Maternal Mortality
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Maternal Mortality

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Causes and prevention of maternal mortality

Causes and prevention of maternal mortality

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  • The highlight is that most of the states recording unfavorable maternal mortality rates are the ones with the highest number of birth rates and huge population bases with poor health infrastructure. There are a number of reasons India has such a high maternal mortality ratio. Marriage and childbirth at an early age, lack of adequate health care facilities, inadequate nutrition and absence of skilled personnel, all contribute to pregnancies proving fatal. The common causes of maternal mortality in India are anaemia, haemorrhage, sepsis, obstructed labour, abortion, and toxaemia. Maternal morbidities are the anaemias, chronic malnutrition, pelvic inflammations, liver and kidney diseases. In addition, the pathological processes of some preexisting diseases, such as chronic heart diseases, hypertension, kidney diseases and pulmonary tuberculosis are aggravated by pregnancy and childbirth.
  • The factors underlying the direct causes of maternal deaths operate at several levels. The low social and economic status of girls and women is a fundamental determinant of maternal mortality in many developing countries including India. Low status limits the access of girls and women to education and good nutrition as well as to the economic resources to pay for health care or family planning services. Lack of decision making power in terms of family planning puts them to repeated childbearing. Excessive physical work coupled with poor diet leads to poor maternal outcomes. Many deliveries in rural areas are either conducted by relatives or traditional birth attendant or at times none. In India three out of every five births take place at home; only two in five births take place in a health facility. However, the percentage of births in a health facility has increased steadily. Less than half of births took place with assistance from a health professional, and more than one third were delivered by a Traditional Birth Attendant. The remaining 16 percent were delivered by a relative or other untrained person. A disposable delivery kit (DDK) was used only in 20% of births taking place at home. Most women receive no postnatal care at all. (13)NutritionalPoor nutrition before and during pregnancy contributes in a variety of ways to poor maternal health, obstetric problems and poor pregnancy outcomes. Stunting predisposes to cephalopelvic disproportion and obstructed labour. Anemia may predispose to infection during pregnancy and childbirth, obstetric hemorrhage and are poor operative risks in the event if surgery is required. Severe vitamin A deficiency make women more vulnerable to obstetric complications. Iodine deficiency increases the risk of stillbirths and spontaneous abortions. Lack of dietary calcium appears to increase the risk of pre-eclampsia and eclampsia during pregnancy.
  • can investigate maternal deaths and implement strategies for improvement in areas such as referral, emergency transport, deployment and support of health care providers and cost sharing.
  • InputsA total of 1748 FRUs have been identified & equipped under CSSM programme. Some of the FRUs are lacking in manpower or infrastructure. Under RCH programme, a provision has been kept for strengthening these FRUs through provisioning of drug kits, laparoscope, blood transfusion and employing contractual staff like PHN/ANM/Lab Asst and anaesthesiologist. 24 Hour Delivery Services at PHCs/CHCsUnder RCH program, arrangements have been made that a doctor on call duty, a nurse and cleaning staff are available beyond normal working hours to encourage people to seek deliveries in PHCs/CHCs. For this doctor could be paid Rs 200/- per delivery & other staff could be hired on contractual basis.Referral Transport to Indigent Families through PanchayatsIn category C districts of eight weakly performing states, communication infrastructure is weak and economic status of families in remote villages is poor. Because of this, even if there is a complication identified during pregnancy or delivery, the women have the delivery conducted in the village and frequently through untrained Dais. This is one of the causes of high maternal mortality and morbidity. This has been addressed by providing financial assistance to Panchayats through District Family Welfare Officers.Blood Supply to FRUs/PHCsDept of family welfare will be taking up pilot projects with the assistance of European Commission under the RCH programme for setting up of regular and reliable supply of blood to PHCs/CHCs by linking them with the nearest blood bankMTP servicesMTP by untrained or experienced persons is responsible for high maternal mortality and morbidity. Therefore, increasing and improving facilities for MTP is an important component of the RCH programme at PHC level. Inputs(a) Need based training in MTP by NIHFW.(b) Supply of MTP equipment to District Hospitals, CHCs & PHCs where trained staff is available.(c) Assistance for engaging doctors trained in MTP to the PHCs once a week on fixed days for performing MTP (Pay Rs 500/- day). These doctors will also provide ANC and PNC services to patients during their visit. (d) Supply of MTP equipment to Private clinics if they have OT & trained doctors.

Maternal Mortality Maternal Mortality Presentation Transcript

  • MATERNAL MORTALITY Introduction Definition Determinants Prevention
  • SOME FACTS 85 % women will deliver normally 10-15 % women will develop complications 3-5 % women will need surgical interventions (blood/Cesarean etc.)More chances of women having a normal deliveryHowever delivery complications can occur suddenly, without any warning signals 2
  • SOME FACTS 20-25% deaths occur during pregnancy. 40-50% deaths occur during labour and delivery 25-40% deaths occur after childbirth (More during the first seven days) It is important to focus attention during pregnancy and also after childbirth 3
  • GLOBAL BURDEN 5,29,000 deaths / yr or 400/ 1 lakh live births 1 death per minute 1% in developed countries Range – 24 to 830 / 100,000 live births 19/20 countries with high MMR – Sub Saharan Africa
  • LIFETIME RISK FOR A WOMAN Continent Risk of Losing a Risk of dying due to neonate maternal cause AFRICA 1 In 5 1 in 16 ASIA 1 in 11 1 in 132LATIN AMERICA 1 in 21 1 in 188 DEVELOPED 1 in 125 1 in 2976 COUNTRIES
  • SCENARIO IN INDIA An Indian woman dies from complications related to pregnancy and childbirth. Every seven minutes The maternal mortality ratio in India stands at approx 200 per 100,000 live births. It has some high performing states like Kerala with MMR of 110 and poorly doing states like Uttar Pradesh
  • MATERNAL MORTALITY Death of a woman who is pregnant or within 42 days of termination of pregnancy, irrespective of the site or duration of pregnancy, from any cause related to or aggravated by the pregnancy or its management
  • MATERNAL MORTALITY Death of a woman who is pregnant or within 42 days of termination of pregnancy, irrespective of the site or duration of pregnancy, from any cause related to or aggravated by the pregnancy or its management
  • MATERNAL MORTALITY Death of a woman who is pregnant or within 42 days of termination of pregnancy, irrespective of the site or duration of pregnancy, from any cause related to or aggravated by the pregnancy or its management
  • MATERNAL MORTALITY Death of a woman who is pregnant or within 42 days of termination of pregnancy, irrespective of the site or duration of pregnancy, from any cause related to or aggravated by the pregnancy or its management
  • MATERNAL MORTALITY Death of a woman who is pregnant or within 42 days of termination of pregnancy, irrespective of the site or duration of pregnancy, from any cause related to or aggravated by the pregnancy or its management
  • DIRECT OBSTETRIC DEATHS The deaths resulting from obstetric complications of the pregnant state (pregnancy, labour and the puerperium), from interventions, omissions, or incorrect treatment, or from a chain of events resulting from any of the above are called direct obstetric deaths. Indirect obstetric deaths Those resulting from previous existing disease or disease that developed during pregnancy and that was not due to direct obstetric causes but was aggravated by the physiological effects of pregnancy.
  •  Late maternal death Late maternal is death of a woman from direct or indirect obstetric causes, more than 42 days but less than one year, after termination of pregnancy. Pregnancy related death defined as : the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the cause of death. To facilitate the identification of maternal death in circumstances in which cause of death attribution is inadequate, ICD-10 introduced a new category, that of “pregnancy-related death”.
  • MEASUREMENT OF MATERNAL MORTALITY There are three main measures of maternal mortality- maternal mortality ratio, maternal mortality rate lifetime risk of maternal death.
  • MATERNAL MORTALITY RATIO This represents the risk associated with each pregnancy, i.e. the obstetric risk. It is calculated as the number of maternal deaths during a given year per 100,000 live births during the same period. This is usually referred to as rate though it is a ratio.
  • NOTE - MMR The appropriate denominator for the maternal mortality ratio would be the total number of pregnancies (live births, fetal deaths or stillbirths, induced and spontaneous abortions, ectopic and molar pregnancies). However, this figure is seldom available and thus number of live births is used as the denominator. In countries where maternal mortality is high denominator used is per 1000 live births but as this indicator is reduced with better services, the denominator used is per 1,00,000 live births to avoid figure in decimals.
  • ‘DELAY’ MODEL Delay in seeking care Delay in transport to appropriate health facility Delay in provision of adequate care
  • DELAY  Onset, time and death  APH-12 hours  PPH – 02hours  Rupture uterus- 24 hours  Eclampsia – 48 hours  Infection – 06 days
  • CAUSES OF MATERNAL MORTALITY 20 % - indirect 80 % - directFour Major causes Haemorrhage Infection (sepsis) Eclampsia Obstructed Labour
  • Source- Registrar General India. Causes of Maternal Mortality in Rural India
  • UNDER LYING FACTORS Socio-economic Nutritional
  • WOMEN ARE DYING IN INDIA DUE TO Marriage and childbirth at an early age. Lack of access to Emergency Obstetric Care (EmOC). Inadequate nutrition Due to six medical causes- Hemorrhage, sepsis, unsafe abortion, obstructed labour, eclampsia, pre-existing anemia, malaria Absence of skilled personnel at delivery Short birth intervals- 30% births at < 24 months interval High parity- 25% births in parity 4 or more Lack of blood transfusion facilities in rural areas
  • IMPACT OF MATERNAL DEATHS Children who lost their mothers are more likely to die within two years of maternal death 10 times the chance of death for the neonate 7 times the chance of death for infants older than one month 3 times the chance of death for children 1 to5 years Enrolment in school for younger children is delayed and older children often leave school to support their family.
  • WHAT IS COMMON TO ALL THESECAUSES ? They all are preventable to a great extent
  • IF THEY ARE ALL PREVENTABLE THENWHY NOT?The reasons are Social Economical Medical
  • SOCIAL ISSUES Early marriage Gender discrimination Illiteracy Desire for selective sex of child- female feticide Domestic violence
  • ECONOMIC ISSUES Lack of money Lack of timely transport and communication Delay in taking decision to shift Improper dietary habits
  • MEDICAL ISSUES  Lack of ANC  Lack of emergency obstetric care  Lack of blood and blood products  Lack of essential drugs  Junior staff dealing with high risk cases without supervision  Delay in diagnosis / wrong diagnosis
  • PREVENTION OF MATERNAL MORTALITY Health Education  Age at marriage  Utilization of RCH services  Awareness of antenatal care  Nutritional education  Importance of Immunization  Spacing / Limitation of births
  • PREVENTION OF MATERNAL MORTALITY Safe Abortion services  Sex education and contraception (Adolescent clinics)  Roleof MVA  MTP under LA  Teaching MTP to RMP
  • PREVENTION OF MATERNAL MORTALITY Health delivery infrastructure  Provision of RCH services at remote rural areas / urban slums  Improved staffing  Facilities for Essential / Emergency obstetric care  Training of traditional birth attendants ( TBAs )
  • PREVENTION OF MATERNAL MORTALITY Health care delivery  Emergency management of Eclampsia / Third stage complications at PHC level  Flying squad services
  • PREVENTION OF MATERNAL MORTALITY Adoption of small family norm
  • PREVENTION OF MATERNAL MORTALITY Prevention of anaemia Concept of 100 tablets  at puberty  at the time of marriage  during pregnancy  during lactation
  • PREVENTION OF MATERNAL MORTALITY Non health strategies  Povertyeradication  Improvement of literacy  Women‟s empowerment measures  Improved communications  Improved transport facilities
  • ACTIONS FOR SAFE MOTHERHOOD Legislative & Policy actions Society & Community Health sector
  • LEGISLATIVE & POLICY ACTIONS  MTP Act  Sharda Act  Janani Suraksha Yojna  Adolescent education  Decentralization  Protocols
  • SOCIETY & COMMUNITY National, regional and district safe motherhood committees Health facility and community committee Raising awareness on danger signs provisioning of DDK for clean deliveries TBAs - remote and inaccessible areas. Improving maternal nutrition Addressing certain diseases like malaria, TB, RTI/STI, HIV/AIDS and Hepatitis. Preventing unwanted births and reducing unsafe abortions
  • HEALTH SECTOR ACTIONS Antenatal clinics EOC -Skilled Birth attendance Postnatal care Abortion services FRUs –EmOC Iron & FA, inj TT Family planning services
  • FIRST LEVEL MATERNAL CARE Such care has three functions- birth takes place in the best of circumstances resolve complications as they arise To respond to life-threatening emergencies organized in midwife led birthing centres, combining cultural proximity in a non- medicalized setting, with professional skilled care, the necessary equipment, and the potential for emergency evacuation.
  • BACKUP CARE ideally provided in a hospital where doctors – specialists, skilled general practitioners or mid- level technicians with the appropriate skills Linked with first level care 24 hrs availability Emergency & non-emergency conditions Both 1st level services & backup care to be rolled out simultaneously
  • INITIATIVES IN INDIA FP program – 1952 AIHPP - 1969 MTP Act -1971 Family welfare -1977 CSSM -1992 RCH JSY Vandemataram scheme EmOC EOC
  • ESSENTIAL OBSTETRIC CARE Registration of pregnancy in the first 12- 16 wks At least 3 prenatal check ups Assistance during delivery.( Skilled Birth Attendant) At least 3 postnatal check ups.
  • EMERGENCY OBSTETRIC CARE Inputs A total of 1748 FRUs - provisioning of drug kits, laparoscope, blood transfusion and employing contractual staff like PHN/ANM/Lab Asst and anaesthesiologist. 24 Hour Delivery Services at PHCs/CHCs For this doctor could be paid Rs 200/- per delivery & other staff could be hired on contractual basis. Referral Transport to Indigent Families through Panchayats In category C districts of eight weakly performing states, issue addressed by providing financial assistance to Panchayats through District Family Welfare Officers. Blood Supply to FRUs/PHCs MTP servicesInputs(a) Need based training in MTP by NIHFW.(b) Supply of MTP equipment to District Hospitals, CHCs & PHCs where trained staff is available.(c) Assistance for engaging doctors trained in MTP to the PHCs once a week on fixed days for performing MTP (Pay Rs 500/- day). These doctors will also provide ANC and PNC services to patients during their visit.(d) Supply of MTP equipment to Private clinics if they have OT & trained doctors.
  • JSY
  • JSY- ELIGIBILITYLPS States All pregnant women delivering in Government health centres like Sub-centre, PHC/CHC/ FRU / general wards of District and state Hospitals or accredited private institutionsHPS States BPL pregnant women, aged 19 years and aboveLPS & HPS All SC and ST women delivering in a government health centre like Sub-centre, PHC/CHC/ FRU / general ward of District and state Hospitals or accredited private institutions
  • Cash AssistanceCat Rural Area Total Urban Area Total Mother’s ASHA’s Rs. Mother’s ASHA’s Rs. Package Package Package PackageLPS 1400 600 2000 1000 200 1200HPS 700 700 600 600
  • SPECIAL DISPENSATION FOR LPS STATES: Age restriction removed Restricting benefits of JSY up to 2 births removed No need for any marriage or BPL certification
  • MICRO BIRTH PLAN -Inform the mother and the family about 4 Is, namely Inform dates of 3 ANC & TT Injection (s) and ensure these are provided, Identify the health centre for all referral, Identify the Place of Delivery, Inform expected date of delivery
  • VANDE MATARAM SCHEME Public Private Partnership with the involvement of Federation of Obstetric and Gynachological Society of India and Private Clinics. Voluntary scheme wherein any Obstetric and Gynaecologist, maternity home, nursing home can volunteer themselves in joining the scheme. Any lady doctor/MBBS doctor providing safe motherhood services can also volunteer to join this scheme. The enrolled „Vandematram‟ doctors will display „Vandematram‟ logo in their clinic. Iron and Folic Acid Tablets, oral pills, TT injections etc. will be provided by the respective District Medical Officers to the „Vandematram‟ doctors/clinics for free distributions to beneficiaries.
  • CHALLENGES IN MATERNAL HEALTH Establishing data base on maternal mortality High risk pregnancy behavior-too early, too many, too close Urban-Rural divide Poor rate of institutional deliveries Lack of skilled care at birth Poor implementation of programs Lack of women empowerment
  • TEN ACTION MESSAGES FOR SAFE MOTHERHOOD Advance Safe Motherhood Through Human Rights Empower Women: Ensure Choices Safe Motherhood is a Vital Economic and Social Investment Delay Marriage and First Birth Every Pregnancy Faces Risks Ensure Skilled Attendance at Delivery Improve Access to Quality Reproductive Health Services Prevent Unwanted Pregnancy and Address Unsafe Abortion Measure Progress The Power of Partnership
  • FINAL MESSAGE Child birth – a miracle of life should not become a nightmare of death
  • Tribute to maternal mortality
  • Perinatal Mortality Rate : This includes both late foetal deaths (stillbirths)and early neonatal deaths. The important thing to consider is the weight 1000gmand more at birth or a gestation of 28 weeks if birth weight is not available and ifboth weightand gestation are not available, body length (Crown to heel) of at least 35 cmshould be used.The preferred criterion is birth weight. The denominator used in calculation ofperinatal mortality is 1000 live births (suits nations with poor recording of stillbirths) but for more precise comparison the denominator includes all live birthsweighing1000 gm or more. Perinatal mortality is a sensitive indicator of essential maternaland newborn care provided at childbirth.The factors responsible for stillbirths and early neonatal deaths are often similar.This indicator also assumes importance in view of the fact that many of the earlyneonatal deaths are recorded as stillbirth in developing nations thereby inflatingfigures for stillbirths but showing figures for early neonatal deaths lower than thefactual. This anomaly is taken care of by Perinatal Mortality Rate. The Perinatalperiod comprises just 0.5 % of the average lifespan but has more deaths in thisperiod than next 30-40 years of life.