7312019 public health 4

7/28/2019 7312019 Public Health 4

http://slidepdf.com/reader/full/7312019-public-health-4 1/53

Chapter 4

Health services

Health services are referred to all activities aim to promote

health, prevent or cure diseases, or rehabilitate disabled.

The term is used for authorized sites with health

professionals offering the services in the different

communities for group of people or for individuals.

Health services providers in Palestine:

The four most important providers of health services in

Palestine are:

1. The Ministry of Health (MOH)

2. The United Nations Relief and Works Agency (UNRWA)

3. Non-Governmental Organizations (NGOs).

4. Private sector accounts for a relatively small proportion

of health services delivered.

Ministry of Health (MOH)

The Palestinian MOH is the main health care provider

for the Palestinian population. The Ministry of health had

taken the responsibilities of Palestinian health since 1994.

The responsibility of the Ministry focuses on primary and

secondary health care services. Primary health care

includes antenatal, natal and postnatal care, health

145

7/28/2019 7312019 Public Health 4


education and health promotion, environmental health,

psychological health, food safety and control, drinking water

quality, vector control and diagnostic facilities. Primary

health care is the vertebral column of the health services

and offer health services through a network of primary

health care centers distributed in all the Governates. The

secondary health services are provided by the hospitals.

Recently MOH develops tertiary health services through

development of the local department and training of the

local specialists to minimize referral outside the country.

Furthermore, the MOH purchases tertiary services from

other health providers, both locally and near counties

(Israel, Jordan and Egypt) (MOH, 2001)

United Nations Relief Works Agency (UNRWA)

UNWRA operated in Palestine since 1948, the agency

has been the main health care provider for the Palestinian

refugee population, providing health service free of charge

to all refugees. UNRWA plays an important role in primary

health care mainly vaccination, antenatal and postnatal care,

nutrition and supplementary feeding, assistance with

secondary health care and environmental health in refugee

camps. Additionally, UNRWA contracts for services with

Non-Governmental Organization (NGOs), primarily for

146

7/28/2019 7312019 Public Health 4


secondary and tertiary care, and with Israeli facilities for

limited specialty particularly for tertiary care (UNRWA, 1999)

Non-Governmental Organization (NGOs)

The NGOs sector was first initiated in the late 1970s as

a direct consequence of the many restrictions, which were

imposed by Israeli Military Authorities on the charitable

sector during the 1970s. NGO become well established

during mid 1980s. As a result of the inability of NGO sector

to obtain licenses for clinics from the Israeli Military

Authorities, most of the NGO clinics had to operate out of

the occupation registration laws. The main NGOs in the

Occupied Territories are Health Services Council (HSC), the

Union of Health Work Committees (HWC), the Health Care

Committees (HCC) and the Union Palestinian Medical Relief

Committees (UPMRC). In 2000, The NGOs sector of health

operates 185 mini PHC centers distributed with larger

number of centers in West Bank than Gaza Strip. Some of

them include medical laboratory equipment to perform

simple investigations, and include mini pharmacies the

provide the attendants with low priced medicines ( MOH,

2001).

147

7/28/2019 7312019 Public Health 4


The Private sector

It includes a large number of private practitioners;

private hospitals and private medical companies provide a

range of primary and secondary level services and diagnostic

testing. These centers provide a range of medical specialists

and other services such as dentistry, physiotherapy, and

laboratory testing.

Types of Health services

1. Promotive

2. Preventive

3. Curative

4. Rehabilitation

1. Promotive health services are concerned with

promotion of health status of the population. These

services aim to maintain the human body in well

functioning status such as improvement of the

nutrition by taking healthy food that provides the

body with the required nutrients and avoiding excess

of undesirable food items. A second example is the

physical exercises that insure fitness of the body and

improvement of the circulation to ensure enough

blood supply for the vital organs in the human body.

148

7/28/2019 7312019 Public Health 4


The Promotive health services are not the

responsibility of health sector only but require the

participation of other sectors such as education,

social welfare and clubs.

2. Preventive health services are activities aim to

prevent an action that could badly influence the

health status. In this text we refer to the bad

influence as a disease or injury. These events could

be cured or lead to disability or death. Preventive

health services are classified to primary prevention,

secondary prevention or tertiary prevention.

Primary prevention includes all measures to prevent

occurrence of the undesired event (disease or injury). All

the promotive services are considered as a primary

prevention. A second example of primary prevention is

immunization against infectious diseases. Health

education for healthy people is a primary prevention,

where public awareness is improved towards prevention

of occurrence of a public health problem that could

endanger the health. Other examples of primary

prevention include safe water and food supply, safe

working conditions and healthy housing.

149

7/28/2019 7312019 Public Health 4


Secondary prevention includes measures taken to

discover the events early and subsequently management

is easier and complications are less. All screening

programs such as routine physical examinations and

screening for cancer breast and for cancer cervix are

secondary health services. Giving Oral Rehydration

Solution (ORS) to children with diarrhea is a measure to

prevent complications of that event and considered as a

secondary prevention. So, these measures do not

prevent the occurrence of the event but minimize its

sequences.

Tertiary Prevention aims to utilize the remaining body

functions to compensate the functions that could not be

maintained due to failure of primary and secondary

prevention. Examples of tertiary prevention include

rehabilitation of a patient with limb amputation or

changing occupation in case of road accident.

3. Curative Health Services: These services could be

given in primary health care centers or inside

hospital departments. These services could be

medical or surgical interventions. Care is given to

manage acute or chronic problems. Health

150

7/28/2019 7312019 Public Health 4


professions including doctors and nurses are only

authorized to provide these services.

4. Rehabilitation Health Services: Rehabilitation centers

with specialized staff are responsible for provision of

these services. Rehabilitation could be integrated

with the primary health care activities or inside

hospital. The modern trend is to conduct these

activities within community based programs.

Levels of Health services

1. Primary: Primary Health Care

2. Secondary: Hospital care

3. Tertiary: Specialized health care.

Primary Health Care

The concept of Primary Health Care is returned back the

year 1978 when WHO called the World Countries to

Participate in Alma Ata Conference. This meeting is the

start point for the Slogan "Health for all by the year

2000". The major outcome of the meeting is Alma Ata

Declaration- Attached. Ten years later during the

International Epidemiological Association meeting in

Helsinki, Finland the Director General WHO Dr. Mahler

presented 10 years achievement after Ala-Ata

151

7/28/2019 7312019 Public Health 4


deceleration. Dr. Mahler concluded that we are far from

achieving health for all by the year 2000 and phrased the

Slogan as: "Health for all and All for Health by the year

2000". Now it is clear that health is not the responsibility

of Ministries of Health but it is the outcome of community

participation and involvement of other sectors, mainly

Education, Agriculture, Industry, Youth, and Social Well

fair.

North Karelia project in Finland is a good example of

community involvement to over come the major health

problems. In this project mortality and morbidity due to

cardio vascular and Cerebro-vascular disease reduced

sharply when community was oriented and contributed to

the organized program to overcome these problems.

Primary Health Care approach is adopted by the world

countries and proved to be cost effective. In Palestine the

approach starts to be gradually implemented since 1982

until the birth of National Health Plan – 1994 where

primary health care is considered the vertebral column of

the health care system in Palestine.

152

7/28/2019 7312019 Public Health 4


Components of Primary Health Care:

1. Education concerning prevailing health problems and

the methods of preventing and controlling them;

2. Promotion of food supply and proper nutrition;

3. An adequate supply of safe water and basic sanitation;

4. Maternal and child health care, including family

planning; immunization against the major infectious

diseases;

5. Prevention and control of locally endemic diseases;

6. appropriate treatment of common diseases and

injuries;

7. provision of essential drugs;

Declaration of Alma-AtaInternational Conference on Primary Health Care, Alma-Ata, USSR, 6-

12 September 1978

The International Conference on Primary Health Care, meeting in Alma-Ata this twelfth day of September in the year Nineteen hundred and seventy-eight, expressing the need for urgent action by all governments, all health and development workers, and the world community to protect and promote the health of all the people of theworld, hereby makes the followingDeclaration:

I

The Conference strongly reaffirms that health, which is a state of complete physical, mental and social wellbeing, and not merely theabsence of disease or infirmity, is a fundamental human right and that

the attainment of the highest possible level of health is a most important world-wide social goal whose realization requires the actionof many other social and economic sectors in addition to the healthsector.

153

7/28/2019 7312019 Public Health 4


II The existing gross inequality in the health status of the people particularly between developed and developing countries as well aswithin countries is politically, socially and economically unacceptableand is, therefore, of common concern to all countries.

III

Economic and social development, based on a New International Economic Order, is of basic importance to the fullest attainment of health for all and to the reduction of the gap between the healthstatus of the developing and developed countries. The promotion and protection of the health of the people is essential to sustained economic and social development and contributes to a better quality of life and to world peace.

IV The people have the right and duty to participate individually and collectively in the planning and implementation of their health care.

V

Governments have a responsibility for the health of their people whichcan be fulfilled only by the provision of adequate health and social measures. A main social target of governments, international organizations and the whole world community in the coming decadesshould be the attainment by all peoples of the world by the year 2000of a level of health that will permit them to lead a socially and economically productive life. Primary health care is the key toattaining this target as part of development in the spirit of social justice.

VI Primary health care is essential health care based on practical,scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in thecommunity through their full participation and at a cost that thecommunity and country can afford to maintain at every stage of their

development in the spirit of self reliance and self-determination. It forms an integral part both of the country's health system, of which it is the central function and main focus, and of the overall social and economic development of the community. It is the first level of contact of individuals, the family and community with the national healthsystem bringing health care as close as possible to where people live

154

7/28/2019 7312019 Public Health 4


and work, and constitutes the first element of a continuing health care process.

VII

Primary health care:

1. reflects and evolves from the economic conditions and sociocultural and political characteristics of the country and its communities and isbased on the application of the relevant results of social, biomedical and health services research and public health experience;2. addresses the main health problems in the community, providing promotive, preventive, curative and rehabilitative services accordingly;3. includes at least: education concerning prevailing health problemsand the methods of preventing and controlling them; promotion of food supply and proper nutrition; an adequate supply of safe water and basic sanitation; maternal and child health care, including family planning; immunization against the major infectious diseases; prevention and control of locally endemic diseases; appropriatetreatment of common diseases and injuries; and provision of essential drugs;4. involves, in addition to the health sector, all related sectors and aspects of national and community development, in particular agriculture, animal husbandry, food, industry, education, housing, public works, communications and other sectors; and demands thecoordinated efforts of all those sectors;5. requires and promotes maximum community and individual self-reliance and participation in the planning, organization, operation and

control of primary health care, making fullest use of local, national and other available resources; and to this end develops throughappropriate education the ability of communities to participate;6. should be sustained by integrated, functional and mutually supportive referral systems, leading to the progressive improvement of comprehensive health care for all, and giving priority to those most in need;7. relies, at local and referral levels, on health workers, including physicians, nurses, midwives, auxiliaries and community workers asapplicable, as well as traditional practitioners as needed, suitably

trained socially and technically to work as a health team and torespond to the expressed health needs of the community.

VIII

All governments should formulate national policies, strategies and plans of action to launch and sustain primary health care as part of acomprehensive national health system and in coordination with other sectors. To this end, it will be necessary to exercise political will, to

155

7/28/2019 7312019 Public Health 4


mobilize the country's resources and to use available external resources rationally.

IX

All countries should cooperate in a spirit of partnership and service to

ensure primary health care for all people since the attainment of health by people in any one country directly concerns and benefitsevery other country. In this context the joint WHO/UNICEF report on primary health care constitutes a solid basis for the further development and operation of primary health care throughout theworld. X

An acceptable level of health for all the people of the world by the year 2000 can be attained through a fuller and better use of the world'sresources, a considerable part of which is now spent on armamentsand military conflicts. A genuine policy of independence, peace,détente and disarmament could and should release additional resources that could well be devoted to peaceful aims and in particular to the acceleration of social and economic development of which primary health care, as an essential part, should be allotted its proper share. The International Conference on Primary Health Care calls for urgent and effective national and international action to develop and implement primary health care throughout the world and particularly in developing countries in a spirit of technical cooperation and inkeeping with a New International Economic Order. It urgesgovernments, WHO and UNICEF, and other international

organizations, as well as multilateral and bilateral agencies,nongovernmental organizations, funding agencies, all health workersand the whole world community to support national and international commitment to primary health care and to channel increased technical and financial support to it, particularly in developing countries.The Conference calls on all the aforementioned to collaborate inintroducing, developing and maintaining primary health care inaccordance with the spirit and content of this Declaration.

II. PHC Mission Statement in Palestine

The Palestinians adopted PHC as a vertebral column for

service provision in Palestine and stated this concept in the

Palestinian Strategic Plan as follow:

156

7/28/2019 7312019 Public Health 4


“To provide preventive, promotion, curative and

rehabilitative health care services to all individuals, families

and groups of the Palestinian population. These services

should be universally accessible, affordable, available,

socially acceptable, attainable, and equitably distributed.

The high risk approach is adopted in PHC, particularly, in

allocating resources to maximize and optimize the efficiency

and to improve the quality of these services. Thus,

mortality and morbidity rates are decreased to the

minimized possible level."

Primary Health Care Activities:

These activities are the core PHC services provided, mainly

by the MOH and UNRWA. NGOs participate in providing

some of these services much more in the West Bank than

Gaza Strip:

• Child’s Health including the care of child at birth, and

immunization;

• Women’s Health including prenatal care, high risk

pregnancy, family planning and reproductive health;

• Nutrition and micronutrient deficiencies, including breast

feeding;

• Communicable and non-communicable disease control

including control of diarrhea diseases, acute respiratory

infections, brucellosis and others;

157

7/28/2019 7312019 Public Health 4


• School health;

• Health promotion and education;

• Environmental health;

• Curative care for children and adults with provision of

essential drugs in the PHC centers including medical

emergency and chronic diseases;

• Oral preventive and curative health care; and

• Diagnostic services including laboratory and X-Ray.

Primary Health Care Centers in Palestine

The following table shows the present available PHC centers

in Palestine. The reader has to remember that the National

Health plan is based mainly on the Primary Health care;

therefore it is difficult to find the same number of PHC

centers in two different references. There is a rapid

expansion of the PHC centers in all the districts in both West

Bank and the Gaza Strip.

158

7/28/2019 7312019 Public Health 4


Distribution of PHC centers in Gaza Strip and West

Bank according to health providers, MOH, 1998

Health Providers

Governorate Governme

nt

UNRWA NGOs Total

North Gaza 5 3 11 19

Gaza City 10 3 25 38

Mid-Zone 6 5 9 20

Khan Younis 8 2 12 22

Rafah 2 3 1 6

Subtotal 31 16 58 105

Jenin 51 5 12 68

Tul Karem 28 2 10 40

Nablus 36 4 17 57

Qalqilia 19 2 3 24Salfit 17 1 3 21

Ramalla 38 5 17 60

Jerusalem 0 3 3 6

Jericho 15 3 5 23

Bethlehem 21 2 7 30

Hebron 113 7 27 147

Subtotal 338 34 104 476

Grand Total 369 50 162 581

Maternal and Child Health

MCH

MCH services are the sites where women and children seek

their preventive and curative services. It is a PHC

159

7/28/2019 7312019 Public Health 4


component where these services should be available,

affordable and accessible to all the population in their

communities. The major aims of these activities are:

To ensure complete health care for all children in the

community;

To ensure antenatal care for all women during their

reproductive life;

Infant mortality in the West Bank and Gaza is estimated at

23 deaths per 1,000 live births. For every 100,000 born

babies every year, 2,300 die before reaching their first

birthdays. Neonatal mortality was estimated at 15 per

1,000, post neonatal at 8 per 1,000. Under – five Child

mortality rate is 27 deaths per 1,000 live births and

maternal mortality rate is estimated about 70 to 80 per

100,000 live births, while the reported rate is 13.8 per

100,000 live births. Immunization coverage rate is over 95%

for Polio 3 and DTP 3 among the 12-23 months old.

Main causes of infant and child mortality reported are

prematurity & low birth weight, congenital anomalies,

hypothermia, acute respiratory infections, diarrhea, birth

trauma, and accidents.

Together with UNRWA services for refugees, the government

heath services are the backbone of primary MCH services.

These services are provided free of charge for children under

age 3 (12% of population), and some basic services are

160

7/28/2019 7312019 Public Health 4


provided free of charge for pregnant mothers. Further, MCH

services are provided for those who are covered by the

governmental health insurance scheme.

Components of MCH activities:

Childe Health:

1. Growth and development monitoring including proper

nutrition with emphasis on breast feeding.

2. Immunization of all children against the vaccine

preventable diseases.

3. Screening of all children for Phenylketoneurea and

Hypothyroidism.

4. Health Education to ensure healthy children.

5. Early discovery of congenital abnormalities.

Women Health:

1. Provision of Antenatal Care including regular

examination, Immunization, proper nutrition and self

care.

2. Provision of safe delivery site.

3. Post natal follow up.

4. Family planning services.

Child Health

1. Physical and Development Assessment:

161

7/28/2019 7312019 Public Health 4


Every newborn is examined physically during the first visit to

MCH center. This examination aims to detect any congenital

anomalies or birth associated injuries.

Subsequently regular physical and developmental check ups

are conducted for children at each visit. These visits are

scheduled with the immunization program.

During each MCH visit each child is assessed for growth

by taking weight and height. Three indicators are used:

Weight/Age, Height/Age, and Weight/Height. These

measurements are plotted on specific charts for this

purpose and serve three purposes:

• Evaluation of the current status of the

individual child in term of percentile. Less

than 10 percentile are classified as

malnourished children.

• Follow up of the individual children by

observing change in their nutritional status

either improving or deteriorating. For example

a child shifting from the castigatory below 10

percentile to 10-50 percentile categories is

improving.

• Community diagnosis: Somatic characteristics

are one of the direct health indices for

measuring the health status of the

162

7/28/2019 7312019 Public Health 4


communities. Communities with a low

percentage of children less than 10 percentile

are healthier than communities with higher

percentage.

2. Screening

Routine screening for phenylketoneurea (PKU) and

hypothyroidism of newborns are conducted at the PHC-MCH

clinics. The screening program has been in MOH since 1994

and expanded to UNRWA clinics in 2001. Incidence of (PKU)

is 28 per 100,000 and the reported incidence for

Hypothyroidism is 33 per 100,000 for the year 2002. The

discovered cases are followed up regularly.

3. Immunization:

Childhood immunization in Gaza Strip and the West Bank

has received major emphasis over many years. This has

resulted in an expanded immunization program (EPI) which

includes a broad range of vaccines with coverage of over

90% of infants and school age children.

The immunization program is under continuous review of

international experts in this field. There have been no

differences between the immunization programs

163

7/28/2019 7312019 Public Health 4


implemented at governmental clinics in Gaza and the West

Bank and at UNRWA clinics since 1995.

During 1992/1993 routine immunization for hepatitis B for

all newborns was instituted in Gaza and the West Bank. The

vaccine was also provided to UNRWA Health Services

Centers and to all hospitals.

Immunization is provided at MCH/PHC centers and with the

help of mobile immunization team regularly visiting villages

in addition to on-site services and UNRWA Health Center

services.

As recommended by WHO, the immunization program is

conducted to cover the following infectious diseases:

Diphtheria, Pertussis, Tetanus, Hepatitis B, Polio, Measles

and Tuberculosis as well as German measles and Mumps.

Vaccines are provided from different sources such as MOH,

UNICEF and WHO. Situation regarding the availability of

vaccines to cover all population is generally good and

immunization activities are regular in the MOH and UNRWA

clinics.

1- Tuberculosis: BCG (Bacillus of Calmet and Gurin):BCG is the most widely used vaccine in the world and the

immunization at birth will reduce the morbidity and mortality

164

7/28/2019 7312019 Public Health 4


from tuberculosis and disseminated disease among children.

BCG should continue to be given as soon after birth as

possible in all populations at high risk of tuberculosis

infection

It is live attenuated Bacilli (Mycobacterium Bacilli). The

vaccine is given intradermally in a 0.05-0.1 ml dose. The

vaccine is given preferably directly after birth but due to

logistic reason it is given during the first week after birth

and not preferred after the 1st month of life. The main

complications of this vaccine are lymphadenitis and

disseminate d T.B.

2-Polio vaccines:

There are two types of Polio vaccines:

A- Oral Polio vaccine = Trivalent Oral Polio vaccine =

Sabin vaccine=live attenuated vaccine… This vaccine

developed by Sabin and it contains the three typed

of Polio, type I, II, and III. The viruses are

cultivated on Monkey Kidney tissue and pass process

of attenuation to ensure weakening of the virus. It

is given in form of 2 drops per month in 3 doses

with 4-8 weeks internal between the doses. A

Fourth booster dose is given 6 months after the 3rd

dose the most serious complication of this vaccine is

the "vaccine associated poliomyelitis". It is not

165

7/28/2019 7312019 Public Health 4


advised to give vaccine for children with

immunodeficiency or children receiving

immunosuppressive medication.

B- Killed Polio vaccine=Salk vaccine = Inactivated Polio

– vaccine. Salk developed this vaccine and it is given

Intramuscular in two doses with one month

between. A booster dose is given 6 month after the

second dose. This vaccine but more expansive and

there is no chance for community dissemination

losing the chance of passively immunizing other

community members.

3-Diphtheria – Pertussis – Tetanus (DTP) = Triple

vaccine:

This is a combination of toxins of Diphtheria Bacteria,

Pertussis killed bacteria and the toxins of Tetanus taxied.

Diphtheria immunization is by diphtheria toxoid, an

activated preparation of diphtheria toxin. It does not

prevent the infection, but prevent the systemic

manifestations. Tetanus is caused by a potential

neurotoxin produced by clostridium tetani and

immunization is by tetanus toxoid, an inactivated

preparation of the toxin. The third component is

immunizations of Pertussis by inject of killed bacteria of

Pertussis. The vaccine is given for children under 3 years

166

7/28/2019 7312019 Public Health 4


but older children are given only DT where Pertussis is not

recommended for older children. Triple vaccine is given in

three doses with 4-8 weeks interval between each dose.

A booster (4th) dose is given 6 months after the third

dose. Tetanus taxied alone is recommended for pregnant

women and for injured people who are not fully

immunized or those older than 12 years old.

4-Hepatitis B vaccine:

Immunization with vaccine containing the hepatitis B surface

antigen (HbsAg) is the recommended for all infants as soon

possible after birth. The given vaccine is an artificial DNA

similar protein. In Palestine this vaccine introduced to the

health care centers in January 1993 and given routinely for

all infants in 3 doses intramuscularly. The dose is given in

the 1st month of life and the 2nd dose in the 2nd month and

a booster dose is given 6 moths after the second dose.

5- Measles Vaccine:

This is a live attenuated vaccine cultivated on egg yolk and

given intramuscularly at age of 9 months. A second dose of

measles is recommended and usually it is given at age 15

months together with Rubella antigen and Mumps antigen in

a vaccine called MMR (Measles- Mumps – Rubella).

167

7/28/2019 7312019 Public Health 4


Immunization schedule

Palestine

Age /months Vaccine

1st month BCG, Hepatitis B (1), Salk (IPV) (1)

2nd month Hepatitis B (2), IPV (2), DPT (1),TOPV (1)

3rd month TOPV (2), DPT (2)

4th month DPT (3), TOPV (3)

9th

month Measles, Hepatitis B (3)10-12 months TOPV (4), DPT (4)

15th month MMR

BCG: Bacillus of Calmet & Gurin DPT: DiphtheriaPertussis Tetanus TOPV: Trivalent Oral Polio VaccineMMR : Measles Mumps R ubella IPV: Inactivated PolioVaccine

168

7/28/2019 7312019 Public Health 4


Summery for the vaccine preventable diseases

A- Relevant to Palestine

Pulmonary Tuberculosis

Description A respiratory disease caused byMycobacterium Bacilli.

Symptoms Cough, dyspnea, low-grade fever and loss of weight

Complications Haemoptesis, Airway obstruction, coma, anddeath if not treated

Transmission Spread by coughing and sneezing

Vaccine BCG (Bacillus of Calmet and Gurin)

Polio

Description A disease of the lymphatic and nervoussystems

Symptoms Fever, sore throat, nausea, headaches,stomach aches, and stiffness in the neck,back, and legs

Complications Paralysis that can lead to permanent

disability and death

Transmission Contact with an infected person

Vaccine Polio vaccines (IPV & TOPV) can prevent thisdisease.

Diphtheria

Description A respiratory disease caused by bacteria

Symptoms Gradual onset of a sore throat and low-gradefever

Complications Airway obstruction, coma, and death if nottreated


Vaccine Diphtheria toxoid (contained in DTP, DTaP, DTor Td vaccines) can prevent this disease.

169

7/28/2019 7312019 Public Health 4


Pertussis (whooping cough)

Description A respiratory disease caused by bacteria

Symptoms Severe spasms of coughing that can interfere

with eating, drinking, and breathingComplications Pneumonia, encephalitis (due to lack of

oxygen), and death, especially in infants.

Transmission Spread by coughing and sneezing (highlycontagious)

Vaccine Pertussis vaccine (contained in DTP andDTaP) can prevent this disease.

Tetanus (lockjaw)

Description A disease of the nervous system caused by abacteria (clostridium tetani)

Symptoms Early symptoms: lockjaw, stiffness in theneck and abdomen, and difficulty swallowing

Later symptoms: fever, elevated blood

pressure, and severe muscle spasmsComplications Death in one third of the cases, especially

people over age 50

Transmission Enters the body through a break in the skin

Vaccine Tetanus toxoid (contained in DTP, DT, DTaP & Td vaccines) can prevent this disease.

Hepatitis B

170

7/28/2019 7312019 Public Health 4


Description A disease of the liver caused by hepatitis Bvirus

Symptoms Potentially none when first infected(likelihood of early symptoms increases with

the person's age)

If present: yellow skin or eyes, tiredness,stomach ache, loss of appetite, nausea, or joint pain

Complications The younger the person, the greater thelikelihood of staying infected and having life-long liver problems, such as scarring of theliver and liver cancer

Transmission Spread through contact with the blood of aninfected person or by having sex with aninfected person

Vaccine Hepatitis B vaccine is will prevent thisdisease.

Measles

Description A respiratory disease caused by a virus

Symptoms Measles virus causes rash, high fever, cough,runny nose, and red, watery eyes, lastingabout a week.

Complications Diarrhea, ear infections, pneumonia,encephalitis, seizures, and death

Transmission Spread by coughing and sneezing (highly

contagious)Vaccine Measles vaccine (contained in MMR and

measles vaccines) can prevent this disease.

171

7/28/2019 7312019 Public Health 4


Mumps

Description A disease of the lymph nodes caused by avirus

Symptoms Fever, headache, muscle ache, and swellingof the lymph nodes close to the jaw

Complications Meningitis, inflammation of the testicles orovaries, inflammation of the pancreas anddeafness (usually permanent)


Vaccine Mumps vaccine (contained in MMR) canprevent this disease.

Rubella (German measles)

Description A respiratory disease caused by a virus

Symptoms Rash and fever for two to three days ( milddisease in children and young adults)

Complications Birth defects if acquired by a pregnantwoman: deafness, cataracts, heart defects,

mental retardation, and liver and spleendamage (at least a 20% chance of damage tothe fetus if a woman is infected early inpregnancy)


Vaccine Rubella vaccine (contained in MMR vaccine)can prevent this disease.

B – Other vaccines:

Haemophilus influenzae type b (Hib)

172

7/28/2019 7312019 Public Health 4


Description A severe bacterial infection, occurringprimarily in infants

Symptoms Skin and throat infections, meningitis,pneumonia, sepsis, and arthritis

(Can be serious in children under age 1, butthere is little risk of getting the disease afterage 5)

Complications Hib meningitis (death in one out of 20children, and permanent brain damage in10% - 30% of the survivors)


Vaccine Hib vaccine can prevent this disease. Hepatitis A

Description A disease of the liver caused by hepatitis Avirus

Symptoms Potentially none (likelihood of symptomsincreases with the person's age) If present:yellow skin or eyes, tiredness, stomach ache,loss of appetite, or nausea

Complications Because young children might not havesymptoms, the disease is often notrecognized until the child's caregiverbecomes ill with hepatitis A.

Transmission Most often: spread by the fecal-oral route(An object contaminated with the stool of aperson with hepatitis A is put into anotherperson's mouth.) Less often: spread byswallowing food or water that contains the

virusVaccine Hepatitis A vaccine will prevent this disease.

Varicella (chickenpox)

Description A virus of the herpes family

173

7/28/2019 7312019 Public Health 4


Symptoms A skin rash of blister-like lesions, usually onthe face, scalp, or trunk

Complications Bacterial infection of the skin, swelling of thebrain, and pneumonia (usually more severe

in children 13 or older and adults)

Transmission Spread by coughing and sneezing (highlycontagious)

Vaccine Varicella vaccine can prevent this disease.

Maternal Health

• Antenatal Care

174

7/28/2019 7312019 Public Health 4


• Natal Care

• Post natal care

• Family planning

• Family Health Counseling

1. Antenatal Care:

Antenatal care is the health care given to the pregnant

women since the first month till the delivery time to ensure

safe pregnancy and safe outcome. The outcome is referred

to safe delivery and healthy newborn. Accordingly the main

goal of ante-natal care programs is to ensure a healthy

pregnancy and safe outcome for both the mother and the

fetus.

Definition of antenatal care (ANC):

Antenatal care is defined as: "The care that is given to an

expectant mother from the time that conception is confirmed

until the beginning of labor" (Bennett and Brown, 1999).

WHO defined that Antenatal care as "the care referred to

pregnancy related care provided by health worker either in

medical facility or at home. In theory antenatal care should

address both the psycho-social and medical needs of the

women in the context of the health care delivery system and

the surrounding culture "WHO, 1996".

Other definition: ANC is "the monitoring of mother and fetus

by trained health personal throughout the whole pregnancy

175

7/28/2019 7312019 Public Health 4


with necessary examinations and recommendations by

regular intervals" (Ozvaris S and Akin A 2002).

1.1 Activities:

Ante natal care activities focus on health supervision, follow

up and surveillance of the pregnant woman through regular

organized program. These activities provide the opportunity

to detect, investigate and respond to the health care needs

of the pregnant woman in order to prevent, contain or

manage any deviation from the normal pattern of pregnancy

which could result in an adverse outcome for the mother

and/or the child. Ante-natal care also provides the

opportunity for the health care provider to undertake health

promotional activities, share information with the pregnant

woman and encourage her participation in her own health

care and that of her unborn child and/or family.

During Antenatal care each pregnant women is served for:

1. Assessment: history, examination and laboratory

A: Each lady is requested to provide information related to

current pregnancy including: Demographic data, maternal

immunization data, antenatal assessment, postnatal

examination data and maternal health education data. Also

information related to past History is requested and include

family history, social history, health history (medical and

176

7/28/2019 7312019 Public Health 4


surgical History), Obstetric history, Delivery data and

Newborn data.

B: Routine physical examination including general

examination and Abdominal Examination. Blood pressure

and Weight are routine measurement during each visit.

Level of the uterus is defined each visit after the 12th week

of pregnancy.

Additions to clinical examination: Ultrasound 3 times: During

the 1st trimester, to confirm date (EDD), 16-22 weeks For

Detailed Ultrasound, 32 weeks For Estimated Fetal weight

(EFW) and for Placental localization.

Ultrasound can provide information about fetal health

including: Age of the fetus, rate of growth of the fetus,

placement of placenta, fetal position, movements, Amount

of amniotic fluid, Number of fetuses and Birth defects.

C: Laboratory tests: Each pregnant woman has to complete

blood examination (CBC) including hemoglobin level, blood

sugar, blood grouping and RH factor and Indirect Coombs for

Rh negative mothers. Serological testing includes Australian

Antigen (AA) and RBS Rubella titer. GTT for women at risk

for Gestational Diabetes The urine is examined for the

presence of Albumin and sugar (Refer MOH Guidelines)

2. Health education: During pregnancy the health services

have to provide all the women enough information about:

nutrition, personal hygiene, dressings, care of the nipple,

177

7/28/2019 7312019 Public Health 4


and awareness about the signs and symptoms associated

with high risk pregnancy.

Antenatal care is an opportunity where women should have

Health promotion during antenatal period coverind these

items:

- Nutritional advice - Dental Care

- Rest/sleep - Breast care

- Discomforts of pregnancy - Drugs

- Hygiene - Smoking

- Safer sex/sexual intercourse - Traveling

- Planning for place of birth - Clothing

- Family planning - Exercise

- Counseling on newborn care, including breast-feeding and

Immunization

1- Provision of supplements including ferrous tablets

and folic acid tablets.

2- Immunization: Tetanus Toxoid should be given for all

pregnant women. The first dose is usually given at

the first visit (preferably after 4 months of

pregnancy), the booster is two months later, and the

third dose is offered six months after the second

dose (postpartum) or to be postponed to the next

pregnancy. If the interval between two pregnancies

178

7/28/2019 7312019 Public Health 4


is more than five years the woman should receive

the toxoid again.

3- Curative services where women are treated for acute

illness including treatment of the Uro-genital tract

infections.

1.2 High Risk Pregnancy:

Although Pregnancy is a normal phenomenon, problems can

however occur. Through the provision of effective ante-natal

care individuals and groups with an increased chance of

complications or disease are defined as being "AT RISK" or

"High Risk". The aim of the health services would be to

identify those "AT RISK" as early as possible and to

intervene in order to reduce the risk.

During ante-natal care women are classified according to

the risks associated with the pregnancy. These categories

are considered as higher risky than others:

1- Prim-Para and Multi-gravida.

2- Short status

3- Age below 18 and higher than 35 years old.

4- History of cesarean section

5- Diabetes Mellitus

6- Hypertension – Albumin urea - Edema

179

7/28/2019 7312019 Public Health 4


7-Anemia

8- Mal presentation

High risk pregnant women are advised for more frequent

antenatal visits and they have to deliver in a hospital.

2. Natal Care:

Natal care is referred to the care given to a woman

during delivery. Delivery sites should be hygienic, well

equipped and have qualified trained persons. These sites

could be in hospitals whether general hospitals or delivery

hospitals, or in the community either in the primary health

care centers or separate maternity homes. The role of the

traditional birth attendants (Daya) is limited during this

time, due to presence of qualified health staff performing

this task. Natal care should not be limited to the delivered

women but care should be given to the newborn at the same

time.

3. Post natal care:

This component is the weakest component in maternal

health care, where the percentage of women who receive

this service is relatively low. During purperium each lady

had to be check for signs of hemorrhage or infection. Post

natal care is either given in the health centers or during

180

7/28/2019 7312019 Public Health 4


home visits. Counseling for family planning during post

natal care visit is recommended in this stage.

The most frequent reported health problems in the

postpartum period are:

1. infections especially genital infections

2. Bladder problems.

3. Frequent Pelvic& headache pain.

4. Hemorrhoids and anemia.

5. Constipation.

6. Depression, anxiety.

7. Breast problems.

Infant health challenges in the postnatal period

1- Preterm birth and Smallness for gestational age.

2- Congenital anomalies.

3- Severe bacterial infection.

4-Neonatal tetanus.

5-Newborns suffering.

6-Hypothermia.

7- Jaundice.

8- Ophthalmia neonatorum.

4. Family planning:

181

7/28/2019 7312019 Public Health 4


Each family has to decide about the desirable size of

the family and the health care providers have to help and

advise for the most appropriate and the safe method to

achieve this activity. Family planning is not family control

and the best acceptable term is family spacing by giving

enough time between the pregnancies to ensure healthy

mother and healthy child

4.1 Methods:

Intrauterine devices (IUDs) and pills are the most

common methods used in family planning programs.

Condom and Natural methods as safe period and coitus

interrupts are accepted by people and recommended when

there is health problems contraindicated the use of pills or

IUDs. Other methods as vaginal diagram and spermicidal

gels are used. Recently injections are available and used

safety and efficiently and more practical. Sterilization of

men or women is the most efficient way but not accepted

socially.

5. Family Health Counseling:

Each family has the right to receive health counseling in the

MCH centers and during the MCH visit. Counseling focuses

on family planning and importance of breast feeding and the

nutrition of the women and the child. Women and children

182

7/28/2019 7312019 Public Health 4


with specific risk is in need for focus on their specific

problems

Counseling Steps “GATHER” Method:

G Greet the ClientA Ask the ClientT Tell the ClientH Help the ClientE Explain to the clientR Repeat

Maternal Mortality

183

7/28/2019 7312019 Public Health 4


Background:

Women health is one of the major concerns of the public and

the health policy makers all over the world. The main

determinant of the women health is the health status during

reproductive age, where women are exposed to risks

associated with the pregnancy and the delivery. In this

chapter we are intending to focus on undesirable event

associated with the process of pregnancy and delivery, that

is the maternal death. We are reviewing the concept and

definitions, methods of measurement and causes of

maternal mortality.

Definition of maternal mortality:

Based on the tenth revision of the International classification

of Diseases (ICD-10) the maternal death defines as:

" the death of a woman while pregnant or within 42 days of

termination of pregnancy, irrespective of the duration and

site of the pregnancy, from any cause related to or

aggravated by the pregnancy or its management but not

from accidental or incidental causes" (WHO, 1992). It is

clear that this definition includes all women deaths during

pregnancy, delivery or during the post partum period (42

days after delivery) is considered whether that is due to a

disease, aggravation of a disease, or due to intervention

during delivery or abortion or surgical intervention as

184

7/28/2019 7312019 Public Health 4


cesarean sections. The only excluded causes are those due

to accidental or incidental causes such as car accident.

Epidemiology:

As shown in the table below: More than half million womenin the world die each year due to complications of pregnancyand delivery. Most of deaths (95%) occur in developing andundeveloped countries.

Maternal mortality estimates by United Nations MDG regions,

2000

Region

Maternal

Mortality ratio(per100,000

live births)

Number of

maternaldeaths

Lifetime

risk of maternal

death,1 in:

WORLD TOTAL 400 529,000 74

DEVELOPED REGIONS 20 2500 2,800

Europe 24 1,700 2,400

DEVELOPINGREGIONS

440 527,000 61

Africa 830 251,000 20

Northern Africa 130 4,600 210

Sub-Saharan Africa 920 247,000 16Asia 330 253,000 94

Eastern Asia 55 11,000 840

South-central Asia 520 207,000 46

South-eastern Asia 210 25,000 140

Western Asia 190 9,800 120

Latin America andthe Caribbean

190 22,000 160

Oceania 240 530 83

Source: WHO (2004): Maternal Mortality in 2000: Estimatesdeveloped by WHO, UNICEF and UNFPA. Department of Reproductive Health and Research World Health Organization,Geneva

Factors affecting maternal mortality:

185

7/28/2019 7312019 Public Health 4


Personal: These personal factors are affecting positively the

maternal deaths where chances of death become more:

1. Age Less than 18 years or More than 35 years old,

2. Living far from the health care facilities whether

hospitals or health primary health care centers,

3. Positive consanguinity,

4. Smoking habits,

5. Long duration of marriage with infertility and use of

ovulatory drugs, OR

6. Short women, less than 150 cm

Poor obstetric history: Recurrent stillbirths, Abortions:

Two or more consecutive first trimester abortions or second

trimester abortion, Previous Early Neonatal Death,

Premature labor Labour <24 weeks of gestation, Prolonged

obstructed labor, Ante Partum Hemorrhage (APH) or Post

Partum Hemorrhage (PPH), Caesarian section delivery,

myomecotomy , scared uterus, Multiple pregnancies, Mal-

presentations, Previous gynecological operations such as

prolapse, fistula, and third degree tears, Pre-eclampsia,

Intrauterine growth retardation, Blood Disorders, Uterine

Abnormality, Uterine fibroid, Obesity (Maternal pre

pregnancy Weight more than 85 Kg), Assisted Reproductive

Techniques OR Previous infertility

186

7/28/2019 7312019 Public Health 4


Presence of Major medical disorders: Hypertension,

Cardiac disease, Diabetes, Anemia, Bronchial Asthma,

Neurological disorders, Blood disorders or Hepatitis B carrier

Availability of Health Services

1. Birth attendants:

1.1 Skilled birth attendant: A skilled birth attendant is

defined as a medically qualified provider with midwifery

skills that could be gained through midwifery, nursing or

medical studies. Beside the study they should complete

training to proficiency in the skills necessary to manage

normal deliveries and diagnose, manage, or refer obstetric

complications. Ideally, skilled attendants live in, and are

part of, the community they serve. They must be able to

manage normal labor and delivery, perform essential

interventions, start treatment and supervise the referral of

mother and baby for interventions that are beyond their

competence or not possible in a particular setting. The fifth

Millennium Development Goal (2000) calls for a reduction in

maternal mortality and morbidity. One of the indicators used

to track progress in meeting this goal is the proportion of

women who deliver with the assistance of a skilled birth

attendant.

1.2. Traditional birth attendant (TBA): A traditional birth

attendant is a community-based provider of care during

187

7/28/2019 7312019 Public Health 4


pregnancy and childbirth. TBAs are not trained in all cases

to proficiency in the skills necessary to manage or refer

obstetric complications. TBAs are not usually salaried,

accredited members of the health system. Although they are

usually highly esteemed community members and are often

the sole providers of delivery care for many women, they

should not be included in the definition of a skilled attendant

for the calculation of the Millennium Development Goals

indicator.

2. Health care facilities: We refer to the facility providing

delivery services and these facilities are called skilled

attendance. Skilled attendance is the site that operating

within an enabling environment or health system capable of

providing care for normal deliveries as well as appropriate

emergency obstetric care for all women who develop

complications during childbirth.

The enabling environment describes a context that provides

a skilled attendant with the backup support to perform

routine deliveries and make sure that women with

complications receive prompt emergency obstetric care. It

essentially means a well-functioning health system,

including equipment and supplies; infrastructure and

transport; electrical, water and communication systems;

human resources policies, supervision and management;

and clinical protocols and guidelines.

188

7/28/2019 7312019 Public Health 4


Causes of Maternal Mortality:

The main direct causes of maternal mortality are:

1. Hemorrhage

2. Obstructed labor

3. Eclampsia (pregnancy-induced hypertension)

4. Infection

5. Complications from unsafe abortion

The table below demonstrates variation of onset of death by

different complications leading to death.

Estimated average time from onset of complication to death

Complication Hours Days

1. Hemorrhage

Postpartum 2

Ante partum 12

2.Eclampsia 2

3.Obstructed labour 3

4. Infection 6

There is a variation between causes of death in developed

and in developing countries, where infection and

hemorrhage are common complications in developing

countries.

Maternal causes could be direct or indirect, direct obstetric

deaths, resulting from obstetric complications of the

pregnant state, from interventions, omissions, incorrect

189

7/28/2019 7312019 Public Health 4


treatment. Indirect obstetric deaths, is stated when they

are resulting from previous existing disease or disease that

developed during pregnancy and which was not due to direct

obstetric causes but was aggravated by the physiological

effects of pregnancy.

Measurement of maternal mortality:

Maternal mortality is measured by one of the three

widespread measures (WHO,2004):

1. Maternal mortality ratio

2. Maternal mortality rate

3. Lifetime risk of maternal death

1. Maternal mortality ratio:

Maternal mortality ratio is defined as the number of

maternal deaths during a given time period per 100,000 live

births during the same time period. It is calculated as the

following:

Maternal deaths

MM Ratio =---------------------- X 100,000

Total live births

This is the most commonly used measure where data

availability and accuracy to calculate this measure is better

than data required for other measures. This measure

190

7/28/2019 7312019 Public Health 4


reflects the probability of death once a woman becomes

pregnant.

2. Maternal mortality rate:

Maternal mortality rate is defined as the number of maternal

deaths in a given period per 100,000 women of reproductive

age during the same time period

Maternal deaths

MM Rate =--------------------------------- X 100,000

Women of reproductive age

This measure reflects the probability of women death during

reproductive period.

3. Lifetime risk of maternal death:

Lifetime risk of maternal death is a cumulative risk over the

reproductive lifetime. For each pregnancy the lady is

exposed to the risk again. Each time the risk is higher.

Approximately life time risk is calculated by multiplying the

maternal mortality rate by the length of the reproductive

period (around 35 years).

191

7/28/2019 7312019 Public Health 4


Approaches for measuring maternal mortality:

One or more of the following approaches are used to

measure maternal mortality:

1. Vital registration

2. Direct household survey methods

3. Direct sisterhood method

4. Indirect sisterhood method

5. Reproductive Age Mortality Studies

6. Verbal autopsy

7. Census

1. Vital registration:

To use the vital registration system in calculation of maternal

mortality necessitates presence of a sufficient coverage and

quality to enable the system to serve as the basis for the

assessment of levels and trends in cause-specific mortality

including maternal mortality. Registration systems are

exposed to misclassification and underreporting, therefore

review of the evidence shows that registered maternal

deaths should be adjusted upward by a factor of 50% on

average. xx In Gaza Sali conducted assessment of maternal

mortality and revealed underreporting and misclassification,

where the reported maternal mortality ratio was 28 and the

assessment figure came to be 42 per 100,000 (50%

more).xx

192

7/28/2019 7312019 Public Health 4


2. Direct household survey methods:

Maternal mortality could be calculated by the household

surveys using direct estimation. These surveys are usually

expensive and complex to implement because large sample

sizes are needed to provide a statistically reliable estimate.

3. Sisterhood method:

The sisterhood approach was designed to overcome the

problem of large sample sizes and thus reduce the efforts

and the costs of the household survey. There are two types

of sisterhood approach: the direct and the indirect methods.

The indirect method depends on obtains information by

interviewing respondents about the survival of all their adult

sisters. This indirect method is applicable for high fertility

rate population, and not appropriate for use in settings

where fertility levels are low total fertility rate (TFR) less

than 4 (Graham W. 1989). The original indirect sisterhood

method asks respondents four simple questions about how

many of their sisters reached adulthood, how many have

died and whether those who died were pregnant around the

time of death. The direct method - is used in Demographic

and Health Surveys. During data collection the respondents

are asked to provide detailed information about their sisters,

including the numbers reaching adulthood, the number who

193

7/28/2019 7312019 Public Health 4


have died, the age at death, the year in which the death

occurred and the years since the death. (WHO,1997,

Shahidullah M.,1995, Rutenberg N, 1991)

Attached the original used questions as stated in the WHO,

1997 report:

A. THE ORIGINAL SISTERHOOD METHOD'S FOUR QUESTIONS:1. How many sisters (born to the same mother) have you everhad who were ever-married (including those who are now dead)?2. How many of these ever-married sisters are alive now? 3.

How many of these ever-married sisters are dead? 4. How manyof these dead sisters died while they were pregnant, or duringchildbirth, or during the six weeks after the end of pregnancy?

B. THE "DIRECT" SISTERHOOD METHOD'S QUESTIONS:1. How many children did your mother give birth to? 2. Howmany of these births did your mother have before you wereborn? 3. What was the name given to your oldest (next oldest)brother or sister? 4. Is (NAME) male or female? 5. Is (NAME) stillalive? 6. How old in (NAME)? 7. In what year did (NAME) die? OR

How many yeas ago did (NAME) die? 8. How old was (NAME)when she died? For dead sisters only: 9. Was (NAME) pregnantwhen she died? 10. Did (NAME) die during childbirth? 11. Did(NAME) die within two months after the end of pregnancy orchildbirth?

5. Reproductive Age Mortality Studies:

Use of this approach enables us to identify and investigate

the causes of all deaths of women of reproductive age. This

analysis could be completed through the vital registry if

reporting is satisfactory. In case of underreporting review of

available records in the health care facilities and community

194

7/28/2019 7312019 Public Health 4


could reveal more information. In such studies

misclassification of causes of death can be calculated.

6. Verbal autopsy:

Verbal autopsy means gathering information about the

causes of maternal death retrospectively (WHO, 1995). This

method is used in absence of reliable death certificates.

7. Census:

Among general questions census could include questions on

deaths in the household. These general questions are

followed detailed questions that would permit the

identification of maternal deaths on the basis of time of

death relative to pregnancy or delivery (Stanton, 2001).

Abbreviations

DHS: Demographic and Health Surveys

GFR : general fertility rate

MDG: Millennium Development Goal

MMR : maternal mortality ratio

RAMOS: reproductive age mortality study TFR total fertility rateUN: United Nations

UNFPA: United Nations Population Fund

UNICEF: United Nations Children’s Fund

WHO: World Health Organization

195

7/28/2019 7312019 Public Health 4


Reference:

Graham W, Brass W, Snow RW. (1989) Indirect estimation of maternal mortality: the sisterhood method. Studies in FamilyPlanning,;20:125-35.

Rutenberg N, Sullivan JM. (1991) Direct and indirect estimates of maternal mortality from the sisterhood method. Washington DC,IRD/Macro International Inc.

Shahidullah M. The sisterhood method of estimating maternalmortality: the Matlab experience. Studies in Family Planning,1995;26:101-6.

Stanton C et al (2001) Every death counts: measurement of

maternal mortality via a census. Bulletin of the World HealthOrganization,79:657-64.

WHO (1992 International Statistical Classification of Diseases andRelated Health Problems. Tenth Revision. Geneva, World HealthOrganization.

WHO (1995) Verbal autopsies for maternal deaths,WHO/FHE/MSM/95.15, Geneva, World Health Organization

WHO (1997) The sisterhood method for estimating maternalmortality: guidance notes for potential users. WHO/RHT/97.28.Geneva, World Health Organization,.

WHO (2004) Maternal Mortality in 2000: Estimates developed byWHO, UNICEF and UNFPA, Department of Reproductive Healthand Research, World Health Organization, Geneva

Ref:

Bennett R. and brown L (1999) Myles text book for

midwives. Antenatal care 13th Ed, London, Charchil living-

stone

196

7/28/2019 7312019 Public Health 4


WHO (1996) Maternal and newborn health WHO antenatal

care randomized trial.

Ozvaris S. and Akin A. (2002) contraception Abortion and

maternal health services in Turkey, Results of further

analysis of the 1998 Turkish demographic and health survey

7312019 public health 4

Documents