AGL – MATERNAL/CHILD HEALTH IN DEVELOPMENT …



AGL 25 – MATERNAL/CHILD HEALTH IN DEVELOPMENT COUNTRIES

WORK PACK – NOT RETAINED BY PARTICIPANTS

CONTENTS

ITEM PAGE NUMBER

1. Program 2

2. Part A: Case – Pregnancy as a Disease 4

3. Part B: Case – Langford’s Village 8

4. Part C: Case – The Mahoney Clinic 13

5. Exercise: Bill Brown Series 17

6. Part D: Magic Pills 24

7. Quiz 30

Prepared as part of the PCP – 1 March 1982 FIJI/THAILAND Training Program at Johns Hopkins School of Hygiene and Public Health by: Connie Brunn, Chuck Hickerson, Richard Hardegger, Joyce Hickerson, Mary McNulty, Donna Palick and Luci De Rose with some guidance from Dr. Robert Chamberlin, Dr. Miriam Labbok, Dr. Robert G. A. Boland and Dr. Mary Young.

Boland/Young – 1982/4

1. PROGRAM

Activity Starting Duration

Mode Time (Minutes)

Day I

1. Introduction MG 8:30 30

2. quiz IND 9:30 30

3. Part A – Study Pregnancy,

& Lactating Mothers MG/SG 9:30 60

4. Break - - 10:30 15

5. Case – Pregnancy as a SG 10:45 60

Disease CSG 11:45 30

MG/SG 12:15 30

6. Lunch - - 12:45 45

7. Part B - Study Child

Development MG/SG (new) 1:30 60

8. Case – Langford’s SG 2:30 45

9. Break - - 3:15 15

10. Case – Langford’s Village CSG 3:30 30

(cont’d) MG/SG 4:00 30

11. Review and homework MG/SG 4:30 30

assignment

Total 510

Activity Starting Duration

Mode Time (Minutes)

Day II

1. Review and Bill Brown

(1-6) SG(new) 8:30 45

2. Part C – Study Common

Problems & Interventions NG/SG 9:15 45

3. Case – The Mahoney

Clinic SG 10:00 45

4. Break - - 10:45 15

5. Case – The Mohoney Clinic

(cont’d) CSG 11:00 30

MG/SG 11:30 30

6. Case – Bill Brown(7-12) MG/SG 12:00 45

7. Lunch - - 12:45 45

8. Part D – Study Family

Planning in LDC’s SG(new) 1:30 30

9. Case-Magic Pills SG 2:00 30

CSG 2:30 30

10. Break - - 3:00 15

11. Case-Magic Pills

(cont’d) MG/SG 3:15 30

12. Quiz IND 3:45 45

13. Review & Feedback MG/SG 4:30 30

Total 510

2. Part A – Case: Pregnancy as a Disease

INTRODUCTION

The Ministry of Health of a small Asian country contracted with the peace Corps to lower the IMR of the population calculated to be 204/1000 currently. The help sought was technological. The peace Corps was to supply health teams made up of a doctor, nurse and dietician. The role of Ministry was to promote the new prenatal screening set up by the medical team.

Ten percent of the pregnant women coming to the clinic were randomly selected to be interviewed for medical history and dieting habits. They were then weighed, a diagnosis made, and treated according to a set protocol. Statistics were collected to discover the problems most prevalent in this population. Malaria, worm infestations, malnutrition, and edema were the most common complaints. A high incidence of anemia was reported. Fifty percent of the women observed were suffering from anemia. This condition contributed to the severity of the other ailments presented. Of those anemia cases, only 10% were in women in their first pregnancy. Sixty percent of the cases were women of parity five or more.

Many women avoided green vegetables, legumes and grains contending that these foods were too heavy and caused flatulence. Some women were dieting to produce a smaller infant and experience an easier labor. Vegetables were being overcooked; this decreased their nutritional value.

The prenatal care program was evaluated for three years and showed excellent results. Very active participation by pregnant women was observed. A significant drop in the IMR was recorded (109/1000). The project was a model for the benefits of cooperation and support between the government, the donor organization, and the people.

QUESTIONS ON THE CASE

1. Outline the key points of the story of the case.

2. What diseases were present and what effect did they have on mother and child?

3. What interventions are called for in this target population? Decide and justify.

4. How would you are a member of the medical team implement these interventions?

AGI. 25 – MATERNAL/CHILD HEALTH IN DEVELOPING COUNTRIES

2.0 Part 6 – Case: Pregnancy as a Disease

ANSWERS

STORY OF THE CASE

a. Place: Small Asian Country

Project goal: To lower IMP from 204/1000

b. Ministry role: to promote new prenatal screening program

Peace Crops role: to provide health teams consisting of doctor,

Nurse and dietician to manage the prenatal program

c. Needs assessment: design of survey 10% randomly selected pregnant women

In Puts: Protocol establishment for health workers

Weighing

Diagnosis

Out Puts: prevalent diseases

1) anemia (50% of women examined, 10% with first pregnancy, 60% of Parity

5 or greater

(2) malaria, hookworm, malnutrition, edema

d. Evaluation – 3 years duration

- Active participation of pregnant women

- IMR dropped to 109/1000

- Model program is cooperative

DISEASES AND EFFECTS ON MOTHER AND CHILD

a. Malaria – may cause immunity if endemic in the area

- Mothers transfer immunity to child for first 6 months

- Anemia caused by malaria

- Immunity can be lowered if other diseases present (pneumonia)

- Children 6 months to 5 years vulnerable

- Pregnant mothers lose immunity (accentuated with folic deficiency)

- Major cause to LBW babies

- Small for date babies in severe infestation can bring on heat failure

b. Hookworm - blood loss can cause anemia

- in children 6-10 years severe infestation can bring on heat failure

c. Malnutrition – kwashiorkor can develop at the time or shortly after a new baby is born

- birth interval exceeded three years

- there would be a marked decline in incidence of malnutrition

d. Edema – malnutrition, therefore protein supplements are required

- pre-eclampsia risk becomes high; patient needs to be referred for medical attention

ANSWERS

INTERVENTIONS FOR THE TARGET POPULATION

a. The base of the prenatal health care program was the education effort directed at improving the nutrition of pregnant mothers emphasizing the iron needs associated with pregnancy.

b. Long range efforts were directed at spacing children to allow mothers to build up reserves for a planned pregnancy. Instruction included the role of breast feeding in resumption of menses and the use of contraception.

IMPLEMENTATION

a. Conduct a survey to find out the health beliefs of the women in the country.

b. Impress on country leaders the importance of prenatal care and nutrition.

c. Conduct nutrition, prenatal classes and organize fathers’ clubs.

d. Evaluate outcomes as to knowledge, attitudes and skills of the women in parenting and food preparation.

LEARNING POINTS

a. The nutritional needs of a pregnant woman, expecting to lactate, are significantly greater than the needs of a non-pregnant woman.

b. Specifically, a woman in the third trimester of pregnancy has iron needs six times greater than when not pregnant.

c. Traditional/cultural habits can contribute greatly to health problems when they are in direct conflict to proper health practices.

d. Positive results from a health program are dependent on integration of all levels of groups participating. Government support, quality aid by donor organization, and willingness by the people to improve.

e. The goal of any health program should be long-term self-supporting which is reflected in a successful educational effort. It should also be financially self supporting. No mention of this is made in the case.

3.0 Part B – Case: Longford’s Village

Latana, a Small village in the mountains of Viti Levu, has a small clinic which serves the miners who are Fijian and Indian. There is a railroad which operates year round except when the road bed is washed out in the rainy season. The population is 150 Indian and 200 Fijian.

The clinic had noted and reported to the government that a high IMR existed in the area. The clinic personnel were overworked, caring for the miners and asked for aid to work with the mothers and children.

The government was unable to support this effort by itself and asked U.S. Aid and UNICEF for funding and personnel.

After a year of negotiation, a peace corps primary Health person was assigned to this project. An Aide from the Ministry of Health brought Alice. Longfford to the village to introduce her to the clinic personnel and village chief. She was received warmly by the clinic staff. Later, a ceremony was held in her honor, welcoming her to the Fijian community. The next day the Indian community also welcomed her.

Alice Langford checked the few clinic records to try to determine what the main cause of infant mortality was in the communities. She noted that most Indian babies had a low birth weight, which is usually a contributing factor to early infant deaths. The Fijian babies were healthy and of normal weight until about six months old. At this time the babies’ weight gain was slightly reduced and by the time were 1-2 years old, she had a feeling that they tended to be sick more often. She also noted from Government Reports that the mortality rate for the Fijian children aged 1-4 years was consistently higher than the Indian children of the same age group. However, this could be due to non-consistent reporting.

She talked with mothers in both communities to discover what they thought about the health of their children. The mothers said most of the had lost at least one child. Most had died from measles with diarrhea complications. Some had died from pneumonia and some from whooping cough. The number of children that died and the causes of death were proportionally the same for both communities, but the ages at which the children were affected were quite different.

When Alice Langford visited the Indian community, she noticed that very little meat or fish was used in the meal preparation. The diet was mainly rice and vegetables. Nursing babies were fed small amounts of mashed rice and vegetables starting about six months.

The Fijian diet was completely different. Their diet consisted of meat, fish (when they could get it) and root vegetables. Mothers breast fed their babies for two years using mashed white tubers as a supplemental feeding.

Working in both communities Alice Longford noted several families in each community who had not lost any children. Their children were all healthy. In talking with the mothers of these children, she discovered their eating habits, and the supplement used to feed their nursing babies were slightly different than their neighbors. Ground nuts were mashed and added to the Indian porridge. The Fijian mothers of healthy children were using yellow tubers and adding a small amount of fish. She worked with these mothers of healthy children to communicate their dietary and weaning practices to other mothers.

All mothers in the community wanted to know how to stop the measles, whooping cough and pneumonia which were so prevalent. With their help, an immunization program was developed. The use of oral rehydration for dehydrated babies was started. Health classes were initiated.

At the end of Alice Longford’s two years in Latana, mothers were more aware of the techniques of oral rehydration and were not so resistant to administering the solutions.

AGL 25 - MATERNAL/CHILD HEALTH DEVELOPING COUNTRIES

3.0 Part B – Case: Langford’s Village

QUESTIONS ON THE CASE

1. What are the key factors of this case?

2. What difference of diet did you note in this case among the adult population?

Weaning population?

3. How did the dietary habits of each community contribute to the age discrepancy of their Mortality Rates?

4. Was the weaning practices of the communities the only problem? How did the weaning Practices contribute to the other problems?

5. How were these problems resolved by the community with the aid of Alice Longford?

ANSWERS TO THE CASE

STORY OF THE CASE

a. Mountainous area in Fiji

b. Fathers were miners—wages, bought food accessible by railroad most of the year

c. Population: two cultures—150 Indian 200 Fijian

d. Funding: U.S. Aid—UNICEF—Ministry of Health

e. High Mortality Rate caused by measles with diarrhea, pneumonia, whooping cough, malnutrition.

f. Indian babies died early prior to six months.

g. Fiji babies died at 1-2 years.

h. Different dietary habits.

DIETARY DIFFERENCES

a. Indians ate rice and vegetables.

b. Fijians ate meats, fish, tubers and vegetables.

c. Supplemental food for Indian babies was mashed rice and vegetables.

d. Supplemental food for Fiji babies was white tubers.

DIET AND MORTALITY RATE

a. Most of the Indian population had insufficient protein for adults.

b. Rice and vegetables would give a balanced diet. This fact was most important when applied to the pregnant women.

c. It led to malnurishment of the developing fetus, resulting in a Low Birth Weight. Low Birth Weight newborn is more susceptible to disease and infection.

d. The Fijian population had healthy, normal weight newborns; however, at about six months with the addition of too little protein supplement the child gradually became malnourished, with increasing susceptibility to disease and infection, because the nutritional demands increased with growth.

WEANING AND OTHER PROBLEMS

a. A malnourished child is less resistant to measles, whooping cough, pneumonia. Measles causes protein wastage.

b. Disease or infection tends to impact harder on a malnourished child.

PROBLEM RESOLUTION

a. Longford involved mothers of healthy children to teach their dietary and weaning

Practices to others of the community. She had to overcome community resistance and backlash. The traditional healers would give her the “evil eye” treatment.

b. An immunization program was get up to prevent measles, whooping cough, and tetanus.

3.6 LEARNING POINTS

a. Different cultures have different problems even living in close proximity.

b. Discover that the community views as a problems. They will try to change if they perceive a problem and are involved in the solution.

c. Local help and support are vital to any long lasting MCH program.

d. Making use of knowledgeable local individuals can increase the effectiveness of the MCH.

e. To have a healthy pregnancy and baby, the woman must have sufficient amounts of protein, energy foods and protective foods prior to, during, and after pregnancy.

f. An undernourished mother has a higher risk of a Low Birth Weight (LBW) baby.

g. LBW infants are much more susceptible to disease.

h. Any malnourished baby is more susceptible to disease.

i. Proper food supplementation is mandatory for a normal growth pattern of the child. (White tubers have little protein or protective food in them.)

j. Use combinations of local foods for breast supplement.

k. Mothers need to replenish own stores between infants, especially if CBW is common; therefore family planning is important.

4.0 Part C – Case: The Mahoney Clinic

As a peace Corps volunteer, Mahoney was assigned to work in a remote village in rural Fiji. The 6000 residents of this village are mostly subsistence farmers. They live in an isolated, mountainous district traveled by a few poor roads, with no electricity and an unreliable water supply. Funding is by international donors.

Although they comprise only 20% of the total population, the 1000 children under five accounted for almost one-half of all the deaths in the district. A group of missionaries who were in the country prior to your arrival assessed diarrhea, malnutrition, pneumonia, polio, measles, and whooping cough as being prevalent.

The people of the village believe illness is caused by evil spirits, a vengeful relative or neighbor, or by a personal violation of a taboo. Because of this, they seek the help of the traditional healer. Skills in traditional healing are a specialization of the priests who then pass their knowledge on to members of their family or lineage. This position holds many privileges and authority, and knowledge of this art is, there-fore, closely guarded.

Villagers afflicted with an illness, symptoms of which being frequent headaches, earaches and general weakness of the body that may confine the victim to his/her bed can only be diagnosed by a traditional healer. The seer identifies the cause of illness: Whether by spirits through human agents (sorcerors and the like), by the spirits themselves acting directly on the victim and those complaints related to bodily dysfunction, by the use of leaves or by the use of cards by fortune tellers. The patient is then either referred to a traditional herbalist or, as in a few cases, where the traditional seer is knowledgeable of the plant and herbal cures used, prescribes some remedy for treatment.

The most common method of preparation of remedies observed and noted was the shred method, where leaves are shredded into a bowl, water is added, and the mixture squeezed with the fingers. The mixture is drunk by the patient.

Based on this information, Mahoney decided to set up an “under five” clinic. Two local nurses are assigned to work with him on this project.

QUESTIONS ON THE CASE

1. What are the key points of the story of the case?

2. What is the target group?

3. How should Mahoney deal with this situation?

4. How do you feel the village will react to his ideas?

5. What type of programs should Mahoney set up?

AGL 25 – MATERNAL/CHILD HEALTH IN DEVELOPING COUNTRIES

4.0 Part C – Case : The Mahoney Clinic

ANSWERS TO THE CASE

4.1 STORY OF THE CASE

a. Rural isolated village, 6000 population, few roads, no electricity,

and unreliable water supply

b. Traditional healers used; people believe that illness is caused

by “spirits”

4.2 TARGET GROUP

a. Rural women pregnant/lactating

b. Children 5 and under

4.3 DEALING WITH THE SITUATION

a. Learn/know language (s) and learn/know cultural norms.

b. Contact healers and establish rapport.

c. Gain support of healers and educate healers so the they begin

to adopt safe methods for health care delivery.

d. Set up under-five clinic. Encourage healers to refer patients to clinic.

4.4 VILLAGE REACTION

a. Skeptical at first and therefore difficult to convince

b. Benefits observed by healers when they assisted at the clinic

c. Local training for auxiliaries was accepted

4.5 PROGRAM TO BE SET UP

a. Screening risk pregnancies

b. Immunization

c. Health education

d. Family Planning

4.6 LEARING POINTS

a. All communities have resources and traditional medicine which must

be understood before appropriate MCH care intervention.

b. Only integration with government systems ensures long-term large

Scale continuity without international financing.

c. Recruitment of local auxiliaries for MCH work enables easier acceptance

and training for establishment of health surveillance and MCH care.

d. Need to know the population well and to anticipate cultural reactions

before projects begin, thus targeting aid appropriately to the

population at risk.

e. Selective MCH care can sometimes be as effective as comprehensive

MCH care.

5.0 EXERCISE – BILL BROWN

1. Lewis’s MCH Program

A peace corps volunteer is sent into a community to start an MCH program. What information is needed before beginning and how would the volunteer obtain the information?

2. Anemia in Pregnant Women

A pregnant woman shows up at a rural Asian Clinic, complaining of weakness. She is 24 years of age. This is her fourth pregnancy. Main diet in this area is rice. Comment on nutrition and maternal aspects of the situation.

3. Oral Rehydration Case

Joyce Hickerson, a community health worker, goes out into the field. On assessing newborns in her area, she finds one that is emaciated. It is reported that diarrhea is common in newborn and young children. What could be the problems in this village?

4. Cultural Patterns and Beliefs

As area is plagued with a high incidence of malnutrition in women of child-bearing age and children under five. Water supply is often contaminated and there is a high mortality and morbidity from diarrhea. Commercial companies have just carried out an extensive promotion of formula feeding nearby. Connie, a Peace Corps Volunteer, noticed an increasing number of women in her village have stopped breast-feeding infants at one year of age; an increase in incidence of bad milk syndrome in which the mother eels her milk is harming her baby, was observed.

There is now a higher rate of diarrhea and death in those infants. What measures need to be taken to reverse this trend?

5. Hardegger Problem

Richard Hardegger, a health worker, was asked by a pregnant woman: “Should I breast-feed my child?” “Why sure, breast feeding is good or both mother and child.” Not satisfied with the answer, the woman questioned another health worker and the following conversation was started:

Woman: “Should I breast-feed my child?”

Health Worker: That’s a good question. What are your thoughts?”

Woman: “I’ve heard that breast-feeding is better for the baby.”

Health Worker: “Where did you hear that?”

Woman: “From my mother.”

Health Worker: “I would like to hear your reasons.”

Which approach to answering the question would you choose? Explain your answer.

6. Immunities in Newborn Babies:

A health care worker noted that during an outbreak of measles in a small Asian Village, all the children contracted the disease except five. All five healthy children were under one year old. The Health Case Worker questioned the mothers of the five children to find out why they didn’t get sick. What common factor did the women have in their health histories which gave these children protection? How did this affect the children?

7. Community Assessment

You are assigned to a rural district with about 30,000 persons scattered about in several villages connected by dirt roads which are often impassable in the rainy season.

The nearest medical facility is a small mission hospital about 30 km. away with one physician and several nurses. Most of the illnesses in the villages are treated by local indigenous healers and the deliveries are attended in the home by traditional birth attendants.

About 60% of the population is made up of mothers and children and most of the mothers are illiterate. Infant mortality rates are 150/1000 live births, most of which are caused by various combinations of diarrhea, pneumonia and malnutrition. There is also a high incidence of neonatal tetanus, measles, whooping cough and polio. Maternal mortality is 10/1000 live births and is related to infection, hemorrhage and arrested labor. The average mother has eight pregnancies during her childbearing years.

You have just arrived fresh out of Peace Corps Training. Outline your initial actions toward developing an MCH program for the district.

8. Non-Responsive Baby

A mother brings her 6-month old child to a health volunteer, stating that the child is apathetic, doesn’t vocalize and is not eating well. After discovering no clinical sings, the health volunteer asks for a recent history of her child’s activities. The child was usually by a 5-year old sister. The parents worked in fields all day. The infant was breast-fed once during the day (morning) and once at night.

Comment on problems with this child. What can be done to correct this situation?

9. Hemorrhaging Mother

You are a doctor working in several villages in rural Sri Lanka. There is a mother in one village who is hemorrhaging and needs a Caesarean done immediately. However, you are expected in the next village where 200 pregnant mothers are waiting to be seen. You can be at only one place – what do you do?

AGL – 25 MATERNAL/CHILD HEALTH IN DEVELOPING COUNTRIES

5.0 EXERCISE – BILL BROWN

10. Traditional Birth Control Methods

You are out in the community trying to start an Outreach Family Planning Program. You begin talking to the local people and they tell you that they douche with herbal tea. THJis system seems to work.

11. Inappropriate Family Planning Methods

As a conscientious community health worker, you cdecide to plan and organize a family planning service within the already established MCH program. You decide to have your program consist of mainly spermicides and condoms. After you begin the program, you find that none of the local people seem to care about your program, and none are using any of the services. What could some of the reasons for this be?

12. Quality vs. Quantity

A mother comes into the clinic with a6 month old child that is slightly underweight and thin for her size. The mother’s history shows fivr pregnancies in the last six years. Three children are living, one infant was stillborn, one child died at four months. She is very anxious to have another child now. What arguments would you present to persuade har to wait one to two years before her next pregnancy?

13. Explanation of Family Planning

You and your in – country supervisor are discussing the MCH program. You begin to talk about family planning, but you find that he/she doesn’t understand wg\hy family planning should be an important part of the MCVH program. You have to explain why family planning is such an important aspect of MCH. What would you say?

AGL – 25 MATERNAL/CHILD HEALTH IN DEVELOPING COUNTRIES

5.0 EXERCISE – BILL BROWN SERIES

ANSWERS

1. Starting an MCH Program

He would need to obtain information concerning language and customs through educational agencies available; establish communication with the leaders of the community first.

2. Anemia in Pregnant women

a. Get patient’s history, may show incidences of bleeding

b. Possibility of anemia

c. Diet needs protein source (lentils, fish, etc) and iron

d. Needs counseling on spacing/family palnning

3. Oral Rehydration Case

Mothers may be stopping breast feeding during diarrhea. Have them continue breast feeding with oral hydration procedure.

4. Cultural Patterns and beliefs

Needs:

a. An educational program, stressing the advantages of breast feeding

b. To continue breast feeding

c. Electrolytes replaced in diarrhea patient

d. Safe water supply or instructions on how to boil water

e. To instruct mothers in correct way of bottle feeding if unable to breast feed.

5. Hardegger Problem

By assuming a neutral attitude, the medical person can learn the true motives behind a patient’s choice and give a constructive report. This approach shows more concern for the other person.

6. Immunities in Newborn Babies

All the mothers had measles when they were children. Their active immunity was passed on to their babies in a weaker form. This “passive” immunity, however, wears off in about nine months. The child then needs to be immunized along with the older children.

7. Community Assessment

a. Contact local officials for permission and help.

b. Try to work with clinic.

c. Develop target priorities – in this case I M R

d. Train help and work with traditional healers and birth attendants, if invited

e. Integrate family planning to complement improved care of children

f. Develop an education program in sanitation, and an immunization clinic to combat tetanus, measles, whooping cough and polio.

8. Non-Responsive Baby

a. Malnutrition – needs more frequent feedings

b. Poor motor, social and speech development

c. Procedure: Monitor child’s weight. Actual handling of child to witness responses. Ask mother, father, neighbours about home conditions. Play with the child at each weight session to record responses.

d. Explain to parents the need for environmental stimulation. Teach parents, and sisters how to play and talk with baby. Assess amount of stress present and perhaps advise on coping with stress.

9. Hemorrhaging Mother

You must look at what can be done to benfit the most people. You must get to the village where the 700 mothers need you. Actual case : Hemorrhaging mother lost her baby, but she was saved. The doctor went to the 700 mothers who were expecting him. Hemorrhaging can mean a lot of things, and the analysis may be complex and the treatment costly.

10. Traditional Birth Control Methods

Should you convince the local people to use your method ? May be try to incorporate your method with their method. Look at other reasons for success besides the douching. Or see if this is cognitive dissonance, i.e., since they have no other method, they depend on the one they have.

11. Inappropriate Family Planning Methods

Haven’t consulted the local people on their input. These may be culturally inappropriate methods of family palnning for this community. The local people may not understand why family planning is important, or how it fits into their life style. You didn’t research enough into the problem.

12. Quality v. Quantity

Mother is underweight and needs time to recover from last pregnancy. The six month old child is underweight and needs to be breast – fed for another year. Discuss the quality of the living children vs. quantity.

13. Explanation of Family Planning

The health of mother and children could be improved with improved birth spacing practices. It is importrant that the quality of health be stressed. Maternal mortality rates and infant mortality rates could go down if mothers had less children, two to three years between each birth, and less children to feed and care for at the same time.

AGL – 25 MATERNAL/CHILD HEALTH IN DEVELOPING COUNTRIES

6.0 PART D: MAGIC PILLS

From November 1968 to June 1970 a Family Planning experiment was conducted using three very successful under – 5’s clinics in the Howrah District of West Bengal, India. The experiment was funded jointly by two organizations, IPFF and the Indian Ministry of Health. The objective of the study was to compare the acceptability and effectiveness of orals among women in urban, rural and slum areas.

The three clinics were located as flows: One in the central city of Howrah, one in the slum area of the same city, and the third in a rural clinic seven miles from the city. Each clinic served approximately 10,000 people.

Eligible women were determined by screening the women who brought their children to the under-5’s clinics. Lists of all women not currently using contraceptives were compiled. These women made up the eligible women used for the experiment. The majority of the eligible women in the central city were literate. The majority of those eligible in the rural and slum areas were illiterate.

Oral contraceptive were distributed by the clinics free of charge. Social workers who were trained expatriate PHC workers made home visits to eligible couples to register them, to convince them to go to the clinic and to make clinic appointment. In urban areas the program had been publicized before initiation. In cases of rejection or broken appointments, these social workers made two or more family planning education visits. If there were no contraindications found when the woman visited the clinic, the she was given the oral contraceptives.

One year after initially receiving the pills, the women were re-contacted by the PHC workers to determine if the pills were being used. In re-contacting the women using the orals, the PHC workers discovered that the majority of the women in all three areas replied that they were conscientiously using the pills. The results are shown in Exhibit A. The cumulative continuation rates were highest for rural areas; slum acceptors showed the highest drop-out rates. The experiment demonstrated that women in rural areas who are likely to be illiterate, will accept the pill.

In addition to these results, the PHC workers discovered that several of the rural and slum area women who reported that the pills had been faithfully taken, became pregnant, and they were upset.

AGL 25–MATERNAL /CHILD HEALTH IN DEVELOPING COUNTRIES EXHIBITA

6.0 PART D: MAGIC PILLS

EXHIBIT A

ACCEPTANCE OF RURAL CONTRACEPTIVES AND

CONTINUATION RATES AMONG URBAN, RURAL

AND SLUM WOMEN IN WEST BENGAL, INDIA

| | Perctg. of Acceptors |

| |continuing |

|Place |Observations |Number of Acceptors |Percentage Accepting |12 Cycles |18 Cycles |

|Urban |Majority were acceptors |203 |42.7 |77.6 |66.7 |

| |prior to visit | | | | |

|Rural |Most accepted after one |106 |24.4 |87.7 |85.1 |

| |contact | | | | |

|Slum |Most accepted after two |158 |31.8 |47.4 |33.3 |

| |contacts | | | | |

QUESTIONS ON THE CASE

1. What are the key factors in the story of the case?

2. How was the project planned?

3. What are the important characteristics of the three different groups targeted?

4. What results did the project achieve?

5. How can the results of the experiment be interpreted in relation to the program

objectives?

6. Can the results of this project be interpreted to be valid for the whole country?

7. Why did the women in the rural and slum areas get pregnant ?

ANSWERS TO THE CASE

1. STORY OF THE CASE

a. Funded by two organizations – IPPF and Indian Ministry of Health.

b. Family planning experiment for 1½ years, West Bengal.

c. Objective: To compare acceptability and effectiveness of orals among women in urban, rural and slum areas.

2. PLANNING

a. Three clinics: one in central city (literate),

one in slum area of central city (illiterate)

one in rural clinic 7 miles from city (illiterate).

Each served 10,000 people.

b. Targeted women who brought kids in under-5’s clinic. Made lists of those not using contraceptives – those were the ones targeted.

c. Pills distributed for free.

d. Trained social workers were expatriates – make home visits.

e. Re-contacted women after starting pills – most said they were using faithfully. Highest use in rural areas, highest drop-outs among slum area.

f. Some women who said were taking pills reported getting pregnant.

g. There was no provision for problems. The social workers were expatriates, there was no involvement of local people, no education for the women getting the pills.

h. Target group is far too small to test effectiveness.

i. Users might not know that family planning is available in clinics.

3. TARGET GROUPS

a. The rural and slum groups were illiterate. The central city people were literate.

b. Living in different areas may have different social and cultural perspectives.

c. Living in different areas may have different nutrition levels, use of traditional family planning methods, duration of lactation, relationship with the clinic, etc.

Randomly selected 10% of the women who brought their kids to the under-5’s clinic. Made lists of those not using contraceptive – those were the ones targeted.

4. RESULTS

See Exhibit A for details.

a. Illiterate women will accept the pill. Several of the rural and slum area women got pregnant. Family planning continuation rates?

5. RESULTS IN RELATION TO PROGRAM OBJECTIVES

a. Showed all three groups accepted the pill.

b. Groups may not be comparable for age, parity, SES, etc. Information is not provided. Not enough data to measure effectiveness.

6. VALIDITY

a. No. These areas may not be typical for the rest of the country. Selection of areas was not explained.

7. PILLS AND PREGNANCIES

a. Possibly the women got pregnant because they were not using the pill correctly, since they were not properly instructed on how to use the pill.

b. Since they knew pregnancy resulted from intercourse with their husbands, they gave their pills to their husbands. (True story!)

c. They were also on TB therapy or antibiotics which negate the effect of the pill.

8. LEARNING POINTS

a. In setting up a Family Planning program, the participants need to be instructed in and demonstrate understanding of the proper use of the method.

b. Local workers should be used is possible to anticipate cultural problems that may be overlooked by expatiate workers.

c. When approaching women in different communities, their differences should be taken into account.

d. When related services are offered in one geographic area they should be integrated if, and only if, integration does not cause negative effects on any of the services. New services should attempt to be integrated into existing programs, if appropriate.

e. In working with Family Planning programs, person-to person contact

f. In starting a Family Planning program, follow-up contact is necessary.

g. Even if the results of a program are those that follow from the objectives, problems can still arise. In developing a program or interpreting results be sure to include or recognize a PFD (Plan For disaster). Study design should not be attempted alone.

h. Family planning is not easy skill. Trading, supervision, logistics and availability are necessary to assure ongoing success.

AGL 25 – MTERNAL/CHILD HEALTH IN DEVELOPING COUNTRIES

7. QUIZ - A TEST OF KNOWLEDGE ACQUIRED FROM THE PROGRAM

CHOOSE THE MOST CORRECT ANSWERS:

1. All of the following are reasons why development of MCH programs should have

high priority in developing countries except:

a) Children are the future of a country.

b) Pregnant mothers and children are the most vulnerable to health problems.

c) To stimulate agriculture economy by increasing food consumption.

d) Children and mothers make up the majority of the population.

2. A three-month old child being breast-fed has diarrhea; the mother should do all of the following except:

a) Stop breast-feeding.

b) Continue breast-feeding.

c) Begin ORT

d) Keep breast clean.

3. Mortality differs from morbidity in that:

a) Mortality indicates death by disease; morbidity shows affliction.

b) Mortality indicates affliction; morbidity indicates death by disease.

c) They are the same.

d) Morbidity indicates the number of diseases populations is exposed to.

4. The example of a factor of high risk pregnancies is:

a) Children spaced three years apart.

b) Parity of 6.

c) Mother at age 26.

d) Pre-pregnancy weight of 125 pounds.

5. Things to consider in gathering survey information from your community include:

a) language

b) culture

c) target population

d) All of above.

6. Symptoms of measles include all of the following except:

a) Coryza

b) Fever

c) Cough

d) Jaundice

7. To successfully rehydrate a child suffering from dehydration, one needs to :

a) Stop breast-feeding

b) Limit food intake.

c) Limit fluid intake

d) Replace lost electrolytes.

Match column I to column II:

I II

8. Sepsis (a) Protein/Carbohydrate deficiency

9. Coryza (b) contraceptive

10. Edema (c) Retain water

11. Kwashiorkor (d) Running nose

12. Marasmus (e) Infection

13. Injectable (f) Protein deficiency

14. Which of these childhood diseases is not preventable?

(a) Tetanus

(b) Measles

(c) Polio

(d) MS

15. Which of the following is incorrect?

(a) L D C Less developed country

(b) M C H Maternal/child health

(c) FP Family planning

(d) C H W Cooperative Health Worker

16. Which of the following is incorrect?

(a) L B W Low Birth Rate

(b) IPPF International Planned Parenthood Federation

(c) P H C Primary Health Care.

(d) O R T Oral Hydration Therapy.

17. Which of the following is incorrect?

a) W H O World Health Organization

b) C D C Center for Disease Control

c) A G L Autonomous Group Learning

(d) T B A Traditional Bath Attendant

18. During which trimester does the fetal body composition increase with fat?

(a) First trimester

(b) Second trimester

(c) Third Trimester

(d) Fourth trimester

19. What diseases may the mother contract during pregnancy which could cause possible congenital defects?

(a) Athlete’s foot

(b) Kidney disease

(c) Measles

(d) Parkinson’s

20. A newborn’s heart rate will average about:

(a) 180 beats/min.

(b) 100 beats/min.

(c) 60 beats/min.

(d) 240 beats/min.

21. What percent solution of silver nitrate is placed in newborn’s eye at birth?

(a) 100%

(b) 11%

(c) 10%

(d) 1%

22. Bonding is necessary for all of the following except:

(a) Normal feeding habits

(b) Normal sleeping habits

(c) Normal heart rate of child.

(d) Normal development of instinct for support.

23. A commonly used growth chart in L D C is called:

(a) “Healthy baby chart”

(b) “Road to health chart”

(c) “Child Growth chart”

(d) “Monitored Growth chart”

ANSWER TRUE OR FALSE

24. A natural immunity system is transferred from the mother to the infant by breast feeding.

25. Breast feeding is sufficient Food supply for the 4-6 month child.

26. Babies should be fed three times a day in large quantities.

27. If a child is not developing as rapidly as his peers, it would be correct to say he is retarded.

28. The following are high risk factors of pregnancy that can be plotted on a J curve, except

(a) maternal age,

(b) parity

(c) birth interval

(d) time or year

29. Factors to consider when Setting up a Family Planning Program includes all except:

(a) risk/benefit

(b) acceptability/culturally appropriate

(c) accessibility and cost

(d) personal bias

30. Breast-feeding is a method of family planning because it causes:

(a) decreased prolactin levels

(b) Sterilization

(c) Anovulation

(d) Production of lutenizing hormone.

31. A family planning program which charges a fee in commodities may do all of the following except:

(a) generate cash income

(b) Increase acceptability

(c) Increase the value of the service

(d) Lower user motivation

32. Child spacing is a less appropriate term to use when talking about family planning in many LDC.

33. In talking about family planning, the quantity should be stressed, not the quality.

34. The risk of pregnancy versus the risk of using a particular method of birth control is what is meant by risk/benefit.

35. In countries where large families are valued by the culture, there are few abortion problems.

36. Outreach programs are generally poor programs because of the cost of training family planning personnel.

38. Different cultures have different problems even living in close proximity.

39. An undernourished mother has a higher risk of a Low Birth Weight (LBW) baby.

40. LBW infants are much more susceptible to disease.

41. Specifically, a woman in the third trimester of pregnancy has iron needs six times greater than when not pregnant.

42. The goal of any health program should be long-term self-supporting which is reflected in a successful educational effort. It should also be financially self-supporting.

43. All communities have resources and traditional medicine which must be understood before appropriate MCH care intervention.

44. Only integration with government systems ensures long-term large scale continuity without international financing.

45. Recruitment of local auxiliaries for MCH work enables easier acceptance and training for establishment of health surveillance and MCH care.

46. Selective MCH care can sometimes be as effective as comprehensive MCH care.

47. In working with Family Planning programs, person-to-person contact is necessary.

48. In setting up a Family Planning program, the participants need to be instructed in and demonstrate understanding of the proper use of the method.

49. Even if the results of a program are those that follow from the objectives, problems can still arise. In developing a program or interpreting results be sure to include or recognize a PFD (Plan for Disaster).

50. Family Planning is not an easy skill. Training, Supervision, logistics and availability are necessary to assure ongoing success.

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