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Minimising Maternal Mortality in India Evidence based Approach. Dr. Sharda Jain Sec General Delhi Gynaecologist Forum. Smita Patil. Maternal Death Clock. 1 woman dies from a pregnancy-related complication In India. Every 5 Minute. UNICEF. maternal mortality.

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Minimising maternal mortality in india evidence based approach
Minimising Maternal Mortality in India Evidence based Approach

Dr. Sharda Jain

Sec General Delhi Gynaecologist Forum



Maternal death clock
Maternal Death Clock

1 woman dies from a pregnancy-related complication

In India

Every 5 Minute...

UNICEF


maternalmortality

severe acute maternal morbidity


Near miss events quality indicator of maternal care
Near Miss EventsQuality Indicator of Maternal Care

"A woman who nearly died but survived a complication that occurred during pregnancy, childbirth or within 42 days of termination of pregnancy“

05_XXX_MM6

6

W.H.O.


Commitment to reducing maternal deaths mdg 5
Commitment to Reducing Maternal Deaths (MDG- 5)

GOAL

Reduce MMR by 75 %

From1990 - to – 2015

i.e. – 109 per lakh

7


Mmr indian scenario
MMR-Indian scenario

Expected in 2015 - 135 per lakh LB

MDF – 5 in 2015 is 109 per lakh

  • 1940 - 20 per 1000 live births

  • 1960 - 10 per 1000 live births

  • 1992 - 437 per 100000 live birth

  • 1997 - 407 per 100000 live births

  • 2003 - 301 per 100000 live births

  • 2006 - 254 per 100000 live births

  • 2009 -212 per 1,00,000 LB

    SRG

8

SRGI



Doable goal
Doable Goal !!

MDG - 5

Political willpower


What do women die of

What Do Women Die Of ?

They Die

of simple Obstetric Complications

that Need Not Be Fatal

WHO

11


Obstetric Complications

5%

life threatening

15% will experience an obstetric complications

…This is true

world over

Nobody Knows Why This Happens.

It is a Fact of Life.

12


Most obstetric complications
Most Obstetric Complications

…Almost All Can Be Saved

Can Neither be Predicted

Nor Prevented…

But if Women Receive Timely Effective Treatment

in Time,

13


How do we know which women will experience complications
How Do We Know Which Women Will Experience Complications?

WE CAN’T !!

14


Spirit of Every Gynaecologist

15


It is necessary to

ENSURE THAT EVERY

PREGNANCY IS WANTED

CONTRACEPTION

Knowledge is not enough

People have to use

16


World Health Organization, Geneva

Evidence – based Interventions

Magnesium Sulfate

Oxytocin and

Manual

Compression

Eclampsia

12%

Family Planning and

Postabortion Care

Severe Bleeding

24%

Unsafe

Abortion

13%

Infection

15%

Antibiotics

Indirect Causes

20%

Iron Supplements,

Malaria Intermittent

Treatment and

Antiretroviral for HIV

Tetanus Toxoid

Immunization

Clean Delivery

Obs-

tructed

Labour

8%

Other

Direct

Causes

8%

17

Partogram


Abortion Deaths (13%)

Ensure that

EVERY ABORTION IS SAFE.

Comprehensive Abortion Care

WHO Guideline


Who guidelines
WHOGuidelines

  • Medical abortion or vaccum aspiration

    are the safest methods

  • MVA (Aspiration Abortion)– It is advocated especially in low resource settings like PHC where reliable source of electricity/maintenance is a problem ???

19


Three key points mmr
Three Key Points MMR

Time- critical factor

Concept of THREE DELAYS.

Three points at which access to care is delayed or denied or total lack of care

leads to

MATERNAL DEATH

20


How much time do we have
How Much Time Do We Have?

It is estimated that, if untreated, death occurs on average in:

2 hours from Postpartum Hemorrhage

12 hours from Antepartum

Hemorrhage

2 days from Obstructed Labor

6 days from Infection

21


Janani suraksha yojana
Janani Suraksha Yojana

JSY is a safe motherhood intervention under the

NRHM

Door step/ Institutional delivery /shifting from PHC – CHCs – District Hospital

22


Education through Medical professionals & self – help groupson risk in pregnancy and benefit of institutional delivery


Birth planning home
Birth Planning groups(Home)

Identify a skilled attendant

Identify appropriate place of birth, and how to get there

Identify support people, (who will accompany the woman and who will take care of the family).

Money

  • To Avoid 3 delays

24


Inform mother and family about 4 i s
Inform mother and family about groups4 I's

ANTENATAL / INTRANATAT PLANNING

  • Inform Dates of ANC's (Anti natal care) and iron folic acid tablate /T.T injections Ensur these are provided.

  • Inform expected date of delivery.

  • Identify place of delivery.

  • Identify health center for referral – For complicated delivery/cessarian Section can be government institution or accredited Private Health Institutional.


MALE groupsInvolvement is the key

Lack of information and inadequate knowledge

Traditional practices

Lack of money

The First Delay - Home

Delay in deciding to seek care

26


The second delay
The Second Delay groups

Inability to access health facilities

  • Out of reach health facilities

  • Poor roads and communication network

  • Poorcommunity support mechanisms

27


Making emergency obstetric care available
Making Emergency Obstetric Care available groups

  • Emergency Referral Services (Toll free no 108) introduced Patchy

28


Obstetric helpline
Obstetric Helpline groups

Networking of various private and public vehicles and locally identified mobile phones forms the core infrastructure of the helpline, which has been made financially sustainable by linking it with JSY.

29


The Third Delay groups

Delay between arriving and receiving care at the health facility:

  • Inadequate skilled attendants

  • Poorly motivated staff

  • Inadequate equipment and supplies

  • Weak referral system

  • system is not geared -prioritize an emergency & respond promptly

30


Addressing the third delay averting maternal death disability program amdd
Addressing the 'third delay‘ groupsAverting Maternal Death & Disability Program (AMDD)

…We Need to Ensure

that Women have Access To…

Emergency Obstetric Care

(EmOC)

31

AMDD Program Orientation


Emoc has 8 key functions
EmOC has groups8 Key Functions

  • Antibiotics (intravenous or by injection)

  • Oxytocic Drugs

  • Anticonvulsants

  • Blood Transfusion

Manual Removal of Placenta

Removal of Retained Products

Assisted Vaginal Delivery

Surgery (Cesarean Section)

32

32


The good news
THE GOOD NEWS groups

UK / Middle East

It is An Important Point

for Resource Poor country

INDIA

Not all these functions need hospitals and doctors

Well-trained nurses and midwives can perform most functions at Basic EmOC Facilities

33


Making emergency obstetric care available functional at chc dist hospital
Making Emergency Obstetric Care available & functional At CHC/ Dist. Hospital

Hiring private ANAESTHETISTS & OBSTETRICIANS to carry out caesarian operations

Total : 45966 (upto Jan2010)

Training MBBS DOCTORS in short term course in Life Saving ANAESTHESIA Skills and Emergency Obstetric Care (EOC).

Total LSCS - 12780

34


Public private parternership
PUBLIC-PRIVATE PARTERNERSHIP CHC/ Dist. Hospital

35


Life saving skill drills
Life CHC/ Dist. Hospital– Saving Skill Drills


Enforcing accountability in medical nursing profession
Enforcing ACCOUNTABILITY CHC/ Dist. Hospitalin Medical & Nursing profession


A government indemnity scheme to cover health professionals
A government CHC/ Dist. HospitalINDEMNITY scheme to cover health professionals


We are committed to achieve the CHC/ Dist. HospitalMDG 5

109 / lack Live Births

Countdown to 2015 begins……..

39


Asha training villages

AN care CHC/ Dist. Hospital

INTRANATAL

ASHATraining (villages)

Equipments

Availability

&

Maintenance

Up gradation of PHC

24 x 7PHC


Anaemia management mmr 20 20
ANAEMIA MANAGEMENT CHC/ Dist. HospitalMMR = 20 + 20%

Mandatory deworming

Supplementation with iron folic acid (100) Vit C and B-12

Use of iron sucrose

Ensuring proper measurement of haemoglobin levels

changing diet and lifestyle of women using slippers.., washing hands prior to food.

ADOLESCENT ANAEMIA

Control programme

“12 by 12 initiative”

41


Standardized countrywide protocol of pph eclampsia severe anaemia regular drills
Standardized countrywide protocol of CHC/ Dist. Hospital PPHEclampsia Severe Anaemia& Regular Drills


PPH CHC/ Dist. Hospital

Number One causes of MMR


Pph box balloon tamponade

PPH BOX BALLOON TAMPONADE

Blood Transfusion

44


Haemorrhagic action committee
Haemorrhagic Action Committee TAMPONADE

Taluka Level & District Level

Combat Haemorrhagia

  • Blood Transfusion Arrangement

  • Arrangements for the blood donation camps.

  • Keeping all the donor cards at the PHC level.

  • When pt. required blood , can be provided without replacement immediately.

  • This arrangement done at Karvan PHC.

  • This innovative step saved three mothers by transfusing blood at the time.

Formation of Haemorrhagic Action Committee

45


Eclampsia drill
Eclampsia TAMPONADE(Drill)


Hb TAMPONADE& IQ

Anaemia FREE Pregnancy


Community involvement
Community Involvement TAMPONADE

48


Outsourcing
Outsourcing TAMPONADE

Objective: To develop conducive environment in all PHCs, making them clean and green, and mobilizing the community through involvement of Self Help Group members

“Clean PHC Green PHC”

49


E mamta
E-MAMTA TAMPONADE

Mother & Child Online tracking system

A GUJARAT initiative adopted by the Central Government for implementation across India

50


Maternal death reviews audit
Maternal death reviews / audit TAMPONADE

51

Prime Show


52 TAMPONADE


Fogsi initiatives
FOGSI Initiatives TAMPONADE

EMOC at primary health centres, sub-centres and district hospitals.

certificate courses for medical officers in conducting normal deliveries as well as caesarean sections

conducting safe abortions

conducting a maternal mortality audit in the states

National Eclampsia registry

save the girl child campaign

53


My role doctor
My Role TAMPONADE ?(Doctor)

Dr. Sharda Jain

.

Will - What to Change ? Why to Change ?Skill - How to Change ?


My role
My Role TAMPONADE ?

Dr. Sharda Jain

DO WHAT YOU CAN, WHERE YOU ARE, WITH WHAT YOU HAVE.


I may not have gone where i intended to go but i think i have ended up where i intended to be
“I may not have gone TAMPONADEwhere I intended to go.But I think I have ended up where I intended to be”

Dr. Sharda Jain


Effects of mothers death
Effects of Mothers’ Death TAMPONADE

The death of a woman and mother is a tragic loss to the child, family, community and nation as a whole.

Dr. Sharda Jain


Together let’s write a new future for TAMPONADE

saving mother in India.

We can do it with willpower &

hard work to respect indian women’s LIFE


Pph step 1 general management
PPH TAMPONADEStep 1 General Management

  • Shout for help

  • Rapid evaluation of Vitals

  • Oxygen by mask

  • Uterine Massage

  • Oxytocin 10 u IM

  • Site 2 large bore(16G – gray color)IV cannula

  • Infuse IV fluid – NS / RL run it fast

  • Catheterize bladder

  • Check the placenta-

    - is it expelled

    - if it is expelied – re examine & make sure it is complete

  • Examine vagina , perineum, and cervix for tears.


Step 2 direct therapy in pph

Placenta TAMPONADE

Expelled

Completely

Placenta retained

Partially expelled

Fundus not felt

+Shock

+ Pain

Complete

Placenta

Atonic ut

B/m Massage

Oxitocis

Compress

MRP/ Evacuate

Inversion

Immediate

Reposition

Of Uterus

Trauma

Cervical Vaginal

Perineal tear

Step 2 Direct Therapyin PPH

Immediately PPH- PALPATE UTERUS

Soft Uterus Contracted uterus


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