NEHARIKA MALHOTRA MD OBGYNAWARDS RECEIVED: Karan Gupta Memorial award for Best Poster on Oligohydramnios in 51st AICOG held in New Delhi Feb 2008. Karan Gupta Memorial award for Best Poster on Fetal growth Restriction in 52 ndAICOG held in Jaipur Jan 2009 Best Poster on LAVH as a minimal access surgery in YUVA FOGSI West zone , November 2009 FOGSI-IPAS young talent research award for Best research in Medical Termination of Pregnancy in 53rd AICOG, Guwhati, Jan 2010 Best Poster Prize at the 3 p’s Conference in Agra ,2010 Best Paper Presentation In NARCHI conference , Nagpur, sept 2010PUBLICATIONS: First author paper published on Septic Abortion in Journal of SAFOG may-august issue 2010 Article published in FOGSI FOCUS on Contraception 2010 Extra-Curricular: Chapter Published in Jeffcoate 22nd edition book of Gynecology State level Swimmer Basketball Captain in High school Chapter Published in FOGSI book of Obstetrics and Gynecology School Sports Captain in Senior High school 3rd author of paper published in SAFOG journal Professional dance training in Kathak for 7 years Co author of many chapters in various books(jaypee Publishers) Published many articles and poetry in various magazines and newspaper. Member of NGO smriti and co editor of magazine smriti ki pehal Worked for a save the stray animals centre
MAJORITY INDIAN WOMEN AREPOOR ,POWERLESS&PREGNANT
Each year more than half a million women die from pregnancy related causes and 10.6 million children die, 40% of them in the first month of life. Almost all of these deaths are in developing countries. Many could be pre- vented with well-known interventions, if only they were more widely available. In establishing the Millennium Development Goals four years ago, the international community made a commitment to reducing maternal deaths by three quarters, and reducing child mortality by two thirds by the year 2015.
OUR INDIAN SCENARIO – SHOCKING !!! Imagine a woman laboring alone and giving birth by herself in a tent in a remote village. There is no one to help and medical care is far away. It is winter, there is no electricity, no heat, no soap, no running water and food is scarce. What will she do if she cannot stop bleeding? If her newborn is not breathing? What will happen if infection sets in for mother or baby? Within minutes or days, both may be dead.
The International Classification of Diseases (ICD) defines maternal death as “Death of a woman while pregnant or within 42 days of the end of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes (ICD 9th revision)”The gestational event could be of anytype e.g. spontaneous or inducedabortions, ectopic pregnancies, pre-term & term pregnancies.
The 9th revision of ICD further divided the deaths into the following subgroups :-1 DIRECT MATERNAL DEATHS :Those deaths due to obstetric complications ofpregnancy, child birth or the puerperium.2 INDIRECT MATERNAL DEATHS :Those deaths due to previous existing disease orcondition that developed during pregnancy &which was not due to direct causes, but wasaggravated by the physiological effects ofpregnancy.3 FORTUITUOS / COINCIDENTAL DIRECTMATERNAL DEATHS :Those deaths from unrelated causes whichhappen to occur in pregnancy.
The 42 days originally recommended in the WHO definition is restrictive & the 10th revision of ICD introduced the following terms : -1. LATE MATERNAL DEATHS : Deaths occurring in between 42 days & 1 year after abortion, miscarriage or delivery that is due to direct or indirect maternal causes.2. PREGNANCY RELATED DEATHS : Those deaths occurring in women while pregnant or within 42 days of termination of pregnancy, irrespective of the cause of death. MATERNAL MORTALITY RATE : The risk of women dying from puerperal causes per 1000 Live Births. MATERNAL MORTALITY RATIO : Number of deaths per 1,00,000 Live Births.
MAGNITUDE OF PROBLEM GLOBAL SCENARIO Annually 200 million women become pregnant. 136 million women bear children. UNICEF & WHO estimates that 300,000 die annually as a result of complications of child birth. As per Dr Malcolm Potts “Globally every 1 minute 1 women dies due topregnancy related causes”!! 99% of these deaths occur in the developing countries! This risk is more due to unregulated fertility.
Haemorrhage (including 33% anaemia) 38% Sepsis Hypertensive disorders Obstructed labour Abortion Others 8% 5% 11% 5%Major cause of Maternal deaths in India 2000-2003;Govt. of India, SRS “Maternal mortality in India; 1997-2003, Trends, causes and Risk factors, RGI, India, New Delhi In collaboration with Centre for Global Health research University of Toronto, Canada
Ranking for neonatal Ranking for Ranking for TOP TEN deaths maternal deaths stillbirths COUNTIRESIndia 1 1 1Nigeria 2 2 3 FOR NUMBERPakistan 3 8 2 OF STILLChina 4 13 8 BIRTHS,NEONDR Congo 5 3 6 ATALEthiopia 6 5 5 ANDBangladesh 7 6 4 MATERNALIndonesia 8 7 7 DEATHS.Afghanistan 9 4 12Tanzania 10 9 11
MAGNITUDE OF PROBLEM INDIAN PERSPECTIVEThe average Indian woman is 100 times morelikely to die of a maternity related event than herwestern counterpart.Pregnancy for our women is an accident ratherthan a choice.Sample Registration System (1991) estimatesthat Crude Death Rate is 9.8/1000.1.1% of all deaths are maternity related.Total deaths are 82,93,770/year of which 91,231deaths are pregnancy related.Maternal Mortality Rate - 3.4/1000 Live Births.
55% of all maternal deaths are in Asia(which accounts for 61% of all theworld births).In developed countries 1% maternaldeaths occur (these countries accountfor 11% of all world births).At least 1 million children becomemotherless each year.If mother dies the risk of death for herchildren who are under the age of 5, isdoubled or tripled.
For 1 mother that dies : 20 suffer acutecomplications & 100 suffer long termcomplications sequelae.Annually 35-40 million suffer seriousacute life-threatening complications.15-20 million have serious long termsequelae.10-20 million risk their lives bysubjecting themselves to clandestineterminations of pregnancy.
We account for 15% of world population but20% of all maternal deaths world wide. Every 5 minutes 1 woman dies dueto pregnancy related causes!!1 in every 48 women are at a risk of dyingby child birth.MMR is 407/1,00,000 LB but NationalHealth Policy 2000 quotes it to be540/1,00,000 LB.Recent Maternal Mortality Ratio by lastyear was 212.
PERINATAL MORTALITY : It is defined as deaths among fetuses weighing 1000gms or more at birth (28 wks gestation) who die before or during delivery or within the first 7 days of delivery.BUT FOR INTERNATIONAL ACCEPTANCE : It is defined as deaths among fetuses weighing 500gms or more at birth (22 wks gestation) who die before or during delivery or within the first 7 days of delivery . # Perinatal Mortality Rate is expressed in terms of such deaths per 1000 total births.PMR = Late Fetal (28 wks of gestation + more) + Early Neonatal Death (1st week) in 1 year x 1000 Live Birth in same year
Purpose of Analysis of Perinatal Mortality :• It gives a clue to the cause of death.• It helps in identifying high risk factors and in taking measures to prevent or reduce their incidence.# The Perinatal Rate in India varies from state to state according to the standard of Obstetric services available and is more in rural area as compared to urban area.# The Perinatal Mortality Rate in India is reported to be 47 / 1000 live births in rural and 30 / 1000 live births in urban area and in combined 44% per 100 live births in 1999.
The Perinatal Mortality Rate in developed countries is less than 10 / 1000 total birth and is gradually decreasing due to improved obstetric and perinatal technologies.National goal was to achieve aPerinatal Mortality Ratebetween 30 to 35 by year 2000.
STILL-BIRTH :It is the birth of a newborn after 28thcompleted week (wt 1000gms or more) when the baby doesnot breath or show any signs of life after delivery.STILL-BIRTH RATE :- It is the number of such deaths per 1000total births (live + still birth) .SBR = Fetal death weighing > 1000gms at birth X 1000 Total live + still-birth weighing >1000gms at birth
NEONATAL DEATH :- It is the death of the baby within 28 days after birth . It can be either early or late.NEONATAL MORTALITY RATE :- It is the number of such deaths per 1000 live births.
Reasons for having these situations • Health is primarily a state subject - so there is diversity Spending on Health -- 0.9% of GDP for decades. Even now 2 - 3% only. (many developed nations spend 6-9%)
Poverty In 2004 -05, 27.8% Indian population lived below one dollar/day consumption” NSS 61st round for the year 2004-05
Education in 15-49 yrs old41% women and 18% men have never been to school NFHS 3Illiteracy in mothers doubles the IMR
Age of marriage 16% of girls 15- 19 already pregnant. Effects--IMR 77 in teenage pregnancy,55 in post-teen age group‖ NFHS 3 (2005-2006); UNICEF(2006) State of World Children Pregnancy in rural girls twice as common as in urban ones
Health care Private and government facilities exist‖ The poor depend on government facility‖ Govt facility – shortage of funds, equipments, trained staff, not enough centres‖
Spending on Health From personal funds of patients‖ Minimum insurance coverage‖ 87% of curative health care in India by Private sectors‖
The Rural Urban Divide Rural UrbanMMR 619 267Skilled Birth 34 73Attendant IMR 50% highIMR in rural area
Analysed in the light of 3 delay model Delay in seeking help – poverty illiteracy Delay in reaching help – Distance No ambulance No money to pay Delay in getting help - Overcrowding Ill equipped Understaffed
GoalsGOAL 5: Improve maternal healthGOAL 6: Combat HIV/AIDS, Malaria &other communicable diseasesGOAL 7: Ensure environmental sustainabilityGOAL 8: Develop a global partnership for development
Race To MDG 4 Indian Planning Commission & MDG monitor (UN initiative)– India, unlikely to achieve targets for child mortality and infant mortality by 2015 IMR steadily declined in India from 146 in 1951 to 58 in 2005. still higher in rural areas & for girls Malnutrition accounts for nearly 50% of child deaths in India Significant inter-state and intra-state variations in India. (11 in Kerala to 90 in Orissa)
Evaluate ICDS & District Pr. EducationProgram. Improving MDG indicators lead tosuccessful programsAttention to neonatal health, nutrition &immunization, Vigil on high-risk pregnancy,focussed antenatal, intra-natal and post-partumperiodSupply safe water & good sanitation
As of 2010, India’s MMR is 254 with 48% births attended by SBA Planning Commission projects that India will miss MMR target of 109 in 2015 States with better socio-economic status and higher educational levels have lower rates of MMR National Rural Health Mission (NRHM) started in 2005 to improve basic health care delivery system in India—is having good impact Promotion of Skilled Attendance at Birth and institutional delivery Involving Not for Profit organisations working at national and regional levels
National Population policy 2000 * 10th 5 yr plan(2002-07) * NRHM (2005-12) * Janani Suraksha Yojana(JSY) * Gujarat Chiranjeevi Scheme (GCS) * 11th 5 yr plan (2008-12) Regular financial flows NRHM allocated Rs 12,070 crore ( $2.5B) Health budget to have 3% of GDP (current 1.4%) Money incentives in Instn. del, Obst/ anaesthetist services
Vince Lombardi,perhaps the greatest-ever football coach,rightly said, ―Theachievements of anorganization are theresults of the combinedefforts of eachindividual.‖
1. Training and building capacity amongst maternity care providers.2. Establishing guidelines to elevate clinical and ethical practices.3. Advocacy with the Government on laws and administrative practices4. Working closely with the Government to complement and supplement services.5. Partnering with other NGOs which are aligned towards improving the state of reproductive health.
Role of FOGSI –EMOC training, catalyst AMDD(Averting maternal deaths and disability) EMOC kit ,EMOC skill training workshop module 12x12 initiative,24x7 initiative Kishori project ,ankur projectGanga yatra and Bharat jagruti yatra by FOGSI, for public awareness onvarious issues FOGSI has declared its mission for next 5 yrs as “Maternal Mortality Reduction”. To carry forward this mission, a national initiative called “Save the Mother and Newborn” has been launched. Consortium of FOGSI-IAP (Indian Academy of Pediatrics)-NNF (National Neonatology Forum)-SOMI (Society of Midwives of India).
CONCLUSIONSAlthough we have come a long way from MMR 2000 in 1950to254 in 2006, still it is a long way to make any global impactChanging attitude to improve individual health by Federal& State governments is ripping benefits now.Financial supports/incentives by states to pregnantmothers-to-be, are already increasing institutionaldeliveriesIndia is short of SBA- urgent need to improve the situations
"Make every mother and child count" It is a call for radical progress in ensuring the health of women and their children. These members of society are often neglected because they are vulnerable. But wherever that happens the whole society is harmed. Today we want to make it absolutely clear to everyone that the health of women, the newborn and children are a priority for our world as a whole, and for every society, every community, and every family.
“mothers are not dying because of disease wecannot treat.They are dying because society has todecide whether their lives are worth saving”-Prof Fathalla
A strong Political will and societyis needed to put the simplemeasure in place to save lives ofwomen dieing in childbirth.We are not attempting to do theimpossible. On the contrary, ouraim is to do what is well known tobe entirely possible. Thisapproach has the potential totransform the lives of millions.Giving mothers, babies andchildren the care they need is anabsolute imperative.
Thank you for hearing me out“Small opportunities are often thebeginnings of great enterprises”(Helen Keller)So lets Us join in this journey ofmaking every mother and childcount !!!! Its time for society to decide whether they want TAJ MAHALS or mothers and neonates