Perinatal and Neonatal issues.

1. Perinatal and Neonatal issues. With special reference to a vulnerable group Dr.N.S.Iyer Consultant, Maternal & Child Health

2. Joyful Motherhood The process of Pregnancy is a Physiological synergism in which Mother, Foetus and Placenta collaborate to sustain a new life. • Pregnancy should be a joyful one • with a positive outcome and not nothing to • worry about for the rest of the life.

3. The period of pregnancy is 40 weeks- • First 8 weeks –it is an embryo • First three months -organs develop • Second three months –Rapid growth • Third three months –Organs mature • Chances of survival depends on the period of prematurity -longer the period of prematurity shorter is the survival rate.

4. Demands of Pregnancy • Additional 40 K calories /day to meet the metabolic work load • Vitamins A –Tissue growth • B- Co enzymes for all enzymatic activities • Folate –Maturity of RBCs and Neural tube • D-Utilization and absorption of calcium • Minerals and Vitamins –Structural metabolic requirements • Calcium and Vit D for Foetal bone growth • Iron for increased Hb synthesis • Iodine for controlling the basal metabolic rate

5. Early embryonic stages

6. The Human metamorphosis

7. Good nutrition Morbidity & Mortality Adequate food, Supplements Safe drinking water Education, work Skilled Birth attendant Alcohol, drugs Teenage marriage Poverty, malnutrition Good Resources, AN care healthy lifestyle Poor resources, AN care Pregnancy 20-25 yrs Healthy adolescent

8. “The most vulnerable population in Kerala”

9. IMR - India 44 per 1000 IMR - Kerala 13/1000 5% of Infants born do not survive 1 year 33 Infant deaths from 430 deliveries in 2012-13.10 Infant Deaths in April-May 2013. Unacceptably high abortions High rates of pre term births.

10. The scenario in Attapady “the most vulnerable population in Kerala” Inter district difference Intra district differentials Major problem : (in a belt around 25 km from Mukkaly to Anakkatty ) Dry , no gain from land No livelihood, Poverty and malnutrition rampant.

11. What is happening in Attappady No regular income–poor food sharing in the family- Unhealthy Girl child No formal education-No Nutritious diet-No Clean Drinking water Very rampant adolescent anaemia Poor menstrual hygiene - Prone to infection.

12. Prevalence of Sickle Cell trait • Pre Pregnant weight most often less than • 35 kg on an average. • Teenage Pregnancy . • Wide prevalence of inbreeding in Irulas • and Mudugas in Attappady • No early registration and no full ANC • Undetected Diabetes & Hypertensive • disorders

13. No regularity in Food given in the ICDS – Take home food from ICDS centres shared by all in the house hold • Gross Iodine Deficiency • No proper drinking water supply –Jalanidhi scheme a failure in Attapady. Increased Fluoride content in the water. • No Nutritious diet .No Iron, Calcium, Vitamin and mineral supplementation. • Habituated to smoking, alcohol and drugs abuse • Poor Knowledge on danger signals and improved health seeking behaviour • language barrier

14. Access to good quality Care a major problem : • Difficult to reach the institutions. • Even now there are Domiciliary deliveries • No assured Skilled attendance during delivery • No Quality New Born care • No Quality Post natal care.

15. Nutritional health of mother and the outcome of pregnancy are interrelated. Malnutrition among pregnant woman may be responsible not only for low birth weight and congenital malformation, but also for the Pre natal and neo natal mortality and morbidity.

16. Nutrition - crucial for the fulfillment of human rights , especially those of the most vulnerable children, girls and women, locked in an intergenerational cycle of multiple deprivation. It reduces susceptibility to infections, reducing related morbidity, disability and mortality,.

17. Consanguinity or inbreeding in humans through marriages among close relatives that is widely prevalent in the tribal areas also contribute to foetal wastage in the pregnant tribal's in the pre natal and Neo natal period. Prof Mathew formerly of Kerala University-Expert, Population genetics Couples who were carriers of haemoglobinopathies had a greater reproductive wastage-In Attapady area Sickle cell traits are commonly seen. Dr Balgir -Odisha ICMR Study on human genetics

18. What can be done now • Launch a multi sectoral programme in mission mode, focusing on children under two years, pregnant and lactating mothers, • Prioritise nutrition at all levels; • Use a rights-based approach.

19. ICDS Restructuring • ICDS Strengthening and Restructuring: ICDS in mission mode with flexibility in implementation • convergence at all levels; more resources for ICDS and additional workers at AWC • focus on reaching ‘under threes’ in community; redefine the role of AWW • Push for better service delivery

20. Child friendly toilets safe drinking water in all AWCs and schools, to reach the most vulnerable. safe and clean drinking water ,chlorination, water testing kits, low cost filters, solid/liquid waste management and behaviour change communication interventions High quality obstetric and New born care services in the Tribal specialty Hospital or encourage Pvt. sector Missionary Hospitals.

21. The key challenge Linkage between Health and Nutrition Development of sustained Linkage between families, Community and Health facilities. Culturally appropriate and innovative interventions required for meeting the challenges. Introduction of an integrated package of Ante natal, Intra natal, and Post natal services that reduces the Newborn deaths .

22. Integrated Management of Neonatal and Childhood illnesses An efficient package of home based neonatal care with an added maternal care will be a good option. Very training intensive, Training of AWW in Medical Colleges –a big task

23. Awareness generation on various govt. programmes High quality training and supportive supervision to ASHA and tribal volunteers. Training in communication skills as well to AWW and ASHA Promotion of Institutional Deliveries and Home based newborn care by ASHA and AWW Establishment of referral linkage with tertiary units in Coimbatore and a neonatal emergency transport unit can be a good option too

24. High IMR –Perinatal and Neonatal issuess from malnutrition is common in all the Tribal areas in India.- Attapady is not an exceptional case. Glad - the media has brought up the issue to more focus Sad –in spite of decades of welfare measures for tribes over the years there is no remarkable improvement Mad -All are taking advantage and mileage out of the issue in one way or other

25. Tribal health and nutrition in general will only improve if there is no delay in Health seeking care, reaching care getting care and that the care is Available 24*7 Accessible Acceptable Affordable Quality ICDS and BEmONC services either Govt or pvt. Encourage Private sector participation in a Missionary mode

26. Yes it is a Right issue • Not only Every child in this wotld has got full rights for a safe birth,earlyare,survival ,growth and development-ECCSGD- But also • Everufoetus ha got its rights for a safe growth to full potential in the womb.

27. 186 hamlets , 9000 families , <40000 people, <20000 tribal women and <500 PW. Let us think of adopting a hamlet or families. Let this be our gift to our own people in Attapady

28. Take away message • Govt HQ – • Monitoring cell and fixing of accountability • Health Dept - • 24*7 BEmONC/CEmONC services • Social welfare – • Restructure ICDS

29. Health and Social welfare – • Introduce IMMNCI • Kerala Water authority – • Provide Clean drinking water • Food and Agriculture Department- • Food security • Labor Dept – • Livelihood opportunities

30. We have the skill, but do we have the will ? Political will + Beurocratic & Professional Skill Thank You