Reproductive CM

Reproductive Health: Condition in which the reproductive process is accomplished in a state of

complete physical, mental and social well being not merely the absence of disease.
Components -
Quality family planning services
Provision of safe motherhood
Prenatal care
Postnatal care
Safe deliveries

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Maternal Health - Health of women during pregnancy, childhood & postnatal period
Maternal health determinants:

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Water/Food/Sanitation
Income/Employment
Education

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Sociocultural practices
Health care
Social services
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Maternal mortality - Annual number of female deaths from any cause (excluding accidental or
incidental causes) during pregnancy and childbirth or within 42 days of termination of pregnancy
irrespective of duration and site of pregnancy
- Young adolescents (aged 10-14 yrs) face a higher risk of complications & death as a result of
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pregnancy

- High risk pregnancies -

- Maternal age (<18 or >35)
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- Short statured women (<5ft)

- Grandmultiparae (>5 pregnancies)
- Short birth spacing
- Hx of complications in previous pregnancy (HTN, Eclampsia, C-S)
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- Medical conditions (Anemia, HTN, CVD & DM)

- Malpresentations (breech, oblique or transverse)
- Multiple pregnancies (twins or triplets)
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- Maternal mortality ratio (MMR) is a key indicator of maternal health globally.

Maternal Mortality Ratio Formula -

No. of Maternal deaths/Number of live births x 100

Maternal Mortality Rate Formula -

No. of maternal deaths/No. of women of childbearing age (15-49 yrs) in population x 100

Determinants of Maternal Mortality in Pakistan:

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Factors leading to women's death in pregnancy -
- Lack of Trained Midwives

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- Low Socio Economic conditions
- Gender Inequality
- Women Illiteracy

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- Early Marriages
- Medical Issues - Direct or indirect issues that can be treated by Basic/Comprehensive EmONC
- Lack of Access to Medical Help -
Three delays Model
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- Delay in decision to seek care
- Delay in reaching care
- Delay in receiving care
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Components of MCHC (Mother & Child Health Care) -
- Antenatal Care
- Intranatal care
- Postnatal care
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- Infant care
- Training Programs/Health education

Team in MCH Centres -

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One doctor for more than 20000 patients

Lady Health Visitor for 3000 to 5000 patients
One trained Dai/Midwife for hundred birth
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- Traditional birth attendants - Who are not formally trained & do not meet the definition of
skilled birth attendants

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Example: Dai
- Skilled Birth attendant - An accredited health professional who has been educated and
trained to proficiency in the skills needed to manage normal pregnancies, childbirth & immediate

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postnatal period.
Example - Midwife, Doctor or nurse

- Safe Motherhood - It is ability of mother to have safe & healthy pregnancy and childbirth
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Pillars of Safe motherhood-
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I. Family planning
- Information & services to plan the timing, number & spacing of pregnancies
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II. Antenatal care

- For early detection & treatment of complications of pregnancy
III. Obstetric care
- Provide proper knowledge & equipments to the birth attendants & ensure emergency safe for
high risk pregnancy
IV. Postnatal care
- For both mother & her baby
- Includes lactation assistance, FP services & management of complications of pregnancy
V. Post abortion care
- Management of complications & FP consultation
VI. STD/HIV control
 - Voluntary counseling & testing (VCT), prevention of mother to child transmission (PMTCT)

Levels of Obstetric Care -

Level I - Obstetric First Aid -

Level II - Basic EmONC

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Level III - Comprehensive EmONC

Emergency Obstetric & Newborn care (EmONC) -

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EmONC Process Indicator -

For Every 500,000 population there should be -
01 Comprehensive EmONC center with 04 Basic EmONC facilities/centers
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Counseling: This is person to person Two-way communication to provide adequate information

in their decision making and help to evaluate their opinion.

Counseling in Family Planning: To help people be able to arrive at informed and voluntary
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choices about the size of family.

Types of Family Planning counseling:

1) Individual counseling
2) Couple counseling
3) Group Information sharing
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Respectful Maternity Care:
Pillars of RMC:
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Social Action Programme (SAP) -
- Improving the efficiency & utilization of basic health care
- Improving program design by paying more attention to quality
- Increasing access to health care by constructing more facilities
- Increasing women's access by recruiting more female staff
- Promoting community participation in the design & management of health care services

- Childhood age periods -

Infancy - upto 1yr of age
Neonate - First 28 days of life

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Postnatal period - 28th day to 1yr
Preschool age - 1-4yrs

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School age - 5-14 yrs
- Critical time - First 24hrs after birth

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- Hyperbilirubinemia affects most of the children following birth
- Majority of neonatal deaths occur during the first week of life.
- Causes of death in neonatal period & through first 5yrs -
Pneumonia, diarrhea, birth defects & malaria
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- Newborn danger signs -
Not feeding well
History of convulsions
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Respiratory rate >60 per min
Severe chest in drawing
No spontaneous movement
Fever (Temp >37.5C)
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Low body temp (<35.5C)

Any jaundice in first 24hrs after birth

- Midwife-led Continuity of care (MLCC) - Provide care to the same woman throughout her
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pregnancy, childbirth and postnatal period calling upon medical support

- Newborn health care activities -

Thermal protection
Hygienic umbilical cord
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Early & exclusive breastfeeding

Assessment of signs (low birth weight, sick or mother health)
Immunization
Identify danger signs
Birth registration

- Breastfeeding -
Start within first hour of birth followed by breastfeeding for six months & continued for upto 2yrs
or beyond

- Each infant should be visited 12 times during a year of infant's life & 4 visits to a preschool
child
- Complementary feeding introduced around age of 6 months

- Components of Infant health care -

- Good antenatal care to mother
- Immunization

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- Nutrition

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- Breastfeeding from birth (0-6 months)
- Iron fortified cereals with breast milk (4-6 months)
- Introduction to fruits & vegetables (6-8 months)
- Introduction to protein foods (8-10 months)
- Introduction to table foods (10-12 months)
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- Monitoring of growth -
- Growth charts
- Measured by weight for age, weight for height & head circumference
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- Monitoring of development -
- 6-8wks - Smiles
- 3 months - Hold head up & language development
- 6 months - Sit up with help
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- 8 months - Starts to say meaningful one or two words

- 9 months - Sit up without help
- 12 months - Stand up
- Infant Mortality rate -
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Infant death registered in a given year/total number of live birth registered in same year x 1000
- Consists of neonatal deaths (early (0-6 days) & late (7-28 days)) & postnatal deaths
- Causes of death - Diarrhea, Malnutrition, malaria, measles & Acute respiratory infections
- Malnutrition is the most common cause of infants death worldwide
- Acute diarrhea is the common cause of death in developing countries & second most
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common cause of Infants death worldwide

Factors affecting Infant MR -

Birth weight - baby under 2.5kg
Age of mother - below 18yrs
Birth order - highest after 3rd birth
Birth spacing - repeated pregnancies
Multiple births - greater risk
Family size - greater the size more infections
High fertility
Preventive & Social measures -
- Nutrition
- Prevention of infection
- Breastfeeding
- Growth monitoring
- Family planning
- Sanitation
- Socio Economic development
- Education

- Integrated Management of Childhood Illness (IMCI) strategy includes -

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- Improving case-management skills of health workers
- Improving overall health systems

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- Improving family & community practices
- IMCI is developed by UNICEF & WHO
- Disease covered by IMCI - Diarrhea, Malnutrition, malaria, measles & Acute respiratory

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infections
- Age groups covered by IMCI -
Children age 2 months upto 5yrs
Young infants age upto 2 months
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- Principles of IMCI -
- All sick young infants upto 2 months must be assessed for bacterial infection, jaundice &
major symptoms of diarrhea
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- All sick children 2 months to 5 yrs must be examined for general danger sign which indicate
the need for referreal or admission in hospital
- All young infants & children 2 months-5yrs must be routinely assessed for nutritional and
immunization status and feeding problems
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- Integrated Case Management Protocol components -

- Assessment of child or young infant
- Assess & classify sick child age 2 months upto 5 yrs -
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 - Classification of illness-

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- Identification of treatment
- Referral & treatment
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- Counseling of Child's caretaker-

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 - Followup -

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- Classification of Pneumonia -

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- Benefits of IMCI -
Addresses major child health problems
Promotes prevention as well as cure
Improves health worker performance and their quality of care
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Reduce under-five mortality

Cost-effective
Improves equity

- Family planning - Allows individuals and couples to anticipate and attain their desired number
of children and the spacing and timing of their births
- The reproductive capacity is called fertility

- Crude birth rate -

No. of babies in live births/Mid year population x 1000
- Fertility rate -
No. of babies/women from 13-40 yrs of age x 1000
- Gross reproductive rate -
Average no. of girls born to a group of women beginning life together if none died or migrated
before reaching the upper limit of child bearing age

- Determinants of Human fertility -

Biological factors -
- Age
- Primary subfertility or sterility
- Secondary subfertility
Social and religious factors -

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- Age at marriage
- Temporary separation of married couple

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- Social norms
- Restraints to widows marriage
- Religious taboos

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- Healthy Timing & Spacing of Pregnancy (HTSP) -
It is an intervention to help women and families to delay or space their pregnancies to achieve
the healthiest outcome for women, newborn, infant and children in the context of free and
informed choice
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- Birth to Pregnancy Interval (BTP) -
Time period between the start of pregnancy and previous birth
- Birth to Birth Interval -
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Time period between a birth & the next birth

- Short BTP is associated with increased risk of induced abortion & low birth weight
- HTSP -
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After live birth - 24 months

After miscarriage or induced abortion - 6 months
Delay timing till 18 years
- Don't prolong BTP for more than 59 months (5yrs)
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- Family Planning methods -

I. Natural methods -
- Lactational amenorrhea
- Fertility awareness-based methods
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- Calendar methods -
- Calendar based method
- Standard days method
- Symptoms based method -
- Ovulation method
- Basal body temperature (BBT)
- Sympothermal method
- Calendar rhythm method
- Withdrawal method (Coitus interruptus)
II. Barrier methods -
- Male condom
 - Female condom
- Diaphragm
- Cervical caps
III. IUCD -
- Copper IUCD
IV. Hormonal Contraceptives -
- Oral (COCPs & POPs)
- Benefits -
- Reduce ovarian cancer risk
- Reduce endometrial cancer risk
- Reduce acne

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- Reduce menstrual disorder
- Injectable

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- Progestin IUCD
- Implants
- Vaginal ring

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- Skin patch
V. Permanent Methods -
- Vasectomy
- Tubal ligation
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- Unmet Need of family Planning (UMNFP) -
The proportion of married women of reproductive age who are not using any method of family
planning but would like to postpone the next pregnancy (unmet need for spacing) or who don't
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want any more children (unmet need for limiting)
- Reasons -
- Difficult access to modern contraceptive methods
- Low quality of health care service
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- Little perceived risk of becoming pregnant

- Opposition from husband, families and community
- Fear about contraceptives side effects (major cause of unmet need)
- Reproductive tract infections -
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On the basis of Incidence STIs are common -

Curable - Syphilis, Gonorrhea, Chlamydia & Trichomoniasis
Incurable - Hepatitis B, HSV, HIV & HPV infections
Transmission -
- Sexually transmitted diseases - Chlamydia, gonorrhea, chancroid & HIV
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- Endogenous infections - Caused by overgrowth

- Bacterial vaginosis
- Vulvovaginal candidiasis
- Iatrogenic infections - Due to improperly performed procedures

- STDs common in pregnant women in developing countries - Gonorrhea, Chlamydia &

syphilis
- STDs responsible for man's infertility - Gonorrhea & Chlamydia

- Major STD pathogen

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- Complications of STDs -
PID

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Tubal infertility
Ectopic pregnancy
Genital cancer

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Chronic pain
HIV/AIDs symptoms

- Drug therapy for STDs -

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Syphilis - Penicillin, Tetracyclines, Erythromycin & Cephalosporins
Chancroid - Ceftriaxone 250mg or Azithromycin
Candida vaginitis - Clotrimazole 100mg (7days)
Trichomonal vaginitis - Metronidazole 2gm
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- Parity - Number of children born alive to a woman
- Gravidity - Number of pregnancies a woman has had whether or not they produce a live birth
- Fecundity - Physiological capacity to conceive
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- Infecundity - Inability of a woman to conceive a pregnancy

- Primary sterility - Never able to conceive a pregnancy
- Secondary sterility - Inability to conceive after one or more children have been born
- Women reproductive age - 15-45 yrs
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Fertility Determinants -
- Crude birth rate - It is the simplest measure of fertility
Birth rate = No. of live births during year/Estimated mid-year population x 1000
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- General Fertility rate -

GFR = No. of live births during year/Midyear female population age15-44or49 during the same
year x 1000
- General Marital Fertility rate -
GMFR = No. of live births in a year/Midyear married female population in the age group 15-49yr
x 1000
- Age specific fertility rate -
ASFR = No. of live births in particular age group/Midyear female population of same age group
x 1000
- Shows the relationship between births & age of mother
- Age specific Marital Fertility Rate -
ASMFR = No. of live births in a particular age group/Midyear married female population of the
same age group x 1000
- Total Fertility Rate -
TFR = 5 x sum of all ASFR/1000
- Represents the average number of children born to a woman during her reproductive years
(or lifetime)
- Standard demographic indicator used internationally to estimate average number of
children that a woman would have over her childbearing years
- Total Marital Fertility Rate -
TMFR = 5 x sum of all ASMFR/1000
- Average number of children that would be born to a married woman if she experienced that

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current fertility pattern throughout her reproductive span
- Gross Reproduction Rate -

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GRR = 5 x sum of all ASFR for female live births/1000
- Average number of girls that would be born to a married women if she experiences that
current fertility pattern throughout her reproductive span 15-49

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- Net Reproduction Rate -
Number of daughters a newborn girl will bear during her lifetime
- Child-Woman ratio -
Number of children 0-4yrs of age per 1000 women of childbearing age
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