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Report on what done and procedures taken by nurses and patients at Maternal and child
health centres
Introduction
Kenyas health care system is structured in a step-wise manner so that complicated cases are
referred to a higher level. Gaps in the system are filled by private and church run units. The
structure thus consists: Dispensaries and private clinics; Health centres; Sub-district hospitals
and nursing homes; District hospital and private hospitals; Provincial hospital and National
hospital

Dispensaries
The government runs dispensaries across the country and is the lowest point of contact with the
public. These are run and managed by enrolled and registered nurses who are supervised by the
nursing officer at the respective health centre. They provide outpatient services for simple
ailments such as common cold and flu, uncomplicated malaria and skin conditions. Those
patients who cannot be managed by the nurse are referred to the health centres there.

Private clinics
Most private clinics in the community are run by nurses. In 2011 there were 65,000 nurses on
their council's register. A smaller number of private clinics, mostly in the urban areas, are run
by clinical officers and doctors who numbered 8,600 and 7,100 respectively in 2011. These
figures include those who have died or left the profession hence the actual number of workers is
lower.

Health centres
All government health centres have a clinical officer as the in-charge and provide comprehensive
primary care. Because of their heavy focus on preventive care such as childhood vaccination,
rather than curative services, local council (municipal) and most mission, as well as many private
health centres, do not have clinical officers but instead have a nurse as the in-charge.

Health centres are medium sized units which cater for a population of about 80,000 people. A
typical health centre is staffed by: at least one Clinical officer, nurses, health administration
officer, medical technologist, pharmaceutical technologist, health information officer, public
health officer, nutritionist, driver, housekeeper and supporting staff. All the health centre staff
report to the Clinical officer in-charge except the public health officers and technicians who are
deployed to a geographical area rather than to a health unit and report to the district public health
officer even though they may have an office at the health centre.

The health centre has the following departments: Administration block; where patients register
and all correspondence and resources are managed from; out-patient consultation rooms where
patients are seen and examined by clinical officers; in-patient (wards) where very sick patients
can be admitted. The wards are divided into male, female and paediatric with newborn units;
laboratory where diagnostic tests are done. These laboratories can do the following tests- blood
slides for malaria parasites, sputum AFB, urinalysis, full haemogram, stool ova and cysts, blood
sugar, Elisa and CD4counts in comprehensive care centres for HIV/AIDS patients: pharmacy;
minor theatre where minor surgical procedures are done e.g. Circumcision, stitching wounds
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and manual vacuum aspiration; maternity; maternal and child health; kitchen and catering and
student hostels for rural health training centres where students go to get rural experience.

Sub-district hospitals
These are similar to health centres with addition of a surgery unit for Caeserian section and other
procedures. Many are managed by clinical officers. A good number have a medical officer and a
wider range of surgical services.

Nursing Home
These are owned privately by individuals or churches and offer services roughly similar to those
available at a sub-district or district hospital. They are also believed to provide better medical
services compared to public hospitals.

District hospitals
Each district in the country has a district hospital which is the co-ordinating and referral centre
for the smaller units. They usually have the resources to provide comprehensive medical and
surgical services. They are managed by medical superintendents.

Provincial hospitals
Kenya has eight provinces, each with a provincial hospital which is the referral point for the
district hospitals. These are regional centres which provide specialised care including intensive
care and life support and specialist consultations.

National hospitals
There are two national hospitals in Kenya, namely:
Moi Teaching and Referral Hospital (MTRH); and
Kenyatta National Hospital (KNH).

Maternal and child healthcare
Maternal health is the health of women during pregnancy, childbirth, and the postpartum period.
It encompasses the health care dimensions of family planning, preconception, prenatal,
and postnatal care in order to reduce maternal morbidity and mortality. Preconception care can
include education, health promotion, screening and other interventions among women of
reproductive age to reduce risk factors that might affect future pregnancies. The goal of prenatal
care is to detect any potential complications of pregnancy early, to prevent them if possible, and
to direct the woman to appropriate specialist medical services as appropriate. Postnatal care
issues include recovery from childbirth, concerns about newborn care, nutrition, breastfeeding,
and family planning.

Around 10 million infants and children die each year, mostly from the combined effects of
infectious diseases and malnutrition. Pneumonia and diarrhoea account for half of the deaths.
Other causes include neonatal tetanus, measles, pertussis, poliomyelitis and diphtheria. A large
number of children who escape death from these diseases suffer blindness, crippling, or mental
retardation. Pregnancy and childbirth complications cause the death of more than half a million
women every year. Malnutrition, particularly anaemia, renders women prone to haemorrhage and
infections. Around a third of those pregnancies are unwanted.
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Apart from poor nutritional status, the risk of maternal and child death is increased by lack of
access to good quality health care, lack of education of mothers, and unhealthy living conditions.
Women who survive the complications of pregnancy and childbirth may suffer painful and/or
embarrassing disabilities. The following tables illustrate the main causes, numbers and
proportion of maternal and neonatal deaths. Most of the causes are preventable.

In June 2011, the United Nations Population Fund released a report on The State of the World's
Midwifery. It contained new data on the midwifery workforce and policies relating to newborn
and maternal mortality for 58 countries. The 2010 maternal mortality rate per 100,000 births for
Kenya is 530. This is compared with 413.4 in 2008 and 452.3 in 1990. The under 5 mortality
rate, per 1,000 births is 86 and the neonatal mortality as a percentage of under 5's mortality is 33.
The aim of this report is to highlight ways in which the Millennium Development Goals can be
achieved, particularly Goal 4 is to Reduce child mortality and Goal 5 to improve maternal death.
In Kenya the number of midwives per 1,000 live births is unavailable and the lifetime risk of
death for pregnant women

Maternal and child health services offer free support and advice to Kenyan families with children
aged from birth to school age. The maternal and child health centre is a great source of support
after the baby is born. A maternal and child shared-care programme is provided to pregnant
women, in collaboration with the obstetric department of hospitals, to monitor the whole
pregnancy and delivery process. To ensure the continuity of quality care, maternal service
clustering between Maternal and Child Health Centres (MCHCs) and hospitals of the same area
county or formerly district where the health centre is based is provided. Pregnant women should
attend the MCHC having shared antenatal care with HA hospitals. If you are expecting a baby or
have just become a new parent, a maternal and child health service can help you. It is a free
primary health service for all Victorian families with children from birth to school age.

The maternal and child health services work in partnership with families, communities and
health professionals with the focus being on prevention, promotion, early detection and
intervention of health and wellbeing concerns of young children and their families. There are
maternal and child health centres in every local government area, which are jointly funded by
state and local governments and usually managed by local government. The centres are staffed
by highly qualified maternal and child health nurses, with support from a range of other health
professionals.

While it is true that health services should be made available to the entire population, there is a
distinct advantage in providing special services to mothers and children or making them the
primary focus of health services, especially when health resources are very limited. Most
complications of pregnancy and diseases in children have the same causes and can be prevented
and effectively managed by simple and affordable interventions.

Improving maternal and child health will reduce the number of medical consultations and
hospital admissions due to complications of pregnancy and childbirth and diseases among
children. This will subsequently reduce the cost of medical care, disability and death, and the
associated loss of productivity of women and children who suffer disabilities or die. The most
valuable benefit that could be derived from improving maternal and child health is to alleviate
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the grief and suffering of countless families. If this is achieved, then it can be truly claimed that
quality of life has been improved.

Reporting of what takes place at the Maternal and Child Health Centre
Routine maternal and child health services
Routine MCH/FP services are globally accepted interventions proven to be effective measures to
improve maternal and child health.

These are part of the basic services that should be made available to women and children. They
include the following:
Before and during pregnancy:
Information and services for family planning;
Antenatal care;
Tetanus toxoid immunization;
Advice regarding proper nutrition, breast-feeding, easing discomforts of pregnancy, and
place of delivery;
Early detection and management of problems such as eclampsia/pre-eclampsia, bleeding,
miscarriage;
detection and treatment of existing diseases such as anaemia, malaria, sexually
transmitted diseases, hookworm infestation, cardio-vascular disease; and sexually
transmitted diseases and AIDS awareness.

During delivery
clean and safe delivery; and
recognition, early detection and management of complications such as haemorrhage,
eclampsia, prolonged/obstructed labour

After delivery, for the mother:
Promotion, early initiation and support for breast-feeding;
advice regarding proper nutrition and hygiene;
management of breast problems;
recognition and management of postpartum complications such as haemorrhage, sepsis,
eclampsia; and
information and services for family planning

After delivery, for the new-born:
Immediate new-born care including basic resuscitation and thermal regulation;
Early and exclusive breast-feeding; and
Prevention and management of infections including opthalmia neonatorum and cord
infections.

Child care:
Immunization;
breast-feeding support;
Advice regarding child care and nutrition;
monitoring of growth and development; and
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Management of acute respiratory infections, diarrhoeal diseases and other common
diseases among children.

1. Issuance of Maternal health Documents (Registration procedure in MCHC)
For the first time visits to maternal and child health centre, the visiting mothers are issued with
documents of a card in nature which she uses during the whole period of pregnancy any time the
mother visits a health centre. The card bears the name of the patient, the blood pressure among
others.

Pregnant women must attend the MCHC for antenatal service within the designated appointment
time. Please refer to the details of appointment booking of your preferred MCHC. Documents /
Forms to bring along

First registration:
1. Valid Kenyan Identity Card (For those without, please bring along valid travel document,
spouse's identity document and marriage document
2. Proof of address dated within the last 6 months
3. Result of pregnancy tests
4. Antenatal record (if available)
5. Completed first registration form
6. Urine sample

Follow up visit:
1. Valid national Identity Card (For those without, please bring along valid travel document,
spouse's identity document and marriage document [copies are acceptable] )
note 1 note 2

2. MCHC Antenatal Registration Card
3. Antenatal record (if available)
4. Urine sample
5. Proof of identity is required
6. For non-local expectant mothers, please bring the Certificate on Confirmed Antenatal and
Delivery Booking issued by the Hospital Authority
7. Collection of urine sample:
a. Urine should be collected before breakfast (drinking water is okay). Discard the
first void urine.
b. Prepare a clean wide-mouth bottle for collecting the second void urine.
c. Clean your vulva with a wet cotton wool pad or toilet paper to remove any
vaginal discharge.
d. Catch only the mid-stream urine with the bottle.

2. Antenatal check up in First registration
Includes obstetric, personal and family medical history, physical and gynaecological examination
if necessary, urine testing for sugar and protein, antenatal blood tests etc.
Charges and fees
Other information
Attendance / Sick leave certificate
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Pregnant women can apply for either attendance or sick leave certificate during the
antenatal check up. Please click here (PDF 0.68MB)for details.

3. Support when you go home
Your local maternal and child health service will be a great source of support after your baby is
born. The hospital will notify your local service and the nurse will contact you during your first
days at home to arrange an appointment. This is usually a visit in your home. During the home
visit, the nurse will give you the location of your nearest centre, information about further visits
and services, and how to contact a maternal and child health nurse at any time.

What maternal and child health centres provide
Visiting your local centre with your child helps identify issues and concerns in your childs
health and development early in life, so that steps can be taken to deal with them.

Maternal and child health nurses can:
Give information, support and advice on a variety of topics, including parenting, child
health, development and learning, child behaviour, maternal health and wellbeing, child
safety, immunisation, breastfeeding, nutrition and family planning
Monitor your childs growth and development in a series of one-on-one consultations at
specific times in your childs early years
Help with sleeping, feeding and behaviour problems
Organise parents groups where you can get information and have the chance to meet
other parents in the local area
Tell you about other local support services
Organise additional activities based on your familys needs, for example, arrange home
visits
Help to contact specialist services if necessary, such as early parenting centres
Offer additional support and services to families experiencing difficulties.

4. Typical visiting schedule
There are particular times when a review of your childs health, learning and development is
recommended. These include: Following discharge from hospital (home visit); At two weeks of
age; Four weeks; Eight weeks; Four months; Eight months; One year; 18 months; Two years and
Three and a half years.

Families are able to access the service at other times by telephone or through a centre visit. Most
centres offer a range of times when families can access the service, and typically operate through
scheduled appointments, open consultation sessions and some after-hours appointments.

5. The Child Health Record
Parents of all babies born in hospitals are given a free booklet called the Child Health Record.
Always take it with you when you go to the health centre, doctor's surgery or dentist, and get
health professionals to complete entries after each visit. It should also be used to record
immunisations. If you keep your childs booklet up to date, it will be an important record of their
development from birth to adolescence.

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After-hours service
The Maternal and Child Health Line is a 24-hour telephone service staffed by qualified maternal
and child health nurses. The telephone line provides over-the-phone information, advice and
referral to all families with young children. An interpreter service is available. The service is also
available to hearing impaired callers who have access to a telephone typewriter (TTY).

6. Expanded voluntary counselling and testing in antenatal care
There are also VCT services offered to at the maternal and child health centres to the visiting
mothers. The mothers are advised to attend to the VCT so that their status can be known in order
to ensure the child is provided with medication that will protect against infection through the
mother. There is a counsellor who undertakes to take the patient through the process of
counselling. The counsellor who is a health expert counsels the patient before and after the test
so that any result is understood well and the patient can overcome the challenge of the result.

In Cambodia, for example, antenatal care includes voluntary HIV counselling and testing. Use of
the rapid HIV finger-prick test in health centres and hospitals has significantly reduced the
number of children infected through their mothers. More expectant mothers are being tested
because they get the results the same day, we do not lose those who may not otherwise return.
This means that for those who test positive, antiretroviral treatment can start straight away.

The hospital also works with non-governmental organisations (NGOs) in communities to
promote same-day testing among expectant mothers, provide home-based care, and HIV
prevention and nutritional counselling. Although Bopha has not disclosed her HIV status in her
community, she says she feels supported by knowing that known HIV positive mothers are being
treated well.

Five months after her HIV test and the start of her antiretroviral treatment, Bopha feels much
better. She says, I have a lot of energy and I rest very well. Her husband, who tested negative,
encourages her to take her medication on time and to keep all her clinic appointments. As a result
of early treatment Bopha is aware that there is a very good chance her baby will be HIV
negative.

7. Expectant Mothers Weight Weighing
This is also done to determine the right weight of the expectant mother so that she is stable in the
process of expectancy. The nurse on duty provides the measuring or weighing scale where the
patient moves on to be taken weight on every visit. This is recorded on a chart of the patient
which will be compared with the previous and the next visits records, to help in advising the
patient. The records are important to monitor the mother against other outcomes such as
hypertension, diabetes, respiratory complications, and obesity of the expectant mother.

Gestational weight gain should typically fall between 11-20 pounds in order to improve
outcomes for both mother and child. Increased rates of hypertension, diabetes, respiratory
complications, and infections are prevalent in cases of maternal obesity and can have detrimental
effects on pregnancy outcomes. Obesity is an extremely strong risk factor for gestational
diabetes. Research has found that obese mothers who lose weight (at least 10 pounds) in-between
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pregnancies reduce the risk of gestational diabetes during their next pregnancy, whereas mothers
who gain weight actually increase their risk.

8. Oral health Diagnosis
The mothers are taken through education process on the need to attend the health centre till the
completion of their gestation period. At the same time they are educated on the need to observe
nutrition value diets. The mothers are taken through regular lessons that teach them of what food
to eat to provide a good health for the mother and the child. The foods not to eat that are harmful
to the mothers during labour time.

Maternal oral health has been shown to effect the well-being of both the mother and her
unborn fetus. The 2000 Surgeons General Report stresses the interdependence of oral health on
the overall health and well-being of an individual Oral health is especially essential during
perinatal period and the future development of the child. Proper management of oral health has
benefits to both mother and child. Furthermore, lack of understanding or maintenance of good
oral health for pregnant women may have adverse effects on them and their children.

Hence, it is imperative to educate mothers regarding the significance of oral health. Moreover,
collabouration and support among physicians across various fields, especially among family
practitioners and obstetricians, is essential in addressing the concerns for maternal oral health. In
2007, the Maternal Oral Health Project was developed to provide routine oral care to low-income
pregnant women in Nassau County, NY. Since its inception, the program has treated more than
2,000 pregnant women, many of whom had significant gum and/or tooth problems.

Oral health has numerous implications on overall general health and the quality of life of an
individual. The Surgeon Generals Report lists that various systemic diseases and conditions
have oral manifestations. The oral cavity serves as both a site of and a gateway entry of disease
for microbial infections, which can affect general health status. In addition, some studies have
demonstrated a relationship between periodontal diseases and diabetes, cardiovascular disease,
stroke, and adverse pregnancy outcomes. Furthermore, the report establishes a relationship
between oral health and quality of life, including functional, psychosocial, and economic
indicators. Poor oral health can affect diet, nutrition, sleep, psychological status, social
interaction, school, and work.

9. Common Tests during Pregnancy
The following are some of the more common tests performed during pregnancy:

a) First Trimester Prenatal Screening Tests
First trimester screening is a combination of fetal ultrasound and maternal blood testing
performed during the first trimester of pregnancy. This screening process can help to determine
the risk of the fetus having certain birth defects. Screening tests may be used alone or in
combination with other tests.




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There are three parts of first trimester screening:
Ultrasound test for fetal nuchal translucency (NT). Nuchal translucency screening
uses an ultrasound test to examine the area at the back of the fetal neck for increased fluid
or thickening.
Two maternal serum (blood) tests. The blood tests measure two substances found in the
blood of all pregnant women:
o Pregnancy-associated plasma protein screening (PAPP-A)--a protein produced
by the placenta in early pregnancy. Abnormal levels are associated with an
increased risk for chromosome abnormality.
o Human chorionic gonadotropin (hCG)--a hormone produced by the placenta in
early pregnancy. Abnormal levels are associated with an increased risk for
chromosome abnormality.

When used together as first trimester screening tests, nuchal translucency screening and maternal
blood tests have a greater ability to determine if the fetus might have a birth defect, such as
Down syndrome (trisomy 21) and trisomy 18.

If the results of these first trimester screening tests are abnormal, genetic counseling is
recommended. Additional testing such as chorionic villus sampling, amniocentesis, cell-free fetal
DNA, or other ultrasounds may be needed for accurate diagnosis.

b) Second Trimester Prenatal Screening Tests
Second trimester prenatal screening may include several blood tests, called multiple markers.
These markers provide information about a woman's risk of having a baby with certain genetic
conditions or birth defects. Screening is usually performed by taking a sample of the mother's
blood between the 15th and 20th weeks of pregnancy (16th to 18th is ideal). The multiple
markers include:
Alpha-fetoprotein screening (AFP). This blood test measures the level of alpha-
fetoprotein in the mothers' blood during pregnancy. AFP is a protein normally produced
by the fetal liver and is present in the fluid surrounding the fetus (amniotic fluid), and
crosses the placenta into the mother's blood. The AFP blood test is also called MSAFP
(maternal serum AFP).

Abnormal levels of AFP may signal the following:
o Open neural tube defects (ONTD), such as spina bifida
o Down syndrome
o Other chromosomal abnormalities
o Defects in the abdominal wall of the fetus
o Twins--more than one fetus is making the protein
o A miscalculated due date, as the levels vary throughout pregnancy
hCG. This is human chorionic gonadotropin hormone (a hormone produced by the
placenta)
Estriol. This is a hormone produced by the placenta
Inhibin. This is a hormone produced by the placenta

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Abnormal test results of AFP and other markers may indicate the need for additional testing.
Usually an ultrasound is performed to confirm the dates of the pregnancy and to look at the fetal
spine and other body parts for defects. An amniocentesis may be needed for accurate diagnosis.
Multiple marker screening is not diagnostic.

This means it is not 100 percent accurate, and is only a screening test to determine who in the
population should be offered additional testing for their pregnancy. There can be false-positive
results indicating a problem when the fetus is actually healthy or false negative results indicating
a normal result when the fetus actually does have a health problem. When a woman has both first
and second trimester screening tests performed, the ability of the tests to detect an abnormality is
greater than using just one screening independently. Nearly all cases of Down Syndrome can be
detected when both first and second trimester screening are used.

c) What is an amniocentesis?
An amniocentesis is a procedure used to obtain a small sample of the amniotic fluid that
surrounds the fetus to diagnose chromosomal disorders and open neural tube defects (ONTDs),
such as spina bifida. Testing is available for other genetic defects and disorders depending on the
family history and availability of labouratory testing at the time of the procedure.

An amniocentesis is generally offered to women between the 15th and 20th weeks of pregnancy
who are at increased risk for chromosome abnormalities, such as women who are over age 35
years of age at delivery, or those who have had an abnormal maternal serum screening test,
indicating an increased risk for a chromosomal abnormality or neural tube defect.




d) How is an amniocentesis performed?
An amniocentesis is a procedure that involves inserting a long, thin needle through the mother's
abdomen into the amniotic sac to withdraw a small sample of the amniotic fluid for examination.
The amniotic fluid contains cells shed by the fetus, which contain genetic information. Although
specific details of each procedure vary slightly, generally, an amniocentesis follows this process:
The woman's abdomen is cleansed with an antiseptic.
The doctor may or may not give a local anesthetic to numb the skin.
Ultrasound is used to help guide a hollow needle into the amniotic sac.
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A small sample of fluid is withdrawn for labouratory analysis.
Strenuous activities should be avoided for 24 hours following an amniocentesis.
Women may feel some cramping during or after the amniocentesis.

Women with twins or other multiples need sampling from each amniotic sac, in order to study
each baby. Depending on the position of the baby, placenta, amount of fluid, or patient's
anatomy, sometimes the amniocentesis cannot be performed. The fluid is sent to genetics
laboratory so that the cells can grow and be analyzed. Alpha-fetoprotein, a protein made by the
fetus that is present in the fluid, is also measured to rule out an open neural tube defect, such as
spina bifida. Results are usually available in about 10 days to two weeks, depending on the
laboratory.

e) What is a chorionic villus sampling (CVS)?
Chorionic villus sampling (CVS) is a prenatal test that involves taking a sample of some of the
placental tissue. This tissue contains the same genetic material as the fetus and can be tested for
chromosomal abnormalities and some other genetic problems. Testing is available for other
genetic defects and disorders depending on the family history and availability of labouratory
testing at the time of the procedure. In comparison to amniocentesis (another type of prenatal
test), CVS does not provide information on neural tube defects such as spina bifida. For this
reason, women who undergo CVS also need a follow-up blood test between 16 to 18 weeks of
their pregnancy, to screen for neural tube defects.



f) How is CVS performed?
CVS may be offered to women who are at increased risk for chromosomal abnormalities or have
a family history of a genetic defect that is testable from the placental tissue. CVS is usually
performed between the 10th and 12th weeks of pregnancy. Although exact methods can vary, the
procedure involves inserting a small tube called a catheter through a woman's vagina and into her
cervix and usually follows this process:
Ultrasound is used to guide the catheter into place near the placenta.
Tissue is removed using a syringe on the other end of the catheter.
Another method is transabdominal CVS, which involves inserting a needle through the
woman's abdomen and into her uterus to sample the placental cells.
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Women may feel some cramping during and after the CVS procedure.
The tissue samples are sent to a genetic labouratory to grow and be analyzed. Results are
usually available in about 10 days to two weeks, depending on the labouratory.

Women with twins or other multiples usually need sampling from each placenta. However,
because of the complexity of the procedure, and positioning of the placentas, CVS is not always
feasible or successful with multiples.
Some women may not be candidates for CVS or may not obtain results that are 100 percent
accurate, and may therefore require a follow-up amniocentesis. In some cases there is an active
vaginal infection, such as herpes or gonorrhea, which will prohibit the procedure. Other times
the doctor obtains a sample that does not have enough tissue to grow in the labouratory, such that
results are incomplete or inconclusive.

g) What is fetal monitoring?
During late pregnancy and during labour, your doctor may want to monitor the fetal heart rate
and other functions. Fetal heart rate monitoring is a method of checking the rate and rhythm of
the fetal heartbeat. The average fetal heart rate is between 110 and 160 beats per minute. The
fetal heart rate may change as the fetus responds to conditions in the uterus. An abnormal fetal
heart rate or pattern may mean that the fetus is not getting enough oxygen or there are other
problems. An abnormal pattern also may mean that an emergency or cesarean delivery is needed.

h) How foetal monitoring is performed?
Using a foetoscope (a type of stethoscope) to listen to the fetal heart beat is the most basic type
of fetal heart rate monitoring. Another type of monitoring is with a hand held Doppler device.
This is often used during prenatal visits to count the fetal heart rate. During labour, continuous
electronic fetal monitoring is often used. Although the specific details of each procedure vary
slightly, generally, electronic fetal monitoring follows this process:
Gel is applied to the mother's abdomen to act as a medium for the ultrasound transducer.
The ultrasound transducer is attached to the abdomen with straps and transmits the fetal
heartbeat to a recorder. The fetal heart rate is displayed on a screen and printed onto
special paper.
During contractions, an external tocodynamometer (a monitoring device that is placed
over the top of the uterus with a belt) can record the patterns of contractions.
Sometimes, internal fetal monitoring is necessary for a more accurate reading of the fetal
heart rate. Your bag of waters (amniotic fluid) must be broken and your cervix must be
partially dilated to use internal monitoring. Internal fetal monitoring involves inserting an
electrode through the dilated cervix and attaching the electrode to the scalp of the fetus,
called a fetal scalp electrode.

i) What are a glucose challenge and a glucose tolerance tests?
The initial 1-hour test is a glucose challenge test. If the results are abnormal, a glucose tolerance
test is done.
A glucose tolerance test, usually conducted in the 24 to 28 weeks of pregnancy, measures levels
of sugar (glucose) in the mother's blood. Abnormal glucose levels may indicate gestational
diabetes.

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j) How is a glucose tolerance test performed?
The glucose tolerance test is done if the woman has an elevated 1-hour glucose challenge test.
Although the specific details of each procedure vary slightly, generally, a glucose tolerance test
follows this process:
The mother-to-be may be asked to only drink water on the day the glucose tolerance test
is given.
An initial fasting sample of blood is drawn from a vein.
You will be given a special glucose solution to drink.
Blood will be drawn several times over the course of several hours to measure the
glucose levels in your body.

k) What is a Group B strep culture?
Group B Streptococcus (GBS) are bacteria found in the lower genital tract of about 25 percent of
all women. GBS infection usually causes no problems in women before pregnancy, but can cause
serious illness in the mother during pregnancy. GBS may cause chorioamnionitis (a severe
infection of the placental tissues) and postpartum infection. Urinary tract infections caused by
GBS can lead to preterm labour and birth, or pyelonephritis and sepsis.

GBS is the most common cause of life-threatening infections in newborns, including pneumonia
and meningitis. Newborn babies contract the infection during pregnancy or from the mother's
genital tract during labour and delivery.

The Centers for Disease Control and Prevention recommends screening of all pregnant women
for vaginal and rectal group B strep colonization between 35 to 37 weeks' gestation. Treatment
of mothers with certain risk factors or positive cultures is important to reduce the risk of
transmission of GBS to the baby. Babies whose mothers receive antibiotic treatment for a
positive GBS test are 20 times less likely to develop the disease than those without treatment.

l) What is an ultrasound?


An ultrasound scan is a diagnostic technique which uses high-frequency sound
waves to create an image of the internal organs. A screening ultrasound is sometimes done
during the course of a pregnancy to check normal fetal growth and verify the due date.
Ultrasounds may be performed at various times throughout pregnancy for different reasons:

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In the first trimester
To establish the dates of a pregnancy
To determine the number of fetuses and identify placental structures
To diagnose an ectopic pregnancy or miscarriage
To examine the uterus and other pelvic anatomy
In some cases to detect fetal abnormalities

Mid-trimester (sometimes called the 18 to 20 week scan)
To confirm pregnancy dates
To determine the number of fetuses and examine the placental structures
To assist in prenatal tests, such as an amniocentesis
To examine the fetal anatomy for presence of abnormalities
To check the amount of amniotic fluid
To examine blood flow patterns
To observe fetal behavior and activity
To examine the placenta
To measure the length of the cervix
To monitor fetal growth

Third trimester
To monitor fetal growth
To check the amount of amniotic fluid
As part of the biophysical profile
To determine the position of a fetus
To assess the placenta

m) How is an ultrasound scan performed?
Although the specific details of each procedure vary slightly, generally, ultrasounds follow this
process. Two types of ultrasounds can be performed during pregnancy:
Abdominal ultrasound
In an abdominal ultrasound, gel is applied to the abdomen and the ultrasound transducer
glides over the gel on the abdomen to create the image.
Transvaginal ultrasound
In a transvaginal ultrasound, a smaller ultrasound transducer is inserted into the vagina
and rests against the back of the vagina to create an image. A transvaginal ultrasound
produces a sharper image and is often used in early pregnancy.

There are several types of ultrasound imaging techniques. The most common is two dimensional,
or 2D. This gives a flat picture of one aspect of the image. If more information is needed, a 3D
ultrasound examination can be performed. This technique, which provides a three-dimensional
picture, requires a special machine and special training. But the 3D image allows the health care
provider to see width, height, and depth of images, which can be helpful in diagnosis. The 3D
images can also be captured and saved for later review.

The latest technology is 4D ultrasound, which allows the health care provider to visualize the
unborn baby moving in real-time. With 4D imaging, a three-dimensional image is continuously
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updated, providing a "live action" view. These images often have a golden color, which helps
show shadows and highlights.

Ultrasound images may be captured in still photographs or on video to document findings.
Ultrasound is a technique that is constantly being improved and refined. As with any test, results
may not be completely accurate. However, ultrasound can provide valuable information for
parents and health care providers to help manage and care for the pregnancy and fetus. In
addition, ultrasound gives parents a unique opportunity to see their baby before birth, helping
them to bond and establish an early relationship.

n) What are the risks and benefits of ultrasound?
Fetal ultrasound has no known risks other than mild discomfort due to pressure from the
transducer on the abdomen or in the vagina. No radiation is used during the procedure.
Transvaginal ultrasound requires covering the ultrasound transducer in a plastic/latex sheath,
which may cause a reaction in patients with a latex allergy.

Fetal ultrasound is sometimes offered in nonmedical settings to provide keepsake images or
videos for parents. While the ultrasound procedure itself is considered safe, it is possible that
untrained personnel may give parents false assurances about their baby's well-being, or perhaps
an abnormality may be missed. Having ultrasound performed by trained medical personnel who
can correctly interpret findings is recommended. Talk with your doctor or midwife if you have
questions.

o) What is genetic screening?
Many genetic abnormalities can be diagnosed before birth. Your doctor or midwife may
recommend genetic testing during the pregnancy if you or your partner have a family history of
genetic disorders and/or you have had a fetus or baby with a genetic abnormality.
Examples of genetic disorders that can be diagnosed before birth include the following:
Cystic fibrosis
Duchenne muscular dystrophy
Hemophilia A
Thalassemia
Sickle cell anemia
Polycystic kidney disease
Tay-Sachs disease

p) What do genetic screening methods include?
Genetic screening methods may include the following:
Ultrasound scan
Alpha-fetoprotein test (AFP) or multiple marker test
Chorionic villus sampling (CVS)
Amniocentesis
Percutaneous umbilical blood sampling (withdrawing a small sample of the fetal blood
from the umbilical cord)


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10. Blood Tests on Pregnant Mothers during visits to maternal and Child Heralth Centre
a) Blood Groups
It's important for the patient to know her blood group, in case she needs a transfusion during
pregnancy or birth. Blood group O is the most common. Groups A, B, and AB are less so.

b) Rhesus (Rh) factor
The doctor and midwife need to know mothers rhesus status. If she is rhesus positive (RhD
positive), she has a particular protein on the surface of her red blood cells, while if she is rhesus
negative (RhD negative), she lacks that.

If the expectant mother is RhD negative and her baby's dad is positive, there's a good chance that
the baby will be RhD positive, too. In this case, the body might produce antibodies that start to
attack the baby's red blood cells. Therefore the nurses at the health centre diagnoses the
Injections of a substance called immunoglobulin, given at 28 weeks, to prevent this happening.

c) Iron levels
A blood test can tell the nurse and the patient if the patients haemoglobin levels are low, which
is a sign of iron-deficiency or anaemia. The patients body needs iron to produce haemoglobin to
carry oxygen around the body in her red blood cells.

If the mother is anaemic due to iron deficiency, her nurse or midwife will talk to her about the
best foods to eat to boost her iron stores. Lean meat and spinach are good sources. She may also
prescribe iron tablets or recommend an iron-rich tonic, which may be more easily digested.

The expectant mothers haemoglobin levels will be checked again at 28 weeks. If she suffers a
lot from tiredness, the nurse or midwife will arrange for a blood test earlier to see if the mother is
anaemic.

d) Immunity to measles (rubella)
Most mums-to-be are immune to measles. Either they've been vaccinated against it, or they've
had the disease as a child. If the expectant mother is not immune, they will be advised to have a
vaccination against the disease once the baby is born. It's important to avoid anyone who has or
might have the infection while she is still pregnant. This is because if she catches measles during
pregnancy, the baby's heart, sight and hearing could be seriously affected.

e) Hepatitis B
The patient could be a carrier of the hepatitis B virus and not even know it. A blood test is often
the only way to find out for certain. If the mother passes the disease on to her unborn baby either
before or after birth, the babys liver could be seriously damaged. Babies at risk of catching
hepatitis B virus from their mums can be protected with injections of vaccine and antibodies,
given as soon as they're born.

f) Syphilis
Thankfully, this sexually transmitted disease is fairly rare nowadays. However, if the mother has
it and it isn't treated during pregnancy, it could cause abnormalities in the baby. Syphilis can
even cause a baby to be stillborn.
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The blood test for syphilis can sometimes produce a false positive result. This is because it's hard
to tell the bacteria that cause syphilis from other similar bacteria that commonly cause non-
sexually transmitted diseases. If the expectant mother is diagnosed with syphilis, she will be
treated with penicillin. This will also protect the baby from the disease.

11. Expectant Mothers HIV/AIDS screening for protection of unborn foetus
All mums-to-be are offered a blood test to detect HIV and AIDS, but you can turn it down if you
want to. If you discover you have the infection, steps can be taken to reduce the chance of the
virus being transmitted to your baby during pregnancy, birth and afterwards. Find out more
about HIV and AIDS in pregnancy.

At the maternal child health centre, visiting expectant mothers are screened for various related
health challenges one of which is HIV/AIDS. This is done to enable the health centre provide
protection to the unborn child so that the child is not infected by the mothers status. The visiting
mothers are taken through a waiting list where they queue to be taken into a room where blood
samples are for labouratory tests. A nurse will then come one by one each mother on the visit is
taken blood sample that is lab tested and results are communicated to them. Those who are found
to be HIV/AIDS infected are taken to VCT counseling programme and immediately diagnosis of
the right medication is prescribed for the mother.

Maternal HIV rates vary around the world, ranging from 1% to 40%, with African and Asian
countries having the highest rates. HIV/AIDS can be transmitted to the offspring during
the prenatal period, childbirth, or breastfeeding. If a mother is infected with the HIV/AIDS virus,
there is a 25% chance that she will pass on the virus to her offspring if she does not receive
proper treatment during pregnancy; on the other hand, if a mother is treated during her
pregnancy, there is a 98% chance that her baby will not become infected.

In 2009, an estimated 860,000 pregnant women were found to be living with HIV in Eastern and
Southern Africa, more than in any other region of the world. The region is also home to 47
percent of the global total of children living with HIV, of which over 90 percent were infected
through vertical transmission from the mother to the baby during pregnancy, delivery or
breastfeeding.

Without effective treatment, more than half of all babies born with HIV will die before their
second birthday. In high-burden countries in Southern Africa, HIV contributes to between 10 and
28 percent of all deaths among children under five years of age. Moreover, HIV contributes to a
high portion of maternal deaths in ESA, especially in Southern Africa where they ranged from
26.8 percent in Mozambique to 67.3 percent in Swaziland in 2010.

According to UNICEF, the last decade has seen a large increase in death among young children
due to HIV/AIDS contracted from their parents, especially in countries where poverty is high
and education levels are low. Although several preventative measures do exist, cost and
infrastructure are two central problems that international organizations and health agencies find
when trying to implement solutions to the problem of mother-to-child HIV transmission in
developing countries. Having HIV/AIDS while pregnant can also cause heightened health risks
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for the mother. A large concern for HIV-positive pregnant women is the risk of contracting
tuberculosis (TB) and/or malaria, in developing countries.

a) Why HIV/AIDS Screening
An increasing proportion of pregnant women are being tested for HIV in Eastern and Southern
Africa, rising from 15 percent in 2005 to 47 percent in 2010. Of those who tested positive, 64
percent received ART to prevent the transmission of the virus to their baby, up from only 19
percent in 2005. The regional average, however, masks huge disparities between and within
countries. Countries such as Botswana, Lesotho, Namibia, South Africa and Swaziland already
achieved coverage rates of more than 80 percent, while in others such as Eritrea have 3 percent
of HIV-positive pregnant women were enrolled in PMTCT programmes.

Table 1.1: The highest HIV burden among pregnant women in Eastern and Southern
Africa in descending order
Country
Estimated No. of HIV-
positive pregnant
women (2009)
% of HIV-positive pregnant women who
received ARVs for PMTCT (2010)
South Africa 330,000 95
Mozambique 76,000 52
Kenya 76,000 43
Tanzania 73,000 59
Zimbabwe 62,000 46
Uganda 61,000 42
Zambia 49,000 75
Malawi 47,000 23 - 31
Botswana 17,000 >95
Lesotho 16,000 89
Angola 11,000 20
Swaziland 10,000 >95
Namibia 9,500 >95
Burundi 9,000 36
Rwanda 8,800 60
Somalia 1,500 <1
Eritrea 1,300 3
Madagascar 700 <1 - 1
Comoros <100 67<95
Ethiopia - -
Source: State of the Worlds Children 2011, UNICEF: Global UNAIDS Response: Epidemic
update and health sector progress towards Universal Access, Progress Report 2011, UNAI DS.

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Botswana leads the way in wide-scale provision of PMTCT services. According to the 2011
Universal Access Progress Report, more than 95 percent of pregnant women were tested for HIV
and more than 95 percent received ARVs to prevent vertical transmission. Mother-to-child HIV
transmission has been reduced to 4 percent in the country. The availability of PMTCT in Lesotho
has further increased to 94 percent of all health facilities, and the proportion of pregnant women
who receive PMTCT services has increased to 89 percent in 2010, from only 16 percent in 2006.

Mozambique has also achieved impressive growth in PMTCT scale up. By the end of 2009,
more than 700 health facilities provided PMTCT services, reaching almost 890,000 pregnant
women (an increase from 668,000 in 2008). Of the total number of sites, 43 percent are
UNICEF-supported. In several countries, UNICEF and partners supported the adaptation of the
new WHO guidelines, as well as reprogramming of existing grants by the Global Fund to fight
AIDS, Tuberculosis and Malaria for PMTCT and helping high burden countries apply for new
funding rounds.

In Kenya, 60 percent of all health facilities (more than 3,000) are now offering PMTCT services,
with 83 percent of all women attending antenatal services being tested in 2010. Also in Kenya,
the Government with support of UNICEF launched the Maisha MTCT-free Zone Initiative, an
innovative approach to prevent mother-to-child transmission of HIV.

Summary and Conclusions
Maternal and child health care services conducted in the early stages of pregnancy is
transforming fetal screenings because they can more accurately predict the risk of genetic
disease. The blood test analyzes fetal DNA from the baby circulating in the mothers blood as
early as 10 weeks into the pregnancy, searching for genes linked to Down syndrome. Physicians
say the test is simple and may reduce the need for more invasive fetal tests, such as
amniocentesis, which uses a needle to extract fluid from the uterus and carries a risk of
miscarriage. Existing prenatal tests are also conducted later in the 11th and 13th week of
pregnancy and combine ultrasound and a hormonal blood test which is less accurate


Activities in maternal and child health programmes are many and complex, and the team
approach to management is the best way to operate the programme. The team approach
maximizes the contributions of each key manager in the programme. This requires group
participation in every management activity, including planning, supervision, evaluation and
problem solving. Planning is a process which helps decide in advance: the problems in maternal
and child health and the objectives of the maternal and child health programme; the activities
that should be done to achieve the programme objectives; the methods or approaches that should
be followed when performing the activities; the time-frame within which the activities should be
accomplished; the persons who will perform or be responsible for the activities; and the
milestones or indicators that should be used to monitor and evaluate the maternal and child heath
programme.

Planning focuses activities on the desired goals and objectives. Good planning dictates the
effectiveness and efficiency of activities because it minimizes changes or uncertainties that may
occur during the implementation of the programme. Good planning enables managers to monitor
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and evaluate programmes based on set indicators, and allows for necessary decisions or actions
when needed.

Figure 1.1: Primary care pathways for SAFE START


Analysing the situation finds out what the problems are and their causes, and what resources are
available through a systematic process of examining health and health-related information. The
review requires collecting and analysing data on population, its health status, health resources
and the socioeconomic factors affecting health. Data sources include office records on health
services and resources, programme evaluation results, national health office, demographic and
health surveys and reports of other institutions which collect health-related information, such as
the civil registry, records of nongovernmental health organizations, etc.

Other information may be obtained through discussions with local government and community
leaders, interviewing clients or attending meetings of sectoral organizations working in the
community or conducting surveys. Monitoring keeps track of the programme activities. Well-
planned and systematic monitoring can provide good information on whether the activities are
moving in the right direction and are within the target time-frame. Monitoring looks at whether
work standards are maintained. It looks at whether resources are being used effectively and
efficiently. It also finds out the reasons if work standards are not maintained or if resources are
not used effectively and efficiently. Regular monitoring identifies problems early so that
solutions can be instituted early, before any damage is done.