple pregnancy

Meconium stained liquor amnii

Parity 5 +

Premature rupture of membranes

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Postnatal Care Care of mother after delivery.Its components are:Postpartum examinationMedical careFollow upHealth educationFamily planning servicesPsychological and social support 45Slide46

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CHILD HEALTHWhy tackle child health? The global equity gap in health is largest among children, and is concentrated in communicable diseases. Children under five years of age account for more than 50% of the global gap in mortality between the poorest and richest quintiles of the world's population. Children under five bear 30% of the total burden of disease in poor countries. Almost all (99%) of the 10.9 million children under five who died in 2000 were from developing countries. Of these children, 36% died in Asia, 33% in Africa. 47Slide48

0

20

40

60

80

100

1983

2000

1983

2000

Post-neonatal mortality

Late neonatal mortality

Early neonatal mortality

Developing Regions

Developed Regions

Source: RHR/WHO, 2003

Deaths among infants under 7 days are decreasing more slowly than among older infants

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4 million newborn deaths – Why?almost all are due to preventable conditionsTwo thirds of all neonatal deaths are in LBW infants 49Slide50

Perinatal mortality accounted for more than 20% of deaths in children under five years of age, in 2000 and includes birth asphyxia, trauma, and low birth weight. 50Slide51

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What can be done to improve child health?52Slide53

Infant and child priorities (UNICEF)Reduction of infant and under 5 mortality rateReduction of moderate and severe malnutritionUniversal access to safe drinking waterAccess to all couples to information and services to prevent pregnancies that are too early, too closely spaced, too late or too many.53Slide54

Infant and child priorities (UNICEF) cont. Reduction of low birth weight babies Elimination of iodine deficiency Elimination of vitamin A deficiency Encouragement of women to breast feed their children exclusivelyGrowth promotion and monitoring Eradication of poliomyelitis Elimination of neonatal tetanus Reduction of measles death54Slide55

Infant and child priorities (UNICEF) cont. Maintenance of a high level of immunization coverage. Reduction of deaths due to diarrheal diseasesReduction of deaths due to ARIsIncreased acquisition of knowledge, skills and values required for better living by all families.55Slide56

The Integrated Management of Childhood Illness (IMCI)IMCI is a broad strategy to improve child health outcomes developed by WHO and UNICEF. IMCI encompasses interventions at home, in the community and in the health system. The aims are to reduce childhood deaths, illnesses, and disability and to improve children's growth and development, with a particular focus on the poorest and most disadvantaged children. IMCI has three main components: Improve family and community practices related to child health and nutrition; Improve the health system for effective management of childhood illness; Improve health workers' skills. 56Slide57

Improve family and community practices related to child health and nutrition; Counseling on child feeding including exclusive breast feedingAdequate amount of micronutrient or supplementationComplete full course of immunization for children Promote safe disposal of waste and hand washing before preparing meals and feeding children Provide adequate care to sick children Promote mental and social development by responding to children's needs for care, Provide adequate prenatal care to every pregnant woman 57Slide58

Improve the health system for effective management of childhood illness; Ensure drugs and supplies for treating major childhood illnesses are available in health facilities Improve quality of care provided at health facilities and organization of work Improve referral pathways Identify and develop methods for sustainable financing and equity of access 58Slide59

Improve health workers' skills. Develop and adapt case management guidelines and standards for major childhood illnesses in the country Train health providers at first level health facilities and referral level in standard case management Improve and maintain health workers' performance through follow-up after training and periodic supervision 59Slide60

A combination of integrated curative and preventive interventions is required to address the immediate and underlying determinants of child health. Maternal determinants and risk factors associated with pregnancy and childbirth are especially important. Simple, cost-effective interventions delivered at the community level can save most newborn and children lives in developing countries. 60Slide61

To summarize Optimum child health is achieved through:Adequate maternal carePeriodic follow up of the “healthy child”Breast feeding and proper child nutritionImmunizationEarly detection and proper managementA sanitary and safe environmentHealth education of parents.61Slide62

Family Planning In Jordan 62Slide63

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BackgroundFamily planning allows people to attain their desired number of children and determine the spacing of pregnancies. It is achieved through use of contraceptive methods and the treatment of infertility64Slide65

BackgroundAn estimated 222 million women in developing countries would like to delay or stop childbearing but not using any contraception methodReasons for this include:• limited choice of methods; limited access to contraception, particularly among young people, poorer segments of populations, or unmarried people• fear or experience of side-effects;• cultural or religious opposition;• poor quality of available services;• gender-based barriers.65Slide66

Benefits of family planningPreventing pregnancy-related health risks in womenFamily planning allows spacing of pregnancies and can delay pregnancies in young women at increased risk of health problems and death from early childbearing, and can prevent pregnancies among older women who also face increased risks. Family planning enables women who wish to limit the size of their families to do so. Evidence suggests that women who have more than four children are at increased risk of maternal mortality.By reducing rates of unintended pregnancies, family planning also reduces the need for unsafe abortion66Slide67

Benefits of family planningReducing infant mortalityFamily planning can prevent closely spaced and ill-timed pregnancies and births, which contribute to some of the world’s highest infant mortality rates. Helping to prevent HIV/AIDSFamily planning reduces the risk of unintended pregnancies among women living with HIV, resulting in fewer infected babies and orphans. 67Slide68

Benefits of family planningEmpowering people and enhancing educationFamily planning enables people to make informed choices about their sexual and reproductive health. Family planning represents an opportunity for women for enhanced education and participation in public life, including paid employment in non-family organizations. Additionally, having smaller families allows parents to invest more in each child. Children with fewer siblings tend to stay in school longer than those with many siblings.68Slide69

Benefits of family planningReducing adolescent pregnanciesPregnant adolescents are more likely to have preterm or low birth-weight babies. Babies born to adolescents have higher rates of neonatal mortality. Slowing population growthFamily planning is key to slowing unsustainable population growth and the resulting negative impacts on the economy, environment, and national and regional development efforts.69Slide70

Review of Contraceptive Methods Modern methods Traditional methods COCCoitus interruptus POPFertility awareness methodsProgesterone only injectable Abstinence Monthly CICIUCDIUD levonorestrel Male condoms

Male and female sterilization LAMEmergency contraception 70Slide71

Key Indicators Total fertility rate (TFR)Total fertility rate represents the number of children that would be born to a woman if she were to live to the end of her childbearing years and bear children in accordance with current age-specific fertility rates.71Slide72

Unmet needThe percent of women of reproductive age who are married or in union, and sexually active but not using any method of contraception, and report not wanting any more children or wanting to delay the birth of the next child (WHO, 2013). 72Slide73

Contraceptive prevalence 61% of currently married women in Jordan are using a method of family planning: 42% are using modern contraceptive methods and 19% use traditional methods. Contraceptive prevalence increased in the 1990s, from 40% in 1990 to 56% in 2002Prevalence has increased from 56% in 2002 to 61% in 2012; however, the increase has been almost entirely in use of traditional methods. 73Slide74

Trends in contraceptive use, 1990-2012(Percentage of currently married women age 15-49 years) (DHS, 2012)74Slide75

Contraceptive prevalence The most popular modern method is the IUD, used by 21% of married women. The next most popular modern methods are the pill (8%) and the condom (8%). Two percent of married women have been sterilized, while less than 1% are using injectable or implants. As for traditional methods, withdrawal is used by 14 percent of currently married women and rhythm or periodic abstinence is used by about 4%.75Slide76

How to get Family Planning in Jordan Public Sector Government hospital Government health center Government MCH center University hospital/clinic Royal Medical Services76Slide77

How to get Family Planning in Jordan Private SectorPrivate hospital/clinicPrivate doctor Pharmacy JAFPP UNRWA clinic Other NGO 77Slide78

Supply Pattern in Jordan more than four in ten modern contraceptive users obtain their method from a public source: 23% from a government health center, 12 percent from a maternal and child health center and 6% from a government hospital. More than half of women who use a modern method obtain the method from a private sector source, mainly pharmacies (15%), the Jordan Association of Family Planning and Protection (JAFPP) (11%), UNRWA clinics (10%), or private doctors (7%). 78Slide79

Supply Pattern in Jordan The source of family planning methods varies according to the method being used. For example, two fifths (39%) of condom users and 35% of pill users obtain their methods from a pharmacy, while IUD users are likely to obtain services from a private hospital or clinic, a government health center, or the JAFPP. More than half of women who are sterilized had the procedure at a government hospital (54%), while one-quarter used the Royal Medical Services. 79Slide80

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THANK YOU Thank You83