Dr. KANUPRIYA CHATURVEDI

Maternal & Newborn HealthWITH reference to

INDIA & RAJASTHAN

KEY ISSUES Maternal & Newborn Health :Where we stand

Creating a supporting environment

Continuum of care across time & location

Risks & opportunities

Strengthening health systems

The Rate of Progress

Maternal & Newborn Health :Where we stand

Maternal & Newborn Health :Where we stand

Global Scenario Regional distribution Maternal mortality ratio & Maternal

mortality rate Direct causes Conceptual framework

Global scenario-Maternal health

Each year, more than half million women die from causes related to pregnancy & childbirth

For every such death there are 20 others who suffer pregnancy related illnesses or other adverse outcome (obstetric fistula, uterine prolapse)

Around 10 million women annually suffer from complications of pregnancy

On average, each day~1500 women die from causes related to pregnancy & child birth

80% of maternal deaths could be avoided by access to essential maternity & basic health services

Global Scenario-Neonatal Health

Nearly 4 million newborns die {40% of under 5 deaths} within 28 days of birth

Three quarters of neonatal deaths occur during first 7 days

For every newborn death ,20 others suffer birth injury, complications of preterm birth or other neonatal conditions

A child born in a least developed country is 14 times more likely to die within first 28 days of life as compared to industrialized country

The big divide The divide between industrialized countries

&developing regions –is perhaps greater than on any other issue

Average lifetime risk of maternal death for a woman in least developed country is >300 times than in industrialized country

In developing world a woman has 1 in 76 lifetime risk of maternal death as compared to 1 in 8000 in industrialized countries

Global MMR stood at 430/lakh live births in 1990,and at 400/lakh in 2005

517

149

228

110134

195

445

172

517

379

162

178

371

358379

371490

194

2001-2003

Source: SRS

India: 301Kerala

110

Uttar Pradesh517

Maternal mortality ratio per 100,000 births

per 100,000 live births

Less than equal to 150

151 - 300

More than 300

Missing Data

Other Conditions

34%Hemorrhage

38%

Abortion 8%

Sepsis 11%Obstructed Labour 5% Hypertensive

Disorders 5%

Medical causes of maternal deaths in India

Source: SRS

Medical Causes of Neonatal Deaths-India

23%

3%

6%

24%

6%

2%

35%

Diarrhoea

Preterm

Congenital

Infection

Asphyxia

Other

Tetanus

Source: Lawn JE Cousen SN for CHERG (Nov 2006)

Infant deaths within 7 days of birth

Infant deaths between7 days of birth and within 28 days

Infant deaths between 28 days and within one year of birth

Child deaths between oneyear and within five years of birth

40%

10%

26%

24%

Neonatal deaths50%

Infant deaths76%

Share of under-five mortality in India

Source : SRS 2007

Infant Mortality Rates by State

7371 70 69

66 65 6562 61

5754

5250

4845 45

43 42 42 4240

38 3836

34 3430 30

15 15

0

10

20

30

40

50

60

70

80

UP

CH

MP

JH AS

OR RJ

BH

AR IN AP

TR GJ

WB

MG JK KA

PJ

UT

HR

DL

MH

NA

HP

MZ

SK

TN

MN

GO

KE

Infant Mortality Rate-Rajasthan

Infant Mortality Rate by Demographic Characteristics

72

56

50

77

80

62

47

64

37

30

50

86

0 10 20 30 40 50 60 70 80 90 100

40-4930-3920-29

< 20MOTHER'S AGE AT BIRTH

7 or more 4-6 2-3

1BIRTH ORDER

4 years or more3 years2 years

< 2 yearsPREVIOUS BIRTH INTERVAL

Childhood Mortality Rates by Sex

37

21

58

23

79

41

15

56

14

70

0

10

20

30

40

50

60

70

80

90

NeonatalMortality

PostneonatalMortality

Infant Mortality Child Mortality Under-fiveMortality

Female Male

Steady Decline in Infant Mortality Rates India

79

68

57

0

10

20

30

40

50

60

70

80

NFHS-1 NFHS-2 NFHS-3

Creating a supporting environment

Creating a supportive environment for women & children

Millennium development Goals Promoting a healthy behavior Securing a quality education Preventing child marriage Ante natal care coverage Skilled delivery care coverage

Promoting a healthy behavior Timing of births Safe motherhood Child development Breast feeding Nutrition & growth Immunization Diarrhoea

Coughs, colds & more serious illnesses

Hygiene Malaria HIV and AIDS Injury prevention Disasters &

emergencies

Quality education & a decent living

Studies show that educated women;

Are more likely to delay marriage Ensure that their children are

immunized Are better informed about nutrition Undertake improved birth spacing

practices

45%

50%

54%

1992-93 1998-98 2005-06

Percentage of women aged 20-24 married before age 18

Age at marriage-India

Early marriage leads to early childbearing thereby enhancing maternal health risks

Source: NFHS

Antenatal Coverage -Rajasthan

Continuum of care across time & location: Risks & opportunities

First 28 Days of life Specific factors

Limited access to skilled care providers Home births [Associated with half of newborn

deaths] Inadequate recognition of newborn illnesses Insufficient care seeking A limited repertoire of interventions for early

neonatal disorders [ e.g. birth asphyxia, premature births ]

A lack of consensus on interventions and delivery strategies

Nutrition among women

36%

56%

33%

52%

0

20

40

60

Any anemia BMI below normal

1998-98 2005-06

Percentage of ever-married women age 15-49 with any anaemia and Body Mass Index (BMI) below 18.5 kg/m2

High percentage of women with anaemia and low BMI results in higher risk of low birth weight and peri-natal deaths

Source: NFHS

65%59%

83%

66%

60%

87%

77%72%

91%

30

40

50

60

70

80

90

100

Urban Rural Total

1992-93 1998-98 2005-06

Antenatal carePercentage of ever-married women age 15-49 years having at least one ante-natal care

There has been a significant increase in ante-natal care in the last 7 years. Further increases are seen in the latest DLHS results

Source: NFHS

Women* Who Received Antenatal Care

65

83

5966 60

86

7277

91

Total Urban Rural

NFHS-1 NFHS-2 NFHS-3

* For last births in the past 3 years* For last births in the past 3 years

Institutional delivery

41

34

26

2005-061998-981992-93

Delivery assisted by health personnel

4942

35

2005-061998-991992-93

Deliveries at institutions / by skilled birth attendants

Institutional births have shown significant improvement in the DLHS results

Source: NFHS

Percentage point change between NFHS-2 and NFHS-3 States

Remained unchanged (2 states)

Arunachal Pradesh, Nagaland

Increased less than 7 percentage point (7 states)

Assam, Chhattisgarh, Delhi, Goa, Jharkhand, Tripura, West Bengal

Increased by 7-14 percentage points(10 states)

Bihar, Gujarat, Maharashtra, Madhya Pradesh, Meghalaya, Rajasthan, Tamil Nadu, Kerala, Uttar Pradesh , Mizoram

Increased by 15 or more percentage points (10 states)

Andhra Pradesh, Haryana, Himachal Pradesh, Jammu & Kashmir, Karnataka, Manipur, Orissa, Punjab, Sikkim, Uttaranchal

Trends in Institutional Deliveries by State

Institutional deliveries –Rajasthan

Post natal care for mothers

37.3

61.0

28.632.4

23.0

Total Urban Rural ScheduledCaste

ScheduledTribe

Percentage of women having at least one postnatal care within two days of delivery

Only 37% of women received postnatal check-ups within the recommended period of two days of delivery

Source: NFHS

Only one in four children in India are breastfed within 1 hour of birth

Initiation of breastfeeding within an hour

23%16%

10%

0

20

40

60

80

100

1992-93 1998-98 2005-06

Percentage of children born in the last three years who started breastfeeding within one hour of birth

Source: NFHS

23%

21%

23% 23%

19%

22%

Total Urban Rural

1998-99 2005-06

Every year at least six million children in India are born with low birth weight which gives them a disadvantaged start in life

Based on reported birth weight data: 30% in NFHS 2 and 34% in NFHS 3

Birth weight

Percentage of children with reported birth weight less than 2.5 kg

Source: NFHS

Strengthening health systems

Proposed action framework

Central premise “.. Essential services for mothers, newborns and children are most effective when delivered in an integrated package at critical points in life cycle, in a dynamic health system, in an environment supportive of

women’s rights”

Essential Services for mothers newborn & children

Basic health care

Quality maternal care

Newborn &child health care

Adequate nutrition

Improved water & sanitation

Hygiene practices

Critical points for service delivery

Adolescence, Pre-pregnancy, Pregnancy, Birth

Infancy, Childhood Post-partum, Neonatal

Supportive environment

Respect for rights of women & children

Quality education

Decent standard of living

Greater involvement of men

Protection from abuse, exploitation, violence & discrimination

Equal participation in home community, social & political life

Women empowerment

The continuum of care across time & location-‘Risks & opportunities’

Across time-{ Key points}

Adolescence Pre pregnancy Pregnancy Birth Post natal Neo natal

Across location-{ Key points}

Household level Community level Outreach services Outpatient services Facility based care

Key actions

• Enhance nutrition of adolescent girls

• Improve quality of reproductive health services

• Ensure adequacy of antenatal care

• Ensure skilled assistance during pregnancy & childbirth

Key actions• Provide access to quality Basic and

Comprehensive Emergency Obstetric

• Initiation of breastfeeding within one hour of birth

• Newborn care when required

• Expand post-natal care for mothers & newborns

• Promote safe water & hygiene practices at households and in facilities

Strengthening health systems to improve maternal & newborn health

Enhancing data collection & analysis

Enhancing human resources, training &

supervision

Fostering social mobilization

Ensuring equitable & sustainable financing

Contd.

Strengthening infrastructure, transportation,

logistics ,supplies & referral process

Improving the quality of care

Global health initiatives{Strengthening

collaberation

The Rate of Progress

The Rate of Progress

Countries/Territories

U5MR [2007]

Average annual Rate of

reduction ( %) [1990-2007]

GDP/Capita Annual

Growth Rate (%) [1990-

2007]

TFR [2007]

Average annual Rate of reduction

( %) [1990-2007]

India 72 [Rank-49]

2.9 4.5 2.8 2

S.E.Asia 78 2.8 4.1 3 2.2

Industrialized

countries

6 3 1.9 1.7 0.2

Developing countries

74 1.9 4 2.8 1.6

Least developed countries

130 1.9 2.5 4.7 1.3

WORLD 68 1.8 2.4 2.6 1.3

Comprehensive Programming for Reducing Maternal Mortality

Political commitment, Poverty, Political will and Leadership

Delays

3rd Delay: Receipt of

adequate and appropriate treatment

2nd Delay: Identifying and

reaching medical facility

1st Delay: Decision to seek care

Quality of care

Socio economic & cultural factors

Access to services

Factors

Accessibility of facilities

Quality of care

Mobilise: men, women, family & community

Link community to services

24-hour quality EmOC

Accountability

Strategies

Building P

artnerships

What will make it happen

Building synergy and partnerships

Generating and sustaining strong political leadership for health of women and children

Mobilizing resources for maternal and newborn health

Empowering families and communities for promoting health and accessing healthcare