40th Agenda 

40th Session Issues

Maternal and Child Health Activities

INTRODUCTION

A majority of the children born every day are born with a severe handicap. Their living environment is so underpriviledged that, because of a lack of food for their mother or the absolute lack of prenatal care, they are born with physical damage to their body. From the very start of their existence, they are at a disadvantage that will hinder them for the rest of their lives, which for most of them is only about half as long as the more fortunate. Although, at a first cursory glance, this seems to be a problem that concerns mostly less developed countries, a more in-depth look will reveal that this is not so. Children born into the wealthiest countries on this planet face dangers which range from poverty and mothers addicted to drugs, to uninformed parents who put their infants and young children "on a diet" because they believe their children are too fat, thus exposing them to qualitative malnutrition.

The first section of this report deals with some aspects of what constitutes the problems, the second with steps taken to solve these problems. While neither claims to be complete, they may provide some insight into the nature of the issue. The third section lists relevant UN documents published in 1988, and the fourth lists suggested reading/research.

DEFINITION

Despite vast improvements and continuing efforts, the problems associated with infant care, from conception through the infant's first years of life, are further from being solved than was hoped for even two decades ago. Infant mortality rates range from 5.5 (deaths per 1000 live births) in Japan to 181.6 in Afghanistan, or about 33 times as many. The number of still births (which are usually not counted in international statistics) may make that multiple even higher. It is not only the less developed countries (LDC's) whose statistics are not favorable; the USA's infant mortality rate is 10.4 (or about twice Japan's) despite some of the most advanced health care capabilities; the USSR's 25.1; and Yugoslavia's 27.3.

Why do so many of this planet's youngest and most helpless citizens die before their first birthday? The problems are legion, and many begin long before they are born.

PROBLEMS

Before Birth

1. Malnutrition:

Malnutrition is the major cause of death among infants, although usually in an indirect way. It is the single most common factor causing low birth weight (defined by WHO as below 2,500 grams at birth), which in itself is recognized as a major health hazard. A fetus that is exposed to either caloric or compositional malnutrition will not only exhibit limited physical growth, but also constraint of brain development. Some of the effects of malnutrition on the brain may not be evident until the beginning of puberty.

Not only do the effects stay with the children throughout their lives, manifesting themselves in such problems as lowered long term learning capabilities and altered behavior, even after "recovery" from the physical effects of malnutrition, all such "acquired" deficiencies are passed on to the children of the next generation by their mothers. Their effects being cumulative, according to some studies, for up to eight generations.

2. Exposure to Toxins:

Another factor endangering the proper development of the fetus is exposure to toxins through the mother's blood. The two toxins foremost in that list are alcohol and nicotine. Both of these substances are used widely throughout the world, in the developed states as well as in LDC's. In recent years many developed countries (foremost the U.S.) have begun a campaign to educate their public, especially pregnant women, to the dangers these substances pose, with some success. Unfortunately, few such programs have had much success in the third world. According to some accounts, fledgling anti-smoking programs were bludgeoned by cigarette manufacturers counter campaigns. Medical reports show that the perinatal (the time between birth and mother/baby leaving the hospital) mortality rate is 20-30% for babies whose mother smoked during pregnancy. Other "environmental" factors that may inhibit or slow development of the fetus are microbial agents (from viral or bacterial infection such as malaria), physical agents (such as radiation from X-ray machines or residual nuclear fallout) and chemical agents (legal and illegal drugs, industrial chemicals and pollution).

3. Lack of Prenatal Care:

Many of the dangers facing mother and child, either at birth or thereafter, can be detected in the early stages of pregnancy, and many of those can be defused easily. Unfortunately, not only must these services be made available, but many mothers also must be convinced to utilize those services. In other words, the functions and capabilities of health services must be "translated" into a "language" the intended users can relate to, and which they can fully comprehend. Statistics of infant mortality rates and educational levels appear to exhibit common trends, and rates tend to be higher in rural areas.

4. Short Birth Intervals:

"Kwashiokor" means, in one of the languages of Ghana, a disease occurring in a young child displaced from his mother's breast by a new baby. In many areas of Africa, the baby who displaced his older sibling is called a thief. Modern day statistics seem to verify ancient tribal customs: short birth intervals are believed to have a direct, negative effect on the well-being of the mother and the infant displaced by the new baby. Scientists propose a two-year interval between births, especially for young women.

5. Elective Abortion:

Although abortion is illegal in many states, it is practiced world-wide as a family planning and population control measure. Some argue that without utilizing all possible forms of population control, our standard of living will steadily decrease. Those abortions that are performed illegally, however, are often performed by medically unskilled personnel in less than ideal hygenic conditions and thus greatly endanger the mother's life.

DURING DELIVERY

70% of the deliveries among the rural population of India take place at home. About 75% of these are conducted by the mother's relatives, based on their previous experience with occasional childbirth. Similar numbers can be assumed for most of the poor and very low income areas of the world. Infection and mortality rates for both mother and infant are high, especially since abnormal labor is usually detected and referred late to skilled medical personnel, and the concept of asepsis is little known. In many countries, trained medical personnel are not available, and local midwives still resort to traditional methods. While being effective, this often exposes both mother and child to tetanus.

AFTER DELIVERY

1. Malnutrition:

Malnutrition poses the biggest danger for the postnatal child. It can be qualitative or quantitative or both, with effects that have both long term and short term implications. In the long term, an improper diet, especially one deficient in certain nutrients, can lead to bone diseases and improper organ functions. In the short term, insufficient nutrition (especially low caloric) leads to underweight infants - for the last two decades nutritional experts have continually emphasized the need to breast feed, at least through an infant's first year. Mother's milk not only offers the proper balance of all essential nutrients, but also seems to buffer the effect of environmental caloric malnutrition, and passes necessary antibodies from the mother on to the infant, thereby supplementing it's immunological system.

2. Diarrhea:

Diarrhea (and subsequent dehydration) is the number one cause of death among infants and young children. For example, in a Peruvian shanty town, 44% of all deaths of children under 5 years were associated with diarrhea. The causes ranged from poor nutritional status, to contaminated water sources (which are sometimes used by mothers to reconstitute powdered infant formula), to poor hygiene (especially handwashing).

3. Other Diseases:

Other diseases caused by malnutrition include nutritional blindness, endemic goitre, and nutritional anemia.

4. Early Weaning and Inappropiate Weaning Foods:

When an infant is displaced by a newborn, or the mother is not capable or willing to continue breast feeding, or feels her milk production is inadequate, feeding supplements are used. These supplements range from the cereal-based "ogi" of West Africa, to the sweet rice of Japan, to animals' milk and infant formula. Unfortunately, many of these foods are not appropriate. While the grain based foods lack animal protein, the milk of animals, especially cow's milk, may actually damage the gastro-intestinal tracts of infants. Infant formula, a man-made feeding supplement, poses it's own hazards: the powdered forms are sometimes reconstituted incorrectly; the ready-to-feed liquid formula cannot be stored well once opened; or the utensils used to rehydrate and feed are not properly cleaned and therefore act as health hazards themselves.

SOLUTIONS

Many steps have been undertaken to combat infant mortality. Programs have been started in the last decades to eradicate these problems, some by states, some by UN agencies, and some by non-governmental organizations. Through the successes and failures of these programs the world community learned that most problems are like tapestries woven of strands of little problems, each born out of different causes, means and ends. Most programs to combat infant mortality focus on one or more of these categories: deficiency in nutrition; insufficient access to medical services; inadequate levels of information.

1. Deficiency in Nutrition:

Although at first glance one might presume that this is the most severe problem causing factor, most short term damage due to malnutrition can be resolved easily. Nutritional blindness may be cured by increasing the intake of Vitamin A; endemic goitre, which afflicts 200 million people, can be effectively cured by the intake of iodized salt. The intake of iodized salt by pregnant women will also eliminate the developmental disorders of deaf mutism and cretinism. Nutritional anemia is the result of nutritional iron deficiency, and the effects can be reversed easily with proper intake of iron. Occurrences of nutritional deficiencies are not limited to the LDC's, where information and medical services are marginal, but are widespread throughout the world. Programs like the Special Supplemental Food Program for Women, Infants and Children (WIC), which has been established in the United States of America, have proven to be unsuccessful if mothers are not told that they exist or if such programs are not easily utilized.

2. Insufficient Access to Medical Services:

The "medical team density" (number of medically trained teams, consisting of at least one doctor and nurse per 100,000 population) in Ethiopia is 6.2, in Congo 200.9 and in Africa overall 101.2. In other words, on average there is a doctor for every 1000 people in Africa overall (be that a neurosurgeon or general practitioner), but only one for about every 16,100 in Ethiopia, and maybe even less in rural areas. It is quite evident that under any circumstances remotely as bad as these, most deliveries occur without any medical personnel attending. More than half the babies delivered into this world are not attended by a trained midwife or doctor. The delivery of a child is, in most instances, something that will run its course more or less the same way whether a traditionally medically trained person or local resident fulfilling the role of a midwife is there to assist (also referred to as traditional birth attendants (TBA). Unfortunately, studies show that limited or non-existant aseptic techniques may infect both mother and child, in the case of neonatal tetanus with lethal consequences. Strategies to deal with these short comings have been multifold. As the case of neonatal tetanus proves, preventative inocculation may provide adequate coverage against many diseases and infections.

Early inocculation also promises to be effective against diptheria, tetanus, pertussis, measles, and polio. The Expanded Programme on Immunization (EPI) of WHO has been at the forefront of this effort. However, present estimates suggest that only 70% of all infants in the developing countries will be covered by 1990.

Other avenues searched for effective solutions to the problem of insufficient numbers of available, medically trained personel have been the risk approach in neonatal care (whose aim it is to give some care to all persons and extra care for those at risk. It involves identifying the risk factors relevant to the local situation, screening the population for those at risk, and providing extra care to them thus allocating slim reserves where they are needed most., and programs to train TBA's medically, provide them with equipment, and have them detect and refer difficult and/or high risk cases to a proper medical facility. The most thorough program of this type was established in Fortaleza, the capital of Brazil's poorest province, where the trained TBAs manned and ran small maternity centers. The results were not only convincing, but were achieved at a very low cost.

WHO is also successfully pursuing the most obvious solution for inadequate supply of medical personnel by granting fellowships to medical students through its Regional Offices.

3. Inadequate Levels of Information:

The most surprising fact may be that once maternity and infant aid programs have been established, many of them are not well utilized by the target population. Mothers either do not know about the programs, or the procedure might be too difficult. Close relationships between maternal education levels and mortality rates have been established.

WHO assists in giving out grants for research. The results of many of those studies are published in the bulletins of WHO. The topics of the studies relate to the status of health care and its improvement; the bulk of them provide much needed data for further research, and many are pioneering new approaches to well-established problems.

4. Other WHO Involvement:

WHO led the fight that eradicated smallpox, and it is now working to ensure protection of children against six major childhood diseases. It has played a major role in the development of oral rehydration salts, which are used to combat diarrheal diseases. The WHO's Diarrheal Diseases control Programme also funds global Scientific Working Groups (SWG's), such as the SWG on Epidemiology and Disease Prevention and the SWG on Immunology, Microbiology, and Vaccine Development. WHO also sponsors meetings between experts on the subject of diarrheal diseases and their prevention, and publishes the data and findings of such meetings for world-wide use.

RELATED UN DOCUMENTS IN 1988

1. E/ICEF/RES/1988/2 - Water, Sanitation and Health for All By the Year 2000
2. E/ICEF/RES/1988/20 - Protecting the Vulnerable and Protecting Growth
3. ST/ESA/SER.12/81 - Assessing the Demographic Consequences of Major Development Projects
4. WFC/1988/4 - The Global State of Hunger and Malnutrition
5. ST/ESA/SER.A/105 - Mortality of Children Under Age Five

SUGGESTIONS FOR RESEARCH

Childbirth in Developing Countries, M. Potts, MB, B Chir, PhD, et al.

Bulletin of the World Health Organizatin (periodical).

Mortality and Health Policy, Proceedings of the Expert Group on Mortality and Health Policy, Rome, 30 May to 3 June 1983; UN Publications 1984.

Other relevant WHO publications.

Modern and Traditional Health Care in Developing Countries, Christiane I. Zeichner.

Medical publications on abnormal fetal growth and its causes; on maternal health care, infant mortality, and related issues.

SOURCES

1. Barnes, Lewis A., MD, et al., Infant Nutrition: Foundation for A Lifetime of Good Health. Philadelphia: Wyeth Laboratories, 1987.
2. Chandrasekhar, Sripati, Infant Mortality in India 1901-55. Ruskin House: George Allen & Unwin Ltd.
3. Department of International Economic and Social Affairs, Statistics Office, Demographic Yearbook 1986. New York: United Nations, 1988.
4. Department of International Economic and Social Affairs, Statistics Office, 1985/86 Statistical Yearbook. New York: United Nations, 1988.
5. Expert Group on Mortality and Health Policy, Mortality and Health Policy: Proceedings of the Expert Group on Mortality and Health Policy, Rome, 30 May to 3 June 1983. New York: United Nations, 1984.
6. Hong, Sung-bong, MD, Induced Abortion in Seoul, Korea. Seoul: 1966
7. McComas, Maggie, et al., Dilemma of Third World Nutrition. Washington, D.C.: Nestle, S.A., 1983.
8. Naftolin, Frederick, Ed., Abnormal Fetal Growth: Biological Bases and Conferences. Berlin: Dahlem Konferenzen, 1978.
9. Potts, M., MB, BChir, PhD, et al., Eds., Childbirth in Developing Countries. Boston: MTP Press Ltd., 1983.
10. Secretariat of the United Nations Commission for Africa, Population Division, The Influence of Development Related Changes on Infant and Childhood Mortality in Africa. New York: United Nations.
11. Simon, Jan, Men and Medicine in the Middle East. Alexandria: The WHO Regional Office for the Mediterranean.
12. Williamson, Richard S., The Importance of the United Nations Agencies. Washington, D.C., United States Department of State, Bureau of Public Affairs, 1988.
13. Wyeth Laboratories, What Your Baby Eats Today May Determine His or Her Health Tomorrow. Philadelphia: Wyeth Laboratories, 1983.

Periodicals:

Annual Editions: Global Issues 85/86

Annual Editions: Third World 89/90

Bulletin of WHO (62), 1984

Bulletin of WHO (63), 1985

Bulletin of WHO (64), 1986

Bulletin of WHO (65), 1987

Bulletin of WHO (66), 1988

Bulletin of WHO (67), 1989

Nursing Outlook Vol.37 No.1