1
Minimising Maternal MortalityMinimising Maternal Mortality
in Indiain India
Evidence based ApproachEvidence based Approa...
2
3
Smita PatilSmita Patil
Every 5 Minute...
Maternal Death ClockMaternal Death Clock
1 woman1 woman
dies from adies from a
pregnancy-pregnancy-
rela...
6
05_XXX_MM6
Near MissNear Miss EventsEvents
Quality Indicator of Maternal CareQuality Indicator of Maternal Care
""AA wom...
7
Commitment to ReducingCommitment to Reducing
Maternal Deaths (MDG- 5)Maternal Deaths (MDG- 5)
GOAL
Reduce MMR by 75 %
Fr...
MMR-Indian scenarioMMR-Indian scenario
• 1940 - 20 per 1000 live births1940 - 20 per 1000 live births
• 1960 - 10 per 1000...
9
INDIA TOTALINDIA TOTAL
Achieved MDG targetAchieved MDG target
212/lakh live birth212/lakh live birth
109/lakh live birth...
Doable Goal !!
MDG - 5
Political willpower
11
What Do Women Die Of ?What Do Women Die Of ?
They Die
of simple Obstetric
Complications
that Need Not Be Fatal
12
15% will experience an
obstetric complications
…This is true
world over
Nobody Knows Why This Happens.
It is a Fact of ...
Most Obstetric ComplicationsMost Obstetric Complications
Can Neither beCan Neither be
PredictedPredicted
Nor Prevented…Nor...
How Do We KnowHow Do We Know
Which WomenWhich Women
Will Experience Complications?Will Experience Complications?
14
WE CAN...
15
Spirit of Every Gynaecologist
16
It is necessary toIt is necessary to
ENSURE THAT EVERYENSURE THAT EVERY
PREGNANCY IS WANTEDPREGNANCY IS WANTED
CONTRACE...
17
World Health Organization, GenevaWorld Health Organization, Geneva
Evidence – based InterventionsEvidence – based Inter...
Abortion Deaths
(13%)
Comprehensive Abortion CareComprehensive Abortion Care
Ensure thatEnsure that
EVERY ABORTION IS SAFE...
19
WHOWHO GuidelinesGuidelines
• Medical abortionMedical abortion oror vaccum aspirationvaccum aspiration
are theare the s...
20
Three Key Points MMRThree Key Points MMR
• TimeTime - critical factor- critical factor
• Concept of THREE DELAYS.Concep...
How Much TimeHow Much Time
Do We Have?Do We Have?
How Much TimeHow Much Time
Do We Have?Do We Have?
It is estimated that,I...
22
Janani Suraksha YojanaJanani Suraksha Yojana
JSY is a safeJSY is a safe
motherhoodmotherhood
interventionintervention
u...
Education through Medical
professionals & self – help groups
on risk in pregnancy and benefit of institutional delivery
24
Birth PlanningBirth Planning (Home)(Home)
– Identify aIdentify a skilled attendantskilled attendant
– Identify appropri...
Inform mother and family aboutInform mother and family about
4 I's4 I's
• InformInform Dates of ANC'sDates of ANC's (Anti ...
26
 MALEMALE Involvement is the keyInvolvement is the key
Lack of information andLack of information and
inadequateinade...
27
The Second DelayThe Second Delay
Out of reach health
facilities
Poor roads and
communication network
Poor community ...
28
Making Emergency ObstetricMaking Emergency Obstetric
Care availableCare available
Emergency Referral Services (Toll fr...
29
Obstetric HelplineObstetric Helpline
Networking of various private and publicNetworking of various private and public
v...
30
 Inadequate skilled attendants
 Poorly motivated staff
 Inadequate equipment and supplies
 Weak referral system
 s...
31
Addressing the 'third delay‘Addressing the 'third delay‘
Averting Maternal Death & DisabilityAverting Maternal Death & ...
32
EmOC hasEmOC has 88 Key FunctionsKey Functions
• AntibioticsAntibiotics
(intravenous or by(intravenous or by
injection)...
THE GOOD NEWSTHE GOOD NEWS
Not all these functions needNot all these functions need
hospitalshospitals andand doctorsdocto...
34
Making Emergency Obstetric Care availableMaking Emergency Obstetric Care available
& functional At CHC/ Dist. Hospital&...
35
PUBLIC-PRIVATEPUBLIC-PRIVATE
PARTERNERSHIPPARTERNERSHIP
Life – Saving
Skill
Drills
Enforcing
ACCOUNTABILITY
in Medical & Nursing
profession
A government
INDEMNITY scheme
to cover health
professionals
39
We are committed to achieve the MDG 5
109 / lack Live Births
Countdown to 2015 begins……..
ASHA
Training
(villages)
Equipments
Availability
&
Maintenance
Up gradation of
PHC
24 x 7
PHC
AN care INTRANATAL
41
ANAEMIA MANAGEMENTANAEMIA MANAGEMENT
MMR = 20 + 20%MMR = 20 + 20%
• MandatoryMandatory dewormingdeworming
• Supplementa...
Standardized countrywide
protocol of
PPH
Eclampsia
Severe Anaemia
PPH
Number One causes of MMR
44
PPH BOX BALLOON TAMPONADEPPH BOX BALLOON TAMPONADE
Blood TransfusionBlood Transfusion
45
Haemorrhagic ActionHaemorrhagic Action
CommitteeCommittee
Formation of Haemorrhagic Action
Committee
Taluka Level & Dis...
Eclampsia
(Protocol)
Hb & IQ
Anaemia FREE Pregnancy
48
Community InvolvementCommunity Involvement
49
OutsourcingOutsourcing
ObjectiveObjective: To develop conducive environment in all: To develop conducive environment in...
50
E-MAMTAE-MAMTA
• Mother & ChildMother & Child Online tracking systemOnline tracking system
• A GUJARAT initiative adopt...
51
Maternal death reviews / auditMaternal death reviews / audit
Prime Show
52
53
FOGSI InitiativesFOGSI Initiatives
• EMOCEMOC at primary health centres, sub-at primary health centres, sub-
centres an...
My Role ?
(Doctor)
.
Dr. Sharda Jain
Will - What to Change ?
Why to Change ?
Skill - How to Change ?
My Role ?
DO WHAT YOU CAN,
WHERE YOU ARE,
WITH WHAT YOU HAVE.
Dr. Sharda Jain
“I may not have gone
where I intended to go.
But I think I have
ended up where I
intended to be”
Dr. Sharda Jain
Dr. Sharda Jain
Effects of Mothers’ DeathEffects of Mothers’ Death
The death of a
woman and mother
is a tragic loss to
the...
Together let’s write a new future for
saving mother in India.
We can do it with willpower &
hard work to respect indian wo...
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  • EmOC Learning Resource Package
  • EmOC Learning Resource Package
  • EmOC Learning Resource Package
  • EmOC Learning Resource Package
  • EmOC Learning Resource Package
  • “ Hope for the best and prepare for the worst” Too many women die because they suffer from serious complications during pregnancy, birth, or postpartum, but cannot get to the level of healthcare that can provide competent care for their problems: because the primary decision-maker is absent and no one else can make a decision to let the woman seek care, because they do not have access to financial assets to pay for the care, and because they do not have access to a means of transportation that can take them. A pregnant woman and her family can prepare for birth before the event occurs - she will need to choose a skilled attendant to assist her at birth and an appropriate birth setting. She will also need to have the necessary money for care, make a decision about how to get where she plans to give birth, and who will accompany her and stay behind to care for the family. She and her family can also gather supplies such as clean bed clothes, perineal pads or cloths, and a bar of soap. The birth plan is an action plan that has been made after discussion by the woman, her family members, and the healthcare provider. It does not need to be a written document, and usually will not be. Rather, it is an ongoing discussion between all concerned parties to ensure that the woman receives the appropriate care in a timely manner.
  • Minimising maternal mortality.lacture 1

    1. 1. 1 Minimising Maternal MortalityMinimising Maternal Mortality in Indiain India Evidence based ApproachEvidence based Approach Lecture - 1Lecture - 1 Dr. Sharda Jain Director :- Chairman PCH OBST/ Gynae Dpt. Secretary General of Delhi Gynaecologist Forum
    2. 2. 2
    3. 3. 3 Smita PatilSmita Patil
    4. 4. Every 5 Minute... Maternal Death ClockMaternal Death Clock 1 woman1 woman dies from adies from a pregnancy-pregnancy- relatedrelated complicationcomplication In IndiaIn India UNICEF
    5. 5. 6 05_XXX_MM6 Near MissNear Miss EventsEvents Quality Indicator of Maternal CareQuality Indicator of Maternal Care ""AA woman who nearly died butwoman who nearly died but survived asurvived a complication thatcomplication that occurred during pregnancy,occurred during pregnancy, childbirth or within 42 days ofchildbirth or within 42 days of termination of pregnancy“termination of pregnancy“ WHOWHO
    6. 6. 7 Commitment to ReducingCommitment to Reducing Maternal Deaths (MDG- 5)Maternal Deaths (MDG- 5) GOAL Reduce MMR by 75 % From 1990 - to – 2015 i.e. – 109 per lakh
    7. 7. MMR-Indian scenarioMMR-Indian scenario • 1940 - 20 per 1000 live births1940 - 20 per 1000 live births • 1960 - 10 per 1000 live births1960 - 10 per 1000 live births • 1992 - 437 per 100000 live birth1992 - 437 per 100000 live birth • 1997 - 407 per 100000 live births1997 - 407 per 100000 live births • 2003 - 301 per 100000 live births2003 - 301 per 100000 live births • 2006 - 254 per 100000 live births2006 - 254 per 100000 live births • 2009 -212 per 1,00,000 LB2009 -212 per 1,00,000 LB SRGSRG 8 SRGISRGI Expected in 2015 - 135 per lakh LBExpected in 2015 - 135 per lakh LB MDF – 5 in 2015 is 109 per lakhMDF – 5 in 2015 is 109 per lakh
    8. 8. 9 INDIA TOTALINDIA TOTAL Achieved MDG targetAchieved MDG target 212/lakh live birth212/lakh live birth 109/lakh live birth109/lakh live birth KeralaKerala 8181 Tamil NaduTamil Nadu 9797 MaharashtraMaharashtra 104104 Close proximity to MDG targetsClose proximity to MDG targets Andhra PradeshAndhra Pradesh 134134 GujaratGujarat 148148 West BengalWest Bengal 145145 HaryanaHaryana 153153 Uttar PradeshUttar Pradesh 359359 Maternal Mortality Ratio, INDIAMaternal Mortality Ratio, INDIA SRS,2007-09SRS,2007-09
    9. 9. Doable Goal !! MDG - 5 Political willpower
    10. 10. 11 What Do Women Die Of ?What Do Women Die Of ? They Die of simple Obstetric Complications that Need Not Be Fatal
    11. 11. 12 15% will experience an obstetric complications …This is true world over Nobody Knows Why This Happens. It is a Fact of Life. 5% life threatening Obstetric ComplicationsObstetric Complications
    12. 12. Most Obstetric ComplicationsMost Obstetric Complications Can Neither beCan Neither be PredictedPredicted Nor Prevented…Nor Prevented… But if WomenBut if Women Receive TimelyReceive Timely Effective TreatmentEffective Treatment in Time,in Time, 13 …Almost All Can Be Saved
    13. 13. How Do We KnowHow Do We Know Which WomenWhich Women Will Experience Complications?Will Experience Complications? 14 WE CAN’T !!
    14. 14. 15 Spirit of Every Gynaecologist
    15. 15. 16 It is necessary toIt is necessary to ENSURE THAT EVERYENSURE THAT EVERY PREGNANCY IS WANTEDPREGNANCY IS WANTED CONTRACEPTIONCONTRACEPTION Knowledge is not enoughKnowledge is not enough People have to usePeople have to use
    16. 16. 17 World Health Organization, GenevaWorld Health Organization, Geneva Evidence – based InterventionsEvidence – based Interventions Severe BleedingSevere Bleeding 24%24% EclampsiaEclampsia 12%12% Indirect CausesIndirect Causes 20%20% OtherOther DirectDirect CausesCauses 8%8% Obs-Obs- tructedtructed LabourLabour 8%8% InfectionInfection 15%15% UnsafeUnsafe AbortionAbortion 13%13% Oxytocin andOxytocin and ManualManual CompressionCompression Iron Supplements,Iron Supplements, Malaria IntermittentMalaria Intermittent Treatment andTreatment and Antiretroviral for HIVAntiretroviral for HIV PartogramPartogram Tetanus ToxoidTetanus Toxoid ImmunizationImmunization Clean DeliveryClean Delivery AntibioticsAntibiotics Family PlanningFamily Planning andand Postabortion CarePostabortion Care MagnesiumMagnesium SulfateSulfate
    17. 17. Abortion Deaths (13%) Comprehensive Abortion CareComprehensive Abortion Care Ensure thatEnsure that EVERY ABORTION IS SAFEEVERY ABORTION IS SAFE.. WHO GuidelineWHO Guideline
    18. 18. 19 WHOWHO GuidelinesGuidelines • Medical abortionMedical abortion oror vaccum aspirationvaccum aspiration are theare the safestsafest methodsmethods • MVA (MVA (Aspiration Abortion)–– It is advocatedIt is advocated especiallyespecially in low resource settingsin low resource settings like PHClike PHC where reliable source ofwhere reliable source of electricityelectricity/maintenance/maintenance is a problem ???is a problem ???
    19. 19. 20 Three Key Points MMRThree Key Points MMR • TimeTime - critical factor- critical factor • Concept of THREE DELAYS.Concept of THREE DELAYS. • Three points at whichThree points at which access to care isaccess to care is delayeddelayed oror denieddenied oror total lacktotal lack of careof care leads toleads to MATERNAL DEATHMATERNAL DEATH
    20. 20. How Much TimeHow Much Time Do We Have?Do We Have? How Much TimeHow Much Time Do We Have?Do We Have? It is estimated that,It is estimated that, if untreated, deathif untreated, death occurs on average in:occurs on average in: 2 hours2 hours from Postpartum Hemorrhagefrom Postpartum Hemorrhage 12 hours12 hours from Antepartumfrom Antepartum HemorrhageHemorrhage 2 days2 days from Obstructed Laborfrom Obstructed Labor 6 days6 days from Infectionfrom Infection 21
    21. 21. 22 Janani Suraksha YojanaJanani Suraksha Yojana JSY is a safeJSY is a safe motherhoodmotherhood interventionintervention under theunder the NRHMNRHM Door step/Door step/ Institutional deliveryInstitutional delivery /shifting from PHC – CHCs – District Hospital/shifting from PHC – CHCs – District Hospital
    22. 22. Education through Medical professionals & self – help groups on risk in pregnancy and benefit of institutional delivery
    23. 23. 24 Birth PlanningBirth Planning (Home)(Home) – Identify aIdentify a skilled attendantskilled attendant – Identify appropriateIdentify appropriate place of birthplace of birth, and how to get, and how to get therethere – IdentifyIdentify support peoplesupport people,, (who will accompany the(who will accompany the woman and who will take care of the family).woman and who will take care of the family). – MoneyMoney To Avoid 3 delaysTo Avoid 3 delays
    24. 24. Inform mother and family aboutInform mother and family about 4 I's4 I's • InformInform Dates of ANC'sDates of ANC's (Anti natal care) and iron folic(Anti natal care) and iron folic acid tablate /acid tablate /T.T injectionsT.T injections Ensur these are provided.Ensur these are provided. • InformInform expected dateexpected date of delivery.of delivery. • IdentifyIdentify placeplace of delivery.of delivery. • IdentifyIdentify health centerhealth center for referralfor referral – For– For complicatedcomplicated delivery/cessarian Sectiondelivery/cessarian Section can be governmentcan be government institution or accredited Private Health Institutional.institution or accredited Private Health Institutional. ANTENATAL / INTRANATAT PLANNING
    25. 25. 26  MALEMALE Involvement is the keyInvolvement is the key Lack of information andLack of information and inadequateinadequate knowledgeknowledge TraditionalTraditional practicespractices Lack ofLack of moneymoney The First Delay - Home Delay in deciding to seek careDelay in deciding to seek care
    26. 26. 27 The Second DelayThe Second Delay Out of reach health facilities Poor roads and communication network Poor community support mechanisms Inability to access health facilities
    27. 27. 28 Making Emergency ObstetricMaking Emergency Obstetric Care availableCare available Emergency Referral Services (Toll free no 108) introduced Patchy
    28. 28. 29 Obstetric HelplineObstetric Helpline Networking of various private and publicNetworking of various private and public vehicles and locally identified mobilevehicles and locally identified mobile phones forms the core infrastructure of thephones forms the core infrastructure of the helpline, which has been made financiallyhelpline, which has been made financially sustainable by linking it with JSY.sustainable by linking it with JSY.
    29. 29. 30  Inadequate skilled attendants  Poorly motivated staff  Inadequate equipment and supplies  Weak referral system  system is not geared -system is not geared -prioritize anprioritize an emergencyemergency & respond promptly& respond promptly The Third Delay Delay between arriving and receiving care at the health facility:
    30. 30. 31 Addressing the 'third delay‘Addressing the 'third delay‘ Averting Maternal Death & DisabilityAverting Maternal Death & Disability Program (AMDD)Program (AMDD) …We Need to Ensure that Women have Access To… Emergency Obstetric Care (EmOC) AMDD Program Orientation
    31. 31. 32 EmOC hasEmOC has 88 Key FunctionsKey Functions • AntibioticsAntibiotics (intravenous or by(intravenous or by injection)injection) • Oxytocic DrugsOxytocic Drugs • AnticonvulsantsAnticonvulsants • Blood TransfusionBlood Transfusion • Manual Removal ofManual Removal of PlacentaPlacenta • Removal of RetainedRemoval of Retained ProductsProducts • Assisted VaginalAssisted Vaginal DeliveryDelivery • Surgery (CesareanSurgery (Cesarean Section)Section) 32
    32. 32. THE GOOD NEWSTHE GOOD NEWS Not all these functions needNot all these functions need hospitalshospitals andand doctorsdoctors Well-trainedWell-trained nursesnurses andand midwivesmidwives can perform mostcan perform most functions at Basic EmOCfunctions at Basic EmOC FacilitiesFacilities 33 It is An Important Point for Resource Poor country INDIA UK / Middle EastUK / Middle East
    33. 33. 34 Making Emergency Obstetric Care availableMaking Emergency Obstetric Care available & functional At CHC/ Dist. Hospital& functional At CHC/ Dist. Hospital Hiring private ANAESTHETISTS & OBSTETRICIANS to carry out caesarian operations Total : 45966 (upto Jan2010) Training MBBS DOCTORS in short term course in Life Saving ANAESTHESIA Skills and Emergency Obstetric Care (EOC). Total LSCS - 12780
    34. 34. 35 PUBLIC-PRIVATEPUBLIC-PRIVATE PARTERNERSHIPPARTERNERSHIP
    35. 35. Life – Saving Skill Drills
    36. 36. Enforcing ACCOUNTABILITY in Medical & Nursing profession
    37. 37. A government INDEMNITY scheme to cover health professionals
    38. 38. 39 We are committed to achieve the MDG 5 109 / lack Live Births Countdown to 2015 begins……..
    39. 39. ASHA Training (villages) Equipments Availability & Maintenance Up gradation of PHC 24 x 7 PHC AN care INTRANATAL
    40. 40. 41 ANAEMIA MANAGEMENTANAEMIA MANAGEMENT MMR = 20 + 20%MMR = 20 + 20% • MandatoryMandatory dewormingdeworming • SupplementationSupplementation withwith iron folic acidiron folic acid (100)(100) Vit CVit C andand B-12B-12 • Use ofUse of iron sucroseiron sucrose • Ensuring properEnsuring proper measurementmeasurement of haemoglobin levelsof haemoglobin levels • changingchanging diet and lifestylediet and lifestyle of women using slippers..,of women using slippers.., washing hands prior to food.washing hands prior to food. ADOLESCENT ANAEMIAADOLESCENT ANAEMIA Control programmeControl programme ““12 by 12 initiative”12 by 12 initiative”
    41. 41. Standardized countrywide protocol of PPH Eclampsia Severe Anaemia
    42. 42. PPH Number One causes of MMR
    43. 43. 44 PPH BOX BALLOON TAMPONADEPPH BOX BALLOON TAMPONADE Blood TransfusionBlood Transfusion
    44. 44. 45 Haemorrhagic ActionHaemorrhagic Action CommitteeCommittee Formation of Haemorrhagic Action Committee Taluka Level & District Level Blood Transfusion Arrangement •Arrangements for the blood donation camps. •Keeping all the donor cards at the PHC level. •When pt. required blood , can be provided without replacement immediately. •This arrangement done at Karvan PHC. •This innovative step saved three mothers by transfusing blood at the time.
    45. 45. Eclampsia (Protocol)
    46. 46. Hb & IQ Anaemia FREE Pregnancy
    47. 47. 48 Community InvolvementCommunity Involvement
    48. 48. 49 OutsourcingOutsourcing ObjectiveObjective: To develop conducive environment in all: To develop conducive environment in all PHCs, making them clean and green, and mobilizingPHCs, making them clean and green, and mobilizing the community through involvement of Self Helpthe community through involvement of Self Help Group membersGroup members Sweeper Gardener Driver/watchman Team “Clean PHC Green PHC”
    49. 49. 50 E-MAMTAE-MAMTA • Mother & ChildMother & Child Online tracking systemOnline tracking system • A GUJARAT initiative adopted by the Central Government for implementation across India
    50. 50. 51 Maternal death reviews / auditMaternal death reviews / audit Prime Show
    51. 51. 52
    52. 52. 53 FOGSI InitiativesFOGSI Initiatives • EMOCEMOC at primary health centres, sub-at primary health centres, sub- centres and district hospitals.centres and district hospitals. • certificate courses for medical officerscertificate courses for medical officers in conducting normal deliveries as well asin conducting normal deliveries as well as caesarean sectionscaesarean sections • conductingconducting safe abortionssafe abortions • conducting aconducting a maternal mortality auditmaternal mortality audit inin the statesthe states • NationalNational EclampsiaEclampsia registryregistry save the girl childsave the girl child campaigncampaign
    53. 53. My Role ? (Doctor) . Dr. Sharda Jain Will - What to Change ? Why to Change ? Skill - How to Change ?
    54. 54. My Role ? DO WHAT YOU CAN, WHERE YOU ARE, WITH WHAT YOU HAVE. Dr. Sharda Jain
    55. 55. “I may not have gone where I intended to go. But I think I have ended up where I intended to be” Dr. Sharda Jain
    56. 56. Dr. Sharda Jain Effects of Mothers’ DeathEffects of Mothers’ Death The death of a woman and mother is a tragic loss to the child, family, community and nation as a whole.
    57. 57. Together let’s write a new future for saving mother in India. We can do it with willpower & hard work to respect indian women’s LIFE
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