Unit 4 Midwifery at Community

4.1 Social determinants of reproductive & sexual health

The factors influencing the health of mothers & children are broad & complex. Their impact
begins long before pregnancy & will continue long after a woman’s discharge from the maternity
services. Community health & social services, therefore, play an important role in the cycles of
family life in many societies. Health & illness are influenced & experienced by people as part of
their lives.

1. Socio-economic status
Socio-economic conditions have long been known to influence health. For the majority of the
world’s people, health status is determined primarily by their level of socioeconomic
development. The per capita GNP is the most widely accepted measure of general economic
performance. There can be no doubt that in many developing countries, it is the economic
progress that has been the major factor in reducing morbidity, increasing life expectancy and
improving the quality of life.

The relationship between socio-economic status & reproductive & sexual health is well
established in the public health field. Socio-economic disadvantage is a cause of poor sexual &
reproductive health. Socio-economic disadvantage can be indicated by low income, poor levels
of educational attainment, high unemployment.

The economic status determines the purchasing power, standard of living, quality of life, family
size, pattern of disease, nutrition, housing, employment, political system of country and deviant
behavior in the community.

People of high economic status are more likely to obtain reproductive & sexual health services
while poor people abstain themselves due to their low economic status.

Mortality rates are higher in women of low socio-economic level as these women are likely to be
less privileged in the area of nutrition, education, housing & prenatal care.

The likelihood of women dying from an unsafe abortion is almost exclusively dependent on
where she lives, with almost all mortality attributable to unsafe abortion occurring in developing
countries.

Sexually transmitted infections excluding HIV are experienced in low- & middle-income
countries & over 50% of the global burden is suffered by women n low income countries.

In access to basic social and economic services and infrastructure, there has been wide spread
social exclusion of certain caste and ethnic groups, women and those living in remote areas.
Entrenched gender discrimination also puts girls and women at disadvantages in terms of
accessing power and resources. e.g. high mortality of girls Childs, fewer girls attend school than
boys, girls have heavier workload at home.

For women, many civil rights are only ensured through marriage e.g. Right in property from her
husband.

2. Education
A second major factor influencing health status is education especially female education. The
world map of illiteracy closely coincides with the maps of poverty, malnutrition, ill health, high
infant and child morbidity and mortality as well as maternal morbidity and mortality rates.
Studies indicate that education to some extent compensates the effects of poverty on health.

Educated women are more likely to use modern family planning methods than less educated
women. Educated women are serious in maintaining hygiene.

Patriarchal social setting- which assigns subordinates status to women, it does not enhance
women’s capabilities and decision-making power within the household.

Poverty place additional work burden on the education of female that is sacrificed. Absolute
poverty prevents the majority of parents for sending their daughter to school.
Lack of accessibility of educational institution related to geographical distribution, girl child
cannot afford.

The provision of scholarship program is inadequate.

Uneducated parents have no knowledge to education to their child.

There is no compulsory education system in Nepal.

Parents seeing fewer economic benefits from educating girls when family resources are limited,
they often give higher priority to the education of sons.

Decisions about schooling for girls are also influenced by social norms such as the value placed
on marrying girls while they are still virgins and on early childbearing.

3. Occupation /Employment
The very state of being employed in productive work promotes health. Unemployed usually
show a higher incidence of ill health and death. Loss of work may mean loss of income and
status which can cause psychological and social damage.

Women & Employment

Most women workers are confined to self –self-employed, unpaid and low wage informal sector
activities, they have few formal job opportunities. Between 1991 and 2001, women moved
gradually from agricultural into nonagricultural work. The fact that the formal sector accounts
for only a small share of the total labor force (8-10%) implies that few workers have benefited
from wage reforms enacted to date.
Although women are slowly joining the expanding modern sector- particularly in manufacturing,
trade, commerce and tourism in urban areas, business looking for salaried job. They are
concentrated in low jobs because of their lack of education and training opportunities, the biases
of their employers and their limited mobility.

4. Poor Housing
While the quality of housing affects all inhabitants, women’s health is more likely to be
adversely affected, given that women in the household environment became of their
responsibility for housework and child care.

5. Social Cultural Status of Women

In Nepal, social and cultural values are inherited down to the next generation. The status of
women is traditionally defined in terms of their marital or sexual status. Daughters are normally
retarded as a liability rather than asset and paid little attentions. Girls are rarely provided with
sufficient food, education or health care. The institution of family is therefore a major barrier to
women’s development.

Social rules and regulations are intensely patriarchal and women are expected to passively
comply with all decisions made by men.

The dominant Hindu religion and culture have popularized a belief that women should be
dependent on males for income from the cradle to the grave. Women are viewed only as
domestic and maternal. Women work is confined to the household and goes unaccounted for by
the state and the family itself.

6. Religious Factor
Daughter as liability
Son’s birth is a celebration and daughter’s is the moment of sorrow because she will be gone to
other’s house. She is deprived from nutritious diet from her childhood son are given well
balanced diet and insufficient amount but for the daughter she has to eat after her brothers eat
and most of the time the quantity is also not sufficient to satisfy her hunger.
Daijoo/ Tilak related torture
Daijoo /Tilak are widely prevalent in the Terai community. Because of this tradition many girls
are suffered from domestic violence and even suicide and homicide.

Untouchability
There is discrimination between castes though it has been punishable by law. So called lower
caste women are less privileged in every right. Even in some caste women during menstrual
period are untouchable and they have to stay away from the home in hut called chhaupadi, in
western region for few days of menstruation. They even are restricted from nutritious diet like
specially cow’s one.

Jhuma and kumari

In the mountain region, Buddhist families offer their second daughter to monasteries where they
live. They must practice celibacy for life.
In Kathmandu valley there is a tradition of living goddesses called Kumari. A girl child from
Bajracharya/Shakya community is kept in temple until she menstruates.
In all above tradition girl has no right to escape because she is selected in very early age of her
life. It is the violation of human right in the name of religion and culture.

Badi
Women who are dalit caste groups called Badi on Nepalgunj and some village in Banke district
in mid-western region and in some village in Dhangadi district in Far western region have been
forced by the society to engage in commercial sex works as their only profession. Because of
their occupation as they are also at risk of STIs and HIV/AIDS.

7. No right on women’s own body

Nepalese women do not have right on one’s own body. They have no right to decide when to
become pregnant, how many times to become pregnant and whether or not to do abortion. Men
usually do decisions about such critical matters and women have to follow them faithfully.

8. Patrilineal/ patrilocal
When the husband moves and lives in his wife's group the marriage is matrilocal; if the wife
moves it is patrilocal. Women change their names to adopt the family name of their husbands
and live in their husband’s home.

9. Age
World is striving to control communicable diseases & other infectious diseases that leads to
increasement of the life expectancy of people. When the life expectancy is increase, the
 number of aged people is also increase. The elder people are at risk to develop chronic
disease, heart disease & other degenerative problems as dementia, alzhemer’s disease that
affects the health care system of the country. Osteoporosis is eight times more common in
women over 40 years of age than men. Uterine Prolapse, Menopausal symptoms, Breast
cancer are major problem of elder women. Cardiovascular disease: Postmenopausal women
have a twofold to threefold increase in CVD compared to premenopausal of the same age.

Unit 4.2: Gender & Women Health

Introduction:
 Gender refers to a socially constructed roles and relations between men & women whereas
'sex' refers to biological characteristics which define human as females or male.
 According to WHO "the word gender is used to describe the characteristics, roles and
responsibilities of men and women, boys and girls, which are socially constructed.
 Gender refers to the array of socially constructed roles & relationships, personality traits,
attitudes, behaviors, values, relative power and influence that society ascribes to the two
sexes on a differential basis, it is the social construction of the biological differences
between men & women, It is learnt through a process of socialization and through a
culture of the particular society. It can change over time and vary with in & between
different cultures.
Sex:
Sex refers to the biological and physiological characteristics that define men & women, it is
related to the biological and physical conditions such as chromosomes. External and internal
genitalia, hormonal states and secondary sex characteristics that determine a person as male or
female.
Different between gender & sex:
Sex Gender
– It is biological – It is socially constructed
– It derives during the process of
– Human being is born with sex
socialization.
– It can be change over time and varies with
– It cannot be changed.
in the different cultures.
– Sex is determined by genetic and anatomical – Gender is an acquired identity that is
characteristics. learned.
– Sex is fixed and based in nature – Gender is like fluid and based in culture
Note:
– Sex is our biology, everything else is gender.
– 'Male' and "Female" are sex categories while "Masculine" and "Feminine" are
gender

Gender equity:
Gender equity is the process of being fair to women & men. Justice and fairness to both men &
women according to their needs rather than biased perception based on gender stereotypes. Both
men & women should be treated fairly without any injustice disparities. Gender equity should be
followed in the levels of physical, psychological, social and emotional well being of a person.
Men and women should equally enjoy socially valued goods, opportunities, resources and
rewards.
Gender equality:
 It refers to equal rights, responsibility and opportunities of men & women as well as boys
& girls and they are benefited from economic, social, cultural and political development.
 Gender equality is a condition in which men & women participates as equals, have equal
access to resources and equal opportunities to control over resources & decisions both
men & women are free to develop their personal abilities and make choices without any
limitations. It is based on men & women being full partners in their home, their
community & their society.
 Gender equality implies that the interest, needs and priorities of both women and men
taken into consideration, recognizing the diversity of different groups of men & women.
 Gender equality is no "women's issue" but should concern and fully equals men as well
as women, equality between men & women are seen both as a human right, issued and
also pre-condition for and indicator of sustainable people centered development.
Gender mainstreaming:
 Gender mainstreaming has been embraced internationally as a strategy towards realizing
gender equality. It involves the integration of a gender perspective into the preparation,
design, implementation, monitoring and evaluation of policies, regulatory measures and
spending programs, with a view to promoting equality between women and men, and
combating discrimination.
 It is the process of assessing of the implications for man and women of any planed action
including legislation, policy, and program in all areas and at all levels.
 It is a strategy for making women as well as men concerns and experiences an integrated
dimension of design, implementation, monitoring & evaluation of policies and programs
in all political, economic and social spheres.
Empowerment:
 Empowerment is the process which enables individual or group to fully access strength,
personal power, authority and influence and to employ that strength when engaging with
other people, institutions or society.
 Empower is about people both women and men taking control over their live, setting
their own agendas, gaining skills, building self-confidence, solving problems and
developing self-reliance.
Women empowerment:
It is defined as enabling women to take an equal place to that of men, participate equally with
men in the developmental process,
Women are needed to be empowering in every steps of life. It is multi-dimensional (change) in
various factors. E.g., Economic, social, political, educational, health care, nutrition & legal.
Ways to empowering the women:
1. Educate the women at first e.g. free ship schooling & collage as well as literacy classes.
2. Gender equality & equity in all sectors e.g. food, education, Rx, cloth, shelter, property,
work division etc.
3. There should be proper job opportunity comparable to men & equal remuneration
(payment) for equal Job.
4. Involvement in political spheres, decision making, policy making.
5. Avoid early marriage & gender discrimination practices.
6. Involvement of women in income generating activities.
7. Equal property right both male & female.
8. Sharing the women health during child birth.
9. Participation in economic & social activities.
10. IEC/BCC from all levels (Sectors) to improve women Reproductive health.

Gender role and responsibilities:

 A gender role is the place you hold in a family or society as a whole for the reason of
being male or female, in other word, gender roles are the social definition of men &
women. They determine how males & females should think speak, dress and interact with
in the context of society. They vary among different societies and cultures, classes, ages.
 A gender role is a set of social & behavioral norms that are generally considered to be
followed by a man or woman in a society.
 Gender roles are socially recognized, taught & maintained throughout life. Various
socializing agents, parent, teachers, peers, movies, television, music, books and religion
teach and reinforce gender roles.
 Gender role is the particular economic, social roles which a society consider appropriate
for man & woman. Man is mainly identified with productive role which tend to be
sequential, while women have a triple roles, domestic responsibilities, productive work,
and community activities.
 In our society, fathers teach boys how to fix and build things, mothers teach girls how to
cook, sew and keep house clean, in this way, children receive parental approval and adopt
culturally accept and conventional roles.
Men’s role:
At present world, in the most developed and industrialized countries, there are few demarcations
between men's and women's occupations. However, in the least developing countries, men have
more visible and recognized roles than women. On the other hand, men are paid more for their
productive works than women. In the present societies, men are usually involved in jobs and
their jobs are counted. But women are mostly engaged in domestic and household tasks.
Women's role: Women's roles in most societies fall under three categories:
 Productive: Related to production of goods for consumption or income through work in
or outside the home.
 Reproductive: Related to domestic or household tasks associated with crating and
sustaining children & family.
  Community management: Related to tasks and responsibilities carried out for the
benefit of the community.
Usually, women's tasks and contributions are not quantified, and valued in our society. Their
productive and reproductive works are not valued as economically productive. In many societies,
women also carry out productive activities such as maintaining small holder agricultural plots in
farming systems but these tasks are often unpaid.
Gender relation:
Gender relations pretty much means what are the male & female roles, attitudes etc. and how do
the different genders interact with each other.
So basically, what are men traditionally like in their culture or religion, what do they do,
similarly what are women like and what do they do? And what are relationship between men &
women? It is a sort pre determine position, it relates responsibility in the family, society
according to different cultures depending domination of the male or female.
Gender discrimination:
 Gender discrimination refers to any distinction, exclusion or restriction made on the basis
of socially constructed gender roles and norms, which prevents a person from enjoying
full human rights.
 Discrimination against women means any distinction, exclusion or restriction made on
the basis of sex, which has the effect or purpose of impairing the recognition, enjoyment
or exercise by women, irrespective of their marital status on the basis of equality of men
& women of human rights & fundamental freedoms in the economic, social, cultural,
political & other field.
 The main areas of discrimination against women are found in relation to trafficking
sexual abuse, education, employment and reproductive health rights.

Impact of gender on various stages of life

1) Intrauterine Period
Many communities and societies pray and preform rituals for the birth of a male child women are
compelled to bear children repeatedly until the male child is born.
Prenatal sex determination test is carried out by many clinics to determine the sex of the unborn
child. When the test reveals female fetus pregnancy is terminated.
A strong son preference inevitably leads to discrimination of the girl child. The birth of a son is
celebrated and the birth of a daughter especially when a son was desired is not celebrated.
Main impacts are;
 Sex-selective abortion
 Female fetocide

2) Birth and during infancy.

Girls and boys are treated differently right from birth. The birth of girl is taken as burden from
the beginning of the life. There is also difference in the quantity and quality of postnatal care
provided to the mother who gives birth to male and female.
An unwanted female baby is not likely to receive the same attention during neonatal illness as a
cherished male baby.
Differences exist in the provision of weaning type, quality and quantity of food. As a result girl
infants face more nutritional problems compared to boys.
Females have inherent biological advantages over males due to their hormonal and genetic
characteristics. Death during the first month of life is higher among males than among females
reflecting biological processes.
Therefore, when higher female mortality occurs in infancy, it implies that environmental factors
such as inadequate feeding and care have nullified the biological advantages.
Main impacts are;
 Female infanticide
 Female neglect in health & nutrition
 High morbidity & mortality of female baby

3) Childhood:
The unequal treatment and the differences in child rearing practices of girls and boys have a
direct impact on the morbidity and mortality of children. Mortality rate in Nepal show that more
girls die during childhood than boys.
Girls, particularly those in resource scarce households & in large extended families, receive
power quality & less food than boys.
There is indifference in providing education for girl’s school enrolment & retention is lower in
case of girls.
Physical abuse & child neglect prevail more commonly for girls. Girls start participation in work
at a younger age.
Main impacts are;
 Malnutrition
 High mortality & morbidity
 Child abuse/ child marriage
 Malnutrition (neglected health)
 Incest
 Child prostitution

4) Adolescence:
Early marriage of girl’s places in future vulnerable position in terms of nutrition, access to
resources & adolescence pregnancy.
Adolescence pregnancy places girls at risk of maternal morbidity & mortality. Early marriage
places an unusually heavy burden on girls for care of family & deprives them of the required
nutrition & education.
Adolescent girls are at risk of sexual harassment & abuse within & outside the home. They are
also vulnerable to being trafficked & raped. In many places adolescent & young girls are sold
into prostitution.
Nutritional deficiency disease like iron deficiency anemia is common among adolescent girls.
During adolescence, while boys are prepared for the world of productive work & decision
making, girls are taught to be wives & mothers.
Main impacts are;
 Forced prostitution
 Girls trafficking
 Forced early marriage
 Psychological abuse
 Rape

5) Adulthood:
Male & female face different level of exposure to diseases during adulthood due to biological as
well as gender differences. Both productive & reproductive activities place greater burden on
women compared to men in developing societies where women bear double burden of work &
deprivation.
The most women are not given sufficient decision-making power to control their own access to
resources such as information, services, money etc. This restricted access to resources prevents
women from developing their decision-making capacity.
Some specific issues are:
 Pregnancy & child birth related problem e.g., VVF, prolapsed, infection, anemia.
 Depression is more prevalent in women.
 Physical & sexual violence at home or at work place
 Prostitutions & exposure to STIs & HIV
 Breast cancer, ovarian cancer, cervical cancer
 Diabetes, Hypertension, & Obesity are more common.
 Most of family planning devices & methods are concentrated on the female.
 Menopausal symptoms
6) Elderly:
It is a well-known fact that the old suffer due to biological as well as social decline. Women in
general live longer than men but not necessarily healthier lives.
Some specific health issues are:
 Osteoporosis is eight times more common in women than men & they do not get
adequate attention from the public health system.
  Mental Depression is more common in women.
 Uterine Prolapse
 Menopausal symptoms
 Breast cancer
 Cardiovascular disease: Postmenopausal women have a twofold to threefold increase in
CVD compared to premenopausal of the same age.
 UTI, RTI

Violence:
Violence is the use of physical force to cause injury, damage & death.

Violence is defined by the World Health Organization as "the intentional use of physical force or
power, threatened or actual, against oneself, another person, or against a group or community,
which either results in or has a high likelihood of resulting in injury, death, psychological harm,
maldevelopment, or deprivation".

Gender Based violence:

 Physical, sexual and psychological violence occur in the family, including battering,
sexual abuse of female children in the household, dowry related violence, marital rape,
female genital mutilation and other traditional practices harmful to women, no spousal
violence and violence related to exploitation.
 Similarly, physical, sexual and physiological violence occur in work place for e.g.
general sexual harassment and presser at work & educational institution, trafficking in
women and force prostitution.
Types of violence:
Physical/ domestic violence (64%) includes:
 Violence by family members
 Sexual abuse without consent
 Bettering, quarreling, kick, bite, slap, punch, burn, throwing acid, use of deadly weapons
to stab or shoot
 Forceful prostitution
 Forceful abortion /sex. Selective abortion
 Medical violence such as –sex selective abortion, induced abortion.
Psychological /social violence (17%) includes:
 Mental torture
 Emotional black mail
 Verbal abuse
 Sexual harassment in public place.
 Sexual harassment in work place.
 Sexual harassment in educational institution.
  Confinement
 Sense of ownership
 Deprivation of resources
 Controlling mobility
Cultural/traditional violence:
 Badi, Deuki, Jhuma, Kumari Pratha
 Chaupadi, Untouchability Practice
 Child marriage
 Polyandry/polygamy
 Dowry related problem
 Witch craft.
Sexual violence:
 Rape
 Sexual abuse without consent
 Forceful prostitution.
 Girl trafficking.
 Female genital mutilation
 Circumcision
 Incest
Economic violence:
 Forceful prostitution
 Girl trafficking

Custodial violence: the protective care or guardianship of institutions/people or system (law,

policy etc). Nature of abuse includes physical or verbal harassment to sexual & physical torture.
Most common form of custodial violence is:
 Laws- violates against women related to property inheritance & polygamy
 No laws addressing domestic violence
 Imprisonment by authority people
 Refugee camp
 Rehabilitation center

Public violence & trafficking

 Ranges from teasing to forced prostitution & mass rape
 Misbehave in public places e.g. vehicle, street, school, working places, market
 Trafficking of women & children
GBV in conflict situation
 Conflict increases all forms of GVB
 Mass displacement leading to more vulnerability of women & children
 Examples are mass rape, military sexual slavery, forced prostitution, forced marriage &
pregnancy
  Women forced to offer sex for survival, or in exchange for food, shelter or protection.
Special form of GBV in Nepal
 Bonded family
 Deuki
 Kumari
 Badi
 Jhuma
 Bhatti pasal & restaurant
Violence against women throughout life span:
Pre-Birth
 Sex-selective abortion
 Female fetocide
Infancy:
 Female infanticide
 Female neglect in health & nutrition.
Child hood:
 Child abuse/ child marriage
 Malnutrition neglected health
 Incest child prostitution
Adolescent
 forced prostitution
 girls trafficking
 forced early marriage
 psychological abuse
 rape
Reproductive age:
 honor killings or shame killing (the traditional practice in some countries of killing a
family member who is believed to have brought shame on the family)
 dowry killing
 intimate partner violence
 sexual abuse
 homicide, sex work
 trafficking
 Sexual harassment.
Elderly
 Elder/widow abuse

Factors Contributing to Domestic Violence against Women:

 Patriarchal society
  Discriminatory laws
 Social practices
 Culture, religion and tradition
 Economic dependency
 Lack of awareness
 Lack of skills
 Vicious cycle of poverty
 Traditionally practices.

Consequences of GBV
The consequences of GBV can be broadly categorized as fatal & nonfatal.
Non fatal outcome
Physical health
 Injury
 Functional impairment
 Physical symptoms
 Poor subjective health
 Permanent disability
Injurious health behaviours
 Smoking
 Alcohol & drug use
 Sexual risk-taking
 Physical inactivity
 Overeating
Functional disorders
 Chronic pain syndrome
 Irritable bowel syndrome
 Gastrointestinal disorders
 Somatic complaints
 Fibromyalgia
Reproductive health
 Unwanted pregnancy
 STIs, HIV
 Gynaecological disorders
 Unsafe abortion
 Pregnancy complications
 Miscarriage, low birth weight
 Pelvic inflammatory disease
Mental health
 Post traumatic stress
  Depression
 Anxiety
 Phobias/panic disorders
 Eating disorders
 Sexual dysfunction
 Substance abuse disorders
Fatal outcome
 Femicide
 Suicide
 Maternal mortality
 AIDS related mortality

Role of the health worker in G.B.V. management

 Show the empathetic attitude towards the women.
 Taking complete history with maintain confidentiality & privacy.
 Listen carefully & reassurance the women
 Detailed assessment of current & past violence
 Do General physical examination
 Provide appropriate medical treatment according to their need basis.
 Refer the women to the available community resources. E.g. safe houses, support group,
legal services.
 Maintain the privacy & confidentiality of client information & records.
 Follow-up if needed.

Prevention of G.B.V.
Primary prevention
 Conduct whole site training/orientation on GBV: training or orientation to the services in
the beginning
 Community awareness- programme should be organized in co-ordination with
community organizers or groups. Like teachers, policies, social workers, women leaders,
youth leader etc.
 Put BCC (Behavior change communication) materials on GBV: offer educational
materials on client's waiting areas, public place, school, clubs, markets, bus stops etc.
including posters on the walls, brochures, hooding boards etc. information about
prevention of GBV should be also given through mass media (television, radio, FM) etc.
 Improve the quality of life & health status of men & women
 Empowering women socially & economically
 Provide economical opportunity to the women (concept of equit)
 Political participation of women
 Male involvement in women empowerment
 Include session about gender based violence in school level curriculum
 Advocate to national & community level
Secondary prevention:
 Ask about abuse with suspected clients e.g. sign & symptoms, types of injury etc., but
information should be kept confidential.
 Offer appropriate counseling & services.
 Refer the clients in appropriate health facility or if available provide early treatment &
diagnosis service for needy client.
 Refer also for other legal & support services.

Tertiary prevention
Refer the clients in rehabilitation center. If the clients are discarded from family or community,
they might need physical, psychological, emotional and legal support sot they should refer in
appropriate rehabilitation center.

4.3 Community based program, local governance

Health post level/urban health clinic (By, HA, ANM, AHW)
Safe motherhood
• Four focused antenatal visits.
• Monitor BP, Weight, FHR.
• IEC/ counseling for danger signs during pregnancy, delivery, postpartum for mother.
• Birth preparedness.
• Detection and management of co-existing conditions and obstetric first aid management.
• Detection and management and referrals of maternal complications such as preeclampsia,
eclampsia, severe anemia, ante and postpartum hemorrhage, heart disease, TB, diabetes.
• Conduct antenatal care clinics according to the clinic schedule or as required.
• Conduct a physical examination of the pregnant women, including assessment of general
health, palpation and auscultation as appropriate.
• Advice the pregnant women about danger sign complications.
• Identify and treat anemia, TB, worm infestation, STDs AND UTIs in pregnant women
and make sure that no contraindicated medicines are given during pregnancy.
• Iron folate supplementation.
• Treatment for night blindness.
• Td immunization to mother.
• Treatment for worms.
• Anti-malarial treatment in endemic areas.
• Facilitated referrals to higher levels of care as necessary.
• Clean and safe delivery (Use of partograph, active management of third stage of labor) by
SBA.
• Initial management of shock and facilitated referral.
• Suture vaginal tears.
• Three postnatal visits for mother and baby.
 • Detection postpartum complications of maternal and obstetric first aid management and
referrals if necessary.
• Detection and management of mastitis.
• Monitor BP, detection of hypertension, first aid management and referrals for postpartum
eclampsia.
• Detection and management (obstetric first aid) of heavy postpartum bleeding with
oxytocin and referral if necessary.
• Insert a pessary if the uterus is prolapsed 42 days after delivery.
• IEC/ counseling for postpartum danger signs for mother.
• Vitamin A for mother.
• Encourage for registration of maternal death.
 

Family planning
• Providing oral contraceptives, condoms, Depo-Provera, implant.
• Providing IUD after screening for contraindication (when applicable).
• Counseling/ management/ referral for side effects, change of methods where indicated.
• Counseling and referral for sterilization.
• Gradually expand choices of methods.
• IEC for Lactation amenorrhea method (LAM).
• Supervision and support to community activities.
 
New born care
• Early, exclusive & extended breast feeding.
• Resuscitation and stabilization of newborn with asphyxia using bag and mask:
management of hypothermia and sepsis.
• Identify, stabilize and manage premature/LBW newborn with kangaroo mother care and
refer if necessary.
• BCG immunization for newborn.
• IEC/counseling for danger signs for newborns.
• Treatment of minor infections and referral after stabilization for major infections in
newborn.
• Encourage for registration of neonatal birth and death event.

Prevention and management of abortion complication

• Diagnosis of early pregnancy
• Counseling on unwanted pregnancy and safe abortion services.
• Referral to nearest safe abortion service if required.
• Detection, management of spontaneous and induced abortion complications.
• MA (Medical Abortion) services
 • Treatment of infection
• Post abortion FP counseling and service.

Prevention & management of RTI, STI, HIV, AIDS

 syndromic treatment & referral for vaginal discharge, lower abdominal pain, genital
ulcers in women & urethral, genital ulcers, swelling scrotum or groin in men as per
national RTI/STI guideline
 Partner identification & referral
 Condom promotion & distribution
 Counseling services
 IEC
 Referral system
 Syndromic treatment

Infertility
Counseling & education for prevention & treatment of infertility
Refer to appropriate health facility for treatment & management of infertility to both partners

Adolescent RH services
 Free availability of oral pills, condom
 Antenatal, delivery, postpartum, newborn care services per MNH guidelines
 Modification of existing MCH/FP service to make it accessible to adolensce
 Conduct family life education clinics
 School health programs
 IEC
 Counseling
 Referral

Problem of elderly women

 Health promotion information (including information on prevention of uterus prolapse &
avoidance of smoking)
 Identification of RH problem related to reproductive organs
 Identification of different health institutions for their treatment & management & referal

2 Primary health care center levels (By staff nurse, MBBS Doctor, ANM, AHW)
Safe motherhood
• Four focused antenatal visits.
• Monitor BP, Weight, FHR.
• IEC/counseling for danger signs during pregnancy, delivery, postpartum for mother.
• Birth preparedness (delivery by SBA and complication readiness with families).
 • Detection and management of co-existing conditions and Basic Essential Obstetric Care
(BEOC) service for complication with facilitated referral if necessary.
• Iron folate supplementation.
• Treatment for night blindness.
• Td immunization.
• Universal treatment for worms.
• Anti-malarial treatment in endemic areas.
• Hemoglobin estimation.
• Blood group typing including Rhesus.
• VDRL test.
• Urine analysis (protein, sugar and bacteria).
• Facilitated referrals to higher levels of care as necessary.
• Clean and safe delivery (partograph, active management of third stage of labor) by SBA.
• Monitor BP, FHR
• Detection of hypertension, management and referrals for postpartum eclampsia if
necessary.
• Management of shock & referral if necessary
• Vacuum delivery
• Suture vaginal & rectal tears
• Three post-natal visit
• Identification of puerperal sepsis and BEOC service with referral if necessary.
• Detection and BEOC service for heavy postpartum bleeding and referral if necessary.
• IEC/counseling for postpartum danger signs for mother.
• Vitamin A for mother.
• Encourage for registration of maternal death.

New born care

• Helping baby breath (HBB)
• Immediate and exclusive breast feeding.
• Resuscitation and stabilization of newborn with asphyxia using bag and mask
hypothermia and sepsis with referral if necessary.
• Identify, stabilize and manage premature/LBW newborn with kangaroo mother care and
refer if necessary.
• Treatment of minor infections and referral after stabilization for major infections in
newborns.
• BCG immunization for newborn.
• IEC/counseling for danger signs for newborns.
• Encourage for registration of neonatal birth and death event.
 Family planning
In addition to service provided to by health post level following are performed;
•  Performing tubal legation, minilap and vasectomy.
• Semen analysis.
• All other contraceptive methods according to government guidelines.
• Post abortion care management.
• Management of complications & referral

Prevention and management of abortion complication

• Diagnosis of early pregnancy.
• Counseling on unwanted pregnancy and safe abortion service.
• MVA (safe abortion procedure) if required.
• MA (Medical Abortion) services
• Referral to nearest safe abortion service if required.
• Detection, management of spontaneous and induced abortion complications with
antibiotics, oxytocins, and MVA /D&C if necessary.
• Post-abortion detection and management of complications with antibiotics, oxytocins and
MVA/D&C if necessary.
• Post abortion FP counseling and service.
 
Prevention & management of RTI, STI, HIV, AIDS
 Diagnostic treatment
 Management of STI on syndromic approach basis when diagnostic facilities are not
available.
 Condom promotion & distribution
 Counseling services
 IEC
 Referral system

Infertility
Diagnosis, treatment & management of infertility & referrals to tertiary care if necessary
Adolescent RH services
 Free availability of oral pills, condom
 Antenatal, delivery, postpartum, newborn care services per MNH guidelines
 Modification of existing MCH/FP service to make it accessible to adolescent
 Conduct family life education clinics
 School health programs
 IEC
 Counseling
 Referral
Problem of elderly women
 Health promotion information (including information on prevention of uterus prolapse &
avoidance of smoking)
 Identification of RH problem related to reproductive organs
 Identification of different health institutions for their treatment & management & referal

3. District/municipal Hospital
Safe motherhood
• Four focused antenatal visits.
• Monitor BP, Weight, FHR.
• IEC/counseling for danger signs during pregnancy, delivery, postpartum for mother.
• Birth preparedness (delivery by SBA and complication readiness with families).
• Detection and management of co-existing conditions and Essential Obstetric Care (EOC)
service for complication with facilitated referral if necessary.
• Iron folate supplementation.
• Treatment for night blindness.
• Td immunization.
• Universal treatment for worms.
• Anti-malarial treatment in endemic areas.
• Hemoglobin estimation.
• Blood group typing including Rhesus.
• VDRL test.
• Urine analysis (protein, sugar and bacteria).
• Stool test for ova & cyst
• Facilitated referrals to higher levels of care as necessary.
• Clean and safe delivery (partograph, active management of third stage of labor) by SBA.
• Monitor BP, FHR
• Detection & management of complications (BEOC/CEOC service) with facilitated
referral if necessary.
• Management of shock & referral if necessary
• Vacuum delivery
• Blood transfusion
• General anesthesia services
• Caesarean section
• Suture vaginal & rectal tears
• Three post-natal visits
• Detection & management of postpartum eclampsia
 • Identification & treatment of puerperal sepsis.
• Detection & management of mastitis.
• Detection and management of heavy postpartum bleeding with oxytocin & blood
transfusion.
• IEC/counseling for postpartum danger signs for mother.
• Vitamin A for postnatal mother.
• Encourage for registration of maternal death.

New born care

• HBB
• Immediate and exclusive breast feeding.
• Resuscitation and stabilization of newborn with asphyxia using bag and mask
hypothermia and sepsis with referral if necessary.
• Identify, stabilize and manage premature/LBW newborn with kangaroo mother care and
refer if necessary.
• Treatment of minor & major infections with referral if necessary.
• BCG immunization for newborn.
• IEC/counseling for danger signs for newborns.
• Encourage for registration of neonatal birth and death event.

Family planning
• Provision/expansion of VSC e.g., tubal legation, minilap and vasectomy including non-
scalpel method.
• Provision of long-acting contraceptive methods & management of side effects.

Prevention and management of abortion complication

• Diagnosis of early pregnancy.
• Counseling on unwanted pregnancy and safe abortion service.
• MVA (safe abortion procedure) if required.
• MA (Medical Abortion) services
• Referral to nearest safe abortion service if required.
• Detection, management of spontaneous and induced abortion complications with
antibiotics, oxytocins, and MVA /D&C if necessary.
• Post-abortion detection and management of complications with antibiotics, oxytocins and
MVA/D&C if necessary.
• Post abortion FP counseling and service.

Prevention & management of RTI, STI, HIV, AIDS

 Clinical diagnosis, laboratory diagnosis & treatment of RTI/STI including HIV/PMTCT
in selected areas according to policy guidelines
  Condom promotion & distribution
 IEC
Infertility
Diagnosis, treatment & management of infertility & referrals to tertiary care if necessary

Adolescent RH services
 FP services as per national guideline
 Antenatal, delivery, postpartum, newborn care services per MNH guidelines
 Modification of existing MCH/FP service to make it accessible to adolescent
 Conduct family life education clinics
 School health programs
 IEC
 Linkage with school & NGO
 Counseling
 Referral

Problem of elderly women

 Health promotion information (including information on prevention of uterus prolapse &
avoidance of smoking)
 Identification of RH problem related to reproductive organs
 Identification of different health institutions for their treatment & management & referral

In conclusion;
Basic practices for community-based health-care interventions (mother & child)
1. Antenatal care (4 focused visits)
2. CB-MNC (community based maternal & child health program)
3. Safe abortion service (SAS)
4. Delivery by SBA
5. Aama surakchhya program
6. IEC & BCC services
7. CB-IMNCI (community based integrated management of neonatal and childhood
program)
8. Early, Exclusive and extended breast feeding
9. Complementary feeding
10. Micronutrient supplementation (Vitamin A supplementation)
11. Better hygiene practice e.g., hand washing with soap, safe disposal of excreta
12. Immunization
13. Malaria prevention
14. Psychosocial care & development
15. Home treatment for sick children
4.4 Community Diagnosis in RH
Community diagnosis is a comprehensive assessment of the health status of an entire community
in relation to its social, physical & biological.
Community diagnosis in RH refers to the identification of reproductive health problems in a
community as a whole in terms of mortality & morbidity rates & ratios, & identification of their
correlates for the purpose of defining those at risk or those in need of health care.
Components of community diagnosis in RH
 Demography including all vital rates
 The causes of morbidity & mortality (maternal & neonatal)
 Use of health services especially maternal & child health clinic
 Nutrition & weaning pattern & the growth of infant
 Society, culture & socio-economic stratification
 Environment especially water, housing & vectors of disease
 The detailed epidemiology of any endemic conditions
 The services & resources available for development such as agriculture, veterinary &
social services
 The degree of involvement of people in their own health care including the use of
traditional healers
 The reasons for failure of health programs in the past & difficulties likely to be
encountered.
Procedure of doing community diagnosis
1. Identification of problems, needs & resources
2. Data processing
3. Interpretation of the collected data by using simple statistical tools
4. Explaining the results to everyone or data presentation
5. Establishment of priorities
6. Planning health action according to priority
7. Implementation of health action plan
8. Follow up & evaluation of health action

4.5 principle of Epidemiology

Epidemiology: is defined as the study of frequency, distribution & determinants of health-

related states or events in specified populations, & the application of this study to the control of
health problem. (John M. Last, 1988)

1. Frequency: it refers to the magnitude or quantity of the disease & summarizing this
information in the form of rates & ratios for e.g., prevalence & incidence rate.

2. Distribution of disease: refers to the partitioning of the disease into units of time, place, &
person.
 • Time distribution: the behaviour of the disease is studied over the hours of the day
(diurnal distribution), months of the year (seasonal distribution), years of decades
(cyclical distribution), and decades of centuries (secular distribution).
• Place distribution: this is the geographic distribution of the disease, for e.g. which states
of the country, which district of states, which urban or village of districts have the
maximum prevalence?
• Person distribution: this presents the magnitude of the disease by age, sex, caste, race,
immunity status, socioeconomic class, literacy occupation.

3. Determinants of disease: it refers to test aetiological hypothesis & identify the underlying
cause or risk factors of disease. This aspect of epidemiology is known as analytical
epidemiology.

Aims of Epidemiology
According to International Epidemiological Association;
 To describe the distribution & magnitude of health & disease problems in human
populations
 To identify aetiological factors or risk factors in the pathogenesis of disease
 To provide the data essential to the planning implementation & evaluation of services for
the prevention, control & treatment of disease & to the setting up of priorities among
those services

Principle of epidemiology
Public health workers use epidemiologic principles as the foundation for diseases surveillance
and investigation activities.
Every health worker should be familiar with the basic principles of epidemiology and how they
are useful.

1. Distribution: It is concerned with frequency and pattern of health events in a population. It

includes not only the number of events in a population but also the risk or rate of diseases in the
population. It is critical for making valid comparisons across different population.

2. Determinants: it is used to search for causes and other factors that influence the occurrence of
health-related events. Example of determinants includes host susceptibility to a disease and
opportunity for exposure to a micro-organism, environmental toxin, insect vector or other
infected individual that may pose a risk for acquiring disease.

3. Specified population: Epidemiologists are concerned with the collective health of people in a
community or other area and the impact of health events on that population.

4. Application: epidemiology provides data for directing public health action. An epidemiologist
uses the scientific methods of descriptive and analytic epidemiology in diagnosing the health of a
community but also must called upon experience and creativity when planning how to control
and prevent diseases in the community.
Epidemiological Approach
1. Asking question
2. Making comparison

Asking question
Question related to health events
1. What is the event?
2. What is its magnitude?
3. Where did it happen?
4. When did it happen?
5. Who are affected?
6. Why did it happen?

Question related to health action

1. What can be done to reduce this problem & its consequence?
2. How can it be prevented in the future?
3. What action should be taken by the community? by the health services? by other sectors?
where & for whom these activities be carried out?
4. What resources are required? How are the activities to be organized?
5. What difficulties may arise & how might they be overcome?

Answer to the above questions may provide clues to disease aetiology & help the epidemiologist
to guide planning & evaluation.

For example: There is an increased incidence of maternal morbidity and mortality due to
pre-eclampsia in a rural village of Mugu district. It has mainly affected women of age
below 20 years and above 35 years belonging to under marginalized socio-economic
groups. The population of reproductive age woman of particular village is around 200
where MMR was 8 per 100000 live births in fiscal year 2076\77.
Asking questions

Related to health events

What is the event? (The problem)

 Pre eclampsia
What is the magnitude?

 8

Where did it happen?

  Rural village of Mugu district
When did it happen?

 Fiscal year 2076\77

Who are affected?

 Women of age below 20 years and above 35 years belonging to under marginalized
socio-economic groups.
Why did it happen?

 Presence of illiteracy, teenage pregnancy

 Poor socio-economic status
 Inadequate maternity services
 Underutilization of the existing services due to inaccessibility
 Lack of communication and referral facilities

Asking questions

Related to health action

What can be done to reduce this problem and its consequences?

 Early identification through risk assessment should be done

 Basic antenatal, intranatal and postnatal care. Skill birth attendant should be
present at every birthing center (24hrs)
 Emergency obstetric care (basic and comprehensive) is to be provided either by
field staff at door step of pregnant women or preferably at the first referral unit

How can it be prevented in the future?

 Regular antennal checkup for early detection

 Organize community education, motivation and formation of safe motherhood
committee at the local level
 Strengthen the referral system for obstetric emergencies
 Improve the standard and quality of care by organizing refresher courses for
health care personnel.
 Adequate maternity services
 Accessibility of services
 Micronutrient (calcium2gm\day) supplementation programs are to be initiated

What action should be taken by the community? By the health services? By other sectors?
Where and for whom these activities be carried out?
  By community

 Wide range of groups (woman’s groups) the health care professionals, religious
leaders and safe motherhood committees (regional, district) can help woman to
obtain the essential obstetric care.
 Early marriage and late pregnancy should be discouraged
 Remove cultural misbeliefs and improving the attitudes

 By health service
 Decentralization of services to make them available to all woman
 Ensure universal and comprehensive health care (sexual, reproductive, maternal
and newborn care)
 Easy access to contraception to prevent unintended pregnancies

 By other sectors
 Legislative and policy Actions
 Girl children and adolescents should have good nutrition,
education and economic opportunity
 Policies should increase woman’s decision-making power
as regard to their own health and reproduction
 Social inequalities and discrimination on grounds of
gender, age and marital status are to be removed
What resources are required? How are the activities to be organized?

 Transportation facilities
 Mobilization of FCHVS, mothers’ groups, social mobilizers
 Adequate medical supplies and equipment
 Periodic refresher courses for continuing education of obstetricians, general practitioners,
midwives and Skilled birth attendants

What difficulties may arise? And how might they be overcome?

 Due to illiteracy and superstitious people, might not want to use modern health facilities
and seek traditional healer
 To overcome the problem, we can train traditional healers about the simple remedial
measures about when should he refer mother to health clinic
 Health awareness campaign should be organized
Making comparison: comparison may be two or more groups, one group having the disease or
exposed to risk factor & the other group not having the disease or not exposed to risk factor or
comparison between individual. The epidemiologist tries to find out the crucial differences in the
host & environmental factors between those affected & not affected.
For comparison

Health survey was conducted in next village of Mugu district where there were pregnant women
without any complications. And after comparing these two villages, we became able to find out
risk factors (age, nutritional and educational status, socioeconomic condition, accessibility of
health facilities) and complications like (premature and low birth weight babies, eclampsia,
accidental hemorrhage, shock, sepsis, etc.)

4.6 Indicators of quality maternal health care

According to WHO, health indicators can be defined as variables which help to measure changes
occurred to the community. it also helps for comparisons, description, analysis of numerical data
among individual, family community and country. It indicates the status and situation of certain
community.

Characteristics of Indicator
 It should be valid that is they should actually measure what they are supposed to measure.
 It should be reliable and objective that is the answer should be the same if measured by
different people in similar circumstances
 It should be sensitive that is they should be sensitive to change in the situation concerned
 It should be feasible that is they should have the ability to obtain data needed and should
of the phenomenon of interest.

Indicators classified as
I) Mortality indicator
II) Morbidity Indicator
III) Disability Indicator
Iv) Nutritional status indicator
v) Health care delivery indicator
vi) Utilization rate
Vii) Indicator of social and mental Health
viii) Environment Indicator
ix) Socio economic Indicator
x ) Health policy Indicator
xi) Indicator of quality life, and
xii) Others indicator
Mortality indicator: Measure the frequency of death in a certain population due to certain
diseases at a specific time. commonly used indicators of mortality are as bellow;

Crude death rate (CDR): CDR gives a rough idea of death that takes place in a particular area.
CDR does not give an accurate number of deaths taking place in each age and sex, so this rate
can’t be use for comparison.

Number of deaths occurred in the year ×100

CDR Estimated midyear population

Perinatal mortality rate

” Death occurs during late pregnancy at 22 completed weeks gestation and over, during
childbirth and upto seven completed days of life”. The perinatal mortality is the sum of the (late)
fetal mortality and the (early)neonatal mortality

No. of fetal deaths after 22 weeks or more and

Perinatal mortality Neonatal death under 7 days of age ×1000
Total number of births during the same year

Neonatal mortality rate

No. of death under 28 days of age occurred in a year ×1000

Number of live births in that year

Post neonatal mortality rate

No. of death between28 days and 1year occurred in a year x 1000

no. of live birth- no. of neonatal death in that year

Infant mortality rate (IMR):

No. of death under 1year of age occurred in a year x 1000
number of live births in that year

Still birth
World Health Organization uses the ICD-10 definitions and recommends that any baby born
without signs of life at greater than or equal to 28 completed weeks' gestation be classified as a
stillbirth.
 No. of fetal death28wks of gestation or more occurring in a year ×100000
no. of live birth ₊late fetal death (stillbirth) in that year

Child mortality rate

The number of deaths of children under five in a calendar year x1000

the number of live births in the same year

Maternal mortality rate

MMR is defined by WHO as “the death of women while pregnant or within 42 days of
termination of pregnancy, irrespective of duration and site of the pregnancy, from any causes
related to or aggravated by the pregnancy or its management but not from accidental or
incidental causes”.

Total no. of female death due to complication pregnancy childbirth or within 42days of delivery
from puerperal causes in a year ×100000

no of live and still birth in that year

Fertility indicators
i) Crude Birth Rate
Number of live births during the year ×1000
Estimated midyear population

ii) General Fertility rate: General fertility rate can be defined as the number of live
births per 1000 women in the reproductive age group (15 to 49) in a given year at
certain area.

No. Of live births in an area during year ×1000

Mid – Year female population age 15-49 in the same year

iii) Age specific fertility rate

No. Of births from specified women age group in year ×1000
Total no. women at that age group in the same time

iv) Total fertility rate: means the no. of children a woman can bear throughout her
life span. The TFR is the measure of the fertility of an imaginary woman who
passes through her reproductive life subject to all the age specific fertility rates for
ages 15-49yrs that were recorded for a given population in a given year.

Calculation of TFR:
It can be calculated by summing up the ASFR for all ages; if 5years age group are
used, the sum of the rate is multiplied by 5 and divided the number by 1000.
 TFR = ∑ ASFR×5 age interval
1000
Morbidity Indicators
i) Incidence rate
No. of new cases of a specific disease
during a given time period (year) ×1000
Estimated mid- year population

ii) Prevalence rate

The total no. of all cases of disease

at a particular time ×100
Population at risk of the disease
at that point of time

Nutritional status Indicator

Nutritional status indicators measure the nutritional status of children mainly below 5 years. The
indicators are: -
 Weight for age.
 Weight for height
 Height for age.
 Birth weight etc.

4.7 Role of the midwife at community level

Special emphasis is given to the role of midwifes in promoting safe motherhood in the community by helping
individuals, families and other community members understand and contribute to safe motherhood.

There are various role and responsibility of midwifes in community:

1. Survey
2. Screening
3. Community Diagnosis
4. Planning
5. Periodic monitoring
6. Implementation
7. Evaluation

Survey
 Visit to home of all pregnant women, lactating mother and child
 Collect necessary data
 Identify all information relevant to the health and wellbeing of pregnant women, lactating mother and child
 Identify community resources for facilitating health problem

Screening
 All midwives need to have broad understanding of screening investigation, because they are responsible for
offering, interpreting and communicating the result.
 The midwives should discuss and offer screening tests to the mother and baby
 When offering test, it is necessary for the midwives to prevent and discuss the option so that women can
make an informed choice that best suits their circumstances
 Tell them about place where the screening is performed
 Midwives commonly recommended antenatal test such as infectious disease screening, full blood count test
 Creating awareness in all women in the community regarding the importance of ANC visit

Community Diagnosis
 Diagnosis pregnancy and monitor normal pregnancy
 Undertaking a thorough examination of the women to identify the problem
 Recognize the warning signs of abnormality in mother or infant
 Identify nutritional status of the mother
 Diagnose that the mother has any infectious disease or not

Planning
 Planning for safe institutional delivery
 Prepare the women for delivery
 Arrange transportation mean to transfer the pregnant women
 Encourage family for economical preparation
 Encourage family member for preparing blood donor which is necessary in case of emergencies
 Planning for child immunization

Periodic monitoring
Tell the mother and families about periodic monitoring such as:
In first trimester:
 Complete blood count
 Blood coagulation test
 TFT
 ABO and RH grouping
 Blood sugar
 Urea creatinine, uric acid
 UPT
 HIV, VDRL
 Immunoglobulin test
 USG
 Blood pressure

Second and third trimester:

 USG
 Fetal heart rate monitoring
 Maternal Weight gain
 Abdominal examination
 Pelvic examination
 Abdominal girth monitoring
 Fetal position/presentation
 Blood pressure
 Oedema

Implementation
The community midwives carry out activities decided upon as being most effective, in order to fulfill the
recognized need. This phase contains all the task, procedures and practices which are performed by
midwife.

Evaluation
The midwife evaluates the done to improve its quality and effectiveness in the community. Evaluation
should be done continuously to determine the changes.
 Overall role of midwives:
 counselor
 advocator
 motivator
 communicator
 researcher
 care provider
 educator
 change agent
 facilitator

References:
 Marshall, J. and Raynor, M. (2014).Myles Textbook for Midwives. (16thed.). Landon: Churchill
Livingstone.
 S, Kamalam. (2005). Essential in Community Health Nursing Practice. (1st ed.). Noida: Gipson’s Paper
Ltd.
 Dahal, K. Rai, A.(2010) Textbook of Community Health Nursing. (2nd ed.). Kathmandu, Dillibazaar:
Pradipta press Ltd.
 Park, K. (2004). Essential of Community Health Nursing. (4th ed.). India, Jbalpur: Prem Nagar, Nagpur
Road.