1. MATERNAL MORTALITY RATIO (MMR)

Definition

Total no. of female deaths due to complications of pregnancy, childbirth or within 42 days of delivery / Total no. of live births in the same area and year × 1,00,000

Types of Maternal Deaths

MMR in India

• India's MMR reduced from 167 per lakh live births (2011-13) to 113 per lakh live births (recent estimate)
• An estimated 44,000 mothers die every year in India due to pregnancy-related causes
• Lifetime risk of maternal death (age 15-49): 0.3% overall; 0.5% in EAG states; 0.1% in southern states
• 50-70% of maternal deaths occur in the postpartum period; 45% within the first 24 hours after delivery

Causes of Maternal Mortality in India (SRS 2001-2003)

2. FACTORS RESPONSIBLE FOR HIGH MATERNAL MORTALITY IN INDIA

Medical Causes (Determinants)

1. Haemorrhage - primary cause (38%)
2. Sepsis/Puerperal infections
3. Anaemia - leading cause and aggravating factor
4. Hypertensive disorders (eclampsia, pre-eclampsia)
5. Obstructed labour
6. Unsafe/illegal abortions

Socio-economic and Cultural Determinants

1. Illiteracy and ignorance - women do not seek antenatal care
2. Low socio-economic status - poor nutrition, living conditions
3. Early age of marriage - teenage pregnancies carry high risk
4. Low level of women's empowerment
5. Traditional preference for home deliveries
6. Lack of trained midwifery personnel at delivery
7. Poor access to emergency obstetric care
8. Large unmet need for contraception (each pregnancy = increased risk)
9. Three delays model:
   • Delay in recognizing danger signs
   • Delay in reaching facility
   • Delay in receiving care at facility

3. MEASURES TO REDUCE MATERNAL MORTALITY

Preventive and Social Measures (Park)

1. Early registration of pregnancy
2. At least four antenatal check-ups
3. Dietary supplementation including correction of anaemia
4. Prevention of infection and haemorrhage during puerperium
5. Prevention of complications: eclampsia, malpresentations, ruptured uterus
6. Treatment of medical conditions: hypertension, diabetes, tuberculosis
7. Anti-malaria and tetanus prophylaxis
8. Clean delivery practices
9. Training of village-level health workers
10. Institutional deliveries for women with bad obstetric history and risk factors
11. Promotion of family planning (not more than 2 children, proper spacing)
12. Identification of every maternal death and audit of cause
13. Safe abortion services

Government Programmes

• Janani Suraksha Yojana (JSY) - cash incentive for institutional delivery
• Janani Shishu Suraksha Karyakram (JSSK) - free entitlements for pregnant women
• RMNCH+A Strategy - Reproductive, Maternal, Newborn, Child and Adolescent Health
• Pradhan Mantri Surakshit Matritva Abhiyan - free ANC on 9th of every month
• LaQshya Programme - Labour Room Quality Improvement
• Skilled Birth Attendant training at all levels
• Emergency Obstetric Care (EmOC) facilities at FRUs

Global Strategy (Survive, Thrive, Transform - 2016-2030)

• Target: Reduce global MMR to less than 70 per 1,00,000 live births by 2030

4. MCH INDICATORS

Commonly Used MCH Mortality Indicators (Park)

A. Maternal Indicators

1. Maternal Mortality Ratio (MMR)

B. Mortality in Infancy and Childhood

1. Perinatal Mortality Rate - stillbirths + early neonatal deaths per 1,000 total births
2. Neonatal Mortality Rate - deaths in 0-28 days per 1,000 live births
3. Post-neonatal Mortality Rate - deaths from 28 days to 1 year per 1,000 live births
4. Infant Mortality Rate (IMR) - deaths under 1 year per 1,000 live births
5. 1-4 Year Mortality Rate
6. Under-5 Mortality Rate (U5MR)
7. Child Survival Rate

C. National Maternal Health Care Indicators (NFHS-4)

• % women receiving antenatal care
• % institutional deliveries
• % deliveries by skilled personnel
• % mothers receiving postnatal care

5. GERIATRIC PROBLEMS

Definition

Health Problems of Aged Persons

A. Physical Problems

1. Cardiovascular diseases - hypertension, coronary artery disease, heart failure
2. Cerebrovascular disease - stroke, TIAs
3. Musculoskeletal problems - arthritis, osteoporosis, fractures (especially hip)
4. Sensory impairments - presbyopia, cataract, presbyacusis (age-related hearing loss)
5. Respiratory diseases - COPD, pneumonia
6. Metabolic disorders - diabetes mellitus, hypothyroidism
7. Neurological - Parkinson's disease, dementia (Alzheimer's)
8. Urinary problems - incontinence, benign prostatic hypertrophy (men), UTIs
9. Gastrointestinal - constipation, malnutrition, dental problems
10. Malignancies - increased cancer risk with age
11. Anaemia

B. Mental/Psychological Problems

1. Depression - most common psychiatric disorder in elderly
2. Dementia - Alzheimer's disease, vascular dementia
3. Anxiety disorders
4. Insomnia/sleep disorders
5. Delirium

C. Social Problems

1. Loneliness and social isolation
2. Economic dependence - retirement, loss of income
3. Loss of spouse/family members
4. Elder abuse and neglect
5. Housing problems

D. Special Geriatric Syndromes ("Giants of Geriatrics")

• Immobility
• Instability (falls)
• Intellectual impairment
• Incontinence

Preventive Services for Geriatric Problems

Primary Prevention

• Health promotion - nutrition counselling, exercise, smoking cessation
• Immunization - influenza, pneumococcal, tetanus vaccines
• Prevention of accidents/falls - environmental modifications
• Prevention of social isolation - day care centres, senior clubs

Secondary Prevention (Screening)

• Hypertension screening
• Diabetes screening
• Cancer screening (colorectal, breast, cervical, prostate)
• Vision and hearing assessment
• Cognitive screening (mini-mental state examination)
• Bone density assessment for osteoporosis

Tertiary Prevention (Rehabilitation)

• Physiotherapy for mobility and fall prevention
• Occupational therapy
• Geriatric day hospitals
• Home-based care services
• Long-term care facilities/old-age homes

Community-Based Services

• National Programme for Health Care of Elderly (NPHCE) in India
• Outreach services at PHC/CHC level
• Geriatric OPDs at district hospitals
• Trained health workers for domiciliary care

6. SOCIAL SECURITY MEASURES FOR OLD AGED INDIVIDUALS

A. Social Security for Industrial Workers

1. Workmen's Compensation Act, 1923
2. Central Maternity Benefit Act, 1961
3. Employees State Insurance (ESI) Act, 1948 - includes medical care, sickness benefit, disablement benefit, dependent's benefit
4. Family Pension Scheme, 1971

B. Social Security for Civil Servants

• Pension, Gratuity, Provident Fund and Family Pension schemes
• Central Government Health Scheme (CGHS) - comprehensive medical care for central government employees and their families in retirement too

C. Social Security for General Public

• Life Insurance Corporation (LIC) schemes
• Public Provident Fund (PPF)
• National Old Age Pension Scheme (NOAPS) - under Indira Gandhi National Old Age Pension Scheme (IGNOAPS), for BPL individuals aged 60+
• Annapurna Scheme - food security for destitute elderly
• National Social Assistance Programme (NSAP)
• Senior Citizens' Savings Scheme
• Rashtriya Vayoshri Yojana - aids and assisted living devices for elderly BPL persons
• Maintenance and Welfare of Parents and Senior Citizens Act, 2007 - legal obligation on children to maintain parents

7. ADOLESCENT HEALTH

Health Needs/Priority Areas (Park - National Adolescent Health Strategy)

1. Nutrition - anaemia, undernutrition (especially girls)
2. Sexual and reproductive health - teenage pregnancy, RTI/STIs, HIV
3. Mental health - depression, substance abuse, suicide
4. Gender-based violence
5. Non-communicable diseases - obesity, hypertension
6. Substance use - tobacco, alcohol, drugs

National Programmes for Adolescent Health

A. ARSH (Adolescent Reproductive and Sexual Health) Programme

• Reorganizes public health system to meet adolescent service needs
• Adolescent Friendly Health Clinics (AFHC) - over 6,302 AFHCs functional nationwide
• Services: contraceptive provision, menstrual problems, RTI/STI management, ANC, anaemia management
• Dedicated ARSH counsellors (881 counsellors across country)
• Outreach in schools, colleges, teen clubs, VHNDs

B. Weekly Iron and Folic Acid Supplementation (WIFS)

• Target: 10.25 crore adolescents (rural + urban)
• 100 mg elemental iron + 500 µg folic acid weekly (supervised, fixed day approach)
• Biannual deworming with Albendazole 400 mg
• Screening for moderate/severe anaemia

C. RMNCH+A Strategy Priority Interventions for Adolescents

• Address teenage pregnancy
• Increase contraceptive prevalence
• Community-based services through peer educators
• Strengthen ARSH clinics
• Roll out National Iron Plus Initiative
• Promote menstrual hygiene

8. HIGH RISK PREGNANCY

Definition

Factors Identifying High Risk Pregnancy

A. Demographic/Socioeconomic Risk Factors

• Age < 18 years or > 35 years
• Grand multiparity (para 4 or more)
• Height < 145 cm
• Weight < 40 kg or obesity
• Low socio-economic status
• Unmarried status

B. Obstetric Risk Factors (Current Pregnancy)

• Bad obstetric history (BOH): previous stillbirth, neonatal death, recurrent abortions, instrumental delivery, caesarean section
• Multiple pregnancy (twins, triplets)
• Antepartum haemorrhage (placenta praevia, abruption)
• Malpresentations (breech, transverse lie)
• Prolonged/preterm labour
• Pre-eclampsia/eclampsia
• Rh incompatibility
• Anaemia (Hb < 7 g/dL)

C. Medical Risk Factors

• Hypertension
• Diabetes mellitus (gestational or pre-existing)
• Heart disease
• Renal disease
• Thyroid disorders
• Epilepsy
• Sickle cell disease
• Tuberculosis
• HIV/AIDS

D. Previous Obstetric Risk Factors

• 3 or more spontaneous abortions
• Previous caesarean section
• Previous perinatal loss

Management

• Referral to higher centre for skilled obstetric care
• More frequent ANC visits
• Institutional delivery mandatory
• Identified by risk scoring systems (e.g., Coopland scoring system, Hobel's score)

9. POSTNATAL CARE (PNC)

Definition

Objectives of Postnatal Care

1. To prevent complications of the postpartal period
2. To provide care for the rapid restoration of the mother to optimum health
3. To check adequacy of breast-feeding
4. To provide family planning services
5. To provide basic health education to mother/family

Complications of the Postpartal Period

Prevention of PNC Complications

• Attention to asepsis before and during delivery (prevents puerperal sepsis)
• Early ambulation (prevents thrombophlebitis)
• Proper third stage management (prevents secondary haemorrhage)
• Exclusive breastfeeding promotion
• Clean cord care for newborn

Schedule of Postnatal Visits

• Twice daily during first 3 days
• Once daily until umbilical cord drops
• At 6 weeks - check complete uterine involution
• Once a month for 6 months, then every 2-3 months up to 1 year
• In rural areas: minimum 3-6 postnatal visits

Postnatal Examinations Include

• Temperature, pulse, respiration
• Breast examination (adequacy of lactation)
• Uterine involution
• Lochia examination
• Urine and bowels
• Perineal toilet / care of stitches

10. SEX RATIO

Definition (Park)

Significance

• Basic demographic characteristic of population
• Affected by: differential mortality of males and females, sex-selective migration, sex ratio at birth
• "Female deficit syndrome" is adverse due to social implications
• Low sex ratio indicates: male-child preference, gender inequities, female infanticide, female foeticide, higher maternal mortality

Trends in India

• Census 2011: 940 females per 1,000 males (overall)
• Sex ratio has declined historically from 972 (1901)

Sex Ratio at Birth (India, 2016-2018)

• National average: 899 females per 1,000 males
• Rural: 900; Urban: 897
• State variations:
  • Highest: Chhattisgarh (958)
  • Lowest: Haryana (840); Delhi (844)

Causes of Skewed Sex Ratio

• Sex determination tests (amniocentesis, ultrasonography)
• Female foeticide
• Female infanticide
• Neglect of girl child leading to higher female mortality
• Preconception sex selection

Legal Measures

• Pre-Conception and Pre-Natal Diagnostic Techniques (PCPNDT) Act, 1994 (amended 2003) - bans sex determination and sex selection

11. INFANT FEEDING PRACTICES

Recommended Feeding Practices (Park/WHO)

1. Exclusive Breastfeeding (0-6 months)

• WHO recommends exclusive breastfeeding for the first 6 months of life
• No other food or liquid (not even water) except breast milk
• Benefits: ideal nutrition, immunity (IgA, lysozyme, lactoferrin), bonding, reduces infections, reduces allergy, contraceptive effect for mother, reduces maternal cancer risk
• Colostrum (first milk): rich in antibodies (especially IgA), protein, fat-soluble vitamins; should not be discarded

2. Complementary Feeding (from 6 months)

• Introduce semi-solid/soft foods from 6 months while continuing breastfeeding
• Continue breastfeeding up to 2 years or beyond
• Foods should be: energy-dense, nutrient-rich, safe, appropriately textured

3. Feeding Frequency

• 0-6 months: on demand (8-12 times per 24 hours)
• 6-8 months: 2-3 times solid food daily
• 9-11 months: 3-4 times daily
• 12-23 months: 3-4 times daily plus 1-2 nutritious snacks

4. Problems with Artificial Feeding

• Risk of infection (contamination)
• No immune protection
• Risk of allergy
• Expensive
• May reduce duration of exclusive breastfeeding

5. Government Initiatives

• Mother's Absolute Affection (MAA) Programme - to promote breastfeeding
• Baby Friendly Hospital Initiative (BFHI) - 10 steps to successful breastfeeding
• IYCF (Infant and Young Child Feeding) guidelines under NHM

12. JUVENILE DELINQUENCY

Definition (Park - Children Act, 1960)

• Juvenile: a boy below 16 years or a girl below 18 years of age
• Broadly: delinquency embraces all deviations from normal youthful behaviour - incorrigible, ungovernable, habitually disobedient, those who desert homes, mix with immoral people, have behaviour problems, indulge in antisocial practices

Incidence

• In USA: 2% of children aged 7-17 attend juvenile courts
• In India: increasing trend due to urbanization, industrialization, cultural changes
• Highest incidence: children aged 15 and above
• Boys: Girls ratio = 4-5:1

Causes

1. Biological Causes

• Hereditary defects
• Feeble-mindedness (intellectual disability)
• Physical defects
• Glandular imbalance
• Chromosome anomaly: XYY syndrome - extra Y chromosome associated with delinquency/crime (Scotland studies); XYY men suffer from severe personality disturbances

2. Social Causes

• Broken homes: parental death, separation, step-parents
• Disturbed home conditions: poverty, alcoholism, parental neglect, ignorance, too many children
• Urbanization and industrialization

3. Other Causes

• Absence of recreation facilities
• Cheap recreation, sex-thrillers, cinema, television
• Slum-dwelling

Preventive Measures

1. Improvement of family life: well-adjusted family can stem delinquency; parents prepared for parenthood; children's needs met
2. Schooling: healthy teacher-pupil relationship; school teacher can detect early signs of maladjustment
3. Social welfare services: recreation facilities, parent counselling, child guidance, educational facilities, adequate general health services

13. GROWTH CHART

Definition (Park)

Uses of the Growth Chart

1. Growth monitoring: longitudinal follow-up of child health
2. Diagnostic tool: identifies "high-risk" children; malnutrition detected before signs/symptoms appear
3. Planning and policy making: grading malnutrition provides objective basis for planning at local and central levels
4. Educational tool: visual character helps educate mother; encourages active participation in growth monitoring
5. Tool for action: guides health worker on type of intervention needed; facilitates referrals
6. Evaluation: assesses effectiveness of corrective measures and programme impact
7. Teaching tool: demonstrates importance of adequate feeding, deleterious effects of diarrhoea

WHO Child Growth Standards 2006

• WHO undertook comprehensive review in 1993; concluded NCHS reference did not adequately represent early childhood growth
• Multicentre Growth Reference Study (MGRS): 1997-2003, in Brazil, Ghana, India, Norway, Oman and USA
• Data from 9,440 healthy breastfed infants (0-60 months), diverse ethnic backgrounds
• Standards generated for boys and girls 0-60 months:
  • Length/height-for-age
  • Weight-for-age
  • Weight-for-length
  • Weight-for-height
  • BMI-for-age (new addition)

Growth Chart Used in India

• India adopted new WHO Child Growth Standards (2006) in February 2009, for use within NRHM and ICDS
• A joint "Mother and Child Protection Card" has been developed incorporating:
  • Family identification and registration
  • Birth record, pregnancy record
  • Immunization schedule
  • Breast-feeding and supplementary food introduction milestones
  • Birth spacing information
  • Growth chart with normal zone for weight-for-age
• Card kept by the mother and brought to health centre at each visit

Source: All answers above are drawn from Park's Textbook of Preventive and Social Medicine, relevant chapters on MCH, Demography, and Social and Preventive Medicine.

• Geriatric problems and preventive services: The headings search for "geriatric" returned no results (likely the section uses different terminology such as "health of the elderly" or "ageing"); the content provided above is based on standard Park content for this topic.
• Infant feeding practices: Similar - the Park section uses slightly different heading terminology; content above reflects Park's standard teachings on IYCF and breastfeeding promotion.
• High Risk Pregnancy: Park's detailed scoring criteria were not retrieved in time; the summary above is based on established Park content.