Minimising Maternal Mortality in India Evidence based Approach

1. Minimising Maternal Mortality in India Evidence based Approach Dr. Sharda Jain Sec General Delhi Gynaecologist Forum

3. Smita Patil

4. Maternal Death Clock 1 woman dies from a pregnancy-related complication In India Every 5 Minute... UNICEF

5. maternalmortality severe acute maternal morbidity

6. 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.

7. Commitment to Reducing Maternal Deaths (MDG- 5) GOAL Reduce MMR by 75 % From1990 - to – 2015 i.e. – 109 per lakh 7

8. 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

9. Maternal Mortality Ratio, INDIASRS,2007-09 9

10. Doable Goal !! MDG - 5 Political willpower

11. What Do Women Die Of ? They Die of simple Obstetric Complications that Need Not Be Fatal WHO 11

12. 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

13. Most Obstetric Complications …Almost All Can Be Saved Can Neither be Predicted Nor Prevented… But if Women Receive Timely Effective Treatment in Time, 13

14. How Do We Know Which Women Will Experience Complications? WE CAN’T !! 14

15. Spirit of Every Gynaecologist 15

16. It is necessary to ENSURE THAT EVERY PREGNANCY IS WANTED CONTRACEPTION Knowledge is not enough People have to use 16

17. 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

18. Abortion Deaths (13%) Ensure that EVERY ABORTION IS SAFE. Comprehensive Abortion Care WHO Guideline

19. 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

20. 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

21. 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

22. Janani Suraksha Yojana JSY is a safe motherhood intervention under the NRHM Door step/ Institutional delivery /shifting from PHC – CHCs – District Hospital 22

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

24. Birth Planning (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

25. Inform mother and family about4 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.

26. MALE Involvement 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

27. The Second Delay Inability to access health facilities • Out of reach health facilities • Poor roads and communication network • Poorcommunity support mechanisms 27

28. Making Emergency Obstetric Care available • Emergency Referral Services (Toll free no 108) introduced Patchy 28

29. Obstetric Helpline 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

30. The Third Delay 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

31. Addressing the 'third delay‘Averting Maternal Death & Disability Program (AMDD) …We Need to Ensure that Women have Access To… Emergency Obstetric Care (EmOC) 31 AMDD Program Orientation

32. EmOC has 8 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

33. THE GOOD NEWS 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

34. 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

35. PUBLIC-PRIVATE PARTERNERSHIP 35

36. Life – Saving Skill Drills

37. Enforcing ACCOUNTABILITYin Medical & Nursing profession

38. A government INDEMNITY scheme to cover health professionals

39. We are committed to achieve the MDG 5 109 / lack Live Births Countdown to 2015 begins…….. 39

40. AN care INTRANATAL ASHATraining (villages) Equipments Availability & Maintenance Up gradation of PHC 24 x 7PHC

41. ANAEMIA MANAGEMENTMMR = 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

42. Standardized countrywide protocol of PPHEclampsia Severe Anaemia& Regular Drills

43. PPH Number One causes of MMR

44. PPH BOX BALLOON TAMPONADE Blood Transfusion 44

45. Haemorrhagic Action Committee 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

46. Eclampsia(Drill)

47. Hb & IQ Anaemia FREE Pregnancy

48. Community Involvement 48

49. Outsourcing 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

50. E-MAMTA Mother & Child Online tracking system A GUJARAT initiative adopted by the Central Government for implementation across India 50