Community Medicine

MCH
Maternal and child Health

Definition of MCH
The term maternal and child health refers to the
promotive,
preventive,
curative
and
rehabilitative health care for mothers and
children.

Components of MCH

Maternal Health
Child Health
Family planning
Handicapped children
Care of adolescent
Care of the children in special setting such as
Day care centre.

MCH Package

Antenatal care
Intranatal care
Postnatal care
Safe delivery
Family planning
Access to emergency obstetric care
Nutritional health

Continuation

Vitamin A capsule distribution

Immunization
Health and Family planning service
Follow up of the client
PHC
Health education

Mother and child one unit

During antenatal period fetus is part of mother.

Child health is closely related to the maternal health.
After birth child is dependent upon the mother like
breast feeding.
Certain diseases of mother affects the child.
Certain drug intake adversely affects the fetus.
Mother is the first teacher of the child.

Objectives of MCH
1. Reduction of maternal, infant, perinatal and
childhood mortality and morbidity.
2. Promotion of reproductive health.
3. Promotion of physical and psychological
development of the child and adolescent
within the family.

Stages of Maternity cycle

Fertilization
Antenatal period
Intranatal period
Postnatal period
Inter conceptional period

Indicators of MCH care

Maternal mortality ratio

Perinatal mortality rate
Neonatal mortality rate
Infant mortality rate
1-4 years child mortality rate
Under-five children mortality rate
Child survival rate

Antenatal Care or Prenatal care

Definition: It is the care of the mother during
pregnancy.
Objective: To achieve at the end of the
pregnancy a healthy mother and a healthy
baby.

Objective
To promote, protect and maintain the health of
the mother during pregnancy.
To detect high risk cases and give them
special attention.
To detect complication and prevent them.
To remove anxiety associated with delivery.
To reduce maternal and infant mortality
&morbidity.

Continuation
To teach the mother about the elements of
child care, nutrition, personal hygiene &
environmental sanitation.
To sensitize the mother to the need for family
planning.

Antenatal visit
Ideal visit: Once a month during the first seven month.
Twice a month during the next month & thereafter once
a week till the expected date of delivery. Total visit:14
Minimum visit: 1st visit- at 20 weeks or as soon as the
pregnancy is known.
2nd visit-at 32 weeks, 3rd visit- at 36 weeks & 4th visitBy the condition of the mother.

Antenatal service
During 1st visit:
Complete history taking.
Physical examination: e.g. height, weight, BP,
anaemia etc.
Laboratory investigation: CBC, Urine
examination, Blood grouping, FBS & 2hrs
ABF/RBS/OGTT, HBsAg, VDRL(for
Gonorrhoea & Syphilis test)

Con
History taking: Present history, past history,
obstetrical history, menstrual history, family
history and immunization history.
Calculation of EDD: From the last day of
menstrual period by adding nine calendar
months and seven days.

Continuation
Subsequent visit:
Physical examination: weight gain and BP,
anaemia, oedema etc.
Lab test: Hb estimation, Urine examination,
Blood sugar etc.

Other services
Iron, folic acid and calcium supplementation
and other medication if necessary.
Immunization against Tetanus usually after 1 st
trimester.
Ultrasonography.
Health education
Referral services where necessary.

High risk mother

Early primi (below 20 years)

Elderly primi (30 years and above)
Short statured primi (140cm and below)
Malpresentation eg. Breech, transverse lie
etc.)
Threatened abortion, antepartum
haemorrhage(APH)
Preeclampsia, Eclampsia.

Continuation

Anaemia
Twins, Hydramnios
Previous still birth, intrauterine death.
Elderly grand multipara
H/O previous caesarean section or instrumental
delivery.
Pregnancy associated with diseases e.g.
Cardiovascular disease, Kidney disease, Diabetes,
liver disease etc.

Antenatal Card
Antenatal card is prepared at the first
examination.
Content: Registration number, Address,
identifying data, previous history and main
health events.

Antenatal advice
Diet: A balanced & adequate diet is an
essential requirement during pregnancy and
lactation period.
Total energy consumption during pregnancy80,000 Kcal (2100+300Kcal/day)
Energy requirement-285Kcal/day during
pregnancy and 550Kcal/day during lactation.
Total weight gain-12 kg

Personal hygiene

Personal cleanliness: bath & wear clean cloth.

Rest & sleep:8 hrs sleep &2 hrs midday rest.
Bowel: To avoid constipation.
Exercise: Light household work encouraged.
Smoking: strict avoidance as risk of LBW.
Alkohol: strict avoidance
Dental care:To maintain oral hygiene
Sexual intercourse:should be restricted in 1 st & last
trimester.

Drugs
Certain drugs taken by mother during
pregnancy may adversely affect the foetus.
Such as deformed hand & feet, chromosomal
damage, 8th cranial nerve damage+
deafness(streptomycin),impaired foetal
growth(corticosteroid), abnormality in bone
growth & enamel formation of
teeth(Tetracycline), depressant
effect(Anaesthetic).

Radiation
X-ray abdomen or chest may be associated
with leukemia, other neoplasm, microcephaly.

Warning Sign

Swelling of the feet

Fits
Headache
Blurring of vision
Per vaginal bleeding

Specific health protection

Anaemia: Premature birth, IUGR, LBW, PPH,
Thromboembolic phenomenon.
Prevention: Iron & folic acid
supplementation.
Toxaemia of pregnancy: Preeclampsia means
an increase in BP, presence of albumin in
urine & oedema. Convulsion makes it
eclampsia.

continuation
2 doses of Tetanus Toxoid is given at 16-20 weeks then
20-24 weeks.
Syphilis: Spontaneous abortion, still birth, IUD, perinatal
death, child with congenital syphilis, neurological
damage.
Prevention: During ANC-VDRL Test.
Treatment: Inj. Procaine Penicillin 6 lacs unit- 1 amp.
Daily for 10 days.

continuation
German measles: Abortion, congenital
anomalous foetus.
prevention: Rubella vaccination of school
going children & women of child bearing age
who are seronegetive.
Rh negetive mother:If the mother is Rhnegetive & the child is Rh-positive,provokes a
immune response in her and forms antibodies

continuation
which can cross the placenta and produce
haemolysis. Clinicaly haemolytic disease
takes the form of hydrops foetalis, icterus
gravis neonatorum and congenital haemolytic
anaemia.
Prevention: Rh anti-D immunoglobulin should
be given at 28 weeks and again 72 hours of
delivery.

continuation
Prenatal genetic screening: It includes
screening for chromosomal abnormalities
associated with serious birth defects,
haemoglobinopathies, Downs syndrome severe
neural tube defect. Women aged 35 years &
above are at high risk.
HIV infection: The virus may pass to the
newborn through placenta, during delivery or
during breast feeding.

continuation
Prenatal testing for HIV infection for those with
HIV risk & motivate them for therapeutic
abortion.

Intranatal Care
It is the care of the mother during delivery.
Aim: clean cut- clean hand- clean surface
Through asepsis
Delivery without injury to infant & mother.
Readiness to deal with complications like
prolonged labour, APH, convulsion,
malpresentation,prolapse of the cord.
Care of baby at delivery.

Domiciliary Care
When mothers with normal obstetric history
have their confinement in their own homes
conducted by the female health worker or
TBA, provided the home conditions are
satisfactory, the delivery in this manner is
known as the domiciliary care.

continuation
Advantage: 1)Familiar surroundings in the home
removes the fear associated with delivery. 2)
The chances of cross infection are fewer. 3) the
mother is able to look after the children &
domestic affairs.
4) Reduce mental tension.
Disadvantage: May have less medical & nursing
supervision, less rest, diet may be neglected.

Danger signals
Sluggish or no pain after rupture membrane
Good pain after rupture membrane but no
progress
Prolapse cord or hand
Meconium stained liquor
Slow irregular or excessive fast foetal heart
beat
Bleeding during labour

Con
Placenta not separated within half hour after
delivery
PPH
Temperature increases during labour

Institutional Care
When deliveries tend to be abnormal and
difficult requiring the services of doctor and
where home condition are not suitable, the
care taken at this stage is known as
Institutional care. Such as hospitals, clinics,
health centers etc.
Rooming in: Keeping the baby by the side of
the mothers bed is called rooming-in.

Post natal care

Definition: Care of the mother along with the
newborn after delivery is known as Post natal
care.
Perinatology: The combined responsibility of
the obstetrician and paediatrician (for mother
and newborn) is known as perinatology.

Objective
To prevent complications of the post partum
period.
To provide care for the rapid restoration of the
mother to optimum health.
To check adequacy of breast feeding.
To provide family planning services.
To provide basic health education to mother
and family.

Complication
Puerperal sepsis: Infection of the genital tract
within 3 weeks after delivary; features: rise in
temperature & pulse, foul smelling lochia, pain
and tenderness in lower abdomen,
subinvolution of the uterus.
Thrombophlebitis: Infection of the veins of the
legs associated with varicose vein. Leg
become pale, swollen, tender.

Continuation
Secondary haemorrhage: P/V bleeding from 6
hours after delivery to the end of the
puerperium.
Postpartum psychosis.
Others: UTI, Mastitis.

Postnatal examination
Health check up upto 6 weeks.
Examination: Temperature, Pulse,
Respiration, Breast, Involution of the uterus,
Lochia, urine, Bowel, Perineal toileting.
Anaemia: Hb estimation routinely.
Nutrition
Exercise: Household activities, Pelvic floor
exercise.

Postnatal advice
Breast feeding
Family planning
Health education: Feeding of the mother &
infant, pregnancy spacing, Birth registration.
Post natal health check up.
Postnatal investigation.

Emergency Obstetric Care(EOC)

Definition: EOC refers to ability to recognize,
stabilize and manage the complications that
arise and threatens the life of the mother and
her unborn child. There are life saving obs.
services that can be performed at various
levels of the health system. The more
pheripheral this kind of obstetric first aid, the
more lives will be saved.

Obstetric First Aid

Administer Parenteral oxytocic drugs
(ergometrine)
Administer Parenteral antibiotics
Administer Parenteral sedatives/
anticonvulsants.

Basic EOC
Administer Parenteral oxytocic drugs
(ergometrine)
Administer Parenteral antibiotics
Administer Parenteral sedatives/
anticonvulsants.
Perform manual removal of placenta
Perform assisted vaginal delivery(vacuum
extraction, forcep etc.)

Comprehensive EOC
All of those included in basic EOC.
Surgery e.g. caesarean section, curettage etc.
Blood transfusion.

3 Delays
Delay in deciding to seek EOC
Delay in reaching in EOC facility
Delay in receiving EOC at facility

Phase of Delay
Economical status
Educational status
Women status

Factor affecting

Phase of Delay
Phase 1-Decide to seek care

Distance, transport, roads& cost.

Phase 2-Reach medical

facility

Quality of care
Phase 3-Receive adequate
treatment

Safe Motherhood
Safe motherhood means creating the
circumstances within which a woman is :
Enabled to choose whether she will become
pregnant, and if she does, ensuring that
She receives care for prevention and treatment of
pregnancy complication
She has access to trained birth assistance
She has access to emergency obstetrics care(if
she needs)

SM
She receives care after birth,
So that she can avoid death or disability from
complications of pregnancy and child birth.
Maternal mortality and morbidity can be reduced
by measures that:
Reduce the incidence of unwanted pregnancy
Prevent the complications from arising during
pregnancy or delivary

SM
Promote early identification and appropriate
treatment of complications.
In Bangladesh maternal health have focused on
family planning, ANC, TT immunization,
identification of high risk pregnancy, TBA
training and promotion of safe birth practice.
These activities can reduce maternal &
neonatal mortality by:

SM
Reducing the number of pregnancies &
thereby reducing the population at risk of
maternal death.
Reducing the number of unwanted pregnancy
Decreasing the incidence of puerperal sepsis
through the promotion of clean birth practice.
Reducing birth trauma by promoting the
services and availability of TBA.

SMI
Reducing the incidence of neonatal tetanus
through TT immunization of pregnant woman.
Safe motherhood initiative (SMI) worldwide effort
that aims to reduce the number of death and
illness associated with pregnancy and
childbirth. The global initiative was launched at
a conference held in Nairobi,Kenya in 1987.
Since 1987 the SMI has become partnership of
GO,NGO,donors and

SMI
working to protect the health and lives of woman
especially during pregnancy and childbirth.
Cause of death
Intervention
Haemorrhage
ANC, TBA, case management
Induced abortion
FP,TBA,CM
Eclampsia
ANC,TBA,CM
Puerperal sepsis
TBA,CM
Obs.labour
ANC,TBA,CM

5 pillars of safe motherhood

Family Planning
Antenatal care
Safe delivery
Postnatal care
Emergency obstetric care

SMI
Advanced safe motherhood through human
right
Empower women, ensure choices
Safe motherhood is a vital economic and
social investment
Delay marriage and first birth
Every pregnancy faces risks
Ensure skilled attendance at delivery

SMI
Improve access to quality reproductive health
service
Prevent unwanted pregnancy and unsafe
abortion
Measure progress
The power of partnership

SMI
(10 initiatives)
Education on safe motherhood.
Promotion of maternal nutrition.
Provision of micronutrient supplementation
and tetanus toxoid, where appropriate.
Prenatal care and counselling.
Adequate delivery assistance.

SMI
Care for obstetric emergencies, including referral
for pregnancy, childbirth, and abortion
complications.
Postnatal care.
Abortion-related care or PAC.
Family planning counselling and promotion of
longer intervals between births.
Neonatal care, including exclusive breast-feeding
for six months.

Early Neonatal Care

Objectives
Establishment & maintenance of cardiorespiratory functions.
Maintenance of body temperature
Avoidance of infection
Establishment of satisfactory feeding regimen
Early detection & treatment of congenital &
acquired disorders especially infections.

Immediate Care
Clearing the airway
Establishment & maintenance of cardiorespiratory function e.g. breathing.
Position the baby with head downclear
mucous & other secretions.
Resuscitation may be required if the baby
fails to breath within minutes.

Immediate care
Care of the cord
Umbilical cord should be cut & tied after it
stops pulsating. cord drops off by 4-5 days.
Sterilized instruments should be used to
prevent tetanus.
Care of the eyes
The lid margins should be cleaned with sterile
wet swab, one for each eye.

continuation
A drop of 1% Silver nitrate-to prevent
gonococcal conjunctivitis.
Single 1% Tetracycline ointment should also
be used.

continuation
Care of the skin: Few hours after birth, the new
born should be given first bath with soap and
warm water to remove vermix, meconium and
blood clot.
Maintenance of body temperature:
To keep the body wrapped with warm clothing &
cotton. First 12-24 hours, the baby should be
attached to the mothers body to receive the
warmth by skin to skin contact.

 Breast feeding should be initiated within an

hour of birth.

Sign

Heart Rate

Apgar score
Score
0

Absent

Slow(<100)

Over 100

Absent

Slow
Irregular

Good Crying

Flaccid

Some flexion Active

of extremities movement

Resp.Rate
Muscle Tone

No Response Grimace
Reflex

Cry

Severe
Mild:4-7,
Colourdepression:0-3,
Blue-pale
Body-Pink NoCompletely
Extrimitypink
depression:7-10
Blue

Neonatal Examination
1st examination: To ascertain that the baby has
not suffered any birth injury, To detect
malformation and to assess maturity.
Abnormality that may be found: Cyanosis of
the lips, Difficulty in breathing, Imperforate
anus, persistent vomiting, sign of cerebral
irritation e.g. convulsion, neck rigidity, twitching,
bulging of anterior fontanel, Temparature
instability.

continuation
2 nd examination: Should be made by a
paediatrician within24 hours after birth
including body size, body temperature, skin,
cardiorespiratory activity, neuro activity,head &
face, abdomen, limbs & joints, spine, external
genitelia.

Infection of the Newborn

Neonatal Tetanus
Congenital Syphilis
HBV positive mother:1 amp. (0.5) ml hepatitis
B vaccine I/M and 2 ml HBs gamma
globulinI/M.
HIV positive mother: Termination of
pregnancy.

Common child health Problem

Low birth weight
Malnutrition
Nutritional deficiency: PEM, Vitamin A
deficiency, Ca ,Iodine deficiency etc.
Infectious disease: Diarrhoea, Respiratory
infection, Measles, Pertusis, Malaria, Polio,
Neonatal Tetanus, TB, Diptheria etc.

Common child health Problem

Parasitic disease: Ascariasis, Ankylostomiasis,
Giardiasis, Amoebiasis.
Accidents: Burn, Trauma, RTA, Falls,
Drowning.
Poisoning: DDT, Bleaching powder.
Behavioral problems.

Factor affecting the health of the

children
Maternal health: Child health is adversely
affected if the mother is malnourished, if she
is too young(18 years or below) or too old(35
years or above), if the pregnancy was too
close and if she was multipara.
Family: Child health depends upon familys
physical & social environment.
Socioeconomic condition

 Environment
Social support & Health care

Low Birth Weight

It may be defined as a birth weight of less
than 2.5 Kg within the 1st hour of life before
significant postnatal weight loss has occurred.
A low birth weight infant is any infant with a
birth weight of less than 2.5 Kg or 2500gm
regardless of gestational age.

Mainly two types

Pre term babies: These are babies born too
early, before 37 weeks of gestation. Their
intrauterine growth may be normal, such as
height, weight, development may be within
normal limits for the duration of gestation.
Cause: Multiple birth, Acute infection, Hard
physical work, Hypertension, Idiopathic.
Management: Neonatal care.

 Small for date: May be born at term or preterm.

Their weight less than 10th percentile for the
gestational age.
Cause: Intra uterine growth retardation:
a) Maternal factor- Malnutrition, Anaemia,
Heavy physical work during pregnancy,
Hypertension, Malaria, Toxaemia, Smoking, Low
economy, short stature, Young age, High pariety,
Close birth spacing, low education.

b) Placental factor: Placental insufficiency,

Placental abnormalities.
c) Foetal factor: Foetal abnormality, Intrauterine
Infection, Chromosomal anomaly.
PretermBorn before 37 weeks.
Term Born 37 to 40 weeks.
Post term Born at 42 weeks.

Prevention
A) Direct intervention:
Identify high risk mother
Increase food intake: Supplementary feeding,
distribution of iron & folic acid
tablets,fortification, enrichment of food.
Infection control: Malaria, UTI, CMV,
Toxoplasmosis, Rubella, Syphilis.

 Early detection & treatment of medical

disorder: HTN, DM, Toxaemia.
B) Indirect intervention:
Family planning
Avoidence of smoking
Improved sanitation measures.
Improving the educational, health & nutritional
status.

Treatment
Incubatory care: adjustment of temperature,
humidity & oxygen supply.
Feeding: Breast feeding and if necessary
feeding by NG tube.
Treatment of infection.
Cause of death: Atelactesis, Malformation,
pulmonary haemorrhage, intracranial
bleeding, pneumonia &other infection.

Growth & Development

Definition: The term growth refers to increase
in the physical size of the body and
development means increase in skills &
function. Growth & development include not
only physical aspect but also intellectual,
emotional & social aspect.

Determinants
Genetic inheritance: Related with height, weight,
mental & social development, personality etc.
Nutrition: Improved nutritionimproved growth
& development; Lack of nutritiongrowth
retardation, malnutrition.
Age: foetal life, 1st year of life. Puberty
maximum growth; other period of life- less
growth.

Continue
Sex: Maximum female growth occurs during
puberty(10-11years); maximum male growth
occurs during puberty(12-13 years).
Physical surroundings: Sunshine, good housing,
lighting, ventilation have growth promoting
effects.
Psychological: Love, proper child parent
relationship affects social, emotional &
intellectual development of child.

Continue
Infection: Infection of the mother during
pregnancy affects intrauterine growth of
children e.g.Rubella, syphilis. Infection after
birth slows down growth & development e.g.
diarrhoea, measles. Intestinal parasites hamper
the routine growth e.g. hook worm, round
worm.
Economic: Children from well to-do family
better height, weight.

Normal growth
Concept of normality: A normal child as one
whose characteristics fall within the range of
measurement accepted as normal for the
majority of children in the same age group.
Method of assessment: Weight for age, Height
for age, Weight for height and Head & chest
circumference.

Milestone of Development

3 month= holds head erect

4-5 month=listening
6-8 month=sits without support
9-10 month= crawling
10-11 month= stand with support and 1 st word
12-14 month=walks wide base, builds
18-21 month= walks narrow base, run, joining word
24 month= runs, making short sentences.
Children 1-4 years of age are called preschool age or
toddlers.

Congenital malformation
Definition: Congenital disorders are defined as
those diseases that are substantially determined
before or during birth & which are in principle
recognizable in early life.
Congenital malformation confined to structural
defects at birth.
Congenital anomaly confined to all structural,
biochemical & functional disorders present at
birth.

Cause
a) Genetic factor:
Chromosomal anomaly: The chromosome is
either missing or excess e.g. Downs
syndrome, Turners syndrome.
Inborn errors of metabolism: Phenyl
Ketoneurea, Galactosaemia.
Others: Thalasaemia, Sickle cell anaemia,
Haemophilia, Neural tube defect, Club foot.

Cause
b) Environmental factor:
Intrauterine infection: Infection with TORCH.
Drugs: Thalidomide, Stilbosterol,
anaesthetics, steroid.
Radiation
Maternal disease: DM, cardiac failure.
Diatory factor: Folic acid deficiency.

Risk factor
Maternal age: Age 40-45years.
Consanguinity: High incidence of mental
retardation, congenital malformation with first
cousin, uncle-niece marriage.

Antenatal diagnosis
Alpha fetoprotein: Neural tube defect can be
detected by this special protein of foetal origin.
Ultrasound
Amniocentesis: Possible in 2nd trimester e.g.
Neural tube defect, Downs syndrome

Prevention
By discouraging further reproduction after the
birth of a malformed child.
The avoidance of pregnancy in advanced age.
Identification and removal of certain teratogen
e.g. Drugs, infective agent, X-ray radiation.

Maternal Mortality Rate

Total No. of female death due to complication
of pregnancy, child birth or within 42 days of
delivary from puerperal causes in an area
during a given year
MMR=
Total No. of live birth in the same area
&same year.

Causes
Direct cause:
a)Toxaemia of pregnancy
b)Haemorrhage
c)Puerperal sepsis
d)Obstructed labour
e) Unsafe abortion

Causes
Indirect cause:
a)Anaemia
b)Medical diseases- cardiac, renal, hepatic,
metabolic, infectious
c)Malignancy
Other direct cause: Ectopic pregnancy,
embolism & anaesthesia related.

Prevention

Early registration of pregnancy

Antenatal check up
Correction of anaemia
Prevention of infection & haemorrhage during
puerperium
Prevention of complication: Eclampsia,
Malpresentation,ruptured uterus

Prevention

Treatment of medical condition: HTN,DM,TB

Clean delivery practice
Institutional delivery
Promotion of family planning

Social factor

Age at child birth

Parity
Too close pregnancy
Family size
Malnutrition
Poverty
Illiterecy
Ignorence

Lack of maternity
service
Shortage of health
manpower
Delivary by untrained
Dai
Poor sanitation
Poor communication &
transport

Maternal Death
The death of a woman while pregnant or 42
days of termination of pregnancy irrespective
of the duration and site of pregnancy, from
any cause related to or aggravated by the
pregnancy or its management but not from
any accidental or incidental causes.

Haemorrhage is the leading cause of

maternal death

Maternal Mortality Ratio (MMR)

Highest rate
Sierra Leone has the highest maternal death
rate at 2,000, and Afghanistan has the second
highest maternal death rate at 1900 maternal
deaths per 100,000 live births, reported by the
UN based on 2000 figures. According to the
Central Asia Health Review, Afghanistan's
maternal mortality rate was 1,600 in 2007.

Lowest Rate
Lowest rates included Ireland at 0 per 100,000
and Austria at 4 per 100,000. In the
United States, the maternal death rate was 11
maternal deaths per 100,000 live births in
2005.This rose to 13.3 per 100,000 in 2006.

Health related data according to BBS and WHO:

Indicator

Current status

Maternal mortality ratio per

100,000 live birth
Infant mortality rate ( Per 1000
live birth)

320 (2009)

Under five mortality rate

( Per 1000 live birth)

67 (2009)

Neonatal mortality rate ( Per

1000 live birth)

36 (2004)

ANC coverage atleast one visit

60.3 (2007)

ANC coverage atleast four visit

20.6 (2007)

Vitamin A Capsule with

measles vaccine

92.7

45 (2009)

Infant Mortality Rate

IMR is defined as the ratio of infant death in a
given year to the total number of live birth in
the same year expressed as a rate per 1000
live birth.

IMR
Number of death of children less than 1
year
of age in a given year
IMR=
Total No. of live birth in the same year

Causes of IMR

Neonatal mortality(0-4 wks)

Low birth weight
Birth injury & difficult labour
Congenital anomali
Haemolytic disease
Condition of placenta & cord
Diarrhoeal disease
ARI & Tetanus

Post neonatal mortality

(1-12 month)
Diarrhoeal diseases
Acute respiratory infection
Other communicable
diseases
Malnutrition
Congenital anomali
Accident

Factor affecting IMR

Biological factor:
Birth weight
Age of the mother
Birth order
Birth spacing
Multiple birth
Family size

continuation
b) Economic factor
c) Cultural & social factor:
Breast feeding
Religion & cast
Early marriage
Sex of the child
Quality of mothering & maternal education

continuation
Quality of health care
Broken family
Bad environmental sanitation

Prevention

Antenatal feeding
Prevention of infection
Breast feeding
Growth monitoring
Family planning
Sanitation
Provision of PHC
Socio-economic development & Education.

Neonatal Mortality Rate

It is the total no. of neonatal death in a given
year per 1000 live birth.
Neonatal period: Birth to 28 days of age.
No.of death of children under 28 days of
age
in a year
NMR=
Total no. of live birth in the same year

Post Neonatal Mortality Rate

Post neonatal period=28 days to below 1 year
28 days & 1 year of age in a given year
PNMR=
Total no. of live birth in the same year

Perinatal mortality rate

It is the ratio of perinatal death in a given year to
the total number of live birth in the same year
usually expressed as per 1000 live birth.
Perinatal death=Late foetal death(still birth) +
early neonatal death.
Perinatal mortality include foetal death after 28
weeks of gestation when foetus become viable.
Those become minimum birth weight.(above
1000gm) and Death within 7 days of neonatal life.

Perinatal period: Lasting from the 28th week of

gestation to the seventh day after birth.
Foetal death weighing over 1000gm
at birth
1000
Still birth=
Total live + stillbirth weighing over 1000g at birth

PMR
Late foetal death+ early neonatal
death weighing over 1000g at birth
PMR=
Total no. of live birth (weighing over
1000g at birth).

Causes
Antenatal causes:
Maternal disease: HTN, DM, Anaemia
Pelvic disease: Uterine myoma,
endometriosis, Ovarian tumor
Anatomical defect: uterine anomali,
Incompetent cervix
Congenital defect
Endocrine imbalance

continuation

Blood incompatibility
Malnutrition
Toxaemia of pregnancy
APH
Advanced maternal age

Intranatal causes
Birth injury
Asphyxia
Prolonged labour

Postnatal causes

Prematurity
Respiratory distress
GIT infection
Congenital anomaly

Prevention
Women with medical problem should avoid
pregnancy till improve
Birth spacing
TT immunization
Control of anaemia
Early treatment of maternal complication
Institutional delivary at high risk case
Referral & care of complication

 Safe delivary practice

Essential newborn care
Resuscitation of newborn.

1-4 year child Mortality Rate

It may be defined as the no. of death of children
aged 1-4 years per 1000 children in the same
age group in a given year. (It excludes IMR).
No. of death of children aged 1-4 year during a
year
1000
=
Total no.of children aged 1-4 years at middle of
the year

Under-5 Mortality Rate

(Child Mortality Rate)

It may be defined as the no. of death of

children aged under 5 years per 1000 live
birth in a given year.
No. of death of children less than 5 years of
age in a given year
1000
=
Total no. of live birth in a same year

Under-fives clinic
It is a comprehensive health care service of
prevention , treatment, health supervision,
nutritional surveillance and education to large
proportion of children in the community.

AIMS and OBJECTIVES

It expresses by a symbol.
Care in illness

Growth monitoring
Preventive care
Symbol for under fives clinic

Aims & objectives

1) The apex of the symbol represents care and
treatment of sick children.
a.Diagnosis and treatment of acute illness,
Chronic illness and disorder of growth and
development.
b.X-ray and laboratory services
c.Referral services.

continuation
2) Preventive care
a.Immunization
b.Nutritional surveillance
c.Health check-up
d.Oral rehydration
e.Family planning
f. Health education

continuation
3) Growth monitoring: Weight of the children
periodically at monthly interval during the 1 st
year, every two month during 2nd year and
every three month upto the age of 5 years.

Child Survival Rate

A child survival rate per 1000 live birth can be
calculated by subtracting the under-5 mortality rate
from 1000; Dividing this figure by 10 will give the
percentage of the same.
1000

under-5 mortality rate

1000

Child survival rate=

10

Baby friendly Hospital

In 1993 WHO established BFH mainly
focused on promoting breast feeding.

Reproductive Health
It is a state of complete physical, mental &
social wellbeing and not merely the absence
of disease or infirmity in all matters relating to
the reproductive system and its function and
processes.

Reproductive health package

Family planning
Antenatal care, skilled birth attendance at
delivery and postnatal care.
Management of obstetrics and neonatal
complications and emergencies.
Management of abortion complication and
provision of post abortion care.
Prevention and treatment of RTI and STDs
including HIV/AIDS.

continuation
Early diagnosis and treatment for breast
cancer Reproductive tract cancer.
Promotion , education and support for
exclusive breast feeding.
Prevention and appropriate treatment of subfertility and infertility.
Active discouragement harmful practice such
as female genital cutting.
Adolescent sexual and reproductive health.

Component of reproductive Health

Safe motherhood
Family planning
Prevention & control of RTI/STD/AIDS
Maternal nutrition
Menstruation regulation &Unsafe abortion
Adolescent care
Infertility
Neonatal care

Family planning
A way of thinking and living that is adopted
voluntarily, upon the basis of knowledge,
attitudes & responsible decisions by
individuals & couples, in order to promote the
health and welfare of the family group & thus
contribute effectively to the social
development of a country.

Objectives

To avoid unwanted birth.

To bring about wanted birth.
To regulate the interval between pregnancies.
To control the time at which birth in relation to
the age of the parent.
To determine the number of children in the
family.

Con
To control population explosion.
To reduce abortion.
To improve the economic condition of the
country & to eliminate poverty.
To improve the developmental activities of the
country.

Classification
Barrier Method:
Physical: Condom, Diaphragm, Vaginal
sponge.
Chemical: Foam, Cream (jelly, paste),
Suppositories.
Combined: Physical + Chemical.

Conti..
Hormonal method:
Oral pills: Combined pill, Progestogen only pill
(POP), Post coital pill, once a month pill, male
pill.
Depot formulation: Injectable, Subdermal
implant, vaginal ring.

Conti..
Intra Uterine Device (IUD): Non-medicated
and medicated. Medicated IUDs release either
copper or hormone (progestogens).
The non-medicated IUDs are reffered to as first
generation IUDs. The copper IUDs comprise
the second and the hormone releasing-IUDs
are the third generation IUDs.

Conti.
Post conceptional method:
Menstrual regulation, Menstrual Induction.
Miscellaneous:
Abstinence, Coitus interruptus, Safe period,
Breast feeding, Natural family planning
method, Basal body temparature, Cervical
mucous.

Condom
It is made of thin latex rubber. Some are
coated with dry lubricant or with spermicide;
different size, shape, colour & texture may be
available.

Advantage
It prevents pregnancy as well as STDs, including
AIDS, when used correctly with every act of
intercourse.
It can be used to prevent STD infection during
pregnancy.
Inexpensive, easily available, light, compact &
disposable.
Safe, no hormonal side effect & can be stopped at
any time.
Help to prevent ectopic pregnancy & premature
ejaculation.

 No hormonal side effect.

Helps to protect against HIV/STDs.
Easy to use, donot require medical
supervision.

Disadvantage
Latex may cause itching for those who are
allergic; may decrease sensation, making sex less
enjoyable for the either partner.
May be slip off or tear during sex.
A mans cooperation is needed for a woman to
protect herself from pregnancy & disease.
It can weaken if stored too long, in too much heat,
sunlight, humidity eventually break during use.
Poor reputation; many people use it with immoral
sex, sex outside marriage, sex with prostitutes.

 May embarrass people to buy.

If condom breaks; immediately insert a
spermicide into the vagina. Washing both
penis & vagina with soap and water should
reduce the risk of STDs and pregnancy. And
use of emergency oral contraception to
prevent pregnancy.

Female Condom
It is a pouch made of polyurethane which lines
the vagina. An internal ring in the close end of
the pouch covers the cervix and an external
ring remains outside the vagina. It is an
effective barrier to STD infection.

Diaphragm
Vaginal barrier, made of synthetic rubber/plastic
material invented by German physician & also
known as Dutch cap. Has a flexible rim made of
spring/metal. It is held in position partly by spring
& partly by vaginal muscle tone.
M/A: Blocks sperm from entering the uterus &
fallopian tube.
A woman can use this method any time during
her monthly cycle and soon after child birth,
abortion or miscarriage.

Advantage

Safe; woman controlled method.

Easy to use with a little practice.
Contraception just when needed, no daily use.
No side effect from hormone.
No effect on breast milk.
Can be stopped at any time.
Prevent some STDs.

Disadvantage
Method have to be ready at hand before every
act of sexual intercourse.
Interrupt sex if not inserted beforehand.
May be hard to conceal from partner.
Require woman or her partner to put
finger/inserter into her vagina.

Chemical method
In 1960 spermicides (vaginal chemical
contraceptives) were used widely. They were 4
categories:
a.Foams: foam tablet, foam aerosol.
b.Creams, jellies and paste
c.Suppositories
d.Soluble films
Main drawback high failure rate.

Hormonal method
Most effective spacing methods of
contraception.
Two synthetic oestrogens are used in oral
contraceptives. These are ethinyl oestradiol
and mestranol. Mestranol is converted into
ethinyl oestradiol in the liver.
Synthetic progestogens: Three groupspregnanes, oestranes and gonanes.

Con..
Pregnanes-It includes megestrol,
chlormadinone and medroxy-progesterone
acetate. Now a days this is not recommended.
Oestranes-Also known as 19nortestosterones, such as norethisterone,
lynestrenol, ethynodiol diacetate and
norethynodrel. These are all metabolised to
norethisterone before coming active.
Gonanes- This is levonorgestrel.

Oral pill
Composition: Oestrogen-30-35 microgram.
Progesterone- 0.5-1mg.
The pill is given orally for 21 consecutive days
beginning on the 5th day of the mens. Cycle
followed by break of 7 days. Combined oral pill
contain two hormones similar to the natural
hormones in a womans body-oestrogen &
progesterone. Also called combined pills or birth
control pills. There are 28 pills in each packet, 21
pills contain hormone and 7 pills are different
colour donot contain hormone.

M/A
Inhibits ovulation by diminishing the secretion
of gonadotropins by pituitary or preventing
them to act on ovary.
It alters/thickens cervical mucosa making it
difficult for sperm to pass through; also
decreases the tubal motility.
Progesterone renders endometrium unsuitable
to the fertilized ovum for implantation and help
in complete shedding of the endometrium.

Advantage
Very effective when used correctly.
No need to do anything at the time of
intercourse.
Monthly periods are regular.
Can be used as long as the woman wants to
prevents pregnancy.
Can be used as any age.
Increased sexual enjoyment.

Con
Can be used by both woman who have
children & who donot have.
Can stop at any time.
Can be used as emergency after unprotected
sex.

Disadvantage
Not highly effective unless taken everyday.
Not recommended for breast feeding woman.
May cause mood change, depression, lack of
sex interest.
Rarely can cause stroke, heart attack, deep
vein thrombosis.
Donot protect against STDs/AIDS.

Contra indication
Absolute

Relative

Ca-breast & genitalia

Disease of CVS, renal, GB e.g

HTN, DM

Undiagnosed vaginal bleeding

Epilepsy, Migraine

Suspected malignancy

Amenorrhoea, oligomenorrhoea
Age>40 years
1st 6 month of lactation

Side effect

Amenorrhoea
Irregular bleeding
Nausea
Headache
Leg cramps
GIT disturbance
Stroke
Ca- breast, ovary,uterus.
Obesity

Progestogen only pill(POP)/

Mini pill
These contain very small amount of only one
kind of hormone PROGESTIN. They donot
contain oestrogen. This is the best among the
oral pills for breast feeding women.

M/A

Thicken cervical mucosa, making it difficult for

sperm to pass through.
Decreases tubal motility.
Stops ovulation.

Advantage
Can be used by nursing mother starting 6
weeks after childbirth.
Quantity & quality of milk not interfered.
No oestrogen related side effect.
Most effective during breast feeding.
Less risk of acne/weight gain.

Disadvantage
Poor mens. Cycle control.
Less common side effect.
Should be taken at the same time in each day.

Post- coital contraception

Morning after pill is recommended within 72
hours of an unprotected sex. Two methods
are available: a) IUD b) Hormonal- one tab. Of
.75mg within 72 hours of unprotected sex and
2nd tab. After 12 hours of 1st dose. Or two pills
containing 50 mcg of ethynyl estradiol within
72 hours after intercourse and same dose
after 12 hours.

 Once a month pill ( long acting) pill

Male pill: preventing spermatogenesis,
interfering with sperm storage and maturation,
preventing sperm transport.

Injectable method
These are long acting, highly effective, reversible and
free progestogens.
Women who use this method receive injection to
prevent pregnancy.
Type:
DMPA- Depot medroxy progesteron acetate, given
every 3 month, contain progestin hormone which is
released slowly into the blood. Depot provera, Depo,
Megestron.The standard dose is 150mg I/M in every 3
month.
NET EN-Norethisteron enanthate-(2monthly)

M/A
It inhibits ovulation
Inducing a thin atrophic endometrial lining
making it less suitable for implantation.
Increasing the viscosity of cervical mucus
secretion and forming a barrier to
spermatozoa and changing the rate of ovum
transport through the fallopian tube.

Advantage
Long term pregnancy prevention but
reversible.
Very effective- 0.3 pregnancies per 100
women in first year of use when injections are
regularly spaced 3 month apart.
Does not interfere with sex.
No oestrogen side effect like heart attack.
Can be used at any age.

Con..
It does not affect lactation.
It is most acceptable during post-partum
period.
It helps to prevent endometrial- Ca, ovarianCa, uterine fibroid, ectopic pregnancy.
It requires minimum motivation.

Disadvantage
It should be used at >35 years where family is
complete.
Weight gain, irregular bleeding and prolonged
infertility.
Delayed return of fertility.
May cause headache, nausea, breast
tenderness, hair loss, acne etc.

Side effect
Weight gain
Amenorrhoea
Irregular bleeding
A new formula of DMPA-SC is injected under
the skin rather than muscle.

Sub Dermal Implant

The Norplant implant system is a set of 6 small
plastic(silicon rubber) capsules/rod/stick. Each
capsules size is about the size of a small
matchstick. The capsules are placed under the
skin of womans upper arm. These contain
progestin, no oestrogen. Norplant capsules can
prevent pregnancy for atleast 5 years.
M/A: Thicken cervical mucous and making it
difficult for sperm to pass through.

Advantage
Very effective, long term protection but
reversible.
Does not interfere with sex.
Effective within 24 hours after insertion.
Fertility returns immediately after removal.
No oestrogen side effects like heart attack.
Quality and quantity of breast milk donot
hampered.

Disadvantage
Client cannot start/stop on her own. It has to
be done by specially trained health care
provider.
Minor surgical procedure are required.
Discomfort for several hours to 1 day after
insertion and removal is sometimes painful.

Side effect

Light spotting or bleeding

Amenorrhoea
Sometimes prolonged bleeding
Headache, dizziness, nausea, change in
appetite, weight gain.
Breast tenderness
Acne/skin rash.

Insertion
The woman receives an injection under L/A.
The health care provider makes a small
incision in the skin on the inside of the upper
arm. Then insert the capsule just under the
skin. Then close the incision with an adhesive
bandage.
Insertion takes about 10 minutes. Bruishing or
slight bleeding at the insertion site is normal.

Removal
Under L/A the health care provider makes a
small incision where the capsules were
inserted.
Pushing against the skin and the provider
pushes each capsule to the incision and pulls
it out. Incision is closed and bandaged. It
takes about 15 minutes.

When to start
Having menstrual cycle, it is reasonably
certain that she is not pregnant.
6 weeks after child birth.
7 days after miscarriage/abortion.

Intra-Uterine Devices
(IUD)
There are two basic types of IUD: nonmedicated and medicated.
The non-medicated referred to as 1 st
generation IUDs.
The Cu IUDs comprise the 2nd generation
IUDs
The hormone releasing IUDs referred to 3 rd
generation IUDs.

1st generation IUD

It is non-medicated Lippes Loop.
It is double S-shaped device made of
polyethylene, a plastic material that is nontoxic and non-tissue reactive.
The loop has attached thread or tail made of
fine nylon which project into the vagina after
insertion.

2nd generation IUDs

In 1970 it was found that metallic copper had a
strong anti-fertility effect easier to fit.
Earlier device was copper-7 and copper T 200.
Newer device is Cu-T 220 C and Cu-T380 A
and Nova T.
Multiload devices- Cu-250 and Cu-375.
Nova T and Cu-T 380 A are distinguished by a
silver core over which Cu wire is wrapped.

Advantage

Low expulsion rate.

Less side effect( Pain, bleeding).
Easy to fit even in nulliparous woman.
Increased contraceptive effect.

3rd generation
It is T-shaped device filled with progesterone.
This hormone is released slowly in the uterus.
It has direct local effect on uterine lining,
cervical mucous & on sperms.
The most widely used device is progestasert.
Another device is T-shaped IUD and it release
Levonorgestrel & expensive.
Low pregnancy rate & no ectopic pregnancy.

M/A
IUD causes foreign body reaction in uterus
and causes cellular and biochemical changes
in the endometrium and this changes impair
the viability of gamete and reduce fertilization
and implantation.
Copper enhance the cellular response in the
endometrium and by altering the biochemical
composition of cervical mucus, Cu ion may
affect the sperm motility.

Con
Hormone releasing device increase the
viscosity of the cervical mucosa and prevent
entering of the sperm into the cervix. This
device also prevent implantation.

Ideal Candidates

Who has borne at least one child.

No H/O pelvic disease.
Who has normal menstrual period.
Who is willing to check the IUD tail.
Iud are not recommended for women who had
no children or who have multiple partner
because of risk of PID and possible infertility.

Contra indication
Absolute

Relative

Suspected pregnancy

Anaemia

PID

Menorrhagia

Undiagnosed vaginal bleeding

Purulent cervical discharge

Ca-cervix/uterus/pelvic tumours

Fibroid/Distortion of uterus

Previous ectopic pregnancy

Unmotivated person

When to start
Having menstrual cycle, any time during the
menstrual period or within 10 days beginning
of menstruation.
Post-partum IUD: Can be inserted within 48
hours after child birth. Best time is within 10
minutes after removal of placenta.
After abortion: Immediately if no infection is
present.

Con..
IUD wearer should regularly check the thread
or tail to be sure that the IUD is in the uterus
and if she fails to locate the threads she must
consult with the doctor.
She should visit the clinic if she experiences
any side effect such as fever, pelvic pain and
bleeding.

Side effects &Complication

Bleeding
Pain
Pelvic infection
Uterine perforation
Expulsion
Pregnancy
Ectopic pregnancy

Some definition
Eligible couple: Newly married couple wherein
the wife is in the reproductive age between 15
to 45 years. These couples are in need of
family planning services.
Target couple: The couple who has had 2-3
living children and family planning is directed
to this couple. The eligible couple is now more
widely used.

Vasectomy
Ligation and excision of a segment of each
vasdeferens is known as vasectomy. It
provides permanent contraception for men.

Procedure
Under L/A in the scrotum the provider feels the
skin of the scrotum to find each vas deferens
inside and makes a tiny incision in the scrotal
skin. Then vas/Allis forcep is introduced and
Vas is pulled out by the forcep and each vas is
transected and both cut end are ligated. Then
the incision are closed by suture/adhesive
bandage. After opn. Use contraceptive for 1020 days.

Complication
Operative: Pain, scrotal haematoma, local
infection.
Sperm granule: Accumulation of the sperm
make this granule. Hard mass 7mm size
appears 10-12 days after operation.
Spontaneous recanalization.
Psychological: Impotence, headache, Fatigue,
reduce sex.

Advantage/Disadvantage
Advantage

Disadvantage

Very effective

Not immediately effective

Permanent and lifelong family planning

Required minor surgery by a specially

trained person.

Nothing to remember except to use

condom or another method for first few
days.

Uncomfortable for 2-3 days, pain in the

scrotum, swelling and bruising.

No need to worry about pregnancy.

Bleeding or infection at the incision site

and blood clots in the scrotum.

No apparent long term health effect.

Reversal surgery is difficult.

Does not affect a mans ability to have

sex.

No protection against STDs/AIDS.

Tubectomy
This is the permanent contraception for
women. Also called tubal ligation/minilap.
Preoperative procedure: Empty bladder before
operation, Antibiotic, Injection Phenergan, Inj.
Pethidine and Local anaesthetics.

Operative procedure
Proper aseptic precaution is taken. L/A is
injected in her lower abdomen just above the
pubic line. A transverse incision(2-5cm) is
given above the upper border of the pubic
symphysis. Uterus is raised and by uterine
elevator each fallopian tube is pulled up and
then each tube is tied and cut. Then the
incision is closed and covered with a adhesive
bandage.

Advantage
Very effective and permanent, leads to lifelong
family planning.
Nothing to remember, no supplies needed and
no repeated clinic visit required.
No interference with sex and no need to worry
about pregnancy.
No side effect or health risk.
No effect on breast milk.

Disadvantage
Usually painful for several days after the procedure.
Infection or bleeding at the incision site, internal
infection or bleeding.
Rare risk of allergic reaction.
Requires physical examination and minor surgery
by specially trained person.
Reversal/Recanalization surgery is difficult.
No protection against STDs/AIDS.

Menstrual regulation
Aspiration of uterine contents 6-14 days of a
missed period but before most pregnancy
tests can accurately determine whether or not
a woman is pregnant.
Complication: Immediate- uterine perforation
and trauma and late- abortion or premature
labour, infertility, menstrual disorder & ectopic
pregnancy.

Abortion
It may be defined as termination of pregnancy
before the foetus becomes viable( before 28
weeks of gestation).
Broadly it is two types: spontaneous and induced
abortion. Induced abortion is legal or illegal.
Illegal abortion are hazardous.
Complication: Early complication- hemorrhage,
shock, sepsis, uterine perforation, cervical injury,
thromboembolism and anaesthetic complication.

Con..
Late complication includes infertility, ectopic
pregnancy, risk of spontaneous abortion.

Fertility awareness method

Calendar method or safe period: This method is
based on fact that ovulation occurs from 12 to 16
days before the onset of menstruation. The shortest
cycle minus 18 days gives the ist day of fertile
period. The longest cycle minus 10 days gives the
last day of fertile period. I f a womans menstrual
cycle varies from 26 to 31 days the fertile period
during which she should not have intercourse from
8th day to 21st day of menstrual cycle. Day one is 1st
day of mens. Period. If calculation is not possible
then avoid intercourse 8th to 22nd day of cycle.

con.
Cervical secretion- increased during ovulation.
BBT or Basal body temparature: slightly
increased during ovulation.
Traditional FP method: a) abstinence means
avoiding sex during fertile period. b)
Withdrawal method, c) Breast feeding/
Lactational amenorrhoea method (LAM).

School Health
School health service is a branch of
community health service which provides
promotive, preventive and curative health care
services to the school children in the
environment of the school.

Objectives
General objective: To provide comprehensive
health care (promotive, preventive, curative
and rehabilitative) to school children in order
to prepare them physically, mentally & socially
for entry into adulthood as a step towards
achieving the goal of Health for All.

Specific objectives
To ascertain the health condition of the school
going children through a programme of periodic
medical examination & follow up.
To promote development of healthful school
environment.
To encourage and help students to acquire
knowledge, attitude & practice with regard to
good health, habits & personal hygiene both at
school and home.

Con
To educate school children in the cultivation of
those habits of living that will promote their
present and future health.
To assist implementation of appropriate
measures for prevention and control of
communicable diseases and other conditions
towards improvement of health status of
school children.

Con..
To detect contagious diseases & thereby protect
the child and community.
To provide emergency service for injury or
sudden sickness.
To find the capacity of individual student to
acquire knowledge in accordance with his mental
and physical status.
To bring about close relationship between the
school & home.

Healthful school environment

Pure water supply

Good lighting and ventilation
Satisfactory toilet
Glare proof black boards, ceiling and walls
Suitable chairs and desks
Restroom and playground
Clean environment

Con.
Location: Away from busy place and properly
fenced.
Class room: Height of the classroom should be
12 feet, area should should not be less than 480
sq.ft, each child should have 15 sq. ft. floor space
&300 sq.ft air space, temp. should be 6872degree. The distance of the blackboard should
not be greater than 25 feet or less than 7 feet.

Con
Play ground: For primary school it should be to
1 acre and for 2ndary school 5-14 acre. Play
ground should be atleast 7 acre.
Seat and desk: 3 types-Zero desk, Plus desk &
Minus desk.
Zero desk: posterior edge of the desk is vertically
in line with the anterior edge of the seat.
Plus desk: there is a space between anterior edge
of the seat and posterior edge of the desk.

Con.
Minus desk: vertical line from the posterior edge
of the desk falls on the seat.
Zero and minus desk are suitable for reading and
writing. The back of the seat should support the
spine in the lumber region.
Sanitary facilities:
Water supply:
First aid:
Communicable disease control:

School health team

Medical officer, Public health nurse,
Pharmacist, Supporting staff along with district
Health education officer/Health inspector and
supervisory post by Chief medical officer/Civil
surgeon and also school teachers and class
monitor also included.
School lunch service known as mid day meal
programme.

Duties of SMO
To conduct periodical examination of students.
To check for immunization.
To control epidemic outbreak of disease in the
school.
To examine & treat minor ailments.
To examine the mental and physical condition
of the children.

Con.
To inspect periodically physical exercise.
To inspect school building and hostel for
improvement of sanitation, water supply,
ventilation, lighting and seating arrangement.
To educate about hygiene.
To advice parents on mental and physical
condition of the children.
To explain importance of personal hygiene in
parent teacher conference.

School health problems

Malnutrition
Communicable disease
Helminthic disease
Skin disease
Eye defect
Ear problem
Throat problem

Environmental problem

Lack of safe drinking water

Inadequate lavatory facility
Over crowded classroom
Absence of play ground
Drug abuse/Smoking/alcoholism.

Definition of Health
According to WHO, Health is a state of
complete physical, mental, spiritual and social
wellbeing & not merely absence of disease or
infirmity that enable a person to lead socially
& economically productive life.

Community medicine
It is a system of delivary of comprehensive
health care to the individual or family at the
level of community by a health team in order
to promote physical, mental or social
wellbeing.

Comprehensive health care

Comprehensive health care means provision
of integrated promotive, preventive, curative &
rehabilitative health care services from womb
to tomb.

Preventive Medicine
It is the branch of medicine distinct from public
health based on etiology and it is for healthy
people. Such as prevention of communicable
diseases based on immunization. The concept
of preventive medicine include health
promotion, treatment & prevention of disability
as well as specific protection.

Social Medicine
It is the study of man as a social being in his
total environment. It is concerned with all the
factors affecting the distribution of health and
ill health in population. It is the relationship
between medicine and social science.

Family Medicine
It may be defined as a field of specialization in
medicine which is neither disease nor organ
oriented. It is the family oriented medicine.

Public Health
In 1920 CEA Winslow defined public health as:
It is the science and art of preventing disease,
prolonging life and promoting health and
efficiency through organized community effort
for the
a) Sanitation of the environment
b) Control of the communicable disease
c) Education of the individual in personal hygiene

Con.
d) The organization of medical and nursing
services for early diagnosis & preventive
treatment of disease.
e) The development of social machinery to
ensure for every individual a standard of living
adequate for the maintenance of health.
So organizing these benefits as to enable every
citizen to realize his birth right health and
longevity.

Changing concept of health

Biomedical concept: The health is absence of
disease, if one was free from disease then the
person was considered healthy. This concept
has basis on germ theory of disease. Human
body is a machine & disease as a
consequence of breakdown of machine.
Ecological concept: Health is a dinamic
equilibrium between man & his environment.

 Psychosocial concept: Health is not a

biomedical phenomenon but one which is
influenced by social, psychological, cultural,
economic & political.
Holistic concept: The strength of social,
economic, political & environmental influence
on health. Health implies a sound mind, ina
sound body, in a sound family and in sound
environment.

Determinants of Health

Biological determinants
Behavioral & socio-cultural condition
Environment: Internal and external
Socioeconomic condition: Economic
status,Education, occupation & political.
Health service
Aging of the population
Gender
Other factor

Indicators of health
Morbidity indicator: Incidence, prevalence,
attendance care at OPD, health centre.
Admission, Readmission & discharge and
duration of hospital stay.
Mortality indicator: Death rate. MMR, IMR,
child mortality rate, under-5 mortality rate,
disease specific mortality rate.
Disability indicator: It is related to illness and
injury.

Con
Nutritional status indicator: Anthropometric measurementHeight, weight, MUAC etc.
Health care delivary indicator: Doctor-population ratio, Doctornurse ratio, population-bed ratio, population per TBAs etc.
Indicators of social & mental health.
Environmental indicator
Socioeconomic indicator
Health policy indicator
Indicator of quality of life
Others: Social, basic need indicator, health for all indicator
and MDG indicators

Occupational diseases
Diseases due to physical agent:
Heat- heat hyperpyrexia, heat exhaustion, heat
cramps, burns, local effect.
Cold- trench foot, frost bite
Light- occupational cataract, miners nystagmus
Pressure- caisson disease, air embolism
Noise- occupational deafness
Radiation- cancer, leukaemia, aplastic anaemia,
pancytopenia

Con.
Mechanical factors- injuries, accident
Electricity- burn

Diseases due to chemical agent

Gases- co2, co etc causes

Tools of measurement
Rate: occurrence of some particular event
(disease, death) in a population during a given
period of time.
It has the four elements: Numerator,
Denominator, Time specification, multiplier, a
power of 10 (10n).
Death rate= No. of death in a year*1000.

Con..
Ratio: A relation in size between two random
quantities( the numerator is not a component
of the denominator), they are separate and
distinct quantities. It expresses the magnitude
of one occurrence in relation to others. In the
result of by dividing one quantity by other like
X:Y or X/Y. Ratio of WBC to RBC is 1:600 or
1/600.

Con..
Proportion: It is the ratio which indicates the
relation in magnitude of a part of the whole
( numerator is included in the denominator).
Here X is the part of the Y. 40/100 or
40/40+60.

Measurement of Epidemiology

Measurement of mortality.
Measurement of morbidity.
Measurement of disability.
Measurement of natality.
Measurement of presence, absence or distribution of
the characteristic or attributes of the disease.
Measurement of medical needs, health care facility,
utilization of health services and other health related
events.
Measurement of demographic variables.

Respiratory problem among the

helpers of human haulers in a selected
area of Dhaka.

Research question: Is their any respiratory

problem existing among the helpers of human
haulers?
General objective: To find out the extent of
respiratory problem among the helpers of
human haulers.
Specific objectives:
To determine the occurrence and pattern of
respiratory problem among the helpers.

Con..
To find out the occurrence of respiratory
problems in relation to duration of job &
smoking habit.
To assess the respiratory status among the
helpers by clinical and spirometric
examination.
To determine the socio-economic
characteristics of the helpers.

Materials and Methods

Study design: Cross sectional study

Study period:
Place of study:
Study population: All the helpers of human haulers in
Mirpur to Mohakhali.
Sample size: All the helpers of human haulers who
will be available during my study period.
Sampling technique: Questionnaire & check list
Equipments: Stethoscope, measuring tape &
spirometer.

Con..
Method of data collection: face to face
interview, clinical examination and spirometric
examination.
Data analysis: Will be done by using SPSS.
Submitted by:
Dr.

Research Protocol
Title: Selected biochemical factors and comorbidities related to rickets in a community.
Research question: What are the patterns of
clinical presentation, biochemical status and
associated co-morbidities related to rickets.
General objective:
Specific objective:
Research methodology:

Title: Health problems among the

garment workers.

General objective: To find out the extent and

type of Occupational Health problem among
the garment workers.
Specific objectives:
To find out the extent and type of
Occupational Health problem among the
workers
To assess the hazards existing in the
working environment.

Con

To find out protective measures used by the

workers.
To find out socio-demographic characters of
the workers.
Research methodology:

Pre-test
For data collection two instruments were used:
a structured questionnaire for interviewing the
selected workers and a medical examination
check list for health check up. Questionnaire
was pre-tested in a garment in the Tejgaon
industrial area. Before finalizing the
questionnaire, necessary correction was done
according to the pre test findings.