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 Section 7 : Family Health
140 Maternal and Child Health A S Kushwaha 809
141 Risk Approach in MCH A S Kushwaha 811
142 Maternal Health Care AS Kushwaha 814
143 Care of Infants A S Kushwaha 826
144 Integrated Management of Neonatal and Childhood Illnesses (IMNCI) A S Kushwaha 835
145 Care of Under Five Children A S Kushwaha 848
146 School Health Services A S Kushwaha 853
147 Adolescent Health A S Kushwaha 856
148 Children’s Right to Health A S Kushwaha 865
149 Growth and Development of Children A S Kushwaha 869
150 Genetics and Public Health Amitava Datta 878
151 Preventive Health Care of the Elderly RajVir Bhalwar 887
152 Demography and Public Health Dashrath R. Basannar 891
153 Contraceptive Technology RajVir Bhalwar 895
 during childbirth, or after the baby has been born due to blood
140 Maternal and Child Health loss and infections. The 5,29,000 annual maternal deaths,
including 68,000 deaths attributable to unsafe abortion,
almost all of these are occurring in poor countries with only
A S Kushwaha
1% in rich countries. Each year 3.3 million babies are stillborn,
more than 4 million (neonatal deaths) are dying within 28
The health of women and children has always been an important days of coming into the world, and a further 6.6 million young
social goal of all societies. Over the years, maternal and child children die before their fifth birthday. Although an increasing
health has evolved through various stages of conceptual number of countries have succeeded in improving the health
approach, technological advances and social prioritization. and well-being of mothers, babies and children in recent
The realization that, improved maternal and child health is the years, in some countries the situation has actually worsened.
key to the ultimate objective of lifelong health in any society, Slow progress, stagnation and reversal are closely related
has led to renewed interest and global focus towards this very to poverty, to humanitarian crises, and, particularly in sub-
important social health issue. Saharan Africa, to the direct and indirect effects of HIV/AIDS.
Mother and Child: A Single Entity Over 300 million women in the world currently suffer from
Mother and child are often spoken of in one breath for a number of long-term or short-term illness brought about by pregnancy or
reasons. Health of the child and the mother are so closely linked childbirth. Programmes to tackle vaccine preventable diseases,
that each has the capacity to influence the other. The outcome malnutrition, diarrhoea, or respiratory infections still have a
of pregnancy in terms of a healthy newborn is dependent on large unfinished agenda.
the physical, physiological, mental and nutritional state of the India
mother during pregnancy. Some specific health interventions Health of Women : The country has a falling low sex ratio
jointly protect pregnant women and their babies e.g. tetanus of 933 female per thousand male. Early marriage in women
toxoid immunization and nutrition supplementation. At and universality of marriage are important social issues. The
childbirth, both mother and child are at risk for complications median age at first marriage among women is 17.2 years.
which can endanger their lives. The postpartum care of the Almost half (46%) of women age 18-29 years got married before
mother is inseparable from newborn care, immunization and the legal minimum age of 18. Among young women age 15-19,
family planning advice, and this provides not only operational 16 percent have already begun childbearing. Indians have poor
convenience but offers continuity of care as well. knowledge about temporary contraceptive methods and this
Important Sub Disciplines Related to MCH coupled with poor availability affects ‘delaying the first and
spacing the second child’ doctrine adversely. Among the married
There are a number of sub disciplines that have developed over
women, 13 percent have unmet need for family planning. Less
the years in the field of maternal and child health. It is in this
than half of women receive antenatal care during the first
endeavour that disciplines like social obstetrics, preventive
trimester of pregnancy, as is recommended. Three out of every
pediatrics, community obstetrics, family health and family
five births in India take place at home; only two in five births
medicine have originated. Various initiatives in child health
take place in a health facility. Less than half of births took
include essential newborn care, well baby clinics, under five
place with assistance from a health professional, and more
clinics, Child guidance clinics and school health services.
than one third were delivered by a Traditional Birth Attendant.
Why So Much Attention to This Issue? The remaining 16 percent were delivered by a relative or other
Firstly, together, mothers (women 15-45 years of age) and untrained person. A Disposable Delivery Kit (DDK) is being
children (under 15 years of age) constitute 70-80% of the used only in 20% of births taking place at home. Most women
population. They also belong to the most vulnerable section of receive no postnatal care at all. Only 37 percent of mothers
society in terms of death, disease, disability and discrimination. had a postnatal checkup within 2 days of birth. Every seven
Women and Children represent economically dependent and minutes an Indian woman dies from complications related to
least empowered section of the society. The falling sex ratio pregnancy and childbirth. The maternal mortality ratio in India
(from 972 in 1901 to 933 in 2001) is a grim reminder of the stands at 300 per 100,000 live births. (Table - 1).
social disadvantage faced by women in India(1). The issue Child Health : Infant mortality is 77 per 1,000 for teenage
also merits attention because of high morbidity and mortality mothers, compared with 50 for mothers age 20-29. Infant
faced by this group. Most of the deaths and illnesses in these mortality in rural areas is 50 percent higher than in urban areas.
groups are avoidable by cost effective interventions which are Perinatal mortality, which includes stillbirths and very early
available to tackle them. infant deaths (in the first week of life), is estimated at 49 deaths
Scenario of Maternal and Child Health per 1,000 pregnancies, that lasted 7 months or more. Less than
half (44%) of children 12-23 months are fully vaccinated against
Global Picture : Of the estimated 211 million pregnancies that
the six major childhood illnesses: tuberculosis, diphtheria,
occur each year, about 46 million end in induced abortion.
pertussis, tetanus, polio, and measles. Although breast feeding
Attending to all of the 136 million births every year is one of
is almost universal in India, only 46 percent of children under 6
the major challenges that is now faced by the world’s health
months are exclusively breastfed. Many infants are deprived of
systems. Globally, huge toll on account of maternal deaths
the highly nutritious first milk (colostrum) as only 55 percent
continues unabated. Often sudden, unpredicted deaths occur
are put to the breast within the first day of life. Almost half
during pregnancy itself (as a consequence of unsafe abortion),

• 809 •
of children under age five are stunted or too short for their risks are highest for both mother and child.
age. Anaemia is a major health problem in India, especially Place: Linking the delivery of essential services in a dynamic
among women and children. Among children between the ages primary-health-care system that integrates home, community,
of 6 and 59 months, about 70 percent are anaemic including outreach and facility-based care. The impetus for this focus is
three percent who suffer from severe anaemia. More than half the recognition that gaps in care are often most prevalent at
of women in India (55 percent) have anaemia with 17 percent the locations – the household and community – where care is
of these have moderate to severe anaemia. most required.
The continuum of care concept has emerged in recognition of the
Table - 1: Important Mortality indicators of Maternal and
fact that maternal, newborn and child deaths share a number of
Child Health (Source-NFHS 3)
similar and interrelated structural causes with undernutrition.
Indicator 1994 2000 2001 2002 2003 2004 2005 The continuum of care also reflects lessons learned from
IMR 74 68 65.9 64 60 58 58 evidence and experience in maternal, newborn and child
health during recent decades. In the past, safe motherhood and
NNMR 47.7 44 40.2 NA 37 37 37
child survival programmes often operated separately, leaving
PNMR 26 23 25.7 NA 23 21 22 disconnections in care that affected both mothers and newborns.
PMR 42.5 40 26.2 NA 33 35 37 It is now recognized that delivering specific interventions at
pivotal points in the continuum has multiple benefits. Linking
SBR 8.9 8 9.3 NA 9 10 9 interventions in packages can also increase their efficiency and
MMR 327 301 cost-effectiveness. The primary focus is on providing universal
coverage of essential interventions throughout the life cycle in
an integrated primary-health-care system.
IMR Infant Mortality rate
NNMR Neonatal Mortality rate
Road Ahead
The NRHM and RCH are aimed at meeting this challenge and
PNMR Post-Neonatal Mortality Rate
have set out their targets as envisaged under various policies
PMR Perinatal Mortality Rate and MDGs. (See Table - 2)
SBR Still Birth Rate
Table - 2 : The Road Ahead (National targets for MCH)
MMR Maternal Mortality Ratio
National
Challenges in MCH 10th Plan RCH -2 Population
MDGs (by
The look at statistics in Table - 1 gives a picture of many Indicator goals (2004- Policy
2015)
unfulfilled promises in the field of maternal and child health (2002-07) 09) 2000 (by
despite a family welfare programme running since 1950s. The 2010)
challenges include lack of universalisation of services, rural 35 per
urban differential, poor status of women in society and lack of Infant 45 per 30 per
1000
political will and acceptance of the issue as a social priority. The mortality 1000 live 1000 live -
live
main challenge to child survival no longer lies in determining rate births births
births
the proximate causes of or solutions to child mortality but
Under 5
in ensuring that the services and education required for Reduce
mortality - - -
these solutions reach the most marginalized countries and by 2/3rd
rate
communities.
150 per
Opportunities in MCH Maternal 200 per 1 100 per 1
1 lakh Reduce
A new paradigm in MCH - Continuum of Care : The continuum mortality lakh live lakh live
live by 3/4th
consists of a focus on two dimensions in the provision of ratio births births
births
packages of essential primary-health-care services:
Time: There is a need to ensure essential services for mothers References
and children during pregnancy, childbirth, the postpartum 1. National Family Health Survey NFHS - 3 India 2005-06, International
period, infancy and early childhood. The focus on this element Institute for Population Sciences, Mumbai, India. http://www.nfhsindia.org/
nfhs3.html
was engendered by the recognition that the birth period – before,
2. World Health Report 2005. Make Every Mother and Child count. WHO, 2005
during and after –is the time when mortality and morbidity

• 810 •
 Attributable Risk : This brings together three ideas - the
141 Risk Approach in MCH frequency of the unwanted outcome when risk factor is present,
frequency of the unwanted outcome when risk factor is absent,
frequency of the occurrence of risk factor in the community.
A S Kushwaha
It indicates what might be expected to happen to the overall
outcome in the community if the risk factor was removed.
Risk as a Proxy for Need
Risk Factors : Risk factor is defined as any ascertainable
In every society there are communities, families and individuals characteristic or circumstance of a person or group of persons
whose chances of future illness, accident and untimely death that is known to be associated with an abnormal risk of
are greater than others; they are said to be vulnerable owing to developing or being especially adversely affected by a morbid
peculiar set of characteristics they share. These characteristics process. Risk factor is one link in a chain of association leading
could be biological, genetic, environmental, psychosocial or to an illness or an indicator of a link.
economic. Similarly there are others who have a chance to enjoy
Risk factors can therefore be causes or signals but they are
better health. Thus as an example we can see that pregnant,
observable and identifiable. Risk factor could be related to
poor, very young children and elderly are vulnerable and young
individual, family, community or the environment. Examples
and affluent are not. Risk however has come to be associated
include - first pregnancy, high parity, teenage pregnancies,
with the vulnerability to disease or illness or death. A pregnant
malnutrition, rural area, birth attendance etc.
woman with high blood pressure is at risk of complications
like eclampsia and this measured risk to her and the child is an The significance of risk factors from the point of application
expression of her need for medical help and intervention. The and utility in practice of preventive community medicine can
risk strategy utilizes these risk estimates as guide for action, be judged by -
resource allocation, coverage and referral care. The hypothesis, (a) Degree of association with the outcome.
on which risk strategy rests, therefore, is that more accurately (b) Frequency of the risk factor in the community.
the risk is measured, the better is the understanding of the Combination of Risk Factors
need. The combination of two or more risk factors increases the
The risk approach is a managerial tool based on the strategy probability of the outcome. For example in a pregnancy, the
for efficient utilization of scarce resources with more care for hypertensive disease and poor antenatal care are independent
those in need and proportionate to the need. risk factors for perinatal mortality but when both factors are
Tools of the Risk Approach present, the probability of perinatal mortality is much higher
than expected. This is because the risk factors may have an
The characters shared by a cohort making them vulnerable
additive or multiplicative effect.
are referred to as risk factors. The measure of association
with the outcome is known as the relative risk and estimation Risk Factors and Causes
of the adverse outcome if these risk factors are present and Not all significant associations between the risk factor and
calculation of effect if these risk factors are removed have made the outcome are part of a chain of causality. Associations are
our decisions in public health prioritization. Risks, predictions usually described as ‘causal’ if they can be seen to be directly
and possible effects are therefore the tools of the risk approach. related to pathological processes, even if the pathways are not
By quantifying the risks to the health of a population group fully understood. e.g. Maternal malnutrition and low birth
and their associated risk factors, it focuses attention on the weight, placenta praevia and foetal death from anoxia, rubella
need for prevention. in first trimester and congenital malformation. The important
attributes in such association are ‘dose response relationship,
Risk Approach Applied to MCH specificity, consistency of association, time relationship and
The mothers and children are most susceptible to good or biological plausibility. The complex relationship between
harmful influences that will permanently affect their health. risk factor and outcome can be explained by an example of
The harm can be inflicted or the good can be promoted in a very gastroenteritis in a child belonging to a poor family where
short time. The preventive and promotive elements of primary the complex of poverty may include contributions to risk from
health care will have greatest yield if applied by using risk large family size, crowding, early weaning, poor nutrition with
approach in MCH. infection of infant and neglect of early Diarrhoea for a variety
Definitions of reasons. Thus it is more than clear that family poverty is a
risk factor for gastroenteritis and death from gastroenteritis.
Risk : It implies that the probability of adverse consequences
The advantage of risk approach is the attention being given to
is increased by the presence of one or more characteristics
all causes regardless of their medical, intersectoral, economic,
or factors. It is a measure of statistical chance of a future
political or social origins.
occurrence.
Relative Risk : It measures the strength of the association Methodology in Risk Approach
between risk factor and the outcome e.g. RR of an outcome due The risk approach involves, first, decisions as to priority
to a risk factor is 1.3, means a 30% excess risk in those with ‘targets’ or unwanted outcomes, measurement of association
the risk factor. between risk factors and the outcome, and then intervention

• 811 •
planned. The risk approach has to be studied by research and To give an example, if it was the Perinatal and maternal
then only applied over a wide population. mortality (Outcome) then the identification of risk factors
Outcome, Risk and Measurement : The risk approach seeks will involve screening at various levels for different risk
to use information about risk to prevent a variety of adverse factors depending upon the complexity of identification and
outcome (illness, injury and death) through the application of infrastructure available and training of the health worker.
a strategy at many levels of care. These decisions to refer or to keep are based on some form of
Outcomes : This is the first information required. Collect risk scoring system. For example, while doing above exercise,
details of morbidity and mortality rates which are our targets suppose there is a risk scoring from 0 - 5, the scheme would
or priorities (prevalence and incidence, trends, distribution in look like (See Table - 1).
geographical area and different groups).
Table - 1 : Risk Scoring System
Risk Factors : Collect information on the following :
(a) Risk factors for each unwanted outcome. Health Func - Exam Keeps Refers Returns
(b) Risk factors or combinations of risk factors for each group level tionary - ines
of unwanted outcome. I TBA 0, 1, 2, 0 1, 2, 3, -
(c) For all risk factors - 3, 4, 5 4, 5
(i) Prevalence and incidence and trends in the
II ANM 1, 2, 3, 2 3, 4, 5 1
population
4, 5
(ii) Relative risk of unwanted outcomes associated with
each risk factors or combinations III Senior 3, 4, 5 3 4, 5 2
(iii) Attributable risk associated with each risk factors Nurse
(iv) Predictive power of each risk factor IV Doctor 4, 5 4 5 3
(v) The ease, accuracy and acceptability of screening for the
V Specialist 5 5 - 4
presence of risk factor in communities and individuals.
Priorities among Outcomes : This will depend upon many Issue of False Positives and False Negatives
variables like -
When screening populations, some of the difficulties faced
(a) Community priority and preference
are related to the issues of false positive and false negatives.
(b) Prevalence or frequency of occurrence
The value of risk factors at predicting outcomes is gauged by
(c) The seriousness of the problem (fatality rate)
proportion of the true association. There are examples where
(d) Degree of preventability
the cases of gastroenteritis deaths may be seen in breastfed
(e) Rising frequency or upward trend of the problem (emerging
infants (though less likely) while some of the bottle fed infants
issues)
may not suffer from gastroenteritis (less likely). The issue of
Steps
false positives and false negatives may make decisions for
1. Identifying the risk factors and the populations and the interpreting and introducing screening tests difficult.
individuals at risk
2. Selection of risk factors Risk Scoring
(i) Optimum grouping Scores must accurately reflect the risk to the mother and
(ii) Usefulness in terms of proposed intervention children which in itself is a proxy for the need for care. Scoring
(iii) Strength of association / cause - effect relationship attempts to provide simple, easy to use index of the urgency,
(iv) Ease of modification (intervention) seriousness and complexity, of the future threat to health. The
(v) Ease and accuracy of identification (test) risk scores are a good managerial tool. Sources of scores are -
3. Who should do the screening? (Fig - 1) (a) Ad hoc - e.g. tall or short, poor or not poor, well fed or
malnourished
Fig. - 1 (b) Points or score based on experience - For example, while
TBA approaches all scoring for poor outcome of pregnancy, 3 points for poor
pregnant mothers obstetric history, 3 for high parity, 2 for maternal age, 1 for
birth interval, family income, poor education etc.
TBA examines (c) Absolute risk
(d) Relative risk
ANM examines (e) Attributable risk
Most scoring systems use the relative risk.
Senior Nurse/ Doctor
examines Trade off : While deciding the cut off for continuous risk factor
there is a compromise between yield and resources by trade
Hospital doctor
off between false positive and false negatives. This decision
examines
is arrived at by weighing how many more false positive can
Specialist sees only be afforded by the community for the desired reduction in the
very high risk mothers
false negatives.
Referred Kept Returned

• 812 •
Basic information needed for planning the use of Risk negligent or dangerous work pattern and numerous intercurrent
Approach illnesses. Some can be modified without delay, some will have
1. Age and sex distribution and geographical distribution by to wait till next pregnancy while yet others will only be changed
community and household in the next generation. Modification of the community risk
2. Mortality by age, sex and cause factors is probably the most important potential achievement
3. Local cultural factors, occupations, religion and attitude to of the risk approach.
health and disease Selecting Target Health Problems : Among many health
4. Services likely to have most impact from risk approach problems of mothers and children, it is usually a simple matter
5. Information on environmental risk factors to choose the most important. This choice is often coloured
6. Local community organizations, groups by opinions. Most important health problems are not always
7. Local health care services including personnel and the best targets for prevention. A method of rating scale which
infrastructure balances the factors like prevalence, seriousness, preventability,
8. Present way to deal with the MCH problems trends in time and local concern (Table - 2) is shown as an
9. Information about traditional systems of medicine and example.
their acceptance
Intervention at different levels of care : This is used to define Table - 2 : Selecting a health problem by Rating / Scoring
the main point of impact of an intervention within the health
Health Rating
care system. Risk approach can be applied at all levels from self Criterion Max rating
Problem accorded
and home to intersectoral policy.
Uses of the Risk Approach Extent 10 3
1. Self & Family Seriousness 10 10
(a) Improved ability to recognize health priorities and health Maternal
Preventability 10 8
lifestyle and behavior. mortality
(b) Informed surveillance of self and family. Local concern 10 10
(c) Earlier self and family referral. Time trend 10 2
2. Local community - village groups, self help groups, Extent 10 8
women’s group.
3. Application within the health care system - resource Seriousness 10 10
Neonatal
allocation. Preventability 10 10
tetanus
4. Increasing coverage - e.g. Universal immunization, Local concern 10 4
essential maternal and newborn care.
5. Improved referral - better facilities, technology and skills. Time trend 10 5
6. Regional and National level - for defining and planning Extent 10 3
priorities, capacity and staffing, design referral chain, Seriousness 10 10
resource allocation and evaluation. Childhood
7. Intersectoral collaboration is the key to planning, designing Preventability 10 5
RTAs
and executing any health intervention. Local concern 10 7
Selecting Interventions : Steps involved are - Time trend 10 8
(a) Potential for change in health care - managerial, avoid
authoritarian approach, no conflict with local, regional The relative importance of each criterion is also given its
and national interest, local values and religious customs weight e.g. say on a five point scale, if we rate, extent and
(MTP, Contraception). seriousness are given 5/5, preventability and local concern is
(b) Criteria for selection - importance, feasibility, given 3/5, time trend is given 2 out of 5. A simple matrix will
acceptability. set the health problems in the order of priority as seen in the
(c) Local priorities for action - Maternal mortality, Infant Table - 3.
deaths, Perinatal mortality. Local priorities to be specific The order of priority in the above example is: first neonatal
and well defined for application of risk approach. tetanus, second maternal mortality and third childhood RTAs.
(d) Local resources - people (trained and trainable), institutions,
facilities and technology, managerial skills, health Lessons from the Risk Approach -
information systems, funds. Most important resources are 1. Application to the whole field of Primary Health care is
time, commitment, enthusiasm and cooperation. limited due to shortage of support from evaluative research.
(e) National priorities Need to develop health system research.
(f) Decision pathway 2. Impediments and Barriers are related to Ethical (No
Modifying Risk Factors : Individual risk factors capable of research without service), Sociological (not in sync with
modification are exemplified by some taboos and cultural local culture), Problems of human motivation, Political,
practices (difficult to change), malnutrition, dwarfing, managerial and technical problems and Shortage of skilled
inadequate family planning services, lack of concern for human resources.
environmental hazards, unsatisfactory personal hygiene, The risk approach in MCH is a very useful tool and can help

• 813 •
in maximizing the output from the limited resources available of the risk approach. The preventive and promotive elements
especially in the developing countries. The risk approach helps of primary health care will have greatest yield if applied by
to ease the pressure on the limited beds and facilities at the using risk approach in MCH. Risk factors could be related to
hospital level and also saving the expert human resources and the individual, family, community and environment and their
sophisticated equipment for those who need it most. The risk significance can be judged by their frequency and the degree
approach also helps in developing health auxiliaries at the of their association with the outcome. The risk approach
periphery providing the basic care in MCH close to home to the involves prioritizing targets, measuring associations and the
clientele within acceptable socio - cultural milieu. The policies interventions to be applied. Info about the risk factors can be
and principles of care under NRHM using ASHA are an example obtained through prevalence, incidence, trends, relative risk of
of this approach. unwanted outcomes and attributable risk associated with each
risk factors and predictive power of risk factors. Prioritization
Table - 3 : Selecting a problem by rating/scoring will depend upon community priority, prevalence, fatality rates,
degree of preventability and rising trend. Risk scoring (most
Criteria and Relative weightage
of them use relative risk) if used must reflect the risk to the
mother and the child.
Health problem

Preventability

Local concern

Increased coverage, improved referral, risk factor modification,

Seriousness

Total score
Time trend
local, national and regional reorganization and training are the
(weight 5)

(weight 5)

(weight 3)

(weight 3)

(weight 2)
some of the uses of risk approach. The risk approach in MCH
Extent

is a very useful tool maximizing the output with the limited

number of tools available in addition to developing the health
auxiliaries at the periphery.
Maternal
3x5 10x5 8x3 10x3 2x2 123
mortality Study Exercises
Neonatal Long Question : Risk approach in MCH
8x5 10x5 10x3 4x3 5x2 142
tetanus Short Notes : (1) Basic information needed for planning the
Childhood use of risk approach (2) Risk scoring (3) Uses of risk approach
3x5 10x5 5x3 7x3 8x2 117
RTAs within and outside the health care system (4) Steps for selecting
interventions.
Summary References
The risk strategy utilizes the risk estimates as guide for action, 1. Backett E M, Davies A M, Petros - Barvazian A. Public Health Papers No 76:
The Risk approach in health care, with special reference to maternal and
resource allocation, coverage, referral and care. Therefore child health, including family planning, WHO Geneva, 1984
the more accurately the risk is measured the better is the 2. Edwards L E et al. A simplified antepartum risk scoring system. Obstetrics
understanding of the need for efficient utilization of scarce and Gynaecology, 54:237 - 240 (1979)
resources with more care for those in need and proportionate 3. Sogbanmu M. Perinatal mortality and maternal mortality in General hospital,
Ondo, Nigeria: Use of high risk pregnancy predictive scoring index. Nigerian
to the need. Risk, predictions and possible effects are the tools Medical Journal, 9: 123 - 127 (1979)

Definitions
142 Maternal Health Care Maternal Death : Maternal death is defined as death of a
woman, while pregnant or within 42 days of termination of
AS Kushwaha pregnancy, irrespective of the duration and site of pregnancy,
from any cause related to or aggravated by pregnancy or its
All mothers and newborns, not just those considered to be management but not from accidental or incidental causes.
at particular risk of developing complications, need skilled (ICD-10)
maternal and neonatal care. Maternal health care includes Direct Obstetric Deaths : The deaths resulting from obstetric
Antenatal, Intranatal care and Postnatal care, Quality intranatal complications of the pregnant state (pregnancy, labour and
care is critical to achieve the aim of a healthy mother and a the puerperium), from interventions, omissions, or incorrect
healthy baby at the end of a pregnancy. This particular period treatment, or from a chain of events resulting from any of the
(perinatal) though constitutes, only a small fraction in terms above are called direct obstetric deaths.
of its share (0.5 %) in the maternity cycle, but is probably, the Indirect Obstetric Deaths : Those resulting from previous
most crucial. existing disease or disease that developed during pregnancy and

• 814 •
that was not due to direct obstetric causes but was aggravated to have a healthy mother and a healthy child at the end of
by the physiological effects of pregnancy. pregnancy. Antenatal care includes visit to antenatal clinic,
Late Maternal Death : Late maternal death is death of a examination, investigations, immunization, supplements
woman from direct or indirect obstetric causes, more than 42 (Iron, Folic acid, Calcium, Nutritional) and interventions as
days but less than one year, after termination of pregnancy. required. This is a comprehensive approach to medical care and
psychosocial support of the family that ideally begins prior to
Pregnancy Related Death : To facilitate the identification
conception and ends with the onset of labour. Preconception care
of maternal death in circumstances in which cause of death
refers to physical and mental preparation of both parents for
attribution is inadequate, ICD-10 introduced a new category,
pregnancy and childbearing in order to improve the pregnancy
that of “pregnancy-related death” which is defined as : the death
outcome (Refer Box - 1). Antenatal (Prenatal) care formally
of a woman while pregnant or within 42 days of termination of
begins with the diagnosis of pregnancy and includes ongoing
pregnancy, irrespective of the cause of death.
assessment of risk, education and counselling and identifying
Skilled Birth Attendant : Skilled Birth Attendants are people and managing problems if they arise (Box - 2).
with midwifery skills (e.g. doctors, midwives, nurses) who have
been trained to proficiency in the skills necessary to manage a Box - 1 : Indications for Preconception Care
normal delivery and diagnose and refer obstetric complications.
This includes capacity to initiate the management of Advanced maternal (>35 years) or paternal (>55 years)age
complications and obstetric emergencies, including life-saving History of neural tube defects in family or previous
measures where needed. Ideally skilled attendants live in, and pregnancy
are part of the community they serve. Congenital heart disease, hemophilia, thalassemia, sickle
Measurement of Maternal Mortality cell disease, Tay-sach’s disease, cystic fibrosis, Huntington
There are three main measures of maternal mortality- the chorea, muscular dystrophy, Down’s syndrome.
maternal mortality ratio, the maternal mortality rate and the Maternal metabolic disorders
lifetime risk of maternal death.
Recurrent pregnancy loss (>3)
Maternal Mortality Ratio : This represents the risk associated
Use of alcohol, recreational drugs or medications
with each pregnancy, i.e. the obstetric risk. It is calculated as
the number of maternal deaths during a given year per 100,000 Environmental or occupational exposures
live births during the same period. This is usually referred to as
rate though it is a ratio. Box - 2 : Objectives of Antenatal Care
The appropriate denominator for the Maternal Mortality Ratio
To promote, protect and maintain health of the mother
would be the total number of pregnancies (live births, foetal
deaths or stillbirths, induced and spontaneous abortions, To detect ‘at risk’ cases and provide necessary care
ectopic and molar pregnancies). However, this figure is To provide advise on self care during pregnancy
seldom available and thus number of live births is used as the
To educate women on warning signals, child care, family
denominator. In countries where maternal mortality is high
planning
denominator used is per 1000 live births but as this indicator
is reduced with better services, the denominator used is per To prepare the woman for labour and lactation
1,00,000 live births to avoid figure in decimals. To allay anxiety associated with pregnancy and childbirth
Maternal Mortality Rate: It measures both the obstetric risk To provide early diagnosis and treatment of any medical
and the frequency with which women are exposed to this risk. condition/ complication of pregnancy
It is calculated as the number of maternal deaths in a given
period per 100,000 women of reproductive age (usually 15- To plan for “Birth” and emergencies / complications (where,
49 years). From the year 2000, the SRS (Sample Registration how, by whom, transport, blood)
System) has introduced this method of verbal autopsy called To provide care to any child accompanying the mother
RHIME (Representative, Re-sampled, Routine Household
Interview of Mortality with Medical Evaluation). Frequency : Under optimal conditions a women should
Lifetime Risk of Maternal Death undergo regular antenatal health check once a month during
first seven months, twice a month for 8th month and every
This parameter takes into account both the probability of
week thereafter till delivery. However, a minimum of four visits
becoming pregnant and the probability of dying as a result of
are essential.
the pregnancy cumulated across a woman’s reproductive years.
Lifetime risk can be estimated by multiplying the maternal Essential Antenatal Care : Under CSSM program three antenatal
mortality rate by the length of the reproductive period (around visits have been recommended as minimum acceptable level
35 years). This is also approximated by the product of the Total of antenatal care. Early registration by 12-16 weeks followed
Fertility Rate and the Maternal Mortality Ratio. by visits at 20, 32 and 36 weeks is recommended during any
pregnancy. At least one home visit by health worker must be
Antenatal Care made. Essential Antenatal Care also includes immunization
The care of women during pregnancy is called antenatal care. with tetanus toxoid and Iron Folic Acid supplements for 100
This begins soon after conception. The ultimate objective is days. Deworming with mebendazole in areas endemic for hook

• 815 •
worm may be provided during 2nd/3rd trimester. Under RCH a appear -
minimum of three visits are to be made. (a) Bleeding PV at any point ( Antepartum haemorrhage)
History Taking and Examination : During history taking (b) Excessive vomiting ( Hyperemesis gravidarum)
important points to be covered are detailed medical, (c) Hypertension, proteinuria
psychosocial and immunization history followed by careful (d) Severe anaemia
physical examination and certain relevant laboratory tests. (e) Abnormal weight gain
Physical examination should include measurement of height, (f) Multiple pregnancy, hydramnios, oligohydramnios
weight, pelvimetry (not very important). Important laboratory (g) Abnormal presentation in 9th month
tests include hemoglobin, urinalysis, PAP smear, VDRL and any (h) Preterm Labour, PROM
other test as warranted by the concerned physician. There is (i) Pre-eclampsia, eclampsia
an opportunity for health promotion like cessation of tobacco, Health Education
alcohol, manage pre-existing medical disorders, appropriate This is one of the most important and often neglected functions
immunization and pregnancy planning. of antenatal care. This is also called prenatal advice. The
First Visit : The patient is registered and antenatal card is communication between the mother and the service provider
initiated. First visit should be made at the earliest possible should be free and encompass the issues concerning not only
after pregnancy is suspected, ideally at 8 weeks of gestation but pregnancy but should spillover to childbirth and childcare.
not later than 12-16 weeks. This is important for determining The family planning issues like spacing and sterilization are
accurate EDD, evaluation of risk and to provide essential better received at this time. Important issues that need to be
patient education. The functions of this visit are- deliberated are given below.
(a) Confirmation of pregnancy (a) Diet & Rest
(b) Screening for high risk pregnancy (b) Personal Hygiene and Habits
(c) Baseline investigations (c) Sexual intercourse
(d) Initiation of Iron and Folic Acid supplementation (d) Drugs
(e) Immunization with Tetanus toxoid (if visit in 2nd (e) Exercise
trimester) (f) Travel
(f) Education of the mother on pregnancy and childbirth (g ) Care of Breasts
Identification of “High Risk” Pregnancies (h) Weight Gain
Warning signs : Besides education on common symptoms
The identification of high risk pregnancies involves meticulous
and their management, the woman should be educated on
history taking, careful examination and relevant investigations.
warning signs during pregnancy which should not be ignored.
The identification of these high risk pregnancies should follow
She should report to health facility in case she has any of the
needful referral and care. History should cover all aspects as
warning signs. The warning signs are-
outlined for preconception care. The ‘at risk’ pregnancies can
be identified as under- (i) Swelling of feet
(ii) Convulsions/ unconsciousness
Maternal Factors
(iii) Severe headache
(i) Age- <18 years or > 35 years (especially in primigravida) (iv) Blurring of vision
(ii) Multiparity (> 4) (v) Bleeding or discharge per vaginum
(iii) Short stature ( < 140 cms ) (vi) Severe abdominal pain
(iv) Weight < 40 Kg / weight gain < 5 Kg (vii) Other unusual symptom
(v) Rh negative
Pregnancy & HIV Infection
Bad Obstetric History
(i) Recurrent abortions ( 2 x1st trimester or 1 mid-trimester) This situation is likely to be encountered in states where HIV
(ii) Intrauterine death or intrapartum death/ stillbirth prevalence amongst antenatal cases is high. This will require
(iii) Prolonged labour, birth asphyxia , early neonatal death special handling. The urgency of preventing mother-to-child
(iv) Previous caesarean section / scar dehiscence transmission (PMTCT) of HIV is clear. Without treatment, half
(v) Postpartum haemorrhage, manual removal of placenta of the infants born with the virus will die before age two.
(vi) Baby which is LBW, SFD or large for date, congenitally Significant reductions in mother-to-child transmission, however,
malformed can occur through implementation of basic but critical actions,
(vii) Malpresentation, instrumental delivery, ectopic pregnancy such as identifying HIV-infected pregnant women by offering
(viii) Twins, hydramnios, pre-eclampsia routine HIV testing, enrolling them in PMTCT programmes,
Medical Disorders ensuring that health systems are fully able to deliver effective
antiretroviral regimens both for prophylaxis and for treatment,
(i) Cardiac (RHD, CHD, Valve defects), Renal, Endocrine
and supporting women in adhering to optimal and safe
(Thyroid) or Gastrointestinal disease.
infant feeding. The counselling of women early in pregnancy
(ii) Infections - TB, Leprosy, Malaria etc.
on risk of transmission to the baby and testing of spouse is
(iii) Hypertension, Diabetes, IHD and Seizures
mandatory. AZT 300 mg every 12 hours is given from 36 weeks
(iv) Anaemia
of pregnancy till onset of labour and thereafter 300mg every 3
Besides the above, the pregnancy at any stage can be classified hours. Alternatively, Nevirapine 200 mg single dose as early
as high risk if any of the following conditions/ complications

• 816 •
as possible in labour and 50 mg in oral solution form to the for vehicle, money and blood can be difficult to make if not
newborn within 72 hours is recommended to prevent mother already planned and can be crucial for the life of both mother
to child transmission. After delivery, this also helps to make and child. Institutional delivery should be encouraged.
required adaptations in infant feeding. Replacement feeding Institutional delivery should be advocated as it is the right of
using principles of AFASS (acceptable, feasible, affordable, safe every pregnant woman.
and sustainable) is a viable solution to prevent transmission of
infection through breast feeding. Intranatal Care and Postnatal Care
Planning for Birth (Birth Plan) Objectives of Intranatal Care - (AMC-N)
1. Thorough Asepsis (“The Five Cleans” - clean hands,
This is an important function of the prenatal care. The planning
surface, blade, cord, tie)
for birth and emergencies is very important as it can take care
2. Minimum injury to mother and child
of many unforeseen complications which may endanger life of
3. To deal with any Complications during labour
both mother and the child and may arise at any point of time
4. Care of the Newborn
without any prior warning in an otherwise normal pregnancy.
Plans made early for emergencies during pregnancy and labour The Postpartum Care
will result in favourable outcomes. The birth plan helps to The Postpartum Care is aimed at achieving a Puerperium which
tide over the uncertain and sudden nature of complications of is free of any complications and to ensure a healthy newborn.
labour. The delivery will take place at hospital or home must be (Box - 4)
decided (See Box - 3).
Box - 4 : Objectives of Postpartum care
Box - 3 : Institutional delivery is a must if there is- 1. Restoration of mother to optimum health
Mild pre-eclampsia 2. To prevent complications of puerperium
PPH in the previous pregnancy 3. Provide basic postpartum care & services to mother and
More than 5 previous births or a primi child
Previous assisted delivery 4. Motivate, educate and provide family planning services
Maternal age less than 16 years 5. To check adequacy of breast feeding
H/o third-degree tear in the previous pregnancy
The Postpartum Visits : The first 48 hours following delivery
Severe anaemia are the most important. The next most critical period is the first
Severe pre-eclampsia/eclampsia week following delivery. The mother is asked to pay another
visit on day 3rd and day 7th, or the ANM in charge of that
APH
area should pay a home visit during this period. The second
Transverse foetal lie or any other Malpresentation postpartum visit should be planned within 7-10 days after
Caesarean section in the previous pregnancy delivery. A visit at 6 weeks is mandatory to see that involution
of uterus is complete. Further visits can be once a month
Multiple pregnancies
for 6 month and thereafter every 2-3 months till the end of
Premature or pre-labour rupture of membranes (PROM) one year. Efforts to organize 3 - 6 visits must be made. If the
Medical illnesses such as diabetes mellitus, heart disease, woman misses her postpartum visits, she should be informed
asthma, etc. regarding the danger signs which if appear she should report
back (Box - 5).
In case of delivery at home what arrangements are there to Complications of the Puerperium : The postpartum period
overcome any unanticipated complication? The arrangement is often neglected after having a successful parturition. Sadly,

Box - 5 : Danger Signs in Puerperium

Advise the woman and her family to go to an FRU Advise the woman that she should visit
immediately, day or night, WITHOUT WAITING the PHC as soon as possible, if . . .
(i) Excessive vaginal bleeding, i.e. soaking more than 2 (i) Fever
or 3 pads in 20-30 minutes after delivery, or bleeding (ii) Abdominal pain
increases rather than decreases after the delivery
(iii) The woman feels ill
(ii) Convulsions (iv) Swollen, red or tender breasts, or sore nipples
(iii) Fast or difficult breathing (v) Dribbling of urine or painful micturition
(iv) Fever and weakness; inability to get out of bed (vi) Pain in the perineum or pus draining from the perineal
area
(v) Severe abdominal pain (vii) Foul-smelling lochia

• 817 •
neglected postnatal period can be the cause of significant Breakdowns of access to skilled care due to war, strife and HIV
mortality in mother and the newborn. The infections and may rapidly result in an increase of unfavourable outcomes,
haemorrhage are two serious dangers of Puerperium. Besides as in Malawi or Iraq. Malawi is one country that experienced a
these UTIs, thrombophlebitis and psychiatric disorders are also significant reversal in maternal mortality: from 752 maternal
seen (Box - 6). deaths per 100,000 live births in 1992 to 1120 in 2000 due
to rise in HIV prevalence. Fewer mothers gave birth in health
Box - 6 : Common Complications of the Puerperium facilities: the proportion dropped from 55% to 43% between
2000 and 2001. The quality of care within health facilities
1. Puerperal sepsis
deteriorated in Iraq as sanctions during the 1990s severely
2. Urinary tract infections disrupted previously well-functioning health care services, and
3. Breast infections maternal mortality ratios increased from 50 per 100,000 in
1989 to 117 per 100,000 in 1997 (12).
4. Venous thrombosis
Scenario in India
5. Pulmonary thromboembolism
Every seven minutes an Indian woman dies from complications
6. Puerperal haemorrhage related to pregnancy and childbirth. The maternal mortality
7. Incontinence of urine ratio in India stands at 300 per 100,000 live births. It has
8. Psychiatric disorders some high performing states like Kerala with MMR of 110 and
poorly doing states like Uttar Pradesh with MMR of 517 (13).
Maternal Mortality The highlight is that most of the states recording unfavourable
maternal mortality rates are the ones with the highest number
Global Burden of birth rates and huge population bases with poor health
Maternal mortality is currently estimated at 5,29,000 deaths infrastructure. There are a number of reasons India has such
per year, a global ratio of 400 maternal deaths per 100,000 a high maternal mortality ratio. Marriage and childbirth at an
live births (1). There are immense variations in maternal early age, lack of adequate health care facilities, inadequate
death rates in different parts of the world (See Table - 1). Only nutrition and absence of skilled personnel, all contribute to
a small fraction (1%) of these deaths occurs in the developed pregnancies proving fatal. The common causes of maternal
world. Maternal mortality ratios range from as high as 830 per mortality in India are anaemia, haemorrhage, sepsis, obstructed
100,000 births in some African countries to as low as 24 per labour, abortion and toxaemia. Maternal morbidities are the
100,000 births in European countries. Of the 20 countries with anaemias, chronic malnutrition, pelvic inflammations, liver
the highest maternal mortality ratios, 19 are in sub-Saharan and kidney diseases. In addition, the pathological processes
Africa. In sub-Saharan Africa, the lifetime risk of maternal of some preexisting diseases, such as chronic heart diseases,
death is 1 in 16, (See Table 1) compared with 1 in 2800 in hypertension, kidney diseases and pulmonary tuberculosis are
rich countries (2). Rural populations suffer higher mortality aggravated by pregnancy and childbirth.
than urban dwellers, rates can vary widely by ethnicity or by
‘Delay’ Model Leading to Maternal Death
socio-economic status, and remote areas bear a heavy burden
of deaths. Such deaths often occur suddenly and unpredictably. The maternal deaths can be explained by this model of delay
Between 11% and 17% of maternal deaths happen during which is due to:
childbirth itself and between 50% and 71% in the postpartum (a) Delay in seeking care
period (3-7). The fact that a high level of risk is concentrated (b) Delay in transport to appropriate health facility
during childbirth itself, and that many postpartum deaths are (c) Delay in provision of adequate care
also a result of what happened during birth, focuses attention Causes of Maternal Mortality
on the hours and sometimes days that are spent in labour and Maternal deaths result from a wide range of indirect and direct
giving birth. The postpartum period - despite its heavy toll of causes (See Fig. 1 & 2). Maternal deaths due to indirect causes
deaths - is often neglected. Within this period, the first week represent 20% of the global total. They are caused by diseases
is the most prone to risk. About 45% of postpartum maternal (pre-existing or concurrent) that are not complications of
deaths occur during the first 24 hours, and more than two pregnancy, but complicate pregnancy or are aggravated by it.
thirds during the first week (3). These include malaria, anaemia, HIV/AIDS and cardiovascular
disease. Their role in maternal mortality varies from country
Table - 1 : Life Time Risk of a Woman to country, according to the epidemiological context and the
health system’s effectiveness in responding.
Losing a Of dying due to
Continents The lion’s share of maternal deaths is attributable to direct
Neonate Maternal cause
causes. Direct maternal deaths follow complications of
Africa 1 in 5 1 in 16 pregnancy & childbirth or are caused by any interventions,
Asia 1 in 11 1 in 132 omissions, incorrect treatment or events that result from these
complications, including complications from unsafe abortion.
Latin America 1 in 21 1 in 188
The four major direct causes of maternal loss are-
Developed countries 1 in 125 1 in 2976 (a) Haemorrhage

• 818 •
(b) Infection (sepsis) needing hospital care depends, to some extent, on the quality
(c) Eclampsia of the first-level care provided to women; for example, active
(d) Obstructed Labour management of the third stage of labour reduces postpartum
bleeding. The proportion that dies depends on whether
Fig. - 1 : World - Causes of Maternal Mortality appropriate care is provided rapidly and with the degree of skill
with which it is provided.
Infection : The second most frequent direct cause of death
is sepsis, responsible for most late postpartum deaths. This
Indirect causes is often a consequence of poor hygiene during delivery. The
20% introduction of aseptic (clean delivery) techniques brought a
Severe bleeding
(Haemorrhage) spectacular reduction of its importance in the developed world.
25% However, sepsis is still a significant threat in many developing
countries.
Other Direct causes
8% Eclampsia : Classic complications of pregnancy include pre-
eclampsia and eclampsia which affect 2.8% of pregnancies in
Infections developing countries and 0.4% in developed countries leading
Unsafe abortion 15% to many life-threatening cases and over 63 000 maternal deaths
13%
worldwide every year accounting for 12 % of the maternal
Obstructed Eclampsia
deaths (17).
Labour 12% Obstructed Labour : The prolonged or obstructed labour
20% accounts for about 8% of maternal deaths. This is often caused
by fetoopelvic disproportion or by malpresentation (transverse
lie, mentoposterior, brow presentation). Disproportion is more
Note : Total is more than 100% due to rounding off
common where malnutrition is endemic, especially among
populations with various traditions and taboos regarding the
Fig. - 2 : India - Causes of Maternal Mortality diets of girls and women. It is worse where girls marry young
and are expected to prove their fertility, often before they are
fully grown.
Others Abortions : More than 18 million induced abortions each
14% year are performed by people lacking the necessary skills or
Anaemia in an environment lacking the minimal medical standards,
24%
Malposition or both, and are therefore unsafe resulting in 68000 deaths
7% (18, 19). Almost all take place in the developing world. With
34 unsafe abortions per 1000 women, South America has the
Puerperal highest ratio (19). Unsafe abortion is particularly an issue
10% for younger women. Around 2.5 million, or almost 14% of all
unsafe abortions in developing countries, are among women
Haemorrhage under 20 years of age. The proportion of women aged 15-19
23% Toxemia years in Africa who have had an unsafe abortion is higher than
10%
in any other region.
Abortion Others : Haemorrhage following placental abruption or
12%
placenta praevia affects about 4% of pregnant women. Less
common, but very serious complications include ectopic
Source : Registrar General India.Causes of Maternal Mortality in Rural India pregnancy and molar pregnancy. Maternal malnutrition is a
huge global problem, both as protein-calorie deficiency and
Haemorrhage : The most common cause of maternal death as micronutrient deficiency. Anaemia is an important indirect
is severe bleeding, a major cause of death in both developing cause of maternal death due to cardiovascular deaths but also
and developed countries (14,15). Postpartum bleeding can kill is an important underlying factor in many direct causes like
even a healthy woman within two hours, if unattended. It is haemorrhage and sepsis.
the quickest of maternal killers. An injection of oxytocin or Factors underlying the medical causes
ergometrine given immediately after childbirth is very effective
Socio-Economic : The factors underlying the direct causes
in reducing the risk of bleeding. In some cases a fairly simple
of maternal deaths operate at several levels. The low social
- but urgent - intervention such as massage of the uterus,
and economic status of girls and women is a fundamental
removal of clot or manual removal of the placenta may solve
determinant of maternal mortality in many developing countries
the problem. Other women may need a surgical intervention
including India. Low status limits the access of girls and women
or a blood transfusion, both of which require hospitalization
to education and good nutrition as well as to the economic
with appropriate staff, equipment and supplies. The proportion
resources to pay for health care or family planning services.

• 819 •
Lack of decision making power in terms of family planning also what mothers and their families ask for. Putting it into
puts them to repeated childbearing. Excessive physical work practice is a challenge that many countries have not yet been
coupled with poor diet leads to poor maternal outcomes. Many able to meet.
deliveries in rural areas are either conducted by relatives or Training of Traditional Birth Attendant - A Failed
traditional birth attendant or at times none. In India three out Experiment! : In the 1970s, training of traditional birth
of every five births take place at home; only two in five births attendants (TBAs) to improve obstetric services became
take place in a health facility. However, the percentage of births widespread in settings where there was a lack of professional
in a health facility has increased steadily. health personnel to provide maternity care, and where there
Nutritional : Poor nutrition before and during pregnancy were not enough beds or staff at hospital level to give all
contributes in a variety of ways to poor maternal health, obstetric women access to hospital for their confinement. TBAs already
problems and poor pregnancy outcomes. Stunting predisposes existed and performed deliveries (for the most part in rural
to cephalopelvic disproportion and obstructed labour. Anaemia areas), they were accessible and culturally acceptable and they
may predispose to infection during pregnancy and childbirth, influenced women’s decisions on using health services. While
obstetric haemorrhage and are poor operative risks in the event WHO continued to encourage this strategy until the mid-1980s
if surgery is required. Severe vitamin A deficiency make women but evidence emerged that training TBAs has had little impact
more vulnerable to obstetric complications. Iodine deficiency on maternal mortality.
increases the risk of stillbirths and spontaneous abortions. Actions for Safe Motherhood : Countries vary widely in terms
Lack of dietary calcium appears to increase the risk of pre- of the situations and challenges they face and their capacity
eclampsia and eclampsia during pregnancy. to address these. However, it is seen that to reduce maternal
Impact of Maternal Deaths (India) mortality requires coordinated, long term efforts. Actions are
needed within families and communities, in society as a whole,
Maternal death has implications for the whole family and an
in health systems, and at the level of national legislation and
impact that rebounds across generations. The complications
policy.
that cause the deaths and disabilities of mothers also damage
the infants they are carrying. The impact is summarized as Legislative & Policy actions : Long term political commitment
under- is an essential prerequisite. This leads to adequate resource
(a) Children who lost their mothers are more likely to die allocation and policy decisions are taken. A supportive social,
within two years of maternal death. economic and legislative environment allows women to access
(b) 10 times the chance of death for the neonate. the healthcare. (transport, money, social barriers limit the
(c) 7 times the chance of death for infants older than one access)
month. (a) Family planning : To avoid pregnancies that are too early,
(d) 3 times the chance of death for children 1 to 5 years. too late or too frequent.
(e) Enrolment in school for younger children is delayed and (b) Adolescents : To encourage late marriage and childbearing
older children often leave school to support their family. by increasing educational opportunities. To improve their
Significant reduction in infant mortality can be achieved by nutritional status by supplementary nutrition (e.g. ICDS-
improving the access to care during labour, birth and the critical Kishori Shakti Yojna). Education of adolescents on reproductive
hours immediately afterwards. health and empowerment of women to control fertility and
Measures to Reduce Maternal Mortality reproduction.
What is known about Reducing Maternal Mortality? (c) Barriers to access : Provision of skilled health worker at
village level health facility to overcome problems of distance and
The countries that have successfully managed to make
transport. These workers to be adequately trained in midwifery
motherhood safer have three things in common.
and paid adequately and to be provided with adequate supplies
(a) First, policy-makers and managers were informed: they
and at minimal cost.
were aware that they had a problem, knew that it could be
tackled, and decided to act upon that information. (d) Develop protocols : Aimed at providing both routine
(b) Second, they chose a common-sense strategy that proved maternal care and referral facilities for obstetric complications.
to be the right one: not just antenatal care, but also (e.g. IMNCI, 2005-Guidelines on pregnancy by MCH Division of
professional care at and after childbirth for all mothers, by Ministry of Health & Family Welfare)
skilled midwives, nurse-midwives or doctors, backed up by (e) Decentralization and delegation : Decentralized facilities
hospital care. available close to people’s homes together with written policies
(c) Third, they made sure that access to these services - and protocols to allow delegation of certain functions at lower
financial and geographical - would be guaranteed for the levels.
entire population. (f) Abortion : Availability of safe abortion services and policy
Where strategies other than that of professionalization of to discourage illegal and unsafe abortions.
delivery care are chosen or where universal access is not Society and Community Interventions : The long term
achieved, positive results are delayed. This explains why many commitment of politicians, planners and decision makers to
developing countries today still have high levels of maternal programmes on safe motherhood depends on popular support
mortality. To provide skilled care at and after childbirth and from community and religious leaders, women’s groups, youth
to deal with complications is a matter of common sense - it is

• 820 •
groups etc. National, regional and district safe motherhood since 1952 which focused mainly on limiting family size. This
committees can be set up. Health facility and community was later made more client oriented and allowed voluntary
committee can investigate maternal deaths and implement acceptance of these services and came to be called as family
strategies for improvement in areas such as referral, emergency welfare from 1977 onwards. The focus on maternal and child
transport, deployment and support of health care providers and services was program centric without involving client. It was
cost sharing. in 1992, that a comprehensive approach to ensure survival of
Health Sector Actions : The role of health sector is to ensure children and safe motherhood was implemented in the form
availability of good quality essential services to all women of CSSM programme. It was later realized, that the overall
during pregnancy and childbirth. It is clear that certain improvement in the reproductive health was the key to achieve
pregnancy complications can be prevented but large number the overall aim of lifelong health and thus, the approach was
of these which occur around the time of childbirth/labour changed and RCH program was launched. Various initiatives
can neither be prevented nor predicted. Therefore, presence that have been taken are spelt out in the succeeding paragraph.
of a skilled birth attendant is crucial for early detection and The MDGs and launching of NRHM have provided the necessary
management of such complications. impetus to the issue of safe motherhood which is the right of
every woman.
First Level Maternal and Newborn Care : First-level care does
save lives and manage emergencies. It does so by controlling All India Hospital Postpartum Programme : The Post Partum
conditions before they become life threatening (e.g. treating Programme, a maternity centered hospital based approach
anaemia) by avoiding complications (e.g. active management to Family Welfare Programme was begun in 1969 with 54
of the third stage of labour). A midwife or other professional participating hospitals, the program had 122 hospitals by
with midwifery skills also actually deals with a range of 1971-1972. 90% of these were attached to medical colleges.
emergencies on the spot, such as by administering vacuum With a view to provide maternal, child health and family
extraction in case of foetal distress or by arranging emergency welfare services in semi-urban/ rural areas, the Post Partum
referral for caesarean section or other back-up care. Programme has been extended to sub-district level hospitals
also by covering 50 institutions during 1980-81. Subsequently
First-level maternal and newborn care should preferably be
the programme was extended in a phased manner and by
organized in midwife led birthing centres, combining cultural
the end of 1988-89, 1075 Sub-district Level Hospitals were
proximity in a non-medicalized setting, with professional skilled
covered. The training of medical students and graduates in
care, the necessary equipment, and the potential for emergency
the techniques of birth control is an important aspect of the
evacuation. Decentralization for easy access obviously has to
program. The major purpose of the program is to convince
be balanced by the need to concentrate the staff and equipment
maternity and abortion patients to adopt birth control practices
necessary to be available 24 hours a day, something more
while they are in the hospital and also to interest others who
easily done in birthing centres with a team of several skilled
hear about the program by word of mouth. Contraceptive
attendants than in solo practices.
services, including sterilization, are available to all friends,
Health workers who provide first-level care need back-up when relatives, and neighbors of the confined women. Rural areas are
a problem occurs that they are unable to deal with as it goes reached through the medical colleges and attached hospitals
beyond their competence or beyond the means they have at which have responsibility for the area. Educational programs
their disposal. are a significant part of the program and are carried out in
Back-up maternal and newborn care encompasses emergencies many parts of the hospitals and clinics.
(such as a LSCS, hysterectomy or treatment of neonatal tetanus Essential Obstetric Care (EOC) : This is the minimum obstetric
or meningitis) as well as non-emergency interventions (such as care that must be made available to all pregnant women.
treatment of congenital syphilis). Back-up is ideally provided (a) Registration of pregnancy in the first 12-16 wks of
in a hospital where doctors - specialists, skilled general pregnancy.
practitioners or mid-level technicians with the appropriate (b) At least 3 prenatal check ups by ANM or in dispensary.
skills - can deal with mothers whose problems are too complex (c) Assistance during delivery. (Skilled Birth Attendant)
for first-level providers. To make the difference between life (d) At least 3 postnatal check ups.
and death, the required staff and equipment must be available Emergency Obstetric Care (EmOC) : This is the service provided
24 hours a day, and the links between the two levels of care to cater for any unforeseen complication that may arise in any
should be strong. pregnancy at any stage. EmOC is an intervention for preventing
Rolling out Services Simultaneously : First-level maternal maternal morbidity and mortality. Early detection and
and newborn care and the referral hospital services that should management of complications such as anaemia, haemorrhage,
provide back-up have to be rolled out in parallel.. The challenge obstructed labour and sepsis can substantially reduce maternal
of simultaneous roll-out has striking similarities to the one mortality & morbidity. This requires competent supervision and
that led the primary health care movement to opt for the health check ups by ANM during antenatal, intranatal & post natal
districts, with both health centres and a district hospital, linked period. ANM should refer all cases having complications during
by referral mechanisms, and organized to ensure a continuum pregnancy or at the time of delivery to PHCs / FRUs.
of care.
Inputs : A total of 1748 FRUs have been identified & equipped
Initiatives in India under CSSM programme. Some of the FRUs are lacking
India has a history of starting Family planning programme in manpower or infrastructure. Under RCH programme, a

• 821 •
provision has been kept for strengthening these FRUs through with delivery and post-delivery care. The success of the scheme
provisioning of drug kits, laparoscope, blood transfusion would be determined by the increase in institutional delivery
and employing contractual staff like PHN/ANM/Lab Asst and among the poor families
anaesthesiologist. The Yojana has identified ASHA, the accredited social health
24 Hour Delivery Services at PHCs/CHCs : Under RCH activist as an effective link between the Government and the
program, arrangements have been made that a doctor on call poor pregnant women in l0 low performing states, namely the
duty, a nurse and cleaning staff are available beyond normal 8 EAG states and Assam and J&K and the remaining NE States.
working hours to encourage people to seek deliveries in PHCs/ In other eligible states and UTs, wherever, AWW and TBAs or
CHCs. For this doctor could be paid Rs 200/- per delivery & ASHA like activist has been engaged in this purpose, she can be
other staff could be hired on contractual basis. associated with this Yojana for providing the services.
Referral Transport to Indigent Families through Panchayats Role of ASHA or other link health worker associated with JSY
: In category C districts of eight weakly performing states, would be to:
communication infrastructure is weak and economic status (a) Identify pregnant woman as a beneficiary of the scheme
of families in remote villages is poor. Because of this, even if and report or facilitate registration for ANC,
there is a complication identified during pregnancy or delivery, (b) Assist the pregnant woman to obtain necessary
the women have the delivery conducted in the village and certifications wherever necessary,
frequently through untrained Dais. This is one of the causes (c) Provide and / or help the women in receiving at least three
of high maternal mortality and morbidity. This has been ANC checkups including TT injections, IFA tablets,
addressed by providing financial assistance to Panchayats (d) Identify a functional Government health centre or an
through District Family Welfare Officers. accredited private health institution for referral and
Blood Supply to FRUs/PHCs : Dept of family welfare will delivery,
be taking up pilot projects with the assistance of European (e) Counsell for institutional delivery,
Commission under the RCH programme for setting up of regular (f) Escort the beneficiary women to the pre-determined health
and reliable supply of blood to PHCs/CHCs by linking them with center and stay with her till the woman is discharged,
the nearest blood bank (g) Arrange to immunize the newborn till the age of 14
MTP services : MTP by untrained or experienced persons weeks,
is responsible for high maternal mortality and morbidity. (h) Inform about the birth or death of the child or mother to
Therefore, increasing and improving facilities for MTP is an the ANM/MO,
important component of the RCH programme at PHC level. (i) Post natal visit within 7 days of delivery to track mother’s
health after delivery and facilitate in obtaining care,
Inputs
wherever necessary,
(a) Need based training in MTP by NIHFW. (j) Counsell for initiation of breast feeding to the newborn
(b) Supply of MTP equipment to District Hospitals, CHCs & within one-hour of delivery and its continuance till 3-6
PHCs where trained staff is available. months and promote family planning
(c) Assistance for engaging doctors trained in MTP to the
The scheme focuses on the poor pregnant woman with special
PHCs once a week on fixed days for performing MTP (Pay
dispensation for states having low institutional delivery
Rs 500/- day). These doctors will also provide ANC and PNC
rates namely the states of Uttar Pradesh, Uttaranchal, Bihar,
services to patients during their visit.
Jharkhand, Madhya Pradesh, Chhattisgarh, Assam, Rajasthan,
(d) Supply of MTP equipment to Private clinics if they have OT
Orissa and Jammu and Kashmir. While these states have been
& trained doctors.
named as Low Performing States (LPS), the remaining states
Janani Suraksha Yojna (Maternal Safety Scheme) have been named as High performing States (HPS).
Janani Suraksha Yojana (JSY) is a safe motherhood Tracking Each Pregnancy : Each beneficiary registered under
intervention under the National Rural Health Mission (NRHM) this Yojana should have a JSY card along with a MCH card.
being implemented with the objective of reducing maternal ASHA/AWW/ any other identified link worker under the overall
and neo-natal mortality by promoting institutional delivery supervision of the ANM and the MO, PHC should mandatorily
among the poor pregnant women. The Yojana, launched on prepare a micro-birth plan. This will effectively help in
12th April 2005, is being implemented in all states and UTs monitoring Antenatal Check-up, and the post delivery care.
with special focus on low performing states. JSY is a 100 % Disbursement of Cash Assistance : As the cash assistance to
centrally sponsored scheme and it integrates cash assistance the mother is mainly to meet the cost of delivery, it should be

Eligibility for Cash Assistance

LPS States All pregnant women delivering in Government health centres like Sub-centre, PHC/CHC/ FRU / general wards
of District and state Hospitals or accredited private institutions
HPS States BPL pregnant women, aged 19 years and above
LPS & HPS All SC and ST women delivering in a government health centre like Sub-centre, PHC/CHC/ FRU / general ward
of District and state Hospitals or accredited private institutions

• 822 •
disbursed effectively at the institution itself. drugs etc. at appropriate places. Mainly, this will entail -
(a) Linking each habitation (village or a ward in an urban
Scale of Cash Assistance for Institutional Delivery area) to a functional health centre- public or accredited
Rural Area Urban Area private institution where 24x7 delivery service would be
Cate- Total Total available,
gory Mother’s ASHA’s Rs. Mother’s ASHA’s
Rs. (b) Associate an ASHA or a health link worker to each of these
Package Package Package Package
functional health centre,
LPS 1400 600 2000 1000 200 1200 (c) It should be ensured that ASHA keeps track of all expectant
HPS 700 700 600 600 mothers and newborn. All expectant mother and newborn
should avail ANC and immunization services, if not in
Cash assistance for Referral transport : This assistance is health centres, at least on the monthly health & nutrition
given to go to the nearest health centre for delivery. The state day, to be organised in the Anganwadi or sub-centre:
will determine the amount of assistance (should not less than Micro-Birth Plan for JSY Beneficiaries : Inform the mother
Rs.250/- per delivery) depending on the topography and the and the family about 4 Is, namely
infrastructure available in their state. It would, however, be (a) Inform dates of 3 ANC & TT Injection(s) & ensure these are
the duty of the ASHA and the ANM to organize or facilitate provided
in organizing referral the transport, in conjunction with gram (b) Identify the health centre for all referral
pradhan, Gram Sabha etc. (c) Identify the Place of Delivery
Note : This assistance is over and above the Mother’s package. (d) Inform expected date of delivery
Cash Incentive to ASHA : This should not be less than Vande Mataram Scheme
Rs.200/- per delivery in lieu of her work relating to facilitating The scheme is continuing under Public Private Partnership with
institutional delivery. Generally, ASHA should get this money the involvement of Federation of Obstetric and Gynaecological
after her postnatal visit to the beneficiary and that the child Society of India and Private Clinics. The aim of the scheme is
has been immunized for BCG. to reduce the maternal mortality and morbidity of the pregnant
Transactional cost (Balance out of Rs.600/-) : It is to be and expectant mothers by involving and utilizing the vast
paid to ASHA in lieu of her stay with the pregnant woman in resources of specialists/trained work force available in the
the health centre for delivery to meet her cost of boarding and private sector. The scheme intends to provide free antenatal
lodging etc. Therefore, this payment should be made at the and postnatal check, counselling on nutrition, breast feeding,
hospital/ heath institution itself. spacing of birth etc. through public private partnership.
All payments to ASHA would be done by the ANM only. In this This is a voluntary scheme wherein any Obstetric and
case too, a voucher scheme be introduced in such a manner Gynaecologist, maternity home, nursing home can volunteer
that for every pregnant woman she registers under JSY, ANM themselves in joining the scheme. Any lady doctor/MBBS doctor
would give two vouchers to ASHA, which she would be able to providing safe motherhood services can also volunteer to join
encash on certification by ANM. this scheme. The enrolled ‘Vandemataram’ doctors will display
‘Vandemataram’ logo in their clinic. Iron and Folic Acid Tablets,
Special Dispensation for LPS States
oral pills, TT injections etc. will be provided by the respective
●● Age restriction removed District Medical Officers to the ‘Vandemataram’ doctors/clinics
●● Restricting benefits of JSY up to 2 births removed for free distributions to beneficiaries. The cases needing special
●● No need for any marriage or BPL certification care and treatment can be referred to the Government Hospitals
Subsidizing cost of Caesarean Section or management of and institutes, who have been advised to take due care to the
Obstetric complications : Generally PHCs/ FRUs / CHCs etc. patients coming with Vandemataram cards.
would provide emergency obstetric services free of cost. Where
Government specialists are not available in the Govt’s health Challenges in Maternal Health
institution to manage complications or for Caesarean Section, (a) Establishing data base on maternal mortality : The
assistance up to Rs. 1500/- per delivery could be utilized by maternal mortality continues to be a problem in rural, remote,
the health institution for hiring services of specialists from the inaccessible and tribal areas where there is hardly any health
private sector. If a specialist is not available. service available and even if available it is inadequate and in
Assistance for Home Delivery: In LPS and HPS States, BPL this setting the deaths in childbirth are either not recorded or
pregnant women, aged 19 years and above, preferring to deliver recorded incorrectly due to causes other than pregnancy or
at home is entitled to cash assistance of Rs. 500/- per delivery. childbirth. There is a need to record each and every maternal
Such cash assistance would be available only upto 2 live births death to ascertain the correct magnitude of this public health
and the disbursement would be done at the time of delivery problem.
or around 7 days before the delivery by ANM/ASHA/ any other (b) High Risk Pregnancy Behaviour - Too Early, Too Many,
link worker. Too Close : The social customs like universality of marriage,
early marriage, social pressure for early childbearing, son
Strategy : While the scheme would create demand for
preference, lack of education and poor social status of women
institutional delivery, it would be necessary to have adequate
in decision making, all lead to consequences of pregnancies
number of 24X7 delivery services centre, doctors, mid-wives,
that are early, repeated and frequent leading to maternal

• 823 •
depletion and debility and even death. deaths which are preventable to a large extent. India has an
(c) Urban-Rural Divide : The rural urban divide is a major enormous task ahead to make assured services available at its
social issue and a challenge for the public health administrators health institutions and universalize the coverage of all women
as most of the women who need the most care continue to be including those marginalized & underserved sections of society
deprived of the same. The rural urban divide is marked not only to realize the goal of safe motherhood. RCH and NRHM provide
by unequal distribution of health services but all the social the necessary direction and opportunity to achieve this goal.
and cultural factors which add up to the negative milieu for Summary
maternal health and survival.
Maternal health includes Antenatal care, Intranatal care and
(d) Poor Rate of Institutional Deliveries : Even after the Postnatal care. The Intranatal period constitutes only 0.5% of
facilities are made available, the uptake of these services maternal cycle and but it is probably the most crucial.
continue to be poor because of various factors like lack of
Maternal death is defined as death of a women while pregnant
adequate manpower, infrastructure and facilities in the PHC/
or within 42 days of termination of pregnancy, irrespective of
CHC, preference to deliver at home due to cultural reasons and
the duration and site of pregnancy, from any cause related to
inability to afford the cost of maternity in a civil or private
or aggravated by pregnancy or its management but not from
health care setting.
accidental or incidental cause. There are three main measures
(e) Lack of Skilled Care at Birth : The care available to of Maternal mortality which are maternal mortality ratio,
mothers at birth continues to be by TBAs or midwives who are maternal mortality rate and life time risk of maternal death.
neither trained nor adequately equipped to handle complicated Antenatal care is the care of women during pregnancy. Its
situations and thus either there is delay in diagnosing, ultimate objective is to have a healthy mother and healthy
transportation and referral to a FRU. child at the end of pregnancy. Antenatal care includes visit
(f) Lack of Women Empowerment : This social aspect of antenatal clinic, examination, investigations, immunization,
women empowerment for a lady to take decisions for her own supplements and interventions as required. Pre-conceptional
safety and health is still lacking where her in laws are making care is indicated in some cases like maternal age more than 35
these decisions for her. The women are still not having the yrs and paternal age more than 55 years, history of congenital
right to decide their age at marriage, pregnancy, spacing and defects in family, recurrent pregnancy loss and use of alcohol.
contraception and even their maternity care. Prenatal care should start as early as 8 weeks but not later
(g) Poor Implementation of Programs : There has been a than 12-16 weeks with registration of patient and initiation of
family welfare programme running in the country since last antenatal card. This is important for determining exact EDD,
six decades but the services available for maternal health and evaluation of risk and essential health education of the patient.
survival at primary level is still inadequate with poor results. The at risk pregnancies are age less than 18 or more than 35,
The reasons are many. The core intervention of providing multiparity, short stature, Rh negative, bad obstetric history,
a skilled care at birth by a midwife and backed by a referral medical disorders for eg IHD, Diabetes, seizures, hypertension,
service has still not materialized. There is a proposal for such tuberculosis, anaemia etc. Health education or prenatal
services under NRHM as part of RCH programme. advice includes issues like diet, rest, personal hygiene, sexual
intercourse, drugs, exercise, travel and care of breasts. Women
Ten Action Messages for Safe Motherhood should also be educated about the warning signs which should
These ten action messages were identified at the Sri Lanka not be ignored like convulsions, severe headache, blurring of
Technical Consultation on Safe Motherhood in 1999, which vision and bleeding or discharge per vaginum.
marked the tenth anniversary of the Safe Motherhood Birth planning is an important function of prenatal care. It
Initiative. takes care of complications which may arise suddenly and
(1) Advance Safe Motherhood Through Human Rights can be dangerous to the life of both mother and the child.
(2) Empower Women: Ensure Choices Institutional delivery should be advocated but it is a must in
(3) Safe Motherhood is a Vital Economic and Social many conditions which should be identified.
Investment Objectives of Intanatal care are asepsis (The five cleans- clean
(4) Delay Marriage and First Birth hands, surface, blade, cord, tie), minimum injury to mother
(5) Every Pregnancy Faces Risks and child, to deal with complications during labour and the
(6) Ensure Skilled Attendance at Delivery care of newborn.
(7) Improve Access to Quality Reproductive Health Services
The first 48 hours following delivery are the most important
(8) Prevent Unwanted Pregnancy and Address Unsafe
followed by first week following delivery. The mother should
Abortion
give postpartum visit at 3rd, 7th day and 6 weeks after delivery
(9) Measure Progress
to see that involution of uterus is complete. Mother should be
(10) The Power of Partnership educated about danger signs and advised to report to hospital
To provide skilled care at and after childbirth and to deal with if they appear. Infections, haemorrhage, UTI, thrombophlebitis,
complications is a matter of common sense - it is also what and psychiatric disorders are common complications of
mothers and their families ask for. Putting it into practice is a puerperium.
challenge that many countries have not yet been able to meet.
The global burden of maternal mortality is 400 maternal deaths
It is time to ensure that each pregnancy receives its due care
per 100000 live births. The burden is very high in developing
with a view to prevent loss of lives in the form of maternal countries as compared to developed countries where it is low.

• 824 •
Rural population, low socio-economic status and remote areas 3. Make Every Mother & Child Count. The World Health Report 2005, WHO,
Geneva
bear a heavy burden of deaths. About 45% of maternal deaths
4. Pregnancy, childbirth, postpartum, & newborn care (PCPNC). A guide for
occur in occur during the first 24 hours and more than two- essential practice. Geneva, WHO, 2004.
thirds during first week. The maternal mortality ratio in India 5. Managing complications in pregnancy & childbirth. Geneva, WHO, 2003.
is 300 per 100,000 live births. The common causes in India are 6. National Family Health Survey NFHS - 3 India 2005-06, International
Anaemia, Haemmorhage, Sepsis, Obstructed labour, Abortion Institute for Population Sciences, Mumbai, India. http://www.nfhsindia.org/
nfhs3.html
and Toxaemia. The 4 major direct causes of Maternal mortality 7. Pasinlioglu T. Health education for pregnant women: the role of background
are Haemmorhage, Infection, Eclampsia & Obstructed labour. characteristics. Patient Education & Counselling, 2004, 53:101-106.
Actions for safe motherhood include legislative and policy 8. Villar J, Bergsjo P. Scientific basis for the content of routine antenatal care.
I. Philosophy, recent studies, & power to eliminate or alleviate adverse
decisions, society and community interventions, and health maternal outcomes. ActaObstetricia et Gynecologica Scandinavica, 1997,
sector actions. Initiatives in India started since 1952 as Family 76:1-14.
planning programme. This was made more client oriented and 9. Maternal mortality in 2000: estimates developed by WHO, UNICEF & UNFPA.
Geneva, WHO, 2004.
voluntary since 1977 and called as Family welfare. In 1992
10. Attending to 136 million births every year. In chapter 4 of World Health
comprehensive approach was started in the form of CSSM Report 2005, Make Every Mother & Child Count. WHO, Geneva 2005.
programme. It was later realized, that the overall improvement 11. Li XF, Fortney JA, Kotelchuck M, Glover LH. The postpartum period: the key
in the reproductive health was the key to achieve the overall to maternal mortality. International Journal of Gynecology & Obstetrics,
1996, 54:1-10.
aim of lifelong health and thus, the approach was changed and 12. Alauddin M. Maternal mortality in rural Bangladesh: the Tangail District.
RCH program was launched. Other programmes are All-India Studies in Family Planning, 1986, 17:13-21.
Hospital post-partum programme, Janani Suraksha Yojana 13. Bhatia JC. Levels & causes of maternal mortality in southern India. Studies
(Maternal Safety Scheme) and Vande Matram Scheme. in Family Planning, 1993, 24:310-318.
14. Koenig MA, Fauveau V, Chowdhury AI, Chakraborty J, Khan MA. Maternal
The main challenges in Maternal Health are establishing data mortality in Matlab, Bangladesh: 1976-85. Studies in Family Planning,
base on maternal mortality, high risk behavior, urban-rural 1988, 19:69-80.
divide, poor rate of institutional deliveries, lack of skilled care 15. MacLeod J, Rhode R. Retrospective follow-up of maternal deaths & their
associated risk factors in a rural district of Tanzania. Tropical Medicine &
at birth, lack of women empowerment and poor implementation International Health, 1998, 3:130-137.
of programmes. 16. Pathmanathan I, Liljestrand J, Martins JM, Rajapaksa LC, Lissner C, de Silva
A et al. Investing in maternal health: learning from Malaysia & Sri Lanka.
Study Exercises Washington, DC,World Bank, 2003.
17. Koblinsky MA, Campbell O, Heichelheim J. Organizing delivery care: what
Long Question : Describe in details the Programmes in India works for safe motherhood? Bulletin of the WHO, 1999, 77:399-406.
directed towards Maternal Health Care. 18. Suleiman AB, Mathews A, Jegasothy R, Ali R, Kandiah N. A strategy for
Short Notes : (1) Causes of Maternal mortality (2) Maternal reducing maternal mortality. Bulletin of the WHO, 1999, 77:190-193.
19. Maternal Mortality Study 2000. Cairo, Min. of Health & Population. 2001.
Mortality Rate (3) All India Hospital Post-Partum Programme 20. Situation analysis of children & women in Iraq. New York, NY, United
(4) Janani Suraksha Yojana Nations Children’s Fund, 1998.
MCQs : 21. AbouZahr C. Antepartum & postpartum haemorrhage. In: Murray CJL, Lopez
AD, eds. Health dimensions of sex & reproduction: the global burden of
1. Which of the following is not included in ‘Cleans’ in conduct sexually transmitted diseases, HIV, maternal conditions, perinatal disorders,
of delivery : (a) Clean hands (b) Clean Perineum (c) Clean & congenital anomalies. Cambridge, MA, Harvard School of Public Health
on behalf of the WHO & the World Bank, 1998 (Global Burden of Disease &
cutting and care of the cord (d) Clean surface of delivery Injury Series, No. III):165-189.
2. In India, majority of deliveries take place at: (a) Hospital 22. AbouZahr C. Global burden of maternal death & disability. In: Rodeck C,
(b) Primary Health Centre (c) Private clinics (d) Home ed. Reducing maternal death & disability in pregnancy. Oxford, Oxford
University Press, 2003:1-11.
3. Ante-natal care includes: (a) Genetic counselling for 23. AbouZahr C, Aahman E, Guidotti R. Puerperal sepsis & other puerperal
prospective parents (b) Spacing of births (c) Ensuring infections. In : Murray CJL, Lopez AD, eds. Health dimensions of sex &
adequate maternal nutrition (d) All of the above reproduction: the global burden of sexually transmitted diseases, HIV,
maternal conditions, perinatal disorders, & congenital anomalies. Cambridge,
4. Janani Suraksha Yojana has been started under: (a) CSSM MA, Harvard School of Public Health on behalf of the WHO & the World
(b) NRHM (c) MCH (d) ICDS Bank, 1998 (Global Burden of Disease & Injury Series, No. III):191-217.
5. Iron/Folic acid tablets are distributed to private doctors for 24. AbouZahr C, Guidotti R. Hypertensive disorders of pregnancy. In: Murray
CJL, Lopez AD, eds. Health dimensions of sex & reproduction: the global
free distribution under which scheme: (a) NRHM (b) CSSM burden of sexually transmitted diseases, HIV, maternal conditions, perinatal
(c) Janani Suraksha Yojana (d) Vande Mataram Scheme disorders, & congenital anomalies. Cambridge, MA, Harvard School of Public
6. Following are high risk ante-natal cases except: (a) Elderly Health on behalf of the WHO & the World Bank, 1998 (Global Burden of
Disease & Injury Series, No. III):219-241.
Primi (b) Pre-eclampsia (c) Twin pregnancy (d) None 25. Unsafe abortion: global & regional estimates of the incidence of unsafe
7. Minimum number of Antenatal visits during pregnancy is: abortion & associated mortality in 2000, 4th ed. Geneva, WHO, 2004.
(a) Two (b) Three (c) Five (d) Six 26. The prevention and management of unsafe abortion. Report of a Technical
8. MMR in India is: (a) 300 per lakh (b) 400 per lakh (c) 200 Working Group. Geneva, World Health Organization, 1992.
27. Loudon I. Death in childbirth: an international study of maternal care and
per lakh (d) 500 per lakh maternal mortality, 1800-1950. Oxford, Clarendon Press, 1992.
Answers : (1) b; (2) d; (3) d; (4) b; (5) d; (6) d; (7) b; (8) a.
Further Suggested reading
References 1. Pregnancy, childbirth, postpartum and newborn care: A Guide for essential
1. WHO/UNICEF. Antenatal care in developing countries. Promises, practice. Geneva, World Health Organization, 2003.
achievements, & missed opportunities. An analysis of trends, levels, & 2. Postpartum care of the mother and the newborn: a practical guide. Geneva,
differentials 1990-2001. Geneva, WHO, 2003. World Health Organization, 1998.
2. Carroli G, Villar J, Piaggio G, Khan-Neelofur D, Gulmezoglu M, Mugford M 3. Managing complications in pregnancy and childbirth. Geneva, World Health
et al. WHO systematic review of randomised controlled trials of routine Organization, 2003.
antenatal care. Lancet, 2001,357:1565-1570

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 (stillbirths) and early neonatal deaths. The important thing to
143 Care of Infants consider is the weight 1000gm and more at birth or a gestation
of 28 weeks if birth weight is not available and if both weight
and gestation are not available, body length (Crown to heel) of
A S Kushwaha
at least 35 cm should be used.
The preferred criterion is birth weight. The denominator used
Infancy is the first year of life and this is marked by the
in calculation of perinatal mortality is 1000 live births (suits
greatest threat to survival and therefore is a good measure
nations with poor recording of still births) but for more precise
of the progress in the fields of socio-economic, medical and
comparison the denominator includes all live births weighing
healthcare development in a country. It is customary to divide
1000 gm or more. Perinatal mortality is a sensitive indicator
infancy into various time periods for convenience of planning
of essential maternal and newborn care provided at childbirth.
service. The determinants of health are also different in these
The factors responsible for stillbirths and early neonatal deaths
phases.
are often similar. This indicator also assumes importance in
Infancy is sub-divided into following four distinct phases or view of the fact that many of the early neonatal deaths are
periods recorded as stillbirth in developing nations thereby inflating
●● Perinatal period figures for stillbirths but showing figures for early neonatal
●● Early neonatal period deaths lower than the factual. This anomaly is taken care of
●● Late neonatal period by Perinatal Mortality Rate. The Perinatal period comprises just
●● Post-neonatal period 0.5 % of the average lifespan but has more deaths in this period
Definitions than next 30-40 years of life.
Perinatal Period : Perinatal period extends from 28th weeks of Babies continue to be very vulnerable throughout their first
gestation to less than 7 days of life, after birth. week of life, after which their chances of survival improve
Neonate : A child in 1st month [under 4 weeks of age (<28 markedly. The conditions causing newborn deaths can also
days)]. Early Neonatal Period- First week of life (<7days or result in severe and lifelong disability in babies who survive.
<168 hours). Late Neonatal period extends from 7th to 28th Infant Mortality Rate : The ratio of infant deaths registered in
day. a given year to the total number of live births registered in the
Post-Neonatal period : Period of infancy from 28 days to same year, usually expressed per 1000 live births.
under 365 days (<1 year) The infants who survive early neonatal period then face the
Live born : A live born neonate is a product of conception, dangers of Malnutrition, Diarrhoea and ARI and certain vaccine
irrespective of weight or gestational age, that after separation preventable diseases like measles.
from the mother, shows any evidence of life such as breathing, Infant mortality has a special significance as -
heart beat, pulsation of umbilical cord or definite movement of ●● Single category with largest age specific mortality.
the voluntary muscle. ●● Measure of health status and level of living of a
Still birth : A foetal death is a product of conception that after community
separation from the mother does not show any evidence of ●● Deaths are due to specific causes different from those that
life. The WHO has recommended that within any country the affect adults.
term stillbirth be applied to a foetus born dead and weighing ●● Indicates social measures directed towards mother and
>500gm which is associated with a gestation of 22 weeks. For child in a country. The importance of IMR can be gauged
international comparisons a weight of 1000gm is to be used from the fact that it is one of the parameters for calculating
which frequently measures to 28 weeks of gestation. Still Physical Quality of Life Index (PQLI). Various programs and
birth rate is the number of foetal deaths (>1000gm weight at policies have included reduction of Infant mortality as an
birth) occurring in a year per 1000 total births (live births + important objective in the progress towards health for all.
stillbirths). Global Scenario : Each year, about four million newborns die
Pre-term Baby : Any neonate born before 37 completed weeks during neonatal period across the world. Almost all (98%) of
(<259 days) of gestation irrespective of the birth weight. these deaths occur in developing countries. Newborn deaths
now contribute to about 40% of all deaths in children under five
Term baby : A neonate born between 37 and 42 weeks of
years of age globally, and more than half of infant mortality.
pregnancies (259-294 days) irrespective of the birth weight.
Rates are highest in sub-Saharan Africa and Asia. Two thirds of
Low Birth Weight (LBW) : Any neonate weighing less than newborn deaths occur in the two WHO Regions (Fig. - 1), Africa
2500 gm at birth irrespective of gestational age. (28%) and South-East Asia (36%). The average IMR for world is
Very Low Birth Weight baby (VLBW) : Any neonate weighing 54 per 1000 live births (2004). The lowest infant mortality rates
less than 1500 gm at birth irrespective of gestational age. in developed nations are under 10 with Japan recording an IMR
Extremely Low Birth Weight baby (ELBW) : Any neonate of 3 per 1000 live births. The figures of IMR in underdeveloped
weighing less than 1000 gm at birth irrespective of gestational nations are as high as 90 and above. The highest rates of IMR
age. are recorded in Sierra Leone (165), Afghanistan (165), Mali
(121) and Mozambique (104).
Perinatal Mortality Rate : This includes both late foetal deaths

• 826 •
 neonatal deaths occur in the 1st week of life (Perinatal deaths).
Fig. - 1 : Region wise and cause wise neonatal deaths
Risk of death is highest during first 24-48 hours of life.
Girls in India face a higher mortality risk than boys. Children
born to mothers under age 20 or over age 40 are more likely
to die in infancy than children born to mothers in the prime
childbearing ages. Infant mortality is 77 per 1,000 for teenage
mothers, compared with 50 for mothers aged 20-29 yrs. Infant
mortality in rural areas is 50 percent higher than in urban
areas. Children whose mothers have no education are more
than twice as likely to die before their first birthday as children
whose mothers have completed at least 10 years of school. In
addition, children from scheduled castes and scheduled tribes
are at greater risk of dying than other children. Infant mortality
Source : Make Every Mother and Child count. World Health Report, 2005 rates are highest in Uttar Pradesh, Chhattisgarh and Madhya
Pradesh, where about 70 children in 1,000 die in their first year
Progress : Consecutive household surveys from developing of life, and lowest in Kerala and Goa, with 15 infant deaths per
countries show that most have experienced a decline in 1,000 live births.
neonatal mortality in recent decades. Much of the progress in
Causes
survival has been made in the late neonatal period, with little
improvement in the first week of life. Reductions in infant and Infant mortality is due to combination of various factors
child mortality in many countries are at least partly driven operating at different stages and are related to issues which
by socioeconomic development: improvements in women’s may range from maternal, foetal, environmental and social.
education and literacy, household income, environmental The causes differ during the neonatal and post neonatal phases
conditions (safe water supply, sanitation and housing), along of infancy. The factors operating in perinatal period do not have
with improvements in health services and child nutrition much relative impact in late neonatal part of infancy. Low birth
weight (57%), respiratory infections (17%), diarrhoeal diseases
Scenario in India : The infant mortality has been declining
(4%), congenital malformations (5%), Birth injury (3%) are the
steadily over the years but the decline has been slower than
major causes of infant mortality in India. A list of causes is
desirable (Table - 1). The progress over the last decade is given
given in the Table - 2.
in Fig. - 2.
Table - 2 : Causes of Infant Mortality
Table-1 : Mortality indicators of infancy: India (1994-
2006) Post neonatal Mortality
Neonatal Mortality
(1-12 months)
Indicator 1994 2000 2006
Low birth weight & prematurity Diarrhoeal diseases
Infant Mortality Rate 74 68 57
Birth injury & difficult labour Acute respiratory
Neonatal mortality rate 48 44 37
Sepsis infection
Post-neonatal mortality rate 26 23 22
Congenital anomalies Other communicable
Still birth rate 9 8 9
Haemolytic diseases of newborn diseases-measles, malaria
Fig.-2:Trend of IMR in India from 1994 to 2006 (NFHS-3) Conditions of placenta & cord Malnutrition

Infant Mortality Rate Diarrhoeal diseases Congenital anomalies

75 74 74 Acute respiratory infections Accidents
73 72 72
71
Neonatal tetanus
71 70
69 68
67 Factors Underlying Infant Mortality : The factors as discussed
66 earlier vary in the Perinatal, neonatal and post neonatal
IMR

65
63 63 phases of infancy. Perinatal mortality and neonatal mortality
61 in particular accounts for nearly half of the infant mortality.
60
59 58 58 Perinatal mortality is linked to a gamut of factors operating in
57 57 the prenatal, intranatal and postnatal period.
55
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 (a) Prenatal
Year
Source : SRS Bulletin - October 2007, Registrar General of India. ●● Maternal factors-age (teenage, elderly), diseases like
hypertension (toxemia), cardiovascular, diabetes, anaemia
The deaths in the 1st year of life account for 18.7 % of total etc.
deaths in the country. Of these infant deaths, >60% occur ●● Anatomical - uterine and cervical defects
during the 1st month of life (Neonatal deaths). Of this 40% of ●● Blood incompatibilities

• 827 •
●● Malnutrition, anaemia Essential Newborn Care
●● Antepartum haemorrhage Care of the newborn at birth is primarily aimed at helping
●● Foetal- congenital defects the newborn to adapt to the extra-uterine environment.
(b) Intranatal Physiological adaptation includes initiation of respiration and
●● Birth trauma oxygenation of the arterial blood, temperature adaptation and
●● Birth asphyxia initiation of breast feeding. Box - 1 shows the actions at birth.
●● Prolonged or difficult labour
●● Obstetric complications Box - 1 : Actions at birth
(c) Postnatal Note timing of birth
●● Preterm baby/ Low birth weight
Note sex of the baby and show to mother
●● Respiratory distress syndrome
●● Congenital anomalies Cleaning the airway
●● Infections Cleaning and drying the baby
The causes operating in perinatal period are related to the
Put a identification mark / tag
maternal, foetal factors and care during delivery to the mother
and the newborn. Factors like birth trauma, sepsis, asphyxia, Transfer the baby
prolonged labour and obstructed labour arise and operate APGAR score at 1 and 5 minutes
due to lack of skilled care during delivery. The factors in the
Take birth weight, length
neonatal period are mainly ‘endogenous’ like prematurity, low
birth weight and gestational age and congenital anomalies. Rule out any major congenital anomaly, birth injury
This part of the infant mortality is the most difficult to tackle.
Factors causing Post neonatal mortality are mainly social and Routine Care at Birth
environmental related. In developed countries the congenital Over 90% of newborns do not require any active resuscitation at
anomalies is the main cause. birth. Efforts are directed to maintain asepsis, prevent infection
Prevention and hypothermia, and to keep the airway patent.
The preventive strategy will be based on some direct and
indirect measures as under - Advise the mother to return immediately if the young
Infant has any of these signs
Direct : These measures if taken can modify the problem of
Infant mortality pretty quickly. These measures act both at Breast feeding or drinking poorly
primary and secondary prevention levels. Becomes sicker
●● Safe and clean delivery with skilled birth attendant Develops a fever or feels cold to touch
●● Essential Care of the newborn at birth
●● Newborn resuscitation Fast breathing
●● Infection control measures Difficult breathing
●● Exclusive Breast feeding Blood in stool
●● Early diagnosis and management of complications
●● Special care for the preterm and premature infants Examination of the Newborn
●● ORT and antibiotics for Diarrhoea and ARI respectively
●● Immunization A complete physical examination is an important part of
newborn care. Each body system is carefully examined for signs
Indirect : These factors though intangible but have a role
of health and normal function. The physician also looks for any
of immense importance and operate at the level of family,
signs of illness or birth defects. The newborn baby at birth is
community, health care and society at large. These factors are
50 cm long & weighs >2.5 kg with a head circumference of 34
mostly acting at promotion and primary prevention levels.
cm.
●● Family planning - timing, spacing births, limiting family
size Risk Identification in the Newborn
●● Prenatal nutrition of mothers An important task of the attending MO in the labour room is
●● Education of the mother on pregnancy and child care the identification of newborns at high risk for morbidity and
●● Antenatal care mortality. These newborns would need special care, either at
●● Growth monitoring of child the PHC where the delivery took place (if the facilities and
●● Prevention of malnutrition- weaning practices trained personnel exist) or at the FRU where these babies
●● Breast feeding should be referred to.
●● Vit A prophylaxis Guidelines to detect these newborns at risk :
●● Improved Sanitation and safe water
Danger Signs in a Newborn
●● Access to primary health care
●● Convulsions
●● Overall socio-economic development
●● Fast breathing (60 breaths per minute or more)
●● Severe chest indrawing

• 828 •
●● Nasal flaring substances and growth factors and has more protein and
●● Grunting Vitamins A and K than mature milk.
●● Bulging fontanelle ●● It enhances the development and maturation of the baby’s
●● 10 or more skin pustules or a big boil gastro-intestinal tract.
●● Severe Jaundice ●● The anti-infective proteins and white cells provide the first
●● Axillary temperature 37.5°C or above (or feels hot to touch) immunization against the diseases that a baby encounters
or temperature less than 35.5°C (or feels cold to touch) after delivery.
●● Lethargic or unconscious ●● Although colostrum is secreted in small quantities
●● Less than normal movements (30-90 ml), it is sufficient to meet the caloric needs of a
●● Blood in the stools normal newborn in the first few days of life.
●● Not able to feed ●● Colostrum also has a mild purgative effect, which helps to
●● Not sucking at all clear baby’s gut of meconium (the first, very dark stools)
●● No attachment at all and helps to prevent jaundice by clearing the bilirubin
Referring the Newborn to an FRU from the gut.
●● It stimulates the baby’s immature intestine to develop
Check on the arrangement for referral. A newborn will benefit
in order to digest and absorb milk and to prevent the
from referral to a higher centre only if it is properly ventilated
absorption of undigested protein.
and kept warm during transport. Two people are needed to
escort a newborn who requires ventilation: one person will Initiate breast feeding as soon as the baby is ready to suckle or
continue to ventilate the baby while the other will assist with as soon as the mother’s condition permits. If breast feeding has
other tasks. If possible, transfer for the mother should also be to be delayed due to maternal or newborn problems, teach the
arranged alongside. mother to express breast milk as soon as possible and ensure
that this milk is given to the newborn. The BFHI promotes,
Stopping Resuscitation protects, and supports breast feeding through The Ten Steps to
Despite complete and adequate resuscitation efforts, some Successful Breast feeding for Hospitals, as outlined by UNICEF/
newborns may undergo brain death if the heart rate is absent WHO are given in Box - 2.
at 15 minutes. Therefore, an absent heart sound, even after
15 minutes, is an absolute indication to stop resuscitation. If Box - 2 : BFHI : Ten steps to successful breast feeding
there is no gasping or breathing at all even after 20 minutes
Maintain a written breast feeding policy that is routinely
of effective ventilation (and cardiac massage, if required), stop 1
communicated to all health care staff
ventilation.
Train all health care staff in skills necessary to implement
Jaundice 2
this policy.
In mild or moderate levels of jaundice, by 5 to 7 days of age
Inform all pregnant women about the benefits and
the baby will take care of the excess bilirubin on its own. If 3
management of breast feeding
high levels of jaundice do not clear up, phototherapy may be
prescribed. The other modalities like exchange transfusion Help mothers initiate breast feeding within 1 hour of
4
and suspension of breast feeding temporarily may be used if birth.
required depending on the cause. Show mothers how to breast feed and how to maintain
5
Common Birth Injuries lactation, even if they are separated from their infants.
A difficult birth or injury to the baby can occur because of Give infants no food or drink other than breast milk,
6
the baby’s size or the position of the baby during labour and unless medically indicated
delivery. Practice “rooming in”-- allow mothers and infants to
7
Breast feeding remain together 24 hours a day.
Feeding of the Newborn : After birth, breast feeding should 8 Encourage unrestricted breast feeding
be initiated as early as possible (within 1 hour) unless there is
Give no pacifiers or artificial nipples to breast feeding
a contraindication. The benefits of early and exclusive breast 9
infants
feeding must be explained to the mother. The baby should be
fed on demand, both day and night. The mother should be Foster the establishment of breast feeding support
advised that she SHOULD NOT- 10 groups and refer mothers to them on discharge from the
●● Force the baby to feed. hospital or clinic
●● Interrupt a feed before the baby is done
Objective of Breast feeding is “Exclusive breast feeding of the
●● Use the artificial teats or pacifiers
first six months of life” to be propagated as it has the following
●● Give the baby any other food or drink for the 1st six months
benefits:
of life.
●● It is the ideal method of infant feeding.
Colostrum : During the first few days after delivery a woman
●● It is the single most cost effective intervention for reduction
produces special milk that is thick, sticky and yellowish or
of infant mortality.
clear in colour. This special milk is called colostrum.
●● Delays return to fertility in the mother and hence acts as a
●● Colostrum contains large quantities of protective
natural contraceptive.

• 829 •
The Infant Milk Substitute (IMS) Act is being implemented and The Causes of LBW : The causes of the LBW have been
following initiatives have been taken- studied and they have inter-related multiple factors acting
(a) Baby Friendly Hospital Initiative simultaneously in the setting of poverty (Table - 4). The famous
(b) Lactation Clinics triad of ‘Malnutrition, Infection and Unregulated fertility’
(c) Peer Counselling operates to produce this unfavourable outcome.
Weaning (Complementary Feeding) : The complementary
feeding means giving the child other nutritious foods in addition Table - 4 : Causes of Preterm and SFA infants
to breast milk. Weaning literally meant taking the child away Preterm infants SFA Infants
from the breast and nourishment by other means. Breast feeding
Incompetent
alone is sufficient to take care of the requirements in 1st six Short stature
cervix
months. Thereafter, concentrated energy dense complementary
foods are essential to maintain adequate velocity of growth for Maternal Medical diseases Undernutrition
the infant. Weaning if not carried out properly, may lead to Primi, grand multipara
malnutrition and illness. Infections
Smoking, tobacco
Small Babies (LBW)
Placenta Abruptio placentae,
Neonates weighing <2500 gm at birth are classified as low Placental
previa, APH infarction, anomalies
birth weight. One third of the births in India are estimated to
be LBWs. These LBWs can be of two broad groups- Preterm Multiple IUGR, multiple
and SFA (small for gestational age) term infants. Most of pregnancy pregnancy
these LBWs are SFA in developing countries while they are Foetal congenital
Congenital
mostly pre-term in developed world. These LBWs face many malformation,
malformation
risks at birth and are prone to many conditions like infections, intrauterine infections
respiratory difficulty and metabolic disturbances. Problems of Uncontrolled
each category are summarized in the Table - 3. Hypertension, toxemia
diabetes

Table - 3 : Hazards of Low Birth Weight (LBW) Infant Hypertension,

Cardiac illness
toxemia
Preterm (<37 weeks) Small for Age (SFA) Medical
Conditions / Cardiac illness Foetal distress
Birth asphyxia Birth asphyxia
complications Foetal distress Rh isoimmunisation
Hypothermia Hypothermia
Rh
Infections Infections Anaemia
isoimmunisation
Metabolic acidosis Meconium aspiration Severe IUGR Malaria
Hyperbilirubinemia Hypoglycemia Improper
Apneic spells Polycythemia Iatrogenic assessment -
of maturity
Respiratory distress ( Hyaline
membrane disease)
Principles of Management of LBWs
Health Risk of being LBW : The low birth weight child begins ●● Care at Birth - All ‘at risk’ pregnancies for LBW babies must
with a disadvantage at birth and this may even have long term take place at a place where optimal facilities exist. Being
implications. The hazards of being born low birth weight are- prone to hypothermia, adequate precautions must be taken
by maintaining a ‘Warm chain’. All arrangements for
Survival : The mortality in infancy is much higher amongst resuscitation of newborn should be available.
those born with weight <2500 gm. This is due to several factors ●● Appropriate place of care - Depending on the birth weight
like physiological immaturity of respiratory, CNS system, liver; the LBW can be cared for at home (>1800 gm) and if
predisposition to hypoglycemia, hypothermia and infections, <1800, at the hospital till the child gains weight and if
malnutrition etc. <1500 gm, these babies will need tertiary level care.
Growth and development : Since LBWs are starting poorly ●● Thermal protection - As outlined elsewhere by delaying
at birth, they are likely to lag behind those born with normal bathing, maternal contact by Kangaroo mother care and
weight. They have delayed milestones and grow poorly. The so external heat source if required.
called ‘catch up growth’ is seen more in preterm babies who are ●● Fluids and feeds - Breast feeding, expressed breast milk,
otherwise appropriate for their age. nasogastric feeding and IV fluids if required.
Syndrome X : This metabolic syndrome is more common ●● Monitoring for early detection and management of
amongst those born with a poor weight at birth. Due to genetic complications like respiratory difficulty, metabolic
programming (thrifty gene hypothesis) they develop tendency disturbances, infections etc.
for accumulation of fat when nutrition is adequate and suffer ●● Kangaroo Mother Care
the ill effects of this condition with increased likelihood of IHD,
hypertension and diabetes.

• 830 •
Kangaroo Mother Care (KMC) : This concept was first presented It is a child’s right to have every chance to survive and thrive.
by Rey and Martinez in Colombia. It has been particularly Moreover, ensuring optimal conditions for a child’s early years
advised in small, preterm and LBW babies but applies well in is one of the best investments that a country can make if it
all babies. In this the key features are as under : is to compete in a global economy based on the strength of
●● Early, continuous and prolonged skin-to-skin contact its human capital. The growth monitoring, correct feeding
between the mother and the baby practices, immunization, responsive health care system, legal
●● Exclusive breast feeding provisions, sensitive society, management during sickness and
●● It is initiated in hospital and continued at home providing protection to these children can help in improving
●● Small babies can be discharged early the lot of this important group of vulnerable population.
●● Mothers at home require adequate support and follow up The concept of well baby clinic, under five clinic and mother
It was developed as an alternative to inadequate and insufficient and child clinics are steps in this direction. The growth and
incubator care for those preterm newborn infants who had development (Growth and Development) and care of sick
overcome initial problems and required only to feed and grow. children (IMNCI) are described in different chapters.
It has been shown to be effective for thermal control, breast Community Based Health Care Interventions
feeding and bonding in all newborn infants. The support binder UNICEF and WHO, have agreed on 12 key household practices
is the only special item required for KMC. The baby is placed for neonates and infants that can help to promote child survival,
between the mother’s breasts in an upright position, chest to health and nutrition in communities:
chest. The position allows mother with both hands free and
(1) Exclusive breast feeding from birth to six months.
ability to move around.
(2) Complementary feeding : Starting at about six months old,
Preventive Strategies to Tackle the Problem of LBW feeding children energy - and nutrient-rich complementary
Direct foods while continuing to breast feed for at least two
●● Maternal nutrition- by improving the pre-pregnancy weight years could prevent more than 10 per cent of deaths from
and maternal nutrition during pregnancy, birth weight of diarrhoea and acute respiratory infections, particularly
the infant can be improved. pneumonia; and increase resistance to measles and other
●● Good antenatal care illnesses.
●● Prevention of infection in the mother (3) Micronutrient Supplementation : Improving the intake of
●● Early diagnosis and management of maternal factors like vitamin A through diet or supplements in communities
anaemia, malaria, hypertension etc. where it is deficient could reduce mortality among children
Indirect aged 6 months to five years by 20 per cent.
●● Delayed marriage and childbearing (4) Hygiene : Better hygiene practices, particularly hand
●● Adequate spacing washing with soap (or ashes) and the safe disposal of
●● Family planning excreta could reduce the incidence of diarrhoea by 35%.
●● Improved socio-economic status (5) Immunization : Vaccination against measles for children
●● Women empowerment under age one could prevent most of the measles - related
deaths each year. Caregivers should make sure children
Infection Prevention in the Newborn : This is an important
complete a full course of immunization (Bacille Calmette-
component of every sphere of newborn care. Newborns are
Guérin; diphtheria, pertussis and tetanus vaccine; oral
more susceptible to infection because of immature immune
polio vaccine; and measles vaccine) before their first
system. This is still more relevant to preterm and low birth
birthday.
weight infants.
(6) Malaria prevention : The use of insecticide-treated mosquito
General Principles nets in households in malaria-endemic areas could lower
●● Consider every person (including staff and the baby) as malaria-related child deaths by as much as 23 per cent.
potentially infectious (7) Psychosocial care and development: Promote mental and
●● Wash hands or use hand rub (alcohol based) before social development by responding to a child’s need for
handling a baby and after care and by talking, playing and providing a stimulating
●● Wear protective clothing like gown, mask, gloves environment.
●● Observe aseptic techniques in all procedures (8) Feeding and fluids for sick children: Continue to feed and
●● Routine cleaning of the ward and all equipment offer more fluids, including breast milk, to children when
●● Isolation of babies with infections they are sick.
●● Routine care of newborn (9) Home treatment: Give sick children appropriate home
Early Childhood treatment for infections.
Children are more likely to survive, to grow in a healthy way, (10) Care seeking: Recognize when sick children need treatment
to have less disease and fewer illnesses, and to fully develop outside the home, and seek care from appropriate
thinking, language, emotional and social skills when well providers.
nurtured and cared for in their earliest years. Frequent illness, (11) Appropriate practices: Follow the health worker’s advice
unsanitary environments and poor nutrition steal a child’s about treatment, follow-up and referral.
potential. (12) Antenatal care: Every pregnant woman should have
adequate antenatal care.

• 831 •
Further important practices that protect children include - are as under-
providing appropriate care for those who are affected by HIV and Infant & Child Health
AIDS, especially orphans and vulnerable children; protecting (a) Reduction of new-born deaths, infant deaths and
children from injury and accident, abuse and neglect; and child deaths by providing continuous health care and
involving fathers in the care of their children. Many of these strengthening of new-born care infrastructure facilities.
practices can be undertaken by community health workers (b) Organizing counselling sessions for the mothers.
or by community members themselves, given the appropriate (c) Implementing integrated management of neonatal and
support and distribution of products and services. The direct childhood illness as a pilot initiative in selected districts.
involvement of the community is perhaps most appropriate for (d) Operationalising infant death/stillbirth verbal autopsy.
those aspects of health care and nutrition that most closely (e) Addressing the issue of female infanticide and foeticide
affect members on a daily basis. These include infant and
IMNCI : Integrated Management of Neonatal and Childhood
young child feeding, other caring practices, and water and
Illness (IMNCI)
sanitation.
Integrated Management of Childhood Illness (IMCI) strategy,
Special Child Survival Initiatives in India which has already been implemented in more than 100 countries
CSSM : The Child Survival and Safe Motherhood Programme all over the globe, encompasses a range of interventions to
jointly funded by World Bank and UNICEF was started in prevent and manage five major childhood illnesses i.e. Acute
1992-93 for implementation up to 1997-98. The Child Survival Respiratory Infections, Diarrhoea, Measles, Malaria and
and Safe Motherhood Programme was implemented in a phased Malnutrition. It focuses on preventive, promotive and curative
manner covering all the districts of the country by the year aspects, i.e. it gives a holistic outlook to the programme. The
1996-97. The objectives of the programmes were to improve details on the care of sick children are given in the chapter on
the health status of infants, child and maternal morbidity and IMNCI.
mortality. The programmes seek to sustain high coverage levels Home Based Care of Newborns and Mothers - (SEARCH) A
achieved under the Universal Immunisation Programme (UIP) Project : In the Gadchiroli district of India, Drs. Abhay and
in good performance areas and strengthen the immunisation Rani Bang and colleagues at the Society for Education, Action
services of poor performing areas. The programme also provides & Research in Community Health (SEARCH) have developed a
for augmenting various activities under the Oral Rehydration remarkable approach to home-based health care that benefits
Therapy (ORT) Programme, universalising prophylaxis schemes both newborns and their mothers. It had to be home-based
for control of anaemia in pregnant women & control of blindness because 83 percent of births in rural India occur at home, and
in children and initiating a programme for control of Acute these villagers have virtually no access to health facilities.
Respiratory Infection (ARI) in children. The Programme yielded After two years of research, SEARCH introduced neonatal
notable success in improving the health status of pregnant care through trained village health workers and trained birth
women, infants and children & also making a dent in IMR, attendants, who provide health education to new mothers,
MMR and incidence of vaccine preventable diseases. support breast feeding and maintenance of body temperature,
UIP : Universal Immunization Programme against six and recognize danger signs in mothers and babies. By the third
preventable diseases, namely, diphtheria, pertussis, childhood year of the program, which tracked results in 39 intervention
tuberculosis, poliomyelitis, measles and neonatal tetanus was villages and 47 control villages, SEARCH had recorded a
introduced in the country in a phased manner in 1985, which 62 percent reduction in the neonatal mortality rate for the
covered the whole of India by 1990. Significant progress was intervention areas as well as a significant reduction in various
made under the Programme in the initial period when more neonatal and maternal morbidities. This strategy has been
than 90% coverage for all the six antigens was achieved. The recognized as a valuable option for the districts with high
UIP was taken up in 1986 as National Technology Mission infant mortality.
and became operational in all districts in the country during Tackling infant mortality is largely an issue of addressing the
1989-90. UIP become a part of the Child Survival and Safe perinatal mortality. Perinatal mortality improves by universal
Motherhood (CSSM) Programme in 1992 and Reproductive coverage of all deliveries with skilled attendance at birth and
and Child Health (RCH) Programme in 1997. Under the essential maternal and newborn care coupled with effective
Immunization Programme, infants are immunized against referral mechanism and back up FRU facilities. Post neonatal
tuberculosis, diphtheria, pertussis, poliomyelitis, measles and mortality is amenable to known interventions and is easiest to
tetanus. tackle by launching child survival methods like ORT, treating
ORT : The diarrhoeal disease control programme was started pneumonia, breast feeding, supplementary feeding, weaning
in the country in 1978. The main objective of the programme practices and immunization. The infant survival is related
was to prevent death due to dehydration caused by diarrhoeal largely to clean delivery practices, correct feeding practices,
diseases among children under 5 years of age due to dehydration. immunization and availability, adequacy and timely health
Health education aimed at rapid recognition and appropriate care during sickness especially due to Diarrhoea, ARI and
management of Diarrhoea has been a major component of the measles. The malnutrition is one single factor which touches
CSSM. Under the RCH programme ORS is supplied in the kits to all of these and determines the survival of the infant. The core
all sub-centres in the country every year. interventions for child survival are given in Box - 3.
RCH : The initiatives under RCH for newborn and infant care

• 832 •
 in Kerala and Goa. Major causes of Infant mortality in India
Box - 3 : Core Interventions to Improve Child Survival
are Low birth weight(57%), Respiratory infections(17%),
Skilled attendance during pregnancy Child birth and the Congenital malformations(5%), Diarrhoeal diseases(4%) and
immediate postpartum period : Nurturing newborns and Birth injury(3%).
their mothers.
Infant mortality can be due to prenatal, intranatal and postnatal
Infant feeding : Exclusive breast feeding during the first causes. Prenatal causes are Maternal age (teenage and
six months of a child’s life, with appropriate complementary elderly), Maternal diseases like hypertension, cardiovascular,
feeding from six months and continued breast feeding for diabetes and anaemia, Uterine and cervical defects, Blood
two years or beyond, with supplementation with vitamin A incompatibilities, Malnutrition, Ante-partum haemmorhage
and other micronutrients as needed. and Feto-congenital defects. Intranatal causes are Birth
Vital vaccines : Increased coverage of measles and tetanus trauma, Birth asphyxia, Prolonged or difficult labour and
vaccines, as well as immunization against common vaccine- Obstetric complications. Postnatal causes are Preterm or low
preventable diseases. birth weight baby, Respiratory distress syndrome, congenital
anomalies and Infections.
Combating diarrhoea : Case management of diarrhoea,
including therapeutic zinc supplementation and antibiotics Preventive strategies for reducing Infant mortality are divided
for dysentery. into direct and indirect methods. Direct methods are Safe and
clean delivery by skilled birth attendant, Essential care of
Combating pneumonia and sepsis : Case management of newborn, Newborn resuscitation, Infection control measures,
childhood pneumonia and neonatal sepsis with antibiotics. Exclusive breast feeding, Early diagnosis and management
Combating malaria : Use of insecticide-treated bednets, of complications, Special care for preterm and premature
intermittent preventive malaria treatment in pregnancy, and infants, ORT and antibiotics for Diarrhoea and ARI respectively
prompt treatment of malaria. and Immunization. Indirect methods are Family planning,
Prevention and care for HIV : Treatment, care, infant Prenatal nutrition of mothers, Education, Antenatal care,
feeding counselling and support for HIV-infected women and Growth monitoring of child, Prevention of malnutrition, Vit A
their infants. prophylaxis, Improved water and sanitation, Access to primary
health care and overall socio-economic development.
Summary Care of newborn at birth is primarily aimed at helping the
Infancy is the first year of life and is marked by greatest threat newborn to adjust to extra-uterine environment. Physiological
to survival and therefore is a good measure of the progress of adaptations include initiation of respiration and oxygenation
a country. It is sub-divided into Perinatal, Early neonatal, Late of the arterial blood, temperature adaptation and initiation of
neonatal and Post neonatal period. Babies are very vulnerable breast feeding. The Baby Friendly Hospital Initiative (BFHI)
during their first week of life and also when they are weaned. promotes, protects and supports breast feeding through the
Infant Mortality Rate (IMR) has special significance because it ten steps to successful breast feeding for hospitals as outlined
is a single category with highest age-specific mortality, measure by UNICEF/WHO. Objective of breast feeding is Exclusive
of PQLI. Deaths are due to causes different from adults and breast feeding for the first six months of life. The Infant Milk
hence IMR indicates measures directed to mother and child in Substitute (IMS) act is being implemented and the initiatives
a country. are Baby friendly hospital initiative, Lactation clinics and Peer
counselling.
Each year, 4 million children die during neonatal period
worldwide. Neonatal deaths contribute to 40% of deaths Over 90% of newborns do not require active resuscitation at
in Under-5 children and more than half of infant mortality birth. In these cases the mother is advised to return to hospital
worldwide. Rates are highest in Sub-saharan Africa and Asia. immediately if infant is breast feeding or drinking poorly,
The average IMR is 54 per 1000 for the world (2004). The becomes sicker, develops fever or feels cold to touch, difficult
highest rates of IMR are in Sierra Leone and Afghanistan and breathing and blood in stools. In case of Jaundice the child is
lowest in Japan. Consecutive household surveys in developing taken to hospital if Jaundice is noted during first 24 hours or
countries have shown a reduction in neonatal mortality rates baby develops a fever over 100°F or colour deepens after day
of which maximum reduction is in late neonatal period. 7 or Jaundice does not disappear after day 15 or baby is not
gaining sufficient weight.
In India the infant mortality rate is declining steadily over the
years but the decline has been slower than desirable. IMR in Complementary feeding or weaning means giving the child other
2006 for India was 57. The deaths in the first year of life account nutritious foods in addition to breast milk and is done after
for 18.7% of total deaths in the country. Of these Infant deaths 6 months. In this, complementary energy dense foods, which
more than 60% occur in neonatal period. Of these neonatal are locally available and are inexpensive, easily digestible and
deaths 40% occur in first week of life (Early neonatal period). culturally acceptable are given.
The greater mortality risk is associated with girl child, children Neonates weighing less than 2500 grams at birth are classified
of mothers aged less than 20 and more than 40, children born as low birth weight. They can be divided into Pre-term babies
in rural areas, children of mothers with no formal education, and Small for Gestational Age (SFA) babies. The health risks
children of scheduled castes and tribes. In India IMR is highest of being low birth weight are decreased survival, delayed
in Uttar Pradesh, Chattisgarh and Madhya Pradesh and lowest milestones, poor growth and development and increased

• 833 •
chances of Syndrome X later in life. The famous triad causing MCQs :
LBW babies include Malnutrition, Infection and Unregulated 1. Premature infant is one which is born: (a) Before 40 weeks
fertility. Principles of management of LBW babies include care (b) Before 38 weeks (c) Between 28-37 weeks (d) Between
at birth, appropriate place of care, thermal protection, fluids 28-42 weeks
and feed, monitoring for early detection and management of 2. All are true of colostrum except: (a) Rich in proteins and
complications and Kangaroo Mother Care (KMC). minerals (b) Rich in anti-infective factors (c) Rich in fats
The preventive strategies to tackle the problem of LBW are (d) Secreted for first few days
improving maternal nutrition, good ante-natal care, prevention 3. Breast feeding should be started _____ hours after birth:
of infection of the mother, early diagnosis and treatment of (a) Within 1 hour (b) 2 hours (c) 24 hours (d) 48 hours
anaemia or hypertension or malaria etc., delayed marriage or 4. LBW baby is one whose weight is below: (a) 2200 grams
childbearing, adequate spacing, family planning, improved (b) 2000 grams (c) 1500 grams (d) 2500 grams
socio-economic status and women empowerment. 5. Exclusive breast feeding is sufficient for ____ months after
UNICEF and WHO has agreed on 12 key household practices birth: (a) 1 month (b) 2 months (c) 6 months (d) 9 months
for neonates and infants that can help promote child survival, 6. Low birth weight child is due to all except: (a) Maternal
health and nutrition in communities. These are Exclusive breast malnutrition (b) Infections (c) Unregulated fertility
feeding for six months, complementary feeding, micronutrient (d) Previous caesarean section
supplementation, hygiene, immunization, malaria prevention, 7. Single most important factor determining survival chances
psychosocial care and development, feeding and fluids for sick of newborn is: (a) Birth order (b) Multiple gestation
children, home treatment, care seeking appropriate practices (c) Intrauterine infection (d) Low birth weight
and ante-natal care. 8. Adverse factor for child health is : (a) Birth order 5 or more
(b) Maternal malnutrition (c) Teenage mother (d) All of the
The important special child survival initiatives in India include above
CSSM (Child Survival and Safe Motherhood Programme), UIP 9. Perinatal period is: (a) 20-32 weeks of gestation (b) 37-42
(Universal Immunization Programme), RCH, IMNCI (Integrated weeks of gestation (c) 28 weeks of gestation to 1 week
Management of Neonatal and Childhood Illness). postnatal period (d) 28 weeks of gestation to 1 week
Initiatives under RCH for newborn and infant care include postnatal period (d) 32 weeks of gestation to 2 week
reduction of newborn deaths, infant deaths and child deaths postnatal period
by providing continuous health care and strengthening of 10. Perinatal mortality includes: (a) Stillbirths (b) Neonatal
newborn care infrastructure facilities, organizing counselling deaths (c) Stillbirths and Early neonatal deaths
sessions for the mothers, implementing IMNCI as a pilot project (d) Stillbirths and Neonatal deaths
in selected districts, operationalising infant death/still birth 11. Infant mortality rate in India in 2006 was: (a) 64 (b) 67
verbal autopsy and addressing the issue of female infanticide (c) 54 (d) 57
and foeticide. 12. The denominator in IMR is: (a) Total no of live births
IMNCI straregy encompasses a range of interventions to prevent (b) Total no of live and still births (c) Total no of still births
and manage five childhood illnesses i.e. ARI, Diarrhoea, (d) Total population
Measles, Malaria and Malnutrition. It promotes on preventive, Answers : (1) a; (2) c; (3) a; (4) d; (5) c; (6) d; (7) d; (8) d;
promotive and curative aspects i.e. it gives a holistic attitude (9) c; (10) c; (11) d; (12) a.
to the programme.
References
Study Exercises 1. Concept and strategy Framework- Integrated Management of Neonatal and
Child Illnesses (IMNCI) - Government of India, State Governments, UNICEF
Long question : Discuss various causes of high IMR in and WHO) - February, 2004.
developing countries and strategies to prevent it. 2. Ministry of Health and Family Welfare. RCH II Document.
3. MCH Division. Ministry of Health and Family Welfare. National Child Survival
Short notes : (1) BFHI (2) IMR and its trend in India (3) Causes and Safe Motherhood program. New Delhi: 1994.
of Infant mortality (4) Essential newborn care (5) Breast feeding 4. Registrar General of India. www.censusindia.net (Census of India, 2001).
(6) Weaning (7) LBW (8) Kangaroo mother care 5. WHO. 1997. Hypothermia in the newborn. In: Thermal protection of the
newborn: a practical guide. Geneva, WHO press, 1997
6. WHO and UNICEF, 2003. Integrated management of neonatal and childhood
illness. Assess and classify the sick young infant age up to 2 months. Ministry
of health and Family Welfare, Government of India, New-Delhi, 2003
7. WHO. Essential Newborn Care. Proceedings of Report of a technical working
group Trieste, 25-29 April 1994. Geneva, WHO press, 1994

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 and Child Development (DWCD), Child-in-Need Institute (CINI),
Integrated Management of WHO, UNICEF, eminent Paediatricians and Neonatologists,
144 Neonatal and Childhood Illnesses and the representatives from Ministry of Health and Family
(IMNCI) Welfare, Government of India. The Adaptation Group developed
Indian version of IMCI guidelines and renamed it as Integrated
Management of Neonatal and Childhood Illness (IMNCI).
A S Kushwaha
Approach
Accumulated evidence has suggested that an integrated and The IMNCI approach has some distinct features which are given
syndromic approach is needed for efficient management of sick as under-
children to improve outcomes. On analysis of the major causes (a) Syndromic Approach : Mostly the children suffer from
of mortality in childhood and evidence based data, an approach a constellation of symptoms and need to be treated as a
called IMCI (Integrated Management of Childhood Illnesses) was whole. Many sick children present with overlapping signs
developed by WHO. This encompasses a range of interventions and symptoms of illnesses, and a single diagnosis may not be
to prevent and manage five major childhood illnesses i.e. feasible or appropriate, especially in a primary care level with
Acute Respiratory Infections, Diarrhoea, Measles, Malaria scarce resources. The Syndromic approach gives the advantage
and Malnutrition. It focuses on the preventive, promotive and of not missing out on co-existing conditions while presenting
curative aspects of the disease management with participation with a particular condition.
of the mother also in the process, i.e. it gives a comprehensive (b) Holistic Approach : This means that taking care of all the
and holistic outlook to the programme. factors that determine the health of the child. While treating
As part of Millennium Development Goals (MDGs), Goal 4 and for diarrhoea, the immunization and nutritional factors are
Target 5 are to reduce by two third, the mortality in the children also addressed.
under five. India is a signatory to the MDGs adopted in 2000 as (c) Triage : Management is planned after triage of the patient
part of the Millennium Declaration. A Core Group was constituted into those needing emergent, early treatment, referral or care
which included representatives from Indian Academy of at home.
Pediatrics (IAP), National Neonatology Forum of India (NNF),
National Anti Malaria Program (NAMP), Department of Women

Fig. - 1 : IMNCI Approach

OUT PATIENT HEALTH FACILITY

Check for DANGER SIGNS
(Convulsions, Lethargy/Unconsciousness, lnability to drink/breastfeed, Vomiting)

Assess MAIN SYMPTOMS

(Cough/Difficulty in breathing, Diarrhoea, Fever, Ear problems)

Assess Nutrition and immunisation status and potential feeding problems

Check for other problems

Classify CONDITIONS AND IDENTIFY TREATMENT ACTIONS

TREATMENT AT OUT PATIENT

HOME MANAGEMENT
HEALTH FACILITY
URGENT REFERRAL HOME
OUT PATIENT HEALTH FACILITY (Caretaker is counselled on Home
OUT PATIENT HEALTH FACILITY
(prereferral treatments. Advice Treatments, Feeding and fluids,
(Treat Local Infection, Give Oral
Parents, Refer child) When to return immediately,
Drugs, Advise and teach caretaker,
Follow up)
Follow up)

REFERRAL FACILITY
Emergency Triage and Treatment, Diagnosis, Treatment, Monitoring and Followup

• 835 •
(d) Standardized Case Management : Standardized case (d) Nasal flaring
management based on the classification / severity of illness (e) Grunting
(e) Primary Health Care Model : Based on primary health care (f) Bulging Fontanelle
model and referral to a facility when required. (g) Abnormal Axillary temperature (more than 37.5°C or less
than 35.5°C)
(f) Community Participation : The IMNCI approach gives due
(h) Large Boil on the skin
importance to the role of the mother in the whole process of
(j) Lethargy or Unconsciousness
prevention, early diagnosis and management of the case at
(k) History of Convulsions
home by providing counselling to the caretaker.
(l) Less than normal Movements
Components of IMNCI If any one of these criteria is present, the infant is classified
The major components of this strategy are: as having possible serious bacterial infection. Infant is to be
(a) Strengthening the skills of the health care workers referred to hospital urgently for admission. The pre-referral
(b) Strengthening the health care infrastructure treatment consists of administering first dose of antibiotics
(c) Involvement of the community (intramuscular ampicillin 100 mg/Kg and gentamicin 5mg/
The first two components are the facility based IMNCI and the Kg) ; giving expressed breast milk (or appropriate animal milk
third is the community based IMNCI in which mother is actively orally or by nasogastric tube) to prevent hypoglycemia and
involved in the care of child in health and disease. providing warmth by skin to skin contact (kangaroo care) to
avoid hypothermia.
Steps in Management
2. Local Infection : The infant has local bacterial infection if
(ACT- assess, classify and treat) (See Fig. - 1)
there is redness of umbilicus, pus discharge from ear or less
The basic steps in the management of the sick children are as than 10 skin pustules. All such cases are given oral antibiotic
under- - (cotrimoxazole 6 mg/kg/day of trimethoprim or amoxicillin 30
(a) Assess the child for group of symptoms mg/kg/day) for 5 days. The mother is taught to apply gentian
(b) Classify the severity of disease violet and dry the ear by wicking. Ear is dried at least 3 times
(c) Treat as per the laid out plan daily. Clean absorbent cloth or soft, strong tissue paper is rolled
(d) Counsell the mother into a wick and placed in the young infant’s ear. It is removed
(e) Follow up care when wet. Replace the wick with a clean one and repeat these
Age Categories steps until the ear is dry. To treat skin pustules or umbilical
Depending on the age of the child, various clinical signs infection, gentian violet paint is applied twice daily. The mother
and symptoms differ in their degree of reliability, diagnostic should gently wash off pus and crusts with soap and water. Dry
value and importance and even the principles of management the area and paint with gentian violet 0.5%. To treat thrush
also differ. The IMNCI guidelines therefore recommend case (ulcers or white patches in mouth) the mother should wash
management procedures based on two age categories: hands and then wash mouth of the child with clean soft cloth
wet with salt water wrapped around the finger. After cleaning,
(a) Young infants (age up to 2 months)
the mouth is painted with gentian violet 0.25%. The infant is
(b) Children (2 months up to 5 years)
followed up after 2 days.
Young Infants (Age Up to 2 Months) : Neonates and infants
below 2 months of age are considered as a special group for 3. Jaundice : (a) Jaundice in a neonate appearing at less than
several reasons. They become sick rapidly and can die quickly 24 hrs or after 14 days or associated with yellow discolouration
due to serious bacterial infections. Certain general signs in of palms and soles is classified as severe jaundice. Infant
these infants such as low body temperature, fever or less body requires urgent referral to the hospital after giving pre-referral
movements may be the only manifestation of illness. On the treatment which includes oral expressed breast milk, skin to
other hand, a finding such as mild chest in-drawing is normal skin contact and advising mother to keep the infant warm en
in them due to a soft chest wall. Therefore the assessment and route to hospital.
classification process is different from that in an older infant (b) If the infant has jaundice but palms and soles are not yellow,
or child. mother is reassured and the infant is reviewed after 2 days.
Assessment (Assess for BCD IF Hypothermic) It is important to advice the mother to return immediately if
the infant develops any signs of serious bacterial infection or
(a) For serious Bacterial infection or local infection
jaundice on palms and soles.
(b) For jaundice (Colour of skin)
(c) For Diarrhoea 4. Low Body Temperature : In every sick young infant, Axillary
(d) Checking the Immunization status temperature should be recorded. If it is 35.5 - 36.4°C, the infant
(e) For Feeding problem or malnutrition and breast feeding is said to have low body temperature. Such an infant is warmed
(f) For low body temperature (Hypothermic) by skin to skin contact for one hour and reassessed. If there
1. Serious Bacterial Infection : Suspect possible serious is no improvement, he is referred to hospital, while feeding
bacterial infection if there is - (remember STING BALL CM) expressed breast milk to prevent hypoglycemia.
(a) Skin pustules (10 or more) 5. Diarrhoea : If the stools have changed from the usual pattern
(b) Tachypnoea (60 breaths per minute or more) and have increased in number and watery (more water then
(c) Severe chest In-drawing fecal matter), infant is said to have Diarrhoea. The normally

• 836 •
frequent or loose stools of a breast fed baby are not considered 6. Feeding Problems and Malnutrition
as Diarrhoea. Duration of Diarrhoea and history of blood in (a) Weight : The present weight and birth weight should
the stool are important questions in the history. Assess for be noted. Using the reference growth charts, the infant is
presence and severity of dehydration. classified as very low weight for age, low weight for age or not
Severe dehydration : If the young infant has two of the low weight for age.
following three signs, the dehydration is severe : (b) Feeding : Feeding should be assessed immediately if the
(a) Lethargic or unconscious infant feeds less than 8 times in 24 hours, receives no other
(b) Sunken eyes foods or drinks, or is low weight for age and has no indications
(c) Skin pinch goes back very slowly (> 2 seconds) to refer urgently to hospital. The infant should be put to the
If such an infant has low weight or any other severe breast and observed for attachment and effective suckling.
classification, he is referred urgently to hospital. The pre-referral Blocked nose, oral thrush and breast or nipple problems (flat
treatment includes first dose of IM antibiotics (ampicillin and or inverted nipples, sore nipples, engorged breasts or breast
gentamicin), giving frequent sips of ORS on the way, continuing abscess) should be looked for. If the young infant is not able to
breast feeding and keeping the infant warm. If the infant does feed, has no attachment at all, is not sucking at all or is very
not have low weight or another severe classification, fluids are low weight for age, he has a life threatening problem and needs
administered for severe dehydration as per plan C and he is urgent admission to hospital after administering pre-referral
then referred to hospital after rehydration. The ORS should be treatment. If there are other feeding problems or the infant is
continued. If IV fluids cannot be given, fluids by nasogastric low weight for age, counselling of the mother is done about
tube could be given. If none of this is feasible refer to a correct position during breast feeding, increasing frequency of
hospital. feeds, treatment of breast and nipple problems and treatment
Some dehydration : If the young infant has two of the of thrush. The infant is followed up after 2 days for feeding
following three signs he is classified to have some dehydration. problem and after 14 days for low weight for age.
Oral rehydration is the mainstay. 7. Checking the Young Infant’s Immunization Status : Check
(a) Restless, irritable whether OPV, BCG, DPT-1 and Hep B-1 vaccines have been
(b) Sunken eyes administered in every sick young infant. An infant who is
(c) Skin pinch goes back slowly. not sick enough to be referred to hospital should be given the
If the infant has low weight or another severe classification, necessary immunization before being sent home.
first dose of IM antibiotics (ampicillin and gentamicin) are 2 Months to 5 Years
given and urgent referral to hospital is done, with mother giving A sick child aged 2 months to 5 years may present to the primary
frequent sips of ORS on the way, continuing breast feeding health care facility with common ailments like pneumonia,
and keeping the infant warm. If the infant does not have low Diarrhoea, fever or an ear infection. The child in addition
weight or another severe classification; fluids are administered may also have malnutrition and anaemia. Irrespective of the
for some dehydration as per plan B. The mother is told to give presenting complaints the child is assessed in a comprehensive
more if child asks. If the child vomits wait for 10 minutes and manner as under-
then resume. Reassess after 4 hours and re-classify. Breast
Steps of Initial Assessment
feeding should be continued. The mother is counselled to
return immediately if not improving, not accepting fluids and (a) Ask the mother about the child’s problem.
has blood in stools. Follow up visit in 2 days is recommended (b) Check for general danger signs.
or earlier if danger signs develop. (c) Ask the mother about the four main symptoms: (CDEF)
(i) Cough or difficult breathing
No dehydration : If there are not enough signs to classify as (ii) Diarrhoea
some or severe dehydration, the infant has no dehydration and (iii) Ear problem
is given fluids to treat Diarrhoea at home as per plan A. The (iv) Fever.
follow up is done in 5 days and mother is also advised when to (d) If one of the four above mentioned symptoms is present:
return immediately. (i) Assess the child further for signs related to the main
Severe persistent diarrhoea : Severe persistent Diarrhoea symptom
is Diarrhoea lasting 14 days or more and the infant with this (ii) Classify the illness according to the signs which are
classification is referred to hospital. Give inj Ampicillin or present or absent.
gentamicin if the child has low weight, Diarrhoea or any other (e) Check for signs of malnutrition and anaemia
severe classification, keep the child warm and treat to prevent (f) Check the child’s immunization status
hypoglycemia as part of pre-referral treatment. (g) Assessing for any other problems.
Severe Dysentery : If there is blood in the stool, the young Look for General Danger Signs : A sick child brought to the
infant has severe dysentery and is similarly referred to primary health care facility may have signs that point towards
hospital. Administer same pre-referral treatment as above a specific problem. However, some children may present with
before sending to hospital in the presence of any criteria of serious, non-specific signs called “General Danger Signs” that
severe classification. may not point to a particular diagnosis. For example, a child
who is having convulsions or is unconscious may be suffering
from any of the diseases like meningitis, epilepsy or cerebral

• 837 •
malaria. It may be simply febrile convulsions. Presence of these immediately.
general danger signs suggest that a child is severely ill and No Pneumonia - Cough or Cold : If there are no signs of
needs urgent attention. The following general danger signs are pneumonia, the classification is no pneumonia. The child
routinely checked in all children : (V ICU) is suffering from minor bout of cough or cold which can be
(a) Repeated Vomiting managed symptomatically at home and does not warrant
(b) Inability to drink or breast feed antibiotics. Such a child is followed up after 5 days if not
(c) Convulsions improving, or immediately if any of the danger signs develop
(d) Lethargy or Unconsciousness or the child deteriorates.
If a child has any one or more of these signs, he is considered (B) Diarrhoea : A child presenting with Diarrhoea should first
seriously ill and should be referred. In order to start treatment be assessed for general danger signs and the child’s caretaker
for severe illnesses without delay, the child should be quickly should also be asked if the child has cough or difficult
assessed for the most important causes of serious illness and breathing.
death - acute respiratory infection (ARI), Diarrhoea, and fever
A child with Diarrhoea may have three potentially lethal
(especially associated with malaria and measles). A rapid
conditions:
assessment of nutritional status is also essential.
(a) Acute watery Diarrhoea (including cholera)
Check for Four Major Symptoms (Remember CDEF) : After (b) Dysentery (bloody Diarrhoea)
checking for general danger signs, the health care provider (c) Persistent Diarrhoea (Diarrhoea that lasts 14 days or
must check for the following main symptoms: more).
(a) Cough or difficult breathing All children with Diarrhoea should be checked to determine the
(b) Diarrhoea duration of Diarrhoea, if blood is present in the stool and if
(c) Ear problems dehydration is present.
(d) Fever
Diagnosis & Management Check Dehydration : Based on a combination of the following
clinical signs, children presenting with Diarrhoea are
(A) Cough or Difficult Breathing : Any child with cough or classified into the three categories of severe dehydration, some
difficult breathing is assessed by respiratory rate, chest in- dehydration and no dehydration and appropriate treatment is
drawing and presence of stridor. to be given. Main clinical signs are used to determine the level
(a) Respiratory rate: A child’s age cut-off rate for fast breathing of dehydration
that suggests pneumonia is:
Severe Dehydration (Plan C) : Presence of at least two
(i) 2 months up to 12 months: 50 breaths per minute or of the following signs classifies the child as having severe
more dehydration.
(ii) >12 months up to 5 years : 40 breaths per minute or (a) Lethargic or unconscious
more (b) Sunken eyes
(b) Lower chest wall in-drawing (c) Not able to drink or drinking poorly
(c) Stridor (d) Skin pinch goes back very slowly
Based on the above clinical signs, children presenting with Child should be managed in the primary health care facility
cough or difficult breathing are classified in to one of the three with fluids. Re-assess every 1-2 hours and if required, fluid
categories: can be repeated once. The ORS should be continued. If IV fluids
(a) Severe pneumonia or very severe disease cannot be given, fluids by nasogastric tube could be given.
(b) Pneumonia If none of this is feasible refer to a hospital. However if the
(c) No pneumonia (i.e. cough or cold). child has any other severe classification, he should be urgently
Severe Pneumonia / Very severe disease : The child is classified referred to hospital. Oral doxycycline (5 mg/kg/day) should be
as severe pneumonia /very severe disease if any general administered if cholera is prevalent in the area.
danger sign or chest in-drawing or stridor in an otherwise Some dehydration : Look for the signs of dehydration-
calm child is present. This child needs urgent attention and
If two or more of the signs are present the, classification is
should be referred to a hospital by quickest means available,
some dehydration. The child should be treated as per Plan B.
after administering the first dose of injectable antibiotic (IM
Chloramphenicol 40mg/kg/dose) or if not possible, give oral Such a child is followed up after 5 days if not improving.
amoxicillin 15mg/kg/dose. Mother is counselled to return immediately if child has any of
the following signs:
Pneumonia : If only fast breathing is present without any
1. Not able to drink or breast feed
stridor or chest in-drawing and there are no general danger
2. Becomes sicker
signs, the child is classified as having pneumonia and is
3. Develops fever
managed by oral antibiotics, cotrimoxazole (trimethoprim
4. Passes blood in stool
8 mg/kg/day) for 5 days. Additional symptomatic treatment to
soothe the throat and a safe cough remedy for children older No dehydration : The child is classified as if there are not
than 6 months may be given. The mother is advised to return enough signs to classify into some or severe dehydration.
for follow up after 2 days. However if danger signs develop or Treatment is given at home with fluids and feeds as per Plan
the child becomes sicker, the mother should be asked to return A. The mother is advised to return after 5 days or immediately

• 838 •
if above danger signs develop like not able to drink or breast Malaria there are no symptoms of runny nose, measles or any
feed, becomes sicker, develops fever or passes blood in stool. other cause of fever. The antimalarials given after making a
Dysentery : A child is classified as having dysentery if the blood smear are as follows:
mother or caretaker reports blood in the child’s stool. This Presumptive treatment
should be treated with oral cotrimoxazole (8mg/kg/day (i) Oral chloroquine 10 mg/kg single dose on Day 1
of trimethoprim in 2 divided doses) for 5 days. The child is (ii) In areas of high chloroquine resistance, give oral
followed up after 2 days. sulphadoxine (25 mg/kg) plus pyrimethamine
Persistent Diarrhoea : All children with Diarrhoea lasting (1.25 mg/kg)
for 14 days or more are said to have persistent Diarrhoea. Radical treatment in Smear positive Pf case
If dehydration is present, the child is classified as severe (i) Oral chloroquine 10 mg/kg single dose
persistent Diarrhoea and should immediately be sent to (ii) Oral primaquin 0.75 mg/kg single dose
hospital. If dehydration is not present, the child is given a Radical treatment in Smear positive Pv case
single dose of vitamin A and oral zinc sulphate 20 mg daily for (i) Oral chloroquin 10 mg/kg single dose
14 days and the mother or caretaker is given counselling on (ii) Oral primaquin 0.25 mg/kg daily for 5 days
feeding of the child. If still breast feeding, give more frequent,
In a child being treated for malaria, the mother should be
longer breast feeds, day and night. If taking other milk replace
advised to return immediately if the child becomes sicker or is
with increased breast feeding OR replace with fermented
unable to drink or breast feed. The child should be followed up
milk products, such as yoghurt OR replace half the milk with
after 2 days if fever persists or recurs within 14 days. If fever
nutrient-rich semisolid food. Add cereals to milk (Rice, Wheat,
persists every day for 7 days the child should be referred for
Semolina). The child is followed up after 5 days.
assessment.
(C) Fever : Children are considered to have fever if the body
Measles : A child with fever is assessed for signs of measles
temperature is above 37.5°C axillary (38°C rectal). In the
such as generalized rash with cough, runny nose and red
absence of a thermometer, children are considered to have fever
eyes.
if they feel hot or there is a history of fever. Body temperature
should be checked in all sick children brought to an outpatient ●● If the child has measles or has had measles within the
clinic. A child presenting with fever should be assessed for last 3 months, and there is any general danger sign or
common serious causes like malaria, meningitis and measles. clouding of cornea or deep / extensive mouth ulcers, the
The following information is important: classification is Severe complicated measles. This child
should be urgently referred to hospital after giving first
(a) Risk of malaria based on the geographic area endemic for
dose of oral vitamin A, chloramphenicol IM and tetracycline
it
eye ointment application.
(b) Presence of bulging fontanelle or stiff neck suggesting very
●● If the child has measles now or has had measles within the
severe febrile illness such as meningitis
last 3 months, and there is pus draining from eye or mouth
(c) Presence of running nose, conjunctival congestion or
ulcers are present, he is classified to have measles with eye
generalized rash suggestive of measles
or mouth complications, and given first dose of vitamin
Serious Febrile Illness : A child with fever is classified as A, tetracycline eye ointment and gentian violet for mouth
having serious febrile illness if there is any general danger sign ulcers. Follow up is done after 2 days.
or stiff neck or bulging fontanel. He requires urgent referral to ●● If the child has measles now or has had measles within the
hospital. Pre- referral required to be given to the child is a dose last 3 months, with none of the above signs, only first dose
of IM quinine (10 mg/kg/dose) after making a blood smear; of vitamin A is given.
first dose of IV or IM chloramphenicol (40 mg/kg/dose or if not
(D) Ear Infections : Any sick child should be assessed for ear
possible oral amoxicillin 15 mg/kg/dose), feeding to prevent
problems such as ear pain or ear discharge. If there is a tender
hypoglycemia and one dose of paracetamol (15 mg/kg) for high
swelling behind the ear, the child has mastoiditis. He should be
fever (temp. 38.5°C or above).
given first dose of IM chloramphenicol and urgently referred to
High Malaria Risk area : Children with fever but without any hospital. If there is pus discharge or ear pain, the classification
danger sign or stiff neck or bulging fontanel are classified as is acute ear infection and oral antibiotic (cotrimoxazole) should
Malaria and should be treated with antimalarials after making be given for 5 days. Dry the ear at least 3 times daily. Roll clean
a blood smear. The antimalarials given are as follows: absorbent cloth or soft, strong tissue paper into a wick. Place
Presumptive treatment - the wick in the young infant’s ear. Remove the wick when wet.
(i) Oral chloroquine 10 mg/kg single dose on Day 1, 10 mg/kg Replace the wick with a clean one and repeat these steps until
single dose on Day 2 and 5 mg/kg single dose on Day 3. the ear is dry.
(ii) In areas of high chloroquine resistance, give oral (E) Malnutrition : Every sick child should be weighed and
sulphadoxine (25 mg/kg) plus pyrimethamine (1.25 mg/ assessed for visible severe wasting and oedema of both feet.
kg) single dose. ●● If there is visible severe wasting or oedema, the child is
Radical treatment : if P. vivax is positive on blood smear - Oral said to have severe malnutrition and given a single dose of
primaquine 0.25 mg/kg daily for 5 days. vitamin A, kept warm and urgently referred to hospital.
Low Malaria Risk Area : Children with fever but without any ●● If the child has very low weight (malnutrition grade II,
danger sign / stiff neck / bulging fontanella are classified as III or IV), the mother is counselled for feeding. The child

• 839 •
 is followed up in 5 days if there is a feeding problem or Acute Respiratory Infections, Diarrhoea, Measles, Malaria and
otherwise after 30 days. Malnutrition. The Adaptation group developed Indian version
(F) Anaemia : Palmar pallor is looked for in every sick child of IMCI guidelines and renamed it as Integrated Management
presenting to primary health care. of Neonatal and Childhood Illnesses (IMNCI).
●● If there is severe palmar pallor, the child has severe IMNCI approach has some distinct features i.e. It is based on
anaemia and should be urgently referred to hospital. syndromic and holistic approach, involves Triage and it works
●● If some palmar pallor is present, the child has anaemia on Standardized case management and Primary health care
and should be given iron and folic acid therapy in a single model with community participation. The major components
dose daily for 14 days (elemental iron 3-6 mg/kg/day and are strengthening the health care infrastructure, strengthening
folic acid 100-200 mcg/day). the skills of health care workers and community participation
●● All other sick children older than 6 months should be given in which mother is actively involved. The basic steps in
prophylactic iron and folic acid (20 mg elemental iron + management are assess, classify, treat and follow up care of
100 mcg folic acid) for a total of 100 days in a year after the child and counselling of the mother. The IMNCI guidelines
the child has recovered from the acute illness. recommend case management procedures separately for age up
Immunization to 2 months and 2 months to 5 years.
Immunization status of every sick child should be checked. For young infants aged up to 2 months the assessment and
Those being referred to hospital should not be immunized. All classification process is different from older infants and
other children should be immunized as per schedule on the children. Assessment in young infants includes Serious
same day. bacterial infections or local infections, Jaundice, Diarrhoea,
Assess Other Problems Low body temperature, Feeding problems or malnutrition
and Immunization status. In case any sign of severe bacterial
Although the IMNCI guidelines focus on the main symptoms
infection is present the child is given first dose of parenteral
as enumerated above, every sick child should be assessed for
antibiotic and referred to hospital. If local infection present
other complaints, which can lead to severe or acute illness. In
the infant is given oral antibiotics and advised home care.
addition, the health of the caretaker should be also be addressed.
Jaundice in a neonate appearing in less than 24 hours or after
Case recording form for management of the sick child age 2
14 days or associated with yellow discolouration of palms and
months up to 5 years is given on subsequent pages.
soles is classified as severe jaundice and urgent referral after
Counselling of the Mother initial treatment is done. Every sick young infant should be
(a) Advise mother on home care for infant-The mother should examined for low body temperature and managed accordingly.
be counselled on breast feeding the child and keeping the If Diarrhoea is present then assessment of dehydration should
baby warm. be done. If dehydration is present with low weight or any other
(b) Advise mother when to return- To return immediately if the severe classification, child is referred after giving first dose
infant is of IM antibiotics and frequent sips of ORS. If dehydration is
(i) Breast feeding or drinking poorly present without low weight or any other severe classification,
(ii) Becomes sicker child is treated based on severity of dehydration. if Diarrhoea
(iii)Develops a fever or feels cold to touch is present without signs of dehydration then child is treated
at home with oral fluids. Weight and feeding of infant should
(iv) Fast breathing
also be assessed. Immunization status should also be checked
(v) Difficult breathing and if feasible immunization should be carried out before
(vi) Yellow palms and soles ( if infant has jaundice) discharging to home.
(vii) Diarrhoea with blood in stool A sick child aged 2 months to 5 years may present with
(c) Counsell the Mother about her own health common ailments like Pneumonia, Diarrhoea, Fever, Ear
●● If the mother is sick, provide care for her, or refer her for infection, Malnutrition and Anaemia. Firstly the general danger
help. signs should be looked for i.e. Lethargy or unconsciousness,
●● If she has a breast problem (such as engorgement, sore Convulsions, Repeated vomiting and Inability to drink or breast
nipples, breast infection), provide care for her or refer her feed. If a child has any one of these signs he is considered
for help. seriously ill and immediately referred. After examining for
●● Advise her to eat well to keep up her own strength and danger signs four major symptoms are looked for. These are
health. Cough or difficult breathing, Diarrhoea, Fever and Ear problems.
●● Give iron folic acid tablets for a total of 100 days. Any child with cough or difficult breathing is assessed by
●● Make sure she has access to: Respiratory rate, Chest-indrawing and Presence of stridor. Based
- Family planning, Counselling on STD and AIDS on these signs children are classified into Severe pneumonia,
prevention Pneumonia and No pneumonia and treated accordingly. A
child with severe pneumonia is referred to a hospital by
Summary quickest means after administering first dose of injectable
WHO developed an approach called IMCI (Integrated antibiotics. A child classified as having pneumonia is treated
Management of Childhood Illnesses) which encompasses a with oral antibiotics at home for 5 days after giving necessary
range of interventions to combat 5 major childhood illnesses i.e. instructions to mother. A child with no pneumonia is treated

• 840 •
without antibiotics at home. A child presenting with Diarrhoea 2. Which of the following is not true of dehydration: (a) Mild
should be first assessed for danger signs and then assessed to moderate dehydration can be corrected at home by ORS
for dehydration. Based on dehydration status child is classified (b) ORS Solution should be made fresh daily (c) Breast
into Diarrhoea with severe dehydration, some dehydration or feeding should be delayed till dehydration is corrected
no dehydration. A child with severe dehydration is treated with (d) Patient should be given as much ORS as he wants
intravenous fluids and reassessed every 1-2 hours. If signs of 3. Young infants in IMNCI guidelines are up to the age of:
severe classification are present child is immediately referred (a) 6 months (b) 1 year (c) 2 months (d) 3 months
to hospital. If a child has some dehydration treat with ORS and 4. For young infants assessment is basically done for
reassess after 4 hours. If a child has no dehydration treat at all except: (a) Jaundice (b) Hypothermia (c) Diarrhoea
home with oral fluids. A sick child should be checked for fever (d) Measles
and if present should be assessed for common serious causes 5. IMNCI recommendations are up to the age of: (a) 10 years
like Malaria, Meningitis and Measles. A child with fever is (b) 8 years (c) 7 years (d) 5 years
classified as having serious febrile illness if there is any danger 6. Severe Jaundice in a neonate are all except: (a) Less than
sign or stiff neck or bulging fontanellae and requires parenteral 24 hours (b) More than 7 days (c) More than 14 days
antibiotics and quinine and urgent referral to hospital. If a child (d) Yellow discolouration of palms and soles
is classified as having Malaria than appropriate treatment is 7. In a 6 month old child breathing rate ___________ or more
given. A child with fever is also assessed for signs of Measles. suggests pneumonia: (a) 40 per minute (b) 50 per minute
Any sick child should also be assessed for Ear infections, (c) 60 per minute (d) 70 per minute
Malnutrition and Anaemia. Immunization status of every sick 8. Signs for classifying a child as having severe dehydration
child should be checked. Mother should also be counselled for are all except: (a) Dry tongue (b) Sunken eyes (c) Not able
child care and her own health. to drink (d) Lethargic or unconscious
9. A case of Simple Pneumonia is treated with: (a) Parenteral
Study Exercises antibiotics (b) Oral antibiotics (c) Referred to hospital
Long Question : Describe in detail the IMNCI guidelines for (d) Parenteral antibiotics and Referral
management of Neonatal and Childhood illnesses. 10. IMCI approach developed by WHO encompasses following
Short Notes: (1) Components of IMNCI (2) IMNCI guidelines childhood illnesses except: (a) Measles (b) Malaria
for Management of Pneumonia (3) IMNCI guidelines for (c) Diarrhoea (d) Chickenpox
Management of Diarrhoea (4) General danger signs in a sick Answers : (1) d; (2) c; (3) c; (4) d; (5) d; (6) b; (7) b; (8) a;
child (9) b; (10) d
MCQs References
1. General danger signs in a sick child include all except: 1. Concept and strategy Framework- Integrated Management of Neonatal and
(a) Convulsions (b) Unconsciousness (c) Inability to Breast Child Illnesses (IMNCI) - Government of India, State Governments, UNICEF
and WHO) - February, 2004.
feed (d) Vomiting 2. WHO and UNICEF, 2003. Integrated management of neonatal and childhood
illness. Assess and classify the sick young infant age up to 2 months. Ministry
of health and Family Welfare, Government of India, New-Delhi, 2003

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Case recording form (Up to 2 Months) Side - 1

• 842 •
Case recording form (Up to 2 Months) Side - 2

• 843 •
Case recording form (2 months to 5 years) Side - 1

• 844 •
Case recording form (2 months to 5 years) Side - 2

• 845 •
Plan A : Treat Diarrhoea at Home

Counsel the mother on the three rules of home treatment: Give extra fluids, continue feeding, return if child worsens
Give extra fluids ( as much as the child will take)
Tell the mother :
 If exclusively breast fed, breast feed frequently and for longer at each feed. If passing frequent watery stools: For less than
6 months age, give ORS and clean water in addition to breast milk. If 6 months or older, give one or more of the home
fluids in addition to breast milk.
 If the child is not exclusively breast fed: give one or more of the following home fluids: ORS solution, yoghurt drink, milk,
lemon drink, rice or pulse based drink, vegetable soup, green coconut water or plain clean water.
It is especially important to give ORS at home when :
 The child has been treated with plan B or Plan C during the visit
 The child cannot return to a clinic if the diarrhea gets worse
Teach the mother how to mix and give ORS. Give the mother 2 packets of ORS to use at home.
Show the mother how much fluid to give in addition to the usual fluid intake:
 Up to 2 years: 50 to 100 ml after each loose stool
 2 years or more: 100 to 200 ml after each loose stool
Tell the mother to :
 Give frequent small sips from a cup
 If the child vomits, wait for 10 minutes. Then continue, but more slowly.
 Continue giving extra fluids until the diarrhea stops

Plan B : Treat Some Dehydration with ORS

Give recommended amount of ORS over a 4 hour period

Determine the amount of ORS to give during next 4 hours as follows:
Age Up to 4 months 4 months to 12 months 12 months up to 2years 2 years up top 5 years
Weight < 6kg 6<10 kg 10 - <12 kg 12-19 kg
In ml 200-400 400-700 700-900 900-1400
 The approximate amount of ORS required (in ml) can also be calculated by multiplying the child’s weight (in kg) times 75
 If a child wants more ORS than shown, give more.
 For infants who are not breast fed, also give 100-200 ml clean water during this period
Show the mother how to give ORS:
 Give frequent small sips from a cup
 If the child vomits, wait for 10 minutes. Then continue, but more slowly
 Continue breast feeding whenever the child wants
After 4 hours
 Reassess the child and classify for dehydration
 Select the appropriate plan and continue treatment
 Begin feeding the child in the clinic
If the mother must leave before completing the treatment
 Show her how to prepare ORS solution at home
 Show her how much ORS to give to finish 4 hour treatment at home
 Give her enough ORS packets to complete rehydration. Also give her two packets as recommended in plan A.
Explain the 3 rules of home treatment:
 Give extra fluids
 Continue feeding
 Return if child worsens, does not pass urine or refuses to drink

• 846 •
Plan C : Treatment of Severe Dehydration

If you can give IV fluid immediately

 If the child can drink, give ORS by mouth while drip is set up.
 Give 100 ml/kg Ringers lactate solution or Normal saline as follows

Age First give 30 ml/kg in : Then give 70 ml/kg in:

Infants( up to 12 months) 1 hour ( repeat once if radial pulse is still very weak or not detectable) 5 hours
Children (12 months – 5 years) 30 minutes( repeat once if radial pulse is still very weak or not detectable) 2 ½ hours
 Reassess child every 1-2 hours. If hydration status is not improving, give the IV fluid more rapidly.
 Also give ORS (about 5 ml/kg/hour) as soon as the child can drink, usually after 3-4 hours(infants) or 1-2 hours(
children)
 Reassess an infant after 6 hours and a child after 3 hours. Classify dehydration. Then choose the appropriate
plan(A,B, or C) to continue
If you cannot give IV fluids immediately and IV treatment is available nearby (within 30 min)
 Refer urgently to hospital for IV treatment
 If the child can drink, provide the mother with ORS solution and show her how to give frequent sips during the trip \
If IV treatment is not available immediately and you are trained to use nasogastric tube for rehydration
 Start rehydration by tube (or mouth) with ORS solution: 20 ml/kg/hour for 6 hours (total of 120 ml/kg)
 Reassess the child every 1-2 hours
- If there is repeated vomiting or increasing abdominal distension, give the fluid more slowly
- If the hydration status is not improving after 3 hours, send the child for IV therapy
 After 6 hours, reassess the child. Classify dehydration. Then choose the appropriate plan (A, B, C) to continue treatment.
If IV treatment is not available immediately ( within 30 min), you are not trained to use nasogastric tube and the child
cannot drink
 Refer urgently to hospital for IV or Nasogastric tube treatment

Feeding recommendations during sickness and health

• 847 •
 years of age expressed as rate per 1000 live births. This rate
145 Care of Under Five Children measures the probability of dying between birth and exactly
five years of age. This indicator is considered as the single
best indicator of social development and well being. The
A S Kushwaha
global figure stands at 72 while India has a rate of under five
mortality at 74 per 1000 live births. There has been a declining
Global Scenario trend in under five mortality but still continues to be very high
In 2006, for the first time since mortality data have been in African countries especially Sub-Saharan countries. Child
gathered, annual deaths among children under five dipped mortality is a sensitive indicator of a country’s development
below 10 million to 9.7 million. This represents a 60 per cent and telling evidence of its priorities and values. It has several
drop in the rate of child mortality since 1960. Most deaths advantages as a barometer of child well-being in general and
among children under five years are still attributable to just child health in particular. First, it measures an ‘outcome’ of
a handful of conditions and are avoidable through existing the development process rather than an ‘input’, such as per
interventions (Fig. - 1). Six conditions account for 70% to over capita calorie availability or the number of doctors per 1,000
90% of all these deaths. These are acute lower respiratory population - all of which are means to an end. Second, the
infections, mostly pneumonia (19%), diarrhoea (18%), malaria U5MR is known to be the result of a wide variety of inputs:
(8%), measles (4%), HIV/AIDS (3%), and neonatal conditions, the nutritional status and the health knowledge of mothers;
mainly preterm birth, birth asphyxia, and infections (37%). the level of immunization and oral rehydration therapy; the
India availability of maternal and child health services (including
prenatal care); income and food availability in the family; the
availability of safe drinking water and basic sanitation; and
Table - 1 : Child Health - India
the overall safety of the child’s environment, among other
1 IMR 57 / 1000 live factors. Third, the U5MR is less susceptible to the fallacy of the
births average than, for example, per capita gross national income
2 Under Five Mortality 74 / 1000 live (GNI per capita). This is because the natural scale does not
births allow the children of the rich to be 1,000 times as likely to
survive, even if the human made scale does permit them to
3 Children <3 yrs who are underweight 42.5 %
have 1,000 times as much income. In other words, it is much
4 Breast feeding initiation in 1 hour 24.5 % more difficult for a wealthy minority to affect a nation’s U5MR,
5 ORS given to children with diarrhoea 26 % and it therefore presents a more accurate, if far from perfect,
picture of the health status of the majority of children (and of
6 Children (12-23 months) with 43.5%
society as a whole).
completed immunization
Child Survival Index : This indicator is calculated by subtracting
7 % of newborn babies LBW 30 % the under five mortality rate from 1000 and dividing this figure
by 10. The child survival is a measure of social development
Definitions and the attention given to the care of under five children. The
Child Death rate (1-4 Year Mortality Rate) : Child death rate child survival index of developed countries is 99 and above
is the number of deaths of children aged 1 to 4 years per 1000 approaching 100 and developing countries like India have a
children in the same age group in a given year. It therefore much lower survival index but it is improving steadily.
excludes infant mortality. This is a more refined indicator of
Evolution of Under Five Child Health Services
the social situation in a country than infant mortality rate. It
reflects the adverse environmental health hazards faced by 1. Primary Health Care Model : During the 1970s,
the children including factors like malnutrition, poor hygiene socioeconomic development and improved basic living
and sanitation, infections and accidents caused due to social, conditions like clean water, sanitation and nutrition were seen
economic, cultural characteristics of the community. This as the keys to improving child health. Primary health care
measure of child health excludes the perinatal and endogenous stood for universal access to care and coverage on the basis
factors operating in the infancy. The second year of life is the of need. Along with intersectoral action for health, community
one which poses greatest risk to life and accounts for nearly involvement and self-reliance, much of the primary health
half of all deaths in the 1-4 years age children. The infectious care strategy was designed with the health of children as the
diseases like measles, diphtheria, ARI, diarrhoea affect this age priority of priorities.
most. The 1-4 years child mortality rate in developed countries is 2. Vertical Programmes-Model : At the end of the 1970s,
negligible and quite high in the developing and underdeveloped the economic recession did not allow for such a development
nations. The countries also show a great interstate variation. of primary health care system. Child health and particularly
The developed countries have home accidents as the leading child survival was such an obvious emergency that by the early
cause in developed countries while infections predominate in 1980s, many countries shifted their focus from primary health
the developing nations. care systems to vertical, “single-issue”, programmes that
Under Five Mortality Rate (U5MR) (Child Mortality Rate): promised cheaper and faster results. Child health continued to
This is defined as the number of deaths in children under five constitute a ‘silent’ emergency, as close to 15 million children
were still dying annually before their fifth birthday.

• 848 •
In the late 1970s, two scientists, Julia Walsh and Kenneth Under Five’s Clinic
Warren, published ‘Selective Primary Health Care : An
interim strategy for disease control in developing countries’
History
- a milestone paper that proposed an alternative strategy for Dr. Morley while working in rural areas of Nigeria developed
rapidly reducing infant and child mortality at a reasonable the concept of growth chart popularly known as ‘Road to
cost. After breaking down the relative role of each major Health’ chart (2-6). He highlighted the problem facing child
cause of child mortality and listing the existing interventions health services throughout the developing world and especially
proved to be effective in addressing them, they concluded that malnutrition which was at the core of all other childhood
a small number of causes (diarrhoea, malaria, respiratory problems. He emphasized the role of growth monitoring through
diseases and measles, among others) were responsible for under-fives ‘clinic to quickly identify and combat malnutrition.
the vast majority of under-five deaths and that these deaths These two measures have subsequently been adopted by
could be easily prevented by immunization oral rehydration many developing countries. Careful emphasis was placed
therapy, breast feeding and antimalarial drugs(1). The Child on the social, economic, cultural and ethical considerations
Survival Revolution of the 1980s, spearheaded by the United which were ignored by most doctors but also nurses and other
Nations Children’s Fund (UNICEF), and built around a package health workers. Morley emphasized low-cost health services,
of interventions grouped under the acronym GOBI (growth within the means of the people involved, and the need to make
monitoring, oral rehydration therapy for diarrhoea, breast extensive use of auxiliaries and villagers themselves. The
feeding, and immunization) soon gained currency. concept of ‘Well Baby clinics’ is being practised with emphasis
on preventive services mainly immunization and promotive
3. Preventive Model (EPI) : Expanded Programme on
growth monitoring.
Immunization of the mid-1970s, and programmes for Control
of Diarrhoeal Disease and Acute Respiratory Infections became Under Fives - A special group
the successful strategy in which at country level, these vertical 1. They constitute about 15 % of the total population.
programmes successfully tackled a number of priority diseases. 2. They suffer high rates of mortality and morbidity.
The Expanded Programme on Immunization started in 1974 3. The effects of malnutrition and other diseases have a role
and widened the range of vaccines routinely provided, from in later life.
smallpox, BCG and DTP to include polio and measles. It set out 4. The majority of the deaths are preventable through
to increase coverage in line with the international commitment available interventions.
to achieve the universal child immunization goal of 80% 5. This is a period of growth and development.
coverage in every country. 6. Brain growth is completed during 1st five years.
4. Breast feeding initiatives (BFHI) : Baby-Friendly Hospital 7. Most causes of morbidity are preventable by
initiative to support promotion of breast feeding in maternities immunization.
was launched in 1992. In 1990, less than one fifth of mothers 8. Health of children under five years and family health are
gave exclusive breast feeding for four months; by 2002 that inter-related.
figure had doubled to 38%. 9. Likely to be neglected in the face of poverty and unregulated
5. Integrated and Syndromic Approach to a Sick Child fertility.
(IMCI): A feverish and irritable child that has difficulty eating Cause of Death in Children
can be suffering from a single illness, such as dysentery, The various causes of death in children are shown in Fig. - 1.
or from a combination of diseases, such as malaria and 1. Pneumonia : Pneumonia kills more children than any
pneumonia. Single-issue programmes were not designed to other disease (19%), more than AIDS, malaria and measles
provide guidance on how to deal with such situations. There combined. It is a major cause of child deaths in every region.
was clearly a need for a more comprehensive view of the needs Undernourished children, particularly those who are not
of the child, one that would correspond to problems as they exclusively breastfed or have inadequate zinc intake, or those
were encountered in the field (4) and would offer a wider range with compromised immune systems, run a higher risk of
of responses than the existing programmes. The response to developing pneumonia. Child suffering from other illnesses,
this new situation was to package a set of simple, affordable such as measles, or those living with HIV, is more likely to
and effective interventions for the combined management of develop pneumonia. Environmental factors, such as living
the major childhood illnesses and malnutrition, under the in crowded homes and being exposed to parental smoking or
label of “Integrated Management of Childhood Illness” (IMCI). indoor air pollution, may also play a role in increasing children’s
Details are covered in chapter on IMNCI, the Indian adapted susceptibility to pneumonia and its consequences.
version of IMCI.
2. Diarrhoea : Diarrhoea is most common in children between 6
6. Child Health - An issue of Rights for the Children : The months and 2 years with highest incidence in the 6-11 months
MDGs have made it binding on all countries to move forward age when weaning occurs. The mortality is estimated at 4.9
on issues of child health focusing on survival, growth, children per 1000 per annum due to Diarrhoea in children
development and protection. The children of the world are under five in the developing regions. The ORS has reduced the
subjected to many violations of their rights like child labour, burden of childhood mortality to a great extent.
abuse and exploitation, neglect, early marriage and even sexual
abuse and violence against them. The UNICEF with many NGOs 3. Malaria : This is a major cause of death in Sub-Saharan
are focusing on these issues. Africa where it causes 25% of childhood mortality. It kills

• 849 •
about 1 million children accounting for 80% of all deaths due or auxiliary worker should be present and treated as an equal
to malaria. It also contributes indirectly to deaths from ARI, colleague. This procedure will encourage mothers to have more
anaemia, diarrhoea and malnutrition. confidence in the skills of the locally trained worker. Mothers
4. Measles : In India, measles is a major cause of morbidity need education and support to institute practices that will
and a major contributor to child mortality. It affects children minimize illness and promote health. Oral rehydration, breast
between 6 months and 3 years. It tends to be severe in feeding, and growth monitoring are all effective practices.
malnourished children. It weakens children’s immunity to other Community health workers can also provide services, such as
life-threatening diseases and conditions, including pneumonia, weighing, right in the residential areas. These workers should
diarrhoea and acute encephalitis, and remains one of the try to communicate with the key decision-makers in the child’s
leading causes of vaccine preventable deaths among children. family - mother, father and grandparents, to inform them of the
child’s nutritional needs.
5. HIV/AIDS : This is an emerging cause of childhood deaths
especially in Sub-Saharan Africa. This accounts for 3% of all
Fig. - 2 : Under Five’s Clinic
under five deaths.
Health Education
Fig. - 1 : Causes of death in Under Five Children

Care in illness

Family Planning

Monitor Growth Preventive Care

Goal
The overall goal of the Under-Fives Clinic is to provide Functions
comprehensive health care to young children in a separate (a) Care in Illness : This is the felt need of the mother and child
specialized facility. for which any child is brought to the clinic. The usual illnesses
The under five clinic is represented by traditional logo of a encountered in children under five are fever, diarrhoea, ARI,
triangle with four internal triangles and an outer enveloping infections of the skin and helminthiasis. The facility should
triangle as shown in the Fig. - 2. provide for essential laboratory investigations and X-ray
Objectives facilities. The Clinic should be backed by an effective referral
mechanism.
1. Care in illness
2. Growth monitoring (b) Growth Monitoring : This is one of the most important
3. Preventive care functions of the clinic. The child is weighed periodically - every
4. Family Planning month during the first year, every 2 monthly from 1 to 3 years of
5. Health education age and every 3 monthly in 4th and 5th years. Besides weighing,
measuring height, mid arm circumference can also be carried
Features
out depending upon the availability of trained manpower and
Under Five Clinics are specifically designed to serve children equipments. The growth is plotted on the growth chart and any
under the age of five in developing nations. It is important for faltering in the growth is detected and suitable action initiated.
the clinics to be as close to the residential areas as possible The milestones are also recorded and any delay in achieving
and for home visits to be a part of the services provided. Clinic milestone is evaluated.
visits also need to be kept as short as possible. The majority
(c) Preventive Care : This involves primarily the immunization
of the staff should be locally trained health care workers,
services during the 1st five years of life and vitamin A
nurses and auxiliary staff, who provide most of the care. The
supplementation (1 lac IU at 18 months, 2 lac IU at 6 month
doctors on staff should be primarily responsible for training,
interval thereafter upto 3 years of age) and administration of
diagnosis, and treatment of more complex conditions. When
Iron supplementation and antihelminthic treatment to prevent
consultation with a senior staff person is necessary, the nurse
anaemia. The preventive care also provides for regular health

• 850 •
check up, nutritional surveillance and use of ORS during manner in 1985, which covered the whole of India by 1990.
Diarrhoea to prevent dehydration from developing. Significant progress was made under the Programme in the
(d) Family Planning : Family planning is central to any initial period when more than 90% coverage for all the six
program directed towards women and children. The mothers antigens was achieved. The UIP was taken up in 1986 as
are more receptive to family planning during early Puerperium National Technology Mission and became operational in all
and lactation. Mother is counselled on the various options districts in the country during 1989-90. UIP became a part of
available, their merits and de-merits so that she can make an the Child Survival and Safe Motherhood (CSSM) Programme
informed choice. in 1992 and Reproductive and Child Health (RCH) Programme
in 1997. Under the Immunization Programme, infants are
(e) Health Education : The opportunity should be made use
immunized against tuberculosis, diphtheria, pertussis,
to educate the mother on issues of child care, breast feeding,
poliomyelitis, measles and tetanus. Universal immunisation
nutrition, growth monitoring, immunization and hygiene of
against six Vaccine Preventable Diseases (VPD) by 2000 was
safe water and food preparation.
one of the goals set in the National Health Policy (1983).
Child Health Programmes in India (d) The ARI Control Programme
In 1951, India was the first country in the world to launch ARI control programme was started in India in 1990. It
a family planning programme. Since then approaches aimed sought to introduce scientific protocols for case management
at reducing population growth have taken a variety of forms. of pneumonia with co-trimoxazole. A review of the health
Till 1977, the major health activity was family planning which facility done in 1992 revealed that although 87% of personnel
was changed into Family welfare programme with Maternal were trained and the drug supply was regular yet there were
and Child Health becoming an integral part of family planning problems in correct case classification and treatment. Since
programme with the vision that reduction in birth rate has 1992 the Programme was implemented as part of CSSM and
a direct relationship with reduction in infant and child later with RCH. Cotrimoxazole tablets are supplied as part of
mortality. drug kit for use by different category of workers for managing
(a) The Diarrhoeal Disease Control Programme cases of Pneumonia. Under RCH-II activities are proposed to
be implemented in an integrated way with other child health
This programme was started in the country in 1978. The
interventions.
main objective of the programme was to prevent death due
to dehydration caused by diarrhoeal diseases among children (e) The Child Survival and Safe Motherhood (CSSM)
under 5 years of age due to dehydration. Health education Programme
aimed at rapid recognition and appropriate management of This Programme jointly funded by World Bank and UNICEF,
Diarrhoea has been a major component of the CSSM. Under the was started in 1992-93 for implementation up to 1997-98.
RCH programme ORS is supplied in the kits to all sub-centres The Child Survival and Safe Motherhood Programme was
in the country every year. implemented in a phased manner covering all the districts
(b) ICDS ( Integrated Child Development Scheme) of the country by the year 1996-97. The objectives of the
The ICDS scheme was initiated by the then Ministry of Social programmes were to improve the health status of infants,
and Women’s Welfare on 02 Oct 1975, in pursuance of the child and maternal morbidity and mortality. The programme
National Policy for children. The Ninth Five Year Plan aimed to provided for augmenting various activities under the Oral
universalise ICDS, i.e. cover the whole country. Rehydration Therapy (ORT) Programme, universalising
prophylaxis schemes for control of anaemia in pregnant women
The beneficiaries of ICDS are -
& control of blindness in children and initiating a programme
(i) Children below 6 years for control of acute respiratory infection (ARI) in children.
(ii) Pregnant and lactating women Under the safe motherhood component, training of traditional
(iii) Women in the age group of 15-44 years birth attendants (TBA), provision of aseptic delivery kits and
(iv) Adolescent girls in selected blocks strengthening of first referral units to deal with high risk
The ICDS seeks to lay a solid foundation for the development and obstetric emergencies were taken up. Programme yielded
of the nation’s human resource by providing an integrated notable success in improving the health status of pregnant
package of early childhood services. These consist of women, infants and children & also making a dent in IMR,
●● Supplementary nutrition MMR and incidence of vaccine preventable diseases.
●● Immunization
(f) Reproductive Child Health (RCH) Programme
●● Health check-up
●● Medical referral services Government of India during 1997-98 launched the RCH
●● Nutrition and health education for women Programme for implementation during the 9th plan period
●● Non-formal education for children up to the age of 6 years by integrating Child Survival and Safe Motherhood (CSSM)
●● Care of pregnant and nursing mothers Programme with other reproductive and child health (RCH)
services. In addition, a new component for management of
(c) Universal Immunization Programme
Reproductive Tract Infection (RTI) and Sexually Transmitted
UIP against six preventable diseases, namely, diphtheria, Infection (STI) has also been incorporated. The RCH Programme
pertussis, childhood tuberculosis, poliomyelitis, measles and is partly funded by World Bank, UNICEF, UNFPA and European
neonatal tetanus was introduced in the country in a phased Commission. The program follows a differential strategy with

• 851 •
inputs under the program linked to the needs of the area preventive model, breast feeding initiative, IMCI. Under fives is
coupled with the capacity for implementation. The details on a special group with pneumonia, diarrhoea, malaria, measles
the RCH are covered under separate chapter on RCH. and HIV/AIDS being attributed as the major killers in this age
(g) IMNCI (Integrated Management of Neonatal and group. For this reason the under five clinics were established in
developing nations with five major objectives of care in illness,
Childhood Illnesses)
growth monitoring, preventive care, family planning, health
This programme has been introduced on the principles of education. In 1951 India was the first country in the world to
integrating all the services for management of sick children launch a family planning programme and in 1977 it was changed
under 5 years of age. This is based on the fact that children have to family welfare programme with maternal and child health
to be assessed as a whole for the entire important symptom becoming an integral part of it. Various child health programmes
complex and to be provided care and treatment involving the have been launched namely the diarrhoeal disease control
caregiver. Integration has different meanings at different levels. programme (1978), ICDS (2 Oct 1975), Universal Immunization
At the patient level it means case management. At the point Programme (1985), the ARI control programme(1990), the
of delivery it means that multiple interventions are provided child survival and safe motherhood programme (1992-93),
through one delivery channel - for example where vaccination Reproductive child health programme(1997-98), IMNCI which
is used as an opportunity to provide vitamin A and insecticide- has been incorporated in RCH programme. Seven of the eight
treated bednets during “EPI-plus” activities, boosting efficiency Millennium Development Goals directly relate to child survival,
and coverage. At the system level integration means bringing growth and development.
together the management and support functions of different
sub-programmes, and ensuring complementarity between Study Exercices
different levels of care. Long Question : Discuss various child health programmes.
Childhood is the foundation of World’s future. There has been a Short Notes : (1) Child death rate (2) Under 5 mortality rate
definite progress in improving the child survival, development (3) Child survival index (4) Under 5 clinics
and protection. The World must make more sustained, collective Fill in the blanks
and focused efforts to realize the dream of ‘World Fit for
1) Child death rate involves _________________ age group
Children’ and fulfill the promise of safe and healthy childhood
2) Child mortality rate involves _______________ age group
for every child. The Millennium Development Goals, ratified
3) CSSM was launched in year _________________
by all UN member states, provide the world’s governments
4) Maximum number of children die because of ___________
with clear and tangible targets to combat poverty and raise
among the five major causes of mortality in under 5
the standard of living for the world’s people by 2015. Early
5) IMR in India is ____________ and Under 5 mortality in
Childhood Development contributes to the achievement of the
India is ________________
goals. Seven of the eight goals directly relate to child survival,
6) The single best indicator of social development of a country
growth and development. Research has shown that the most
is ________________
effective interventions to improve human development and
break the cycle of poverty occur most in children’s earliest years. Answers : (1) 1-4 yrs; (2) Less than equal to 5 yrs; (3) 1992;
Prevention is more cost-effective than treating a problem later. (4) Pneumonia; (5) 57/1000,74/1000 live births; (6) Under 5
The important issues are ensuring positive gender socialization, mortality rate.
supporting parents and families and developing standards and References
indicators for effective planning, monitoring and documentation 1. World Health Report, 2005. Make every mother and Child Count, WHO
of the progress in Early Childhood development. 2. Integrated Management of Pregnancy and Childbirth. Managing complications
in Pregnancy and Childbirth: A guide for midwives and doctors. Department
Summary of Reproductive Health and Research, Family and Community Health, WHO,
Geneva, 2003
Childhood is the foundation of world’s future. Only six 3. The State of the World’s Children, 2005. Childhood Under Threat, UNICEF,
conditions account for 70% to over 90% of the total deaths in New York
under 5 age group. Child death rate excludes infant mortality 4. Morley D. A medical service for children under five years of age in West
Africa. Trans Roy Soc Trop Med Hyg. 1963;57:79-94.
rate and is a better indicator of social situation in a country 5. Morley D. The spread of comprehensive care through under-fives’ clinics.
than the IMR where as under 5 mortality rate is considered to be Trans Roy Soc Trop Med Hyg. 1973;67(2):155-170.
the single best indicator of social development and well being. 6. Morley DC. Paediatric priorities in developing world. London: Butterworths,
1973.
It measures the outcome of the development process and is a
7. Sources : Committing to action: Achieving the MDGs, Background note by the
result of various inputs. Child survival index is calculated by Secretary-General for the High-level Event on the Millennium Development
subtracting under 5 mortality rate from 1000 and dividing this Goals, United Nations, New York, 25 September 2008; The Millennium
Devel­opment Goals Report 2008, United Nations; The State of World’s
figure by 10. Its a measure of the social development and the Children 2008, UNICEF; MDG Monitor Website http://www.mdgmonitor.org/,
attention given to the care of under 5 children. Evolution of the UNDP; WHO re­leases new guidance on insecticide-treated mosquito nets,
under 5 child health services passes through various models WHO press release, on http://www.who.int/mediacentre/news/releases/2007/
pr43/en/index.html
like primary health care model, vertical programmes model, 8. United Nations Children’s Fund, Accelerated Child Survival and Development
in Ghana, UNICEF, March 2005, pp. 1-2.

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 School Health Service
146 School Health Services The objectives of the school health care are as follows:
(a) Help children in this critical period of their physical and
A S Kushwaha mental growth.
(b) Maintaining working efficiency at a high level and
School is a setting that plays an important role in the physical, improving mental assimilating power by:
emotional, social and mental development of children. Schools (i) Ensuring congenial working conditions.
present an extraordinary opportunity to help millions of young (ii) Keeping them physically and mentally fit at all times.
people to acquire health supportive knowledge, values, attitudes (iii) Improving the general nutrition of the children.
and behavior. They can influence health behavior of other (iv) Reducing absenteeism and thus increasing average
children, their families and community. School health services study hours/days.
provide an opportunity to improve health of the students and (v) Prevent spread of infections, reduce and detect minor
promote healthful behavior through health education. ailments.
(vi) Imparting health education and physical training to
History children.
In India, the history of school health service can be traced (vii) Providing special arrangement for the education of
back to 1909, when medical examination of school children handicapped children.
was started in Baroda. This important issue of social value Healthful School Environment
has been raised repeatedly in various forums but continues
to be a neglected aspect of Community Health service till The environment at the school has an important influence on
date. Bhore committee in 1948 emphasized the need to put the health of the school children. The following points should
in place an organized system of school health service but this be kept in mind as regards school premises.
is still an unfulfilled dream. In 1953, Secondary Education 1. School premises
Committee recommended medical examination and feeding (a) The school should be located in areas free from crowded
of all school children to promote positive health early in the surroundings, away from market, butcheries, factories,
life as key to a healthy nation. The “National School Health disposal grounds for waste matters, public sanitary areas
Council” has been established since 1963 to plan and organize or enclaves, and such other places which may create a
school children’s health care. Provisions have been made in the health nuisance.
municipal, cantonment and state regulations for organization (b) There should be sufficient open space around the
and maintenance of a school health service. buildings.
The concept of school health service has undergone change from (c) Enough playgrounds should be provided. Free muscular
mere health check up to become a comprehensive service with activity reduces mental boredom and strain and provides a
elements of preventive, promotive, curative and rehabilitative stimulus for growth.
services. (d) There should not be any water collections for mosquito or
fly breeding places around the school area.
Global School Health Initiative (GSHI) (e) Traffic should be restricted to the minimum so as to avoid
WHO’s Global School Health Initiative was launched in 1995. noise, smoke and dust nuisance and mainly accidents.
The initiative is designed to improve the health of students, (f) Accidents should be prevented not only on roads around
school personnel, families and other members of the community school but also on the playgrounds and in class rooms.
through schools. First aid should be taught to all.
2. Seating Arrangement : These should be such as to allow
Goal
adequate space, permitting freedom of movement for children
The goal of GSHI is to increase the number of schools that can on the bench so as to enable them to work without strain.
truly be called “Health-Promoting Schools”.
3. Drinking Water : It should be procured from an authorized
Health Promoting School clean source. Arrangements for central storage and safety must
WHO defines a health promoting school as one that is be provided. Ladles should be provided to take out water if taps
constantly strengthening its capacity as a healthy setting for are not possible.
living, learning and working. 4. Sanitary arrangements : A minimum of one urinal for 60
Components of Comprehensive School Health Policy students and one latrine per 100 students should be provided.
(a) School environment that is safe and promotes health These should be maintained regularly and kept clean at all
(b) A sequential health education curriculum times. Adequate water supply should be arranged for sanitary
(c) A sequential physical education curriculum block. Toilet facilities should be separate for boys and girls.
(d) Nutrition services programme 5. Nutrition services (Mid-day meal) : These should provide
(e) School Health Service programme about one third of the total daily requirements of calories,
(f) A counselling, psychological & social service programme proteins, vitamins ‘A’ and ‘B’ complex and calcium. They
(g) Integrated family and community involvement activities should provide about 20-30 g of fat, 20 g of protein of which
(h) Staff health promotion policy one third should be of animal origin. Inclusion of milk in the

• 853 •
meals will ensure this requirement. The school meals not only an emergency. The telephone number of the clinic or hospital
aim at supplementing the nutritional requirement but also at should be known to the staff.
inculcating healthy food and eating habits. 11. Physical Training : It is a major item of a school curriculum
6. Canteen Facility : All schools have some facilities which and should be insisted upon. Physical Training Instructors
provide eatables. This canteen must observe cleanliness and (PTI) should be appointed. Besides this if possible yoga trained
hygiene of food preparation. Selling of junk food items at teacher may also be appointed.
canteen must be prohibited. 12. Health Education : This should be part of the curriculum.
7. Vaccination : School settings provide suitable conditions It can be imparted either as an integrated part of curriculum
for spread of communicable diseases droplet infections and or otherwise. Health education is also incidentally acquired by
gastrointestinal diseases. All diseases amenable to prevention children through the experiences and observation of healthy
by vaccination should be covered. Children should be immunized school life as described above.
against typhoid group of fevers, diphtheria and tetanus as a 13. School Health Committee : All schools must have a school
routine. If and when facilities exist, immunization against health committee. It should consist of the Headmaster or
poliomyelitis and tuberculosis by BCG should be carried out. Principal as the Chairman and class teacher, health educator,
8. Health Check up : All children should be thoroughly school nurse, physical training instructor and the school
examined at least once a year or three times during the medical officer as its members. They should meet once a month
curriculum in addition to the one carried out at the time of or at least once in a quarter. A few parents should also be
entry. Results are recorded in the health record card and parents invited to attend these health committee meetings.
should be advised regarding remedial action. There should be a Management of Children with “Scholastic
permanent register and health cards with column for remarks
backwardness”
against examination of each system. The card is meant to be
transferred to the institution the child may go after leaving Once a child starts struggling with his studies, the school
one institution. A monthly, quarterly and annual report must environment turns ‘hostile’ to him. He gets punished by the
be sent to the coordinating authority and medical authorities. teachers and friends make fun of him. The young child is
The special points, to look for during any check up, are given clueless as to why he cannot score like his classmates, in spite
below: of effort. He reacts to all these the way children do - either,
turn defiant and fight back, or swallow the insults and give
(a) Eyes for trachoma and vision (including tests for acuity of
up. A sensitive Teacher, sensitized to the various causes of
vision).
poor school performance can turn out to be his saviour and
(b) Ears for perforated drums, otitis media & hearing acuity.
guardian angel. She can identify the cause of this particular
(c) Teeth for caries, non-alignment, mottling, gingivitis and so
child’s failure and institute an appropriate remedial strategy.
on.
After ruling out visual impairment and hearing problems
(d) Nose & throat for adenoids and enlarged/infected tonsils.
and mental and psychological deficiency, the child should be
(e) Chest for lungs, cardiac anomalies (congenital).
considered to be evaluated for learning disorders. It may first
(f) Abdomen for enlarged spleen, liver and any palpable lymph
appear as behaviour problems : Attention deficit, Hyperactivity,
nodes.
naughtiness, defiance, aggression, addiction to TV or computer,
(g) Genitalia for phimosis, undescended testis or patent
forging progress reports, Tics, Obsessive disorders, Anxiety,
inguinal canal.
Depression, School phobia etc. A Schematic algorithm for
(h) Lower limbs for skeletal & muscular defects/deformities.
evaluation of a child with poor scholastic performance is given
(i) Spine for any deformity.
in Fig. - 1.
(j) Skin for ring worm, scabies & any de-pigmented patches.
(k) Hair for pediculosis, dandruff. Notes :
(l) Weight and height for age and sex and nutritional profile 1. Many normal children display some of these symptoms.
(anthropometry). 2. Not all LD children display all pointers.
(m) Any abnormal curvatures/postures, delicate health, 3. Severe problems need multidisciplinary assessment.
nutrition etc. 4. LD - Learning Disorder; ADHD - Attention Deficit
9. Sick Reporting Facility : This should be provided and Hyperactive Disorder.
children are encouraged to report sick whenever they feel Educating ‘Special’ children
unwell. It not only helps to reduce minor ailments from Categories of Disabilities
developing into major ailments or disabilities but also helps
1. Physical Disability
to detect any other major ailments or disabilities undetected
2. Mental Disability
in the incipient or early stages. A trained staff is designated to
3. Developmental Disability
provide necessary assistance whenever required. Availability of
4. Learning Disability
commonly required medications must be ensured at all times.
5. Hearing Disability
10. Referral Facilities : Facilities for reference of children 6. Visual Impairment
to a specialist for investigation of ailments and their 7. Emotional Disability
treatment/ hospitalization should be ensured. There should be Common disabilities
arrangements for emergency transport and referral in case of
1. ADD/ADHD

• 854 •
2. Autism placing children with disabilities in regular schools, the
3. Cerebral Palsy Planning Commission, in 1971, included in its plan a programme
4. Down Syndrome for integrated education. The Government launched the IEDC
5. Multiple Sclerosis scheme in December 1974.
6. Muscular Dystrophy The aim of IEDC is to :
7. Seizure Disorders ●● Provide educational opportunities to CWSN in regular
schools.
Fig. - 1 : A Schematic algorithm for evaluation of a child
●● Facilitate their retention in the school system.
with poor scholastic performance
●● Place children from special schools in common schools.
The scope of the scheme includes pre-school training,
counselling for the parents, and special training in skills for all
kinds of disabilities. The scheme provides facilities in the form
of books, stationery, uniforms, and allowances for transport,
reader, escort etc. Similar Scheme in US is known as 504
Plan, which is a legal document falling under the provisions
of the Rehabilitation Act of 1973, designed to plan a program
of instructional services to assist students with special needs
who are in a regular education setting.
Project Integrated Education for the Disabled (PIED): Under
PIED, there has been a significant increase in the number of
not only mildly disabled, but also severely disabled children,
with the number of orthopaedically handicapped children far
outstripping other disabled children. All these perform at par
with non - disabled children; in fact their retention rate is
higher than that of non - disabled children and absenteeism
is low. PIED has also had a positive impact on the attitudes
of the teachers, the heads of schools, as well as parents and
the community in general. Also, the interaction between the
disabled and the non - disabled children is good.
DPEP estimates clearly showed that there were a large number
of disabled children in the relevant age group. Gradually
realization dawned that UPE could not be achieved unless
children with special needs were also brought under the ambit
of primary education. This led to more concrete planning and
Special Schools in India : Along with other parts of the world, strategization of providing resource support and remedial
India too, witnessed the emergence of special schools for people assistance to children with special needs. As the programme
with disabilities. The first school for the deaf was set up in progressed, many models of service delivery evolved with
Bombay in 1883, and the first school for the blind at Amritsar the sole aim of providing supportive learning environment
in 1887. There was rapid expansion in the number of such to children with special needs. The thrust was on imparting
institutions. Today, there are more than 3200 special schools quality education to all disabled children.
throughout India. However, these special schools have certain The steps needed for implementation of IED under SSA (Sarva
disadvantages which became evident as the number of these Shiksha Abhiyan) are classified under three headings:
schools increased. These institutions reached out to a very 1. Direct Services to Children.
limited number of children, largely urban, and they were not 2. Support Services.
cost effective. But most important of all, these special schools 3. Monitoring and Evaluation.
segregated CWSN from the mainstream, thus developing a This is an important aspect for assessing progress and providing
specific disability culture. improvement in the process.
Integrated Education Summary
The emergence of the concept of integrated education in India
School plays an important role in the physical, emotional,
during the mid 1950s began by the Royal Commonwealth
social and mental development of children. The medical
Society for the Blind, and the Christopher Blind Mission.
examination of school children was started in Baroda in 1909.
The Ministry of Education, too, launched a comprehensive
The “National School Health Council” has been established
scholarship scheme in 1952, a rudimentary beginning of the
since 1963 to plan and organize school children’s health care.
integrated education initiative by the Government.
WHO’s Global School Health Initiative (GSHI) was launched in
Integrated Education for Disabled Children (IEDC) : 1995. The goal of GSHI is to increase the number of schools
Consequent to the success of international experiments in that can truly be called “Health-Promoting Schools”. The

• 855 •
concept of school health service has undergone change from Study Exercises
mere health check up to become a comprehensive service with
Long Question : School health services in India
elements of preventive, promotive, curative and rehabilitative
services that must include elements of safety, health education, Short Notes: (1) GSHI (2) Healthful school environment
physical education, nutrition and counselling and social service (3) Causes of poor scholastic performance in school children
programme. A healthful school environment should be provided (4) IEDC
with due consideration to premises, seating arrangement, MCQs & Fill in the blanks
drinking water, sanitary arrangement, mid day meal, canteen, 1) National School Health Council was established in _____
vaccination, sick reporting with referral facilities, physical 2) Global School Health Initiative was launched in ________
education and health education which are to be monitored and 3) The first school of deaf in India was setup in (a) Bombay
supervised by a school health committee. Management of the (b) Calcutta (c) Delhi (d) Bangalore
children with scholastic backwardness should be proper as per 4) The first school of blind in India was setup in (a) Bombay
algorithm for the evaluation of a child with poor scholastic (b) Calcutta (c) Delhi (d) none
performance. The Planning Commission, in 1971, included 5) IEDC scheme was launched in India in the year ________
in its plan a programme for integrated education of disabled 6) The medical examination of school children was started in
children in regular schools. The Government launched the IEDC __________ In the year __________
scheme in December 1974. The steps needed for implementation Answers : (1) 1963; (2) 1995; (3) a; (4) d; (5) December 1974;
of IED under SSA (Sarva Shiksha Abhiyan) are classified under (6) Baroda,1909.
three headings namely direct services to children, support
services, monitoring and evaluation. School health services References
can influence health behaviour of other children, their families 1. Govt of India (1946). Report of the health survey and development committee;
Govt of India press, Shimla.
and community. 2. Govt of India (1961), Report of school health committee, part I, Central
Health Education Bureau, New Delhi
3. Central Health Education Bureau (1965), Report of seminar on school health
services, New Delhi
4. Idem (1965), Report of workshop for the development of criteria for healthful
aspects of a school programme, New Delhi
5. Turner, C.E. et al (1957). School health and health education, CV Mosby

the latest addition to the multiple dimensions of adolescent

147 Adolescent Health health with huge implications on their health. Unfortunately,
the special needs of adolescents’ have not been addressed by
the educational, health, and family welfare programs in India
A S Kushwaha
so far.

Adolescence is a critical period of life marked by biological, Definition of Adolescence

social and psychological changes for an individual. These are The word ‘Adolescent’ has been derived from Latin word
formative years for behaviour patterns and activities relevant ‘Adolescere’ which means ‘to grow to maturity’. Adolescent is
to health. It is a period of major transition during which considered to be, no longer a child, and not yet an adult. The
adolescents learn to become adults. They can benefit from definitions vary as to the exact range of age for this period.
guidance in respect of vital issues of human biology, health, Most cultures relate the beginning of adolescence to the onset of
disease and behavioural adaptation. Recent discoveries in puberty, but differ on specifying the end of adolescence. Different
biological, behavioural, clinical and epidemiological research cultures define the roles, responsibilities and prerogatives of
have clarified the concepts of this transition. The lifestyle and adults differently and thus the above variation. Thus in certain
behaviour developed during adolescence has an impact on the societies, an individual may have attained biological maturity
health not only during adolescence but even in later life. In fact, but may not have attained full adult status. The chronological
the bulk of morbidity and mortality in adulthood is due to the definition of adolescence has been kept broad so that it can be
health related behaviours (smoking, alcohol, exercise and diet) used in a variety of socio-cultural and health settings. WHO
developed during the adolescence. The major issues concerning defines Adolescence as 10-19 years old, ‘Youth’ as 15-24 years
adolescents are growth and development, STDs and RTIs, drug, old and ‘Young People’ as 10-24 years old. The adolescence has
alcohol and tobacco abuse, teenage pregnancy, abortion, RTAs, been divided into two phases: ‘early’ (10-14 years) and ‘late’
suicide, homicide and issues of behavioural problems. HIV is (15-19 years).

• 856 •
The need to focus on Adolescent Health is because level. During this period that adolescents gain up to 50% of
(a) Adolescents face serious health challenges their adult weight, more than 20% of their adult height and 50%
(b) Adolescent health and development affect economic of their adult skeletal mass. In under-nourished children rapid
prosperity growth during adolescence may increase the severity of under-
(c) Investing in youth helps to break cycle of poverty nutrition. Iron is deficient in almost all age groups. Naturally
(d) Health is a key element of overall youth development the shortfalls create more vulnerability for adolescent girls. The
(e) Young people have a right to health factors that may interfere with nutrition are inadequate food
Adolescents : A special group with special needs supplies in quantity and quality, psychological factors affecting
appetite, food fads and cultural attitudes and infections and
The need to focus on adolescent health exists for a number of parasitosis.
reasons. (See Box 1)
Adolescence is a period of change and, consequently, one of
stress, characterized by uncertainties in regard to identity
Box - 1 : Why Adolescents are a special group?
and position in the peer group, in the family, in the society
Because of their number: they constitute more than 22% of at large and in the context of one’s own responsibilities as an
the population. adult. The compulsions of parental approval often encounter
Adolescence is the period of rapid physical growth, sexual the emerging aspirations for independence. Their behaviour is
and psychological changes. guided by an intense desire for independence and identity. In
the process, adolescents undergo intense psychological stress
Habits and behaviour picked up during adolescence (risk
and personality change.
taking behaviour, Substance abuse, eating habits, conflict
resolution) have lifelong impact. 3. Socio-Cultural Factors Affecting the Development : In
most parts of the world, especially developing world, girls are
Adolescence is the last chance to correct the growth lag and
deprived of nutrition, access to health care, and opportunities
malnutrition.
for education and employment. They are taken out of schools
Many adolescent boys and girls are sexually active but lack when they reach menarche. In most traditional societies, from
information and skill for Self- protection. the very beginning of life, girls are groomed to accommodate the
They have simple but wide pervading crucial reproductive male-dominated, patriarchal society. With the rising proportion
health needs - Menstrual hygiene, contraception (including of children attending school and ever increasing functions of
emergency contraception) safety from STI and HIV. education, opportunity to facilitate healthy development of
adolescents has opened up in many developing countries.
Communication gap exists with parents and other adults. Increasing urbanization, globalization, cosmopolitan type of
population, explosion of information technology, pervasive
Some Basic Physiological & Psychological Needs scientific attitude and changing social and cultural values in
1. Growth and Development : The early part of adolescence the evolving society affect the psychological development of
is characterized by rapid physical growth, changes in an adolescent.
psychological functions and organ systems of the body and
Health Problems of Adolescence
completion of sexual development. During adolescence marked
morphological changes occur and hypothalamic-pituitary- Though adolescence is a relatively healthy period in the life
gonadal system becomes mature. The ovaries and testes of an individual with lowest age specific mortality (NFHS-3);
produce enough steroid hormones which result in the growth however, it has certain characteristics that put them at risk to
of genital organs and appearance of secondary sex characters. health hazards specific to this age group. The health problems
The body composition changes and there is increased strength of the adolescents relate to a large extent to their growth
and efficiency of body energy production. In adolescence these and development, sexual maturation, psychological changes.
variations are exceedingly large within the same individual These issues are not discussed with the parents and health
and between different individuals. This aspect needs to professionals due to lack of privacy and confidentiality and
be understood by the adolescents, their families, health thus remain either unresolved or attempts are made through
professionals in particular and society in general. The puberty peers and available media which may not always be helpful
in females is earlier as compared to males. Many adolescent and appropriate. The adolescent, because of rapid biological-
boys and girls are sexually active but lack information and psychosocial changes, is prone to impulsivity, emotional and
skills for self-protection (low level of information on Family risk taking type of behaviour putting them at risk to problems
Planning, low contraception use). They have simple but wide like STDs/RTIs, accidents, drug and substance abuse and
ranging crucial reproductive health needs- menstrual hygiene, psychological and mental health disorders.
contraception (including emergency contraception) safety from The health care system have provided for health of the children
STI and HIV. and adults but adolescents have been left out, without any
2. Nutritional and Psychosocial Needs : The adolescents specific health programmes directed towards them especially
in developing countries may suffer from malnutrition and in developing nations where resources are scarce. However,
dietary imbalance while those in developed countries may of late this special group of population has been given some
have problems of obesity. Adolescents have greater nutritional attention in the post HIV period as the adolescents constitute
requirements because of rapid growth and physical activity highly vulnerable group

• 857 •
Behaviour Related Health Problems important health issues and problems that affect them. An
Alcohol, Smoking and Drugs : The adolescents tend to Indian Council of Medical Research (ICMR) study showed
experiment with alcohol, smoking and other drugs. The use that knowledge and awareness about puberty, menstruation,
of tobacco and alcohol is widespread in both developing and physical changes in the body, reproduction, contraception,
developed nations. 30-50% of high school students in USA pregnancy, childbearing, reproductive tract infections, Sexually
consider use of marijuana as an accepted way of life. In Transmitted Infections (STIs), and HIV was low among boys
Sweden, drug dependence reaches its peak in the age group 12- and girls, especially in younger adolescents (ages 10-14). The
20 years. The factors responsible for smoking in young people study reported, however, that older adolescents (ages 15-19)
are peer pressure, following example of sibling and parents and had better knowledge. About 80 percent had knowledge of
employment outside the home. STIs, including HIV.
Dietary Habits : Inappropriate dietary habits in adolescence Education : Only 83 percent of primary-school age children (6-
are also commonplace. They tend to consume junk food and 10 years) attend school. School attendance drops to 75 percent
imbalanced diet more than any other age group. They may also for children aged 11-14 years and is only 41 percent for children
develop habit of compulsive eating at one end and anorexia age 15-17 years. Education is linked to delayed marriage and
nervosa at the other end of spectrum. childbearing and better outcomes besides decreased fertility.
Sexual Behaviour : Sexual indiscretion, lack of education Marriage, Sex & Reproductive health : The importance
on skills of responsible sexual behaviour and urge for of reproductive health of adolescents is receiving increased
experimentation can lead to myriad of problems ranging from attention due to multiple factors- they are almost ¼ of the
unplanned pregnancy, STDs, HIV, unwed mothers, illegal population, they are going to be parents of the next generation
abortions, psychological breakdowns and complex social and HIV has provided the necessary impetus to this important
problems. issue. The fall in age at menarche and increased age at marriage
coupled with changing social-cultural values and attitudes has
Risk Taking Behaviour : Adolescent males tend to challenge
increased the potential of pre-marital sexual activity. The effect
difficulties without taking the danger into account to the extent
of increased urbanization, migration, economic independence
that most adults would. This impulsive risk taking behaviour
and declining family influence has provided suitable conditions
has implications for health of the adolescents, whether the
for increased exposure of the young people to risky sexual
activity is driving a vehicle, sports, any work or various health
behaviour.
related behaviours like drugs, alcohol or sexual urge.
High fertility rates, high rates of teenage pregnancy, high risk
Adolescence - A Stressful Transition Period of STI/HIV and poor nutritional status are the main health
The world in which adolescents of today live is marked by problems among the adolescent population in India (4,5). The
vastness as far as mobility is concerned and rapid technical and median age at first marriage among women is 17.2 years.
social changes. This demands a great degree of adjustments Among young women aged 15-19 years, 16 percent have already
and adaptation by the adolescents who are undergoing rapid begun childbearing. Of those who seek medical termination of
biological-social-psychological transition. The adolescents tend pregnancy, 8-10% are teenage mothers and unmarried girls.
to explore actively in seeking information on new situations,
Public Health Implications
new roles and future difficulties.
The public health implications of adolescent health are
Adolescent Health : Global Scenario far reaching and have intergenerational effects as well.
The health of the adolescents can be measured by studying (See Box - 2)
age specific morbidity, mortality, prevalence of behavioural
disorders and DALYs. This relatively healthy phase of life Box - 2 : Public Health Implications of Adolescent Health
must also be seen in the light of barriers to health seeking
Mortality in Adulthood : The 70% of the mortality in
behaviour and under-reporting of adolescent related data in
adulthood is linked to habits picked up during adolescence
the developing countries. However, DALYs has been found to
(risk-taking behaviour, substance abuse, eating habit and
be most suitable indicator for the purpose of international
conflict resolution.)
comparison. More than 33 percent of the disease burden and
almost 60 percent of premature deaths among adults can be Intergenerational Effects : Prevailing malnutrition,
associated with behaviours or conditions that began or occurred anaemia, stunting and lack of immunization have adverse
during adolescence - for example, tobacco and alcohol use, poor impact on MMR, IMR and morbidity.
eating habits, sexual abuse and risky sexual behaviour (WHO Adolescent Sexuality : Leads to adolescent pregnancy,
2002). Adolescence-related risk factors are a greater problem unsafe abortion, RTI, STI/HIV and social problems.
in wealthier countries, largely because of the relatively greater Adolescent Pregnancy : In this the risk of adverse outcome
impact of smoking and diet-related risks in those countries, (IMR, MMR LBW babies) is higher.
though the prevalence of these risks is expanding rapidly in
many low - and middle-income countries. Risk Taking Behaviour : Lack of “connectedness” with
parents and other adults prevents transmission of health
Indian Scenario messages and crucial skills leading to adoption of risky
Awareness on Common Health Issues : There is a lack behaviour, substance abuse, early sexual debut and STI,
of knowledge and awareness amongst adolescents about HIV etc.

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Interventions private channels, such as pharmacies and for-profit medical
Improving the health of young people is a complex and difficult services, where many young people prefer to seek care.
issue. Programs will have to seek multi-sectoral solutions that Initiatives in India for Health and Development of
link health sector interventions with other types of interventions Adolescents
delivered through other sectors, either at the program level or at The Government of India has identified “Survival, Protection,
the policy level. Research has created international consensus and Development” as a major theme, focusing on gender-
over a multi-pronged intervention approach based on the specific needs. This was a conscious effort to ensure equitable
following principles (Box - 3). rights, opportunities, benefits, and status to girl children as
part of National Plan for the SAARC decade of the Girl child.
Box - 3 : Principles of Health Programming for
Realizing for the first time, the importance of this population
Adolescents
sub group, the Planning Commission has set up a Working Group
Recognize the diversity of the youth age group. for the Welfare and Development of Adolescents, to provide
Involve young people. inputs into the Tenth Five Year Plan. Most importantly, policies
and programmes need to cover the entire range of health and
Design comprehensive programs
related problems of adolescents and not confined to education
Make health services Youth Friendly. and service delivery for reproductive health alone. The Working
Address gender inequality of Women. Group proposed an allocation of at least Rs.112 crore for the
Tenth Five Year Plan for the schemes for adolescents to be
Address the needs of boys.
implemented by the nodal Ministry (Ministry of Youth Affairs
Address non-health factors that influence health & Sports). The adolescents have been recognized as valuable
Address underlying risk and protective factors. human resource with certain rights.
The initiatives taken under inter-related issues concerning
(a) Life-Skills and Health & Sexuality Education in Schools: adolescents under various schemes are given as under-
Well designed, well-implemented sexuality and reproductive 1. National Policy on Education (1986 modified in 1992):
health education can provide young people with a solid The main emphasis in the National Education Policy is on
foundation of knowledge and skills to enable them to engage the eradication of illiteracy and universalization of primary
in safe and responsible sexual behaviour. education. Education helps to develop adolescent health by
(b) Peer Education : Peer education programs are especially delaying marriage, childbearing while generating positive
appropriate for young people who are not in school and for hard- health behaviour.
to-reach, at-risk subsets of the youth population including, sex 2. National Population Policy : They are specifically referred
workers and street children. to in the sections on information, nutrition, contraceptive use,
(c) Mass Media and Community Mobilization : Mass media STDs and other population-related issues. There is a special
and community mobilization efforts that engage influential mention about developing a health package for adolescents
adults, such as parents, teachers, community and religious and enforcing the legal age at marriage.
leaders, and music and sports stars, can help normalize positive 3. National AIDS Prevention and Control Policy : Since
adolescent behaviours and gender roles as well as direct young unprotected sex is a major source of AIDS and adolescents
people to appropriate health services. form a significant portion of the sexually active population,
(d) Youth Development Programs : Youth development they should form a special focus group under the Policy.
programs typically address a range of key adolescent needs, While the policy talks about programmes for adolescents like
including life skills, education, jobs, and psychosocial needs. University Talk AIDS and NYKs, surprisingly, the policy does
Programs with a voluntary community service component have not specifically mention adolescents. One can say that even
successfully improved key reproductive health behaviours, but without specifically mentioning adolescents, the policy is
no evidence is available for developing countries. crucially relevant to them and aims at addressing their needs.
(e) Clinical Health Services : Although some young people 4. National Nutrition Policy (1983) : The National Nutrition
seek care through the formal health system, many others are Policy has focused on adolescent girls and that too only
deterred by the often judgmental attitudes of health workers, in relation to the importance of their role as mothers and
particularly when seeking care and advice on matters related housewives. Adolescent boys do not find any mention in the
to sexuality. policy. The need for the well being of adolescents, as a group
(f) Social Marketing : This approach involves the use of has not been recognized. ICDS is providing supplementary
public health messages to promote healthy behaviours and nutrition to adolescent girls (Kishori Shakti yojna) but the
the use of condoms and other health products and services. coverage is abysmally low (3%). The 10th Five Year Plan and
Effective programs bring products and services to places in the Nutritional Policy proposed a nutritional program for girls
community that young people frequent, such as shops, kiosks weighing less than 35 Kg and for pregnant women weighing
and pharmacies. less than 45 Kg and below poverty line, who would get ration
of Rs 6/- per month in the form of wheat or rice, through
(g) Workplace and Private Sector Programs : Programs that
the Public Distribution System. The adolescent girls need
reach young people do so at their places of work and through

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appropriate nutrition, education, health education, training criteria have been laid down to provide financial assistance
for adulthood, training for acquiring skills as the base for to the mother of a newborn girl child in the form of grants
earning an independent livelihood, training for motherhood, and investments through a postal financial instrument to be
etc. Similarly on the other side their potential to be a good applied toward the education and economic independence of
community leader has to be realized. A scheme for adolescent that child. The deposit will mature and be paid to the girl if
girls in ICDS was launched by the department of Women and she remains unmarried until she reaches 18 years of age. This
Child Development, Ministry of Human Resource Development helps to delay the age of marriage.
in 1991. 3.National Service Scheme (NSS) : NSS was launched in 1969
All adolescent girls in the age group of 11-18 years receive the with a primary focus on students’ personality development
following common services: and community service. NSS involved more than 1.6 million
(a) Immunization student volunteers from more than 175 universities and 22
(b) General health check up once in every six months senior secondary councils. The scheme’s programs include
(c) Training for minor ailments “regular activities” and “special campaign programs.”
(d) Deworming 4.Bharat Scouts and Guides : It is the third largest youth
(e) Prophylactic measures against anaemia, goiter, vitamin organization in the world. Scouting and guiding movements
deficiency, etc. aim to develop boys’ and girls’ characters with the goal of
(f) Referral to PHC/District hospital in case of acute need making them good citizens of India. It inculcates in them a
(g) Watch over menarche spirit of patriotism and promotes balanced physical and mental
5. National Policy for the Empowerment of Women (2001) : development.
The policy has recognized the girl child as a separate category 5. Child Labour Projects : The Ministry of Labour is running
and adolescent girls seem to be covered there under. The policy 76 national Child Labour Projects in the country.
relates to their nutrition, education, holistic approach to health,
6. Integrated Program for “Street Children” : The Ministry of
violence against them, sexual abuse of them and the rights of
Social Justice and Empowerment has been implementing this
the girl child.
program since 1992-93. One of the important initiatives under
6. Reproductive & Child Health : The special package of the program’s revision in 1998 was the establishment of the
interventions for adolescents under RCH are- Child Help Line Services in a number of cities. The Child Help
(a) One booster dose of TT at the age of 16 & immunization of Line provides emergency assistance to children.
girls against Rubella. 7. Population Council : The Population Council has supported
(b) Sex education to promote responsible and healthy initiatives on adolescent transition in different states in
reproductive & sexual behaviour. colLabouration with several NGOs. The Population Council
(c) Prevention of STD/HIV and AIDS. supported programs on adolescence run by Mahila Samakhya
(d) Adult Literacy especially among women. in Karnataka and Andhra Pradesh and in the state of Haryana,
(e) Vocational training. Apni Beti Aapna Dhan and services in the areas of personality
(f) Pre marital counselling. development, education, health, reproductive health, economic
(g) Gender equality. participation, and life skills training.
(h) Family life education.
8. International Centre for Research on Women (ICRW):
It will be seen from the above that the present policies address
ICRW is coordinating a multi-site intervention and research
specific sectors like education, health, family welfare, nutrition,
program to develop effective programs for adolescent sexual
HIV/AIDS, sports etc. or address certain population groups like
and reproductive health and development in India. The studies
women, children and youth. None of the policies however take
confirmed that a lack of power, decision making opportunity,
an integrated and holistic view of adolescents. Adolescents
autonomy, and access to resources underlie the reproductive
in difficult circumstances like adolescents with disabilities,
health risks faced by adolescents, particularly adolescent
learning disorders, adolescent sex workers or children of
females, and those who are unmarried.
sex workers and street children need much more visibility in
policies. 9. Centre for Development and Population Activities
(CEDPA) : CEDPA, An international NGO with operations in
Specific Programs on Adolescents Delhi, in collaboration with local NGOs, UNFPA, UNESCO and
Brief of some specific programs initiated by governmental and USAID, has adapted “Choose a Future: Issues and Options for
non-governmental organization directed towards adolescents Adolescent Boys” to the Indian cultural context and is currently
in India is given below- implementing programs in 11 states.
1.Kishori Shakti Yojana : To improve the health and 10. Planned Parenthood Federation : Planned Parenthood has
nutritional status of girls by supplementary nutrition, anaemia promoted four major projects with the help of local NGOs:
prophylaxis under ICDS. Poor coverage of the target population (a) Improving the Reproductive Health of Young Women
is the limitation of this programme. and Men : The goal of the project is to improve the lives of
2.Balika Samridhi Yojana, 1997: This scheme works to raise adolescents and youth by providing contraceptive services and
the status of girl children born in families below the poverty sexuality education in 20 rural villages in a district in West
line by providing financial help to these families. Some specific Bengal with a local NGO.

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(b) Couple to Couple : The project employs peer couples to work on health of adolescents in India. Priority Target Groups under
with groups of newlyweds and other young couples to motivate the policy are given in Box - 4.
them to increase gender awareness, encourage supportive
relationships, and plan for their new families together. Box - 4 : Priority Target Groups
(c) Improving the Reproductive Health of Adolescents and ●● Rural and Tribal Youth
Youth : Located in Jharkhand state, the project aims to increase ●● Out-of-school Youth
young people’s knowledge and understanding about sexuality ●● Adolescents particularly female
and reproductive health and help them develop communication ●● Youth with disabilities
and decision-making skills so that they may lead healthy ●● Adolescents under special circumstances like victims of
reproductive lives. trafficking; orphans and street children.
(d) Reproductive Health Through Advocacy and Services:
The project is a part of a larger program to improve the Implementation Mechanism : The Union Ministry of Youth
reproductive health and rights of adolescents and youth in the Affairs & Sports (with the guidance of this Committee) will
Indian states of Bihar and West Bengal. be the Nodal Ministry for all such programmes and schemes
and will oversee the implementation of the provisions of this
National Youth Policy, 2003
Policy. A National Youth Development Fund will be created
The National Youth Policy, 2003 reiterates the commitment of through contributions, including from Non-Governmental
the entire nation to the composite and all-round development Organizations, which would be utilized for youth development
of the young sons and daughters of India. This Policy covers all activities.
the young people in the country in the age group of 13 to 35
years. The age group is, therefore divided into two broad sub-
Life Skills Education
groups viz. 13-19 years and 20-35 years. Life skills have been defined by World Health Organization as
Strategy ‘the abilities for adaptive and positive behaviour that enable
individuals to deal effectively with the demand and changes
1. Youth empowerment of everyday life’. Life skills are abilities that help to promote
(a) Attainment of higher educational levels and expertise by mental well being and competency of young people to face the
the youth, as per their abilities and aptitudes, and access challenges of life. Effective acquisition of life skills can influence
to employment opportunities accordingly. the way one feels about oneself and others and can enhance
(b) Adequate nutrition for the full development of physical one’s productivity, efficacy, self-esteem and self-confidence.
and mental potential and the creation of an environment Life skills can also provide the tools and techniques to improve
which promotes good health. interpersonal relations.
(c) Protection from disease agents and unwholesome habits.
There are three kinds of life skills : Thinking skills, social
(d) Development of youth leadership.
skills and negotiating skills. Thinking Skills include problem
(e) Equality of opportunity.
solving, thinking critically, processing information and
2. Gender Justice : The Policy recognizes that prevailing gender exercising choice, making informed decisions and setting goals.
bias is the main factor responsible for the poor status of health Social skills include appreciating/validating others; building
and economic well-being of women in our society. The Policy positive relationship with peer groups and family; listening
enunciates that: and communicating effectively; taking responsibility; and
(a) Every girl child and young woman will have access to coping with stress. Negotiating skills include self realization
education and would also be a primary target of efforts to that enables an individual to understand ones values, goals,
spread literacy. strengths and weaknesses. Thus, negotiating skills need to
(b) Women will have access to adequate health services and be enhanced at two levels - within oneself and with others.
will have full say in defining the size of the family. Adolescents need to learn to be assertive, including learning to
(c) Domestic violence will be viewed not only as violation of say “no” to adopt risky and harmful behaviour like drug use
women’s freedom but also as that of human rights. or casual sex before marriage. During adolescence, life skills
(d) All necessary steps should be taken for women’s access to development is an active process. Despite superior intellectual
decision-making process, to professional positions and to abilities, the adolescent’s behaviour is occasionally influenced
productive resources and economic opportunities. by emotions rather than by rational thinking. Frequently the
(e) Young men, particularly the male adolescents shall be adolescent is in an emotional dilemma of wanting to be guided
properly oriented, through education and counselling to by parents, yet wishing to be free from them, and more aligned
respect the status and rights of women. to their peers. They also have the need to exercise skills to
3. Inter-Sectoral Approach :   The Policy recognizes that indicate and establish their individuality and independence.
an inter-sectoral approach is a pre-requisite for dealing with This becomes complex, as an adolescent has multiple situations
youth-related issues. to deal with. Many critical issues arise during adolescence like
4. Information & Research Network : The Rajiv Gandhi - puberty, dealing with sexuality and gender issues, tackling
National Institute of Youth Development (RGNIYD) will emotional upheaval, finishing education, need to make future
serve as the apex Information and Research Centre on youth career choices, facing responsibilities as an adult, etc. Hence,
development issues. There is a crying need to have valid data Life Skills Development is of immense value to the adolescents

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in managing their lives. It is recommended that 30 to 45 day a healthy member of society, it is necessary to understand
‘Life Skills Development Programmes’ be organized by NGOs/ all these causes and remove them through improving family
NYKs/other community groups for both school going and out life, proper schooling, reducing harmful peer influences, and
of school adolescents. Adolescents who go through such a social welfare services. Under the Juvenile Justice Act, 1986,
training programmes could thereafter be used as peer educators. separate provisions have been laid down for the neglected and
Education of adolescents on family life is an important exercise uncontrollable juveniles. They are dealt with by the Juvenile
as they are the parents of tomorrow. It is defined as “an Welfare Boards and not by Juvenile Courts.
educational process designed to assist young people in their Common Problems seen in Juvenile Delinquents
physical, social, emotional and moral development as they 1. Behavioural problems e.g. lying, stealing, gambling
prepare for adulthood, marriage, parenthood, ageing as well aggressiveness, destructiveness, disobedience, over
as their social relationship in their socio cultural context of the activity.
family and society” (UNESCO). 2. Learning disabilities.
Counselling 3. Emotional problem e.g. depression, school refusal, fears,
Counselling is a process of enabling and empowerment to help timidity, shyness.
a person in problem solving and crisis management. This may 4. Adjustment reactions e.g. school related problem, grief.
be required at different stages of life. One of these stages is 5. Development disorder e.g. autism, bedwetting & soiling.
the period of adolescence when adolescents are usually either 6. Intellectual deficit.
in school or college or out of school as ‘drop-outs’ and ‘left- 7. Psychosomatic disorders.
outs’), and therefore the need and importance of counselling is 8. Bizarre and abnormal behaviours.
highest during this period and for these groups. 9. Relationship (including parent-child, sibling and marital)
problem.
Adolescents in Difficult Circumstances 10. Socio-legal issues and problem e.g. child custody
Adolescents in difficult circumstances are those who belong assessment, sexual offences, child abuse and head
to special groups like drug addicts, adolescents with AIDS injuries.
and adolescents with parents afflicted by AIDS, adolescent 11. Other e.g. eating and sleep disorders, sexual problems in
prostitutes and children of the same, juvenile delinquents adolescence, tics (movement disorder) & stress reaction.
and adolescent victims of crime, street adolescents, neglected Prevention & Management of Juvenile Delinquency
juveniles and adolescents who are physically and mentally ●● Improvement of family life
challenged. Any intervention to address adolescents must also ●● Life Skills development
keep in mind the environment in which adolescents live - their ●● Schooling
families and society. It is equally essential for any intervention ●● Social welfare services - Child guidance clinics, juvenile
aimed at adolescents in difficult circumstances, to address the court, Child placement (Orphanages, Foster homes,
parents and families of these adolescents. Needless to say a Borstals, Remand home)
holistic and integrated approach has to be adopted.
Child Guidance Clinic (CGC)
Juvenile Delinquency The concept originated in USA when Child Guidance Clinic was
It refers to a large variety of behaviour of children and started in 1909 in Chicago. These were originally intended
adolescents which the society does not approve of and for to deal with juvenile delinquency. Now the concept has been
which some kind of admonishment, punishment or preventive widened to also deal with those children who are not adjusted
and corrective measures are justified in public interest. with their environment. The basic objective of these clinics
●● Juvenile- ‘Juvenis’- young - boy who has not attained 16 is to prevent children from becoming neurotics, psychotics,
yrs, girl aged less than 18 criminals in later life by offering a gamut of services provided
●● Delinquent - “delinquere” by a team which may include-
- A child who has committed an offence ●● Psychiatrist
- All deviations from normal youthful behaviour ●● Clinical psychologist
This includes all children who are incorrigible, ungovernable ●● Educational psychologist
and habitually disobedient and who desert their homes, ●● Psychiatric social worker
with behavioural problems and anti-social practice. The term ●● Public health nurse
‘juvenile’ has been defined in clause (h) of Section 2 of the ●● Pediatrician
Juvenile Justice Act, 1986, as a boy who has not attained the ●● Speech therapist
age of sixteen years or a girl who has not attained the age of ●● Neurologist
eighteen years. Offence under clause (n) of Section 2 of the The composition of the team is variable depending on the need
above Act means an offence punishable under any law for and the resources available.
the time being in force which includes the Narcotics Drugs The clinic offers a number of services for these children.
and Psychotropic Substances Act, 1985 and the Terrorist and Psychotherapy is central to all other services provided.
Disruptive Activities (Prevention) Act, 1987.
Services
A child becomes a criminal through the interaction of many
●● Psychotherapy- core of services
causes, social and individual, familial, psychological and
●● Physical health
economic. In order to rehabilitate the juvenile delinquent as

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●● Children’s One-Stop Psycho-Educational Services (COPES) the final authority to dispose of cases for the care, protection,
Treatment treatment, development and rehabilitation of the children
●● Medical treatment as well as to provide for their basic needs and protection of
●● Individual psychotherapy human rights. Where a Committee has been constituted for
●● Family and marital therapy any area, such Committee shall, notwithstanding anything
●● Behavioural / Cognitive therapy contained in any other law for the time being in force but save
●● Occupational therapy as otherwise expressly provided in this Act, have the power to
●● Group therapy deal exclusively with all proceedings under this Act relating to
●● Play therapy children in need of care and protection.
●● Social case work (b) Juvenile Justice Board : State Government may, by
Prevention : The preventive measures are based on the belief notification in the Official Gazette, constitute for a district or
that juvenile delinquents are shaped by the socio-economic- a group of districts specified in the notification, one or more
cultural influences on a vulnerable child. A stable, emotionally Juvenile Justice Boards for exercising the powers and discharging
fulfilling and healthy family environment is the best vaccine the duties conferred or imposed on such Boards in relation to
against this disorder. School plays an important role in shaping juveniles in conflict with law under this act. A Board shall
the behaviour of a child and healthy interaction with teachers consist of a Metropolitan Magistrate or a Judicial Magistrate
and peers will result in a child who is emotionally balanced of the first class, as the case may be, and two social workers
and mentally healthy. The role of developing life skills and of whom at least one shall be a woman, forming a Bench and
family life education cannot be overemphasized. every such Bench shall have the powers conferred by the Code
Juvenile Justice (Care and Protection of Children) Act of Criminal Procedure, 1973 (2 of 1974), on a Metropolitan
Magistrate or, as the case may be, a Judicial Magistrate of the
(2000)
first class and the Magistrate on the Board shall be designated
Background as the principal Magistrate. No Magistrate shall be appointed
1. The constitution in Articles 15, 39, 45 & 47 has imposed as a member of the Board unless he has special knowledge
on the state a primary responsibility of ensuring that all or training in child psychology or child welfare and no social
the needs of children are met and that their basic human worker shall be appointed as a member of the Board unless
rights are fully protected. he has been actively involved in health, education, or welfare
2. Convention on the rights of the Children adopted by UN activities pertaining to children for at least seven years.
general assembly in 1989.
(c) Children Homes : The State Government may establish
3. Government of India ratified the convention in 1992.
and maintain either by itself or in association with voluntary
4. United Nations Standard Minimum Rules for the
organizations, children’s homes, in every district or group of
administration of Juvenile Justice,1985 (Beijing rules) and
districts, as the case may be, for the reception of child in need
UN rules for the protection of Juveniles deprived of their
of care and protection during the investigation of any pending
liberty (1990).
inquiry and subsequently for their care, treatment, education,
5. Juvenile Justice Act 1986.
training, development and rehabilitation. The State Government
Earlier the Children Act, 1960 amended in 1977 laid down may, by rules made under this Act, provide for the management
that delinquent children needed to be provided with care, of children’s homes including the standards and the nature
education, maintenance, training and rehabilitation. This of services to be provided by them, and the circumstances
covered victimized, uncontrollable, ungovernable, destitute under which, and the manner in which, the certification of a
and delinquent children. The Juvenile justice Act 2000 has children’s home or recognition to a voluntary organization may
removed all the inadequacies of the children act and has made be granted or withdrawn.
the care more comprehensive and encompassing. The Act has
been published in “The Gazette of India” No.70: The Juvenile (d) Rehabilitation : The rehabilitation and social reintegration
Justice (Care & Protection of Children) Act 2000 (No. 56 of of a child shall begin during the stay of the child in a children’s
2000) published by the Legislative Department of Ministry of home or special home and the rehabilitation and social
Law, Justice and Company Affairs after receiving the assent of reintegration of children shall be carried out alternatively by-
the President of India on 30 December 2000. (i) Adoption
(ii) Foster care
The salient features of the Act are given below
(iii) Sponsorship
(a) Child Welfare Committee : The State Government may, (iv) Sending the child to an aftercare organization
by notification in Official Gazette, constitute for every district
(e) Special Juvenile Police Unit : Special juvenile police unit,
or group of districts, specified in the notification, one or
to handle juveniles or children may be created in every district
more Child Welfare Committees for exercising the powers
and city to co-ordinate and to upgrade the police treatment of
and discharge the duties conferred on such Committees in
the juveniles and the children.
relation to child in need of care and protection under this Act.
The Committee shall consist of a Chairperson and four other Child Placement
members as the State Government may think fit to appoint, of 1. Orphanages : These are for the children who have no home,
whom at least one shall be a woman and another, an expert no parents or single parents or parents too poor to care for them.
on matters concerning children. The Committee shall have The concept is not very favourable to the overall wellbeing of

• 863 •
the child as it does not provide emotional and social warmth specific needs. The initiatives have been taken under inter-
required for their development. related issues concerning adolescents under various schemes.
2. Foster Home : This is a setting which provides all that The notable ones are National policy on education (1986
is available in a family setting but a home other than their modified in 1992), National population policy, National AIDS
original family. prevention and control policy, National nutrition policy (1983),
National policy for empowerment of women and Reproductive
3. Borstals : These are institutions somewhere between a
and child health policy. These policies address specific sectors
certified school and an adult prison for the children 16 years
like education, health, family welfare, nutrition, HIV/AIDS,
and above who have some social adjustment pathology.
sports etc. or address certain population groups like women,
4. Remand Homes : This is for those children who have been children and youth. There are specific programs initiated by
arrested by the police in some situation which warrants them governmental and non-governmental organization directed
to be taken care of like immoral trafficking, prostitution etc. towards adolescents. National Youth Policy, 2003 reiterates the
commitment of the entire nation to the composite and all-round
Summary
development of the young sons and daughters of India. This
WHO defines Adolescence as 10-19 years old, Youth as 15-24 policy covers all young people in the country in the age group of
years old and Young people as 10-24 years old. The adolescence 13 to 35 years. The strategies are Youth empowerment, Gender
has been divided into two phases: early (10-14 years) and late Justice, Inter-sectoral approach and Information and research
(15-19 years). The need to focus on adolescent health exists network. The areas of focus are General health, Mental health,
for many reasons. They constitute 23.1% of Indian population. Spiritual health, AIDS and STDs, Population education/Family
It is the period of rapid physical growth, sexual maturation life education/Reproductive health and Tobacco/Substance
and psychological changes. Habits and behaviours picked up abuse. The implementation is by Union Ministry of Youth
during this period (risk taking behaviour, substance abuse, Affairs and Sports.
eating habits and conflict resolution) have long lasting impact.
Life-skills has been defined by WHO as ‘the abilities for
Adolescence provides the last chance to correct the growth lag
adaptive and positive behaviour that enable individuals to
and malnutrition of childhood.
deal effectively with the demands and changes of everyday
There are various health problems related to the period of life’. Effective acquisition of life skills can influence the way
adolescence. The adolescent because of rapid biological and one feels about oneself and others and can enhance one’s
psychosocial changes, is prone to impulsivity, emotional and productivity, efficacy self esteem and self confidence. There
risk taking type of behaviour putting them at risk to problems are three kinds of life skills- Thinking skills, Social skills and
like STDs/RTIs, accidents, drug and substance abuse and negotiating skills. Adolescents need to be assertive, including
psychological and mental health disorders. Inappropriate learning to say “no” to adopt risky and harmful behaviour like
sexual behaviour may lead to unplanned pregnancy, STDs, HIV, drug use or casual sex before marriage.
unwed mothers, illegal abortions, psychological breakdowns
Juvenile Delinquency refers to a large variety of behaviour of
and complex social problems. An unfavourable family
children and adolescents which the society does not approve
environment in the form of poverty, marital discord between
of and for which some kind of admonishment, punishment
parents, and alcoholic parent puts the adolescent at risk of
or preventive and corrective measures are justified in public
Delinquency and prone to psychological problems. Adolescence
interest. Juvenile is a boy who has not attained the age of 16
is also a stressful transitional period. The transitions include
years or a girl less than 18 years. The common problems seen
educational, occupational, marriage, pregnancy/parenthood
in Juvenile delinquents are Behavioural problems like stealing
and migration related to education and employment.
or lying or gambling or aggressiveness or destructiveness
The health of the adolescents can be measured by studying or disobedience, Learning disabilities, Emotional problems,
age specific morbidity, mortality, prevalence of behavioural Adjustment problems, Development disorder, Intellectual deficit,
disorders and DALYs. DALYs have been found to be the most Psychosomatic disorders, Bizarre and abnormal behaviours,
suitable indicator for international comparisons.. Relationship problems and Socio-legal issues and problems.
In India there is lack of knowledge and awareness among Prevention and management of Juvenile delinquency includes
adolescents about important health issue problems that affect improvement in family life, life skill development, schooling and
them according to an ICMR study. High fertility rates, high rates social welfare services (child guidance clinics, juvenile courts,
of teenage pregnancy, high risk of STI/HIV, and poor nutritional orphanages, foster homes, borstals and remand homes).
status are important problems in adolescents in India. The Child Guidance Clinics (CGC) started in USA in 1909, deals
median age at first marriage in India is 17.2 years. with children who are delinquents and also those who are
Improving the health of young people is a complex problem. not adjusted to their environment. The Juvenile Justice (Care
A multi-pronged intervention approach which should include and Protection of Children) Act 2000 (No. 56 of 2000) was
life-skills and health and sexuality education in schools, published by the Legislative Department of The Ministry of Law,
peer education, mass media and community mobilization, Justice and Company Affairs on 30 December 2000. The salient
youth development programs, clinical health services, social features of the Act include Child welfare committee, Juvenile
marketing and work place and private health sector programs. Justice Board, Children homes, Rehabilitation and Special
The Government of India has identified Survival, Protection Juvenile Police Unit. The various Child placement institutions
and Development as a major theme, focusing on gender are Orphanages, Foster homes, Borstals and Remand homes.

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Study Exercises 10. All of the following are problems antisocial in nature
except (a) Lying (b) Gambling (c) Unsociability
Long Question: Describe various adolescent health problems
(d) Destructiveness
in India and Programs directed against them.
11. The percentage of adolescents among total population in
Short Notes: (1) Specific programs on adolescents in India India is (a) 27.3% (b) 18.7% (c) 21.2% (d) 23.1%
(2) National Youth Policy 2003 (3) Life skills education 12. According to WHO adolescents are ________ years of age
(4) Juvenile Delinquency (5) Child Guidance Clinic (6) Children (a) 10-19 (b) 11-18 (c) 10-17 (d) 12-21
Homes Answers : (1) b; (2) b; (3) b; (4) c; (5) c; (6) d; (7) d; (8) c;
MCQs (9) c; (10) c; (11) d; (12) a
1. The concept of Child Guidance Clinic was started in
(a) India (b) USA (c) Russia (d) France References:
1. Towards adulthood- WHO 2003 ( Exploring adolescent sexual and
2. Median age at first marriage among women in India is reproductive health in south Asia)
(a) 18.5 years (b) 17.2 years (c) 16.2 years (d) 19.5 years 2. The reproductive health of adolescents- A strategy for action : A joint WHO/
3. The Population Council supported program on adolescents UNFPA/UNICEF statement
‘Apni Beti Aapna Dhan’ is running in (a) Punjab 3. Health needs of adolescents. Report of a WHO Expert committee, TRS 609,
WHO Geneva, 1977
(b) Haryana (c) Himachal Pradesh (d) Uttar Pradesh 4. Gupta S D. In. Adolescent and Youth Reproductive Health in India: Status,
4. A Juvenile boy is one who is under _________ years of age Issues, Policies and programs- Dir-Indian institute of Health Mgt Research,
(a) 17 years (b) 18 years (c) 16 years (d) 15 years Jaipur- 2003
5. National Youth Policy,
5. Child Guidance Clinics deals with (a) Juvenile Delinquents
6. Elizabeth Lule, James E. Rosen, Susheela Singh, James C. Knowles, and
(b) Children who are not adjusted to their environment Jere R. Behrman. Adolescent Health Programs. Chapter 59. In: Disease
(c) Both (d) None Control Priorities in Developing Countries.
6. A 13 year old with no father, runs from school and caught 7. Kirby, D. 2001. Emerging Answers: Research Findings on Programs to
Reduce Teen Pregnancy. Washington, DC: National Campaign to Prevent
in a theft should be kept in (a) Foster home (b) Prison
TeenPregnancy.
(c) Orphanage (d) Remand home
7. Which of the following closely resembles Juvenile Further Suggested Reading
Delinquency (a) Bedwetting (b) School failure (c) Speech 1. James E rosen. Adolescent Health and Development- A resource book for
problem (d) Destructiveness World bank Operations staff and Government counterparts. 2004, World
bank, Washington DC
8. The main service of Child guidance Clinic is (a) Career 2. Health needs of adolescents. Report of a WHO Expert committee, TRS 609,
counselling (b) Management of Orphans (c) Psychotherapy WHO Geneva, 1977
(d) Recreation facilities 3. Adolescence - The Critical Phase, The Challenges & Potential, WHO 1997
9. Children with parental disharmony are more prone 4. National Youth Policy-2003
to: (a) Mental retardation (b) Epilepsy (c) Delinquency
(d) Accidents

State of Children in India

148 Children’s Right to Health UNICEF 2005 Report on the state of the world’s children was
published under the title “Childhood under Threat”. Speaking
A S Kushwaha about India, the report states that millions of Indian children
are equally deprived of their rights to survival, health, nutrition,
“We are guilty of many errors and many faults, but our worst education and safe drinking water. A girl child is the worst
crime is abandoning the children, neglecting the foundation of victim as she is often neglected and is discriminated against
life. Many of the things we need, can wait. The child cannot. because of the preference for a boy child. In India, children’s
Right now is the time his bones are being formed, his blood vulnerabilities and exposure to violations of their protection
is being made and his senses are being developed. To him we rights remain spread and multiple in nature. The manifestations
cannot answer “Tomorrow”. His name is “Today”.” of these violations are various, ranging from child labour, child
trafficking, to commercial sexual exploitation and many other
- Gabriela Mistral, 1948 forms of violence and abuse. With an estimated 12.6 million
The early years of life are crucial. When well nurtured and children engaged in hazardous occupations (2001 Census); for
cared for in their earliest years, children are more likely to instance, India has the largest number of child labourers under
survive, to grow in a healthy way, to have less disease and the age of 14 in the world. The lack of available services, as well
fewer illnesses, and to develop thinking, language, emotional as the gaps persisting in law enforcement and in rehabilitation
and social skills. schemes also constitute a major cause of concern.

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Child Protection Against Exploitation the Child) was held. The commitment to promote and protect
An estimated 300 million children worldwide are subjected to rights of children was reaffirmed. The aim is to create a ‘World
violence, exploitation and abuse including the worst forms of Fit for Children’ through following principles (See Box-1).
child labour in communities, schools and institutions; during
armed conflict; and to harmful practices such as female genital Box - 1 : World Fit for Children
mutilation/cutting and child marriage. Millions more, not yet Put children first
victims, also remain without adequate protection.
Eradicate poverty: Invest in children
Protecting children from violence, exploitation and abuse is an
Leave no child behind
integral component of protecting their rights to survival, growth
and development. UNICEF advocates and supports the creation Care for every child
of a protective environment for children in partnership with Educate every child
governments, national and international partners including
Protect children from harm and exploitation
the private sector, and civil society. National child protection
systems, protective social practices and children’s own Protect children from war
empowerment coupled with good oversight and monitoring are Combat HIV/ AIDS
among the elements of a protective environment and enable
countries, communities and families to prevent and respond to Listen to children and ensure their participation
violence, exploitation and abuse. Protect the Earth for children
The UN Convention on the Rights of the Child states that all
Initiatives on Child Rights
children are entitled to the same rights, regardless of the child’s,
or their parent’s or legal guardian’s race, colour, sex, language, (a) National Policy on Children, 1974 : India is a party to the
religion, political or other opinion, national, ethnic or social UN declaration on the Rights of the Child 1959. In 1974, the
origin, property, disability, birth or other status. However, Government of India adopted a National Policy for Children,
discrimination is a daily reality for millions of the world’s declaring the nation’s children as ‘supremely important assets’.
children. There are numerous forms of discrimination. The The policy reaffirmed the constitutional provisions for adequate
most common include: services to children, both before and after birth and through the
(a) Gender period of growth to ensure their full physical, mental and social
(b) Disability development. This policy lays down recommendations for a
(c) Ethnicity and race comprehensive health programme, supplementary nutrition
(d) Caste for mothers and children, nutrition education for mothers,
(e) HIV/ AIDS free and compulsory education for all children up to the age
(f) Birth status of 14, non-formal preschool education, promotion of physical
education and recreational activities, special consideration
Actions to Provide Protective Environment to for the children of weaker sections of the population like
Children the scheduled castes and the schedule tribes, prevention of
Building a protective environment for children that will help exploitation of children and special facilities for children with
prevent and respond to violence, abuse and exploitation handicaps. The policy provided for a National Children’s Board
involves the following essential components as defined by to act as a forum to plan, review and coordinate the various
UNICEF: services directed toward children. The Board was first set up
1. Strengthening government commitment and capacity to in 1974.
fulfill children’s right to protection. (b) The Department of Women and Child Development : This
2. Promoting the establishment and enforcement of adequate was set up in the Ministry of Human Resource Development
legislation addressing harmful attitudes, customs and in 1985. The Department, besides ICDS, implements several
practices. other programmes, undertakes advocacy and inter-sectoral
3. Encouraging open discussion of child protection issues monitoring catering to the needs of women and children.
that includes media and civil society partners.
(c) Convention on the Rights of the Child (CRC), 1990 : The
4. Developing children’s life skills, knowledge and
Government of India ratified the CRC on 12 November 1992. By
participation.
ratifying the Convention on the Rights of the Child, the
5. Building capacity of families and communities.
Government is obliged “to review National and State legislation
6. Providing essential services for prevention, recovery
and bring it in line with provisions of the Convention”. The
and reintegration, including basic health, education and
Convention re-validates the rights guaranteed to children by
protection.
the Constitution of India. The Ministry of Women and Child
7. Establishing and implementing ongoing and effective
Development has the nodal responsibility of coordinating the
monitoring, reporting and oversight.
implementation of the Convention. Since subjects covered
UNGASS (UN General Assembly Special Session on under the Articles of the Convention fall within the purview of
Children): The UN held its 27th special session on children in various departments/ ministries of the Government, the Inter-
May 2002. This was to review the progress made since 1990 Ministerial Committee set up in the Ministry with representatives
when World Summit for Children (Convention on the Rights of from the concerned sections monitor the implementation of the

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Convention. In pursuance of this, the Department formulated a priorities and the intensity of the challenges that require utmost
National Plan of Action for Children in 1992. and sustained attention in terms of outreach, programme
(d) National Plan of Action for Children, 1992 : India is a interventions and resource allocation, so as to achieve the
signatory to the World Declaration on the Survival, Protection necessary targets and ensure the rights and entitlements of
and Development of Children. In pursuance of the commitment children at each stage of childhood. Key result areas of the
made at the World Summit, the Department of Women and action plan are given in the Box - 3.
Child Development under the Ministry of Human Resource
Development has formulated a National Plan of Action for Box - 3 : Key Result Areas of the National Action Plan for
Children. Most of the recommendations of the World Summit Children 2005
Action Plan are reflected in India’s National Plan of Action- Reducing Infant Mortality Rate.
keeping in mind the needs, rights and aspirations of children in
Reducing Maternal Mortality Rate.
the country. The priority areas in the Plan are health, nutrition,
education, water, sanitation and environment. The Plan gives Reducing Malnutrition among children.
special consideration to children in difficult circumstances Achieving 100% civil registration of births.
and aims at providing a framework, for actualization of the
Universalization of early childhood care and development
objectives of the Convention in the Indian context.
and quality education.
(e) Education - Right of every Child, 2002 : The Constitution
(86th Amendment) Act was notified on 13th December 2002, Complete abolition of female feticide, female infanticide and
making free and compulsory education a Fundamental Right child marriage.
for all children in the age group of 6-14 years. Improving Water and Sanitation coverage both in rural and
(f) National Charter for Children, 2004 : The National Charter urban areas.
for Children, adopted on 9th February 2004, emphasizes Addressing and upholding the rights of Children in Difficult
Government’s commitment to children’s rights to survival, Circumstances.
development and protection. It also stipulates the duties for
Legal and social protection from all kinds of abuse,
the State and the community towards children and emphasizes
exploitation and neglect.
the duties of children towards family, society and the Nation.
Complete abolition of child labour
(g) National Action Plan for Children, 2005 : In recognition of
the fact that 41% of India’s population is below 18, constituting Monitoring, Review and Reform of policies, programmes and
a significant national asset, The National Plan of Action for laws
Children, 2005 re-affirms the Nation’s commitment to wisely, Ensuring child participation and choice
effectively and efficiently invest its national resources to fulfill
its commitments to children. This plan commits itself to ensure (h) National Commission for Protection of Child Rights,
all rights to all children up to the age of 18 years. The guiding 2006 : In order to ensure child rights practices and in response
principles of the action plan are given in the Box - 2. to India’s commitment to UN declaration to this effect,
the Government of India set up a National Commission for
Box - 2 : The Guiding Principles of the National Plan of Protection of Child Rights. The Commission is a statutory body
Action for Children, 2005 notified under an Act of the Parliament on December 29, 2006.
To regard the child as an asset and a person with human Besides the chairperson, it will have six members from the fields
rights. of child health, education, childcare and development, juvenile
justice, children with disabilities, elimination of child labour,
To address issues of discrimination emanating from biases child psychology or sociology and laws relating to children. The
of gender, class, caste, race, religion and legal status in order Commission has the power to inquire into complaints and take
to ensure equality. suo motu notice of matters relating to deprivation of child’s
To accord utmost priority to the most disadvantaged, rights and non-implementation of laws providing for protection
poorest of the poor and least served child in all policy and and development of children among other things.
programmatic interventions. (j) Constitutional Provisions : India’s commitment to children
To recognize the diverse stages and settings of childhood, is clearly manifested in its Constitution wherein several articles
and address the needs of each. are dedicated to children (See Box - 4).
National Plan of Action for Children, 2005 : GOALS
The National Plan of Action for Children, 2005 is divided into
following four sections; and all categories of rights apply to all The National Plan of Action for Children 2005 has set out
age groups, including before birth. goals related to various fields of child welfare, exploitation,
(i) Child Survival abuse and their right to health. The salient goals are laid out in
(ii) Child Development Box - 5 to 9.
(iii) Child Protection The ultimate objective of the entire international, regional,
(iv) Child Participation national and sub-national effort is to create a society where
The Plan has identified twelve key areas keeping in mind children will get the most favourable conditions to survive,

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grow and develop into healthy adults. This in other words can Box - 6 : Care and Education Goals (NAP 2005)
happen only in a Child Friendly Society that promotes survival,
protection, development of children ensuring their protection To universalize early childhood services to ensure children’s
against all forms of exploitation with their participation. physical, social, emotional and cognitive development.
There has been a lot of progress in the field of child health in To ensure that care, protection and development opportunities
terms of not only improved child health indices but also with are available to all children below 3 years.
respect to global focus towards this very vital social issue. The To ensure integrated care and development and pre-school
Convention on the Rights of Children to a healthy childhood is learning opportunities for all children aged 3 to 6 years.
a milestone in this endeavor. However, it is disturbing to note
To provide day care and crèche facilities to parents in rural
uneven progress not only in different regions and countries but
and urban areas.
also country to country variation and rural urban differential
not only continue to exist but widening as well. The global
pledge to address these child health issues by adopting MDGs Box - 7 : Children in Difficult Circumstances Goals (NAP
is a ray of hope for the children of the world. The society has 2005)
a moral duty to give every child a right to survival, growth, To ensure that best interest of the child is upheld in all
development and protection so that they can achieve their full policies, plans, programmes, interventions and in strategies
potential. The ultimate aim of all initiatives towards rights and for children in difficult circumstances.
protection of children is to develop a child friendly society.
To create and uphold a safe, supportive and protective
Box - 4 : Constitutional Provisions to Children environment for all children within and outside the home.

Article 14 : Equality before the law or the equal protection Box - 8 : Protection Against Sexual Exploitation And Child
of laws Pornography Goal (NAP 2005)
Article 15 : The State shall not discriminate against any To protect all children, both girls and boys, from all forms of
citizen. Nothing in this Article shall prevent the State from sexual abuse and exploitation.
making any special provisions for women and children.
To prevent use of children for all forms of sexual exploitation,
Article 21 A : The State shall provide free and compulsory including child pornography.
education to all children of the age of 6-14 years in such
To develop new and strengthen existing legal instruments to
manner as the State may, by law, determine.
prevent sexual abuse and exploitation of children.
Article 23 : Traffic in human beings and beggar and other
forms of forced labour are prohibited and any contravention Box - 9 : Combating Child Labour Goals (NAP 2005)
of this provision shall be an offence punishable in accordance
To eliminate child labour from hazardous occupations by
with the law.
2007, and progressively move towards complete eradication
Article 24 : No child below the age of 14 years shall be of all forms of child labour.
employed to work in any factory or mine or engaged in any
To protect children from all kinds of economic exploitation
other hazardous employment.
Article 45 : The State shall endeavour to provide early Summary
childhood care and education for all children until they
The early years of life are the most crucial years. Violations
complete the age of six years.
of the basic rights of children ranging from child labour,
Article 243 G read with Schedule 11 : Provide for child trafficking, to commercial sexual exploitation may lead
institutionalization of child care by seeking to entrust to various problems in the future. An estimated 300 million
programmes of Women and Child Development to Panchayat children worldwide are subjected to violence and many others
(Item 25 of Schedule 11) remain without adequate protection. The lack of available
services with India having the largest number of under 14 child
labourers in the world is a major cause of concern especially
Box - 5 : Child Health Goals (NAP 2005)
with India being a signatory to UN declaration on the Rights
To reduce Infant Mortality Rate to below 30 per 1000 live of the Child, 1959. UNGASS in its 27th special session in
births by 2010. May 2002 aims to create a ‘World Fit for Children’ through
certain laid out principles. As a initiative to child rights, India
To reduce Child Mortality Rate to below 31 per 1000 live
adopted National Policy on Children in 1974 and a number of
births by 2010.
conventions and departments were setup followed by National
To reduce Neonatal Mortality Rate to below 18 per 1000 live Action Plan for Children, 2005 as a recognition of the fact that
births by 2010. 41% of India’s population is below 18. It has set out various
goals related to various fields of child welfare, exploitation,
To explore possibilities of covering all children with plan for abuse and their right to health. India’s commitment to children
health insurance. is clearly manifested in its several articles which are dedicated

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to children. The ultimate aim is to develop a Child Friendly 7) No child will be employed in any factory or mines according
Society. to Article __________
8) Infant mortality rate should be brought down to below
Study Exercises __________ by 2010 according to child health goals
Long Questions: India’s initiatives on Child Rights. 9) Child labour from all hazardous occupations should be
Short Notes : (1) National Action Plan for Children, 2005 eliminated by __________ according to child health goals
(2) Constitutional provisions relating to child’s rights 10) The department of women and child development was set
up under the Ministry of __________
MCQs and Fill in the blanks :
Answers: (1) United Nations General Assembly Special Session;
1) UNGASS stands for __________
(2)1974; (3) d; (4) 2005; (5) 41; (6) d; (7) 24; (8) 30/1000 live
2) India adopted the National Policy on Children in the year
births; (9) 2007; (10) HRD
__________
3) Free and compulsory education is a fundamental right References
of the children in the age group (a) 7-12 yr (b) 6-8 yr 1. Paediatric priorities in the developing World. D Morley
(c) 6-12yr (d) 6-14 yr 2. World Health Report, 2005. Make every mother and Child Count, WHO
4) National action plan for children was launched in ______ 3. Integrated Management of Pregnancy and Childbirth. Managing complications
in Pregnancy and Childbirth: A guide for midwives and doctors. Department
5) At present _____ % of population is under 18 years of age of Reproductive Health and Research, Family and Community Health, WHO,
6) Free and compulsory education is a fundamental right of Geneva, 2003
the children according to the article (a) 14 (b) 15 (c) 24 4. The State of the World’s Children, 2005. Childhood Under Threat, UNICEF,
New York
(d) 21A
5. GOI, National Action Plan for Children 2005.

provisions, sensitive society, management during sickness and

Growth and Development of
149 Children
providing protection to these children can help in improving
the lot of this important group of vulnerable population. The
concept of well baby clinic, under five clinic and mother and
A S Kushwaha child clinics are steps in this direction.
Definitions
Early Childhood Growth and Development : Growth is the progressive increase
in the size of a child. Development is progressive acquisition
When well nurtured and cared for in their earliest years,
of various skills (abilities) such as head support, speaking,
children are more likely to survive, to grow in a healthy way,
learning, expressing the feelings and relating with other people.
to have less disease and fewer illnesses, and to fully develop
Growth and development go together but at different rates.
thinking, language, emotional and social skills. Although it is
never too late to improve the quality of a child’s life, the first Importance : The assessment of growth and development is
three years are the most crucial for their survival and thriving. very helpful in finding out the state of health and nutrition of
Frequent illness, unsanitary environments and poor nutrition a child. Continuous normal growth and development indicate a
steal a child’s potential. good state of health and nutrition of a child. Abnormal growth
or failure to thrive (growth failure) is a symptom of disease.
When they enter school, their prospects for performing well
Hence, measurement of growth is an essential component of
are improved, and as adolescents, they are likely to have
the physical examination.
greater self-esteem. Later in life, they have a greater chance
of becoming creative and productive members of society. It Factors affecting growth and development : Each child’s
is a child’s right to have every chance to survive and thrive. pattern of growth and development is determined by its genetic
Moreover, ensuring optimal conditions for a child’s early years and environmental influences. The genetic factors determine
is one of the best investments that a country can make if it the potential and limitations of growth and development.
is to compete in a global economy based on the strength of If favourable, the environmental factors, such as adequate
its human capital. The growth monitoring, correct feeding nutrition, facilitate the achievement of the genetic potential of
practices, immunization, responsive health care system, legal growth and development. Unfavourable factors, acting singly or

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in combination, slow down or stop the growth and development. the weight becomes 5 times the birth weight. On an average
Some of the unfavourable factors are malnutrition, infections child gains 2 kg per year in 3-7 years age and 3 kg after that
(prenatal and postnatal), congenital malformations, hormonal till puberty.
disturbances, disability, lack of emotional support, lack of play, Head Circumference (HC) : HC is important because it is
and lack of language training. To promote optimum growth, closely related to brain size. It can be used as an index of
these environmental factors can be removed or minimized. Once chronic protein energy nutritional status during the first two
they are removed, infant follows a period of catch up growth. years of life. Chronic malnutrition during the first few months
During this period the growth rate is greater than normal. This of life, or intrauterine growth retardation, may decrease the
growth rate continues until the previous growth pattern is number of brain cells and result in an abnormally low head
reached. Then the growth rate is reduced to the normal rate circumference.
determined by the individual’s genetic factors.
Beyond the age of two years, growth in HC is slow and its
A child genetically determined to be tall grows slightly more measurement is no longer useful.
rapidly than a child genetically determined to be short. Socio-
The head circumference is measured by encircling the head
economic factors, emotional and cultural factors too exert their
with an unstretchable tape measure, or a piece of string in
influence on the growth and development of children.
the absence of a tape measure. This is passed over the most
Laws of growth : Growth and development is a continuous prominent part of the occiput posteriorly and just above the
and orderly process and follows a particular pattern over supra-orbital ridges anteriorly to obtain the greatest distance
a period of time termed as sigmoid curve. There are periods around the head. At birth HC is 35 cm, at 3 months 40 cm, 45
of rapid growth and slower growth. Growth pattern of each cm at 1 year and reaches 48 cm by second year and 52 by 3rd
child is unique. Each organ system and body part also has its year. Crown rump length (CRL) is always <HC in 1st year of
characteristic pattern of growth. The body, brain and gonads life.
grow in a different manner in different phases of childhood.
Mid Upper Arm Circumference (MUAC) : Arm contains
The children grow in 3 different types of physical patterns of
subcutaneous fat and muscle. A decrease in MUAC may therefore
growth, ectomorphs, endomorphs and the mesomorphs.
reflect a reduction in muscle mass, a reduction in subcutaneous
1. Somatic growth (Body size) : This is rapid during foetal tissue or both. In developing countries, where the amount of
life, 1st 2 years of life and after onset of puberty. This follows subcutaneous fat is frequently small, a change in MUAC tend
a sigmoid curve pattern. to parallel changes in muscle mass and hence is particularly
2. Brain growth : The brain enlarges rapidly during latter useful in the diagnosis of PEM or starvation. Changes in MUAC
months of foetal life and early months of postnatal life. At birth can also be used to see progress during nutritional therapy.
head size is 65-70% of the expected head size of the adult. It MUAC changes are easy to detect and require a minimal amount
reaches 90% by the age of two years. of time and equipment. Some investigators claim that MUAC
3. Gonadal growth : Gonadal growth is dormant in childhood can differentiate normal children from those of PEM as reliably
with rapid growth during puberty. The growth spurt during as weight for age. MUAC changes very little from 1-5 years of
puberty is attributed to neuro-hormonal stimulation of the age and it can be used as an age-independent measurement.
hypophysis by the hypothalamus. Low MUAC has been shown to be a sensitive indicator of risk
4. Lymphoid growth : This is most notable in mid-childhood of death in children.
and may be even larger than in an adult. The mid upper arm circumference is measured using a tape
Weight : Body weight represents the sum of protein, fat, water, or string in the absence of a tape. The tape or string is placed
and bone mineral mass, and does not provide any information around the upper arm, midway between the olecranon and
on relative changes in these four chemical components. acromion processes. Care is taken not to pull the tape or string
too tightly. The mid upper arm circumference increases fairly
Weight for age in children from 6 months to 7 years of age is
rapidly to about 16 cm by the age of one year. In the period 1 to 5
an index of acute malnutrition, and is widely used to assess
years, the mid upper arm circumference increases by only 1 cm.
protein energy malnutrition and over nutrition, especially in
So, irrespective of age, the mid upper arm circumference of well
infancy when the measurement of length is difficult. A major
nourished children ranges 16 -17 cm in the period 1-5 years.
limitation of it as an index of PEM is that it does not take
Conversely, if the mid upper arm circumference of a child of 1
into account height differences. As a result children with low
to 5 years of age is less than 16 cm, that child has malnutrition
weight for age are not necessarily wasted. To interpret a single
and corrective intervention should be carried out.
measurement of weight in relation to the reference data, the
exact age of the child must be known. The average birth weight Length / Height : The length of a child is measured in the first
in Indian children is around 2.6 Kg and 3 kg in developed 3 years and the height is measured after 3 years of age. The
countries. After losing 10% weight in 1st week, the infants length is measured using a horizontal measuring board put on
regain their weight by the second week. They gain weight at an the ground or on a table. The child is laid on his back with the
approximate rate of 25-30 gm per day for 3 months. The gain head against the fixed head board. A helper holds the child’s
in weight in next 9 months is @ 400 gm per month. An infant head so that the eye angle- external ear canal line is vertical
doubles weight by 5 months and triples by one year of age and and also keeps the body straight. With one hand of the health
becomes 4 times his birth weight by end of 2 years. At 3 years worker, the child’s knees are pressed down to straighten the
child’s legs fully while, with the other hand, the sliding foot

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board is placed to touch the child’s heels firmly. With the foot age the child has achieved the various milestones. Still, it is
board in place, the child’s length is read on the metre scale. important to remember that every child develops at his/her own
To measure the height, a bare foot child stands with the feet rate or pace. Some walk early, others late.
together. The heels, the buttocks and the occiput lightly touch Infant development occurs in an orderly and predictable manner
the measuring device. The head is aligned so that that the that is determined intrinsically. It proceeds from cephalic to
external eye angle- external ear canal plane is horizontal. The caudal and proximal to distal as well as from generalized
child is told to stand tall and is gently stretched upward by reactions to stimuli to specific, goal-directed reactions that
pressure on the mastoid processes with the shoulders relaxed. become increasingly precise. Extrinsic forces can modulate the
The sliding head piece is lowered to rest firmly on the head. velocity and quality of developmental progress.
The height is read and recorded. An average term baby is 50
cm long. The length increases by 50% in the first year. In the Table - 1 : Important Developmental Milestones
second year, the average height growth is about 12 cm. The
birth length doubles by 4 years of age. After the second year Age Motor Development Language and social
of age, the annual height growth averages 5-6 cm until the range development
beginning of the adolescent growth spurt. Height growth stops Birth When prone turns Cries
at about the age of 18 years in girls and at the age of about 20 head to one side to
years in boys. After plotting the child’s height or length on a avoid suffocation
height chart, you should determine whether the growth pattern 3-6 Good head control Can follow an object with
is normal. A normal growth pattern is parallel to the printed Months eyes, plays with hands
percentile lines.
6-9 Can sit unsupported Grasps actively,
Chest circumference : The chest circumference is 3 cm less
Months makes loud noises
than the head circumference at birth. They become equal by
end of 1st year and thereafter chest circumference exceeds the 9-12 Able to stand Understands a few
head circumference. Months words, tries to use them
Tooth eruption : Tooth eruption is an important part of growth. 9-18 Able to walk Grasps small objects with
In general, teething in infants usually starts at about 6 months Months thumb and index finger
of age, but some start later than 6 months. A new tooth appears 15-30 Able to run around as Can say several words
approximately every month so that by 2 - 2½ years of age the Months much as he wants or even some sentences
baby will have 20 primary teeth. This makes the number of
teeth roughly equal to age in months minus 6. 3 Years Plays actively, is able Starts talking a lot,
to jump and climb is curious and asks
A parent should only start to worry about tooth eruption if a many questions
child has not yet started teething by 13 months. This is because
at this age the child should be eating solid foods. Teething may Each developmental domain must be assessed during ongoing
cause excessive salivation, irritability, disturbed sleep and some developmental surveillance within the context of health
pain. Sometimes it also causes Diarrhoea. At the age of about supervision. Generalizations about development cannot be
6 years, the shedding of the primary teeth starts and continues based on the assessment of skills in a single developmental
through to the age of 12 years. Eruption of permanent teeth domain (i.e. one cannot describe infant cognition based on
starts at about 6 years of age. gross motor milestones). However, skills in one developmental
Development domain do influence the acquisition and assessment of skills
Development is defined as the progressive acquisition of various in other domains.
skills (abilities) such as head support, speaking, learning, Speech delays are the most common developmental concern.
expressing the feelings and relating with other people. Each A sound understanding of the distinction between an isolated
child follows a unique path in growth and development that is speech delay (usually environmental and often can be
laid down from the beginning of life by what he has inherited alleviated) and a true language delay (a combined expressive
from both parents. Unfortunately, many factors may change and receptive problem that implies more significant pathology)
the genetically determined path of growth and development. will help the clinician refer appropriately for precise diagnosis
These things include, for example, infections, lack of care, and appropriate management.
psychological trauma, bad education, and malnutrition, to It is essential to understand normal development and acceptable
mention just a few. The normal well-fed infant who is protected variations in normal developmental patterns to recognize early
from infections develops quickly, particularly during the first patterns that are pathologic and that may indicate a possible
3 months. It is very important to know the age ranges when developmental disability. Assessment of the quality of skills
most children acquire certain skills. The various skills the and monitoring the attainment of developmental milestones
baby and a young child learn are called milestones (Table - 1). are essential to early diagnosis of developmental disabilities
In monitoring development, we notice at what age the child and expedient referral to early intervention programs.
achieves various milestones, such as smiling at the mother, Theories of Development : Developmental theory has been
sitting without support, grasping objects with his/her hands, shaped by the persistent debate of whether nature (intrinsic
standing, walking and talking. You should record at what forces) or nurture (extrinsic forces) is the predominant

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influence. Earlier theories centered on the role of nature. By The motor age and the developmental quotient are good
mid 20th century, theories that stressed the importance of summary descriptors of the child and have more meaning than
nurture began to prevail. Pavlov (1930s), Watson (1950s), plotting each milestone. Because the lower limit is 70, this
and Skinner (1960s) promoted the view that development boy’s DQ falls within the “suspect” or gray zone. In reality,
was a function of learning. Operant conditioning (positive infants falling into the gray zone of motor domains usually do
and negative reinforcements through social interactions or quite well and rarely require referral to an early intervention
environmental changes) promoted learning and shaped the program. This is in contrast to those falling in the gray zones
child’s development. During the second half of the century, of the cognitive domains.
the name of Piaget became almost synonymous with child Factors in Development : The factors that promote development
development. Piaget was the first to describe the infant as having include good nutrition, emotional support, play and language
intelligence. Piaget revealed that infants were, indeed, capable training.
of thinking, analyzing & assimilating. He viewed development
1. Good Nutrition : Good nutrition is essential for normal
as stage-like cognitive changes. The child actively explores
growth and development. Unlike most other organs in the body,
objects in an effort to understand his or her environment.
the brain is not fully developed at birth. Good nutrition in the
Fields of Development : Gross motor; Fine motor; Social; first 6 months of life is extremely important. Malnutrition in
Cognitive; Psychological; Emotional; Problem solving; Adaptive; this period may impair the growth of the brain. As a result of
Language development. impaired brain growth, the child may suffer for the rest of life. A
Developmental Quotient : Developmental Quotient (DQ) is malnourished child is often tired, apathetic and not interested
the developmental age divided by chronologic age times 100 in learning new things that will promote normal development.
(see Example in Box - 1). This provides a simple expression of Nutrition is discussed in detail elsewhere.
deviation from the norm. A quotient above 85 in any domain 2. Emotional Support : The first 5 years of life are critical
is considered within normal limits; a quotient below 70 is for the foundation of the skills. A newborn starts with no
considered abnormal. A quotient between 70 and 85 represents knowledge and learns a great deal during his/her first year of
a gray area that warrants close follow-up. Values in the upper life. It is very important to realize that a child is a growing
limit of normal do not particularly indicate supernormal and developing human being right from birth. He ought to be
abilities. The concept of windows of achieving milestones treated very carefully, with love and affection, so that he can
(Fig. - 1) becomes relevant as proposed by the WHO. develop normally. He needs full emotional support.
3. Play : Play is a source of information, stimulation for
Box - 1 : Example - Motor Quotient
the brain, stimulation for the muscles and a lot of fun. All
these activities are necessary for physical, mental and social
A 12-month-old boy is seen for health supervision. He is not development. All normal children like to play.
walking alone, but he pulls up to stand (9 months), cruises
around furniture (10 months), and walks fairly well when 4. Language Training : Another factor that promotes
his mother holds both hands (10 months). This child has a development is language training. Children should be offered
gross motor age of 10 months at a chronologic age of 12 opportunities to meet, use, and play with words in conversation
months. Should this 2-month discrepancy is a concern? To and in reading books.
decide, one should calculate the DQ by using these gross Growth Monitoring
motor milestones : DQ =motor age/chronologic age X 100 = Growth Monitoring was popularized by David Morley in 1960s’
10 X100/12 months= 83 and 70s’ (1-5). This strategy proved that growth monitoring
could improve nutritional status. His “road to health” chart
was a tool which possessed a number of precise functions-
Fig. - 1 : Windows of Development (a) Provide a health record of the child which included weight
but also relevant information on immunization, disease
episodes, family planning, etc.
(b) Emphasize integration of curative and preventive care.
(c) Increase proportion of “care” as opposed to the prevailing
“cure”.
g (d) Help the family to take care of its own health.
(e) Provide a support for the less qualified rural health
worker.
In 1982, growth monitoring i.e. the regular weighing of children
and charting their weight on a chart was taken up by UNICEF as
part of the GOBI program. G= growth promotion, O= ORT (oral
rehydration therapy), B = breast feeding, I= immunization.
This programme was later extended with the three Fs of Family
Planning, Food and activities for Females to GOBIFFF.
Source : WHO Child Growth Standards Growth monitoring is the process of maintaining regular

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observation of a child’s growth. It starts with measurements 6. Helps in identification of mild, moderate or severe degree
of weight daily, weekly, monthly, bimonthly etc. The successive of malnutrition
weights are plotted on the growth chart of the child health card. 7. Helps in evaluation of nutritional status over time and
A curve deviating downwards indicates a situation that the from one generation to the next (secular trend)
child is losing weight. The child needs extra care immediately. 8. May be used in nutritional screening to identify individuals
The baby may be suffering from malnutrition, tuberculosis, at high risk of malnutrition
AIDS or other medical conditions. The mother is advised to Limitations of anthropometric assessment
take the baby to hospital for investigations and treatment. Any 1. Relatively insensitive method and can not detect change of
infant who does not gain weight for one month or a child who nutritional status over short period of time.
does not gain weight for two months should receive urgent 2. Anthropometric information is non-specific and does not
attention. Such an infant or child is becoming malnourished. identify the cause of growth failure.
Importance of Growth Monitoring : Health workers and 3. In poor communities, dietary inadequacies and infection
parents should monitor the growth of children for the following are often major environmental determinants of growth
reasons - failure. While anthropometry may index the problem, it
(a) For early detection of abnormal growth and development. does not, by itself, identify the specific cause or indicate
(b) To facilitate the early treatment or correction of any the specific solution.
conditions that may be causing abnormal growth and 4. Certain non-nutritional factors, viz. disease, genetics,
development. diurnal variation, reduced energy expenditure, etc. can
(c) To provide an opportunity for giving health education and reduce specificity and sensitivity of anthropometric
advice for the prevention of malnutrition. methods.
Growth monitoring is one of the basic activities of the Under 5. Appropriate sampling or experimental design can largely
Five clinics where the child is weighed periodically at monthly exclude such limitations.
intervals during the 1st year, every 2 months during the 2nd Uses of Anthropometry
year and every 3 months thereafter up to the age of 5 to 6 1. Population assessment
years. The Anganwadi under ICDS is also based on Growth 2. Identification of target groups
monitoring and supplementary feeding for children under six 3. Nutritional surveillance
years of age. 4. Monitoring of nutritional status
IAP Guidelines on Growth Monitoring : Growth Monitoring 5. Evaluation of program impact
Guidelines Consensus Meeting of the IAP recommended that- 6. Growth monitoring of individuals
Reference Vs Standard : Height and weight measurements
(i) Birth to 3 years : Immunization contacts at birth, 6, 10
mean little unless compared to a growth reference.
and 14 weeks, 9 months, 15-18 months may be conveniently
used for growth monitoring. An additional monitoring visit Instead of the term “standard”, which originated from the
at 6 months with opportunistic monitoring at other contacts “Harvard Standard” that was developed in 1955, the preferred
(illness) is recommended. Normally growing babies should not term today is “growth reference”, which is used to compare
be weighed more than once per fortnight under 6 months and no measurements. The characteristics of a reference population
more than monthly thereafter, as this increases anxiety. After as defined by WHO, include measurements taken from a well-
18 months measurements are to be taken every 6 monthly. It is nourished population with at least 200 children/age and sex
recommended that the height, weight and head circumference group, and from a cross-sectional sample. There have been
be measured up to 3 years of age. several growth references developed. The first was the “Harvard
Standard”, also known as the “Boston Standard,” the “Stuart-
(ii) 4 to 8 years : It is recommended that height and weight
Meredith Standard” or the “Jelliffe Standard”. A “Reference” is
be measured 6 monthly during this period and BMI should be
defined as a tool for grouping and analyzing data and provides
assessed yearly from 6 years of age.
a common basis for comparing populations; no inferences
(iii) 9 to 18 years : It is recommended that height, weight and should be drawn about the meaning of observed differences.
BMI be assessed yearly during this period.
Deciding Cut-off Points : Environment plays a more important
Anthropometry role than genetics in determining preschool age child
Anthropometry means “body measurements”. Anthropometry nutritional status using anthropometry, given an adequate
is very useful for measuring overall health status, not just environment, preschool-age children around the world should
nutritional status. have similar growth curves. There are three different types of
The advantages of anthropometry cut-off points that can be used to identify stunting, wasting,
1. Simple, safe, non-invasive procedure and underweight. Percentiles are useful but are problematic
2. Applicable to large sample sizes in classifying children who fall outside the extreme centiles
3. Requires inexpensive, portable and durable equipment, of the growth reference (i.e. below the 3rd and above the 97th
which can be made or purchased locally percentiles) since they cannot be accurately classified. The
4. Methods are precise and accurate if standardized techniques percent of median is very useful since it provides a more precise
are used estimate of the HFA, WFH and WFA of a population, particularly
5. Information on past long term nutritional history can be where stunting, wasting, and underweight are expected, which
obtained is common in developing countries. The median of the NCHS

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growth reference is used since it is the best comparison point towards the extremes of the reference distribution there is
in distributions of HFA, WFH and WFA. For example, with HFA, little change in the percentile values for significant changes in
in any population there will be a few tall children, a few short height or weight.
children, and the rest in-between. Since the few very tall or For example : Consider a child of age 2 years having a weight
few very short children do not adequately represent the group, of 10.5 kgs. When the child is tracked on the growth chart we
the median is selected as the comparison point. The cut-off first locate the age of 2 years i.e. 24 months on the Age axis
points of <90%, <80% and <70% of reference median for HFA, and weight of 10.5 kgs on the weight axis. The intersection of
WFH and WFA to define stunting, wasting and underweight these two is the point shown by coloured circle (Fig. - 2). We
respectively, were selected because studies have shown that observe that the individual falls in between 50th percentile and
significant increases occur approximately at these three cut- 3rd percentile.
off points for various functional parameters, such as mortality.
(c) Percent of Median : The ratio of a measured value in
Therefore, these cut-off points are really not as arbitrary as it
the individual, for example weight, to the median value of
may appear. The preferred method of cutoff points is Z-score,
the reference data for the same age or height, expressed as
which is the number of standard deviation units (SD) from the
percentage. The disadvantage is that this does not correspond
reference median, which is “0” Z-score. The Z-score gives a
to a fixed point of the distribution across age or height status.
much more precise measurement of stunting, wasting, and
underweight than percentiles or percent of median. For example consider a child who is 18 months of age and
Measuring Growth weighs around 7.5 kgs. Again while tracking the child on the
growth chart we first locate the intersection point at the specified
Measurements : There are various measurements that are age and corresponding weight of the child. The coloured point
used to measure growth. denotes the intersection on the growth chart (Fig. - 3). We
1. Weight observe that the child falls in Grade II of malnutrition. Hence
2. Head circumference intervention is needed in this child.
3. Mid Upper Arm Circumference (MUAC)
Why use ‘Z score’? : One of the problems with percent of
4. Height / length
median is that although 90% of reference median is the cut-off
5. Chest circumference
point for HFA where a child who has a HFA below the cut-
Indices : Anthropometric indices are combinations of the off point is classified as stunted, each age group of children
measurements. They are important since mere measurements actually has a different cut-off point when using percent of
provide little useful information. For example, mere body median. For example, the cut-off point at -2 Z-score of boys
weight has little utility unless it is related to age or height. 2 years 4 months is 92.2%; for boys 3 years 5 months, it is
An example of such combination of two measurements is BMI 91.1%; for boys 4 years 4 months, it is 91.7%. Therefore, using
(weight in kg / height2). Ponderal index is weight/ height3. a cut-off point of 90% for all children may create problems in
In children three common indices used are WFH (weight for properly classifying children’s nutritional status - using Z-score
height), HFA (height for age) and WFA (weight for age). These eliminates this problem.
indices could be expressed in the form of Z-scores, percentiles
and % of median which can then be used to compare a child Advantages of using Z score over percentage of median
to a reference population. To be useful, these measurements 1. Z-score cut-off point always at -2 Z-score
must be taken accurately using reliable equipment and correct 2. Different cut-off points for % of median for different ages of
measuring techniques. children
3. Z-score and percentage of median can yield different
(a) Z score : The deviation of the value for an individual from
results - can cause misclassification
the median value of the reference population, divided by the
4. Clearer interpretation of Z-score
standard deviation for the reference population.
5. Misleading interpretation of % of median
(observed value) – (median reference value) Indicators
Z score = Standard deviation of the reference population
An indicator refers to the use or application of indices. Example,
proportion of children below a certain level of weight for age
(b) Percentile : The rank position of an individual on a given (say -3SD) can be used as an indicator of undernourished
reference distribution, stated in terms of what percentage of children in a given community. These indicators could be used
the group the individual equal or exceeds. For example, a child as indicators of body size, health or nutrition or a combination
whose weight falls in the 10th percentile weighs the same or of these. The use of these indicators should be clearly defined
more than 10% of the reference population of children of the as incorrect interpretation and its usage may lead to formation
same age. Percentiles are easy to use and thus preferred in of unscientific interventions.
clinical settings. The percentile is interpreted by the percent Growth Charts
of individuals above and below specified percentile value. For In Haiti, in the mid sixties, Beghin with Fougère and King
example 35th percentile is described by 35% of the individuals designed a growth chart based on Gomez classification of
lying below the value and 65% above. However, the same degrees of malnutrition, to select children for referral to
interval of percentile values corresponds to different changes nutritional rehabilitation centers (1). In Colombia, Rueda
in absolute height or weight according to which part of the Williamson adapted a chart developed earlier by Tony, which
distribution is concerned. Another disadvantage being that

• 874 •
combined weight and height. As the Director of National boys (50th percentile) and the lower curve represented the 3rd
Institute of Nutrition, he actively promoted his “auxogramme” percentile for girls. This chart had an advantage of application
which, interestingly enough, was also used for counselling to both the sexes.
the child’s mother. While working on malnourished children, NCHS (National Center for Health Statistics) developed the
Dr David Morley introduced the concept of growth monitoring growth charts in 1977 and were adopted by the WHO as a
and developed the earliest growth charts. These have come to clinical tool to monitor growth of children. CDC (Center for
be known as ‘Road to Health’ charts. The growth chart shows Disease Control) in 2000 brought out growth charts and they
progressive changes in the height and weight of a child in a represent the revised and improved version of NCHS charts. The
graphic form. They depict average and permissible range of CDC has introduced two BMI charts besides 16 (8 for boys and 8
variation for the particular age and attribute. for girls) charts. In 1993, the World Health Organization (WHO)
The Indian Council for Medical Research (ICMR) undertook undertook a comprehensive review of the uses and interpretation
a nationwide cross sectional study during 1956 and 1965 to of anthropometric references. The review concluded that the
establish Indian reference charts. The measurements were NCHS/WHO growth reference, which had been recommended
made on children of the lower socio-economic class and hence for international use since the late 1970s, did not adequately
cannot be used as a reference standard. There are a number of represent early childhood growth and that new growth curves
different types of growth charts in use in India. The commonly were necessary. In response, WHO undertook the Multi-centre
used and approved by the Government had four reference Growth Reference Study (MGRS) between 1997 and 2003 to
curves depicting three different grades of malnutrition. The generate new curves for assessing the growth and development
topmost curve represented 80 % of the median of WHO reference of the children which could be applicable the world over.
standards which is approximately equivalent to 2 SD below the WHO Multi-centre Growth Reference Study (MGRS) Charts:
median which is the conventional lower limit of normal range. The MGRS combined a longitudinal follow-up from birth to
The three lines below this curve represent 1st to 3rd degree of 24 months and a cross-sectional survey of children aged 18
malnutrition. The prototype WHO chart (home based) had two to 71 months. Primary growth data and related information
reference curves. The upper curve represented the median for were gathered from 8440 healthy breastfed infants and young

Fig. - 2

• 875 •
children from widely diverse ethnic backgrounds and cultural and nutritional status of the index population.
settings (Brazil, Ghana, India, Norway, Oman and USA). The
MGRS is unique in that it was purposely designed to produce a
Summary
standard by selecting Ensuring an optimal condition for a child’s early years is
(a) Healthy children living under conditions likely to favour one of the best investments that a country can make and it
the achievement of their full genetic growth potential. is a child’s right to have every chance to survive and thrive.
(b) The mothers of the children selected for the construction of Environment plays a more important role than genetics in
the standards engaged in fundamental health-promoting determining preschool age child nutritional status. Growth
practices, namely breast feeding and not smoking. is the progressive increase in the size and development is
progressive acquisition of various skills. Measurement of
The growth standards provide a technically robust tool that
growth is an essential component of the physical examination
represents the best description of physiological growth for
in finding out the state of health and nutrition of a child. It
children under five years of age. The standards depict normal
follows a particular pattern over a period of time termed as
early childhood growth under optimal environmental conditions
sigmoid curve and the body, brain and gonads grow in a
and can be used to assess children everywhere, regardless of
different manner in different phases of childhood. There are
ethnicity, socioeconomic status and type of feeding. The new
various measurements that are used to measure growth like
growth curves are expected to provide a single international
Weight, Head circumference, Mid Upper Arm Circumference
standard that represents the best description of physiological
(MUAC), Height / length, Chest circumference. Weight for age
growth for all children from birth to five years of age and
in children from 6 months to 7 years of age is an index of
to establish the breastfed infant as the normative model for
acute malnutrition, and is widely used to assess protein energy
growth and development.
malnutrition and over nutrition. HC is important because it is
Epidemiological Aspects of the Standards : As expected, closely related to brain size. It can be used as an index of chronic
there are notable differences with the NCHS/WHO reference protein energy nutritional status during the first two years of
that vary by age, sex, anthropometric measure and specific life. Arm contains subcutaneous fat and muscle. A decrease in
percentile or z-score curve. MUAC may therefore reflect either a reduction in muscle mass,
1. Differences are particularly important in infancy. a reduction in subcutaneous issue, or both and it changes
2. Stunting will be greater throughout childhood when very little from 1-5 years of age and it can be used as an age-
assessed using the new WHO standards compared to the independent measurement. The length of a child is measured
NCHS/WHO reference. in the first 3 years and the height is measured after 3 years
3. The growth pattern of breastfed infants will result in a of age. On a height chart, you should determine whether the
substantial increase in rates of underweight during the growth pattern is normal. A normal growth pattern is parallel
first half of infancy and a decrease thereafter. to the printed percentile lines. The various skills the baby and
4. For wasting, the main difference is during infancy when a young child learn are called milestones and that’s why we
wasting rates will be substantially higher using the new notice at what age the child achieves various milestones, such
WHO standards. as smiling at the mother, sitting without support, grasping
5. With respect to overweight, use of the new WHO standards objects with his/her hands, standing, walking and talking.
will result in a greater prevalence that will vary by age, sex Infant development occurs in an orderly and predictable

Fig. - 3

• 876 •
manner that is determined intrinsically. Speech delays are the MCQs and fill in the blanks
most common developmental concern. Piaget was the first 1) At birth head size is ________ % of the expected head size
to describe the infant as having intelligence. Developmental of the adult.
quotient (DQ) is the developmental age divided by chronologic 2) Weight for age in children from ________ years to ________
age times 100. This provides a simple expression of deviation years of age is an index of acute malnutrition
from the norm. A quotient above 85 in any domain is considered 3) Head circumference at birth is ________ cm
within normal limits. The factors that promote development 4) The length of a child is measured in the first _____ years.
include good nutrition, emotional support, play and language 5) By 2 - 2½ years of age the baby will have _________
training. Growth Monitoring was popularized by David Morley primary teeth.
in 1960s’ and 70s’ (1-5). This strategy proved that growth 6) A developmental quotient below ___________ is considered
monitoring could improve nutritional status. In 1982 growth abnormal
monitoring, i.e. the regular weighing of children and charting 7) Growth Monitoring was popularised by ________
their weight on a chart was taken up by UNICEF as part of 8) Weight / height3 represents a) Brocas index b) Ponderal
the GOBI program. Anthropometry is very useful for measuring index, c) Quetelet index, d) none
overall health status, not just nutritional status. IAP has laid 9) Z score = ___________
down various guidelines for growth monitoring according to Answers: (1) 65 to 70; (2) 0.5 yrs to 7 yrs;
different age groups. Height and weight measurements mean (3) 35; (4) 3; (5) 20; (6) 70; (7) David Morley; (8) b;
little unless compared to a growth reference. Anthropometric
indices are combinations of the measurements. They are (observed value) – (median reference value)
(9) Z score = Standard deviation of the reference population
important since mere measurements provide little useful
information; for example Ponderal index, WFH (weight for
height), HFA (height for age) and WFA (weight for age). These
References
indices could be expressed in the form of Z-scores, percentiles 1. Beghin I, Fougère W, King KW. L’alimentation et la nutrition en Haïti. Paris:
and % of median. The prototype WHO chart (home based) had Presses Universitaires de France,1970. 248 pages
two reference curves. The upper curve represented the median 2. Morley D. A medical service for children under five years of age in West
Africa. Trans Roy Soc Trop Med Hyg. 1963;57:79-94.
for boys (50th percentile) and the lower curve represented
3. Morley D. The spread of comprehensive care through under-fives’ clinics.
the 3rd percentile for girls. The growth standards provide a Trans Roy Soc Trop Med Hyg. 1973;67(2):155-170.
technically robust tool that represents the best description of 4. Morley DC. Paediatric priorities in developing world. London: Butterworths,
physiological growth for children under five years of age. 1973.
5. Morley D. The design and use of weight charts in surveillance of the
Study Exercises individual. In: Beaton GH and Bengoa JM (Eds.): “Nutrition in preventive
medicine”. Geneva: WHO, 1976; 520-529.
Long Question : “Growth and development is very helpful in 6. Morley D, Woodland M. See how they grow: monitoring child growth for
finding out the state of health and nutrition of a child”. Explain appropriate health care in developing countries. London: Mc. Millan, 1979.
7. The World Health Organization. Expert Committee on Physical Status. The
in detail. Use and Interpretation of Anthropometry. Physical Status: Report of a WHO
Short Notes : (1) Mid upper arm circumference (2) Development Expert Committee: WHO Technical Report Series 854, WHO, Geneva, 1996.
8. MGRS- 2006.
quotient (3) Growth monitoring (4) Anthropometry (5) Growth
charts (6) IAP guidelines for growth monitoring

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 was proposed by Watson and Crick to explain the versatility
150 Genetics and Public Health of the transmission mechanism. The chromosome structure is
however more complex. DNA sequences make up genes which
code for different proteins necessary for life. It is estimated that
Amitava Datta
there are upto 1,00,000 genes in the nuclear genome, which
code for specific proteins in humans. Many human genes are
Historical Aspects single copy genes coding for polypeptides which carry out a
Homosapiens first appeared on this planet approximately variety of cellular functions. These include enzymes, hormones,
50,000 years ago. Early man seemed to be as curious as in receptors and structural and regulatory proteins.
the present day on matters of inheritance. Engravings in
Chaldea in Babylonia (now Iraq) dating back at least 6000 Fig - 1 : Structure of Cell
years show pedigrees documenting the transmission of certain
characteristics of the mane in horses. Early Greek philosophers Mitochondria
and physicians such as Aristotle and Hippocrates concluded
with typical masculine modesty that important human
characteristics were determined by semen utilizing menstrual Nuclear
membrane
blood as a culture medium and the uterus as an incubator. Our
Chromosomes
present understanding of human genetics owes much to the work
of the Austrian monk, Gregor Mendel, who in 1865 presented Nucleolus
the results of his breeding experiments on garden peas. The Endoplasmic
importance of these findings were however only realized in reticulum
1900. It was a Danish botanist, Johannsen who coined the term Ribosome
“gene” for the hereditary factors postulated by Mendel. Credit
for first recognition of a single gene trait is shared by William
Bateson and Archibald Garrod who proposed that alkaptonuria Cell
was a rare recessive disorder. During the twentieth century, it Cytoplasm membrane
gradually became clear that hereditary factors are implicated
in many conditions and that different genetic mechanisms are
involved. The study of genetics and its role in the causation
of human disease has in modern times been at the forefront
The original concept of a gene as a contiguous sequence of DNA
of medical research. Francis Crick, James Watson and Maurice
coding for a protein was turned on its head in the early 1970s
Wilkins in 1962 gained acclaim for their elucidation of the
by detailed analysis of the structure of the β-globin gene which
structure of DNA. In the next 30 years or so the Nobel prize
revealed it to be much longer than the length necessary to code
was awarded on twelve occasions to scientists working in the
for the β-globin protein. The gene was found to be containing
field of human and molecular genetics. Dramatic advances in
non-coding intervening sequences or “introns” separating the
technology lead to better and more complete understanding of
coding sequences or “exons”. The number and size of introns
the way we inherit different characteristics, why diseases occur
in various human genes is extremely variable although the
and human biology. Increasing globalization and the internet
general trend is that larger the gene, the greater the number
enabled the gigantic “Human Genome Project” started in 1991,
of exons.
mainly with funding by United States Government, to map
the complete human genome. Thus throwing up tremendous
Fig. - 2 : Structure of Gene
potential for diagnosis and management of human disease.
Gene therapy, which till recently was considered in the realms of Transcription Transcription
Initiation Termination
science fiction, suddenly became eminently possible although
its routine use in the management of disease is still several
years away. ‘CAT’ ‘TATA’
Box Box
Increasing control world wide on communicable diseases, Exon1 Exon2 Exon3
ethical considerations of gene manipulation and better 5’ 3’
understanding of genetic basis of disease has pushed genetics Promoter Intron1 Intron2
into the realm of public health. A comprehensive knowledge of region
elementary genetics is now therefore inescapable for a potential Translation Polyadenylation
Translation
public health specialist. Initiation Termination Signal
Codon
Cellular basis of Inheritance Codon
(TAA)
(ATG)
The structure of a cell as evident on light microscopy is shown
in Fig 1. The process whereby genetic information is transmitted from
The transmission of hereditary characteristics is controlled by DNA to RNA is called “transcription”. The information stored
chromosomes located inside the nucleus and containing genes in the genetic code is transmitted from DNA to messenger
which are made up of DNA. The double helical structure of DNA RNA (mRNA) which is single stranded. The mRNA leaves the

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nucleus after undergoing “post-transcription processing”. The coding” sequences, it is only in the former that some disease
transmission of the genetic information from mRNA to protein or condition arises. A mutation occurring in a somatic cell
is called “translation”. mRNA migrates out of the nucleus into cannot be transmitted to future generations. It is estimated
the cytoplasm where it becomes associated with the ribosomes, that each individual carries upto six lethal or semi-lethal
which are the site of protein synthesis. In the ribosomes, the recessive mutant alleles which in the homozygous state would
mRNA forms the template for producing a particular sequence have very serious effects. Occurrence of mutations in DNA, if
of amino acids (See Fig. - 3a & b). left unrepaired, would have serious consequences both for the
individual and subsequent generations. The stability of DNA is
Fig. - 3a : Process of Transcription dependent on “DNA repair”. Defects in this mechanism can lead
TRANSCRIPTION TRANSCRIPTION to chromosomal breakage syndromes.
INITIATION TERMINATION
Chromosomes
3’
Exon1
Intron1
Exon2
Intron2
Exon3
3’
Chromosomes are thread like structures and can be considered
TATA BOX
5’ 5’ to be made up of genes. The centromere divides the chromosome
Translation start Translation stop Poly (A)
into short and long arms designated ‘p’ = petit and ‘q’ = grand
Transcription
Signal
Polyadenylation
respectively. The tip of each end is referred as telomere, which
Primary RNA Capping plays an essential role in sealing the ends of the chromosome.
1’ Cap Poly (A) tall In human cells, there are 22 pairs of autosomes and a pair of
sex chromosomes - XX in female and XY in male. One member
Splicing
of each chromosome is derived from each parent. Somatic
mRNA
cells have a diploid component consisting of 46 chromosomes
Translation whereas gametes (ova or sperm) have haploid complement
Post-transitional
Protein processing
of 23 chromosomes. Recent developments have allowed the
study of chromosomes to detect regions of allele loss and gene
Fig. - 3b : Process of Translation amplification. The process of cell division ensures that the
DNA human zygote which is a single cell at conception undergoes
A A A C T C C A C T T C T T C
U U U G A G G U G A A G A A G rapid division leading to approximately 1014 cells in an adult.
m-RNA In some organs and tissues, the process of cell division
continues throughout life. In mitosis (somatic cell division)
the chromosome divides longitudinally and after separation
Nuclear
membrane forms two daughter cells. In meiosis (gamete formation) the
chromosome number is halved during Meiosis I while Meiosis
Ribosome II is like ordinary mitotic division. Meiosis facilitates halving of
m-RNA
U U U G A G G U G A A G A A G the diploid number of chromosomes so that each child receives
(template) C U C C A C
A A
A
U U
half of its chromosome complement from each parent. It also
t-RNA C provides an extraordinary potential for generating genetic
Glutamic Acid Valine
Pheny diversity as DNA derived from both parents are present in each
lalanin Lysin
e Peptide e
chromatid. The process of gametogenesis is different in male
and female.
Genetic information is stored with the DNA molecule in the form
In oogenesis, oogonia derived from primordial germ cells start
of a triplet code, that is a sequence of three bases determines
undergoing meiosis by 3 months of intra uterine life. At birth
one amino acid. Only 20 different amino acids are found in
all the primary oocytes enter a phase of maturation arrest
proteins. By experimentation with various refinements, triplet
known as dictyotene in which they remain suspended until
codes have been assigned to all 20 amino acids. The triplet of
meiosis I is completed at the time of ovulation when a single
nucleotide bases in mRNA which codes for a particular amino
secondary oocyte is formed. The lengthy interval between onset
acid is called “codon”. In addition to “Structural genes” ( which
of meiosis and its eventual completion upto 50 years later has
are concerned with the synthesis of specific proteins), there are
been suggested as the reason for the well documented increase
“control genes” which regulate the activity of structural genes.
in chromosomal abnormalities in offspring of older mothers.
It was initially believed that genetic information was transferred
from DNA to RNA and thence translated into protein. However, In spermatogenesis, spermatogonia mature into primary
at times genetic information can occasionally flow from RNA to spermatocytes at puberty. Spermatogenesis is a continuous
DNA (as in the case of retro virus). This is referred to as “RNA process involving many mitotic divisions so that spermatozoa
directed DNA synthesis”. produced by a man of 50 years or older could well have
undergone several hundred mitotic divisions. DNA copy errors
Mutations may lead to mutations in offspring of older parents.
A mutation is defined as an alteration or change in the genetic
Chromosomal Abnormalities
material. Mutations are usually harmful and can arise due to
exposure to mutagenic agents but may occur in a vast number A large number of disorders are due to chromosomal
of cases spontaneously through errors in DNA replication and abnormalities which can be due to either numerical or structural
repair. Although mutations can occur in “coding” or “non- abnormality of chromosomes. Numerical abnormalities

• 879 •
involve the gain or loss of one or more
Fig. - 4 : Chromosomal Non-dysjunction
chromosomes- aneuploidy or addition of
one or more complete haploid complement A B C
of chromosomes - polyploidy. The common
examples are Trisomy 21 (Down’s syndrome),
Trisomy 13 (Patau’s syndrome), Trisomy Meiosis I
18 (Edward’s syndrome), Monosomy X Non dysjunction
(Turner’s syndrome), Super males (XYY)
or Super females (XXX). The commonest
cause is non-disjunction during meiosis
Meiosis II Non dysjunction
(Fig.-4). Polyploidy is found relatively often
in spontaneous miscarriage and is usually
not commensurate with life. It is usually
due to failure of a maturation meiotic
Normal Monosomic Disomic Nullisomic Disomic Nullisomic Normal
division in ovum or sperm or fertilization of Gametes Gametes Gametes Gamete Gamete Monosomic
an ovum by two sperms. Gametes

Structural chromosomal abnormalities

result from chromosome breakage with Diabetes mellitus, cancers etc. are multi- factorial in origin. The
subsequent reunion in a different configuration (Fig. - 5). genetic predisposition with suitable environmental conditions
This may be due to translocation (transfer of genetic material can lead to the occurrence of these diseases. The very process
from one chromosome to another), deletions (loss of part of of aging is now considered to be genetically determined as are
a chromosome), insertions (segment of one chromosome some of the diseases which have a rising incidence with age -
becomes inserted into another chromosome), inversions (two “acquired somatic genetic disease”.
break rearrangement involving a single chromosome in which Certain predictions have been made based on the assumption
a segment is reversed in position), ring chromosome (break on that heritability of disease declines with increasing age :
each arm of a chromosome leaving two “sticky” ends which ●● Persons with early onset of symptoms are more likely to
reunite as a ring) and Isochromosomes (loss of one arm of have severe disease and also to have affected first degree
a chromosome with duplication of the other arm). In all the relatives.
structural abnormalities, when there is loss or gain of genetic ●● Age specific age at onset should reach a peak and then
material called balanced rearrangement, the effect is mild. decline.
When there is incorrect amount of genetic material due to loss ●● Multi-genic diseases do not require a specific environment
or gain, it is called unbalanced arrangement and the clinical for their occurrence.
effects are usually very severe. ●● Migration, socio-economic status and other environmental
change may affect the age of onset and the likelihood of
Fig. - 5 : Chromosomal Abnormalities : Inversion the clustering of the disease in families.
●● If one sex is less often affected, early onset, severity and
A A increased incidence in affected relatives should characterize
B C it.
●● Concordance in monozygotic twins should be greatest
C B
when disease onset is early.
●● Patients with late onset of the disease have milder forms
D D
of the disease which are more amenable to prevention and
E E treatment.
Burden of Genetic Disease
The burden of diseases of genetic etiology in a community
A A is determined by the “Gene pool”, customs regarding
marriage (breeding patterns) and migrations. The social and
B C demographic structures of populations play a very significant
role in the distribution patterns of specific inherited disorders.
C B In countries with recent industrialization and urbanization,
widespread population movement from the countryside (rural
D D areas) to rapidly expanding towns and cities (urban areas) have
resulted in dissolution of historical, local, regional and national
boundaries. This has helped to exert a partial homogenizing
Incidence and Prevalence of Genetic disease effect on national gene pools. This is similar to the effect that
Genetic disease may manifest at birth or may remain without large scale migration from Europe to Americas and Australia
manifesting till several decades later. Besides the disorders had in the previous centuries which resulted in significant
which are clearly genetic in origin, several disorders like mixing of previously distinct populations.

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In most developing countries, local and regional clan, tribal environmental factors or more likely to be an interaction
and ethnic grouping have largely remained intact. In India, between the two.
Pakistan and Bangladesh which collectively account for more Categories of Genetic Disease
than 20% of the world’s population, marriage continues to be
arranged within caste and biraderi boundaries that probably The broad classification of various categories of genetic disease
date back some 3000 years. In India, it is estimated that there has evolved with the availability of sophisticated diagnostic
are 50,000 to 60,000 separate endogamous communities. 25 tools which has enabled identification of genetic and molecular
percent of the population of more than 1 billion are members basis of these disorders.
of the scheduled castes and scheduled tribes which number Chromosomal Disorders
more than 1600. Muslims account for 130 million of India’s
Since the demonstration in 1959 that the presence of an
population. Each of these groupings forms separate breeding
additional number 21 chromosome (Trisomy 21) results in
pools - Hindus (divided into castes & regions), Muslims, Sikhs,
Down’s syndrome, more than 1,000 chromosomal syndromes
Christians Jains, Buddhists, Parsis etc.
have been reported. They have a major contribution to morbidity
Therefore diseases caused due to mutations of ancient origin and mortality in infants and account for a large proportion of
are likely to be distributed throughout the population. However spontaneous abortions. Chromosomal abnormalities have been
diseases due to mutation which have arisen more recently may detected in 10 percent of spermatozoa and 25 percent of mature
be restricted or even unique to individual ethnic groups, sub- oocytes. It is estimated that 15-20 percent of pregnancies do not
castes, tribes or clans. survive beyond a few weeks due to presence of chromosomal
Although adequate statistics are not available in India of abnormalities and also that more than 50 percent of all
the incidence and prevalence of genetic disorders, certain spontaneous abortions are having chromosomal abnormalities.
studies have attempted to estimate the burden due to genetic The common abnormalities are :
diseases in India. The large population, high birth rate and ●● Trisomy (50 percent)
favouring of consanguineous marriage by significant numbers ●● Monosomy X (20 percent)
of communicates, should lead to high prevalence of genetic ●● Triploidy (15 percent)
disorders in the country. According to a study it is estimated ●● Tetraploidy (5 percent)
that every year 4,95,000 infants with congenital malformations, ●● Others (10 percent)
3,90,000 with G-6 PD deficiency, 21,400 with Downs Syndrome, The presence of chromosomal abnormality in newborns
9,000 with thalassaemia, 5,200 with sickle cell disease and ranges up to 90 per 10,000 births. The common abnormalities
9,760 with amino acid disorders are born each year. Studies are Autosomal (20 per 10,000) & Sex chromosome (30 per
on haemoglobinopathies indicate that they represent a 10,000). The presence of chromosomal abnormality reduces
significant national health burden in India. Distribution of from conception to birth. The presence in still births is about
specific disorders varies geographically and by community. 5 percent. It is known that spontaneous pregnancy loss occurs
Heterozygote frequencies of thalassaemia range from 1 to 15 commonly in the presence of chromosomal abnormalities,
percent resulting in an estimated 20 million carriers. Sickle cell with as high as 80%-98% pregnancies being lost among foetus
anaemia is mainly present in tribal communities with carrier having Monosomy or various forms of Trisomy. The common
presence as high as 40 percent in some cases. It is estimated that chromosomal disorders are :
there are 50,000 affected Hemophilia patients nation wide with
Autosomal Disorders (Gain of entire chromosome)
an additional 1,500 new cases born each year. The prevalence
●● Down syndrome (Trisomy 21)
of late onset multifactorial disorders including coronary artery
●● Patau syndrome (Trisomy 13)
disease, hypertension and psychiatric disorders is also large.
●● Edward’s syndrome (Trisomy 18)
Genetic eye disorders have been reported in large numbers.
Shankar Nethralaya, the premier institute for ophthalmology Chromosomal Deletion Syndromes (Deletion of part of
chromosome)
in South India has reported 2,335 patients with genetic eye
disorders over a five year period. 673 (28.8 percent) of these ●● Wolf Hirschhorn syndrome (Chromosome 4)
patients reported a family history of consanguinity. Retinitis ●● Cri-du-chat syndrome (Chromosome 5)
pigmentosa was detected in a large proportion (63.9 percent) of ●● Retinoblastoma (Chromosome 13)
those reporting family history of consanguinity. ●● Wilm’s tumour (Chromosome 11)
Sex Chromosomal Disorders (Gain or loss of entire
The seriousness of the burden of genetic disorders in India is chromosome or part)
thus clearly appreciable inspite of lack of population based
●● Klinefelter’s syndrome (47, XXY)
studies. Determining the role of genetics in disease will require
●● Turner’s syndrome (45, X)
better methods of classifying disease and processing health
●● Super females (47, XXX)
data. Computerized record keeping will become very important
●● Super males (47, XYY)
not only to build longitudinal health histories on individuals
●● Fragile X Syndrome (46, XX*)
but also to link these into sibships and family groupings.
The chromosomal disorders are all potentially detectable by
Administrative and other health data sets that already exist
pre natal diagnosis. Since only those subgroups of women
can be combined to evaluate if familial clustering occurs. If
identified as being at higher risk (due to family history or age)
familial clustering is detected, then various methodologies may
are screened pre-natally, there is an opportunity to avoid only
be used to untangle whether this is due to genetic or shared
a proportion of these conditions at present.

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Single Gene or Mendelian Disorders Sex Linked Inheritance
Credit for the first recognition of a single gene trait is shared by It refers to the pattern of inheritance shown by genes which are
William Bateson and Archibald Garrod who together proposed located on either of the sex chromosomes. Genes carried on the
that alkaptonuria was a rare recessive disorder. Since then many X chromosome are referred to as X-linked, while genes carried
more disorders have been identified - by 1966 almost 1500 on the Y chromosome are referred to as exhibiting Y - linked or
single gene disorders or traits had been identified which follow “Holoandric inheritance”.
the mendelian rules of inheritance. An American physician, X-linked Recessive disorders (XR) : An X linked recessive
Victor Mckusick published a catalogue of all known single gene trait is one determined by a gene carried on the X chromosome
disorders. An online version of Mckusick’s catalogue has been and usually only manifests in males. These disorders are
created which is known as “Online Mendelian Inheritance in transmitted by healthy heterozygous female carriers to affected
Man” (OMIM) which can be accessed on the World Wide Web. males, as well as by affected males to their obligate carrier
As on 07 July 2008, there were 18,811 single gene traits or daughters. The mode of inheritance whereby only males were
disorders which were included in this catalogue. There are affected by a disease which is transmitted by normal females
mainly four categories into which single gene disorders are was appreciated by the Jews nearly 2000 years ago. They were
grouped, based on patterns of inheritance as indicated below : excused from circumcision, the son of all sisters of a mother
Autosomal Dominant Disorders (AD) who had sons with the “bleeding disease” i.e. Haemophilia. The
sons of the father’s sibs were not excused. A male transmits his
An autosomal dominant trait is one which manifests in the
X chromosome to each of his daughters and his Y chromosome
heterozygous state i.e. in a person possessing both the abnormal
to each of his sons. If a male affected with Haemophilia has
or mutant allele and the normal allele. It is often possible to
children with a normal female, then all his daughters will be
trace a dominantly inherited trait or disorder through many
obligate “carriers”, but none of his sons will be affected. A male
generations of a family. The disorder is transmitted to both
can not transmit his X-linked disorder to his son except in very
sexes of the progeny. Any child born to a person affected with a
rare circumstances. For a carrier female having children with
dominant trait has a one in two (50%) chance of inheriting it and
a normal male, each son has a 1 in 2 (50%) chance of being
being similarly affected. Autosomal dominant traits can involve
affected and each daughter has a 1 in 2 (50%) chance of being
only one organ or part of the body e.g. Polydactyly. The clinical
a carrier. Duchenne muscular dystrophy and Haemophilia are
features can show striking variation from person to person
common examples of X-linked recessive disorders.
and in some cases the findings can be undetected - “reduced
penetrance” possibly due to the modifying influence of other X-linked Dominant Disorders (XD) : There are few disorders
genes. Examples of autosomal dominant traits or disorders are in this category like familial Hypophosphataemia with rickets,
Huntington’s chorea, Neurofibromatosis, Polyposis coli. There Alport’s syndrome etc. It superficially resembles autosomal
may be also some cases due to new mutations. In these cases dominant inheritance. Both sons and daughters of an affected
it will not be possible to trace the trait in the family and hence female have a 1 in 2 (50%) chance of being affected. However,
pose problems in genetic counselling. an affected male transmits only to his daughters and not to his
sons. Affected females are more common than males but are
Autosomal Recessive Disorders (AR) less severely affected as compared to males.
Most recessive disorders are individually rare, each with a birth
Y-linked Inheritance : Y-linked or holandric inheritance
prevalence of 1 in 15,000 to 1 in 1,00,000. However, since there
implies that only males are affected. An affected male transmits
are so many, they have a considerable impact with 1 in 500
Y-linked traits to all his sons but not his daughters. Hairy
live born individuals being identified as having one of these
ears, H-Y histocompatibilty antigens and genes involved in
disorders before age 25 yrs. The recessive traits and disorders
spermatogenesis are carried on Y chromosome and therefore
are only manifest when the mutant allele is present in a double
transmitted accordingly.
dose i.e. homozygosity. Individuals who are heterozygous for
a recessive mutant allele show no features of the disorders Mitochondrial Genetic Disorders
and are perfectly healthy i.e. they are carriers. It is usually Genes coding for proteins involved in oxidative phosphorylation
not possible to trace an autosomal trait or disorder through are located in mitochondria in human cells. These are always
the family tree. However, consanguinity can be detected in inherited from the mother. Disorders involving these genes
the ancestors. Generally speaking, the rarer a recessive trait therefore do not behave like other mendelian disorders. Some
or disorder, the greater the frequency of consanguinity among examples of mitochondrial genetic disorders are Leber’s optic
the parents of the affected persons. Autosomal recessive traits atrophy, infantile bilateral striatal neurosis and Kearns-Sayre
are transmitted both to sons and daughters equally and both syndrome.
are capable of transmitting it to their sons and daughters.
The progeny may however, not manifest unless they are in Multifactorial Disorders
homozygous state. The chance of having an affected child Many disorders demonstrate familial clustering which does not
inheriting the recessive trait is 1 in 4. Common examples of conform to any recognized pattern of mendelian inheritance.
autosomal recessive traits or disorders are : cystic fibrosis, Francis Galton, a cousin of Charles Darwin, had carried out
albinism, alkaptonuria, and haemoglobinopathies. research on human characteristics like stature, physique
and intelligence based on studying identical twins. The
differences among twins in these parameters could only be

• 882 •
due to environmental influences. He introduced to genetics the of malignancies and possibly explain the rising incidence with
concept of “Regression co-efficient” as a means of estimating increasing age of many serious illnesses including the ageing
the degree of resemblance between various relatives. This process itself.
model, polygenic inheritance, of quantitative inheritance in
which many genes play a role in the phenotypic expression Public Health Issues in Genetic Diseases
is now widely accepted to explain the pattern of inheritance Epidemiological studies have helped us understand how
of many relatively common conditions including cleft lip and genetic diseases are distributed in a population. Genetic
palate, hypertension and diabetes mellitus. The underlying methods are increasingly allowing us to identify genetically
genetic mechanisms are however, still not well understood. susceptible individuals. New molecular genetic techniques now
The liability / threshold model to explain multi-factorial allow particular DNA sequences to be evaluated in patients
inheritance of disorders proposes that a threshold exists above and compare with control subjects and hold out the hope
which the abnormal phenotype is expressed. This hypothesis for future progress in early detection and even management
(rather than proven fact) helps to explain the observed system (gene therapy). Various considerations in prevention of genetic
of inheritance of certain multi-factorial diseases like cleft lip/ diseases, thus needs detailed analysis.
palate, pyloric stenosis and spina bifida as follows : Primary Prevention
●● The incidence of the condition is greatest amongst relatives Eugenics : It is science of improvement of genetic endowment
of the most severely affected patients. through breeding. It has long attracted the attention of mankind.
●● The risk is greatest amongst close relatives of the index The term was first coined by Francis Galton. “Positive Eugenics”
case and decreases rapidly in more distant relatives. seeks to improve the genetic endowment in the population of
●● If there is more than one affected close relative then the “favourable traits” by encouraging persons with these traits to
risks for other relatives are increased. intermarry. However, as we now know, the inheritance of most
●● If the condition is more common in individuals of one of these traits like appearance, skin colour, height, intelligence
particular sex, than relatives of an affected individual of etc. are inherited in a complicated manner and are difficult to
the less frequently affected sex will be at higher risk than control. “Negative Eugenics” in which people suffering from
relatives of an affected individual of the more affected serious disorders which are genetic in origin are debarred from
sex. producing children is practiced in most communities. Many
●● The risk of recurrence for first degree relatives (siblings countries do not allow migration of people who are known
and offsprings) approximates to the square root of the to have serious genetic diseases. However, as new mutations
general population incidence, for e.g. if the incidence in continue to occur negative eugenics can not be an effective
the general population of a disease is 1 : 1000, the risk public health tool to reduce the burden of genetic diseases.
for first degree relatives of an affected person will equal Genetic Counselling : More than 40 years ago genetic
approximately 1 in 32 or 3%. counselling services to cater for the needs of persons seeking
The inheritance patterns in insulin dependent diabetes mellitus information regarding genetic diseases were first introduced.
or type - I diabetes mellitus lends a good example of the above Genetic counselling caters for the concerns of individuals /
elucidated multi-factorial inheritance. The concordance rate in families who have a family history of serious diseases. Their
monozygotic and dizygotic twins is 50% and 12% respectively. concern may be whether they can develop the disease or
The sibling recurrence risk is 6%. These observations point whether they can transmit the disease.
to contributions both by environmental and genetic factors.
Genetic counselling has been defined as a process of
Known environmental factors include diet, viral exposure
communication and education which addresses concerns
in early childhood and certain drugs. The disease produces
relating to the development and / or transmission of a hereditary
irreversible destruction of insulin producing beta cells in the
disorder. The person who seeks genetic counselling is known as
pancreas by the body’s own immune system probably as a
“consultand”. During genetic counselling, the counsellor tries
result of an interaction between infection and an abnormal
to provide the consultand with information which enables him/
genetically programmed immune response. The polygenic
her to understand :
susceptibility consists of one major locus (IDDM-1, which is
in the HLA locus on chromosome 6p21), and up to 20 minor ●● The medical diagnosis and its implications in terms of
loci. The product of these gene loci are believed to interact in a prognosis and possible treatment
complex and poorly understood manner to confer susceptibility ●● Mode of inheritance of the disorder and the risk of
to environmental triggers of auto immune pancreatic beta cell developing and / or transmitting it
destruction. ●● Choices or options available for dealing with the risks
Genetic counselling is non directive, with no attempt to lead
Acquired Somatic Genetic Disease the consultand in any particular direction. The process presents
Not all genetic errors are present from conception. During medical scientific facts / risks so that the “consultand” can make
the billions of cell division (mitosis), which occur during their own decisions. Commonly, people seek counselling after
the life time, the opportunity for occurrence of mutations the occurrence of a hereditary disorder in the family. Rarely,
due to DNA copy errors and numerical chromosomal errors individuals / couples may seek pre-marital advice. Usually , for
exist. Accumulating somatic mutations and chromosomal diseases like mental retardation, congenital abnormalities, etc.,
abnormalities are now known to account for a large proportion there is occasional seeking of such counselling which is thus

• 883 •
“retrospective” in nature. In certain occasions there may be an understood by the Consultand during the limited duration of the
attempt to identify heterozygous individuals for a disease and counselling session. A letter summarizing the topics discussed
explaining the risks of marrying another heterozygote for the is then sent to the Consultand. Informal contact through a
same disease - “prospective” counselling. In both prospective network of genetic associates or nurse specialist are also an
as well as retrospective counselling, the outcomes sought added features of genetic counselling clinics.
would range from contraception, pregnancy termination or Other Health Promotional Measures : Problems of increased
even adoption of a child. genetic diseases in late marriages and advancing age of
Steps in Genetic Counselling mother are now common knowledge. Appropriate counselling
Establishment of diagnosis : It is the most crucial step in is required to restrict pregnancies arising from late marriages
any genetic counselling. Misleading advice may be given based or in women past 35 years.
on incorrect diagnosis which may lead to tragic consequences. Consanguineous marriages are another cause for concern.
A correct clinical diagnosis will require proper history taking, Community involvement will be needed to overcome this social
detailed clinical examination and appropriate investigations. occurrence. A consanguineous marriage is defined as one in
The family history may need to be obtained by a properly trained between blood relatives with at least one common relative no
genetics nurse or counsellor. Chromosomal and molecular more remote than great-great-grand parents. Hearing loss,
studies will also be needed to establish the inheritability mental retardation, alkaptonuria are common among offsprings
and genetic basis of the disease. At times, for example in of consanguineous marriages.
hearing loss, etiological heterogenosity may affect the ability Specific Protection : Radiation, chemicals and drugs are
to correctly calculate the “recurrence risk”. Other disorders known to produce mutations and teratogenic effect. Adequate
like congenital cataract (AD, AR, XR), ichthyosis (AD, AR, protection is needed to be ensured for persons in the
XR), retinitis pigmentosa (AD, AR, XR) and polycystic kidney reproductive age group. X-Ray and other ionizing radiations
disease(AD, AR) can also show “genetic heterogenosity”. produce mutations which are proportional to the dose of
Calculating and presenting the risk : This is the next step radiation. There is no threshold. Genetic effects are known to
based on the genetic diagnosis and calculation of risk based be cumulative and protection is routinely provided to all those
on well established norms like use of Bayes Theorem or use of who are likely to be occupationally exposed to radiation.
“empirical risks”. The recurrence risks need to be quantified, Chemicals like mustard gas, benzene, formaldehyde, caffeine,
qualified and placed in context. A risk statement “1 in 4“ can be etc. are known mutagens in animals. Caution is therefore
misunderstood that once it has occurred it will recur only after required to prevent exposure to these and basic dyes by human
3 normal children. Inheritance does not have any “memory” specially those in the reproductive age groups. A large number
and applies for each offspring. For a risk of recurrence of “1 of drugs have been known to be teratogenic and need to be
in 25”, it must also be explained that “24 out of 25” chance avoided in pregnancy.
is for a normal baby. The risk needs to be qualified by aspects
Early Diagnosis : Increasing awareness of the role of
like long term burden rather than its precise numerical value.
genetics in the etiology of disease and its overall impact on
For a trivial disorder like polydactyly even a risk of “1 in 2”
the burden imposed on individuals, families and society has
may not deter having more children. Whether a disease can be
lead to introduction of several population genetic screening
successfully treated, associated with pain and suffering and
programs. The primary objective is to enable individuals to be
whether pre-natal advice is available can be relevant to the
better informed about genetic risks and reproductive options. A
decision making process. Placing the risk in context is equally
secondary objective is the prevention of morbidity due to genetic
important . For a disease with a population risk of 1 in 40 , an
diseases and alleviation of the suffering. The scope of early
additional risk of 1 in 50 may in fact be considered low. As an
diagnosis thus covers apparently healthy persons who may
arbitrary guide, risk of 1 in 10 or greater can be regarded as
wish to be made aware of genetic disease in themselves or their
high while 1 in 20 or less can be regarded as low.
offspring, diagnosis of the presence of genetic abnormalities
Discussing the options : It is a natural follow up after making in utero as well as the new born and for diagnosis of genetic
the diagnosis and presenting the “risks”. All the choices should disease or carrier state in the siblings of a person (adult or
be provided with no attempt made to guide the consultand to child) diagnosed with a genetic disease.
select one of them. The issues need to be broached with care
A number of tests of different types are available to detect
and sensitivity as the realization of the disease, its risks and
carriers for Autosomal and X-linked recessive disorders and
the likely outcomes may be cause of great emotional shock to
for pre-symptomatic diagnosis of heterozygotes for Autosomal
the consultand.
dominant disorders. Biochemical or hematological techniques
Communication and support: It is provided by most genetic can be used to detect carriers of Autosomal recessive disorders
counselling clinics. The setting of the counselling must be like Tay-sachs disease (reduced hexoseaminidase A levels
agreeable, private and quiet with ample time for discussion in serum), sickle cell disease / trait ( sickling of RBCs in
and questions. As far as possible, technical terms must be deoxygenated condition), Duchenne muscular dystrophy
avoided but no attempt must be made to hide facts and (elevated serum creatinine kinase level) and G-6PD deficiency
questions answered honestly and openly. It is necessary to (reduced erythrocyte - G6PD activity). However these tests are
reiterate the aspects covered specially the aspects of risk in reliable only in those cases where the gene involved is directly
written communication as all aspects may not have been clearly involved in the biochemical activity.

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Table - 1 : Pre-natal diagnostic techniques
Technique Test & Result Foetal age Genetic conditions diagnosed
Chorionic villus sampling Chromosome analysis Chromosomal abnormalities
10-11 wks
(2-3% risk of miscarriage) Biochemical assay Metabolic disorders, Molecular defects
α -fetoprotein raised Neural tube defects
Amniocentesis
Chromosome analysis 16 wks Chromosomal abnormalities
(0.5-1%risk of miscarriage)
Biochemical assay Metabolic disorders, Molecular defects
Ultrasound ( also indirect evidence Structural abnormalities
18 wks
of chromosomal disorders) (heart, kidney, limbs, CVS)
2nd
Fetoscopy (3-5% risk of miscarriage) Structural abnormalities & others
trimester
Radiography (now rarely used) 10 wks Skeletal dysplasias
Fetoprotein raised Neural tube defects
Quad test
Maternal serum screening - α-fetoprotein reduced
(usually standard screening - Unconjugated 16 wks
Down’s syndrome
for “at risk” mothers) oestriol reduced
- HCG increased
- Inhibin A increased

Table - 2 : Treatment modalities in genetic diseases

Treatment Disorder
Enzyme induction by drugs : Phenobarbitone Congenital Non-haemolytic Jaundice
Replacement of deficient enzyme / protein :
Blood transfusion SCID
a-glucosidase Gaucher’s disease
Factor VIII Haemophilia A
Replacement of deficient vitamin / co-enzyme :
B6 Homocystinuria
D Vit D resistant rickets
Substrate reduction in diet :
Phenylalanine Phenylketonuria
Leucine/isoleucine/valine Maple syrup disease
Galactose Galactosaemia
Cholesterol Fam. hypercholesterolaemia
Drug therapy :
Pancreatic enzymes Cystic fibrosis
Penicillamine Wilson’s disease
Replacement of diseased tissue :
Kidney transplant Polycystic kidney disease
BM transplant X-linked SCID
Removal of diseased tissue:
Colectomy Polyposis coli
Splenectomy Hereditary spherocytosis

• 885 •
Until the recent past, couples at high risk of having a child Newer molecular genetic techniques allows to detect particular
with a genetic disorder had to choose between taking the risk DNA sequence responsible for causation of disease and therefore
or considering other reproductive options. In the recent past escalating importance of prevention of genetic diseases by
reliable pre-natal diagnosis of abnormalities in an unborn ethically utilizing preventive approaches viz Eugenics, Genetic
child have been widely used to assist decision making by such counselling, avoidance of consanguineous & late marriages
couples. The ethical issues are however very complex. The and avoiding exposure to radiation, mutagenic/ teratogenic
techniques used are amniocentesis, chorionic villus sampling, chemicals and drugs. Besides, myriad of population genetic
ultrasonography, fetoscopy, foetal blood sampling, radiography screening tests and prenatal diagnostic tests are also available
and maternal serum screening. A summary of the techniques is for early detection and timely intervention. A new initiative
indicated in Table - 1. GRAPH Int - Genome based research and population health
Treatment : A large number of genetic diseases are “treatable” international has been established to promote the strategy for
and the disablement reduced provided the defect has been public health action in this genomic era.
diagnosed in time. Some of these treatable conditions are Study Exercises
enumerated in Table - 2. Although still in the realm of research,
1. The Austrian monk who presented the results of his
gene therapy to correct the genetic abnormality is a distinct
breeding experiments on garden peas in 1865 was
possibility and needs serious consideration.
(a) James Watson (b) Gregor Mendel (c) William Bateson
Strategy for public health action (d) Johannsen
The volume of new knowledge and technologies from genetic 2. The term ‘Gene’ was coined by (a) James Watson (b) Gregor
and genomic research is such that a concerted effort is needed Mendel (c) William Bateson (d) Johannsen
to ensure the effective translation of these scientific advances 3. The double helical structure of DNA was proposed by
into benefits for population health. International consensus (a) Watson & Crick (b) Mendel & Wilkins (c) Bateson &
has been achieved on a public health strategy for achieving Garrod (d) Johannsen & Maurice
this goal. This strategy recognizes the importance of knowledge 4. How many genes are estimated to be in the human genome
integration. This integrated and interdisciplinary knowledge (a) 50,000 (b) 1,00,000 (c) 1,50,000 (d) 2,00,000
base is used for informing public policy, developing new 5. The process where genetic information is transmitted
health services (both preventive and clinical), communication from DNA to RNA is called (a) Processing (b) Transcription
and stakeholder engagement, and education and training of (c) Translation (d) Sequencing
health professionals. A new initiative GRAPH Int (Genome- 6. The site for protein synthesis in the cell is the
based Research And Population Health International) has been (a) Mitochondria (b) Nucleus (c) Cytoplasm (d) Ribosome
established to promote this strategy for public health action 7. How many amino acids are involved in formation of
in the genomics era. It facilitates the responsible and effective proteins (a) 10 (b) 15 (c) 20 (d) 25
integration of genome-based knowledge and technologies into 8. The triplet of nucleotide bases in mRNA which codes
public policies, programme and services for improving the health for a particular amino acid is called (a) Structural genes
of populations. Practitioners of public health are expected to (b) Codon (c) Control genes (d) Genome
contribute to this endeavour by remaining aware of the growing 9. The stability of DNA is based on (a) Coding (b) Non-coding
importance of the understanding of genetic mechanisms in (c) Mutation (d) DNA repair
disease & of the potential to utilize the new genetic knowledge 10. The process of cell division ensures that the human zygote
for the benefit of both individuals & society. which is a single cell at conception undergoes rapid division
leading to cells in an adult (a) 104 (b) 1010 (c) 1014 (d) 1020
Summary 11. Edward’s syndrome is (a) Trisomy 21 (b) Trisomy 13
Our present understanding of human genetics owes much to (c) Trisomy 18 (d) Trisomy 22
the work of Sir Gregor Mendel in 1865 on breeding experiments 12. Patau’s syndrome is (a) Trisomy 21 (b) Trisomy 13
on garden peas. In 1962, James Watson and Maurice Wilkins (c) Trisomy 18 (d) Trisomy 22
discovered the structure of DNA. The gigantic “Human 13. Concordance in monozygotic twins should be greatest
Genome Project” started in 1991 by US Govt to map the when disease onset is early: True/False
complete human genome to tap its tremendous potential for 14. Multigenic diseases require a specific environment for their
diagnosis and management of human disease through ‘gene occurrence. True/False
therapy’. Genetic disease may manifest at birth or later or 15. The burden of diseases of genetic etiology in a community
may remain without manifesting. Broadly genetic diseases are is determined by all except (a) Gene pool (b) Breeding
classified as Chromosomal disorders - numerical chromosomal pattern (c) Migration (d) None
abnormalities arising due to non-disjunction during meiosis 16. Chromosomal deletion disorder associated with
while structural chromosomal abnormalities results from Chromosome 4 is called (a) Wolf Hirschhorn syndrome
chromosomal breakage syndrome; Single gene / Mendelian (b) Cri-du-chat sydrome (c) Retinoblastoma (d) Wilm’s
disorders-includes autosomal dominant, autosomal recessive tumour
& sex linked disorders; Mitochondrial disorders; Multifactorial 17. Chromosomal deletion disorder associated with
disorders-viz spina bifida, diabetes mellitus, cleft lip & cleft Chromosome 13 is called (a)Wolf Hirschhorn syndrome
palate etc; and Acquired somatic genetic disease-due to (b) Cri-du-chat sydrome (c) Retinoblastoma (d) Wilm’s
accumulation of somatic mutations & aging process itself. tumour

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18. As on 07 July 2008, there were _____ single gene disorders 24. The person who seeks Genetic counselling is called
included in Mckusick’s catalogue (a)16,811 (b) 17,811 ______
(c) 18,811 (d) 19,811 25. GRAPH Int stands for ___________
19. The genes coding for proteins involved in oxidative 26. Chorionic Villous Sampling is ideally done at (a) 8 -10wks
phosphorylation are located in (a) Mitochondria (b) 10 -12wks (c) 12 -14wks (d) 14 -16wks
(b) Nucleus (c) Cytoplasm (d) Ribosome Answers : (1) b; (2) d; (3) a; (4) b; (5) b; (6) d; (7) c; (8) b;
20. The concept of “regression coefficient” as a means of (9) d; (10) c; (11) c; (12) b; (13) True; (14) False; (15) d;
estimating the degree of resemblance between relatives (16) a; (17) c; (18) c; (19) a; (20) d; (21) True; (22) a;
was given by (a) James Watson (b) Gregor Mendel (23) c; (24) Consultand; (25) Genome-based Research &
(c) William Bateson (d) Francis Galton Population Health International; (26) b.
21. In multifactorial diseases, the incidence of a condition
is greatest among relatives of the most severely affected Further Suggested Reading
1. Genetics in disease prevention. Ron Zimmern and Alison Stewart in Oxford
patients : True/False Handbook of Public Health Practice. 2nd ed, 2007. 276-281
22. The science of improvement of genetic endowment 2. Genetics and the Public Health. Patricia A. Baird and Charles R Scriver in
through breeding is (a) Eugenics (b) Euthenics (c) Genetic Maxcy-Rosenau-Last. Public Health & Preventive Mediicne. Appleton &
counselling (d) None Lange. 14th ed, 1998. 1069-1080
3. Human and medical genetics. Friedrich Vogel and Arno G. Motulsky in Oxford
23. The term ‘Eugenics’ was coined by (a) James Watson Textbook of Public Health. 4th ed, 2002. 131-148.
(b) Gregor Mendel (c) Francis Galton (d) Johannsen

of isolation and lack of physical support of the old parents,

Preventive Health Care of the
151 Elderly
left behind at ancestral places, will come up. Even day to
day requirement of life like going out to pay the electricity /
telephone bills, buying fresh fruits and vegetables and even
RajVir Bhalwar cooking a proper nutritious meal would become difficult.
Psycho-Emotional Aspects : With loneliness at home, isolation
In general, “elderly” age group is defined as persons aged 65 will occur which would get aggravated if one of the spouses
years and above. With improvements in health care, there have passes away. Friend circle will also get restricted because
been resultant increases in life expectancy and increase in the friends would also get old. The problem of isolation would get
percentage of “elderly population”. For instance, the current worse because of retirement when the old persons would find it
estimates are that in our country the percentage of population difficult to keep them occupied. This complex interplay will not
who are aged 65 years and above, which was 3% a few decades only increase the risk of mental stress and its consequences
back, is now 5% and is likely to increase to 10% by 2025 AD but also aggravate the impact of stress related diseases as IHD
and 18% by 2050 AD. These demographic changes will require and hypertension.
shifting our focus to cater to geriatrics. i.e. special preventive Financial Issues : Unless backed up by adequate financial
health care needs as well as medical care needs of the elderly savings or pension plans, or else financially assisted by
population. children, there will be definite reduction in income, to the
Peculiarities of elderly population in context of health extent that it may interfere with bare needs of life as adequate
nutrition, clothing and shelter.
needs
Issues Related to Health care System : At present we do not
The peculiarities of health needs of elderly people are that their
have a very effective health insurance system in our country,
health problems cannot be seen in isolation. There is a wide
which coupled with the inadequacies of public / Govt. funded
gamut of social, psycho-emotional and physical correlates
general health care system and inadequate training of medical,
which determine the medical problems and this entire gamut of
paramedical personnel in geriatric medicine would adversely
factors (and not simply the treatment of concerned condition)
affect the health care of the elderly.
needs to be addressed. The important ones of these factors are
as follows : Medical Problems of the Elderly
Social Aspects : As industrialization progresses, it will be A description of medical problems of the elderly is given in
difficult for the children to stay on with their parents and carry this chapter. However, as said earlier, these problems should
on with the conventional family occupations. As children move not be seen as isolated medical issues but should be viewed in
out and take up the vocation in other places, the problems the larger context of socio-economic-emotive determinants as

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an overall health issue. For example, organizing an eye camp Increased Susceptibility to Adverse Effects of Physical
for the elderly would have little benefit if the transportation Environment : People aged >65 years are more susceptible
system, traffic control and street / domestic lighting is not to adverse effects of heat (heat stroke and heat exhaustion) as
improved. well as environmental cold (generalized hypothermia and local
Medical officers and public health programme managers adverse effects of cold).
should make special efforts to understand both the preventive Increased Susceptibility to Infections : Age >65 years
as well as curative aspects of health care of the elderly since a increases the susceptibility to nearly all infections due to decline
significant proportion of our clientele would belong to this age in immunologic defenses. More particularly, lower respiratory
group, and the proportion is likely to further increase, given tract infections (pneumonia) and urinary tract infections are an
the steady increases in life expectancy that are occurring in our important cause of morbidity and mortality among elderly.
population. Degenerative Neurological Diseases : Alzheimer’s disease
The health problems of elderly can be divided into 3 groups : and Parkinsonism are almost exclusively encountered among
(a) Problems which are important for both genders. elderly. Besides morbidity, these diseases substantially reduce
(b) Problems which mainly concern the elderly males. the quality of life.
(c) Problems which mainly concern the elderly females. Complication of Diabetes : The micro vascular as well as
Problems which are Important for Both the Genders macro vascular complications are more prominent during
Ocular Diseases : Age related diminution of vision and advanced age.
cataracts are major issues among elderly and significantly Cancers : Oral, gastric, lung and colorectal cancers are more
compromise the quality of life as well as Activities of Daily common in elderly age group.
Living (ADL). Glaucoma also is an important cause of suffering Problems which mainly affect the Elderly Male
among elderly.
Benign Prostatic Hypertrophy (BPH) : This is one of the
Hearing Defects : Reduction in acuity of hearing not only commonest diseases affecting males >50 years, particularly
compromises the quality of life but even drives an old person >60 years age.
into emotional isolation because they find it difficult to
Prostatic Cancer : The incidence shows a steep climb after 50
communicate.
years age. Yearly Digital Rectal Examination (DRE) is a good
Reduced Muscular Strength and Coordination : Reduction in screening tool for both BPH and prostate cancer. In addition,
muscular strength due to reduction in lean mass coupled with Prostate Specific Antigen (PSA) could be useful screening test
reduced flexibility and neuromuscular coordination occurs for prostate cancer after 50 years of age. Levels of < 4 ng/ml
with age and results in increased proneness to accidents and can be considered as normal, 4 to 10 ng/ml as suspicious and
injuries. >10 ng/ml as strongly suspicious and need to be followed up
Accidents and Injuries : There is marked increase in risk of with a biopsy.
accidents and injuries among the aged. The major physio- Male Sexual Dysfunction : Male sexual dysfunction among
pathological factors which contribute to such increased elderly may manifest as either libido, erectile or ejaculation
proneness are diminution of vision and hearing, reduced problems.
muscular strength and neuro-muscular coordination, and
Problems which mainly concern with Elderly Females
various environmental factors, notably wet, slippery floors and
poor lighting. The commonest areas of accidents are the toilet Menopausal Problems : There are five areas which are
(due to wet floor, and a large number of fixtures in a small predominantly affected by menopause - increased risk of
space), kitchen (mainly due to open flames), staircases and cardiovascular diseases; genitourinary atrophy; skeletal
roads. bone loss; skin and hair changes; and neuroendocrine and
vasomotor changes. Skin changes include loss of elasticity
Nutritional Deficiencies : Both macro and micronutrient
(apparent as lagging and wrinkled skin), dryness of mucosal
deficiencies are common among elderly. They result due to
surface, minor facial hirsutism and voice changes. Uro-genital
interplay of four major reasons, viz., lack of financial resources
changes include atrophic vaginitis, dysparuenia, pruritis
to buy nutritious food items; reduced ability to go out to the
vulvae and irritable bladder. Neuroendocrine changes include
market and buy nutritious raw items; reduced physical abilities
hot flushes (which may sometimes interfere with quality of
with resultant reduced ability to cook nutritious meals; and
life) and psychological/ mood problems.
physical ailments especially oro-dental problems causing
difficulty in mastication and reduced sense of taste. Urinary Incontinence : The impact is considerable both from
medical as well as psychological point of view.
Dental Problems : Reduction in number of teeth /
edentulousness interferes with mastication, digestive process Cancers and Other Disease of Female Genital Tract : The 3
and also with the desire to eat. Ill-fitting dentures further major cancers of genital tract affecting the elderly women are
aggravate the problem. uterine (endometrial), ovarian and cervical cancers. Prolapse of
uterus is another debilitating problem among elderly females.
Cardiovascular Diseases : The end result of atherosclerotic
process becomes most evident in the elderly age group. The Osteoporosis : Osteoporosis occurs in both sexes (Type-II
incidence (as well as mortality due to) of IHD, Stroke and Osteoporosis) but the incidence as well as the impact is much
Hypertension is significantly increased in this age group. higher among females especially after menopause (Type-I

• 888 •
osteoporosis). Osteoporosis represents only a small proportion common galleries is important. In general, the principles
of the problem, in any community, for every case of osteoporosis of construction and maintenance are that the floor should
there would be additional 3-4 cases of osteopenia. Osteoporosis not be slippery / wet; that the fixtures and furniture should
results in a large number of low-trauma fractures. The major be adequately separated giving enough space for movement;
fracture sites are hip, spine, wrist and pelvis. Risk factors for lighting should be adequate; staircases should have side-
primary osteoporosis include low body weight, history of prior supports, made of non-slippery material and be well lighted;
fracture, family history of maternal hip fracture, lack of dietary open flames should be restricted to the minimum and,
calcium and vitamin D, menopause, lack of weight bearing preferably, enclosed.
exercise, smoking and excessive alcohol use, tall and thin Health Measures: These include the following :
stature and white-race. Weight of <58 kg may indicate risk.
Need to Initiate Primary Preventive Measures in Early
In fact, a rough guide is to calculate an index as {0.2 X (Body
Adulthood : While a number of diseases finally manifest in
weight in Kg - Age in years)}; if the result is less than 2, the
elderly age (as cardiovascular disease, osteoporosis, cancers),
same indicates increased risk.
the basic pathologic processes start during early adulthood,
Prevention & Control even during adolescence. Therefore, it would be wise for
Prevention and control of health problems of elderly would children / young people to start prevention at young age itself
need multifaceted approach. A well coordinated approach from through healthy lifestyle (adequate and regular physical
health, social welfare, rural / urban development and legal exercise, healthy diet, avoidance of tobacco and alcohol use).
sectors is desirable. The details are discussed in the section on healthy lifestyle.
Developing a Policy and Programme : A community based Information, Education & Communication Strategies : Health
geriatric health care programme should start with development education should focus towards three broad groups - firstly, the
of a policy, which should be comprehensive so as to include not elderly persons, secondly, the middle aged who would move
only medical aspects but the large gamut of social, economic into elderly age group in near future and thirdly the younger
and emotive aspects of geriatric problems as well. Strong people who are the potential care providers for their elderly
political commitment and social action is imperative for the parents / relatives. The major areas of education should address
enunciation and implementation of such a policy. There is also the issues of hygiene, nutrition, physical exercise, avoidance of
a need to translate such policy into a comprehensive geriatric tobacco and alcohol, accident prevention measures, awareness
health care programme, to be delivered at the grass root level about recognition of early signs / symptoms of common geriatric
by the general health services, but coordinated at the district / problems and motivation to seek treatment, and education
state level by specialized personnel. regarding periodic health check-up.
Social Measures : Developing social ethos wherein children Training and Re-training of Medical and Paramedical
voluntarily take the responsibility of looking after their aged Personnel : This should be undertaken regarding the special
parents is important. In fact, young people need to be educated health needs of the elderly and updating their knowledge
and motivated to utilize the experience and support of their regarding prevention and treatment of common geriatric
parents / grandparents in day to day household matters to diseases.
facilitate passing on the cultural heritage to the children. There Immunization : Vaccines which have a potential for use
is also a need to develop regulatory mechanisms which make among elderly include those against streptococcal pneumonia,
it obligatory for the members of society to look after their aged influenza and tetanus.
parents.
Periodic Health Assessment : Ideally, all people, males &
Developing a Health Insurance Scheme : A large majority of females, should undergo a detailed health assessment once
the elderly are those who are not covered by any formal public they are 45-50 years of age. Subsequently, a thorough health
sector health care support, unlike retired govt. servants. The evaluation should be done once in every 5 years till 65 years age
need is to develop an affordable health insurance scheme in and thereafter every year or at least once in 2 years. Assessment
which people contribute, along with the employer and the should include general clinical examination, assessment
government, to cater to subsequent expenses on medical care of hearing & vision, assessment of Dental and oral health,
during old age. nutritional status including obesity, cardiovascular status,
Pensionary Benefits : Similar to the health insurance musculoskeletal system including spine, per-rectal examination
schemes suggested above, there is need to develop pension for males and gynecological and breast examination for
schemes based on contribution from employee, employer and females. Depending on availability, important investigation
government, so that old people can feed for themselves during would include Hb%, GBP, urine routine and microscopic, stool
old age, even if not supported by their children. routine and microscopy and test for occult blood, blood sugar
Proper Construction of Roads, Walkways, Stair cases and estimation, lipid profile, renal function parameters and an ECG
Houses : Accidents and injuries are an important cause of if required. Depending on the requirement, bone densitometry,
morbidity and mortality among the elderly. Proper designing PSA, Colonoscopy, USG studies and histo-pathological studies
of roads / walkways, and stair cases, along with adequate may be undertaken as indicated.
enforcement of traffic rules is a clear need. In addition, Provision of Prostheses and Other Medical Aids : Elderly
construction of “elderly friendly houses”, giving particular persons will often need devices as spectacles, hearing aids,
attention to construction of toilets, kitchens, bedrooms and walking aids, dentures, cervical collars, wheel chairs and

• 889 •
so on. The preventive health care for elderly should cater to changes, and neuroendocrine and vasomotor changes; Urinary
provide these implements to all those who are in need, ensuring incontinence; Osteoporosis; Cancers of female genital tract
availability, accessibility and affordability. mainly uterine (endometrial), ovarian and cervical cancers.
Development of Gerontology Units : There is a felt need to Prevention and control of these problems need multifaceted
develop specialized units which would take care of the special approach. There is need to develop social ethos wherein
and wide health related needs of the elderly as well as train children voluntarily take the responsibility of looking after
health care workers in these issues. It would be worthwhile their aged parents. The need is to develop an affordable health
if a coordinated approach between departments of community insurance scheme and pension schemes. There should be
medicine, internal medicine, general surgery, gynaecology, proper designing of roads / walkways, and stair cases, along
orthopaedics, ENT and ophthalmology be developed to initiate with adequate enforcement of traffic rules. Houses should be
such comprehensive care through gerontology units, for the constructed in such a manner that these are “elderly friendly
population of three PHCs which is to be providing health care houses”. Primary preventive measures should start in early
by various medical colleges. Subsequently, such units may be adulthood through life style modification. IEC about health
developed at the level of district hospitals. problems of elderly should be targeted to elderly, adults who
Ensure Effective Communication : Elderly people need special are likely to move in elderly group and also to younger people
efforts for communication. Hence, medical personnel dealing who are care provider to elderly. Training and retraining of
with elderly should very effectively communicate their findings health staff, so as to efficiently address health needs of elderly
and advise to this group and ensure a system of feedback to is required. Periodic health examination should be done at least
verify that their communication has been correctly understood every 5 years starting with age of 45 - 50 years till the age of
by the elderly subjects. 65, and thereafter it should be done at least once in every two
years. All these measures should be communicated to elderly
Summary in an effective manner.
Elderly age is defined as persons aged 65 years or more. In our
country, proportion of elderly is consistently increasing and
Study Exercises
there is need to focus on their health needs. Health problems Long Question : Describe your plan of providing comprehensive
of elderly should not be seen as isolated medical issues but health care to the elderly persons in your district, in your
should be viewed in the larger context of socio-economic- capacity as the district health officer.
emotive determinants as an overall health issue. Due to children Short Notes : (1) Osteoporosis (2) Benign Prostatic Hypertrophy
moving out of home for employment, elderly face problems of (3) Health problems of the elderly
isolation and lack of physical support. This isolation may be MCQs
worsened by retirements or death of spouse, and predispose 1) Elderly is defined as the person aged above: (a) 60 yrs
them to variety of lifestyle diseases. Financial crisis because of (b) 65 yrs (c) 70 yrs (d) 75 yrs
lack of income sources may compound the problem. Moreover 2) The proportion of elderly in our country is: (a) 1% (b) 2%
the present health care system in our country is not very well (c) 4% (d) 5%
geared up to cater to the health needs of elderly. The health 3) Which of the following is not the primary disease of elderly
problems of elderly can be divided into 3 groups, i.e. problems age group: (a) Parkinsonism (b) Alzheimer’s (c) Multiple
which are important for both genders, problems which mainly sclerosis (d) Cerebrovascular disease
concern the elderly males and problems which mainly concern 4) Which of the following malignancy is not commonly seen
the elderly females. in elderly age group: (a) Stomach (b) Colorectal (c) Prostate
Problems which are important for both the genders include- (d) Testis
ocular diseases like age related diminution of vision, cataract 5) IEC strategies for prevention and control of health
and glaucoma; hearing defects; reduced muscular strength and problems of elderly should be targeted to: (a) Elderly
coordination resulting in increased proneness to accidents and (b) People in late adulthood (c) Younger people (d) All of
injuries; nutritional deficiencies; dental problems like reduction the above
in number of teeth or edentulousness; cardiovascular diseases 6) Characteristics of “elderly friendly houses” does not
like IHD, stroke and hypertension; increased susceptibility to include: (a) Furnitures should be adequately separated
effects of heat and cold; increased susceptibility to infections, (b) Lighting should be adequate (c) Floor should not be
particularly lower respiratory tract infections (pneumonia) slippery (d) Electrical appliances should not be used to
and urinary tract infections; degenerative neurological avoid threat of electrocution
diseases like Alzheimer’s disease and Parkinsonism; micro and 7) Periodic Health Assessment for elderly should ideally be
macrovascular complications of diabetes and cancers like oral, done once in every: (a) 5 yrs (b) 4 yrs (c) 3 yrs (d) 1 yr
gastric, lung, uterus, ovaries and colorectal cancers are more 8) Routine Periodic Health Assessment for elderly should
common in elderly age group. Problems which mainly affect include all except: (a) Stool test for occult blood
the elderly males include benign prostatic hypertrophy (BPH); (b) blood sugar estimation (c) Renal function parameters
prostate cancer and male sexual dysfunction. Problems which (d) Pulmonary function tests
mainly concern with elderly females include Menopausal 9) Risk factors for primary osteoporosis does not include:
Problems like increased risk of cardiovascular diseases, (a) High BMI (b) History of prior fracture (c) Family
genitourinary atrophy; skeletal bone loss, skin and hair history of maternal hip fracture (d) Lack of weight bearing

• 890 •
 exercise. 15) Normal level of PSA (Prostate specific antigen) is (in ng/dl)
10) Which of the following is not a postmenopausal problem: : (a) <2 (b) <6 (c) <4 (d) <8
(a) increased risk of cardiovascular diseases 16) Presbyopia occurs in elderly because of: (a) Cataract change
(b) Genitourinary atrophy (c) Skeletal bone loss in ocular lens (b) Retinal degeneration (c) Insufficiency of
(d) Atrophy of ovary power of accommodation (d) Corneal degeneration
11) Major physio-pathological factors which contribute to 17) Hearing loss among elderly is mainly because of:
increased proneness to accidents among elderly are all (a) Sensorineural deafness (b) Conductive deafness
except: (a) Reduced muscular strength (b) Poor neuro- (c) Degenerative changes in temporal cortex (d) None of
muscular coordination (c) Restlessness (d) Diminution of the above
vision and hearing Fill In the Blanks
12) Elderly are at risk of nutritional deficiencies because of: 1. The proportion of elderly in India is like to reach _________
(a) Lack of financial resources to buy nutritious food by year 2050 AD.
items (b) Reduced physical abilities with resultant reduced 2. Prostate Specific Antigen (PSA) of the level higher than
ability to cook nutritious meals (c) Oro-dental problems _____________ indicates strong suspicion of Ca prostate.
(d) All of the above 3. Females are at much higher risk of developing osteoporosis
13) Hot flushes occurring in postmenopausal women Type ______________ especially after menopause.
are mainly due to: (a) Psychological response 4. Common fracture sites among elderly are ______________
(b) Neuroendocrine disturbance (c) Macrovascular changes 5. Hearing loss commonly occurring among elderly because
(d) Microvascular changes of sensori-neural deafness is called as ______________
14) A rough guide to calculate an index of risk of osteoporosis Answers : MCQs : (1) b; (2) d; (3) c; (4) d; (5) d; (6) d; (7) d;
based on body weight is { 0.2 X (Body weight in Kg - Age in (8) d; (9) a; (10) d; (11) c; (12) d; (13) b; (14) d; (15) c; (16) c;
years) } the value of index which indicates increased risk if (17) a. Fill In the Blanks : (1) 18%; (2)10 ng/ ml; (3) Type - I;
it is: (a) >1 (b) <1 (c) >2 (d) <2 (4) Hip, wrist, spine and pelvis; (5) Presbyacusis

and their developments is essential. The following are number

152 Demography and Public Health of the applications of demography in health related fields.
The knowledge in demography is helpful to public health
Dashrath R. Basannar administrators for various purposes :
i) Mortality rates by age-sex and its geographical distribution
Demography is the scientific study of human populations. It is with respect to various diseases are helpful in locating
mainly concerned with and identifying diseases of public health importance with
respect to age-sex-location, for planning remedial measures
Size : It refers to the total number of persons in the given
to control these diseases, future planning for prevention of
population.
these diseases, for determining leading causes of mortality,
Distribution : It refers to the arrangement of entire population for planning drugs/medicines/equipment/manpower/other
with respect to the geographical areas at a given point of time. medical facilities requirements etc.
Structure : It refers to the distribution of the given population ii) Percentage distribution of population by age-sex-location
with respect to age and sex. are helpful in understanding health and health care needs
Change : It refers to the increase or decrease in the size of the of various age groups by sex by location, for planning,
given population due to fertility, mortality and migration. designing, evaluation and effective implementation of
various public health programs. For example : Vaccination
Development : It refers to the development of the given
and immunization program for children under 5 years of
population with respect to socio economic aspects.
age, Mother and Child Health program for mother and
Other characteristic like genetic inheritance, intelligence and new born, Family planning program, old age program,
health. nutritional program etc.
Role of Demography in Public Health Administration : iii) Determining the success or failure of health programs.
For effective planning, designing, evaluation and execution iv) To describe the level of community health.
of health and health care needs for the entire population for v) To determine the leading causes of mortality and
the present as well as for the future, the knowledge about morbidity.
population with respect to its size, structure, change in its size vi) To determine the relative importance of different fatal

• 891 •
 diseases with respective to age and sex. = 63,252.69
vii) To discover solution to health problems and find clues for
public health administration. c) Exponential Growth Method : In this method it is assumed
Sources of Demographic Data : The following are the sources that there is an exponential growth. Exponential Growth
of demographic data. The details of these sources have already
Method for estimating population is
been dealt with in detail in an exclusive chapter in the section
on epidemiology :
1. Census where r is exponential growth rate
2. Vital Events Registers
3. Surveys In the above example =0.05878 and
4. Sample Registration System
Measures of Population Projection : By “Population = 63,252.69
projections”, we mean estimating and forecasting the population
of a country or a region for a given time. There are mainly three
d) Component Projection Method : This method is mainly
types of population estimates namely inter-censal (during
used for future population projections (future estimates) using
any two consecutive census period), post-censal (any period
following model.
following latest census up to the present moment of time) and
future (any period time after the present moment). Generally
the data on population are available for census year only hence
population estimates (inter-censal estimates) are required for Here 0 stands for base year from which population projected
calculating fertility rates, mortality rates etc. during the inter- is made, t denotes the period of projection from the base year.
censal period. Future population projections (future estimates) represents number of births, number of
are very essential basically for understanding and planning deaths, number of immigration and number of emigration
future needs of the population for various purposes such as during the period 0-t respectively. P0 Represents population at
health, education, economic, social, employment, irrigation, the base year 0.
food, housing, etc. The following measures of population This method makes assumptions about fertility, mortality and
estimates are commonly used. migration for the projection period based. This method requires
i) Mathematical Methods : Some of the mathematical models information regarding age-sex distribution, age-sex specific
which are commonly used for estimating inter-censal and post- mortality, fertility and migration distribution by age-sex for the
censal population estimates are : base year 0 and estimates for the period t.
●● Arithmetic Growth Method Demographic Transition : In 1929 the American demographer
●● Geometric Growth Method Warren Thompson, observed changes in birth and death rates
●● Exponential Growth Method in industrialized societies over the past two hundred years or so
●● Component Projection Method and then formulated a model called “Demographic Transition”
a) Arithmetic Growth Method : In this method it is assumed that describes population change over time in fully developed
that there is an equal addition every year to the population country today, such as The United States or Canada, the
during the inter censal period and this addition is taken to countries of Europe, or similar societies elsewhere (e.g. Japan,
be average increase per year. Arithmetic Growth Method for Australia etc.). The model is a generalization that applies to
estimating population is where P0 population at these countries as a group and may not accurately describe to
time t is, P0 and P1 are populations at two consecutive censuses. less developed societies. As shown in the Fig. - 1, Demographic
a = P0 and b = (( P1 - P0 ) ÷ 10) and inter census period = Transition model recognises five demographic stages namely
10years. For example populations of a town A at censuses 1st high stationary, early expanding, late expanding, low stationary
Mar 1981 and 1st Mar 1991 were 50,000 and 90,000. Estimate and declining.
population of the town on 1st Mar 1985. Here a = 50,000, ●● High stationary (first stage) : The first stage is associated
inter-censal period = 10 years, b =4,000 per year and t =4, with pre Modern times, and is characterized by very high
= 66,000 birth rates and very high death rate (30-50 per 1000)
b) Geometric Growth Method : This method assumes the balance between them results in only very slow population
population begets population at a constant rate of increase growth that is referred to as the “High Stationary Stage”
on the compound interest law. Geometric Growth Method for of population growth. This situation was true of all human
estimating population is where r is growth rate populations up until the late 18th century.
●● Early expanding (second stage) : The second stage is
characterized by a rise in population caused by a decline in
and . In the above example, the death rate while the birth rate remains unchanged, or
perhaps even rises slightly. The decline in the death rate in
Europe began in the late 18th century.
=0.0605. ●● Late expanding (third stage) : The third stage is
characterized by further decline in the death rate while birth
rate tends to fall that results in increase in the population

• 892 •
 growth. In general the decline in birth rates in developed the developed countries like United States and Canada. During
countries began towards the end of the 19th century. this period life expectancy at birth increased from 23.63 years
●● Low stationary (fourth stage) : The fourth stage is for male and 23.96 years for female in 1901 to 62.30 years
characterized by a low birth rate and low death rate; the for male and 65.27 years for female in 2001. Similarly CBR
balance between them results in no population growth that declined from 49.2 in 1911 to almost half i.e. 26.1 in 2001.
is referred to as the “low Stationary Stage” of population India with 238.4 million population in 1901 almost doubled
growth. in 1961 in 60 years while it took just 30 years to double the
●● Declining (fifth stage) : The fifth stage is characterized by a population from 439.2 million in 1961 to 844.0 million in
birth rate lower than death rate the balance between them 1991. The population of India has increased nearly five times
results in decline in population growth that is referred to from 238 million to 1 billion during this century period.
as the “Declining Stage” of population growth.
In 2001 census India’s population was 1,028,737, i.e. about 16
Demographic transition in national Context : As shown in percent of the world’s population on 2.4 percent of the globe’s
the Table - 1 and Fig. - 1 & Fig. - 2, India’s population growth land area. It is the second largest populous country in the world.
during the twentieth century can be classified into four distinct If current trends of fertility and mortality continue, India may
phases as follows : 1901-1921, this period was characterised overtake China in 2045, to become the most populous country
by a high birth rate and high death rate (46-49 per 1000) and in the world. As per census 2001 report, state with highest
growth rate was slow, close to zero and it was negative during population was Uttar Pradesh (166,197,921) and state with
1911-21and the year 1921 is called the year of great divide. lowest population was Sikkim (540,851); union territories
There after growth rate steadily increased till 1991. with highest population was Delhi (13,850,507) and union
During 1921-1951, birth rate steadily declined from 48.1 in territories with lowest population was Lakshadweep (60,650) ;
1921 to 39.9 in 1951 and death rate also declined from 47.2 district with highest population was Medinipur (West Bengal)
in 1921 to 39.9 in 1951 while growth rate steadily increased (9,610,788) and district with lowest population was Yanam
during this period which was more than 1 but less than 2. (Pondicherry) ( 31,394 ).
During this period India experienced rapid growth. National Policies to Control Population Growth : India was the
During 1951-1981, birth rate little further increased and then first country in the world to launch a national family planning
declined and death rate further declined and growth rate further to control birth rates to stabilize the population in 1952. The
increased and it crossed over 2 during this period. During this role of family planning programme was mainly to deliver
period India experienced explosive rapid growth. contraceptive methods and creating facilities for abortion. After
During 1981-2001, birth rate further declined and came down 1952, sharp declines in death rates were observed, however, not
to 26.1 and death rate further declined while growth rate accompanied by a similar drop in birth rates. The Government
started slowing down during this period. Growth rate during has passed Child Marriage Act in 1978 and this Act specified the
1971 to 1991 was more than 2, first time after 40 years fall minimum age at marriage for females and males to be 18 and
down below 2, still it characterises as very rapid growth. 21 years respectively. The National Health Policy, 1983 stated
From the Table - 1, it is evident that there is declining trend in that replacement levels of Total Fertility Rate (TFR) should be
CDR, it declined from 46.2 in 1911 to less than 10 i.e. 8.7 in achieved by the year 2000. Half a century after formulating
2001 and it was less than 7 in 2007 and it is close to some of the national family welfare programme, reduced Crude Birth

Table - 1: Birth Rate, Death Rate and Growth Rate in India (1901-2001)
Total Average annual Growth rate Birth Death
Decadal
Census year population exponential over 1901 Rate/1000 Rate/1000
Growth (%)
(million) growth rate (%) (percent) live births population
1901 238.4
1911 252.1 5.75 0.56 5.75 49.2 46.2
1921 251.3 -0.31 -0.03 5.42 48.1 47.2
1931 279 11 1.04 17.02 46.4 36.3
1941 318.7 14.22 1.33 33.67 45.2 31.2
1951 361.1 13.31 1.25 51.47 39.9 27.4
1961 439.2 21.64 1.96 84.25 41.7 22.8
1971 548.2 24.8 2.2 129.94 41.2 19
1981 683.3 24.66 2.22 186.64 37.2 15
1991 844 23.86 2.14 255.03 29.5 9.8
2001 1027 21.34 1.93 330.8 26.1 8.7
Source: SRS data 1999 and Census of India 2001

• 893 •
 Fig. - 1 Fig. - 2

Rate (CBR) from 40.8 (1951) to 26.4 (1998, SRS) ; the Infant Demographic Transition model recognises five demographic
Mortality Rate (IMR) from 146 per 1000 live births (1951) to 72 stages namely high stationary, early expanding, late expanding,
per 1000 live births (1998, SRS) ; Crude Death Rate (CDR) from low stationary and declining. High stationary is characterized by
25 (1951) to 9.0 (1998) ; Total Fertility Rate from 6.0 (1951) to very high birth rates and very high death rate. Early expanding
3.3 (1997). The National Population Policy (NPP), 2000, recently is characterized by a rise in population caused by a decline
adopted by the Government of India states that ‘the long-term in the death rate while the birth rate remains unchanged, or
objective is to achieve a stable population by 2045, at a level perhaps even rises slightly. Late expanding is characterized
consistent with the requirements of sustainable economic by further decline in the death rate while birth rate tends to
growth, social development, and environment protection’. It fall that results in increase in the population growth. Low
has been assumed in the policy document that the medium- stationary is characterized by a low birth rate and low death
term objective of bringing down the Total Fertility Rate (TFR) rate the balance between them results in no population growth.
to replacement level of 2.1 by 2010 will be achieved. It is Declining is characterized by a birth rate lower than death rate
envisaged that if the NPP is fully implemented, the population the balance between them results in decline in population
of India should be 1013 million by 2002 and 1107 million by growth.
2010. In 2001 census India’s population was 1,028,737, i.e. about 16
Summary percent of the world’s population on 2.4 percent of the globe’s
land area. It is the second largest populous country in the world.
Demography is the scientific study of human populations and it
If current trends of fertility and mortality continue, India may
is mainly concerned with size, distribution, structure, change,
overtake China in 2045, to become the most populous country
development and other characteristics like genetic inheritance,
in the world. As per census 2001 report, state with highest
intelligence and health. Demography plays an important role in
population was Uttar Pradesh (166,197,921) and state with
public health administration for effective planning, designing,
lowest population was Sikkim (540,851).
evaluation and execution of health and health care needs for
the entire population for the present as well as for the future. National policies to control population growth : India was the
first country in the world to launch a national family planning
The important sources of demographic data are Census, Vital
to control birth rates to stabilize the population in 1952. The
Events, Registers, Surveys, and Sample Registration System.
Government has passed Child Marriage Act in 1978, the National
There are mainly three types of population estimates namely
Health Policy in 1983, and the National Population Policy (NPP)
inter-census (during any two consecutive census period), post
in 2000. It has been assumed in the policy document that the
census (any period following latest census up to the present
medium-term objective of bringing down the Total Fertility Rate
moment of time) and future (any period time after the present
(TFR) to replacement level of 2.1 by 2010 will be achieved. It is
moment). The measures of population estimates commonly
envisaged that if the NPP is fully implemented, the population
used are Mathematical Methods - Arithmetic Growth Method,
of India should be 1013 million by 2002 and 1107 million by
Geometric Growth Method, Exponential Growth Method, and
2010.
Component Projection Method.

• 894 •
Study Exercises 5. The most cost effective family planning method is
(a) Vasectomy (b) Barrier method (c) IUCD (d) Oral pills
Short Notes : (1) Important sources of Demographic Data
6. The year of “Big Divide” is (a) 1900 (b) 1901 (c) 1920
(2) Demographic Transition (3) Role of Demography in Public
(d) 1921
Health
7. As per Census 2001 Average annual growth rate of India is
MCQs (in %) (a) 2.01 (b) 1.93 (c) 1.80 (d) 1.86
1. According to the demographic cycle, India is in the 8. As per Census 2001 Decadal growth rate of India is (in %)
following phase (a) High Stationary (b) Early Expanding (a) 21.34 (b) 31.93 (c) 11.80 (d) 9.86
(c) Late Expanding (d) Low Stationary 9. As per Census 2001, the % of world’s population from India
2. According to Central Registration Act of 1969, birth is to is (a) 26 (b) 16 (c) 10 (d) 06
be reported within : (a) 7 days (b) 14 days (c) 10 days 10. As per Census 2001, lowest populated state of India is
(d) 21 days (a) Kerala (b) Sikkim (c) Goa (d) Nagaland
3. Annual growth rate is between (a) Crude birth rate - Crude 11. The annual growth rate of India presently characterized as
death rate (b) Crude birth rate - IMR (c) Total Fertility rate (a) slow (b) rapid (c) very rapid (d) explosive
- Death rate (d) Crude birth rate - Total Fertility rate Answers : (1) c; (2) b; (3) a; (4) b; (5) a; (6) d; (7) b; (8) a;
4. Census in India is done every (a) 05years (b) 10years (9) b; (10) b; (11) c.
(c) 15 years (d) 20 years

The numerator (total failures) should include all pregnancies

153 Contraceptive Technology which occur during the period of observation, irrespective of
their outcome (i.e. whether the pregnancy terminated in live
birth, still birth or abortion etc.). The denominator is taken in
RajVir Bhalwar
months and hence the numerator is multiplied by 1200, to make
it equal to 100 years. In the denominator, for every pregnancy
As per the National population policy - 2000 and the RCH which is continued till full term, 10 months are deducted, while
program in our country, the couples should be given a choice out for every pregnancy that terminates in abortion, 4 months are
of various contraceptive methods. Promotion of contraception deducted, from the total period of follow up for each woman.
purely on a voluntary basis, without any coercion, and with When studying the effectiveness of contraceptives, it is
provision of due information about the various contraceptive recommended that at least 600 woman-months (50 woman-
alternatives is the central ethos of our national family welfare years), preferably more, of follow up should be done. A failure
programme. The strategies and operational details of the rate of 3.33 per HWY means that, given the fertile period of
programme and the various contraception facilities being a woman is 30 years (usually 15 to 44 years age) and if a
provided to the community are dealt with in the chapter on woman uses that contraceptive continuously for her entire
RCH program. The technical details of various methods of fertile period, she is likely to have one pregnancy due to failure
contraception are being dealt with in this chapter. of the contraceptive. (Calculated as 3.33 failures in 100 years
Broadly, methods of contraception would fall into two groups, for 1 woman, hence (30 X 3.33) / 100 = 1 failure in 30 years of
viz. “Natural Methods” and “Artificial Methods”. Artificial usage. It also means that if 100 women use the contraceptive
methods are further grouped into Temporary and Permanent for 10 years continuously, thus giving 1000 woman years,
methods. then about 33 accidental pregnancies are likely to occur, in all,
Efficacy of Contraceptive Methods : Efficacy of a given among these 100 women over the 10 years of use.
contraceptive procedure is evaluated in terms of the “Pearl Natural Methods of Contraception
Index” which measures the number of failures (i.e. pregnancies
These methods utilize either total avoidance of sexual
occurring despite continuous usage of the particular method)
intercourse (Abstinence) or by discharging the semen outside
per 100 woman years (HWY), or for every 1200 woman -
female genitalia (Coitus interruptus or withdrawal method)
months.
or else by utilizing methods which observe the naturally
occurring signs / symptoms of fertile versus non-fertile periods
Total failures (pregnancies
of the menstrual cycle and avoiding sexual intercourse during
Pearl Index despite use of the contraceptive)
= X 1200 the fertile period. These methods, which are also sometimes
(Failure rate per HWY) Total months of continuous
use of the contraceptive referred as the “Standard Day Methods” (SDM) work on
the principle that during one menstrual cycle, one ovum is

• 895 •
discharged; very rarely, a second ovum can be discharged after whichever is earlier. If used correctly and consistently, the
24 hours. Secondly, after intercourse, sperms stay alive upto 5 failure rate is 1 to 1. 5%. Chances of pregnancy are, however,
days (rarely 7 days) but can actually fertilize the ovum for at more if the woman is not having full lactation or if not fully
most 4 days. With this background the most fertile period of breast feeding the infant.
women is from 10th day to the 18th day, provided the cycle is Artificial Methods
of 28 days. Natural methods are based on detecting the fertile
period and avoiding intercourse during the period. These are : Artificial, Temporary Methods : The broad categories of
contraceptives included in artificial (temporary) methods are
(a) Rhythm Method : For women who have a regular 28 days Barrier methods, Spermicides, Intrauterine devices (IUDs), Oral
cycle, the fertile period would be generally from day 7 to day contraceptives and Non-oral hormonal contraceptives.
21 (the day of onset of menstrual bleeding is taken as the first
day). Sexual intercourse is avoided during this period. Barrier Contraceptives

(b) Basal Body Temperature Method : The woman should Condoms : Condoms are made of latex and are available
record her oral temperature first thing on getting up in the as nonlubricated (Nirodh, Kohinoor), lubricated (Nirodh -
morning, daily, and plot it on a graph paper with the days of Lubricated, Kamasutra, Kohinoor - Pink and Sawan) and
menstrual cycle along horizontal axis and temperature along more lately, coated with spermicidal jelly which is usually
vertical axis. Immediately following ovulation there is increase nonoxynol-9 (Share, Rakshak). The average shelf life is 5 years
in oral temperature by 0.5 to 0.8°F (0.2 to 0.4°C). Couples should from date of manufacture and they should be stored in cool and
avoid intercourse for 3 days, once the rise in temperature is dry place. If further lubrication is required then glycerin, K-Y
noted. jelly or a spermicidal jelly can be applied, but not Vaseline, oils
or butter. Some couples may complain of initial reduction in
(c) Cervical Mucous Method : The woman notices daily, the pleasure due to slight decrease in sensations and interruption
quality of vaginal mucus discharge, by putting a finger into in sexual play (since the man has to put on the condom just
the vagina. Following cessation of menstrual flow, no mucus is before insertion). However, it should be explained to them that
felt in the vagina for couple of days. These are called the “dry this is only a transient phenomena, and most couples will
days”. Following the dry days, cloudy, white or cream coloured adapt well with passage of time. Besides contraceptive effect,
mucus of sticky consistency with little moisture appears. This condoms are also very effective in preventing transmission of
indicates that ovulation is approaching. Thereafter, just before HIV, STDs, HPV infection (and amnionitic fluid infections while
and at time of ovulation the mucus becomes copious, clear and having sex during pregnancy).
slippery, resembling the white of an egg and can be stretched
into a thread if the thumb and finger on which the mucus is The total “slippage” and “breakage” rate is 4% to 9%. The
stuck, are gently moved apart. This persists for 3 days and is average failure rate is 12% to 14%, but if correctly used, it
called the “wet days”. Following this wet period, the mucus may be as low as 3%. Concurrent use of spermicidal jelly will
again becomes scanty, sticky and cloudy indicating the post further reduce the failure rate. Condoms are very good choice
ovulation phase, which persists till onset of next menstrual as temporary method, especially for couples in whom use of
flow. The couple should abstain as soon as the first sign of hormonal contraceptives and IUDs is not indicated among
mucus appears in the pre-ovulatory phase, during the wet days the female partner. The only contra-indication to condom
in ovulatory phase and for 3 days after the completion of wet use is allergy to latex rubber in which case condom made of
period. polyurethane or silicon rubber may be used.

(d) Symptothermal Method : This is based on combined Diaphragm, Cervical Cap (Check Pessary), Vault Cap and
observation of changes in BBT, mucus changes and also by Vimule : These are barrier methods to be used by the females
palpating the cervix with a finger high up in the vagina. The but not much used now due to wide availability of other
cervix becomes softer and cervical os becomes more open contraceptives.
during the fertile period. Female Condoms : Available under trade name of “Femindon”
Natural methods are reasonable efficacious; however, the and “Reality”. The device is inserted like a vaginal diaphragm.
problem is mainly the difficulty in maintaining compliance. At present it is not much used as contraceptive but has potential
If consistently and properly used, the failure rates per 100 in prevention of HIV transmission.
women per year (HWY) (indicating the number of women who Spermicides : Most commonly used spermicide is nonoxynol-
will become pregnant during one year out of 100 women who 9. They are available as vaginal pessaries which are inserted
are using these method are : high up in the vagina, 10 to 15mts before sex or as creams /
(i) Calendar Method - 9 / 100 HWY (9%) jelly, as Delfen cream, Orthogynol jelly etc.
(ii) BBT Method - 1 - 2 / 100 HWY (1-2%) Foam Tablets : These are very commonly used. It is marketed
(iii) Cervical mucus Method - 3 / 100 HWY (3%) in our country as “Today” as a vaginal foam suppository
(iv) Symptothermal Method - 2 / 100 HWY (2%) containing nonoxynol-9. The tablet is to be inserted high in the
(e) Lactational Amenorrhoea Method : Full or nearly full vagina (may be moistened slightly with water if vagina is dry),
breast feeding means that at least 85% of the baby’s food 10 minutes before sex act and the action lasts for 1 hour after
requirement is being provided by breast milk. For women who sex. If properly used, failure rates are as low as only 0. 5%.
are fully breast feeding their infants, chances of pregnancy Intra Uterine Devices (IUDs) : IUDs have been in use as
are very less for 6 months or when menstrual flow returns, contraceptives for many decades. However, their exact mode of

• 896 •
action is still not clear. In all probabilities, they act by inducing Timing of Insertion
mild inflammatory changes and foreign body reaction in the (a) The best time to insert is during or soon after menstrual
endometrium, which combined with alterations in prostaglandin periods, post partum within 48 hours of delivery and after
levels, incapacitate the sperms and ovum, prevent sperm from abortion.
fertilizing the ovum, and even if fertilization occurs, makes (b) However, after delivery or abortion it is preferable to insert
the uterine environment inhospitable for the blastocyst to be IUD 6 weeks after the delivery / abortion and the couple
implanted. The earliest IUDs, namely lippies loop, have now may be advised to use another method, as condom, for that
been almost phased out by copper-T and its subsequent variants. period.
Copper - T 200 (Gynae-T) is made of propylene impregnated (c) It may be noted that as for as possible insertion should not
with BaSO4 and carries 120mg of 0. 25mm diameter copper be delayed just because of timing. In fact, the best timing
wire wound around the vertical limb. The tail limb has a pair is the one which is most convenient to the potential user, if
of threads (some variants have only one thread) which comes it can be reasonably ascertained that she is not pregnant.
out of cervical os, into vaginal canal after the Copper-T has (d) It can also be inserted post coitus, even up to 5 days after
been inserted and can be felt with a finger to check that the coitus to prevent pregnancy
Copper-T is in place. The copper has an exposed area of 200 sq. Instructions to be given to the lady, after insertion
mm and hence the name Cu-T- 200. The US-FDA approved Cu- (a) For the next few periods (at least for next 3 periods) she
T-200 has an effective life of 4 years. Some additional variants should watch her pads for any expelled IUD and, after the
available commercially in our country are Multiload ML Cu-T- periods, should feel for the threads (tails) coming out of
250, ML Cu-T-375 and Nova Cu-T-200 (Nova T) which has a the cervical os, to ensure that the device is in place. She
silver core added to the copper wire. The conventional Cu-T-200 should report if she cannot feel the threads or sees the
has failure rate of 2%, while the newer variants have lower device on her pads, or feels the device to be in the vagina
failure rate of 1-2%. In general Cu-T-200 is referred to a Group-I (b) She should come for a routine health check up after the
IUD; ML-250 and 375 as Group-II; while Nova-T and Cu-T-386A next menstrual period
are referred to as Group-III IUDs. The advantages of IUDs is (c) She should report in case of persistent, irregular or heavy
the ease of insertion (can be inserted at Sub centre level by bleeding, severe pain in lower abdomen or abnormal
paramedical workers), the semi-permanency (Cu-T-200 can be vaginal discharge, or amenorrhoea (in which case
left in place and remains effective for 3 years) and the ease of pregnancy should be excluded)
removal. However, before advising IUD, proper history should (d) She should also report if she feels that she has been
be taken from the couple and correct advice given as per details exposed to STD or HIV
given in succeeding paragraphs.
Indications for Removal
Conditions which are absolute contra - indications to IUD (a) Abnormal or excessive bleeding
insertion / continuation (b) Persistent pelvic pain or cramping
(a) Pregnancy (c) Expiry of effective life span (3 to 4 years from date of
(b) Puerperal or Post abortal sepsis manufacture, for Cu-T-200)
(c) Unexplained vaginal bleeding (d) Pregnancy
(d) Pelvic inflammatory disease within last 3 months (e) Acute pelvic infection or neoplasm of genital tract
(e) Known pelvic TB (f) Displacement of IUD either inside the uterus or outside it
(f) STD during the past 3 months (g) Personal reasons
(g) Suspected neoplasia of genital tract (h) After menopause (within one year)
(f) Uterine abnormalities Routine problems after insertion
Conditions which increase the risk due to IUD, and
The lady should be advised that she may face certain routine
alternative contraceptive may be considered, if possible
problems following insertion as follows, and she should not
(a) Post partum 48 hours to 4 weeks (more chances of unduly worry about them :
perforation)
(a) Some cramping abdominal pain for a few days
(b) Women having increased chances of STD / HIV transmission
(b) Some vaginal discharge for a few weeks
(prefer condom)
(c) Heavier menstrual bleeding and possibly inter-menstrual
(c) Age <20 years
bleeding for a few weeks
(d) Nulliparity
(e) Endometriosis Complications of IUD
(e) Menstrual irregularities with increased bleeding or (a) Increased menstrual bleeding and sometimes inter-
dysmenorrhoea menstrual spotting
Women who are best suited for IUD include those aged >20 (b) Cramping lower abdominal pain
years, who have given birth to at least one child, have diseases (c) Explusion : The overall expulsion rate is 2 - 8% in first year.
or conditions like Obesity, Tobacco use, Headache, IHD, RHD, It is commonest in first 3 months, especially after the 1st
Diabetes, Thyroid disease, Benign breast disease and Irregular period following insertion
menstruation but without heavy bleeding and those who are (d) Leucorrhoeic vaginal discharge
breast feeding. (e) Perforation of uterus (occurs in approximately 1 per 1000
insertion)

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(f) Infection, especially during first month and restarted after a gap of 7 days, irrespective of the onset or
(g) Pregnancy, due to failure (1 to 2%) stoppage of menstruation during these pill free periods.
(h) Ectopic pregnancy (Rare, approximately 1 per 1000 women Very often the packet has 28 pills. In such cases, the last 7
years. However, if pregnancy occurs with IUD in situ, then tablets are actually iron tablets. In this scenario the next packet
chances of its beings ectopic are very high, almost 30%) should be started on the very next day after the previous packet
Oral Contraceptives is finished, without any gap. Secondly, care should be taken
Hormonal Contraceptives have revolutionized the to take the actual (hormonal) tablets on first 21 days and iron
implementation of Planned Parenthood Programmes all over tablets on days 22 to 28.
the world. Broadly, hormonal contraceptives could be either Action to be taken when a Pill is Missed : If a pill is missed
oral or parenterally administered. Oral contraceptives (OCs) can on a day, two pills should be taken on the next day, as soon
be further divided into two broad groups, viz. “Combined pills” as the woman remembers (preferably within 12 hours of
(Containing both Estrogen & Progestogen) and “Progestogen last missed dose) and the other at bedtime; or else, if not
only pills” (mini pills). remembered earlier, 2 tablets at bedtime on the next day. If 2
(a) Combined Pills : These can be of two types, viz, Monophasic or 3 tablets are missed, the woman should take 2 tablets on
pill in which every pill has same amount of Oestrogen as well each of the consecutive 2 or 3 nights and continue with rest of
as Progestogen, and the multiphasic pill in which, in a given the packet as usual. In all such cases, when the pills have been
pack for one menstrual cycle, the pills will have variable missed the next packet should be started as usual after a gap
amount of Oestrogen & Progestogen. An example is “Triquila” of 7 days from the time last 21 days packet is finished. In such
available in our country. Monophasic pills can be, in turn, low cases where this prompt initiation immediately after 7 days
dose pills which contain less than 0.05 mg of ethinyl estradiol is delayed by 1 or 2 days, the women should use additional
(EE) in each pill along with progestogen. The other variety, i. barrier method till the time of starting the next normal course
e. high dose pills containing > 0.05mg EE per pill have been of 1 pill a day (from the 7th or 8th day). These rules apply to all
discontinued by now. Similarly, the earlier used sequential OC users, whether using combined or triphasic pills.
pills, which used only oestrogen in the tablets for first 14 days Effectiveness : Combined OC are very effective, with an
followed by combined Oestrogen & Progestogen for next 7 days overall failure rate of 0.1% (1 per 1000 women year). Failures
have also been abandoned by now. are maximum during first year of use and are mainly due to
(b) Progestogen only (Mini pill) : These contain small amount missed pills, delay in starting the next course exactly after 7
of only a progestogen but no oestrogen. They are indicated days of finishing the last 21 days pack, and due to stopping
for women >40 years age or who are lactating and have not the pill abruptly due to side effects without taking any other
completed 6 months from delivery. They are available under appropriate contraceptive measure.
trade names of Microval or Femulen; they are generally not Side Effects : These are of two categories, viz, minor side effects
available in our country. which are often temporary and the subject should therefore
Choice of pill : Any of the low dose combined pill or else a be properly counselled so that she does not unnecessarily
triphasic pill (Triquilar) can be used. The choice will mainly discontinue the pills. The second category is the major side
depend on cost, since the triphasic pills are costly. effects.
Commonly Available Pills : In our country, the following pills Minor Side Effects : These include nausea, vomiting and
are commonly available : decrease in appetite for the initial 2 or 3 months; breakthrough
bleeding usually during first few months; menorrhagia,
Common low dose pills
irregular bleeding or oligomenorrhoea; breast heaviness and
(a) Ovral-L or Mala-D - This contains L-norgesterol (LNGL) tenderness; headache; weight gain; acne and oily skin; and,
0.15 mg and EE 0.03 mg per pill. Mala-D is available at rarely, depression and decline in libido.
subsidized rates in our country under the FW program.
(b) Mala-N - This contains dl-NGL 0.30mg and EE 0.03mg per Major Side Effects : These include increased risk of IHD, and
pill. This is available free of cost under the FW program in stroke especially if the woman is also a smoker or hypertensive
our country. or diabetic or has history of venous thromboembolism. There
is also risk of raised blood pressure especially if age is >35
Triphasic pills : Triquilar contains L-NGL 0.05mg and EE
years; slightly increased risk of breast cancer and possibly
0.03mg for first 6 days, 0.75mg and 0.04 mg respectively for
cervical cancer; interference with insulin action in diabetics;
next 5 days and 0.125mg L-NGL with 0.03 mg EE for the next
exacerbation of existing hepatic conditions and reduction in
10 days.
lactation.
Mechanism of Action : Combined OCs produce contraceptive
Who Should Avoid OCs : The following women should avoid
effect in different ways, viz. and inhibition of ovulation by
OCs and try to use some other contraceptive device :
bringing about changes in FSH & LH secretion, by altering
the endometrium and by bringing about changes in cervical (a) Smokers, especially if age >35 years.
mucus. (b) Women who are breast feeding their children, up to 6
months post partum.
Mode of Administration : The day on which menstrual flow (c) Hypertensives.
starts is taken as day-1. The first pill is taken on Day-6, one (d) Past H/o breast cancer.
pill every day for next 21 days. Thereafter the pill is stopped (e) Unexplained vaginal bleeding.

• 898 •
(f) H/o stroke, thromboembolism or IHD cirrhosis, liver tumor, severe headache, undiagnosed breast
(g) Cirrhosis of liver or active hepatitis or liver tumors disease, previous OC related liver diseases, and H/o IHD,
(h) Using Rifampicin or anti-epileptics. hypertension or stroke. Fertility may take 6 to 12 months to
(j) Undergoing major surgery or prolonged immobilization. return after discontinuation of this injection.
(k) Diabetes with >20 years duration or with vascular Emergency (post-coital; morning-after) contraception
complications.
(l) Hyperlipidaemia. Emergency contraception pills (ECPs) are a very good method
of preventing pregnancy likely to occur due to unprotected sex
Warning Features : Women should be educated to watch out
or else due to suspected failure, as rupture of a condom. The
for following features and seek medical attention should they
following are the salient features of ECPs :
occur :
(a) ECPs are hormonal oral contraceptives having the same
(a) Chest pain
hormones as used in OCs but in a higher concentration.
(b) Shortness of breath
(b) ECPs come in a pack of two pills. The first should be taken
(c) Headaches which are severe or throbbing or occur on one
as soon as possible, but certainly within 72 hours of an
side.
unprotected sex. The second should be taken 12 hours
(d) Blurred or diminished vision.
after the first pill.
(e) Swelling or severe pain in a leg
(c) One ECP packet can protect only against one episode of
(f) Missed periods, especially if 2 periods are missed.
unprotected sex.
(g) Post coital or persistent irregular vaginal bleeding after
(d) ECPs are available free of cost at PHCs and with ANMs
3 months of pill usage or excessive, white discharge
at subcentres, under the name of “E-Pill”. They are also
especially if mixed with blood.
commercially available under brand names like Ecee-2,
(h) Yellowness of eyes or urine.
Norlevo, E-P-72 and Pill72.
Advantages of OC use
(e) ECPs are safe for all women including those who are breast
(a) Very effective, require minimal effort. feeding.
(b) Return of fertility on stopping the pills is very prompt. (f) If the lady vomits within 1 hours of taking the pill, the dose
(c) Can bring about relief in certain menstrual disorders as should be repeated after taking an antiemetic as Meclizine
dysmenorrhoea. HCL (Pregnidoxin)
(d) May be protective against endometrial cancer and ovarian (g) Some women may have minor side effects as breast
cancer. tenderness, headache, nausea, vomiting, spotting, fatigue,
(e) May be protective against benign diseases of breast and and dizziness which may last for maximum of 24 hours.
ovaries. (h) It should be clearly conveyed to the clientele that ECP is
(f) Likely to be protective against ectopic pregnancy, not an abortion pill since it cannot dislodge an implanted
PID, hirsutism, acne, osteoporosis and progression of ovum.
rheumatoid arthritis. (j) ECP is quite effective in that they may prevent up to 75%
(g) At times, the increase in weight is quite welcome to pregnancy which would have otherwise occurred following
women. unprotected sex.
Non-Oral Hormonal Contraceptives (k) After taking ECP, if onset of next menstrual cycle is delayed
These are of 3 broad categories : by more than 1 week of expected date, a pregnancy test
should be done. She should also report if the period
(a) Injectable : These include the progesterone only (Depot
starts on time but the flow is scanty or is unusually foul
Medroxy Progesterone Acetate - DMPA and Norethesterone
smelling.
Enanthanate - NETEN) or the combined ones (DMPA 25mg Plus
(l) ECP should not be used as a regular contraceptive
oestradiol 5mg or NETEN plus oestradiol 5mg)
method.
(b) Contraceptive Implants : These include Norplant (6 (m) In case E-pill or such ECP preparation is not available,
capsules of levo-norgesterol) and Implanon (single rod of the women can take 4 tabs of Mala-D at the earliest but
3-keto desogesterol). within 72 hours of unprotected sex, followed by 4 Tablets
(c) Contraceptive Impregnated Devices : as progesterone of Mala-D after 12 hours of first dose.
releasing IUD (progestinsert, LNG-20, Levonova); or (n) Reassure the women that her next period will start on the
contraceptive vaginal rings. expected date or sometime 2-3 days earlier or later than
Of the above, DMPA (Depot provera) and NET-EN are often expected date.
used and available in India. DMPA is given 150mg i. m. inj and Non-Hormonal Oral Contraceptives : Centchroman
remains effective for 3 months; NETEN is given 200mg as an This is a new form of oral contraceptive pill that does not
oil based i. m. inj and remains effective for 2 months. These are contain any steroidal hormones, developed by the Central
most effective when given within first 1-5 days of menstrual Drug Research Laboratory, Lucknow. It appears to be safe and
cycle. The failure rate is only 0.1 to 0.4%. economical and is sold under the brand names “Saheli” and
Absolute contra-indications for their use are pregnancy, “Centron”. It is taken once a week and is very convenient. It
unexplained vaginal bleeding and current breast cancer. Relative is very effective and can increase client privacy. There are no
contraindications include less than 6 weeks postpartum among known side effects, except that in about 8% of users there is a
breast feeding women, history of breast cancer, jaundice, delay in menses.

• 899 •
Permanent Methods In Laparoscopic tubectomy the tubes are either blocked by
Permanent methods include male sterilization (Vasectomy) electrocoagulation or sealed with a silastic band. The ideal
and female sterilization (Tubectomy). Any couple who has at time for tubectomy is soon after menstrual flow is over or in
least one child and is voluntarily motivated can be offered the post partum period. However, it can be done anytime in
sterilization procedure. Medical officers should emphasize on between the menstrual period but the woman should continue
the clientele that these procedures are perfectly safe and do to use alternative contraceptive till her next menstrual flow.
not carry adverse effects like decline in libido, low backache, Recanalisation : For couples who have undergone sterilization
obesity and so on, as are commonly thought of. In fact the operation but now need children, recanalisation operations
sexual performance and pleasure may improve since the fear of are available. The success of recanalisation depends on many
unwanted pregnancy is removed. factors, the most important being the fertility state of both
Vasectomy : In the conventional procedure, an incision is given the partners. In case of tubal recanalisation it also depends
on the scrotal skin and a piece of vas deferens 1 to 1. 5 cm on the original method by which tubectomy was done - if the
long is removed. In the more recent technique of “No Scalpel original method was spring loaded clip, the pregnancy rate
Vasectomy” a puncture is made in scrotal skin using a reverse following recanalisation may be as high as 88%, while for
scissor and a hole of approx half a cm is created through which Pomeroy method it is about 60%. As regards recanalisation of
vas is ligated after removing a piece 1 cm long. The advantage vas, in expert hands, the patency rate may be as high as 80%
of this method is that no stitches need to be given on the but actual pregnancy rate may be lower due to various other
scrotal skin. It must be emphasized on the acceptor that it will factors as fertility status of the husband and wife.
take 3 months for him to become completely sterile. For this Summary
duration, he or his wife should use an alternative temporary
method. After 3 months, seminal analysis should be done to As per present policy in the country, people are given choice to
confirm azoospermia. The following advice should be given for adopt contraceptive methods voluntarily out of various choices
implementation during post operative period : available. The various methods of contraception are divided
broadly into artificial and natural methods. The natural
●● He or his partner should use some other contraceptive
methods include Rhythm method, Basal body temperature
procedure till such time the semen exam indicates definite
method, cervical mucous method, Symptothermal method and
azoospermia, which is generally after 3 months.
Lactational amenorrhoea method.
●● To keep the local area clean and dry.
●● To wear a T-bandage for 2 weeks Artificial methods are further subdivided into temporary
●● To avoid cycling or lifting heavy weights for 2 weeks and permanent methods. Temporary methods include barrier
●● To get the stitches removed as advised by the surgeon. contraceptives, spermicides, IUDs, oral & non-oral hormonal
There are very few complications of vasectomy and even contraceptives. Most commonly used barrier contraceptive
these are minor. Some persons may get pain, local infection is condom which has the additional advantage of providing
and haematoma which last for a few days and respond well protection against STDs and HIV. It has average failure rate of
to antibiotics and analgesics. Local granuloma formation may 12-14 HWY, mainly because of incorrect technique of use.
occur in a very few patients and subsides over time. The most IUDs act mainly by inducing inflammatory changes in
important complications are, in fact, psychological, as feeling endometrium, incapacitating the sperm & ovum and preventing
of low backache, development of abdominal obesity and implantation. IUDs are divided into Gp I, II & III. Before its
reduced sexual drive. Subjects should be adequately educated insertion, various contraindications should be ruled out. It
and counselled about these psychological problems. should be inserted soon after menstruation upto 10th day of
Overall failure rate of vasectomy is between 1 to 2 per 1000 cycle. It can also be inserted in immediate postpartum or ideally
person years (0.1 to 0.2 per 100 person years). The two important 6 weeks after delivery/abortion. It can be used as a postcoital
causes of its occurrence are firstly, mistakenly removing some contraceptive. After its insertion woman should be instructed
other anatomical structure (as a local vein or spermatic chord) regarding regular checking of IUD in place, and regular health
instead of vas. This problem is negligible in expert hands. The checkups. Important complications include menorrhagia,
second reason is spontaneous recanalisation of the vas, the dysmenorrhoea, expulsion, perforation, Infection & ectopic
potential of which always exists to the tune of 0 to as high pregnancy. Average failure rate is 1-2 HWY.
as 6%. Therefore, all persons undergoing vasectomy should be OCPs are divided into combined pills and progesterone only
explained of this unforeseen complication and advised regular pills. Progesterone only pills can be used in women >40 yrs. or
follow up for at least 3 years. In addition, another cause of lactating period upto 6 months of postpartum. Combined pills
pregnancy could be unprotected intercourse before complete act by inhibiting ovulation, altering endothelium and changing
azoospermia, which usually takes 3 months, but may be more cervical mucus. Combined pills can be monophasic or triphasic.
in some subjects. It is therefore important to advise the subjects Commonly used monophasic pills now come with low amount
on these various aspects, since misconceptions and lack of of estrogen i.e. < 0.05mg ethinyl estradiol. The first pill is
knowledge may lead to serious domestic conflicts. taken on 6th day of period and is continued for 21 days, and
Tubectomy : In the conventional method (Pomeroy’s method), after stopping for 7 days it is restarted. Failure rate is as low as
a piece of the loop of Fallopian tubes about 1 cm long on 0.1 HWY. Major side effects are increased risk of IHD, CVA and
both sides is removed. The same is done in minilaparotomy. venous thromboembolism.

• 900 •
Non-oral hormonal contraceptives include Injectable (DMPA, (d) Bleeding P/V of unknown etiology
NETEN), Contraceptive Implants (Norplant, Implanon), 11) Which of the following is not the likely adverse effect of
Contraceptive Impregnated Devices (Progestinsert, LNG-20). IUD : (a) Menorrhagia (b) Metrorrhagia (Intermenstrual
Emergency contraception pills (ECPs) have the same hormones bleeding) (c) Polymenorrhoea (d) Anaemia
as combined pills but in higher dose, the 1st dose should be 12) Single pill of MALA-D contains : (a) L-norgesterol (LNGL)
taken as soon as possible after unprotected sex (max 72 hr) 0.15mg and EE 0.03mg (b) L-norgesterol (LNGL) 0.03mg
and 2nd dose 12hr after the 1st dose. and EE 0.15mg (c) D-norgesterol (LNGL) 0.15mg and EE
Permanent methods include vasectomy and tubectomy. 0.03mg (d) D-norgesterol (LNGL) 0. 03mg and EE 0.15 mg
Vasectomy can be conventional or No scalpel vasectomy. An 13) Which of the following is not the likely mechanism of
alternative temporary method should be used till azoospermia action of OCPs : (a) Inhibition of ovulation by bringing
is achieved after vasectomy (usually 3 months). Tubectomy about changes in FSH & LH secretion (b) By altering the
can be done by Pomeroy’s method using conventional, endometrium (c) By bringing about changes in cervical
laparoscopic or minilap procedure. In laparoscopic tubectomy, mucus (d) Incapacitates sperm
electrocoagulation or sialistic rings are used. Recanalisation 14) Which of the following is not the likely adverse effect of OCP
after permanent methods is possible with varying degree of : (a) Menorrhagia (b) Breast Heaviness (c) Oligomenorrhoea
success results. (d) Dysmenorrhoea
15) The failure rate of OCP is : (a) 1 HWY (b) 2-3 HWY (c) 0.1
Study Exercises HWY (d) 10 HWY
Long Question : How will you educate a group of approximately 16) Which is not the containdiaction for OCP use
150 adult, married men and women aged 20 to 50 years, (a) Hyperlipidaemia (b) Cirrhosis of liver (c) Unexplained
belonging to a rural background and most of them educated vaginal bleeding (d) Anaemia
between 4th to 8th class, as regards the various available 17) Which of the follwing is most cost effective method for
contraceptive procedures. permanent sterilization : (a) Vasectomy (b) Pomeroy’s
tubectomy (c) Laparoscopic tubectomy (d) No scalpel
Short Notes : (1) Pearl Index (2) Compare and contrast OCs and
vasectomy
IUDs (3) Emergency contraception.
18) After vasectomy/ no scalpel vasectomy, for at least how
MCQs & Exercises many months should the couple use alternative temporary
1) In Rhythm method for contraception, intercourse is avoided method of contraception : (a) 3 weeks (b) 3 months (c) 2
during : (a) 3-14 days (b) 5-25 days (c) 10-28 days (d) 7-21 weeks (d) 2 months
days 19) Emergency contraceptive pill should be used within a max
2) In Basal Body Temperature Method for contraception, period of : (a) 24 hr (a) 48 hr (c) 72 hr (d) 96 hr
increase in body temperature occurs : (a) Just before the 20) What is a mini pill : (a) Pill containing lesser amount
ovulation (b) Ovulation period itself (c) Immediately after of estrogen and progesterone (b) Once a month pill
ovulation (d) Menstruation (c) Progesterone only pill (d) Emergency pill
3) The failure rate of cervical mucus method if used correctly Match the Following :
is : (a) 1 per HWY (b) 2 per HWY (c) 3 per HWY (d) 4 per
HWY 1. Cervical mucus Method a. 12 to 14 / HWY
4) The failure rate of Condom is : (a) 12-14 HWY (b) 14-
17 HWY (c) 17-20 HWY (d) 20-25 HWY 2. Condoms b. 3 / HWY
5) The active agent in spermicidal jelly is : (a) 9- Xylenolol 3. IUDs c. 1 per 1000 women year
(b) 9- Xylene (c) 9- Nonoxynol (d) 9- Nonxylenol
4. Combined OC d. 1 to 2/ HWY
6) In Cu T-200, 200 signifies : (a) Weight of Cu in mg
(b) Surface area of Cu in sqmm (c) Length of Cu wire in mm Fill in the Blanks
(d) Diameter of Cu wire in µm
1. Emergency Contraceptive Pills (Hormonal) come in a pack
7) The mechanism of action of IUD does not include
of _____ Pills, The first should be taken as soon as possible,
(a) Inducing mild inflammatory changes and foreign
but certainly within ____ hours of an unprotected sex. The
body reaction in the endometrium (b) Incapacitate the
second should be taken ______ hours after the first pill.
sperms and ovum, prevent sperm from fertilizing the
2. The first pill is taken on Day _________, one pill every day
ovum (c) Makes the uterine environment inhospitable for
for next ___ days. Thereafter the pill is stopped & restarted
the blastocyst to be implanted (d) Increases the reverse
after a gap of ______ days, irrespective of the onset or
peristalsis of uterus
stoppage of menstruation during these pill free periods.
8) Which of the following IUDs belong to Gp II IUDs : (a) Cu
3. _________ Oral contraceptive pill is available free of cost
T- 200 (b) Lippe’s loop (c) Cu T-380A (d) ML-250
under the FW program in our country. This contains _____
9) The presence of Cu-T in place is checked routinely by
dl-NGL and __________ Ethinyl estradiol (EE) per pill.
(a) Feeling the thread coming out of cervical os (b) Absence
4. Oral Contraceptives produce contraceptive effect by
of menstruation (c) Feeling the metal tip in upper part of
__________ and __________ and __________
vagina (d) None of the above only X-ray can check it
5. The best time to insert Copper-T is_________________
10) Which one is not an absolute contraindication for IUD
insertion : (a) Pregnancy (b) Puerperal sepsis (c) Anaemia

• 901 •
 Answers : MCQs : (1) d; (2) c; (3) c; (4) a; (5) c; (6) b; (7) d; mucus (5) During or soon after menstrual period.
(8) d; (9) a; (10) c; (11) c; (12) a; (13) d; (14) d; (15) c;
(16) d; (17) d; (18) b; (19) c; (20) c; Match the Following : Further Suggested Reading
1. Hatcher RA, Rinechant W, Blackburn R, Galler JS. The essentials of
(1) b; (2) a; (3) d; (4) c; Fill in the Blanks : (1) 2, 72, 12 (2) 1, contraceptive technology. John Hopkins School of Public Health, Baltimore,
21, 7; (3) Mala-N, 0.30mg, 0.03mg (4) Inhibition of ovulation USA. First edition 1997.
by bringing about changes in FSH & LH secretion, by altering 2. Chaudhari SK. Practice of fertility control : A comprehensive text book. BI
Chuchil Livingstone, New Delhi, 5th Edition 2001.
the endometrium and by bringing about changes in cervical

• 902 •

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