Induction to Maternal Health

Maternal Health Division MOHFW

The burden of Maternal Mortality

Magnitude of the Problem

~3.45 million women/year ~67,000 Avoidable ~26 million pregnancies/year

23develop complications million Maternaldeliveries/year Deaths / year

Maternal Mortality
Maternal Mortality Ratio:

Number of women who die in a year due to causes related to pregnancy and child birth for every 100, 000 live births
Wide Variations: India 254/100,000 live births Kerela Tamil Nadu Bihar U.P. Assam 95/ 100,000 live births 110/100,000 live births 312/100,000 live births 440/100,000 live births 480/100,000 live births

Maternal Mortality Ratio

(per 1,00,000 live births)

International Comparison India Bangladesh Pakistan Sri Lanka Malaysia Thailand Brazil U.S.A. Sweden Greece 254 340 260 39 31 48 58 24 5 2

Maternal Mortality Ratio over the years

NSS(1957-60)* 1321 NSS(1963-64)* 1195 SRS(1972-76) 853 SRS(1977-81) 810 SRS(1982-86) 580 SRS (1998) 407 SRS (2001-03) 301 SRS (2004-06) 254 * Based on indirect time series estimates
Declining trend

MMR Trends

Projected to reach 231 by 2012 Source-(RGI-SRS-2006)

100

200

300

400

500

600

0
INDIA TOTAL UP/Uttarakhand Assam Rajasthan MP/Chattisgarh Bihar/Jharkhand Orissa Karnataka Andhra Pradesh West Bengal Gujarat Punjab Haryana Maharashtra Tamil Nadu Kerala
RCH II / NRHM/ MDG

MMR Trends: Statewise

MMR 2004-06 MMR 2001-03

MMRwe need to accelerate pace of decline

Maternal Mortality by Causes in India

Direct causes : Haemorrhage Sepsis Severe bleeding Obstructed Labor Abortion Sepsis Unsafe Abortion Eclampsia Iron tablets, Antimalarials Obstructed Labor , Regular Others (Ectopic 34% ANC Pregnancy, Severe Anemia, Embolism, Anesthesia related) Indirect causes: Malaria, Safe Abortion Services, Anemia and 8% Post partum IUCD Insertion Heart & Chest diseases 5% ANC,Partogram 5% etc.
Hypertensive disorders Other Conditions

ANC, AMTSL

37%

11%

PNC, Antibiotics

ANC, Magnesium Sulphate

Source: SRS 2004-06

Reduction of Maternal Deaths-Existing Interventions

S.No Interventions Proportion of maternal deaths prevented 40% Absolute no. of maternal deaths likely to be prevented( India) 30,800

1)

Improved Access to Comprehensive Essential & Emergency Obstetric Care Services (Haemorrhage, Puerp Infecn, Eclampsia, Obst.Labor) Improved Access to Safe Abortion Services Active Management of 3rd Stage of Labour Treatment for Iron Deficiency Magnesium Sulphate etc for Pre Eclampsia Drugs for preventing Malaria etc. TT Immunization Calcium Supplementation during Pregnancy Antibiotic for treating Pre term Rupture of Labour Antibiotic for treating Bacterial Vaginosis
Source: WBReport2004

2) 3) 4) 5) 6) 7) 8) 9) 10)

12% 8% 6% 6% 4% 2% 2% 1% 1%

9240 6160 4620 4620 3080 1540 1540 770 770

Hemorrhage
Pregnant women
Timely Detection

Service Providers (ANMs, SNs, Doctors)

1) Skills and Training 2) Facility Readiness 3) Assured Referral

Antenatal/ Post Natal Check ups Orientation & Sensitization on danger signs Tools: Micro Birth Planning Safe motherhood booklet MCP card Institutional Delivery

1) ANC/PNC and its records 2)SBA, BeMOC, EmOC, LSAS Trainings 2) 24*7 PHC for Basic Obstetric Care FRUs For Comprehensive Obstetric Care 3) Assured availability of transport (EMRI, other PPP, Govt, Any other)

Hypertensive Disorders
Pregnant women
Early and timely identification

Service Provider
Skills and training
Strengthen and ensure quality BeMOC & SBA training. Recognize and treat Hypertensive disorders. Identify and treat Preeclampsia and eclampsia. Quality ANC\ INC \PNC Assured referral transport & Maintaining referral register

Orientation & Sensitization on danger signs BP, Edema, Urine albumin check ups Tools: Safe motherhood booklet MCP card Quality ANC\ INC \PNC

Sepsis
Pregnant women
Early & timely identification
Orientation & Sensitization on Fever & signs of infection and Sepsis Tools: Counselling Safe motherhood booklet MCP card Quality ANC\ INC \PNC

Service Provider
Skills and training
Training of ANMs and Staff nurses Permission to ANMs,(To use Antibiotics) Reorientation of MOs Availability of drugs Implementation of IMEP

Abortions
Pregnant women
Early Detection of pregnancy, counselling on unplanned pregnancy, and Awareness of the available services

Service Provider
1) Skills And Training 2) Facility readiness

Ensure Confidentiality & provision of services as per the MTP Law Information on assured quality services in the Nearest facility Counselling & Sensitization (Pre and post abortion)

Scaling up - MTP /CAC centres and Training for MOs Availability of first trimester services (upto 8 weeks)(MVA/MMA) at 24 x 7 PHCs and comprehensive MTP services at all FRUs and above (MVA/EVA/MMA) Availability of drugs (esp. MMA) and equipments Maintaining privacy and confidentiality (ASHA &ANM &SNs) Private sector accreditation through DLCs Delivering quality services

Avoid coercion for adopting sterilization .

Obstructed Labor
Pregnant women
Early identification

Service Provider
Skills and training Facility readiness

Regular ANC Deliver at Institution Awareness on RT

SBA partograph CEmOC LSAS Assured Referral Transport

Other causes including Anemia

Pregnant women
Early identification: Pallor, Hb Estimation.

Service Provider
1) Skills And Training 2) Adequate logistics and supplies

Awareness about Anemia and nutrition (VHND) Regular Hb testing Quality ANC/PNC

Comprehensive plan for control and treatment of mild/moderate and severe anemia. Initiate tracking from Childhood to adolescent to Pregnancy. Nutritional counselling and provision of IFA tablets. IV iron sucrose for treatment of severe anemia. (being implemented on
pilot basis in various states)

Evidence based strategies to improve Maternal Health

 Quality ANC/PNC services( MCP card, safe motherhood booklet, Micro Birth Planning, Counselling on nutrition, birth preparedness, safe abortion, family planning & institutional deliveries) Pregnancy Tracking. Assured Referral Transport Institutional deliveries Availability of first trimester services (upto 8 weeks)(MVA/MMA) at 24 x 7 PHCs and comprehensive MTP services at all FRUs and above (MVA/EVA/MMA). Proper Record Keeping

 Capacity Building
Accreditated Training sites Accreditated Trainers Trained service providers:
ANMs, SNs- SBA trained MOs- BeMOC trained For FRUs MOs- EmOC & LSAS trained.

S. No
1

Strategy
SCs Operationalisation.

Area of special focus

SBA trained ANM, Building with labour room, duly filled records and registers, Drugs, linkage with referral centres, Monitoring of outreach services including VHND. Testing facility for Hb, urine (sugar and albumin) MO trained in BEmOC/MTP/RTI/IMNCI/ENBC/FP, Paramedical (SNs and ANMs trained in SBA/IMNCI and IUD), Functional LR, 48hrs stay, Ambulance/Referral transport, 24 hr Water and electric Supply, Equipments /Drugs for: LR/OT/New Born Equipments. 1)OBG/MO (EmOC), 2)Paed/MO (FIMNCI/ENBC), 3) Anesthetic/MO (LSAS) Paramedical (SNs), Ambulance/Referral transport, Infrastructure Strengthen/Constructions: Blood Storage Centre, Availability of Genset. 24 hr Water Supply, Procuring Equipments /Drugs for: LR/OT/BSC/New Born Equipments

24 X 7 PHCs Operationalisation

FRU Operationalisation: DH/Sub DH/ WCH/ CHCs

4 5

Maternal Health Trainings Referral transport

Training Site, Master Trainers, skills practiced, training plan, post training supportive supervision of service providers, deployment. Referral register, referral slip, EMRI, any other PPP, Govt or any other, communication with referred facility

Out Reach: VHNDs

Cross checking with due list, facilities for ANC, counselling skills of ANMs , AWW

Maternal Health Trainings

S.No 1 Type SBA Time 3 wks Site DH Trainers OBGY/MO/ SN, nursing tutors & Pead. OBGY /Paed Anesth I/C- BB and other staff OBGY/ med specialist and others OBGY To be trained MO, SN, ANM Batch Size 2

2 3 4 5

EmOC LSAS BST RTI/STI

16 wks 18 wks 3 dys 2 dys

MC/DH MC/DH BB Identified training institutes Identified training institutes MC/DH

MO MO MO, LT MO, SN, ANM, LT, Dermatologist

8 4 15-25 25

MTP including MVA BeMOC

15 dys

MO

10 dys

OBGY/paed

MO

4-5

RTI/STI
Controlling STI/RTI helps decrease HIV infection rates and provides a window of opportunity for counselling about HIV prevention and reproductive health. Key Issues: Trained providers.(Expenditure of training at the district level and above is funded
by NACO and below district level is funded by MOHFW)

Map out the Training schedule to prioritise the training and utilisation of service providers Facility based RTI/STI Services(Clinics). Tests like wet mount Color coded drug kits through central supply by NACO. Essential drugs for RTI/STI management. Counseling with focus on partner counseling Follow up.

To improve the quality of obstetric care by identifying medical causes, delays and other factors and using this information to adopt measures to fill gaps in service delivery. MDR Status of States Key Issues The pace of orientation training needs to be accelerated. The constitution of Distt MDR Committees needs to be fast tracked. Substantial number of states started reporting deaths, actual review of these deaths is not being done. States are not following the prescribed MDR formats for the review Based on the data analysis, the states need to provide information to GOI on number of maternal deaths reviewed out of the reported deaths in the prescribed monthly reporting format Necessary corrective actions to fill the identified gaps need to be undertaken at block/district/state level and communicated to GOI.

Maternal Death Review

Prerequisite: A commitment to act upon the findings Not for punitive action

Non-Negotiable Maternal Health Issues.

1) Mechanisms for monitoring and supportive supervision of the work done by ANMs and her team particularly ANC and related activities (ensuring utilization and adherence to the protocols in MCH cards) at VHNDs and Sub-Centers. 2) Practice of standard protocols in health facilities for ANC, INC and PNC like AMTSL, partograph etc. (including 48 Hrs stay with KMC/EBF/Spacing methods of FP). 3) Provision of comprehensive abortion services in FRUs and DHs and MVA up to 8 weeks at every functional 24X7 PHC. 4) All maternal deaths to be reviewed as per guidelines and formats given by the GoI and monthly monitoring reports to be sent to GOI (monitoring formats to be provided). 5) Ensuring cashless (free) institutional delivery of pregnant women including diet, drugs, blood and consumables and free referral transport from home to facility, from facility to higher facility and drop back home.

SC (SBA trained Del )

PHC- BEmOC trg ( 24x 7 PHCs, CHCs other than FRUs)

All in SC + Availability of follwing services round the clock Episiotomy & suturing cervical tear Assisted vaginal Deliveries like outlet forceps, vacuum Stabilization of patients with obstetric emergencies e.g. Eclampsia, PPH, shock, sepsis. Referral linkages with higher facilities Blood grouping & Rh typing, Wet mount (saline/KOH), RPR/VDRL Management and provision of all basic obstetric & newborn care including management of complications other than those requiring blood transfusion or surgery Linkages with nearest ICTC/PPTCT centre for voluntary counselling and testing for HIV and PPTCT services CAC services upto 8 week

FRU- CEmOC trg (DH, SDH, RH, selected CHCs)

All in SC/PHC +Availability of following services round the clock: Management of obstructed labour Surgical interventions like CSection Comprehensive Management of all obstetric emergencies e.g. Eclampsia, PPH, shock, sepsis In-house BB/ BSU Referral linkages with higher facilities including medical colleges Blood cross matching + management of severe anemia

Early detection of pregnancy. Registration within 12 wks Physical exam +wt+ BP + Abdominal exam Identification & Referral for danger signs Tracking of pregnancy, Preparation of due list and provision of quality ANC/PNC (Micro birth planning, MCP card, Safe motherhood booklet) 100 IFA tabs Essential lab investigations (Hb, Urine :Alb & Sugar, Preg test) TT immunization Counselling on nutrition, birth preparedness, safe abortion, family planning & institutional deliveries Use of partograph AMTSL Infection prevention Pre-referral management for obstetric emergencies e.g. Eclampsia, PPH, shock, Normal Delivery with the Assured referral linkages with higher

Management of complications in pregnancy referred from Levels 1 & 2 CAC services

Comprehensive Monitoring
1) Special Focus on 264 High Focus Districts in the country a) District Level Monitoring b) Facility Level Monitoring(MCH-1, MCH-II , MCH-III) c) State Level Monitoring Points

2) Monthly Monitoring of Deliveries and C-sections at Delivery points