Maternal and child health in India: a critical review.

PIP: The Lady Dufferin Fund, founded in 1885 in India, had by 1940 established 400 hospitals to alleviate diseases and mortality related to childbirth. After independence 2328 community health centers and 21254 primary health centers were created in the country. During 1974-94 more than 131,000 subcenters were set up and about 620,000 auxiliary nurse midwives (ANMs) had been trained. The Ministry of Health introduced four health prevention schemes in 1969: 1) immunization of children against diphtheria, pertussis, and tetanus; 2) immunization of pregnant women against tetanus; 3) prophylaxis of mothers and children against nutritional anemia; and 4) prophylaxis of children against blindness caused by vitamin A deficiency. As a result, infant mortality declined from 146/1000 live births to 74/1000 in 1993; but maternal mortality still stayed around 4-5/1000. In 1993 an estimated 117,356 maternal deaths occurred out of a total of 26,057,000 births, equalling 4.5 deaths per 1000 live births. The main causes of maternal deaths are hemorrhage, anemia, abortion, toxemia, and puerperal sepsis. Only about 411 first referral units in community health centers are functioning properly. Prenatal care of mothers includes the administration of tetanus toxoid and iron-folic acid tablets. However, the prenatal coverage reached only about 50% of mothers; and the coverage was only 21.4% in Bihar, 23.8% in Nagaland, 29.3% in Rajasthan, and 29.6% in Uttar Pradesh. In these areas administrative inefficiency is widespread with nonavailability of essential drugs for malaria, infections, sepsis, dysentery, and colds. During 1992-93 the rate of hospital deliveries ranged from 6.1% in Nagaland to 88.4% in Kerala, with a national average of only 25.6%. 71% of deliveries in rural areas and 30% in urban areas were conducted by untrained assistants. Although there are 450 ANM training schools in the country, the level of training has deteriorated. The major causes of infant deaths are respiratory infections and diarrhea, responsible for 13.5% and 6.9% of mortality, respectively. Severe malnutrition and inadequate vaccination are other major causes of child deaths and morbidity.^ieng

Population and the health of the mother and the child.

PIP: In January 1991, staff from the al-Bashir Hospital, the Ministry of Health, and Jordan University Hospital conducted a study of the status of maternal and child health (MCH) in Jordan and the health services. Maternal mortality was 40/100,000 deliveries which was better than it was for the developing and semideveloped regions (140 and 59, respectively), but much higher than it was for developed countries (9). A key reason for Jordan's relatively low maternal mortality was the high percentage of deliveries attended by qualified physicians (89.5%). The figure for physician-attended deliveries for underdeveloped, developing, semideveloped, and developed countries was 28%, 46%, 84%, and 99%, respectively. High use of contraceptives for birth spacing (35% vs. 6% in developing countries, 34% in semideveloped countries, and 73% in developed countries) reduced deaths attributed to repeated and consecutive pregnancies. The team found it difficult to determine specific causes of adult death because of insufficient data in official records. Likewise, official records of child deaths were fragmentary. The mortality rate for children of breast feeding age, excluding stillbirths, was 37 which was lower than that in underdeveloped and developing countries (118 and 67, respectively), but greater than that in semideveloped and developed countries (27 and 9, respectively). Insufficient human and medical resources and a high fertility rate continued to contribute to a high perinatal mortality rate (21), however. The leading causes of perinatal deaths included premature birth, deformities, and respiratory infections. The most frequent illnesses in children were respiratory diseases, gastrointestinal diseases, and malnutrition. For vaccinated children, they suffered most from nose, ear, and throat infections and eye problems. Between 1980 and 1990, the number of obstetricians increased 95%, mainly due to the increase in MCH clinics and hospital beds for obstetric/gynecologic cases and for children.^ieng

Strategies which reduced sepsis-related neonatal mortality.

PIP: A marked reduction in neonatal mortality was achieved during 1986, which can be attributed largely to the decline in the incidence of infections as a result of modification of a few of the routine practices in the Intensive Care Nursery of the All India Institute of Medical Sciences (AIIMS) in New Delhi. Over 80% of pregnant women attending the antenatal clinics of AIIMS have 1 or more perinatal high risk factors. All deliveries are performed by obstetricians, and each neonate is managed at birth by 1 or more residents of the neonatology unit. Data on every neonate is recorded on a specially designed case sheet. Cause of neonatal death is classified according to the criteria of Wigglesworth. A monthly report of the census and morbidity mortality data is recorded on a special proforma and discussed in a joint meeting of the staff of the obstetrics and neonatology services. The information presented is based on these monthly reports. A table shows the data on the live births in 1985 and 1986 and their distribution according to birth weight. The total number of live births in the 2 years were nearly the same. There was no significant difference in the neonatal population in different birth weight groups. There were 66 neonatal deaths in 1985 but only 43 in 1986. This significant decline in the neonatal mortality was attributable to reduction in the late neonatal deaths. The neonatal mortality rate (per 1000 live births) dropped from 36.6 in 1985 to 23.9 in 1986. There was a decline in the neonatal mortality rate in birth weight groups from 1001-2500 g. The reduction of deaths in the birth weight group of 1001-1500 g was most pronounced. Neonatal mortality rate (per 1000 live births) dropped from 525.4 in 1985 to 377.7 in 1986 in this group. The overall neonatal mortality rate in infants weighing 2500 g or less declined from 12.3 to 8.5%. The difference in the proportion of deaths in relation to individual causes was significant only in the case of sepsis. The decline in the sepsis-related neonatal mortality was a consequence of 2 factors: the incidence of neonatal sepsis declined from 38.2/1000 live births to 18.8/1000 live births; and a definite though less pronounced improvement occurred in the case fatality rate -- 24.6% versus 17.7% in 1985 and 1986, respectively. The significant decline in late neonatal deaths was largely attributed to the reduction in the sepsis-related late neonatal deaths -- 16 versus 3. Sepsis ranked as number 2 as cause of neonatal mortality in 1985; it ranked as number 4 in 1986.^ieng

Integrating health services into an MCH-FP program: lessons from Matlab, Bangladesh.

Since 1977 the International Centre for Diarrhoeal Disease Research, Bangladesh, has conducted a field experiment in family planning and MCH in its Matlab research station. The project began with an emphasis on family planning and MCH services were added in stages. This paper uses time series regression methods to address the question of whether the addition of health services contributed to family planning efficacy in Matlab in a program launched with minimal MCH services. The results show that some MCH interventions increased contraceptive prevalence, some decreased it, and others had no effect. The broader significance of these findings for implementing integrated programs is discussed.

PIP: Since 1977, the International Centre for Diarrhoeal Disease Research, Bangladesh, has conducted a field experiment in family planning in its Matlab research station. The project began with an emphasis on family planning; maternal-child health (MCH) services were added in stages. This analysis aims to determine whether additional health and MCH services enhance effectiveness of a comprehensive family planning program that contained limited MCH components from the beginning. Initial Family Planning and Health Services Project (FPHSP) effects on contraceptive prevalance were pronounced. Use prevalence increased to 25% in the 1st 6 months and to 32% within a year. This was followed by a general fertility decline of 25%. Prevalence gradually converged to 43%. The tetanus toxoid program--introduced to prevent tetanus neonatorum--did not discrup the contraceptive prevalence trend. Prevalence increased until 2 interventions for treating diarrhea were introduced: 1) packets, consisting of a premixed sugar and electrolyte powder that is dissolved in water; and 2) "labon-gur,"--a homemade mixture of locally available salt and molasses that has been shown to be as effective as the packets and costs less. The tetanus program was changed to as mass maternal immunization program. A measles immunization program was launched. This result in rising prevalence. Household insertion of IUDs (Copper T) resulted in a pronounced increase in IUD prevalence and concomitant decline in the prevalance of other methods. An antenatal care program was launched. It was followed by a program to train traditional birth attendants. This did not have much of an effect on contraceptive prevalence.

Transferring health and family planning service innovations to the public sector: an experiment in organization development in Bangladesh.

The International Centre for Diarrhoeal Disease Research, Bangladesh, has launched a field experiment in two rural thanas of Bangladesh to test the transferability of its successful health and family planning experiment in Matlab to the Ministry of Health and Population Control service system. This paper reviews the Matlab experiment with particular attention to its organization and identifies elements for transfer. The intervention strategy and operations research design of the new experiment are discussed. The proposed design follows an organization development strategy in which collaborative diagnostic research is used to foster institutional change.

PIP: The International Center for Diarrheal Disease Research, Bangladesh has launched a field experiment in 2 rural thanas of Bangladesh to test the transferability of its successful health and family planning experiment in Matlab to the Ministry of Health and Population Control service system. The 1st family planning experiment began in 1975 and concentrated on the household distribution of contraceptives. It was further designed to provide a broad range of contraceptive and immunization services and oral rehydration therapy. Strong management control is vested in the non-medical, male supervisory staff. Maternal and child health services were later combined with the family planning project. This extension project has 2 components: an intervention strategy and a research strategy to assess the efficacy of the program. The analysis of the effects of this extension program is achieved through the longitudinal observation of households with a sample registration system. The proposed design follows an organization development strategy in which collaborative diagnostic research is used to foster institutional change. The original Matlab experiment posited that a significant proportion of clients desire to limit or space childbearing, but lack contraceptive services for doing so. The experiment demonstrated that there is a set of conditions under which a significant proportion of a rural Bangladeshi population will use contraception, and thereby reduce fertility. In transferring the programs to the supervision of the Ministry of Health, a number of modes were used: 1) use of a team appraoch, especially on household distribution; 2) train more community workers, especially females, and use teams of both males and females; 3) develop a Tertiary Health Center referral system, especially for sterilization; 4) enlarge training of present workers to include better preventive and MCH care; and 5) arrange monthly meetings of union-level workers at the field centers. No change in salary structure or administrative structure was planned.