Maternal and Child Health Services/Care

Because parents and children are generally healthy and childbearing is usually a normal healthy event the practice of maternal and child health nursing emphasizes health promotion and prevention of disease(Novak & Broom,1999). Global and national vital statistics indicate that the status of maternal infant health has improved but it still of major concern Maternal child health is a component of PHC
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What is maternal and child health services

It is a specialized area of nursing focus on the health needs and identifiable response of women, their partners, and families to real or potential health problems associated with childbearing and childrearing Novak & Broom,1999). It also include concern for the developing fetus from conception to birth and the child from birth through adolescence
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objectives
At the completion of this unit the student is able to: 1.Explain: i) The objectives and the policies of maternal and child health services ii) The extent and factors contributing to problems in child health services iii) The organization structure in the planning, implementation and evaluation of maternal and child health services
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cont- objective
2. Describe the operations and management of MCH clinics in the provisions of ANC, PNC and child health services. 3. Demonstrate skills in planning, targeting & evaluating MCH services 4. Identify and discuss factors that are significant in the prenatal environment that influence neonatal health 5.Describe the characteristic element of physical and psychosocial growth and development in the first 5years of life
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cont
6. Identify & discuss major cause of death & illness in the child from through to the first 5 years of age 7. Discuss the appropriate nursing assessment tools for the child from birth to 5 years 8. Identify the role of the community health nurse & discuss appropriate nursing intervention that promote & maintain the health of infants, toddlers and preschoolers
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MCH overall objective

The ultimate goal of maternal and child health nursing is to help children and parents attain and maintain optimal health To achieve that goal, nurses must be aware of historical and current trends as well as national goals to improve the health of the mother and child The overall objective of maternal child health is to protect the health of the mother and the child
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Factors contributing to problem in child health services

Environmental Variables Socio-economic and Cultural: Culture is made up of ideals, values, and assumptions about life that guide peoples behavior transmitted from generation to generation Believe that what happens in their culture is natural and correct and what happens in other culture is unnatural and incorrect
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cont
- child rearing beliefs and practices, food preference and eating habits, concept of health and illness and the use of lay healer and folk medicines all vary across different subgroups/Ethnicity - primary health care worker needs to be aware of this differences in order to successfully bridge this cultural gap and to integrate scientific medicine with traditional 8 care pattern

cont
Socio-economic Status -Poverty is the most handicapping, disabling condition in childhood that affects the health services of a child. Education level, age, employment and unemployment pattern and the use of prenatal services -being poor and uneducated increases substantially the possibility of having a complication of pregnancy in general and a low birth weight in particular (Berk 2004)
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cont
Socio-economics status appears to influence nutritional status a low family income is also related to high incidence of poor diet Lack of education in these families also contributes to poorly balanced diet Child-rearing beliefs and practices- numerous studies have shown that differences in education level and socio-economic background affects the attitude and child-rearing practices of parents
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cont
Health Services(State) Lack of resources- Government or state are not servicing the community as expected because of unavailability of resources e.g. out of stock of syringes and needles, vaccines etcetera. -poor support for the cold chain system -transportation problem to take nurses to work sites Shortage of manpower-many nursing stations have been without a nurse for years &some zones have 11 been empty for a lengthy period of time

DPH Dr J Koroivueta National MCH/FP Manager/Dr J Samuela DHS C,E,W,&N SDHS MCH Nurse Zone Nurse District Nurse
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Organization Chart for MCH/FP

Ante Natal Care

High maternal mortality in developing countries is considered a major public health problem so much so that it has become a UN Millennium Development Goal 5 It is estimated that 515,000 women die each year of pregnancy related causes (global overview) and the fifth MDG is to reduce maternal mortality by 75 percent between 1990 to 2015 but the progress has been slow 80 percent of maternal deaths are the result of direct causes ( complications of pregnancy, labor and delivery)

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cont
Provision of Ante Natal clinic Essential for a community health nurse to set time apart for caring her ante-natal mothers special day for ANC Provide special set up- privacy & comfort Bookings should be corresponding with the population(CBA) of the zone, area of coverage or district & the gestational status of the mother/client
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cont
Clinical set-up Provide privacy Comfortable examination couch/pillows/ linen Stethoscope/fetoscope/ doppler Urine testing equipment- urine cup, urine dipstick Centimeter tape measure Scale/height measure Non sterile gloves Pap smear supplies Speculum Gestational calendar Folders/necessary documents

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cont
Provision of Post Natal Clinic Also important for the community health nurse to set aside a time for PNC as it an essential part of maternal care 6weeks after delivery(postnatal) the mother is called back to the clinic to undergo series of examination to confirm return to normalcy of the reproductive system after confinement of pregnancy and delivery Another important concept of PNC is to assist the the mother to choose freely, family planning 16 whether it is a contraceptive or natural family

cont
Why family planning at PNC? Most suitable time for the nurse to see the mother and to interview them individually and offer assistance regarding their choice of family planning This clinic should be running concurrently with the MCH clinic or at least MCH in the am and post natal clinic in the pm Most mothers will give priority to family planning when they have a small infant to care for so they will seek protection 17

cont
Clinical set up A room with complete privacy, comfortable examination couch Equipment for examining the vagina and pap smear taking Assortment of contraceptives Equipment for taking vital signs/blood pressure & weight

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Significant factors in the prenatal environment that influence neonatal health body Prenatal environment is the mothers
virtually everything that impinges on her wellbeing from her diet to her moods, may alter her unborn childs environment and affect its growth (Papalia, Olds & Feldman, 2004) Many factors can affect the developing embryo and fetus and one of them is an unsafe environment Teratogens refers to any environment agent that causes damage to the developing embryo or fetus during the prenatal period. Greek word tera means malformation or monstrosity(Novak&Boom 2004)
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Environmental factors
Prescription and nonprescription drugs Illegal drugs( marijuana,(opiates,cocaine) Tobacco/nicotine smoking Alcohol Caffeine Sexually Transmitted Infection
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cont
Environmental pollution Radiation Infectious disease

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Maternal factors
Factors influencing the health of pregnant women and infants may be related to their obstetric history genetic, socio economic status, or life style choices Regular moderate exercise e.g. walking, swimming, hiking aerobics is related to increase birth weight(Hatch et al.,1993 cited by Berk.,2004).

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 Nutrition-a developing fetus depends completely on its mother for nutrition, which comes from the mothers blood children born to malnourished mothers are more likely to be malformed children grow more rapidly during prenatal period than any other phase of development-totally depend on the mother for nutrients so a healthy diet ensures the 23 health of the mother and the baby

cont
Prenatal malnutrition can cause serious damage to the central nervous system (Berk 2004)- the poorer the mothers diet the greater the loss in the brains weight especially if malnutrition occur in the last trimester Poor nutrition suppresses development of the immune system prenatal malnourished babies frequently catch respiratory illness(Chandra 1991)
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cont
Vitamins & minerals enrichment is also crucial e.g. folic acid supplementation around the time of conception greatly reduces abnormalities of the neural tube such as anencephaly and spina bifida Adequate folate intake during the last 10 weeks of pregnancy reduces by half the risk of premature delivery and low birth weight When the poor nutrition persist through the prenatal period infants usually require more than dietary improvement
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cont
Emotional stress When women experience severe emotional stress & fear during pregnancy their babies are at risk for a variety of difficulties producing adrenalin in response to fear restricts blood flow to the uterine area and may deprive the fetus from oxygen Intense anxiety is associated with higher rate of miscarriage, prematurity, low birth weight, newborn irritability, respiratory illness, and digestive disturbances(Santrock, 1998). It is also related to certain physical defects such an 26 cleft palate and hare lip(Santrock, 1998).

Physical growth &development

One important set of parameters required for pediatric health assessment is physical growth The parameters of weight, length or height & head circumference(depend on age) are essential in physical growth measurements e.g. by plotting a childs growth (weight) on a chart, you are able to determine normal or abnormal growth curves according to the childs age
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cont
Childs growth and development are orderly and sequential Growth and development are related to environment The pace of growth and development is specific for each child Growth and development occur in a cephalocaudal direction
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cont
Growth & development occur in a proximodistal direction controlled movements closest to the centre of the body occur before controlled movement that are distant to the body axis Growth & development become increasingly differentiated-general responses progress to skilled, specific, responses 29

cont
Growth & development become increasingly integrated- behavior and function progress from simple to complex as the child gains new skill Growth & development are continuous and are influenced by many factors- heredity and environment work together genetic factors provide the potential & set in the motion that is stimulated 30

cont
Infants average birth weight is 3.5kg Length: 48-53cm Head circumference : 33- 35cm Infants should double the birth weight at 6mths and triple birth weight at 1yr of age Infants height increases about 1inch(2.5cm) per month for the first 6/12 and slows to inch(1.3cm) per month until 12 months Toddler(12-24 months) growth, begins to slow.
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cont
The birth weight usually quadruples by 2.5 years of age with an average weight gain of (1.8 - 2.7kg) in a year. The toddler usually grows(7.6cm) per year Preschoolers (2-6yrs) each gain an average of (2.3kg) per year Height increases between(6.4 - 7.6cm) per year (Estes 2002).
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development
Development refers to patterned and predictable increases in the physical, cognitive, socioemotional and moral capacities of individuals that enable them to successfully adept to their environment(Estes 2002) Growth refers to an increase in body size and function to the point of optimum maturity. Assessing the growth and development status of a child is an integral part of patient (child) assessment. It must be noted, however it should not be imposed to a particular child, each child 33 have their unique development

Developmental tasks of infants

Infancy is a period of dramatic, and rapid physical, motor, cognitive, emotional and social growth, which makes it one of the most critical period of growth and development During the first year of life, infant change from totally helpless, dependent new born to unique individual who actively interact with their environment and form meaningful relationships with significant others(Estes 2004).
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Week 2
objectives At the completion of this unit the student is able to: 1. i)Assess and monitor growth and development of a child ii) Detect abnormalities early and refer/write referral letters iii) Effectively educate mothers on child care iv)Document intervention/services rendered
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Cont objective
Demonstrate skills in planning, targeting and evaluating MCH services Identify and discuss the major causes of death and illness in the child from birth through to the first 5yrs of life Identify the role of the community health nurse and discuss appropriate nursing interventions that promote and maintain the health of infants.

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cont
The objective of child health services is classified into 4: Monitoring of growth and development Immunization administration Nutrition- feeding and nutritional advises/breast feeding Health Education and management of minor ailments and childhood illnesses(IMCI)
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cont
Conducting a child health clinic focuses on these 4 main objective Monitoring Growth & Development the infant/child is weighed, carefully examined and assessed for:  any deviation or delay from the normal growth and development according to age  Successful weight gain/weight loss at every visit  Presence or absence of normal reflexes according to age.
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cont
Counseling and advise to the mother of the management of identified problems. Referral of delayed milestone cases to proper management for further intervention- write a referral letter e.g. CRA Prioritizing problems to assist in the quick recovery- will include assessment of the family, socio-background, home and the environment. Subsequent follow up of mother and child to ensure progress is maintained
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cont
Immunization To ensure the protection of the child from the 9 target diseases Assess the childs age, check the immunization record and compare with the immunization schedule for any vaccine that is due for administration Inform the mother of the injection to be administered, give all the information about the vaccine and advise the mother/caregiver on how to care for the child after the administration of 40 vaccines.

cont
Feeding & Nutritional Advices Weight measure is very important in the monitoring of the growth of the baby,- wt is measured at every visit, chartered and plotted Poor wt gain, wt loss,and steady wt in the first month indicates poor attachment and positioning of the infant in breastfeeding. May also indicate other underlying problems Assist the mother in the correct positioning of the child and proper attachment.
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cont
Guiding the mother/caregiver in nutritional advises according to age Emphasizing on the importance of the continuity of breastfeeding while weaning of breast Give the child local fresh fruits and foods from the three food groups Specific care and follow ups for underweight baby
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planning & targeting MCH services

To design programs and services for maternalinfant population ,nurses need to have a sound understanding of the population they serve The maternal-child population makes up a major potion of a CHNs caseload Vital statistics and other data regarding maternalinfant populations serves nurses as they determine both the appropriateness and the effectiveness of programs and services
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cont
Delivering services vary based on the population and its specific needs The geographic distribution of clients( CHN should know her catchments area at the back of her hand The hard to reach villages or settlement The heavily populated area Low socioeconomic( squatters/ slums)
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cont
The nursing staff available to deliver the services The main form of transportation for the area of coverage(zone) The socio- economical structure of the community

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evaluation of MCH programs

Evaluation is a critical aspect of maternal-infant health program planning as it is with any planning 4 questions in particular should be addressed i) Did the program meet the identified needs of this particular population ii) Did the program meet its goal and objectives iii)Was the program cost effective/ iv) What is the programs long term impact on the health of this population
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cont
Auditing of clients record-whether objective have been met Checking the daily total book Auditing the child health register book Feed back from clients through periodic questionnaires and personal interviews or telephone surveys Health status of pregnant women, mothers and children
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major causes of death & illness from birth 5yrs

The UN Millennium Development Goal 4 is reducing childhood mortality Healthy children are a vital resource to ensure the future well being of a nation, and their future lie in the hands of those people responsible for their wellbeing, including the community health nurse. Accidents and injuries are a leading cause of death (Allender & Spreadly 2005) Preventable communicable diseases increase mortality among the very young infant
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Accidents & Injury

Toddlers and preschools are vulnerable to many types of accidents and unintentional injuries e.g. MVA Injury from burns can happen to children of all ages-sources of burns electrical, cigarette lighters, matches and scalds from hot water Young children are at risk of drowning wherever water occurs in depth exceeding few inches such as in toilet bowels, bath 49 tubs, buckets filled with rain water

cont
Currently the infant mortality rate, often considered to be a fairly sensitive indicator of the general health status of a population Major cause of death among the birth 4yr old population are : NEONATES Asphyxia/hypoxia Infection Congenital abnormality trauma Malignant neo-plasms
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cont
Unintentional injuries MVA falls drowning

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cont
Poisoning-sources are: Household plants, prescription medication, unintentional medication overdoses, household cleaning products and other chemical stored within the childs reach Communicable Diseases e.g. respiratory illness, infectious and parasitic disease and digestive conditions are the most common The incidence of measles and rubella, pertussis, and other vaccine preventable diseases have dropped considerably because of immunization

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cont
Chronic Diseases e.g. asthma most common, food allergies,muscular dystrophy Nurses Roles in promoting the health of infants Nurses working with maternal-infant population require special qualities and education Solid understanding of the nursing process Effective communication skills Effective organizational and leadership skills A sincere nonjudgmental approach to clients Willingness to work with other community res. 53

cont
Educator Because nursing is such an integral part of any maternal-infant program, nurses working in these area must possess good communication and teaching skills Nurse should select teaching methodologies that are appropriate to the client group Teaching aids should be appropriate for each audience- should be congruent with the language, race and culture of the population being served so client can understand and identify with them 54

cont
Teaching and motivating women to promote their own health and the health of their babies are major challenges and there is no single correct way to approach the task Community Health Nurses need to be innovative and creative in their approach to teaching
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cont roles
Advocator The maternal-infant population has complex needs- the nurse cannot meet all the needs of this client, they must act as advocates in referring clients to other community resources. The nurse must have working knowledge of available community resources for maternal-child health including family planning services, community childbirth education classes, resources available through the state department of social services. 56

cont
Facilitator The CHN can influence legislation and policies that affect the services provided at the local level. the role of the nurse may include giving testimony on behalf of the maternal-infant population The role of the facilitator may also include writing grants/proposal to obtain funding for new project or to maintain existing programs
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Reference List
Allender, J.N. & Spradley, B. W. (200) . Community Health Nursing : Promoting and Protecting the Public Health, Philadelphia: Lippincott Williams & Wilkins. Bennett. R. & Brown, L. K.(1999) .Myles Textbook for Midwives (13th ed.). London : Churchill Livingstone. Estes, M. E. Z. Health Assessment: Physical Examination (2nd ed). New York: Thomson Learning Inc. Mott. S. R.,& James. S. R.(1998). Child Health Nursing California : Addison Wesley Publishing Company. Novak, J. C. , & Broom, B. L. (1999). Maternal and Child Health Nursing (9th ed.). St Louis: Mosby. Papalia, D. E., Olds, S. W., & Feldman, R. D. (2004) . Human Development (9th ed.). New York : McGraw Hill Companies, Inc. 58