Answer on Neonatal mortality 6. Marks as per parks latest edition

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Neonatal Mortality

(Park's Textbook of Preventive and Social Medicine)

Definition

Neonatal deaths are deaths occurring during the neonatal period - commencing at birth and ending 28 completed days after birth.

Neonatal Mortality Rate (NMR)

NMR = (Number of deaths of children under 28 days of age in a year / Total live births in the same year) × 1000

India (2018): NMR = 9 per 1000 live births (both rural and urban areas)

Sub-classification

Type	Period
Early neonatal mortality	Deaths in first 7 days of life
Late neonatal mortality	Deaths from day 7 to day 28

Causes of Neonatal Mortality (Global, 2018)

Global distribution of neonatal deaths by cause, 2018 - Park's

Fig. 13 - Global distribution of neonatal deaths by cause, 2018 (Source: Park's)

Cause	Percentage
Preterm birth complications	35%
Intrapartum-related complications	24%
Sepsis	15%
Congenital abnormalities	11%
Pneumonia	6%
Other	7%
Diarrhoea	1%
Tetanus	1%

Key points:

Intrapartum-related complications, low birth weight, and preterm birth are causal factors in 60% of neonatal deaths
Prematurity and congenital anomalies account for ~60% of newborn deaths, mostly in the first week of life
~25% of neonatal deaths are attributable to asphyxia - also mainly in the first week
In the late neonatal period (after day 7), infections (diarrhoea, tetanus) predominate
The role of tetanus as a cause of neonatal death has diminished sharply due to intensified immunization

Determinants / Risk Factors

Neonatal mortality is a measure of "endogenous factors" (e.g., low birth weight, birth injuries)
Directly related to birth weight and gestational age
Neonatal mortality rates of babies born to mothers with no education are nearly twice as high as those born to mothers with secondary education or higher
Family wealth and rural/urban residence remain powerful determinants
Ending child marriage, reducing adolescent pregnancy, and extending birth intervals are key to reducing newborn mortality risk

Priority Areas to Improve Newborn Health (Park's Table)

Timing	Key Interventions
Before/during pregnancy	Delayed childbearing, well-spaced pregnancies, well-nourished mother, tetanus & rubella immunization, female education, prevention of HIV MTCT
During pregnancy	Early antenatal contact, birth preparedness, treatment of anaemia, infections (malaria, syphilis), good diet
During & soon after delivery	Skilled birth attendant, newborn resuscitation, warmth & cleanliness, cord/eye/skin care, early exclusive breastfeeding, special care for preterm/LBW
First month of life	Early postnatal contact, exclusive breastfeeding support, prompt disease detection, immunization, protection of girl child

International Comparisons (IMR, 2018)

Country	IMR 1990	IMR 2018
India	88	32
Bangladesh	100	25
Japan	5	2
World average	63	29

World IMR (2018): ~29 per 1000 live births
Developed countries: 4 per 1000 | Least developed: 46 per 1000

Source: Park's Textbook of Preventive and Social Medicine, p. 658-659

RMNCH+A

RMNCH+A stands for Reproductive, Maternal, Newborn, Child, and Adolescent Health - a flagship national health strategy launched by the Government of India in 2013. It integrates services across the life cycle from adolescence through pregnancy, childbirth, newborn care, and childhood.

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RMNCH+A Strategy (2013)

Reproductive, Maternal, Newborn, Child and Adolescent Health

(Park's Textbook of Preventive and Social Medicine)

Background / Launch

In June 2012, the Governments of India, Ethiopia, USA and UNICEF convened the "Global Child Survival Call to Action: A Promise to Keep" summit in Washington, DC.
More than 80 countries pledged to reduce child mortality to ≤ 20 per 1000 live births in every country by 2035.
In February 2013, the Government of India launched "A Strategic Approach to RMNCH+A in India" at its own historic Summit on Call to Action for Child Survival.
RMNCH+A became the heart of the National Health Mission (NHM).

The "+" (Plus) Significance

The "+" within the strategy focuses on:

Including adolescence for the first time as a distinct life stage
Linking maternal and child health to reproductive health, family planning, adolescent health, HIV, gender, preconception care, and PCPNDT
Linking home and community-based services to facility-based care
Ensuring linkages, referrals, and counter-referrals between PHC, CHC, and District Hospital (primary, secondary, tertiary levels)

Five Pillars (Thematic Areas)

Pillar	Focus
R - Reproductive Health	Family planning, RTI/STI, comprehensive abortion care
M - Maternal Health	ANC, skilled delivery, EmOC, postnatal care
N - Newborn Health	Essential newborn care, home-based newborn care (ASHA), SNCUs
C - Child Health	Immunization, IMNCI, RBSK (4Ds), nutrition
+A - Adolescent Health	ARSH clinics, IFA, menstrual hygiene, peer educators

The strategy is guided by central tenets of equity, universal care, entitlement, and accountability.

5 × 5 Matrix

A key management tool that identifies:

5 high-impact interventions across each of the 5 thematic areas
5 cross-cutting and health systems strengthening interventions
Minimum essential commodities

Used for organizing technical support and monitoring progress with states and 184 High-Priority Districts (HPDs).

Goals and Targets (12th Five Year Plan, 2012-2017)

Indicator	Target by 2017
Infant Mortality Rate (IMR)	25 per 1000 live births
Maternal Mortality Ratio (MMR)	100 per 1,00,000 live births
Total Fertility Rate (TFR)	2.1

Implementation Strategies - Area-wise

1. Reproductive Health

Focus on spacing methods - PPIUCD at high caseload facilities
Home Delivery of Contraceptives (HDC) and Ensuring Spacing at Birth (ESB) through ASHAs
Pregnancy Testing Kits ("Nischay Kits"), comprehensive abortion care
Quality sterilization services

2. Maternal Health

Use MCTS (Mother and Child Tracking System) for early registration and full ANC
Detect high-risk pregnancies (including severely anaemic mothers)
Equip delivery points with trained HR; access to EmOC at FRUs
Distribution of Misoprostol to selected women in 8th month of pregnancy
Strengthen referral system for high-risk pregnancies

3. Newborn Health

Early initiation and exclusive breastfeeding
Home-based newborn care through ASHA
Essential Newborn Care and resuscitation at all delivery points
Special Newborn Care Units (SNCUs) with trained HR
Community-level use of Gentamycin by ANM

4. Child Health

Complementary feeding, IFA supplementation, nutrition focus
Diarrhoea management with ORS and Zinc
Management of pneumonia
Full immunization coverage
Rashtriya Bal Swasthya Karyakram (RBSK) - screening for 4Ds: Birth Defects, Development Delays, Deficiencies, and Diseases

5. Adolescent Health

Address teenage pregnancy; increase contraceptive prevalence in adolescents
Community-based services through peer educators
Strengthen ARSH (Adolescent Reproductive and Sexual Health) clinics
Roll out National Iron Plus Initiative with weekly IFA supplementation
Promote menstrual hygiene

Cross-Cutting Interventions

Bring down out-of-pocket expenses - JSSK, RBSK, and other free entitlements
ANMs and nurses to provide specialized, quality care
Address social determinants through convergence
Focus on un-served, underserved villages, urban slums
Performance-based and difficult-area incentives

Health Systems Strengthening

Caseload-based deployment of HR at all levels
Ambulances, drugs, diagnostics, reproductive health commodities
Health education, demand promotion and BCC (Behaviour Change Communication)
Supportive supervision and HMIS-based scorecard monitoring
Public grievance redressal and quality assurance

Clinical Services at Facility Level

Component	Services
Reproductive Care	Comprehensive abortion care, RTI/STI management, PPIUCD, sterilization
Pregnancy & Childbirth	Skilled obstetric care, newborn resuscitation, EmOC, PPTCT of HIV
Newborn & Child Care	Essential newborn care, SNCU, IMNCI, NRC (Nutrition Rehab Centre), immunization

Key Coverage Targets (Table 14)

Increase institutional births (Government + accredited private) at 5.6%/year from 61% baseline
ANC coverage increase at 6%/year from 53% baseline
Postnatal care increase at 7.5%/year from 45% baseline
Exclusive breastfeeding increase at 9.6%/year from 35% baseline
Reduce under-five underweight at 5.5%/year from 45% baseline (NFHS-3)
Reduce unmet need for family planning at 8.8%/year from 21% baseline
Reduce anaemia in adolescent girls (15-19 years) at 6%/year from 56% baseline

Source: Park's Textbook of Preventive and Social Medicine, pp. 523-526

School health services pls teach in a way I can learn quick too

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🏫 School Health Services

Park's Textbook of Preventive and Social Medicine

🧠 Quick Memory Hook

"School = Future Community" School health is NOT just about checking sick kids - it's about building the health of future generations.

What is School Health Service?

A personal health service that evolved from mere medical examination of children to comprehensive care of health and well-being throughout school years.

📅 Historical Timeline (India) - Easy to Remember

Year	Event
1909	First medical examination of school children - Baroda city
1946	Bhore Committee - said services were "practically non-existent"
1953	Secondary Education Committee - emphasized need for medical exams + school feeding
1960	Govt of India constituted School Health Committee
1961	School Health Committee Report with recommendations

🎯 Objectives - Remember "PEEA"

	Objective
P	Promotion of positive health
E	Early diagnosis, treatment and follow-up of defects
E	Enabling healthful environment
A	Awakening health consciousness in children
(+)	Prevention of diseases

🏥 Health Problems of School Children in India

Remember: "MIISED"

Malnutrition
Infectious diseases
Intestinal parasites
Skin, Eye & Ear diseases
Dental caries

📋 12 Aspects of School Health Service

This is the most important exam section - memorize with the mnemonic "HR PC NF DEH Rec"

#	Aspect	Key Detail
1	Health Appraisal	Medical exam at entry + every 4 years; daily morning inspection by teacher
2	Remedial measures & follow-up	Exams must be followed by treatment; clinics for every ~5,000 children
3	Prevention of communicable diseases	Immunization, isolation of sick, fumigation
4	Healthful school environment	Safe water, sanitation, lighting, ventilation, seating
5	Nutritional services	Mid-day meals, nutrition education, monitoring height/weight
6	First-aid & emergency care	First-aid box, trained teacher, referral system
7	Mental health	Identify maladjusted children, counselling
8	Dental health	Fluoride, toothbrushing, dental clinics
9	Eye health	Refractive errors, squint, trachoma, Vitamin A
10	Health education	Most important element - personal hygiene, environment, family life
11	Education of handicapped children	Help reach maximum potential, multi-agency cooperation
12	School health records	Cumulative record: DOB, history, exam findings, services provided

🔍 Health Appraisal - Deeper Look

Periodic Medical Examination covers:

History + physical examination
Tests for vision, hearing, speech
Routine blood & urine tests
Nutritional deficiency screening
Stool examination for parasites
Tuberculin testing / mass screening

Daily Morning Inspection by Teacher - watch for these 16 signs:

Flushed face, rash, cold symptoms, cough/sneeze, sore throat, rigid neck, nausea/vomiting, red eyes, headache, chills/fever, listlessness, won't play, diarrhoea, body pains, scabies/ringworm, pediculosis (lice)

Key point: In India, teacher observation is critically important because of limited trained personnel for school health.

🍎 Health Education - The MOST Important Element

Three areas covered:

Personal hygiene - skin, hair, teeth, clothing, posture; address cigarette smoking
Environmental health - keeping surroundings clean, participating in community health campaigns
Family life - healthy attitudes towards human reproduction

💡 Key quote from Park: "Every school child is a health worker" - children carry health messages home to their families!

Who does it? The school teacher is the key person. The health officer/PHN only provides materials and advice.

🏛️ School Health Administration

Two main bodies:

(a) School Health Committee

Coordinates between Education and Health departments
Sets policy, reviews progress

(b) School Health Committees (at school level)

Principal + teachers + health staff
Day-to-day implementation

Key principle: School health requires coordination between Education and Health departments - neither can do it alone.

📝 School Health Records - Contents

A cumulative health record for each student must contain:

Identifying data - name, DOB, parent's name & address
Past health history
Physical examination findings and screening test results
Record of services provided

Purpose: Continuing intelligent health supervision + data for health planning

🧩 Quick Revision Summary

School Health = 12 Aspects
├── EXAMINE: Health appraisal (entry + every 4 yrs)
├── TREAT: Remedial measures + follow-up
├── PREVENT: Communicable disease prevention
├── ENVIRONMENT: Safe school building
├── FEED: Nutritional services (mid-day meals)
├── EMERGENCY: First aid
├── MIND: Mental health
├── TEETH: Dental health
├── EYES: Eye health (Vit A, refractive errors)
├── EDUCATE: Health education (MOST IMPORTANT)
├── SPECIAL NEEDS: Handicapped children
└── RECORD: School health records

⭐ High-Yield Exam Points

Point	Detail
School health started in India	1909, Baroda
Bhore Committee finding	Services "practically non-existent"
Exam frequency	Entry + every 4 years
Most important aspect	Health education
Key person in health education	School teacher (not doctor)
Clinic for how many children	1 clinic per ~5,000 children
Famous quote	"Every school child is a health worker"
India's main health problems	MIISED (Malnutrition, Infections, Intestinal parasites, Skin/Eye/Ear, Dental)

Source: Park's Textbook of Preventive and Social Medicine, pp. 670-674

What are important causes of infant mortality in India. Describe the organization of healthcare delivery system with objective of reducing infant mortality.

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Infant Mortality in India - Causes & Healthcare Organization

Park's Textbook of Preventive and Social Medicine

Definition & Formula

Infant Mortality Rate (IMR) = ratio of infant deaths in a given year to total live births in the same year, expressed per 1000 live births.

$$\text{IMR} = \frac{\text{Deaths of children} < 1 \text{ year of age in a year}}{\text{Live births in the same year}} \times 1000$$

India's IMR (2018) = 32 per 1000 live births (Down from 204 in 1911-15 → 129 in 1970 → 32 in 2018)

IMR - India at a Glance

Highest IMR state: Madhya Pradesh - 48
Lowest IMR state: Kerala - 7
Critical infant mortality belt: Odisha, Madhya Pradesh, Assam, Bihar, Chhattisgarh, Uttar Pradesh, Rajasthan (all above national average)
Rural IMR always higher than urban in all states

PART 1 - Important Causes of Infant Mortality in India

A. Medical Causes (Table 26)

Neonatal (0-4 weeks)	Post-neonatal (1-12 months)
1. Low birth weight & prematurity	1. Diarrhoeal diseases
2. Birth injury & difficult labour	2. Acute respiratory infections
3. Sepsis	3. Other communicable diseases
4. Congenital anomalies	4. Malnutrition
5. Haemolytic disease of newborn	5. Congenital anomalies
6. Conditions of placenta & cord	6. Accidents
7. Diarrhoeal diseases
8. Acute respiratory infections
9. Tetanus

Key percentages in India:

Low birth weight - 57% (single largest cause)
Respiratory infections - 17%
Congenital malformations - 5%
Diarrhoeal diseases - 4%
Birth injury - 3%
Cord infection - 2%
Unclassified - 18%

In developing countries: mainly LBW + infections + malnutrition In developed countries: mainly congenital anomalies + anoxia/hypoxia

B. Factors Affecting Infant Mortality

1. BIOLOGICAL FACTORS

(a) Birth Weight - most important single determinant

LBW (<2.5 kg) AND high birth weight (>4 kg) are at risk
Main cause of LBW = poor maternal nutrition

(b) Age of Mother

Risk highest if mother is <19 years or >30 years
Teen mothers are poorer, less educated

(c) Birth Order

Highest mortality: 1st born; lowest: 2nd born
Risk escalates from 3rd child onwards
Nutritional deficiency deaths 3-4× higher for 5th+ birth order

(d) Birth Spacing - critical factor

Khanna Study (India): IMR highest when births <1 year apart
WHO study: Same finding in rural India
Births within 1 year of each other = 2-4× higher risk of death
Optimal spacing: >2-4 years between births

(e) Multiple births - greater risk due to higher frequency of LBW

(f) Family size - IMR increases with family size (more infections, malnutrition, less maternal care)

(g) High fertility - high fertility and high IMR go together

2. ECONOMIC FACTORS

Socioeconomic status is most important variable - both directly and indirectly
IMR highest in slums, lowest in richer localities
Health care quality and child's environment are closely related to socioeconomic status

3. CULTURAL AND SOCIAL FACTORS

(a) Breast-feeding - early weaning / bottle feeding under poor hygienic conditions greatly increases mortality risk

(b) Religion and caste - socio-cultural patterns of living (habits, customs, traditions affecting cleanliness, child care)

(c) Early marriages - babies of teenage mothers have highest risk of neonatal and post-neonatal mortality

(d) Sex of child - in India, female infants receive less attention

Neonatal death rate: higher for males
Post-neonatal death rate: higher for females (due to neglect)

(e) Quality of mothering - maternal care is a key determinant

(f) Untrained midwives (dais) - illiterate, unhygienic delivery practices - a major cause of high IMR in India

(g) Bad environmental sanitation - unsafe water, poor housing, overcrowding, insect breeding

PART 2 - Organization of Healthcare Delivery to Reduce Infant Mortality

Park emphasizes: "No single programme - only a multipronged approach will reduce infant mortality."

1. Prenatal Nutrition

Improve maternal nutrition - risk of infant death begins before birth
Food supplementation during pregnancy: extra 500 kcal + 10g protein in last 4 weeks → birth weight increases by ~300g (Indian controlled study)
ICDS (Integrated Child Development Services) is key programme in India

2. Prevention of Infection

Universal Immunization Programme (1985) - protection against 9 vaccine-preventable diseases for mothers and children
Immunization prevents neonatal tetanus, diphtheria, pertussis, measles etc.
Specially targets EPI diseases

3. Promotion of Breast-feeding

Most effective single measure for lowering IMR
Protects against gastrointestinal and respiratory infections
Protects against protein-energy malnutrition (PEM)

4. Growth Monitoring

Weigh all infants at least once a month
Maintain growth charts (Road-to-Health chart)
Early identification of children at risk of malnutrition
Low-cost, high-impact technology

5. Family Planning

Birth limitation + birth spacing substantially lowers IMR
Risk is greatly enhanced if:
- Last child born <2 years ago
- Mother already has ≥4 children
Wider birth spacing = improved infant and child survival in all societies

6. Environmental Sanitation

Safe water supply, proper housing, drainage, control of flies
Infant risk of dying closely related to environment
IMR = indicator of social environment quality

7. Provision of Primary Health Care (Organization)

A team-based, tiered approach:

Level	Role
Community (ASHA, dai, ANM)	Antenatal registration, home deliveries, postnatal visits, immunization
PHC (Medical Officer)	Prenatal care, high-risk detection, referral
CHC / FRU	Management of obstetric complications, EmOC
District Hospital	Special Care Baby Units for babies <2000g, tertiary referrals

Key organizational measures:

All personnel from obstetrician to local dai must work as a team
Prenatal care to detect mothers with high-risk factors (toxaemia, APH, diabetes)
High-risk mothers to be hospitalized and treated
Special Care Baby Units (SCBUs) for all babies <2000g
Proper referral services at all levels

8. Socio-economic Development

Ultimate solution lies in overall socioeconomic development:
- Spread of female literacy (most powerful single determinant)
- Safe water + basic sanitation
- Improved housing
- Growth of agriculture and industry
- Commerce and communication

9. Education (especially Female Education)

Educated women:
- Avoid early pregnancies
- Space pregnancies better
- Have better personal hygiene knowledge
- Make better use of health services
Tamil Nadu example: Mid-day meal programme + improved MCH care → IMR fell from 90 (1984) to 57 (1991) → fertility reduced to 2.5 per woman → eventually zero population growth

Quick Summary Mnemonic - Preventive Measures: "PPI-FG SSE"

Letter	Measure
P	Prenatal nutrition
P	Prevention of infection (immunization)
I	Initiate breast-feeding
F	Family planning
G	Growth monitoring
S	Sanitation
S	Special Care Baby Units / PHC organization
E	Education (female literacy)

Source: Park's Textbook of Preventive and Social Medicine, pp. 658-663

Preventive geriatrics

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Preventive Geriatrics

Park's Textbook of Preventive and Social Medicine

🧠 Opening Quote to Remember

"You do not heal old age. You protect it; you promote it; you extend it." - Sir James Sterling Ross

This IS the philosophy of preventive geriatrics.

Key Definitions

Term	Meaning
Gerontology	Study of physical and psychological changes incident to old age
Geriatrics	Clinical care of the aged (= clinical gerontology)
Social gerontology	Deals with social problems of the increasing number of old people
Experimental gerontology	Research into basic biological problems of ageing (physiology, biochemistry, pathology)
Senescence	Deterioration in vitality / lowering of biological efficiency that accompanies ageing

Size of the Problem

World elderly population (2019): 694 million (540 million in developing countries)
India (2019): 9.3% of total population above 65 years
By 2025: elderly expected to exceed 1.2 billion globally
Countries with highest proportion of elderly: Italy and Japan (~24% and 16% respectively)
Brings social, economic, and healthcare policy challenges

Health Problems of the Aged

(1) Problems Due to the Ageing Process

Disabilities incident to ageing:

Senile cataract
Glaucoma
Nerve deafness
Osteoporosis (affecting mobility)
Emphysema
Failure of special senses
Changes in mental outlook

Note: Biological age ≠ Chronological age. "Years wrinkle the skin, but worry, doubt, fear and self-distrust wrinkle the soul."

(2) Problems Associated with Long-Term Illness

Mnemonic: "CADDLE RDM"

Disease	Key Points
(a) Degenerative cardiovascular diseases	Atherosclerosis, HT, thrombus formation; major cause of death in developed countries; starts after age 40
(b) Cancer	Incidence rises rapidly after age 40; prostate cancer common >65 years
(c) Accidents	Fragile bones (decalcification); Fracture neck of femur = very common geriatric problem; more common at HOME
(d) Diabetes	~75% of diabetics are >50 years; leading cause of death in ageing population
(e) Diseases of locomotor system	Fibrositis, myositis, neuritis, gout, rheumatoid arthritis, osteoarthritis, spondylitis - cause most discomfort and disability
(f) Respiratory illnesses	Chronic bronchitis, asthma, emphysema
(g) Genitourinary system	Prostatic enlargement, urinary incontinence, renal problems

(3) Social and Psychological Problems

The aged face the triple evils (Park's famous phrase):

🔺 Poverty + Loneliness + Ill-health

Social isolation, depression, dementia
Retirement → loss of income, purpose, social role
Dependence on family, institutional care needs

Potential for Disease Prevention in the Elderly

Prevention in the elderly is categorized under three levels:

1. PRIMARY PREVENTION

(Prevent disease before it occurs)

Diet and nutrition: Adequate calories, proteins, vitamins (especially Vit D, Vit B12), calcium; avoid obesity
Physical activity: Regular moderate exercise preserves muscle strength, bone density, cardiovascular fitness, mental health
Avoidance of risk factors: Stop smoking, reduce alcohol, control hypertension and diabetes
Immunization: Influenza vaccine annually; Pneumococcal vaccine; Tetanus booster
Accident prevention: Remove home hazards (loose rugs, poor lighting), use of walking aids, hip protectors
Social integration: Maintain social contacts, productive activities; combat loneliness

2. SECONDARY PREVENTION

(Early detection and treatment)

Periodic health examination / screening for:
- Hypertension
- Diabetes mellitus
- Cancer (colorectal, prostate, breast, cervical)
- Glaucoma and cataract
- Hearing loss
- Osteoporosis (bone density scans)
- Depression and cognitive decline (dementia screening)
- Dental disease
Geriatric assessment (comprehensive)

3. TERTIARY PREVENTION

(Rehabilitation and preventing disability)

Rehabilitation after stroke, fractures, joint replacement
Physiotherapy, occupational therapy, speech therapy
Prevent complications of chronic diseases
Day-care centres and old-age homes for those unable to live independently
Home-based care programmes

Implications for Preventive & Social Medicine

Ageing population = greater demand on health services
Healthy ageing is a prerequisite for economic growth
Predicted explosion of NCDs (CVD, cancer, depression) will cause enormous human and social costs unless preventive action is taken
Developing countries face a double burden of infectious + non-communicable diseases with limited resources
Modern philosophy: The old must continue as active members of the community

Government Programmes for the Aged in India

Programme	Details
National Policy on Older Persons (1999)	First national policy for elderly welfare
Integrated Programme for Older Persons	Day-care centres, mobile medical units, old-age homes
Indira Gandhi National Old Age Pension Scheme (2007)	Monthly pension for >65 years below poverty line; ₹200/month central + state contribution
National Social Assistance Programme	Old age pension to 4+ million destitute elderly
OASIS Project	Old Age Social and Income Security - policy framework
HelpAge India	Largest voluntary organization; free cataract ops, mobile medicare units, income generation, adopt-a-gran, disaster mitigation
Travel concessions	Indian Railways, Airlines, State Transport
Tax concessions	Income tax benefits for senior citizens

Quick Revision Summary Table

Aspect	Key Points
Philosophy	"Protect, Promote, Extend" old age
Triple evils	Poverty + Loneliness + Ill-health
Commonest geriatric accident	Fracture neck of femur
Most common chronic disease cause of disability	Locomotor diseases
Prevention levels	Primary, Secondary, Tertiary
India elderly % (2019)	9.3% above 65 years
National policy year	1999
Key pension scheme	IGNOAS (2007) - for >65 years BPL
Largest NGO for elderly	HelpAge India

Source: Park's Textbook of Preventive and Social Medicine, pp. 689-693

What do you mean by adolescence? What aer hte health problems fo adolescents? Enlist preventive and promotive steps requiredot kep (2012) adolescents healthy ni India. Or

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Adolescence - Health Problems & Preventive/Promotive Measures

Park's Textbook of Preventive and Social Medicine

PART 1 - What is Adolescence?

Definition

WHO defines adolescence as the period of life between 10 and 19 years of age.

It is the transitional phase between childhood and adulthood
Characterized by rapid physical, psychological, and social changes
Marked by puberty - the biological process of sexual maturation

Stages of Adolescence

Stage	Age
Early adolescence	10-13 years
Middle adolescence	14-16 years
Late adolescence	17-19 years

Key Characteristics

Biological age of puberty and physical maturation does not vary greatly worldwide
Adolescence as a stage is influenced by economic development, social/cultural values, and historical traditions
The age at which development occurs may differ between countries in the same geographic region

India's Adolescent Population

India has 253 million adolescents (one of the largest adolescent populations in the world)
Adolescents constitute ~21% of India's total population

PART 2 - Health Problems of Adolescents

Under RMNCH+A, the priority adolescent health areas are:

1. Nutritional Problems

Anaemia - most widespread problem
- Prevalence of anaemia in adolescent girls: 72.6% (DLHS 2002-04)
- Severe anaemia: 21.1% in adolescent girls
- Iron deficiency is the main cause
Undernutrition - low body weight, stunting
Obesity - emerging problem especially in urban areas
Micronutrient deficiencies - Vitamin D, B12, folate

2. Sexual and Reproductive Health Problems

Early marriage and early pregnancy - teen mothers have highest risk of maternal and neonatal mortality
Unsafe abortions - significant cause of morbidity and mortality
Sexually Transmitted Infections (STIs) and RTIs
HIV/AIDS - adolescents are a vulnerable group
Menstrual problems - dysmenorrhoea, irregular cycles, poor menstrual hygiene
Unmet need for contraception

3. Mental Health Problems

Depression, anxiety disorders
Behavioural problems
Learning disabilities
Suicide and self-harm (adolescent suicide is a significant public health issue)
Body image issues, eating disorders

4. Substance Misuse

Tobacco (smoking and smokeless)
Alcohol
Drug abuse
India has inadequate information on the true prevalence

5. Injuries and Violence

Road traffic accidents - leading cause of death in adolescents
Gender-based violence - domestic, sexual abuse, eve-teasing
Child marriage and sexual coercion

6. Non-Communicable Diseases (NCDs)

Risk factor formation begins in adolescence (smoking, sedentary habits, unhealthy diet)
Hypertension, diabetes - seeds sown in adolescence
Rheumatic heart disease in low-income groups

7. Communicable Diseases

Tuberculosis
Vector-borne diseases (malaria)
Diarrhoeal diseases, typhoid
Worm infestations (affecting nutrition)

8. Life-Skills Deficits

Peer pressure, inability to resist risk behaviours
Poor decision-making, lack of information on health issues
Gender inequity - girls especially disadvantaged

PART 3 - Preventive and Promotive Steps for Adolescent Health in India

A multipronged approach operating at four levels: Individual, Family, School, Community

A. NUTRITIONAL INTERVENTIONS

1. Weekly Iron and Folic Acid Supplementation (WIFS)

Launched by MoHFW to address high anaemia prevalence
Covers 10.25 crore adolescents (10-19 years) across rural and urban India
Key interventions:
- Supervised weekly IFA tablet (1 tablet/week)
- Biannual deworming with albendazole
- Nutrition and health education
- Screening for severe anaemia and referral

2. Kishori Shakti Yojana

Implemented through ICDS infrastructure
Targets adolescent girls aged 11-18 years
Addresses: self-development, nutrition, health, literacy, numerical skills, vocational skills

3. Nutrition Programme for Adolescent Girls

For undernourished girls (11-19 years) - weight <30 kg (age 11-15 yrs) or <35 kg (age 15-19 yrs)
6 kg free food grain per beneficiary per month
Implemented in 51 identified districts

4. National Iron Plus Initiative (2013)

Provides IFA supplementation to children, adolescents, and women in reproductive age group
WIFS for adolescents (10-19 years) is a key strategy

B. RASHTRIYA KISHOR SWASTHYA KARYAKRAM (RKSK) - 2014

Launched January 2014 - most comprehensive adolescent health programme:

Reaches 253 million adolescents in their own spaces
Introduces peer-led interventions at community level
Supported by augmentation of facility-based services
Broadens focus BEYOND reproductive health to include:
- Life skills
- Nutrition
- Injuries and violence (including gender-based violence)
- Non-communicable diseases
- Mental health
- Substance misuse

C. ADOLESCENT REPRODUCTIVE AND SEXUAL HEALTH (ARSH) PROGRAMME

Adolescent Friendly Health Clinics (AFHCs):
- 6,302 AFHCs functional nationally
- Services for >2.5 million adolescents
- Fixed-day clinics at PHC, CHC, and District Hospital levels
- Services: contraceptives, menstrual problems, RTI/STI, ANC, anaemia
- For both married and unmarried, girls and boys
Dedicated ARSH Counsellors:
- 881 counsellors providing comprehensive counselling
- Topics: nutrition, puberty, RTI/STI, contraception, delaying marriage, substance misuse, mental health
Outreach Activities:
- Schools, colleges, teen clubs, vocational training centres
- Village Health Nutrition Days (VHNDs), health melas
- Collaboration with self-help groups

D. CORE PACKAGE OF ADOLESCENT HEALTH SERVICES (at PHC level)

Essential:

Adolescent reproductive health information, counselling and services (pregnancy, contraception, abortion, menstrual problems)
Tetanus immunization for adolescents
Nutritional counselling + prevention/management of nutritional anaemia
STI/HIV/RTI management
Referral for VCTC, PPTCT, safe termination of pregnancy

Outreach (Essential):

Periodic health check-ups in schools
Health education activities
Awareness generation and co-curricular activities

E. OTHER PREVENTIVE AND PROMOTIVE MEASURES

Area	Measures
Mental health	Life skills education, counselling, suicide prevention, stress management
Substance misuse	School-based anti-drug programmes, peer education
Gender-based violence	Legal framework (Child Marriage Act), girls' education, community sensitization
School health	Screening for anaemia, vision, hearing, dental; deworming; micronutrient supplementation
Immunization	Tetanus toxoid, HPV vaccine (girls), catch-up vaccines
Menstrual hygiene	Scheme covers 152 districts, ~1.5 crore adolescent girls in 20 states
Delayed marriage	Legal minimum age (18 for girls, 21 for boys), enforcement
Female education	Girl's education linked to delayed marriage, lower fertility, better health outcomes

F. RMNCH+A STRATEGY (2013)

Includes adolescence as a distinct life stage for the first time
Links adolescent health to maternal health, child survival, and family planning
Works through the continuum of care model across all health facility levels

Quick Revision Summary

Adolescence = 10-19 years (WHO)
India's adolescents = 253 million

Health Problems:
├── NUTRITION: Anaemia (72.6% girls), undernutrition
├── REPRODUCTIVE: Early marriage, STI, unsafe abortion
├── MENTAL: Depression, suicide, substance abuse
├── NCDs: Risk factor formation begins now
├── INJURIES: RTAs, gender-based violence
└── COMMUNICABLE: TB, malaria, worms

Preventive Programmes:
├── WIFS (Iron+Folic acid weekly)
├── RKSK (2014) - peer-led, holistic
├── ARSH + AFHCs (adolescent friendly clinics)
├── Kishori Shakti Yojana
├── National Iron Plus Initiative
└── RMNCH+A (adolescence included for 1st time)

Source: Park's Textbook of Preventive and Social Medicine, pp. 524-527

.2 Complementary feeding of infants

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Complementary Feeding of Infants

Park's Textbook of Preventive and Social Medicine

🧠 Quick Memory Hook

Exclusive breast milk (0-6 months) → Add complementary foods at 6 months → Continue breastfeeding up to 2 years or beyond

This is the current WHO/Government of India recommendation.

Definition

Complementary feeding (also called weaning) is the process of introducing foods other than breast milk to an infant's diet, starting at 6 months of age, while continuing breastfeeding.

It is a gradual process - NOT sudden withdrawal from the breast
Starts when breast milk alone is no longer sufficient to meet the growing child's nutritional needs (beyond 6 months)

"Weaning is not sudden withdrawal of child from the breast. It is a gradual process starting around the age of 6 months." - Park's

Why is Complementary Feeding Needed at 6 Months?

Reason	Detail
Nutritional insufficiency	Breast milk alone cannot sustain growth and energy needs beyond 6 months
Caloric demand increases	Rapid growth requires more energy and micronutrients
Iron stores deplete	Fetal iron stores start depleting by 6 months
Developmental readiness	By 6 months, infant can sit with support and has oral motor readiness for semi-solids

Current National Policy (India)

As per the Infant Milk Substitutes, Feeding Bottles and Infant Food Act 1992 (amended 2003, effective 1st January 2004):

Exclusive breastfeeding for the first 6 months (replacing the old 4-6 month range)
Introduction of complementary foods at 6 months while continuing breastfeeding
Breastfeeding to be continued up to 2 years or beyond

Principles of Complementary Feeding (Key Rules)

Principle	Detail
Timely	Start at exactly 6 months - not before, not after
Adequate	Sufficient quantity, frequency, and energy density
Safe	Hygienically prepared and stored
Appropriately given	Responsive feeding, age-appropriate texture
Locally appropriate	Use home-available foods

What Foods to Give - A Practical Guide

Sequence of Introduction

Age	Food type	Examples
6 months	Soft semi-solid, single ingredient	Soft cooked rice (kanji), suji (semolina), mashed dal, mashed vegetable
6-8 months	Thick porridge, mashed foods	Rice+dal khichdi, mashed banana, mashed potato, curd
8-10 months	Finely chopped foods	Soft chapatti pieces, finely chopped vegetables, soft cooked egg
10-12 months	Family foods (modified)	Small pieces of family meals
12 months onwards	Regular family foods	Same as family diet, modified in texture

Recommended foods (Park's):

Cow's milk
Fruit juice
Soft cooked rice
Suji (semolina)
Dhal (lentils)
Vegetables

At 1 year: child should receive solid foods consisting of cereals, pulses, vegetables, and fruits

Frequency of Feeding

Age	Number of meals/day
6-8 months	2-3 meals + frequent breastfeeds
8-12 months	3-4 meals + breastfeeds
12-24 months	4-5 meals including snacks + breastfeeds

The Weaning Period - Why It is Critical

"The weaning period is the most crucial period in child development"

During weaning, children are particularly exposed to the deleterious synergistic interaction of malnutrition and infection.

Improper weaning leads to:

Diarrhoea
Months of growth failure
Kwashiorkor (protein deficiency)
Marasmus (severe caloric deficiency)
Immunodeficiency
Recurrent and persistent infections (which may be fatal)

What NOT to Do (Common Mistakes)

Error	Consequence
Starting too early (<6 months)	Increased infection risk; immature gut
Starting too late (>6 months)	Growth faltering, iron deficiency, micronutrient deficiencies
Sudden weaning (abrupt)	Psychological and nutritional distress
Using bottle feeding with formula	Risk of diarrhoea, infections, loss of breastfeeding
Giving very dilute, low-energy foods	Inadequate caloric intake, malnutrition
Poor food hygiene	Diarrhoea, gastroenteritis

Local/Home-Made Weaning Foods (Park's Recommendation)

"There is now enough evidence to show that children can be properly weaned by local foods of a kind usually consumed by the older children and adults in their families."

Efforts should be made to design and promote home-made weaning foods rather than expensive commercial preparations.

Examples of good home-made weaning foods in India:

Rice + dal (khichdi) - excellent protein-calorie combination
Ragi porridge - rich in calcium and iron
Suji (semolina) halwa - energy dense
Banana mash - easy to prepare, energy-rich
Fortified atta (wheat flour) preparations

Government Targets (National Guidelines, India)

The Government of India set the following goals:

Enhance complementary feeding rate at 6 months from 33.5% → 75%
Enhance exclusive breastfeeding (0-3 months) from 55.2% → 80%
Enhance early breastfeeding (colostrum feeding) from 15.8% → 50%

Baby Friendly Hospital Initiative (BFHI) - Relevance to Complementary Feeding

Key BFHI steps relevant to complementary feeding:

Step 6: Do not provide breastfed newborns any food or fluids other than breast milk, unless medically indicated
Step 9: Counsel mothers on the risks of feeding bottles, teats, and pacifiers
Step 10: Coordinate discharge with ongoing support

Summary Table - "FAST" Principles of Complementary Feeding


Frequency	Age-appropriate number of meals per day
Amount	Gradually increasing quantity as age advances
Safety	Hygienic preparation and storage
Texture	Start semi-solid → progress to solid

High-Yield Exam Points

Point	Fact
Start age	6 months
Continue breastfeeding until	2 years or beyond
Weaning period is	Most crucial period in child development
Risk of improper weaning	Kwashiorkor, marasmus, diarrhoea
Home-made vs commercial	Home-made preferred (Park's)
Legal framework	IMS Act 1992, amended 2003
Government target (CF rate)	33.5% → 75%
Most important principle	Timely + adequate + safe

Source: Park's Textbook of Preventive and Social Medicine, pp. 630-631

Services of coiled under icds

You mean "Services offered under ICDS" - the Integrated Child Development Services scheme!

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Services Offered Under ICDS

Integrated Child Development Services (ICDS) Park's Textbook of Preventive and Social Medicine

Background

ICDS is currently the most important scheme in child welfare in India
Blueprint prepared by the Department of Social Welfare in 1975
33 pilot projects launched in October 1975 (4 urban, 19 rural, 10 tribal areas across 22 states)
Both a preventive and developmental effort
Implemented through Anganwadi Centres (AWCs)

AWC Population Norms

Area	Norm
Rural/Urban	1 AWC per 400-800 population
Tribal/Hilly/Difficult areas	1 AWC per 300-800 population
Mini-AWC	1 per 150-400 population
Anganwadi on demand	If ≥40 children under 6 years with no AWC

Objectives of ICDS

Improve nutritional and health status of children 0-6 years
Lay foundations for proper psychological, physical and social development
Reduce mortality, morbidity, malnutrition and school dropout
Achieve coordination among departments for child development
Enhance the capability of the mother through nutrition and health education

6 Services of ICDS

(The most important exam question)

Mnemonic: "SIN NRE" Supplementary Nutrition, Immunization, Nutrition & Health Education, Health Check-up, Referral Services, Non-formal Pre-school Education

1. Supplementary Nutrition

Given to: Children below 6 years + Nursing and expectant mothers from low-income groups

Caloric norms:

Beneficiary	Calories	Protein
Child 6-72 months (normal)	500 kcal	12-15 g
Severely malnourished child	800 kcal	20-25 g
Pregnant/nursing woman	600 kcal	18-20 g

Additional points:

Supplementary nutrition given for 300 days/year
Children weighed every month
Children below 3 years and pregnant/lactating mothers get "Take Home Ration"
AWC children get morning snack (milk/banana/egg/seasonal fruit) + hot cooked meal
Universal scheme - below poverty line is NOT a criterion; all are eligible
Children with Grade 2 and 3 malnutrition get therapeutic supplementary nutrition
Grade 4 malnutrition → referred for hospitalization

2. Immunization

Children immunized against 9 vaccine-preventable diseases
Expectant mothers receive tetanus immunization
Services provided through PHC/CHC/sub-centre infrastructure

3. Nutrition and Health Education

Given to all women 15-45 years of age
Priority to nursing and expectant mothers
Imparted through:
- Specially organized courses in villages
- Home visits by Anganwadi Workers (AWW)
Topics: infant feeding, weaning, personal hygiene, family planning

4. Health Check-up

Covers three groups:

(a) Expectant mothers (ANC):

Minimum 3 physical examinations
Iron and folic acid tablets + protein supplements
High-risk mothers referred to appropriate institutions

(b) Nursing mothers and newborns (PNC):

Postnatal care of mother and newborn

(c) Children under 6 years:

Record of weight and height at periodic intervals
Watch over developmental milestones
Immunization
General check-up every 3-6 months (detect disease, malnutrition)
Treatment of common diseases (diarrhoea, ARI, dysentery)
Deworming
Prophylaxis against Vitamin A deficiency and anaemia
Referral of serious cases to hospital

Health records - card containing child's health record given to mother

5. Referral Services

Cases beyond the capacity of anganwadi worker are referred
Serious cases sent to PHC, CHC, or District Hospital
High-risk mothers referred to FRUs
Referral for Grade 4 malnutrition

6. Non-Formal Pre-School Education

For children 3-6 years of age
Objective: Develop desirable attitudes, values, and behaviour patterns
Locally produced, inexpensive toys and materials used
Play-based and creative activities
Provided at the Anganwadi Centre

Beneficiary-wise Services (The Master Table from Park's)

Beneficiary	Services Provided
Pregnant women	Health check-up, Tetanus immunization, Supplementary nutrition, Nutrition & health education
Nursing mothers	Health check-up, Supplementary nutrition, Nutrition & health education
Other women (15-45 years)	Nutrition & health education only
Children <3 years	Supplementary nutrition, Immunization, Health check-up, Referral services
Children 3-6 years	Supplementary nutrition, Immunization, Health check-up, Referral services, Non-formal education
Adolescent girls (11-18 years)	Supplementary nutrition, Nutrition & health education

Delivery Mechanism

Anganwadi Worker (AWW) - key functionary; delivers most services at the AWC
Health services (immunization, health check-up, referral) - provided through Sub-centre / PHC / CHC infrastructure
ICDS is much more than a health programme - it is a social development programme

Funding Pattern

State/UT	Central : State share
General states/UTs	60 : 40
North-East & Himalayan states	90 : 10
UTs without legislature	100% central

Quick Summary: 6 Services in 10 Seconds

ICDS = 6 Services
1. Supplementary Nutrition (500 kcal/child; 300 days/year)
2. Immunization (9 diseases for children; TT for mothers)
3. Nutrition & Health Education (all women 15-45 yrs)
4. Health Check-up (ANC + PNC + child care)
5. Referral Services
6. Non-formal Pre-school Education (3-6 yrs)

Source: Park's Textbook of Preventive and Social Medicine, pp. 686-688

Services of child under icds

This is directly covered in the previous answer! Here's a focused, clean extract specifically on services provided to children under ICDS:

Services for Children Under ICDS

Park's Textbook of Preventive and Social Medicine

Children are Divided into 2 Age Groups:

Group 1: Children BELOW 3 Years (0-3 years)

Service	Details
1. Supplementary Nutrition	500 kcal + 12-15 g protein/day (300 days/year); Take Home Ration provided
2. Immunization	As per national immunization schedule (9 vaccine-preventable diseases)
3. Health Check-up	Weight & height recording, milestone monitoring, deworming, Vit A prophylaxis, anaemia prophylaxis, treatment of common illnesses
4. Referral Services	Serious/complicated cases referred to PHC/CHC/hospital

❌ No non-formal education for this age group (that starts at 3 years)

Group 2: Children 3-6 Years

Service	Details
1. Supplementary Nutrition	500 kcal + 12-15 g protein/day; hot cooked meal + morning snack at AWC
2. Immunization	Catch-up doses as needed
3. Health Check-up	Same as above
4. Referral Services	As needed
5. Non-formal Pre-school Education	Play-based learning at AWC; develops attitudes, values, behaviour patterns using locally made toys

✅ Non-formal education is an additional (5th) service only for the 3-6 year age group

Detailed Breakdown of Health Check-up for Children (Under 6 Years)

This is the most detailed service - it has 8 components:

#	Component
1	Recording weight and height at periodic intervals
2	Watch over developmental milestones
3	Immunization
4	General check-up every 3-6 months (detect disease, malnutrition)
5	Treatment of common diseases - diarrhoea, dysentery, ARI
6	Deworming
7	Prophylaxis against Vitamin A deficiency and anaemia (IFA)
8	Referral of serious cases to hospital

Supplementary Nutrition - Caloric Norms for Children

Child Type	Calories	Protein
Normal child (6-72 months)	500 kcal	12-15 g
Severely malnourished child	800 kcal	20-25 g

Additional rules:

Given 300 days per year
Children weighed every month
Grade 2 & 3 malnutrition → therapeutic supplementary nutrition
Grade 4 malnutrition → referred for hospitalization
Universal - BPL not a criterion; all eligible

Side-by-Side Comparison Table

Service	<3 years	3-6 years
Supplementary Nutrition	✅ (Take Home Ration)	✅ (at AWC - hot meal + snack)
Immunization	✅	✅
Health Check-up	✅	✅
Referral Services	✅	✅
Non-formal Education	❌	✅

Key Exam Points

Fact	Detail
Services for <3 yrs	4 services (no education)
Services for 3-6 yrs	5 services (includes non-formal education)
Calories (normal child)	500 kcal, 12-15 g protein
Calories (malnourished)	800 kcal, 20-25 g protein
Nutrition given how many days	300 days/year
Weight monitoring	Monthly
Grade 4 malnutrition	Hospitalization
Pre-school education age	3-6 years only

Source: Park's Textbook of Preventive and Social Medicine, pp. 686-688

Growth surveillance in child

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Growth Surveillance in the Child

Park's Textbook of Preventive and Social Medicine

Definition

Growth surveillance (also called growth monitoring) is a specific function of Mother and Child Health Services. It is an important component of routine anticipatory care of children.

Main purpose: To identify children who are not growing normally - so that early intervention can be taken.

Growth surveillance also reflects the effectiveness of other components of child care - nutrition, sanitation, and control of infection.

Aspects of Growth Surveillance

Growth surveillance covers:

Physical growth (weight, height, arm circumference)
Developmental milestones (motor, language, social)

1. PHYSICAL GROWTH

(a) Weight-for-Age - The Most Important Parameter

"Measurement of weight and rate of gain in weight are the best single parameters for assessing physical growth."

Frequency of weighing:

Age	Weighing Frequency
Birth to 1 year	Monthly
Second year	Every 2 months
2-5 years	Every 3 months

This age group (0-5 years) is at greatest risk from growth faltering, so regular monitoring is essential.

Normal weight milestones (Park's):

Milestone	Age
Gain ≥500 g/month	First 3 months
Double birth weight	5 months
Triple birth weight	End of 1st year
Quadruple birth weight	2 years
Weight increase in 1st year	~7 kg
Weight gain in 2nd year	~2.5 kg
Weight gain till puberty	~2 kg/year

Key principle: A single weight reading only shows the child's size at that moment. What matters is the trend over time - the direction of growth is more important than the position on the chart.

THE GROWTH CHART (Road-to-Health Chart)

First designed by David Morley, later modified by WHO

ICDS Growth Chart for Boys - Weight for age, Birth to 3 years (WHO Child Growth Standards)

ICDS Growth Chart (Boys) - Weight-for-age, Birth to 3 years, as per WHO Child Growth Standards

The growth chart is a visible display of the child's physical growth and development, designed primarily for longitudinal follow-up (growth monitoring) so that changes over time can be interpreted.

Why weight only (not height)?

Weight is the most sensitive measure of growth
Any deviation from normal is easily detected by comparison with reference curves
A child can lose weight but not height

WHO Child Growth Standards (2006)

WHO undertook a comprehensive review in 1993 and conducted the Multicentre Growth Reference Study (MGRS) from 1997-2003
Conducted in 6 countries: Brazil, Ghana, India, Norway, Oman, USA
9,440 healthy breastfed infants and young children (0-60 months) studied
Generated curves for boys and girls: length/height-for-age, weight-for-age, weight-for-length, weight-for-height, and BMI-for-age
India adopted WHO Child Growth Standards 2006 in February 2009 (within NRHM and ICDS)

Growth Chart Used in India - Zones

Zone	Cut-off	Colour
Normal	Above -2SD	Normal (white)
Undernutrition	Below -2SD	Light shading
Severely underweight	Below -3SD	Dark shading

In Maharashtra, chart additionally shows Grade 1, 2, 3, and 4 malnutrition zones

Interpreting the Chart

Pattern	Interpretation
Curve rising (upward)	Normal growth - Good
Curve flat (horizontal)	Growth faltering - Warning
Curve falling (downward)	Growth failure - Danger

"Flattening or falling of the child's weight curve signals growth failure - the earliest sign of PEM - and may precede clinical signs by weeks or months."

The objective: Keep the child in the normal zone.

Mother and Child Protection Card

A joint card developed by Government of India which records:

Family identification and registration
Birth record and pregnancy record
Immunization details
Breastfeeding and supplementary feeding milestones
Baby's developmental milestones
Birth spacing
Growth chart

Kept by the mother, brought to the health centre at each visit.

Uses of Growth Chart (7 Uses)

#	Use
1	Growth monitoring - track child health over time
2	Diagnostic tool - identify high-risk children, detect malnutrition before symptoms appear
3	Planning and policy making - provides objective basis for child health planning at local and central levels
4	Educational tool - mother educated in care of her child and encouraged to participate actively
5	Tool for action - health worker decides what action to take (counselling, referral, supplementation)
6	Teaching tool - demonstrates importance of adequate feeding, dangers of diarrhoea
7	Passport to child health care (internationally recognized)

Alternative Methods of Growth Monitoring

Growth charting is only one method. Others:

Height-for-age (stunting)
Weight-for-height (wasting)
Mid-Upper Arm Circumference (MUAC) - independent of age; especially useful when age is unknown

Growth Monitoring vs. Nutritional Surveillance

(Very important distinction - often asked in exams)

Factor	Growth Monitoring	Nutritional Surveillance
Strategy	Preservation of normal growth	Detection of undernutrition
Approach	Educational-motivational	Diagnostic-interventional
Target	All infants (individual focus)	Representative sample (community focus)
Age of enrolment	Start before 6 months; monthly	Representative ages, longer intervals
Group size	Small (10-20 per session)	50-100 most efficient
Weigher	Mothers guided by worker	Trained worker
Response	Early home intervention	Nutritional rehabilitation with supplements
Response time	Brief (resumption of normal growth)	Long (regain good nutrition in community)
Interventions	ORS, vaccines, Vit A, deworming, treatment	Food supplements, food subsidy
Referral	Health system + brief food supplements	Malnutrition rehabilitation centre

Key Exam Points

Fact	Detail
Growth chart designed by	David Morley (modified by WHO)
WHO growth standards year	2006
India adopted WHO standards	February 2009
Frequency of weighing (0-1 yr)	Monthly
Birth weight doubles	5 months
Birth weight triples	End of 1st year
Most important direction	Direction of growth > position on chart
Earliest sign of PEM	Flattening/falling of weight curve
Growth chart called	"Passport to child health care"
MUAC used when	Age unknown

Source: Park's Textbook of Preventive and Social Medicine, pp. 632-638, 747

What are the causes of high MMR ni India? Explain what steps will you take to reduce level to target level.

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Causes of High MMR in India & Steps to Reduce It

Park's Textbook of Preventive and Social Medicine

PART 1 - Definition & Measurement

Maternal Death (WHO): Death of a woman while pregnant or within 42 days of termination of pregnancy, from any cause related to or aggravated by the pregnancy or its management (excluding unintentional/incidental causes).

$$\text{MMR} = \frac{\text{Maternal deaths in a year}}{\text{Total live births in same year}} \times 1,00,000$$

India's MMR (trend):

India's MMR has significantly declined but still high
~44,000 mothers continue to die every year in India
India and Nigeria together account for ~35% of global maternal deaths
Target (RMNCH+A / 12th Five Year Plan): MMR ≤ 100 per 1,00,000 live births by 2017
SDG target: MMR < 70 per 1,00,000 live births by 2030

PART 2 - Causes of High MMR in India

A. MEDICAL CAUSES

Direct Obstetric Causes (80% of deaths):

Major causes of maternal deaths in India (2003) - Park's

Fig. 11 - Major causes of maternal deaths in India, SRS 2001-2003

Cause	%
Haemorrhage (mainly PPH)	38%
Other conditions	34%
Sepsis	11%
Abortion (unsafe)	8%
Obstructed labour	5%
Hypertensive disorders (eclampsia)	5%

Anaemia (19%) - not only a direct cause of death but also an aggravating factor in haemorrhage, sepsis, and toxaemia

Indirect Obstetric Causes (20% of deaths):

Anaemia - affects ~50% of all pregnant women; most significant indirect cause
Cardiac diseases (rheumatic heart disease)
Renal diseases
Hepatitis
Tuberculosis
Malaria (~10,000 maternal deaths/year globally)
HIV/AIDS (increasingly important)
Endocrine and metabolic diseases
Malignancy
Accidents

B. SOCIAL AND DETERMINANT FACTORS

(Park's Table 16 - Determinants of Maternal Mortality in India)

Social Factor	How It Causes High MMR
Age at childbirth	Risk highest <20 yrs and >30 yrs; optimal age 20-30 years
High parity	Grand multiparity = higher risk; 75% of deaths in high-parity women
Too-close pregnancies	Short birth intervals → maternal depletion syndrome
Large family size	Nutritional depletion, anaemia
Malnutrition	Anaemia → haemorrhage deaths; poor immunity → sepsis
Poverty	Cannot access health services; poor nutrition
Illiteracy	No awareness of danger signs; no ANC seeking
Ignorance and prejudices	Traditional preference for home deliveries, refusal of institutional care
Lack of maternity services	Inadequate ANC, EmOC, skilled birth attendants
Untrained dais (traditional birth attendants)	Unhygienic delivery - infection; inability to manage complications
Shortage of health manpower	Inadequate obstetricians, nurses, ANMs especially in rural areas
Poor environmental sanitation	Infections, puerperal sepsis
Poor communications and transport	Delay in reaching facility during emergency ("3 Delays")
Social customs	Female seclusion, preference for male child, low women's empowerment

C. THE "3 DELAYS MODEL" (Key concept for understanding MMR)

Maternal deaths in India are largely due to three types of delays:

Delay	Description
Delay 1	Delay in deciding to seek care (ignorance, poverty, low women's status)
Delay 2	Delay in reaching healthcare facility (poor transport, distance)
Delay 3	Delay in receiving adequate care at the facility (understaffed, no blood, no surgeon)

D. CURRENT STATUS OF MATERNAL CARE IN INDIA (NFHS-4, 2015-16)

Indicator	National Average
ANC in first trimester	Only 58.6%
≥4 ANC visits	Only 51.2%
Full ANC	Only 21.0%
IFA for ≥100 days	Only 30.3%
Institutional births	78.9% (rural 75.1%)
PNC within 2 days	62.4%

These gaps explain why MMR remains high.

PART 3 - Steps to Reduce MMR to Target Level

"The problem of maternal mortality is principally one of applying existing obstetric knowledge through antenatal, intranatal and postnatal services rather than developing new skills." - Park's

1. ANTENATAL CARE (ANC)

Early registration of pregnancy - ideally in 1st trimester
At least 4 ANC visits (WHO now recommends 8 contacts)
Full ANC package: BP check, weight, Hb, urine albumin, TT, IFA
Dietary supplementation including iron-folic acid for ≥100 days
Correction of anaemia - the most important preventable indirect cause
Detection and management of high-risk pregnancies (toxaemia, APH, diabetes, cardiac)
Anti-malaria prophylaxis + Tetanus immunization
MCTS (Mother and Child Tracking System) for early registration and follow-up

2. INTRANATAL CARE (During Delivery)

Clean delivery practices - prevents puerperal sepsis
Skilled birth attendant (SBA) for every delivery
Institutional delivery for all, especially high-risk mothers
Emergency Obstetric Care (EmOC) - essential: blood transfusion, C-section, manual removal of placenta
First Referral Units (FRUs) at CHC level - equipped for complicated deliveries
Active management of 3rd stage of labour (AMTSL) - oxytocin/misoprostol to prevent PPH
MCH Wings - 100/50/30 bedded maternal and child health wings at high caseload facilities

3. POSTNATAL CARE (PNC)

PNC visit within 48 hours of delivery
Monitor for postpartum haemorrhage, infection, eclampsia
Postnatal IFA supplementation
Breastfeeding support

4. KEY GOVERNMENT PROGRAMMES

Programme	Role in MMR Reduction
Janani Suraksha Yojana (JSY)	Cash incentive for institutional delivery; increases skilled birth attendance
Janani Shishu Suraksha Karyakram (JSSK)	Free delivery, C-section, medicines, transport for pregnant women
RMNCH+A Strategy (2013)	Comprehensive continuum of care approach; targets EAG states
ARSH / Adolescent health	Reduces early marriage and teenage pregnancies
National Iron Plus Initiative	Reduces anaemia (leading indirect cause)
Safe abortion services (MTP Act)	Eliminates unsafe abortion deaths
Family planning	Reduces high parity and closely spaced pregnancies

5. ADDRESSING SOCIAL FACTORS

Female education / literacy - most powerful single determinant of MMR
Delay age of marriage (Child Marriage Restraint Act)
Women's empowerment - ability to decide to seek care
Poverty reduction through socioeconomic development
Improve transport and communication - reduce Delay 2
Community mobilization through ASHA workers

6. HUMAN RESOURCES & SYSTEMS STRENGTHENING

Train and deploy more skilled birth attendants, ANMs, obstetricians
Train traditional dais in clean delivery and danger sign recognition
Ensure availability of blood banks, blood transfusion services at FRUs
Maternal Death Review (MDR) - identify cause of every maternal death and take corrective action
Equip CHC/PHC with EmOC capabilities

7. FAMILY PLANNING

Limit family to ≤2 children
Spacing births by ≥3 years
Reduces high parity and associated risks
Addresses large unmet need for contraceptives

Summary: The 3 Levels of Action

PREVENT disease:         ANC + nutrition + immunization + family planning
TREAT complications:     EmOC + FRUs + MCH Wings + skilled care
ADDRESS social causes:   Female literacy + women's empowerment + poverty reduction

High-Yield Exam Facts

Fact	Detail
Single most common cause (India)	Haemorrhage (38%)
Most important indirect cause	Anaemia
Target MMR (RMNCH+A)	≤100 per 1,00,000 live births
SDG target	<70 by 2030
Full ANC coverage in India (NFHS-4)	Only 21%
Key scheme for institutional delivery	JSY (Janani Suraksha Yojana)
Scheme for free delivery services	JSSK
Maternal death review purpose	Identify cause of EVERY death + take corrective action
Optimal age for childbearing	20-30 years
3 Delays	Decision to seek + Reaching facility + Receiving care

Source: Park's Textbook of Preventive and Social Medicine, pp. 649-656

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