Maternal mortality in Punjab has declined but remains above the national average. Postpartum hemorrhage is the leading cause of maternal death in the state, accounting for 35-40% of deaths. While programs and initiatives aim to further reduce the maternal mortality rate, challenges remain in ensuring trained healthcare workers and resources are available, administering active management of the third stage of labor, managing complications, and addressing preventable factors like anemia. Strengthening antenatal care, ensuring access to emergency services, and preventing postpartum hemorrhage through practices such as active management of the third stage of labor are important for reducing maternal mortality in Punjab.

1. 1
Maternal Mortality
Punjab
Current Scenario
Dr Inderdeep Kaur
Programme Officer
Maternal and Child Health

2. PREGNANCY AND CHILD BIRTH IS A
JOURNEY...
Not just of one woman or
her family,
BUT WHERE ALL OF
US AS A NATION HAVE
A ROLE TO PLAY.

3. Maternal mortality is a
sensitive indicator.
It helps to understand the health care
system of a country and also
indicates the prevailing socio-
economic scenario.
Despite the appreciable decline of
MMR in our State, the current MMR
(105)

4. What is
Maternal
Mortality Ratio
The maternal mortality ratio is the number of women who die
from any cause related to or aggravated by pregnancy or
its management (excluding accidental or incidental causes)
during pregnancy and childbirth or within
42 days of termination of pregnancy, Irrespective of the
duration and site of the pregnancy, per 100,000 live births.

5. 5
130
122
113
103
97
122
122
129
114
105
0
50
100
150
200
250
2014-16 2015-17 2016-18 2017-19 2018-20
India Punjab
Current Trend Maternal Mortality

6. Trend of MMR in Punjab according State
*Collected by the state through dedicated email from all the districts
Fiscal Year
No. of Maternal deaths
reported by the districts*
Live Births
(HMIS)
MMR
(HMIS)
MMR
(Based SRS)
FY 2022- 2023
438
361706
121 105
FY 2021 2022 477 370505 128
105
FY 2020 2021 453
357336
127 114
FY 2019-2020 428 377072 113 114
FY 2018 - 2019 480 371274 129 129
FY 2017 - 2018 593 371692 159 129
FY 2016 - 2017 590 378752 155 122

7. Antenatal care indicators (NFHS 5&4)
Indicator India Punjab
NFHS-4
( 2015-16)
NFHS-5
(2020-21)
NFHS-4
( 2015-16)
NFHS-5
(2020-21)
32. Mothers who had an antenatal check-up in the first
trimester (%)
58.6 70.0 75.6 68.5
33. Mothers who had at least 4 antenatal care visits (%) 51.2 58.1 68.5 59.3
34. Mothers whose last birth was protected against
neonatal tetanus9 (%)
89.0 92.0 92.9 89.7
35. Mothers who consumed iron folic acid for 100 days or
more when they were pregnant (%)
30.3 44.1 42.6 55.4
36. Mothers who consumed iron folic acid for 180 days or
more when they were pregnant (%)
14.4 26.0 19.9 40.5

8. Target
• To bring down maternal mortality to 70
per 1000 live births by 2030.

9. Maternal Health
Programmes
Quality Antenatal
care
Surakshit Matritva
Aashwashan
(SUMAN)
Janani Shishu
Suraksha Karyakram
(JSSK)
Janani Suraksha
Yojana (JSY)
Pradhan Mantri
Surakshit Matritva
Abhiyan (PMSMA)
Maternal Death
Surveillance &
Response (MDSR)
LaQshya – Labour
Room Quality
Improvement
Initiative
MCH Wings Obs HDU/ICU
Hypothyroidism
Screening For All
Pregnant Women
E-Sanjeevani online
Gynae OPD
Midwifery Initiative
Hepatitis-B Testing for
all Pregnant Women.
Gestational Diabetes
Mellitus Testing for
Pregnant Women.
Universal screening
for HIV and Syphilis
for all Pregnant
Women.

10. 10
MATERNAL DEATH SURVEILLANCE AND RESPONSE
We need to IDENTIFY, REVIEW and TAKE ACTIONS
TO CORRECT the causes and determinants of
Maternal Deaths to PREVENT FUTURE DEATHS
Each Maternal Death leaves a clue, so…
Data collection must
be linked to action
Focusing on Response –
Analysis & Action
Planning

11. Maternal Mortality and its leading causes –
Global Vs Indian causes
Abortion
8%
Embolism
3%
Haemorrhage
27%
Hypertension
14%
Sepsis
11%
Obstructed Labour
10 %
Indirect
27%
Worldwide
Haemorrhage
31%
Anemia
19%
Sepsis
16%
Obstructed
Labour
10%
Others
8%
Pre/Eclampsia
[8%]
Abortion
8%
India

12. Maternal Deaths April 2022 to March 2023
• Total Maternal Deaths Reported- 450
• Co –incidental death -12
• Total deaths reported - 438
• Live birth -361706
• MMR - 121

13. Maternal Mortality
FY April 2022- March 23
41
78 82 85 87 88 89
100 100 106 106 110
116 121
130 130 141
144 149 151 152 154
171
369
0
50
100
150
200
250
300
350
400
Major MMR identified Districts are – Ferozpur, Tarn Taran, Pathankot, Gurdaspur

14. Maternal Death Report
S.No. District Number of Live Birth Death MMR
1 Amritsar 34840 52 149
2 Barnala 8013 8 100
3 Bathinda 19970 26 130
4 Faridkot 10254 9 88
5 Fatehgarh Sahib 4822 2 41
6 Fazilka 14131 12 85
7 Firozepur 8131 30 369
8 Gurdaspur 19061 29 152
9 Hoshiarpur 18385 15 82
10 Jalandhar 30485 27 89
11 Kapurthala 9415 10 106
12 Ludhiana 50099 58 116
13 Malerkotla 5969 9 151
14 Mansa 8438 11 130
15 Moga 11371 12 106
16 Pathankot 12318 19 154
17 Patiala 28373 22 78
18 Rupnagar 9028 9 100
19 Sangrur 13665 15 110
20 S.A.S Nagar 12471 18 144
21
Shahid Bhagat Singh
Nagar
8092 7 87
22 Sri Muktsar Sahib 12090 17 141
23 Tarn Taran 12285 21 171
Punjab 361706 438 121

15. Obstetric Haem
morhag 20%
Hypertensive dis
orders in pregna
ncy, birth and p
uerperium
17%
Pregnnancies wi
th abortive outc
ome
1%
Sepsis
13%
Other Obstetric
complications
6%
Non obstetric
complications …
Coincidental
3%
Cause Number
Obstetric Haemmorhage (Except
haemorrage)
91
Hypertensive disorders in pregnancy,
birth and puerperium
77
Pregnnancies with abortive outcome 5
Sepsis 57
Other Obstetric complications 27
Non obstetric complications 181
Coincidental 12
Total 450
Distribution of Maternal Death based on Cause
of Deaths n=450

16. Maternal Deaths April to August 2023
• Total Maternal Deaths Reported- 163
• Co –incidental death - 5
• Total deaths reported - 158
• Live birth -122528
• MMR - 128

17. April - August 2023
32 40 44
59 65 73
86 86 90
109 116 120 133 135 140 145 145 155 158
182
218
237
265
354
0
50
100
150
200
250
300
350
400
Rupnagar Shahid Bhagat Singh Nagar Jalandhar Bathinda Sangrur Pathankot
Mansa Malerkotla Ludhiana Moga Hoshiarpur Fatehgarh Sahib
Punjab Kapurthala Barnala Fazilka Patiala Sri Muktsar Sahib
Faridkot Gurdaspur Amritsar S.A.S Nagar Firozepur Tarn Taran

18. Distribution
Based on
Timing of
Death
Antepartum
45%
Intrapartum
6%
Postpartum
49%

19. Distribution of Maternal Death based on Cause
of Deaths n=163
HEMORRHAGE A
PH/PPH
21%
PREGNANCY-
INDUCED HYPER
TENSION (PIH)
16%
SEPSIS
7%
OTHER OBSTERTI
C COMPLICATION
13%
PENDING
9%
OTHERS
31%
Co incidental
Deaths
3%
CAUSE NUMBER
HEMORRHAGE APH/PPH 34
PREGNANCY-INDUCED
HYPERTENSION (PIH)
26
SEPSIS 12
OTHER OBSTERTIC
COMPLICATION
21
PENDING 14
OTHERS 51
Co incidental Deaths 5

20. Post Partum Hemorrhage
Despite the improved management of primary post partum haemorrhage
(PPH).
PPH remains an important cause of maternal morbidity in both
developing and technologically advanced countries.
It remains a condition that puts the obstetrical team under a lot of stress.
Complications of PPH can only be reduced when the condition is
promptly diagnosed and therapeutic measures instituted immediately.

21. Post Partum
Hemorrhage
• Postpartum Haemorrhage (PPH) is
commonly defined as a blood loss of 500 ml
or more within 24 hours after birth. PPH is
the leading cause of maternal mortality in
low-income countries and the primary cause
of nearly one quarter of all maternal deaths
globally. (WHO)
• Blood loss sufficient to cause signs and
symptoms of hypovolemia
• Woman soaks 1 pad or cloth in <5 min

22. Postpartum haemorrhage (PPH): a global public
health concern
• Severe bleeding after childbirth -
• Postpartum haemorrhage (PPH) - is the leading cause of Maternal Mortality
world-wide. Each year, about 14 million women experience PPH resulting in
about 70,000 maternal deaths globally.
• Even when women survive, they often need urgent surgical interventions to
control the bleeding and may be left with life-
long reproductive disability.

23. Current
scenario of
Maternal
Mortality
Rate (MMR)
in Punjab
• The MMR in Punjab has decreased
significantly in recent years, from 211
maternal deaths per 100,000 live births in
2012-13 to 105 maternal deaths per
100,000 live births in 2021-22.
• However, the MMR in Punjab is still higher
than the National average of 97 maternal
deaths per 100,000 live births.
• Postpartum hemorrhage (PPH) is the
leading cause of maternal death in Punjab,
accounting for 35-40% of all maternal
deaths.

24. Challenges in PPH Management
3 Delays –(in Seeking care, Approaching Hospital, Initiating Adequate care)
• Availability of Trained HR, Trained Gynecologist/ LMO/MO
• Availability of Necessary items – PPH Management Kit in every Labour room.
• AMTSL - Greater use of the active management of third stage of labor.
• Non Trained Birth Attendant - Administration of misoprostol by nontrained birth attendants will provide beneficial reductions in
hemorrhage.
• Availability of blood units in case of emergency with out replacement
• Public Awareness – Need to strengthen ANC services and existing NGO’s to facilitate in community-related intervention, upgrading
training on Ante Natal Care, Intrapartum care & Post Partum Care of Health Care workers.
• Detection of HRP or Complication and to be reported on MCP card and Portal.
• Follow complete referral protocol: Prior communication to referral facility
• Emergency Transportation – 104/108, or identified Private Vehicle.

25. National Family Health Survey
Key Indicators
S. No Indicators Punjab
NFHS-4
(2015-16)
Punjab
NFHS-5
(2019-21)
India
NFHS-5
(2019-21)
1
Children age 6-59 months
who are anaemic (<11.0
g/dl) (%)
56.6 71.1 58.6
2 Non-pregnant women age
15-49 years who are anaemic
(<12.0 g/dl) (%)
54.0 58.8 53.2
3 Pregnant women age 15-49
years who are anaemic (<11.0
g/dl(%)
42.0 51.7 50.4
4 All women age 15-49 years
who are anaemic (%)
53.5 58.7 53.1
5 All women age 15-19 years
who are anaemic
(%)
58.0 60.3 54.1

26. PREVENTION OF PPH IS THE MOST IMPORTANT
PART OF ITS MANAGEMENT
Haemorrhage
27%
Sepsis 11%
Hypertensive
disorders 14%
Obstructed
labour 10%
Abortion 8%
Others 30%
Source- WHO 2014
PPH can be prevented by:
• Ensuring BPCR, SBA and treatment of anaemia
• Early identification of prolonged and obstructed
labour by partograph
• Avoiding unnecessary augmentation, fundal
pressure and episiotomies
• Controlled head delivery with perineal support
• Active Management of Third stage of Labour
(AMTSL)
• Checking of completeness of placenta after delivery

27. Way forward
• Catching up on “lost/ missed” ANCs
• Certification of LR and OT under
LaQshya
• Robust implementation of C -Section
audit
• MD reviews & Data feeding in MPCDSR
Software
• Functionalization of MCH wings
• JSSK utilization and Data Entry
• HRP management in PMSMA
27

28. Thank You
28