Manisha Malik, profile picture
Uploaded byManisha Malik
PPTX, PDF202 views

critical review MMR

This document provides an overview of maternal mortality in India. It begins with definitions and statistical measures related to maternal mortality. It then discusses trends in maternal mortality worldwide and in India, highlighting that India accounts for 19% of global maternal deaths. The main causes of maternal death in India are also reviewed. National programs and policies aimed at reducing maternal mortality are outlined. Several constraints to reducing maternal mortality are then described at various levels of the health system. Examples from other countries are provided to illustrate how some constraints have been addressed successfully.

Embed presentation

Download to read offline
Critical Review - MMR Dr Manisha Junior Resident Department of Community Medicine PGIMS,Rohtak
Content • Introduction – definitions & statistical measures • Trends of MMR : World • Trends of MMR : India • Main Causes & Interventions to prevent • National programmes & policies • Constraints • Examples
Friday, October 12, 2012
• India has the highest burden of maternal deaths in the world – 56,000 per year--19 % of total worldwide • Actual Situation is worse -- maternal deaths--in remote rural areas – remains under- reported.
Definitions related to maternal death in ICD-10 1. Maternal death Alternative definitions: 2. Pregnancy-related death 3. Late maternal death The death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes. This definition allows identification of maternal deaths, based on their causes, as either direct or indirect Direct : resulting from obstetric complications of the pregnant state (pregnancy, delivery and postpartum), interventions, omissions, incorrect treatment, or a chain of events resulting from any of the above. e.g. obstetric hemorrhage or hypertensive disorders in pregnancy, or those due to complications of anaesthesia or caesarean section Indirect: resulting from previously existing diseases, or from diseases that developed during pregnancy and that were not due to direct obstetric causes but aggravated by physiological effects of pregnancy. e.g. deaths due to aggravation of an existing cardiac or renal disease The death of a woman from direct or indirect obstetric causes, more than 42 days but less than one year after termination of pregnancy. Complications of pregnancy or childbirth can lead to death beyond the 6 weeks’ postpartum period The death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the cause of death. Useful in settings where accurate information about causes of deaths based on medical certificates is unavailable. e.g. in population-based surveys
Statistical measures • Maternal mortality is the combination of two factors: (i) the risk of death in a single pregnancy or a single live birth; (ii) the fertility level, that is, the number of pregnancies or births that are experienced by women of reproductive age. • Measures are 1) Maternal mortality ratio 2) Maternal mortality rate 3) Adult lifetime risk of maternal death 4) The proportion maternal death among deaths of females of reproductive age (PMDF)
TRENDS IN WORLD
Maternal Mortality: A Global Tragedy • Annually, 287,000 women die of pregnancy related complications • 99% in developing world • ~1% in developed countries Every minute one Maternal Death occur • 10 to 20 million women develop physical or mental disabilities every year as a result of complicated pregnancies and deliveries.
World : 2010 Estimated maternal deaths : 287,000 (decline of 47% from levels in 1990) Global MMR : 210 (in 1990 : 400) (source:Trends in maternal mortality:1990 to 2010 WHO, UNICEF, UNFPA and The World Bank estimates)  Highest MMR -- Sub-Saharan Africa (500) . Lowest MMR-Eastern Asia (37)  Sub-Saharan Africa (56%) and Southern Asia (29%) accounted for 85% of the global burden . 2 countries account for 1/3 of global maternal deaths: India -- 19% (highest- 56000) Nigeria -- 14% . In developing regions (240) 15 times higher than in developed regions (16). low moderate high Extremely high
47% 54% 42% 66% 40% 42% 66%
Millennium Development Goal 5:Improve maternal health Targets Indicators 5.A Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio 5.1 Maternal mortality ratio 5.2 Proportion of births attended by skilled health personnel 5.B Achieve, by 2015, universal access to reproductive health 5.3 Contraceptive prevalence rate 5.4 Adolescent birth rate 5.5 Antenatal care coverage (at least one visit and at least four visits) 5.6 Unmet need for family planning
Maternal Mortality Estimation Inter-Agency Group (MMEIG)-MDG estimates • Categories : To measure progress, countries with MMR ≥100 in 1990, • “on track” : if the annual percentage decline between 1990 and 2008 is 5.5% or more :: 9 countries • “making progress” : annual decline between 2% and 5.5%, :: 50 countries {INDIA– 5.2} • “insufficient progress” : annual decline of less than 2% . :: 14 countries • “no progress” : countries with rising MMR . :: 11 countries 10 countries that already achieved MDG 5 by 2010 : Estonia (95%), Maldives (93%), Belarus (88%), Romania (84%), Bhutan (82%), Equatorial Guinea (81%), Islamic Republic of Iran (81%), Lithuania (78%), Nepal (78%) and Viet Nam (76%).
TRENDS IN INDIA
Projected value-139 by 2015 8% 16% during 2003-06 17% during 2006-09 Source – SRS(2007-09) 153 HARYANA Only 7 States-Andhra Pradesh, Goa, Karnataka, Kerala, Punjab, Sikkim and Tamil Nadu -likely to achieve or close by 2015.WHO estimates 437 India :
Major policy and program goals in MM Year Document Goals 1983 Health policy statement by Govt of India MMR reduction by 200-300 by 1990 and below 200 by the year 2000 2000 National population policy MMR reduction to less than 100 by 2010 2002 National health policy MMR reduction to less than 100 by 2010 2002-2007 Tenth Five year plan MMR reduction to less than 200 by 2007
CAUSES & INTERVENTIONS
Maternal Mortality-Magnitude and Causes About 28 million pregnancies and 56,000 maternal deaths per year in India
20 Maternal deaths averted throughMaternal deaths averted through access to servicesaccess to services (World(World Bank, 2004)Bank, 2004)
But WHY Do These Women Die? Three-Hurdle Race against Death • Delay in Decision to Seek Care • Lack of understanding of complications • Acceptance of maternal death • Low status of women • Socio-cultural barriers to seeking care • Delay in Reaching Care • Mountains, islands, rivers — poor organization • Delay in Receiving Care • Supplies, personnel • Poorly trained personnel with punitive attitude • Finances Three Delays Model
PROGRAMMES & POLICIES
MCH care in India • 1880-- Establishment of training of dais in Amritsar • 1902--Passing of first Midwifery Act in London to promote safe delivery. • 1931-32--Setting up of advisory committee on maternal mortality. They scrutinised causes leading to maternal deaths in hospitals and recommending actions. • 1946--Bhore committee- Primary health centres came up in 1952&MCH centres became its integral part by 1956. • 1992--Child Survival & Safe Motherhood programme, FRU - EmOC • 1997--RCH • 2005-- RCH II under National Rural Health Mission (NRHM)
RCH NRHM ICDS JSY JSSK Ladli Rashtriya Swasthya Bima Yojana Balika Samriddhi Yojna Janani Suvidha Yojna Indira Gandhi Matritva Sahyog Yojana Rajiv Gandhi National Creche Scheme Kishori Shakti Yojana Delivery Hut Schme Vikalp Yojana Jachcha Bachcha Scheme WOMEN’S HEALTH- govt. policies
INDIA MDG – MATERNAL HEALTH SERVICES-Good quality services are not universally available and accessible 0 10 20 30 40 50 60 70 80 34 41 62 27 17 42 48 65 30 16 47 56 74 37 13 1993 1999 2006 MILLENNIUM DEVELOPMENT GOALS INDIA COUNTRY REPORT 2011 Still more gaps left to be bridged for safer motherhood…
CONSTRAINTS ….
Constraints to Improving Access, by Level • Community and household level- 1.lack of demand for effective interventions due to knowledge,perceptions,culture or language 2. barrier to the use of effective interventions(physical,financial,social) • Health services delivery level: 1.Shortages and inadequate distribution of appropriately qualified staff 2.Weak information system,technical guidance,program management or supervision 3.Inadequate drug or other medical supplies 4.Lack of equipment,infrastructure or referral system
• Health sector policy and strategic management level- 1.weak or overly centralized planning and management system 2.insufficient use of evidence in decision making 3.weak drug policy or drug supply system 4.lack of interministerial and intersector action 5. Weak partnerships for health between government, civil society & private sector Constraints to Improving Access, by Level
• Environmental and contextual characteristics – • Government and overall policy framework 1.corruption,weak government, weak rule of law 2.low priority attached to social sector- • Physical environment unfavourable to service delivery • Global level 1.lack of reliable estimates 2.number of global initiatives and misalignment of reforms 2.reliance on project funding modes and limited use of country’s financial management system Constraints to Improving Access, by Level
Lack of reliable estimates of maternal mortality • Without it, the impact of safe motherhood programmes remains unknown. • Sweden, Sri Lanka, and Malaysia established robust vital registration systems at early stages of their battle against maternal mortality. • Information on the levels, causes, and patterns of maternal mortality in India is, at best, incomplete and unsatisfactory 1. Civil registration system - Ideal 2.Household surveys ,Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS) 3.Census 4. Reproductive-age mortality studies (RAMOS) 5. Verbal autopsy
Lack of demand for effective interventions & financial barrier • Despite guarantee of free health services from the public health system, households contribute 71.13 % of total health expenditure for availing health care services from different institutions (NHA-2004-05) • Among mothers in lowest wealth quintile households, 59 % received any antenatal care & 23 % received check- ups from doctor; corresponding figures -97 % & 86 % for highest quintile households
Demand-side incentives - conditional cash transfers (CCTs) India JSY- 2005 In just two years, enrollment in JSY increased 10-fold, from a low of 0.7 million JSY beneficiaries in 2005/06 to 7.3 million beneficiaries in 2007/08. Latin America Since 1997,encouraging poor mothers to seek preventive health services and attend health education talks Sudden and dramatic increases in service utilization The health system needs to be sufficiently geared up . Otherwise the poor quality of services received will result in clients having a low opinion of the services and ultimately reduce demand for services at these facilities. Lack of demand for effective interventions & financial barrier
Shortages and inadequate distribution of appropriately qualified staff • A dearth of available skilled manpower and mismanagement of available human resources, especially in the rural public-health system inspite of : by increasing recruitment adding more tasks to the workload of existing staff or task shifting (e.g. ANM), or contracting with the private sector
0 0.5 1 1.5 2 2.5 Number of PHCs with no Staff Nurse 0 0.5 1 1.5 2 2.5 3 3.5 Number of PHCs with no MOs NO.OFPHCs NO.OFPHCs
0 1 2 3 4 5 Number of PHCs with LMO 0 1 2 3 4 5 SUB-DIVISIONAL HOSPITALS GYNAECOLOGISTS PAEDIATRICIANS ANAESTHETISTS
KNOWLEDGE & SKILLS PERCENT SN WHO KNEW 1. Identification of high risk pregnancies 51.5% 2. Identification of high risk newborn 46.6% 3. Blood pressure measuring 55.3% 4. Abdominal examination 48.5% 5. FHS hearing ability 52% 6. Asepsis maintainance during delivery 48.5% 7. Filling the partograph 28.6% 8. PPH management 49.6% 9. Mucous extractor use 48.1% 10. Ambu-bag use 39.7% 11. Radiant warmer use 22.5%
Maternal death audits and reviews of maternal deaths • allows lessons learned to be utilized in prevention in future • If in all health facilities - the total number can be calculated Botswana >98 % deliveries with skilled health personnel Maternal Mortality Monitoring System in 2005 • midnight census of admissions and deaths at all health facilities; • birth notification forms for non- institutional deliveries • completion of maternal death notification forms after a maternal death audit More accurate national estimates of maternal mortality (Source: Republic of Botswana et al. 2006) India HMIS and civil registration systems ??? Weak information systems
Rwanda: after the war, user fees were instituted-- dramatic decline in the use of health services. In 1998 • use of skilled health personnel for delivery with performance- based schemes • free delivery care for regular antenatal care beneficiaries. institutional deliveries increased from 12.2 percent in 2001 to 23.1 percent in 2004, in contrast to 6.7 percent in 2001 to 9.7 percent in 2004 in the non- participating provinces (Source: Rusa et al. 2009) India Jachha bachha scheme??? Accurate data is needed to verify the outcomes of performance- based financing approaches. HMIS should be strengthened to provide reliable routine data with periodic verification. Lack of incentives to provide quality health services • An extreme example is the ANM or doctor, who lives in a remote village and provides 24-hour services, gets the same salary and benefits as an ANM or a doctor who lives in a city, and commutes irregularly to a rural health centre for a few hours a day where s/he is posted.
Lack of equipment, infrastructure • Poor & inadequate drug supply • Poor condition of equipments • Lack of leadership in taking initiative at lower levels – district, block level • Policy on upgrading of infrastructure & equipments – does not cover all range of issues , centrally managed, takes long time in processing
Privacy assured during the stay at PHC X-Ray Unit in PHC Baby warmers at PHC Clean and Neat environment RO , Solar water heater Communication
Lack of referral system • FRUs • Secondary referral system-DH,SDH in poor condition • Patient load directly to trtiary level—poor quality care due to patient and health care giver disproportion Djibouti (high urban population >80% in a small geographical area, In 2002,to reduce load on referral national hospitals • trained health personnel to better handle emergency obstetric complications; • renovated/equipped the hospital; • strengthened the capacity of the secondary level health facilities (e.g., renovated operating rooms, radios, and ambulances) percentage of births in health facilities had, remarkably, increased from 40 percent in 2002 to 93 percent in 2006 (Source: World Bank, reporting background for Health Sector Development Program Project, Djibouti, Project P071062.)
Weak partnerships for health between government, civil society & private sector Public private parternership Honduras collaboration with private providers to set up 13 birthing centers in remote areas known for high maternal mortality. MMR ↓ from 182 to 108 Between 1980 and 1997 (Source: Koblinsky 2003) Cuba Maternity waiting homes MMR ↓ from 118 to 31 Between 1963 and 1984 (Source: Koblinsky 2003) Geographical areas or marginalized populations may remain outside the reach of the public sector--- strategic partnerships .
Gujrat’s initiatives to reduce MMR The Chiranjeevi Yojna (CY) • launched in five poor districts in 2005 and since 2007 it has been extended to entire Gujarat • acute shortage of gynecologists in public health facilities (only 7 against 273 CHC positions) so,GoG decided to enlist their support from private • Aim to remove the financial barrier to access of qualified health care facility in vicinity. • The cost will be borne by GoG Moreover Rs. 200 for transport and Rs. 50 for accompanying person- A bridge between private sector and the poor • Qualified EPPs are paid Rs. 1,79,000 for a bunch of 100 deliveries including CS.
The Chiranjeevi Yojna (CY) - pitfalls • Out of more than 200 gynecologist in Surat district, only 56 were registered for CY. Most of them located in Surat city and remaining in peri urban area. None in remote rural areas. • Even out of registered 56, very few have been active and conducting deliveries under the scheme, • Some EPPs joined CY in hope that they will get license/certificate for MTP by joining hands with government. • some EPPs taking only “safe” cases and diverting complicated cases to public hospitals. In this case,the whole purpose of the scheme is defeated .
• BPL card is required to become beneficiary of the scheme but migrants don’t have documentary evidences and therefore are left out of the scheme. • Aanganwadi workers are the links between poor HHs and EPPs but sometime the trust is broken as EPPs demand money. The Chiranjeevi Yojna (CY)
Lack of intersectoral coordination Improvements in non-health sectors also have influence on maternal health outcomes. Malaysia In 1950s--multisectoral approach  rural development including • expansion of rural health services, • improving basic education and female education, • improving sanitation and water supply, • extending road networks in rural areas.  specific health interventions such as professional midwifery MMR ↓ from 534 to 19 Between 1950 and 1997 (Source: Padmanathan et al. 2003) Integrated rural development together with key maternal health interventions is the long term solution. FACTORS OUTSIDE HEALTH SECTOR Poor maternal nutrition • Short spacing • Early age at marriage • Low levels of education in women • Skewed gender relations • Social position of women,family
EXAMPLE…
Tamil Nadu’s initiatives to reduce MMR • 3 staff nurses in each PHC -SBA skills trained. • Filling vacancies of MOs and equipping the PHCs to provide BEmONC services. • Untied funds and Patient Welfare Society funds • Innovative IEC techniquesImproved Utilization Of PHCs • Hiring private anaesthetists and obstetricians to carry out caesarian operations • Training MBBS doctors in short term course in Life Saving Anaesthesia Skills and Emergency Obstetric Care. • Emergency Referral Services (Toll free no 108) introduced Making Emergency Obstetric Care available
Melakkal PHC, Madurai HUD Old Building New Building Tamil Nadu’s initiatives to reduce MMR
MMR YEAR 110 127 126 114 123 126 133 145 123 114 109 94 95 91 79 0 20 40 60 80 100 120 140 160 Source DPH & PM Before RCH RCH NRHM AMTSL, LSAS training, Hiring of Specialists Blood storage facility, AN protocol, etc EMRI TREND MATERNAL MORTALITY--- TAMIL NADU
Interventions taken to reduce major cause of maternal death • AMTSL training for the whole state • Blood storage centres and logistics of how to use them in resource poor settings Haemorrhage • Retraining to all VHNs in ante natal care protocols and skills including basic BP measurement • Use of electronic BP apparatus • Calcium supplementation for antenatal women PIH • Post natal care visits- emphasis of danger signs in home based care training • IEC/ BCC messages on danger signs • Infection management practices in labour rooms and post natal wards Sepsis
Interventions taken to reduce major cause of maternal death • Training on use of partogram • Emphasis on prompt referral • District level quality control circles -- obstetricians and nurse trainers Obstructed/ prolonged labour • Use of iron sucrose for severe anaemia • Mandatory deworming • Supplementation with Vit C and B-12 • Ensuring proper measurement of Hb levels • Adolescent Anaemia Control programme Anaemia • Pregnancy cohort monitoring • Verbal community death autopsy by the district collector • Focus higher order births- strong IUD campaign for those unwilling to accept sterilization • Policy for safe abortion and ensuring availability of MVA services at least at the block level. Others
THE SRI LANKA STORY- A low-income country which has successfully REDUCED MATERNAL MORTALITY
Maternal Mortality Reduction Sri Lanka 1940–1985 0 200 400 600 800 1000 1200 1400 1600 1800 1940–45 1950–55 1960–65 1970–75 1980–85 MaternalDeathsper100000livebirths 56 85%birthsattended bytrainedpersonnel
• • A vast network of health infrastructure extending into rural areas by the 1950s to make health services more accessible. • Blood transfusion services. • Free Services . • Training of Large cadres of professional midwives - both at the health facilities & in communities . • Additionally, midwives visited pregnant women at home and encouraged them to seek antenatal care and assistance during delivery. Sri Lanka ’s initiatives to reduce MMR
• Family planning was integrated into maternal and child health services and offered as part of the basic package of services. • A strong referral system ensured timely access to basic and comprehensive emergency obstetric and newborn care (EmONC) when necessary, backed by the availability of ambulances and telephones. • Given that public expenditure on health care was low (on average less than 2 percent of GDP) during the 1950- 1999 period, this reduction cannot be attributed to a huge investment of funds. Sri Lanka ’s initiatives to reduce MMR
Ultimate aim for women health LIFE CYCLE APPROACH HEALTHY MOTHER HEALTHY CHILD HEALTHY ADOLESCENT HEALTHY REPRODUCTIVE YEARS CYCLECONTINUESINTO NEXTGENERATION
Conclusion • Long-term sustained policy and financial commitment to improve maternal health outcomes • Strengthening health systems to effectively deliver the Essential Package MCH interventions must be integrated into the larger health system. Not be a stand-alone program Ensuring Adequate available skilled health personnel in basic and comprehensive EmONC - doctors, midwives,nurses with midwifery skills, and anesthetists. Staff trained in referral protocols, esp. outreach staff. A strong monitoring system -(i) to respond effectively to specific implementation challenges; and (ii) to enhance quality of care . Known package of essential interventions . The challenge To deliver this package at a sufficient scale and with sufficient quality to have a significant impact.
References • MILLENNIUM DEVELOPMENT GOALS .INDIA COUNTRY REPORT 2011..Central Statistical Organization, Ministry of Statistics and Programme Implementation, Government of India.www.mospi.nic.in • REDUCING MATERNAL MORTALITY:Strengthening the World Bank Response .June, 2009 • Maternal & Child Mortality and Total Fertility Rates, Sample Registration System (SRS),Office of Registrar General, India.7th July 2011 • Trends in maternal mortality: 1990 to 2010. WHO, UNICEF, UNFPA and The World Bank estimates • How to reduce maternal deaths: rights and responsibilities,department of international

More Related Content

PPTX
Infant Mortality Rate, perinatal mortality
byRoselin V
 
PPTX
Mdsr ppt
bybitan sengupta
 
PPTX
EMERGENCY OBSTETRIC CARE - AN INTERVENTION OF MATERNAL MORTALITY
byImAn NoOr
 
PPTX
Near miss maternal mortality (Dr Amenda Ann Davis)
byAmenda Ann Davis
 
PPTX
Resident presentation maternal mortality
byaisha ali issaka
 
PDF
MCH indicators and related SDGs
byJayaramachandran S
 
PPTX
Maternal Mortality
byArvind Kushwaha
 
PPTX
Safe Motherhood and Newborn Program
byPublic Health
 
Infant Mortality Rate, perinatal mortality
byRoselin V
 
Mdsr ppt
bybitan sengupta
 
EMERGENCY OBSTETRIC CARE - AN INTERVENTION OF MATERNAL MORTALITY
byImAn NoOr
 
Near miss maternal mortality (Dr Amenda Ann Davis)
byAmenda Ann Davis
 
Resident presentation maternal mortality
byaisha ali issaka
 
MCH indicators and related SDGs
byJayaramachandran S
 
Maternal Mortality
byArvind Kushwaha
 
Safe Motherhood and Newborn Program
byPublic Health
 

What's hot

PPTX
Rmnch+a
bymrikara185
 
PDF
Health Governance & Reproductive Health in Bangladesh
byMd. Nazmul Alam
 
DOCX
Swot analysis of Safe motherhood, HIV & AIDS, ARI and Logistic Management Pro...
byMohammad Aslam Shaiekh
 
PDF
Perinatal mortality for 4th year med.students
byDr. Aisha M Elbareg
 
PPTX
Fertility indicators
byDivija Ramachandran
 
PPTX
Maternal Near Miss Operational Guidelines
byRajesh Ludam
 
PPTX
Abortion law in Nepal
byRashmi Luintel
 
PDF
Brief Overview of Management of Safe Motherhood and Newborn Health Services i...
byMohammad Aslam Shaiekh
 
PPTX
Maternal death review -surveillance and indicator analysis
byTapas Chatterjee
 
PPTX
LaQshya programme
byPavithra Reddy
 
PPT
01 Emergency Obstetric care
byPrabir Chatterjee
 
PPTX
Safe Motherhood Program in Nepal: Challenges and Way Forward
byKusumsheela Bhatta
 
PPT
National rural health mission
byAbino David
 
PDF
Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA): Latest Guidelines
byDepartment of Health & Family Welfare, Government of West Bengal
 
PPT
Basic obstetric care dr rabi
byRabi Satpathy
 
PDF
JSY
byAkhilesh Bhargava
 
PPTX
MATERNAL DEATH REVIEW AND CHILD DEATH REVIEW
byJoshua Anish
 
PDF
CB-IMNCI Program in Nepal
byMohammad Aslam Shaiekh
 
PDF
LaQshya- Labour Room Quality Control Innitiative
byTaniyaMondal6
 
PPTX
Verbal autopsy
byAmanBansal134
 
Rmnch+a
bymrikara185
 
Health Governance & Reproductive Health in Bangladesh
byMd. Nazmul Alam
 
Swot analysis of Safe motherhood, HIV & AIDS, ARI and Logistic Management Pro...
byMohammad Aslam Shaiekh
 
Perinatal mortality for 4th year med.students
byDr. Aisha M Elbareg
 
Fertility indicators
byDivija Ramachandran
 
Maternal Near Miss Operational Guidelines
byRajesh Ludam
 
Abortion law in Nepal
byRashmi Luintel
 
Brief Overview of Management of Safe Motherhood and Newborn Health Services i...
byMohammad Aslam Shaiekh
 
Maternal death review -surveillance and indicator analysis
byTapas Chatterjee
 
LaQshya programme
byPavithra Reddy
 
01 Emergency Obstetric care
byPrabir Chatterjee
 
Safe Motherhood Program in Nepal: Challenges and Way Forward
byKusumsheela Bhatta
 
National rural health mission
byAbino David
 
Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA): Latest Guidelines
byDepartment of Health & Family Welfare, Government of West Bengal
 
Basic obstetric care dr rabi
byRabi Satpathy
 
JSY
byAkhilesh Bhargava
 
MATERNAL DEATH REVIEW AND CHILD DEATH REVIEW
byJoshua Anish
 
CB-IMNCI Program in Nepal
byMohammad Aslam Shaiekh
 
LaQshya- Labour Room Quality Control Innitiative
byTaniyaMondal6
 
Verbal autopsy
byAmanBansal134
 

Similar to critical review MMR

PPTX
Maternal mortality in India
byAayupta Mohanty
 
PPTX
Maternal Mortality in Madhya Pradesh Complete.pptx
byKritika Sarkar
 
PPTX
Mdsr final
byMitasha Singh
 
PDF
mdsr-final-150406235433-conversion-gate01.pdf
byIdrisSham1
 
PPTX
Maternity mortality rate ppt where explain about
byanupgnit91
 
PPT
Maternal death Review- national perspective-wb-2011
byPrabir Chatterjee
 
PPTX
1.1. Midwifery concept in maternal health 3.pptx
byselvashankar93
 
PPTX
Mmr
bydrbishmita
 
PPTX
MMR issue.pptx
byCalvin Kaaya
 
PPTX
MMR as PH issue - G#3 21.09.22-1.pptx
byCalvin Kaaya
 
PPTX
Risk of labour and its management scenarios
byNitin840505
 
PDF
Maternal Mortality
byrdlj
 
PPTX
Ozzz(maternal mortality)
byViju Rathod
 
PPTX
Maternal Mortality.pptx
bysandhya397837
 
PPTX
Maternal mortality
bydrmcbansal
 
PPTX
MATERNAL MORTALITY AND MATERNAL NEAR MISS.pptx
byPaulMocha3
 
PPTX
Maternal Mortality Rate nishita 81 .pptx
bynishita0723
 
PPTX
vital statistics related to maternal health in indIA.pptx
byAnju Kumawat
 
PPTX
Health index in contrast of maternal health
byNehaNupur8
 
PPTX
Maternal Mortality 2018
byKervindran Mohanasundaram
 
Maternal mortality in India
byAayupta Mohanty
 
Maternal Mortality in Madhya Pradesh Complete.pptx
byKritika Sarkar
 
Mdsr final
byMitasha Singh
 
mdsr-final-150406235433-conversion-gate01.pdf
byIdrisSham1
 
Maternity mortality rate ppt where explain about
byanupgnit91
 
Maternal death Review- national perspective-wb-2011
byPrabir Chatterjee
 
1.1. Midwifery concept in maternal health 3.pptx
byselvashankar93
 
Mmr
bydrbishmita
 
MMR issue.pptx
byCalvin Kaaya
 
MMR as PH issue - G#3 21.09.22-1.pptx
byCalvin Kaaya
 
Risk of labour and its management scenarios
byNitin840505
 
Maternal Mortality
byrdlj
 
Ozzz(maternal mortality)
byViju Rathod
 
Maternal Mortality.pptx
bysandhya397837
 
Maternal mortality
bydrmcbansal
 
MATERNAL MORTALITY AND MATERNAL NEAR MISS.pptx
byPaulMocha3
 
Maternal Mortality Rate nishita 81 .pptx
bynishita0723
 
vital statistics related to maternal health in indIA.pptx
byAnju Kumawat
 
Health index in contrast of maternal health
byNehaNupur8
 
Maternal Mortality 2018
byKervindran Mohanasundaram
 

More from Manisha Malik

PPTX
Randomized trial seminar
byManisha Malik
 
PPTX
Viral hepatitis
byManisha Malik
 
PPTX
ug class environment 5n6
byManisha Malik
 
PPT
ug class environment 4
byManisha Malik
 
PPTX
ug class environment 1
byManisha Malik
 
PPTX
us class environment 2n3
byManisha Malik
 
PPTX
Ug class dengue
byManisha Malik
 
PPTX
ARSH pg seminar
byManisha Malik
 
Randomized trial seminar
byManisha Malik
 
Viral hepatitis
byManisha Malik
 
ug class environment 5n6
byManisha Malik
 
ug class environment 4
byManisha Malik
 
ug class environment 1
byManisha Malik
 
us class environment 2n3
byManisha Malik
 
Ug class dengue
byManisha Malik
 
ARSH pg seminar
byManisha Malik
 

Recently uploaded

PPTX
Infective Endocarditis: Epidemiology, Diagnosis, Imaging, and Management
byGuganesh Vasan G
 
PPTX
Management_of_Maternity_Women in outpatient .pptx
byMudaSsarChaudhary2
 
PPTX
PCOS ,PCOS MANAGEMENT, WEIGHT LOSS,INFERTILITY IN PCOS
bymukeshkumar559904
 
PPTX
Drug use evaluation and WHO drug use Indicators.pptx
byLok Raj Pant
 
PDF
overview of human urinary system anatomy
bynusratjahanpharmacy
 
PPTX
Sacroiliac Joint Pain: Clinical Diagnosis, Provocation Tests, and SI Joint Bl...
byDaradia: The Pain Clinic
 
DOCX
NON-STEROIDAL pdf nsaid nsad nsaid nsaid
byVarunSoni76
 
PPTX
SAMVAHANA AND PADHAGHATA_11625_Pancha-T_26-11-2024.pptx
byDr.Satyendra Vishwakarma
 
PPTX
Glasgow coma scale .pptx GCS by EYES response VERBAL response MOTOR response
byMAHEK KHAN
 
PDF
Top 9 Websites for Purchasing Google Voice Accounts Online.pdf
bymarketing
 
PPTX
Chemistry of Hemoglobin (Types, Derivatives and Disorders)
byDr. Santhosh Kumar. N
 
PPTX
Diabetic retinopathy- Investigation and Management
byDr. Sambandha Khati
 
PPTX
COVID -19 or SARS-CoV-2(2019-nCoV) disease
byNandiniM72
 
PPTX
From Planning to Delivery: Precision Workflows That Reduce Errors, Toxicity, ...
bySubrata Roy
 
PDF
Abdominal Muscles (Ant. & Post).pdf anatomy
bynehalhelmy2005
 
PDF
Bachelors in nursing science TOS Sem I KMU (1).pdf
byjesusebagahj73
 
PPTX
Describe affinity in proper way on ppt.pptx
bymedhiuddipan045
 
PPTX
Diabetes in Ramadan.pptx................
byshaarehanza
 
PPTX
BRAIN TUMORS- final.pptx diagnosis, management
bydorcascherop63
 
PPTX
EBOLA VIRUS DISEASE ppt -Ayurveda Detailing
byNandiniM72
 
Infective Endocarditis: Epidemiology, Diagnosis, Imaging, and Management
byGuganesh Vasan G
 
Management_of_Maternity_Women in outpatient .pptx
byMudaSsarChaudhary2
 
PCOS ,PCOS MANAGEMENT, WEIGHT LOSS,INFERTILITY IN PCOS
bymukeshkumar559904
 
Drug use evaluation and WHO drug use Indicators.pptx
byLok Raj Pant
 
overview of human urinary system anatomy
bynusratjahanpharmacy
 
Sacroiliac Joint Pain: Clinical Diagnosis, Provocation Tests, and SI Joint Bl...
byDaradia: The Pain Clinic
 
NON-STEROIDAL pdf nsaid nsad nsaid nsaid
byVarunSoni76
 
SAMVAHANA AND PADHAGHATA_11625_Pancha-T_26-11-2024.pptx
byDr.Satyendra Vishwakarma
 
Glasgow coma scale .pptx GCS by EYES response VERBAL response MOTOR response
byMAHEK KHAN
 
Top 9 Websites for Purchasing Google Voice Accounts Online.pdf
bymarketing
 
Chemistry of Hemoglobin (Types, Derivatives and Disorders)
byDr. Santhosh Kumar. N
 
Diabetic retinopathy- Investigation and Management
byDr. Sambandha Khati
 
COVID -19 or SARS-CoV-2(2019-nCoV) disease
byNandiniM72
 
From Planning to Delivery: Precision Workflows That Reduce Errors, Toxicity, ...
bySubrata Roy
 
Abdominal Muscles (Ant. & Post).pdf anatomy
bynehalhelmy2005
 
Bachelors in nursing science TOS Sem I KMU (1).pdf
byjesusebagahj73
 
Describe affinity in proper way on ppt.pptx
bymedhiuddipan045
 
Diabetes in Ramadan.pptx................
byshaarehanza
 
BRAIN TUMORS- final.pptx diagnosis, management
bydorcascherop63
 
EBOLA VIRUS DISEASE ppt -Ayurveda Detailing
byNandiniM72
 

critical review MMR

  • 1.
    Critical Review -MMR Dr Manisha Junior Resident Department of Community Medicine PGIMS,Rohtak
  • 2.
    Content • Introduction –definitions & statistical measures • Trends of MMR : World • Trends of MMR : India • Main Causes & Interventions to prevent • National programmes & policies • Constraints • Examples
  • 3.
  • 5.
    • India hasthe highest burden of maternal deaths in the world – 56,000 per year--19 % of total worldwide • Actual Situation is worse -- maternal deaths--in remote rural areas – remains under- reported.
  • 6.
    Definitions related tomaternal death in ICD-10 1. Maternal death Alternative definitions: 2. Pregnancy-related death 3. Late maternal death The death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes. This definition allows identification of maternal deaths, based on their causes, as either direct or indirect Direct : resulting from obstetric complications of the pregnant state (pregnancy, delivery and postpartum), interventions, omissions, incorrect treatment, or a chain of events resulting from any of the above. e.g. obstetric hemorrhage or hypertensive disorders in pregnancy, or those due to complications of anaesthesia or caesarean section Indirect: resulting from previously existing diseases, or from diseases that developed during pregnancy and that were not due to direct obstetric causes but aggravated by physiological effects of pregnancy. e.g. deaths due to aggravation of an existing cardiac or renal disease The death of a woman from direct or indirect obstetric causes, more than 42 days but less than one year after termination of pregnancy. Complications of pregnancy or childbirth can lead to death beyond the 6 weeks’ postpartum period The death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the cause of death. Useful in settings where accurate information about causes of deaths based on medical certificates is unavailable. e.g. in population-based surveys
  • 7.
    Statistical measures • Maternalmortality is the combination of two factors: (i) the risk of death in a single pregnancy or a single live birth; (ii) the fertility level, that is, the number of pregnancies or births that are experienced by women of reproductive age. • Measures are 1) Maternal mortality ratio 2) Maternal mortality rate 3) Adult lifetime risk of maternal death 4) The proportion maternal death among deaths of females of reproductive age (PMDF)
  • 8.
  • 9.
    Maternal Mortality: AGlobal Tragedy • Annually, 287,000 women die of pregnancy related complications • 99% in developing world • ~1% in developed countries Every minute one Maternal Death occur • 10 to 20 million women develop physical or mental disabilities every year as a result of complicated pregnancies and deliveries.
  • 10.
    World : 2010 Estimatedmaternal deaths : 287,000 (decline of 47% from levels in 1990) Global MMR : 210 (in 1990 : 400) (source:Trends in maternal mortality:1990 to 2010 WHO, UNICEF, UNFPA and The World Bank estimates)  Highest MMR -- Sub-Saharan Africa (500) . Lowest MMR-Eastern Asia (37)  Sub-Saharan Africa (56%) and Southern Asia (29%) accounted for 85% of the global burden . 2 countries account for 1/3 of global maternal deaths: India -- 19% (highest- 56000) Nigeria -- 14% . In developing regions (240) 15 times higher than in developed regions (16). low moderate high Extremely high
  • 11.
  • 12.
    Millennium Development Goal 5:Improvematernal health Targets Indicators 5.A Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio 5.1 Maternal mortality ratio 5.2 Proportion of births attended by skilled health personnel 5.B Achieve, by 2015, universal access to reproductive health 5.3 Contraceptive prevalence rate 5.4 Adolescent birth rate 5.5 Antenatal care coverage (at least one visit and at least four visits) 5.6 Unmet need for family planning
  • 13.
    Maternal Mortality EstimationInter-Agency Group (MMEIG)-MDG estimates • Categories : To measure progress, countries with MMR ≥100 in 1990, • “on track” : if the annual percentage decline between 1990 and 2008 is 5.5% or more :: 9 countries • “making progress” : annual decline between 2% and 5.5%, :: 50 countries {INDIA– 5.2} • “insufficient progress” : annual decline of less than 2% . :: 14 countries • “no progress” : countries with rising MMR . :: 11 countries 10 countries that already achieved MDG 5 by 2010 : Estonia (95%), Maldives (93%), Belarus (88%), Romania (84%), Bhutan (82%), Equatorial Guinea (81%), Islamic Republic of Iran (81%), Lithuania (78%), Nepal (78%) and Viet Nam (76%).
  • 14.
  • 15.
    Projected value-139 by2015 8% 16% during 2003-06 17% during 2006-09 Source – SRS(2007-09) 153 HARYANA Only 7 States-Andhra Pradesh, Goa, Karnataka, Kerala, Punjab, Sikkim and Tamil Nadu -likely to achieve or close by 2015.WHO estimates 437 India :
  • 16.
    Major policy andprogram goals in MM Year Document Goals 1983 Health policy statement by Govt of India MMR reduction by 200-300 by 1990 and below 200 by the year 2000 2000 National population policy MMR reduction to less than 100 by 2010 2002 National health policy MMR reduction to less than 100 by 2010 2002-2007 Tenth Five year plan MMR reduction to less than 200 by 2007
  • 17.
  • 18.
    Maternal Mortality-Magnitude andCauses About 28 million pregnancies and 56,000 maternal deaths per year in India
  • 20.
    20 Maternal deaths avertedthroughMaternal deaths averted through access to servicesaccess to services (World(World Bank, 2004)Bank, 2004)
  • 21.
    But WHY DoThese Women Die? Three-Hurdle Race against Death • Delay in Decision to Seek Care • Lack of understanding of complications • Acceptance of maternal death • Low status of women • Socio-cultural barriers to seeking care • Delay in Reaching Care • Mountains, islands, rivers — poor organization • Delay in Receiving Care • Supplies, personnel • Poorly trained personnel with punitive attitude • Finances Three Delays Model
  • 22.
  • 23.
    MCH care inIndia • 1880-- Establishment of training of dais in Amritsar • 1902--Passing of first Midwifery Act in London to promote safe delivery. • 1931-32--Setting up of advisory committee on maternal mortality. They scrutinised causes leading to maternal deaths in hospitals and recommending actions. • 1946--Bhore committee- Primary health centres came up in 1952&MCH centres became its integral part by 1956. • 1992--Child Survival & Safe Motherhood programme, FRU - EmOC • 1997--RCH • 2005-- RCH II under National Rural Health Mission (NRHM)
  • 24.
    RCH NRHM ICDS JSY JSSK Ladli Rashtriya Swasthya Bima Yojana BalikaSamriddhi Yojna Janani Suvidha Yojna Indira Gandhi Matritva Sahyog Yojana Rajiv Gandhi National Creche Scheme Kishori Shakti Yojana Delivery Hut Schme Vikalp Yojana Jachcha Bachcha Scheme WOMEN’S HEALTH- govt. policies
  • 25.
    INDIA MDG –MATERNAL HEALTH SERVICES-Good quality services are not universally available and accessible 0 10 20 30 40 50 60 70 80 34 41 62 27 17 42 48 65 30 16 47 56 74 37 13 1993 1999 2006 MILLENNIUM DEVELOPMENT GOALS INDIA COUNTRY REPORT 2011 Still more gaps left to be bridged for safer motherhood…
  • 26.
  • 27.
    Constraints to ImprovingAccess, by Level • Community and household level- 1.lack of demand for effective interventions due to knowledge,perceptions,culture or language 2. barrier to the use of effective interventions(physical,financial,social) • Health services delivery level: 1.Shortages and inadequate distribution of appropriately qualified staff 2.Weak information system,technical guidance,program management or supervision 3.Inadequate drug or other medical supplies 4.Lack of equipment,infrastructure or referral system
  • 28.
    • Health sectorpolicy and strategic management level- 1.weak or overly centralized planning and management system 2.insufficient use of evidence in decision making 3.weak drug policy or drug supply system 4.lack of interministerial and intersector action 5. Weak partnerships for health between government, civil society & private sector Constraints to Improving Access, by Level
  • 29.
    • Environmental andcontextual characteristics – • Government and overall policy framework 1.corruption,weak government, weak rule of law 2.low priority attached to social sector- • Physical environment unfavourable to service delivery • Global level 1.lack of reliable estimates 2.number of global initiatives and misalignment of reforms 2.reliance on project funding modes and limited use of country’s financial management system Constraints to Improving Access, by Level
  • 30.
    Lack of reliableestimates of maternal mortality • Without it, the impact of safe motherhood programmes remains unknown. • Sweden, Sri Lanka, and Malaysia established robust vital registration systems at early stages of their battle against maternal mortality. • Information on the levels, causes, and patterns of maternal mortality in India is, at best, incomplete and unsatisfactory 1. Civil registration system - Ideal 2.Household surveys ,Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS) 3.Census 4. Reproductive-age mortality studies (RAMOS) 5. Verbal autopsy
  • 31.
    Lack of demandfor effective interventions & financial barrier • Despite guarantee of free health services from the public health system, households contribute 71.13 % of total health expenditure for availing health care services from different institutions (NHA-2004-05) • Among mothers in lowest wealth quintile households, 59 % received any antenatal care & 23 % received check- ups from doctor; corresponding figures -97 % & 86 % for highest quintile households
  • 32.
    Demand-side incentives -conditional cash transfers (CCTs) India JSY- 2005 In just two years, enrollment in JSY increased 10-fold, from a low of 0.7 million JSY beneficiaries in 2005/06 to 7.3 million beneficiaries in 2007/08. Latin America Since 1997,encouraging poor mothers to seek preventive health services and attend health education talks Sudden and dramatic increases in service utilization The health system needs to be sufficiently geared up . Otherwise the poor quality of services received will result in clients having a low opinion of the services and ultimately reduce demand for services at these facilities. Lack of demand for effective interventions & financial barrier
  • 33.
    Shortages and inadequatedistribution of appropriately qualified staff • A dearth of available skilled manpower and mismanagement of available human resources, especially in the rural public-health system inspite of : by increasing recruitment adding more tasks to the workload of existing staff or task shifting (e.g. ANM), or contracting with the private sector
  • 34.
    0 0.5 1 1.5 2 2.5 Number of PHCswith no Staff Nurse 0 0.5 1 1.5 2 2.5 3 3.5 Number of PHCs with no MOs NO.OFPHCs NO.OFPHCs
  • 35.
    0 1 2 3 4 5 Number ofPHCs with LMO 0 1 2 3 4 5 SUB-DIVISIONAL HOSPITALS GYNAECOLOGISTS PAEDIATRICIANS ANAESTHETISTS
  • 36.
    KNOWLEDGE & SKILLS PERCENTSN WHO KNEW 1. Identification of high risk pregnancies 51.5% 2. Identification of high risk newborn 46.6% 3. Blood pressure measuring 55.3% 4. Abdominal examination 48.5% 5. FHS hearing ability 52% 6. Asepsis maintainance during delivery 48.5% 7. Filling the partograph 28.6% 8. PPH management 49.6% 9. Mucous extractor use 48.1% 10. Ambu-bag use 39.7% 11. Radiant warmer use 22.5%
  • 37.
    Maternal death auditsand reviews of maternal deaths • allows lessons learned to be utilized in prevention in future • If in all health facilities - the total number can be calculated Botswana >98 % deliveries with skilled health personnel Maternal Mortality Monitoring System in 2005 • midnight census of admissions and deaths at all health facilities; • birth notification forms for non- institutional deliveries • completion of maternal death notification forms after a maternal death audit More accurate national estimates of maternal mortality (Source: Republic of Botswana et al. 2006) India HMIS and civil registration systems ??? Weak information systems
  • 38.
    Rwanda: after the war, userfees were instituted-- dramatic decline in the use of health services. In 1998 • use of skilled health personnel for delivery with performance- based schemes • free delivery care for regular antenatal care beneficiaries. institutional deliveries increased from 12.2 percent in 2001 to 23.1 percent in 2004, in contrast to 6.7 percent in 2001 to 9.7 percent in 2004 in the non- participating provinces (Source: Rusa et al. 2009) India Jachha bachha scheme??? Accurate data is needed to verify the outcomes of performance- based financing approaches. HMIS should be strengthened to provide reliable routine data with periodic verification. Lack of incentives to provide quality health services • An extreme example is the ANM or doctor, who lives in a remote village and provides 24-hour services, gets the same salary and benefits as an ANM or a doctor who lives in a city, and commutes irregularly to a rural health centre for a few hours a day where s/he is posted.
  • 39.
    Lack of equipment,infrastructure • Poor & inadequate drug supply • Poor condition of equipments • Lack of leadership in taking initiative at lower levels – district, block level • Policy on upgrading of infrastructure & equipments – does not cover all range of issues , centrally managed, takes long time in processing
  • 40.
    Privacy assured duringthe stay at PHC X-Ray Unit in PHC Baby warmers at PHC Clean and Neat environment RO , Solar water heater Communication
  • 41.
    Lack of referralsystem • FRUs • Secondary referral system-DH,SDH in poor condition • Patient load directly to trtiary level—poor quality care due to patient and health care giver disproportion Djibouti (high urban population >80% in a small geographical area, In 2002,to reduce load on referral national hospitals • trained health personnel to better handle emergency obstetric complications; • renovated/equipped the hospital; • strengthened the capacity of the secondary level health facilities (e.g., renovated operating rooms, radios, and ambulances) percentage of births in health facilities had, remarkably, increased from 40 percent in 2002 to 93 percent in 2006 (Source: World Bank, reporting background for Health Sector Development Program Project, Djibouti, Project P071062.)
  • 42.
    Weak partnerships forhealth between government, civil society & private sector Public private parternership Honduras collaboration with private providers to set up 13 birthing centers in remote areas known for high maternal mortality. MMR ↓ from 182 to 108 Between 1980 and 1997 (Source: Koblinsky 2003) Cuba Maternity waiting homes MMR ↓ from 118 to 31 Between 1963 and 1984 (Source: Koblinsky 2003) Geographical areas or marginalized populations may remain outside the reach of the public sector--- strategic partnerships .
  • 43.
    Gujrat’s initiatives toreduce MMR The Chiranjeevi Yojna (CY) • launched in five poor districts in 2005 and since 2007 it has been extended to entire Gujarat • acute shortage of gynecologists in public health facilities (only 7 against 273 CHC positions) so,GoG decided to enlist their support from private • Aim to remove the financial barrier to access of qualified health care facility in vicinity. • The cost will be borne by GoG Moreover Rs. 200 for transport and Rs. 50 for accompanying person- A bridge between private sector and the poor • Qualified EPPs are paid Rs. 1,79,000 for a bunch of 100 deliveries including CS.
  • 45.
    The Chiranjeevi Yojna(CY) - pitfalls • Out of more than 200 gynecologist in Surat district, only 56 were registered for CY. Most of them located in Surat city and remaining in peri urban area. None in remote rural areas. • Even out of registered 56, very few have been active and conducting deliveries under the scheme, • Some EPPs joined CY in hope that they will get license/certificate for MTP by joining hands with government. • some EPPs taking only “safe” cases and diverting complicated cases to public hospitals. In this case,the whole purpose of the scheme is defeated .
  • 46.
    • BPL cardis required to become beneficiary of the scheme but migrants don’t have documentary evidences and therefore are left out of the scheme. • Aanganwadi workers are the links between poor HHs and EPPs but sometime the trust is broken as EPPs demand money. The Chiranjeevi Yojna (CY)
  • 47.
    Lack of intersectoralcoordination Improvements in non-health sectors also have influence on maternal health outcomes. Malaysia In 1950s--multisectoral approach  rural development including • expansion of rural health services, • improving basic education and female education, • improving sanitation and water supply, • extending road networks in rural areas.  specific health interventions such as professional midwifery MMR ↓ from 534 to 19 Between 1950 and 1997 (Source: Padmanathan et al. 2003) Integrated rural development together with key maternal health interventions is the long term solution. FACTORS OUTSIDE HEALTH SECTOR Poor maternal nutrition • Short spacing • Early age at marriage • Low levels of education in women • Skewed gender relations • Social position of women,family
  • 48.
  • 49.
    Tamil Nadu’s initiativesto reduce MMR • 3 staff nurses in each PHC -SBA skills trained. • Filling vacancies of MOs and equipping the PHCs to provide BEmONC services. • Untied funds and Patient Welfare Society funds • Innovative IEC techniquesImproved Utilization Of PHCs • Hiring private anaesthetists and obstetricians to carry out caesarian operations • Training MBBS doctors in short term course in Life Saving Anaesthesia Skills and Emergency Obstetric Care. • Emergency Referral Services (Toll free no 108) introduced Making Emergency Obstetric Care available
  • 50.
    Melakkal PHC, MaduraiHUD Old Building New Building Tamil Nadu’s initiatives to reduce MMR
  • 51.
    MMR YEAR 110 127 126 114 123 126 133 145 123114 109 94 95 91 79 0 20 40 60 80 100 120 140 160 Source DPH & PM Before RCH RCH NRHM AMTSL, LSAS training, Hiring of Specialists Blood storage facility, AN protocol, etc EMRI TREND MATERNAL MORTALITY--- TAMIL NADU
  • 52.
    Interventions taken toreduce major cause of maternal death • AMTSL training for the whole state • Blood storage centres and logistics of how to use them in resource poor settings Haemorrhage • Retraining to all VHNs in ante natal care protocols and skills including basic BP measurement • Use of electronic BP apparatus • Calcium supplementation for antenatal women PIH • Post natal care visits- emphasis of danger signs in home based care training • IEC/ BCC messages on danger signs • Infection management practices in labour rooms and post natal wards Sepsis
  • 53.
    Interventions taken toreduce major cause of maternal death • Training on use of partogram • Emphasis on prompt referral • District level quality control circles -- obstetricians and nurse trainers Obstructed/ prolonged labour • Use of iron sucrose for severe anaemia • Mandatory deworming • Supplementation with Vit C and B-12 • Ensuring proper measurement of Hb levels • Adolescent Anaemia Control programme Anaemia • Pregnancy cohort monitoring • Verbal community death autopsy by the district collector • Focus higher order births- strong IUD campaign for those unwilling to accept sterilization • Policy for safe abortion and ensuring availability of MVA services at least at the block level. Others
  • 54.
    THE SRI LANKASTORY- A low-income country which has successfully REDUCED MATERNAL MORTALITY
  • 55.
    Maternal Mortality Reduction SriLanka 1940–1985 0 200 400 600 800 1000 1200 1400 1600 1800 1940–45 1950–55 1960–65 1970–75 1980–85 MaternalDeathsper100000livebirths 56 85%birthsattended bytrainedpersonnel
  • 56.
    • • Avast network of health infrastructure extending into rural areas by the 1950s to make health services more accessible. • Blood transfusion services. • Free Services . • Training of Large cadres of professional midwives - both at the health facilities & in communities . • Additionally, midwives visited pregnant women at home and encouraged them to seek antenatal care and assistance during delivery. Sri Lanka ’s initiatives to reduce MMR
  • 57.
    • Family planningwas integrated into maternal and child health services and offered as part of the basic package of services. • A strong referral system ensured timely access to basic and comprehensive emergency obstetric and newborn care (EmONC) when necessary, backed by the availability of ambulances and telephones. • Given that public expenditure on health care was low (on average less than 2 percent of GDP) during the 1950- 1999 period, this reduction cannot be attributed to a huge investment of funds. Sri Lanka ’s initiatives to reduce MMR
  • 58.
    Ultimate aim forwomen health LIFE CYCLE APPROACH HEALTHY MOTHER HEALTHY CHILD HEALTHY ADOLESCENT HEALTHY REPRODUCTIVE YEARS CYCLECONTINUESINTO NEXTGENERATION
  • 59.
    Conclusion • Long-term sustainedpolicy and financial commitment to improve maternal health outcomes • Strengthening health systems to effectively deliver the Essential Package MCH interventions must be integrated into the larger health system. Not be a stand-alone program Ensuring Adequate available skilled health personnel in basic and comprehensive EmONC - doctors, midwives,nurses with midwifery skills, and anesthetists. Staff trained in referral protocols, esp. outreach staff. A strong monitoring system -(i) to respond effectively to specific implementation challenges; and (ii) to enhance quality of care . Known package of essential interventions . The challenge To deliver this package at a sufficient scale and with sufficient quality to have a significant impact.
  • 60.
    References • MILLENNIUM DEVELOPMENTGOALS .INDIA COUNTRY REPORT 2011..Central Statistical Organization, Ministry of Statistics and Programme Implementation, Government of India.www.mospi.nic.in • REDUCING MATERNAL MORTALITY:Strengthening the World Bank Response .June, 2009 • Maternal & Child Mortality and Total Fertility Rates, Sample Registration System (SRS),Office of Registrar General, India.7th July 2011 • Trends in maternal mortality: 1990 to 2010. WHO, UNICEF, UNFPA and The World Bank estimates • How to reduce maternal deaths: rights and responsibilities,department of international

Editor's Notes

  • #10 9
  • #11 A total of 40 countries had high MMR (defined as MMR ≥300 maternal deaths per 100 000 live births) in 2010. Of these countries, Chad and Somalia had extremely high MMRs (≥1000 maternal deaths per 100 000 live births) at 1100 and 1000, respectively.
  • #13 The Millennium Development Goals (MDGs) and targets come from the Millennium Declaration, signed by 189 countries, including 147 heads of State and Government, in September 2000. The eight (8) Goals as under: Goal 1: Eradicate Extreme Poverty and Hunger Goal 2: Achieve Universal Primary Education Goal 3:Promote Gender Equality and Empower Women Goal 4: Reduce Child Mortality Goal 5: Improve Maternal Health Goal 6: Combat HIV/AIDS, Malaria and TB Goal 7:Ensure Environmental Sustainability Goal 8:Develop Global Partnership for Development Eighteen (18) targets were set as quantitative benchmarks for attaining the goals, 53 indicators (48 basic + 5 alternative)
  • #14 The percentage reductions for the 10 countries that have already achieved MDG 5 by 2010 are: Estonia (95%), Maldives (93%), Belarus (88%), Romania (84%), Bhutan (82%), Equatorial Guinea (81%), Islamic Republic of Iran (81%), Lithuania (78%), Nepal (78%) and Viet Nam (76%). Among countries with MMR ≥100 in 1990, nine countries are “on track”, in addition to those mentioned above: Eritrea (6.3%), Oman (6.2%), Egypt (6%), Timor-Leste (6%), Bangladesh (5.9%), China (5.9%), Lao People’s Democratic Republic (5.9%), Syrian Arab Republic (5.9%) and Cambodia (5.8%). Maternal Mortality Estimation Inter-Agency Group (MMEIG), comprising WHO, UNICEF , UNFPA, the United Nations Population Division, and The World Bank, together with a team at the University of California at Berkeley, United States of America.
  • #19 2003—park textbook 2009
  • #22 21
  • #57 56