06 Obstetric Care


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  • EmOC Learning Resource Package For each woman who dies during pregnancy, 30 women suffer complications. Initiatives should include: Family planning Management of complications of abortion Management of complications of pregnancy and childbirth
  • EmOC Learning Resource Package
  • EmOC Learning Resource Package Review of the past interventions: Traditional birth attendants and antenatal care still play a role, but the role needs clarification.
  • EmOC Learning Resource Package Wide use of antenatal care in UK, US and Australia. Still, maternal mortality in US was 700/100.000 in 1940s.
  • EmOC Learning Resource Package Risk screening is another intervention that has been used. It is problematic because only about 10 – 15% of women who are thought to be “at risk” for a complication actually go on to have a problem. And most women who do develop complications have no risk factors. If “risk factors” are ruled out, the patient and provider develop a false sense of security, and are then not prepared when complications arise. All women, therefore, should be considered at risk.
  • EmOC Learning Resource Package
  • EmOC Learning Resource Package Midwifery skills: Provision of emergency obstetric care. Untrained birth attendants are unable to provide emergency obstetric care.
  • EmOC Learning Resource Package
  • EmOC Learning Resource Package Other interventions can make a difference, but not as substantial as skilled providers. For example, in this graph, the implementation of antenatal care did not reduce maternal mortality in the UK. Improvements came only with skilled providers who could provide surgical intervention if needed, and who had access to and could use appropriate antibiotics and blood products. Nevertheless, antenatal care remains an important intervention in maternal care because it provides an opportunity to detect problems and to be prepared to handle them.
  • EmOC Learning Resource Package A skilled provider should have a good range of skills, be able to identify problems, recognize complications early, be able to perform essential basic interventions and make referrals to appropriate levels of care when necessary.
  • 06 Obstetric Care

    1. 1. Reducing Maternal Deaths
    2. 2. What Is Maternal Death? The death of a woman while she is pregnant … From any cause related to or aggravated by the pregnancy World Health Organization (WHO) within 42 days of the termination of the pregnancy… … or…
    3. 3. Maternal Mortality: Scope of Problem <ul><li>180 – 200 million pregnancies per year </li></ul><ul><li>75 million unwanted pregnancies 1 </li></ul><ul><li>50 million induced abortions 2 </li></ul><ul><li>20 million unsafe abortions (same as above) </li></ul><ul><li>600,000 maternal deaths (1 per min.) </li></ul><ul><li>1 maternal death=30 maternal morbidities </li></ul>1 Sadik 1997. 2 WHO 1998.
    4. 4. Newborn Mortality: Scope of Problem <ul><li>3 million newborn deaths (first week of life) </li></ul><ul><li>3 million stillbirths </li></ul>
    5. 5. India-latest trends in MMR <ul><li>MMR of India:212 per 100,000 live births -2007-2009(The Special Bulletin for Maternal Mortality Ratio (MMR) in India- Office of the Registrar General of India) </li></ul><ul><li>MMR of India has shown a decline of around 17 percent points from 254 in 2004-06 </li></ul><ul><li>Eleven states show decline of more than 15 percentage points, notable being Maharashtra, Madhya Pradesh/Chhattisgarh, Assam, Uttar Pradesh/Uttaranchal and Rajasthan </li></ul><ul><li>Assam with MMR of 390 per 100,000 live births is the worst state and Kerala is the best state recording MMR of 81 in 2007-09 </li></ul><ul><li>West Bengal is the only state which has shown an increase in MMR from 141 in 2004-06 to 145 in 2007-09 </li></ul>
    6. 6. India & WB- Neonatal Mortality Source-SRS Annual Report 2009 INDICATOR INDIA WEST BENGAL Infant Mortality Rate 50 33 Neonatal Mortality Rate 34 25 Early Neonatal Mortality Rate 27 19 Perinatal Mortality Rate 35 30 Under-5 Mortality Rate 64 40
    7. 7. What Do Women Die Of? They Die of Obstetric Complications that Need Not Be Fatal
    8. 8. Causes of Maternal Death Infection 14.9% Hemorrhage 24.8% Indirect causes 19.8% Other direct causes 7.9% Unsafe abortion 12.9% Obstructed labor 6.9% Eclampsia 12.9%
    9. 9. WHERE DO WOMEN DIE TODAY? 99% of Maternal Deaths Today Occur in Africa, Asia and Latin America
    10. 10. Most Obstetric Complications Occur Suddenly If women do not receive medical treatment on time, they will probably suffer disability… Or Die Without Warning
    11. 11. Most Obstetric Complications <ul><li>Can Neither </li></ul><ul><li>Be Predicted </li></ul><ul><li>Nor Prevented… </li></ul><ul><li>But if Women Receive Effective Treatment </li></ul><ul><li>in Time, </li></ul>… Almost All Can Be Saved
    12. 12. How Much Time Do We Have? <ul><li>It is estimated that, if untreated, death occurs on average in: </li></ul><ul><li>2 hours from Postpartum Hemorrhage </li></ul><ul><li>12 hours from Antepartum Hemorrhage </li></ul><ul><li>2 days from Obstructed Labor </li></ul><ul><li>6 days from Infection </li></ul>
    13. 13. The Three Delays <ul><li>Delay 1: Delay in decision to seek care </li></ul><ul><li>Delay2: Delay in reaching care </li></ul><ul><li>Delay3: Delay in receiving care </li></ul>
    14. 14. Interventions to Reduce Maternal Mortality <ul><li>Historical review </li></ul><ul><li>Traditional birth attendants </li></ul><ul><li>Antenatal care </li></ul><ul><li>Risk screening </li></ul><ul><li>Current approach </li></ul><ul><li>Skilled provider at childbirth </li></ul><ul><li>Emergency Obstetric Care (EmOC) </li></ul>
    15. 15. Interventions: Antenatal Care <ul><li>Antenatal care clinics started in US, Australia, Scotland between 1910 – 1915 </li></ul><ul><li>New concept — screening healthy women for signs of disease </li></ul><ul><li>By 1930s large number (1,200) antenatal care clinics opened in UK </li></ul><ul><li>No reduction in maternal mortality </li></ul><ul><li>But, widely used as a maternal mortality reduction strategy in 1980s and early 1990s </li></ul><ul><li>Is antenatal care important? YES!! </li></ul><ul><li>Early detection of problems and birth preparation </li></ul>
    16. 16. Interventions: Risk Screening <ul><li>Disadvantages </li></ul><ul><li>Very poorly predictive </li></ul><ul><li>Costly — removes woman to maternity waiting homes </li></ul><ul><li>If risk-negative, gives false security </li></ul><ul><li>Conclusion: Cannot identify those at risk of maternal mortality — every pregnancy is at risk </li></ul>
    17. 17. Why Change the Focus of Antenatal Care <ul><li>Every pregnancy faces risks </li></ul><ul><li>It is almost impossible to predict accurately which woman will face life- threatening complications </li></ul><ul><li>Antenatal risk assessment has not reduced maternal mortality </li></ul><ul><li>Many antenatal routines have not been effective in preventing complications </li></ul>
    18. 18. Risk Approach Does Not Work <ul><li>Large number of women classified as “high risk” never develop any complications </li></ul><ul><li>Most women who develop complications do not have risk factors and were classified as “low risk” </li></ul>
    19. 19. Implications of Risk Approach <ul><li>Women classified as “low risk” have a false sense of security </li></ul><ul><li>Women classified as “high risk” undergo unnecessary inconvenience and cost </li></ul><ul><li>Health systems overburdened by unnecessary management of “high risk” mothers and resources for dealing with actual emergencies reduced </li></ul>
    20. 20. Interventions: Traditional Birth Attendants <ul><li>Advantages </li></ul><ul><li>Community-based </li></ul><ul><li>Sought out by women </li></ul><ul><li>Low tech </li></ul><ul><li>Teach clean childbirth </li></ul><ul><li>Disadvantages </li></ul><ul><li>Technical skills limited </li></ul><ul><li>May keep women away from life-saving interventions due to false reassurance </li></ul>There will no substantial reduction in maternal mortality by TBAs providing clinical services
    21. 21. Maternal Mortality Reduction Sri Lanka, 1940 – 1985 <ul><li>Health System Improvements: </li></ul><ul><li>Introduction of system of health facilities </li></ul><ul><li>Expansion of midwifery skills </li></ul><ul><li>Decreased use of home childbirth and births by untrained birth attendants </li></ul><ul><li>Spread of family planning </li></ul>
    22. 22. Maternal Mortality Reduction Sri Lanka, 1940 – 1985 85% births attended by trained personnel
    23. 23. Maternal Mortality: UK 1840 – 1960 Improvements in nutrition, sanitation Antibiotics, banked blood, surgical improvements Antenatal care
    24. 24. Maternal Mortality Ratio per 100,000 live births % Skilled Attendant at Delivery Source : Safe Motherhood Initiative website and Maternal Mortality in 1995: Estimates developed by WHO, UNICEF, UNFPA 2001. Relationship between Skilled Attendant at Delivery and MMR for countries with MMR<500
    25. 25. Source : Safe Motherhood Initiative website and Maternal Mortality in 1995: Estimates developed by WHO, UNICEF, UNFPA 2001. Maternal Mortality Ratio per 100,000 live births % Skilled Attendant at Delivery Relationship between Skilled Attendant at Delivery and MMR for countries with MMR>500
    26. 26. Good Quality Maternity Services Will Save the Lives of Newborns AbouZahr and Wardlaw 2001.
    27. 27. Interventions: Skilled Provider at Childbirth <ul><li>Has relevant training, range of skills </li></ul><ul><li>Recognizes onset of complications </li></ul><ul><li>Observes woman, monitors newborn </li></ul><ul><li>Performs essential basic interventions </li></ul><ul><li>Refers mother and newborn to higher level of care if complications arise requiring further interventions </li></ul><ul><li>Has patience and empathy </li></ul>WHO 1999.
    28. 28. Interventions: Emergency Obstetric Care <ul><li>From late 1930s, MMR in West started to show a steady & steep decline, which is still sustained </li></ul><ul><li>The main reason: Effective treatment for obstetric complications was developed and used, e.g., antibiotics for infection, blood transfusions for hemorrhage & other EmOC interventions </li></ul><ul><li>To Avert Death and Disability We Need to Ensure that Women have Access To Emergency Obstetric Care (EmOC) </li></ul>
    29. 29. How Can We Improve Access to EmOC? By making sure health facilities provide the services needed to save women’s lives. Eight key functions “signal” a facility’s ability to provide EmOC
    30. 30. EmOC Key Functions Cover These Services: <ul><li>Antibiotics (intravenous or by injection) </li></ul><ul><li>Oxytocic Drugs (intravenous or by injection) </li></ul><ul><li>Anticonvulsants (intravenous or by injection) </li></ul><ul><li>Manual Removal of Placenta </li></ul><ul><li>Removal of Retained Products </li></ul><ul><li>Assisted Vaginal Delivery </li></ul><ul><li>Surgery (Cesarean Section) </li></ul><ul><li>Blood Transfusion </li></ul>
    31. 31. Basic and Comprehensive EmOC Facilities <ul><li>Antibiotics (intravenous or by injection) </li></ul><ul><li>Oxytocic Drugs (intravenous or by injection) </li></ul><ul><li>Anticonvulsants (intravenous or by injection) </li></ul><ul><li>Manual Removal of Placenta </li></ul><ul><li>Removal of Retained Products </li></ul><ul><li>Assisted Vaginal Delivery </li></ul>BASIC EmOC Facilities Provide the First Six Services
    32. 32. Basic and Comprehensive EmOC Facilities <ul><li>Antibiotics (intravenous or by injection) </li></ul><ul><li>Oxytocic Drugs (intravenous or by injection) </li></ul><ul><li>Anticonvulsants (intravenous or by injection) </li></ul><ul><li>Manual Removal of Placenta </li></ul><ul><li>Removal of Retained Products </li></ul><ul><li>Assisted Vaginal Delivery </li></ul>COMPREHENSIVE EmOC Facilities Provide All Eight Services <ul><li>Surgery (Cesarean Section) </li></ul><ul><li>Blood Transfusion </li></ul>
    33. 33. <ul><li>Access to… </li></ul>THE 6 PROCESS INDICATORS tell us about changes in: Utilization of… and Quality of… EmOC Services
    34. 34. EmOC Process Indicators <ul><li>For every 500,000 population, there should be at least: 1 Comprehensive EmOC Facility & 4 Basic EmOC Facilities </li></ul><ul><li>Geographical Distribution of EmOC Facilities: EmOC Facilities should be well-distributed to serve 500,000 people </li></ul><ul><li>Proportion of All Births in EmOC Facilities: At Least 15% of All Births in the Community Should Take Place in EmOC Facilities </li></ul><ul><li>Met Need for EmOC Services: At Least 100% of Women Estimated to Have Obstetric Complications Should Be Treated in EmOC Facilities </li></ul><ul><li>Cesarean Sections as a Percentage of All Births </li></ul><ul><ul><li>Minimum: 5% Maximum: 15% </li></ul></ul><ul><li>Case Fatality Rate: Proportion of Women with Obstetric Complications Admitted to a Facility Who Die: Maximum Acceptable Level: 1% </li></ul>
    35. 35. Solutions for Maternal and Newborn Survival <ul><li>Delay in decision to seek care </li></ul><ul><ul><li>Lack of understanding of complications </li></ul></ul><ul><ul><li>Acceptance of maternal death </li></ul></ul><ul><ul><li>Low status of women </li></ul></ul><ul><ul><li>Socio-cultural barriers to seeking care </li></ul></ul><ul><li>Delay in reaching care </li></ul><ul><ul><li>Mountains, islands, rivers — poor organization </li></ul></ul><ul><li>Delay in receiving care </li></ul><ul><ul><li>Supplies, personnel, finances </li></ul></ul><ul><ul><li>Poorly trained personnel with punitive attitude </li></ul></ul><ul><li>Community involvement and social mobilization </li></ul><ul><ul><li>Mother-friendly services </li></ul></ul><ul><ul><li>Community education </li></ul></ul><ul><li>Taking care to the community </li></ul><ul><ul><li>Skilled provider at every birth </li></ul></ul><ul><ul><li>EmOC </li></ul></ul><ul><ul><li>Innovative community programs </li></ul></ul><ul><li>Improved standards of care </li></ul><ul><ul><li>Developing guidelines </li></ul></ul><ul><ul><li>Preservice training </li></ul></ul><ul><ul><li>Performance improvement strategies </li></ul></ul><ul><ul><li>Periodic audits, e.g., near miss audits </li></ul></ul>Identifying the problem: Maternal and newborn death Embracing the solution: Maternal and newborn survival
    36. 36. MULTI-PRONGED APPROACH.. MATERNAL HEALTH STRATEGIES-NRHM Demand Promotion- ( Janani Suraksha Yojana) <ul><li>Provision of services </li></ul><ul><li>Public sector </li></ul><ul><ul><li>1. Essential and Emergency Obstetric Care </li></ul></ul><ul><ul><ul><li>Quality ANC, INC, Safe and Institutional delivery </li></ul></ul></ul><ul><ul><ul><li>Skilled birth attendance </li></ul></ul></ul><ul><ul><ul><li>Multi-skilling </li></ul></ul></ul><ul><ul><li>Operationalize FRU s & 24*7 PHCs </li></ul></ul><ul><ul><li>3. Services for RTIs & STIs – convergence with the NACP </li></ul></ul><ul><ul><li>4. Safe abortion services- New Guidelines </li></ul></ul><ul><ul><li>5. Strengthen referral systems </li></ul></ul><ul><ul><li>Village Health and Nutrition Day.. </li></ul></ul><ul><ul><li>Mother-Child Protection Card </li></ul></ul><ul><li>Provision of Services : Private sector </li></ul><ul><li>Accreditation of Pvt. Health Facilities for RCH services and SBA training </li></ul><ul><li>Fixed package for outsourcing services </li></ul><ul><li>Maternal Death Review </li></ul><ul><li>Pregnancy and Child Tracking –web based system </li></ul><ul><li>Prioritising resources for identified “delivery points” or MCH Centres </li></ul>New
    37. 37. Continuum of Care <ul><li>From Mother to Newborn </li></ul><ul><li>From EmOC to EmO N C </li></ul><ul><li>From Community to Facility </li></ul><ul><li>MCH Centres under NRHM: </li></ul><ul><ul><li>level 1 (24x7 delivery) </li></ul></ul><ul><ul><li>Level 2 (BEmONC) </li></ul></ul><ul><ul><li>Level 3 (CEmONC) </li></ul></ul>
    38. 38. Some ongoing maternal health activities in the state <ul><li>Capacity building : SBA training; EmOC training; Anesthesia training; MVA training </li></ul><ul><li>Operationalization of facilities: Infrastructure, Equipments & HR- for 24x7 PHCs, BEmOC & CEmOC centres, Blood Storage Units </li></ul><ul><li>Maternal Death Review </li></ul><ul><li>Referral transport (Matri Yan) </li></ul><ul><li>JSY </li></ul><ul><li>Training of ASHAs on maternal & newborn care </li></ul><ul><li>Nischay-kit (early registration) </li></ul>
    39. 39. Thank You