2. RISK APPROACH
The risk approach is developed &
promoted by WHO to identify precisely the
risk group or target group( e.g. at risk
mothers, at risk infants) in the population
by certain defined criteria and direct
appropriate action to them.
The risk approach is a managerial device
for increasing the efficiency of health care
services within the limits of existing
resources.
3. Risk
approach
The risk approach is developed & promoted by
WHO to identify precisely the risk group or
target group( e.g. at risk mothers, at risk infants)
in the population by certain defined criteria and
direct appropriate action to them.
The risk approach is a managerial device for
increasing the efficiency of health care services
within the limits of existing resources.
4. Risk
approach
It implies identification of high risk
case at early stage & ongoing them
skilled care.
The main aim of risk approach is to
improve the efficiency &
objectiveness of the maternal & child
health services through maximum
utilization of available services
including nursing care.
5. Terminolo
gy used in
risk
approache
s
RISK FACTORS
A risk factor refers to an aspect of personal
habits or an environmental exposure, that
is associated with an increased probability
of occurrence of a disease.
It can usually be modified, intervening to
alter them in a favorable direction can
reduce the probability of occurrence of
disease.
6. Terminolo
gy used in
risk
approache
s
It is defined as the characteristics or
circumstances of a person or group that are
associated with an increased risk of having,
developing or being especially adversely
affected by morbid process.
In epidemiology, a risk factor is a variable
associated with an increased risk of disease or
infection.
Sometimes, determinant is also used, being a
variable associated with either increased or
decreased risk.
7. Terminolo
gy used in
risk
approache
s
A risk factor is any attribute,
characteristic or exposure of an
individual that increases the
likelihood of developing a disease
or injury.
Some examples of risk factors
are underweight, unsafe sex,
high blood pressure, tobacco and
alcohol consumption, and unsafe
water, sanitation and hygiene.
8. Terminolog
y used in
risk
approache
s
Population at risk
The people who are susceptible to a
given disease are called the
population at risk, and can be defined
by demographic, geographic or
environmental factors.
For instance, occupational injuries
occur only among working people, so
the population at risk is the workforce.
9. Introduction
A population at risk is a group of people who are more likely
to be exposed to a specific negative outcome than the
general population. This could be due to a number of factors,
including: Biological risk, Environmental risk, Social risk
factors, and Behavioral risk factors.
10. Population at risk
The people who are susceptible to a
given disease are called the
population at risk, and can be defined
by demographic, geographic or
environmental factors.
For instance, occupational injuries
occur only among working people, so
the population at risk is the workforce.
12. Terminolo
gy used in
risk
approache
s
Relative risk
The relative risk is the ratio of the risk of
occurrence of a disease among exposed people to
that among the unexposed.
or
Relative risk is the ratio of the incidence of the
disease(or death) among exposed & the incidence
among non -exposed
It is also called the risk ratio.
13. TERMINOLOGY USED IN RISK APPROACH
Contingency table applied to hypothetical cigarette
smoking & lung cancer example.
Cigarette
smoking
Developed
lung cancer
Did not
develop lung
cancer
Total
Yes
No
70
(a)
3
(c)
6930
(b)
2997
(d)
7000
(a+b)
3000
(c+d)
15. TERMINOLOGY USED IN RISK APPROACH
Relative risk
Incidence of disease ( or death) among
exposed
RR
Incidence of disease ( or death) among non
exposed
RR of lung cancer= 10
1
= 10
16. Terminolo
gy in risk
approach
Estimation of relative risk is
important in etiological enquiries.
The risk ratio is a better indicator of
the strength of an association than
the risk difference, because it is
expressed relative to a baseline level
of occurrence.
A relative risk of one indicates no
association; RR greater than one
suggests positive association
between exposure & the disease
under study.
17. Terminolo
gy in risk
approach
A relative risk of 2 indicates that the
incidence rate of disease is 2 times
higher in the exposed group as
compared with the unexposed.
The RR 10 implies that smokers are 10
times at greater risk of developing
lung cancer than non smokers.
The larger the RR, the greater the
strength of the association between
the suspected factor and the disease.
18. Terminolo
gy in risk
approach
It may be noted that risk does not
necessarily imply causal association.
Of course, smaller risk ratio can also
indicate a causal relationship, but care
must be taken to eliminate other possible
explanations.
For example, the risk ratio of lung cancer
in long-term heavy smokers compared
with non-smokers is very high and
indicates that this relationship is not likely
to be a chance finding.
19. Terminoterlogy in
risk apTerminology
in risk approach
proach
Attributable risk (AR)
Attributable risk is the difference in
incidence rates of disease (or death)
between an exposed group and non-
exposed group.
Some authors use the term risk
difference to attributable risk.
It is often expressed as a percent. It is
given by formula;
20. TERMINOLOGY USED IN RISK APPROACH
Incidence of disease rate among exposed minus
incidence of disease rate among non exposed
*100
Incidence rate among exposed
10- 1
* 100 = 90%
10
21. Terminology
Attributable risk indicates to what extent the disease under
study can be attributed to the exposure.
The above figure(example) indicates that the association
between smoking and lung cancer is casual, 90% of the lung
cancer among smokers was due to their smoking.
This suggests the amount of disease that might be eliminated
if the factor under study could be controlled or eliminated
22. Terminol
ogy
First pregnancy, high parity, too frequent
pregnancies, pregnancy at the extremes of
reproductive age, previous child loss and
malnutrition are examples of universal risk
factors, which increase the chances of poor
outcome of pregnancy.
Combination of these, and other risk factors in
the same individual further raises the chance of
poor outcome.
Moreover, the interaction of biologic risk factors
with other derived from the social and
environmental setting will also have an effect.
23. Terminology
For example, multiparity in young mothers living in poverty
usually results in high perinatal mortality.
Risk factors are in fact, characteristics that have a significant
association with a defined end- point.
It is important to specify the end-point or outcome for
which each risk.
24. Common maternal
risk factor
The characteristics of mothers whose
infants have an increased chance of
dying from hypoxia during delivery,
for instance, may be quite different
from those of mothers whose infant
die more usually from gastro-enteritis.
Thus maternal risk factors may be
specific for a particular outcome, such
as previous induced abortion leading
to cervical incompetence.
25. Common maternal risk factor
More frequently, one risk factor increases the frequency of
occurrence of a number of end points.
For example a grand multiparity with its increased risk of
several complications of pregnancy and delivery, such as
transverse lie, postpartum hemorrhage and precipitate birth
etc
26. Common
maternal
risk factor
More frequently, one risk factor
increases the frequency of occurrence
of a number of end points.
For example a grand multiparity with
its increased risk of several
complications of pregnancy and
delivery, such as transverse lie,
postpartum hemorrhage and
precipitate birth etc
27. Common maternal risk factor
c. Medical and obstetrics disease
Anemia- Increased risk of pre-eclampsia, heart failure, preterm
labour, PPH, shock.
Hypertensive disorder It can lead to eclampsia, pre-term labour,
HELLP syndrome(helolysis,elivated liver enzyme, low lipid profile),
DIC (disseminated intravascular coagulation).
Diabetes mellitus- It increases risk of preterm labour due to
infection or polyhydraminous, maternal distress , diabetic
nephropathy , ketoacidosis, prolonged labour ,shoulder dystocia
due to big body size.
28. Common
maternal
risk factor
Jaundice Increased risk of abortion ,
preterm labour , still birth , PPH ,
hemorrhagic manifestations and
hepatic coma.
Renal disease Women with renal
disease may develop severe anemia
during pregnancy.
Due to the use of corticosteroid by
mother, infant may develop
hyperglycemia.
29. Common
maternal
risk factor
Tuberculosis More likely to
develop pre eclampsia , pre term
labour , miscarriage , difficult labour ,
PPH.
Cardiovascular disease Increased
risk of preterm labour , miscarriage ,
IUGR, risk of congenital heart disease
and increased maternal mortality
rate.
30. Common
maternal
risk factor
d. Previous CS Increased risk of
postpartum hemorrhage that
requires blood transfusion.
Increased risk of ectopic
pregnancy and still birth. More
chance of infection in wound and
anesthetic complications.
e. History of sub fertility , PPH,
and retained placenta
31. Common
maternal
risk factor
2.Psychosocial risk factors- Psychosocial
risk is maternal behavior or adverse lifestyles
that have a negative effect on the health of
mother and fetus.
-Risks include smoking, consuming alcohol,
caffeine and drugs use, situational crisis,
etc.
-These psychological factors may increase
the risk of PIH, premature rupture of
membrane, abruption placenta, placenta
previa.
-Smoking causes premature birth, birth
defects (heart defect), low birth weight,
sudden infant death syndrome,
miscarriage, still birth etc.
32. Common
maternal
risk factor
3.Socio-demographic status
a.Low socioeconomic status- It is
associated with increased risk of adverse
pregnancy outcome, perinatal mortality,
LBW, high risk of anemia, preterm labour,
growth retardation.
b.Lack of prenatal care- Due to the lack of
prenatal care, progression or deterioration
of labour cant be determined that may
lead to complications (anemia).
c.Age (age at first pregnancy: 19 years or
below and 35 years or above)
33. Common
maternal
risk factor
Teenage pregnancy: complications
associated with teenage pregnancy-
preterm birth, LBW, perinatal mortality,
sudden infant death syndrome, short
interval to next pregnancy, abortion, high
rate of hypertensive disorders, anemia
and also increased risk of nutritional
deficiencies, HIV infection and other STIs.
-It has been suggested that competition
for nutrition between fetus and mother
could affect the pregnancy outcome in
adolescents by interrupting the normal
growth process.
34. Common
maternal
risk factor
Advanced Maternal Age :
women who are pregnant at age
35 or older are often referred to
as advanced maternal age.
There are six pregnancy-related
risk factors associated advanced
maternal age: decreased fertility,
miscarriage, genetic problems,
high blood pressure, stillbirth,
and maternal death.
35. Common
maternal
risk factor
Statistically, older women are less
fertile.
Advanced maternal age is widely
recognized as increasing the risk for
chromosomal abnormalities. These
are genetic problems that can cause
health problems for the baby,
including Down Syndrome, Tay-Sachs
disease, cystic fibrosis and others.
36. The rate of spontaneous miscarriage climbs gradually with
age, from a 9% miscarriage rate among 22-year olds, to 18%
among 30 year olds, ~20% at age 35, ~40% at age 40, and
84% at age 48.
High rates of miscarriage in older women are more related
to egg quality than the physical ability to stay pregnant. We
know this because older women who use donor eggs from
younger women do not have such high rates of miscarriage.
37. Women aged 40 and older are both more likely to have
higher pre-pregnancy hypertension, and more likely to
develop pregnancy-related hypertension. High blood
pressure can cause premature delivery or low-birth weight
babies.
38. Also associated with advanced maternal age is stillbirth.
Women aged 40+ are two and-a-half times as likely to have a
stillborn baby.
Increased maternal age increased risk of maternal
death during pregnancy, labor and delivery. Some studies
have indicated that women 35 and older may be three times
as likely to die because of pregnancy or childbirth,
compared to younger mothers
39. d.Weight
Underweight woman- These women are more likely than women of
normal weight to give birth to infant who are small for gestational
age.
Poor fetal growth increased birth asphyxia, neonatal hypoglycemia,
hypothermia, perinatal mortality etc.
Overweight- Increased risk of gestational diabetes mellitus,
miscarriage, high risk of hypertension, pre-eclampsia, shoulder
dystocia, PPH and still birth.
40. e. Ethnicity- It is one of the factors that is most strongly
associated with LBW.
f. Height- Height below 148 cm may lead to Cephalo Pelvic
Disproportion leading to maternal and fetal distress.
g. High parity- Multiparous women are at increased chance
of anemia, malpresentation, PPH, ruptured uterus, transverse
lie, prolapsed cord, hypertension, placenta previa, abruption
placenta
41. Environmental factors
Infection- Maternal infection may result in spontaneous
abortion, preterm labour, premature rupture of membrane.
Exposure to chemicals- It leads to increased risk of
polycystic ovarian syndrome and shortened lactation.
42. 5. Surgical condition- Previous caesarean section and
previous surgery like pelvic floor repair, vesicovaginal fistula
repair, myomectomy, tubal ligation, pregnancy with fibroid,
ovarian cyst, carcinoma of cervix can lead to various
complications like ectopic pregnancy and uterine rupture.
6. Congenital genital tract anomalies- Congenital genital
tract anomalies like septate uterus, bicornuate uterus can
lead to ectopic pregnancy, abortion, birth defects in child
etc.
43. Identification of high- risk women can be based on two
classifications:
1.Relationships between the risk factor and adverse out
come.
Causative or triggerring - maternal malnutrition- LBW, placenta
previa, congenital malformation.
Contributory - grand multiparty can lead to transverse lie,
Prolapse of the cord, PPH .
Predictive or associative mother with multiple previous fetal
loss have more risk of having another fetal loss.
44. 2. Biological, medical, social condition
Biological - Age, birth interval, weight gain
Medical - diabetes, obstetric complications, pre eclampsia,
health care utilization.
Social - work load, birth attendant, economic status,
specific culture/ customs of child bearing
45. Requires knowledge of the characteristics associated with
poor outcomes and the ability to recognize and measure
them.
Some factors are easily detected even by untrained health
worker, e.g. age, parity, maternal height and previous fetal
or child loss.
At this level, clear instructions must be given as to the
action to be taken in each case.
46. With increased training, the proportion of detectable
factors increases, leading to improved precision (accuracy)
in predicting outcomes.
Measurement of BP, detection of twin pregnancy and
estimation of hemoglobin level are examples of methods of
detecting further risk factors during pregnancy.
47. For the infant, the measurement of birth weight,
monitoring of growth and knowledge of feeding practices all
give desirable bits of information that permit the detection
of risk factors and facilitate early intervention.
48. Unhealthy & illiterate mother, large families, crowded
environment, poor sanitation, malnutrition and specific
culture/customs of child bearing and rearing are well known
examples of childhood risk factors.
e.g. gastroenteritis as for a number of other diseases.
Certain risk factors are specific for particular outcomes, but
more often one risk factor- grand multiparity, for example-
increases the frequency of various undesirable outcomes.
49. In some situations, culture and customs may act as risk
factors by limiting the education or status of women.
Climate, non-availability of certain foods, or poor
environmental sanitation increases the risks for both
mothers and children
50. 1. Pre-term birth:
Any infant born before completion of 37 weeks of
gestation regardless of birth weight is called preterm
birth.
It may lead to consequences like birth asphyxia, feeding
difficulties, hypothermia, hypoglycemia,
hyperbilirubinemia, necrotizing enterocolitis, etc.
51. 2. Low birth weight:
Birth weight of an infant is the single-most important
determinant of its chances of survival and healthy growth
and development.
The consequences of low birth weight are: birth
asphyxia, hypothermia, infection, hyperbilirubinemia, intra
ventricular hemorrhage etc.
