Practical Mother and Child Health in Developing Countries

Book 1 Chapter 1 Mother and Child Health: Introduction

Chapter 1 Maternal and Child Health: Introduction

Chapter 1 Maternal and Child Health: Introduction ............................................................................1
Maternal and child health: introduction ...........................................................................................2
Causes of maternal and child mortality............................................................................................5
Common health problems of mothers and children .......................................................................10
Planning for better health of mothers and children........................................................................10
Figure 1.1 Population pyramids of developed and developing regions...............................................2
Figure 1.2 Services for Mother and Child Health................................................................................3
Figure 1.3 Maternal Mortality in Year 2000........................................................................................4
Figure 1.4 Causes of maternal deaths ..................................................................................................5
Figure 1.5 Child deaths in year 2000 (Each dot represents 5000 deaths)............................................6
Figure 1.6 Causes of deaths in children ...............................................................................................8
Figure 1.7 Coverage with proven interventions in 42 countries accounting for 90% of under-five
deaths .................................................................................................................................................12
Table 1.1Deaths of children under age of five years as proportion of total deaths .............................6
Table 1.2 Causes of deaths in children by WHO region......................................................................7
Table 1.3 An estimated contribution of ten major risk factors to the burden of disease in year 2000 7
Table 1.4 Measures of ill-health in developing countries....................................................................9
Table 1.5 Effective Interventions.......................................................................................................11
Table 1.6 Core interventions at family and community level............................................................12
Table 1.7 Core Interventions at the level of health facility................................................................13
Table 1.8 Core Interventions at Health System Level .......................................................................14

Practical Mother and Child Health in Developing Countries

Book 1 Chapter 1 Mother and Child Health: Introduction

Maternal and child health: introduction

In developing countries, children and young adults under the age of 15 make up about 45 per cent
of the population). If to this is added the number of expectant and lactating mothers, then about 65
per cent of the population need to be covered by the maternal and child health service. (See Figure
1.1).

Figure 1.1 Population pyramids of developed and developing regions

Practical Mother and Child Health in Developing Countries

Book 1 Chapter 1 Mother and Child Health: Introduction

Since mothers and children make up some two-thirds of the population the main focus of health
services of necessity has to be different from that in the developed parts of the world where the bulk
of the population consists of people of working age. A maternal and child health service is
principally a preventive/promotive service compared to national health programmes in developed
countries where the focus is on keeping the labour force in good health. (See fig. 1.2) The aims of a
maternal and child health service are to ensure that:
1. Every expectant mother maintains good health, is prepared both physically and
psychologically to look after her child, goes through a normal delivery and bears a healthy
child.
2. Every child grows up in healthy surroundings, receives proper nourishment and adequate
protection from disease.
3. Communicable diseases are controlled in vulnerable groups by taking adequate preventive
measures and by health education.
4. Sickness is detected and treated early, before it becomes serious or chronic.
5. Simple statistical data on morbidity and mortality are maintained at regional and national
levels.

Figure 1.2 Services for Mother and Child Health

Pregnancy related health problems can be prevented or managed without recourse to expensive and
sophisticated technology. Experience has shown that maternal and neonatal morbidity can be reduced when
communities are informed about danger signs and symptoms and good quality health care is accessible
with a back up referral system for managing complications at a higher level of health care system. And yet
some 500 000 maternal deaths occur each year, most of them in developing countries. (See Fig. 1.3)

Practical Mother and Child Health in Developing Countries

Book 1 Chapter 1 Mother and Child Health: Introduction

Figure 1.3 Maternal Mortality in Year 2000

(maternal mortality ratio is the number of maternal deaths per 100 000 live births)

An estimated half a million women die every year in pregnancy and childbirth due to largely preventable
causes. Maternal deaths are the result of complications of pregnancy haemorrhage, sepsis, hypertensive
disorders of pregnancy, obstructed labour and unsafe abortion. (See Fig. 1.4). Millions of women suffer
such complications and survive and go on to develop acute or chronic ill health or lifelong disability.

Practical Mother and Child Health in Developing Countries

Book 1 Chapter 1 Mother and Child Health: Introduction

Figure 1.4 Causes of maternal deaths

Causes of maternal and child mortality
Many of the health problems encountered by mothers and children in developing countries are
preventable either by means of health education or regular supervision and immunisation; yet it is
these illnesses that take a heavy toll of lives. It is estimated that up to 99 per cent of the half million
maternal deaths occurring each year are in the developing world
In a number of countries, between a quarter and a half of all deaths in women aged 15-30 years are
related to pregnancy. Some three-quarters of maternal deaths are due to five causes as described
above viz. obstructed labour, haemorrhage, toxaemia, infection, and complications arising from
spontaneous or induced abortion. But this is only part of the story. Health care and its availability
are important determinants. In addition, many other problems line the road to maternal death. They
begin soon after a baby girl's birth and continue throughout childhood when preferential treatment
of boys in the household makes undernourishment and ill health more common in girls. The road to
death continues through adolescence when girls marry early and become pregnant before they have
completed their full growth. In adulthood, a heavy workload, poor nutrition and repeated
pregnancies often render many women unable to cope with the physical demands of pregnancy,
childbirth and lactation. Lack of access to antenatal care from trained health workers and to skilled
assistance in childbirth make matters worse. When complications arise, health facilities may be
inaccessible or unable to cope with the emergency.
In the case of children, deaths under the age of five forms a high proportion of all deaths (Table
1.1), indicating the vulnerability of children in a harsh environment. Children under the age of five
account for more than half of the global gap in mortality between the poorest and the richest
5

Practical Mother and Child Health in Developing Countries

Book 1 Chapter 1 Mother and Child Health: Introduction

sections of the world population. In low income countries they bear 30 per cent of the total burden
of disease. Almost all (99%0 of the 10.9 million children under the age of five who died in the year
2000 were from developing countries. (See Fig. 1.5)
Table 1.1Deaths of children under age of five years as proportion of total deaths
Region

Percentage of all deaths

Africa
Near east
Asia
China
Latin America and Caribbean
Developed countries

53
48
42
15
34
3

Most of the deaths are due to preventable causes. The three main causes (the 'Big 3') are
malnutrition, respiratory infections, and diarrhoea. They account for between 30 and 40 per cent of
all paediatric admissions to hospitals. The next six most common illnesses are anaemia, measles and
other common infectious diseases of childhood, malaria and other parasitic diseases, tuberculosis,
burns and accidents, and poisoning. Together with the Big 3, these illnesses constitute the
'Dominant 9' paediatric problems in the developing world. (See Fig. 1.6)

Figure 1.5 Child deaths in year 2000 (Each dot represents 5000 deaths)

Practical Mother and Child Health in Developing Countries

Book 1 Chapter 1 Mother and Child Health: Introduction

It is interesting to note that in many industrial societies of Western Europe the health problems were
very similar not so long ago and they have been finally controlled by the development of suitable
health programmes. Thus England and Wales experienced a reduction in the under-five mortality
rate from 74 per cent in 1730 to 31 per cent in 1830. The infant mortality rate in England and Wales
has fallen from 153 per thousand in 1900 to 19 per thousand in 1966. In France during the past 50
years, the infant mortality rate has dropped from 120 to 24 per thousand.
By comparison in the years 2000-2003 six causes accounted for 73% of the 10.6 million yearly
deaths in children younger than 5 years viz. pneumonia (19%), diarrhoea (18%), malaria (18%),
neonatal sepsis or pneumonia (10%), pre-term birth (10%), and asphyxia at birth (8%). (See Table
1.2). The four communicable disease categories accounted for more than half 54%.
Undernutrition is an underlying cause of 53% of all deaths in children younger than age 5 years. Of
all child deaths communicable disease killers are the main ones, and are the same in all WHO
regions with the exception of malaria. Some 94% of global deaths attributable to this disease occur
in the Africa region.
Table 1.2 Causes of deaths in children by WHO region
WHO
region

No.
(mill.)

Pneumonia
(%)

Diarrhoea
(%)

Malaria
(%)

Measles
(%)

HIV/AIDS
(%)

Neonatal*
(%)

Injuries
(%)

Other
(%)

AMR
AFR
EMR
SEAR
EUR
WPR

0.439
4.396
1.409
3.070
0.263
1.020

12
21
21
19
12
13

12
16
17
18
13
17

0
18
3
0
0
0

0
5
4
3
1
1

1
6
0
1
0
0

44
26
43
44
44
47

5
2
3
2
7
7

25
5
9
12
23
13

*Causes of neonatal deaths Tetanus (7%); diarrhoea (3%); sepsis or pneumonia (26%);
asphyxia (23%); congenital (8%); preterm (28%).
Not only are there high death rates due to preventable diseases but also there are high
rates of blindness, lameness and other forms of disability. Many of these could be prevented or
minimized with a Primary Health Care programme. A few countries have begun to measure the
effects of high morbidity rates on the national economy. This is measured by estimating the number
of days of healthy life lost due to sickness, disability or death caused by each sickness. The following are the ten major causes of sickness, disability and death found in the global study (see table
l .3).
Table 1.3 An estimated contribution of ten major risk factors to the burden of disease in year
2000
Per cent disability associated life years attributable to ten risk factors
Risk factor
Malnutrition
Poor water, sanitation,

Developing countries
18.0
7.6

Developed countries
0.1
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Practical Mother and Child Health in Developing Countries

Book 1 Chapter 1 Mother and Child Health: Introduction

hygiene
Unsafe sex
Tobacco
Alcohol
Occupation
Hypertension
Physical inactivity
Illicit drugs
Air pollution

3.7
1.4
2.7
2.5
0.9
4.0
0.4
0.4

2.1
12.1
9.6
4.6
4.7
0.8
1.9
1.5

One interesting feature of childhood mortality, as seen from the statistics of teaching hospitals, is
the presence of multiple pathology. Thus reports from Ibadan show that amongst children dying in
hospital, death could be ascribed to two causes in 35 per cent, three causes in 20 per cent and four
or more causes in 6 per cent of the cases.
All these diseases that cause heavy mortality in the children of tropical countries are global and not
necessarily confined to the tropics. Thus geography has very little to do with the large variety of
sicknesses seen in the children of the tropics; the causes lie in ignorance, lack of hygiene, lack of
sanitation and inadequate health facilities.

Figure 1.6 Causes of deaths in children

Maternal mortality, deaths in children and low life expectancy jointly provide the measures of ill-health in
developing countries. They not only set them apart from the more developed countries of the world but also
by themselves act as proxy measures of development. (See Table 1.4)

Practical Mother and Child Health in Developing Countries

Book 1 Chapter 1 Mother and Child Health: Introduction

Table 1.4 Measures of ill-health in developing countries

Infant
Mortality
(per 1000 live
births)
89
97 (16-118)
116 (57-140)
49 (23-77)
52 (48-92)
90 (61-147)

Life
Expectancy

Under-5
mortality

Maternal
mortality
ratio*

49
43 (33-76)
43 (39-58)
67 (54-75)
46 (33-51)
50 (33-60)

148
163 (15-223)
163 (15-223)
65 (23-131)
88 (75-158)
150 (88-321)

968 (24-1800)
968 (24-1800)
209 (84-220)
310 (230-550)
939 (540
2000)

53
34 (3 58)
41 (3-88)

67
72 (62 79)
67 (55-80)

71
40 (6 88)
55 (4-144)

53 (20 110)
237 (30-650)

68 (20-162)

63 (43-76)

94 (16-283)

581 (76-1900)

44 (6-83)

69 (59-81)

57 (9-112)

127 (5-570)

Latin America
and Caribbean

32

71

41

Caribbean
Central America
South America

35 (7-63)
30 (10-41)
32 (12-56)

67 (64-80)
72 (63-81)
70 (62-79)

58 (8-119)
38 (11-58)
40 (12-77)

189 (23-680)
145 (43-240)
176 (27-420)

Africa
Eastern Africa
Middle Africa
Northern Africa
Southern Africa
Western Africa

Asia
Eastern Asia
South-Eastern
Asia
South-Central
Asia
Western Asia

More
Developed
Regions
Less
Developed
Regions
Least
Developed
Regions

76

61

64

89

50

160

97

* Maternal Mortality ratio is the number of deaths of women per 100,000 live births and which result from conditions
related to pregnancy, delivery and related complications.
More Developed Regions (North America, Japan, Europe, Australia and New Zealand).
Less Developed Regions (all regions of Africa, Latin America and Caribbean, Asia (excluding Japan), and Melanesia,
Micronesia, and Polynesia)
Least Developed Regions (according to UN classification 67 countries with lowest GDP)

Practical Mother and Child Health in Developing Countries

Book 1 Chapter 1 Mother and Child Health: Introduction

10

Common health problems of mothers and children

During pregnancy, the main problems are anaemia, malnutrition and other forms of maternal
depletion syndromes. The average mother in these countries, during the child-bearing years, passes
through a series of cycles of pregnancy, prolonged lactation, and pregnancy again, without any rest
in between. All this time her diet is poor and supplies her with only marginal nutrition. During
pregnancy the mother has to supply the raw materials, mainly in the form of proteins, iron and
calcium, for the formation of the foetal tissues. During lactation, the mother has to supply all the
nutritional requirements of the baby in her breast milk. If her diet is poor, which is usually the case,
and if she does not get a period of rest between successive childbirths, her maternal stores will be
exhausted.
The problems of children in early infancy are mainly low birth-weight, anaemia and infections. All
of these can be prevented by proper antenatal care of mothers, and education in the care of children.
In pre-school children the main causes of ill health are malnutrition, respiratory infections, and
diarrhoeal diseases. Often these coexist, one perpetuating the other. The pre-school age mortality
rate in developing countries is several times higher than that in Europe or North America. Children
die, not because of any one severe disease, but due to the accumulated effect of several factors.
Thus the child of a poorly nourished mother begins life with a low birth-weight, passes through a
series of attacks of malaria, becomes anaemic and increasingly subjected to malnutrition, until it
takes only an attack of diarrhoea or an upper respiratory infection to deal the final blow. With health
education for the parents and regular supervision of the child from birth until about the age of five,
this high mortality rate can be reduced.
Planning for better health of mothers and children
The health of the mother and the newborn baby are closely linked. It is therefore important that the
same team of health workers that looks after the expectant mother should continue to look after the
infant after he is born. This may not be possible in urban areas where clinic attendances are high
and a large number of women must be catered for. Under such circumstances, a close liaison
between different teams of workers is necessary.
The health of mothers and children is closely related to the general health of the community. Public
health measures that bring about an improvement in general health, such as better sanitation and
water supply, will also produce improved maternal and child health and control of such
communicable diseases as tuberculosis.
From the above discussion it would appear that the health needs of the mother and the young child
need to be given priority in national health programmes and a suitable service should be evolved to
look after them. The service for maternal and child health should be thought of as a channel for
directing medical and health services to special groups and not a new subject or a specialty. It is a
service encompassing the preventive aspects of paediatric, obstetrics, nutrition, health education and
child development. In every country the maternal and child health service should be adapted to the
needs and resources of the community it serves; it has to be moulded to the local culture and traditions
and cannot be modelled on a set pattern copied from another country.

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Practical Mother and Child Health in Developing Countries

Book 1 Chapter 1 Mother and Child Health: Introduction

11

Experience in several countries has identified interventions of proven effectiveness for improving
health and survival chances of mothers and children. Many of these interventions are low cost and
affordable in countries with economic constraints. (See table 1.5)
Table 1.5 Effective Interventions
Preventive Interventions
Breastfeeding (Exclusive in the first 6 months of life and continued from 6 to 11 months with weaning)
Insecticide treated bed-nets
Complementary feeding with multimixes
Water, sanitation, hygiene
Zinc supplementation during diarrhoea and respiratory infection
Vitamin A
Antenatal steroids prophylactic against pre-term births
Tetanus toxoid
Nevirapine to prevent vertical transmission of HIV
Measles vaccine
Intermittent antimalarials in pregnancy

Treatment Interventions
Oral rehydration therapy
Antibiotics in lower respiratory infection
Antibiotics for sepsis
Antibiotics for dysentery
Zinc supplementation in diarrhoea
Vitamin A

It has been estimated that 5.5 million (57%) deaths could be prevented by achieving universal
coverage with interventions like the ones described and for which there is sufficient evidence.
In particular such interventions are urgently needed in the 42 countries responsible for 90 per cent
of child deaths in year 2000. A review of coverage in these 42 countries revealed that breastfeeding
of infants aged 6 to 11 months was the only intervention to reach nearly all children. Measles
vaccine was received by 66% children under the age of 5, and all other interventions had coverage
of less than 60 %. Among 22 countries in sub-Saharan Africa with endemic malaria, surveys carried
out between 1999 and 2000 revealed that a median less than 2% of children slept under an
insecticide treated net the previous night. (See fig.1.7). And yet these interventions happen in a
random and patchy manner rather than in a disciplined and concerted form especially in the 42
countries that account for 90% of the under-fives deaths. (See Fig. 1.11)

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Practical Mother and Child Health in Developing Countries

Book 1 Chapter 1 Mother and Child Health: Introduction

12

Figure 1.7 Coverage with proven interventions in 42 countries accounting for 90% of underfive deaths

For improving the health of mothers and children, a three-pronged approach is needed as follows:
1) Effective community based health care for screening and surveillance; good routine care for the
healthy; identification of those at high risk and their referral for more skilled care; and
promotion of better family health and nutrition. Such a system of care may operate through
health posts and outreach services or may be entirely run for small settlements by community
health workers. Core interventions for improving family and community practices are
summarised in table 1.6 below (See table 1.6)
Table 1.6 Core interventions at family and community level
Interventions
Counseling
on
feeding including:

Beneficiaries / target
groups

Indicators of success

child

Exclusive
breast Children under 2 years of
feeding up to 6 age
months

Breast feeding with

appropriate
weaning between 6
and 24 months

Adequate amount
of micronutrients

% infants under 6
months of age
exclusively
breastfed

% infants aged 6-9

months who are
receiving
breast
milk
and
complementary
food

12

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Book 1 Chapter 1 Mother and Child Health: Introduction

(vitamin A iron
zinc) through diet
and
supplementation as
necessary
Promote
insecticide Children under five years
impregnated bed nets in of age
malaria endemic areas

% children under
five who sleep
regularly
under
insecticide
impregnated
bed
nets.

Promote safe disposal of Caretakers and children

faeces and hand washing under five years of age.
after defecation and before
preparing
meals
and
feeding children

Access to safe
drinking water. %
of population who
use any of the
following sources:
piped water, public
tap, protected well
or spring bore well.

Access to sanitary
means of excreta
disposal:
%
population who use
toilet or pit latrine

Complete full course of Children under 2 years of

immunization for children age
before their first birthday
(BCG, triple, polio and
measles)

Immunization
coverage rates

% children under
12 months fully
immunized

Promote mental and social Children under five years

development
of age

Encourage
community
develop
groups
nurseries.

to
play
and

2) Adequate referral facilities at health centres and hospitals to provide backup for frontline workers,
and to take care of emergencies or complications. (see table 1.7)
Table 1.7 Core Interventions at the level of health facility
Intervention

Beneficiaries / target
groups
Provide adequate prenatal Pregnant women
care to pregnant women

Indicators of success
3) % of pregnant
women receiving
antenatal care
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Practical Mother and Child Health in Developing Countries

Book 1 Chapter 1 Mother and Child Health: Introduction

Provide adequate care to Children under the age of

sick children
five
Caretakers

14

4) Caretakers know at
least two signs for
seeking care
5) % children sick
with malaria who
receive appropriate
treatment
6) % children with
respiratory
infection
and
diarrhoea
who
receive appropriate
treatment

3) An efficient system of transportation for transferring emergencies to facilities where more

skilled care may be available. (see table 1.8)
Table 1.8 Core Interventions at Health System Level
Intervention
Ensure drug supplies for
treating major childhood
illnesses

Beneficiaries / target
groups
Health facilities

Develop case management

guidelines and standards
for major childhood
illnesses and maternal care
Train health workers

Pregnant women and

children under age of five

Streamline referral
pathways

Women with
complications of
pregnancy and labour
Children under age of five

Health workers at all

levels

Indicators of success
% health facilities
with all essential
equipment material
and drugs for
treating major
illnesses
Case management
guidelines made
available at all
health facilities
% mothers and children
correctly assessed and
treated
% complications of
pregnancy and/or
labour receiving
prompt referral
% severely ill
children receiving
prompt referral

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Practical Mother and Child Health in Developing Countries

Book 1 Chapter 1 Mother and Child Health: Introduction

15

Although the goals of maternal and child health care are in people's homes, in schools and in
clinics, the care is based in hospital wards or health facilities where adequate attention to
emergencies and sick individuals can be promptly given.
The basic activities in maternal and child health can be summarised under the following headings:
1) Screening of expectant mothers. Identification of those at risk or with abnormalities and
their referral for more expert care.
2) Assistance during delivery and puerperium.
3) Growth monitoring, regular health surveillance and immunisation of children. Identification of
high risk families and further care of such families.
4) Simple recording of health events in individual children, using a weight chart. Data
collection and evaluation.
5) Health education emphasising nutrition, child-rearing, immunisation and fertility
problems.
6) Providing information on community health problems to other agencies and workers in
the area and also to the community itself.
7) Counseling and assistance with family planning.
8) Distribution of simple medicines, food supplements and contraceptives.
9) The recognition and primary management of the most common diseases in
the area.
10) Participation in the control of the communicable diseases through immunisation, through
diagnosis and treatment of index cases as in tuberculosis, or through treatment of a
reservoir of disease as in mass de-worming.
11) Liaison with community development, agricultural extension, education and other similar
services in the area.
Maternal and child health services can reach out to the people through the following routes:
1) Hospital and home-visiting of problem cases, through:
a) Antenatal clinics.
b) Young child clinics.
c) Outpatient departments.
d) Children's wards.
e) Nutrition rehabilitation centres
2) Health centres and dispensaries, through:
a) Antenatal clinics.
b) Children's clinics.
c) Home-visiting.
3) Community projects, through:
a) Community centres.
b) Day-care centres.
c) Mobile clinics.
d) Schools.

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Practical Mother and Child Health in Developing Countries

Book 1 Chapter 1 Mother and Child Health: Introduction

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