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Minimising Maternal Minimising Maternal MortalityMortality in India in India

Evidence based ApproachEvidence based Approach

Lecture - 1Lecture - 1 Dr. Sharda Jain Director :-

Chairman PCH OBST/ Gynae Dpt. Secretary General of Delhi Gynaecologist Forum

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Smita PatilSmita Patil

Every 5 Minute...

Maternal Death ClockMaternal Death Clock

1 woman 1 woman dies from a dies from a pregnancy-pregnancy-related related complicationcomplication

In India In India

UNICEF

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05_

XX

X_M

M6

Near MissNear Miss Events EventsQuality Indicator of Maternal Quality Indicator of Maternal

Care Care

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

WHOWHO

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Commitment to Reducing Commitment to Reducing Maternal Deaths (MDG- 5) Maternal Deaths (MDG- 5)

GOAL

Reduce MMR by 75 %

From 1990 - to – 2015

i.e. – 109 per lakh

MMR-Indian scenarioMMR-Indian scenario• 1940 - 20 per 1000 live births1940 - 20 per 1000 live births• 1960 - 10 per 1000 live births1960 - 10 per 1000 live births• 1992 - 437 per 100000 live birth1992 - 437 per 100000 live birth• 1997 - 407 per 100000 live births1997 - 407 per 100000 live births• 2003 - 301 per 100000 live births2003 - 301 per 100000 live births• 2006 - 254 per 100000 live births2006 - 254 per 100000 live births

• 2009 -212 per 1,00,000 LB2009 -212 per 1,00,000 LBSRGSRG

8SRGISRGI

Expected in 2015 - 135 per lakh LBExpected in 2015 - 135 per lakh LBMDF – 5 in 2015 is 109 per lakhMDF – 5 in 2015 is 109 per lakh

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INDIA TOTALINDIA TOTAL

Achieved MDG targetAchieved MDG target

212/lakh live birth212/lakh live birth

109/lakh live birth109/lakh live birth

KeralaKerala 8181

Tamil NaduTamil Nadu 9797

MaharashtraMaharashtra 104104

Close proximity to MDG targetsClose proximity to MDG targets

Andhra PradeshAndhra Pradesh 134134

GujaratGujarat 148148

West BengalWest Bengal 145145

HaryanaHaryana 153153

Uttar PradeshUttar Pradesh 359359

Maternal Mortality Ratio, INDIAMaternal Mortality Ratio, INDIASRS,2007-09SRS,2007-09

Doable Goal !!

MDG - 5

Political willpower

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What Do Women Die Of ?What Do Women Die Of ?What Do Women Die Of ?What Do Women Die Of ?

They Die of simple Obstetric

Complications that Need Not Be Fatal

They Die of simple Obstetric

Complications that Need Not Be Fatal

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15% will experience an obstetric complications …This is true

world over

Nobody Knows Why This Happens.It is a Fact of Life.

Nobody Knows Why This Happens.It is a Fact of Life.

5% life threatening

Obstetric ComplicationsObstetric Complications

Most Obstetric ComplicationsMost Obstetric ComplicationsMost Obstetric ComplicationsMost Obstetric Complications

Can Neither be Can Neither be Predicted Predicted Nor Prevented…Nor Prevented…

Can Neither be Can Neither be Predicted Predicted Nor Prevented…Nor Prevented…

But if Women Receive But if Women Receive Timely Effective Timely Effective Treatment Treatment

in Time, in Time,

But if Women Receive But if Women Receive Timely Effective Timely Effective Treatment Treatment

in Time, in Time,

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…Almost All Can Be Saved…Almost All Can Be Saved

How Do We Know How Do We Know Which Women Which Women

Will Experience Complications?Will Experience Complications?

How Do We Know How Do We Know Which Women Which Women

Will Experience Complications?Will Experience Complications?

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WE CAN’T !!WE CAN’T !!

15Spirit of Every Gynaecologist

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It is necessary toIt is necessary to

ENSURE THAT EVERY ENSURE THAT EVERY PREGNANCY IS WANTEDPREGNANCY IS WANTED

CONTRACEPTIONCONTRACEPTIONKnowledge is not enough Knowledge is not enough

People have to use People have to use

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World Health Organization, World Health Organization, GenevaGeneva

Evidence – based Interventions Evidence – based Interventions

Severe Severe Bleeding Bleeding

24%24%

EclampsiEclampsiaa

12%12%

Indirect Indirect CausesCauses

20%20%OtherOther

DirectDirect

CausesCauses

8%8%

Obs-Obs-

tructetructedd

LabourLabour

8%8%

InfectionInfection

15%15%

Unsafe Unsafe

AbortionAbortion

13%13%

Oxytocin andOxytocin and

ManualManual

CompressionCompression

Iron Iron Supplements,Supplements,

Malaria Malaria IntermittentIntermittent

Treatment andTreatment and

Antiretroviral for Antiretroviral for HIVHIV

PartogramPartogram

Tetanus ToxoidTetanus Toxoid

ImmunizationImmunization

Clean DeliveryClean Delivery

AntibioticAntibioticss

Family Family Planning Planning andand

Postabortion Postabortion CareCare

MagnesiuMagnesium m SulfateSulfate

Abortion Deaths (13%)

Comprehensive Abortion CareComprehensive Abortion Care

Ensure thatEnsure that

EVERY ABORTION IS SAFEEVERY ABORTION IS SAFE..

WHO GuidelineWHO Guideline

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WHOWHO GuidelinesGuidelines

• Medical abortionMedical abortion or or vaccum aspirationvaccum aspiration

are the are the safestsafest methods methods

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

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Three Key Points MMRThree Key Points MMR

• TimeTime - critical factor- critical factor

• Concept of THREE DELAYS.Concept of THREE DELAYS.

• Three points at which Three points at which access to care is access to care is delayeddelayed or or denieddenied or or total lacktotal lack of care of care

leads toleads to

MATERNAL DEATH MATERNAL DEATH

How Much Time How Much Time Do We Have?Do We Have?

How Much Time How Much Time Do We Have?Do We Have?

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

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

2 hours 2 hours from Postpartum Hemorrhagefrom Postpartum Hemorrhage

12 hours 12 hours from Antepartum from Antepartum HemorrhageHemorrhage

2 days2 days from Obstructed Laborfrom Obstructed Labor

6 days6 days from Infectionfrom Infection

2 hours 2 hours from Postpartum Hemorrhagefrom Postpartum Hemorrhage

12 hours 12 hours from Antepartum from Antepartum HemorrhageHemorrhage

2 days2 days from Obstructed Laborfrom Obstructed Labor

6 days6 days from Infectionfrom Infection21

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Janani Suraksha YojanaJanani Suraksha Yojana

JSY is a safe JSY is a safe motherhood motherhood intervention intervention under the under the

NRHMNRHM

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

Education through Medical professionals & self – help groups

on risk in pregnancy and benefit of institutional delivery

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Birth Planning Birth Planning (Home)(Home)

– Identify a Identify a skilled attendantskilled attendant – Identify appropriate Identify appropriate place of birthplace of birth, and how to get , and how to get

therethere– Identify Identify support peoplesupport people,, (who will accompany the (who will accompany the

woman and who will take care of the family).woman and who will take care of the family).– Money Money

To Avoid 3 delaysTo Avoid 3 delays

Inform mother and family aboutInform mother and family about

4 I's 4 I's • Inform Inform Dates of ANC'sDates of ANC's (Anti natal care) and iron folic (Anti natal care) and iron folic

acid tablate /acid tablate /T.T injections T.T injections Ensur these are provided.Ensur these are provided.• Inform Inform expected dateexpected date of delivery. of delivery.• Identify Identify placeplace of delivery. of delivery.• Identify Identify health centerhealth center for referral for referral – For – For complicated complicated

delivery/cessarian Sectiondelivery/cessarian Section can be government can be government institution or accredited Private Health Institutional.institution or accredited Private Health Institutional.

ANTENATAL / INTRANATAT PLANNING

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MALE MALE Involvement is the keyInvolvement is the key

Lack of information and Lack of information and inadequate inadequate knowledgeknowledge

Traditional Traditional practices practices

Lack of Lack of moneymoney

The First Delay - Home

Delay in deciding to seek careDelay in deciding to seek care

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The Second DelayThe Second Delay

Out of reach health facilities

Poor roads and communication network

Poor community support mechanisms

Inability to access health facilities

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Making Emergency Obstetric Making Emergency Obstetric Care availableCare available

Emergency Referral Services (Toll free no 108)

introduced Patchy

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Obstetric HelplineObstetric Helpline Networking of various private and public Networking of various private and public

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

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Inadequate skilled attendants Poorly motivated staff Inadequate equipment and supplies Weak referral system system is not geared -system is not geared -prioritize an prioritize an

emergencyemergency & respond promptly & respond promptly

The Third Delay

Delay between arriving and receiving care at the health facility:

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Addressing the 'third delay‘Addressing the 'third delay‘

Averting Maternal Death & Disability Averting Maternal Death & Disability Program (AMDD)Program (AMDD)

…We Need to Ensurethat Women have Access To…

Emergency Obstetric Care(EmOC)

AMDD Program Orientation

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EmOC has EmOC has 88 Key Functions Key FunctionsEmOC has EmOC has 88 Key Functions Key Functions

• Antibiotics Antibiotics (intravenous or by (intravenous or by injection)injection)

• Oxytocic Drugs Oxytocic Drugs

• Anticonvulsants Anticonvulsants • Blood TransfusionBlood Transfusion

• Manual Removal of Manual Removal of PlacentaPlacenta

• Removal of Retained Removal of Retained ProductsProducts

• Assisted Vaginal Assisted Vaginal DeliveryDelivery

• Surgery (Cesarean Surgery (Cesarean Section)Section)

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THE GOOD NEWSTHE GOOD NEWSTHE GOOD NEWSTHE GOOD NEWS

Not all these functions need Not all these functions need hospitals hospitals and and doctorsdoctors

Well-trained Well-trained nursesnurses and and midwivesmidwives can perform most can perform most functions at Basic EmOC functions at Basic EmOC FacilitiesFacilities

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It is An Important Point

for Resource Poor country

INDIA

It is An Important Point

for Resource Poor country

INDIA

UK / Middle EastUK / Middle East

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Making Emergency Obstetric Care available Making Emergency Obstetric Care available & functional At CHC/ Dist. Hospital& 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

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PUBLIC-PRIVATE PUBLIC-PRIVATE PARTERNERSHIPPARTERNERSHIP

Life – Saving Skill

Drills

Enforcing ACCOUNTABILITYin Medical & Nursing

profession

A government INDEMNITY scheme

to cover health professionals

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We are committed to achieve the MDG 5

109 / lack Live Births

Countdown to 2015 begins……..

ASHATraining

(villages)

EquipmentsAvailability

& Maintenance

Up gradation of

PHC 24 x 7

PHC

AN care INTRANATAL

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ANAEMIA MANAGEMENTANAEMIA MANAGEMENTMMR = 20 + 20%MMR = 20 + 20%

• Mandatory Mandatory deworming deworming • SupplementationSupplementation with with iron folic acidiron folic acid (100) (100) Vit C Vit C and and

B-12 B-12 • Use of Use of iron sucroseiron sucrose• Ensuring proper Ensuring proper measurement measurement of haemoglobin levelsof haemoglobin levels• changing changing diet and lifestylediet and lifestyle of women using slippers.., of women using slippers..,

washing hands prior to food.washing hands prior to food.

ADOLESCENT ANAEMIAADOLESCENT ANAEMIA Control programmeControl programme““12 by 12 initiative”12 by 12 initiative”

Standardized countrywide protocol of

PPHEclampsia

Severe Anaemia

PPH

Number One causes of MMR

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PPH BOX BALLOON TAMPONADEPPH BOX BALLOON TAMPONADE

Blood Transfusion Blood Transfusion

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Haemorrhagic Action Haemorrhagic Action CommitteeCommittee

Formation of Haemorrhagic Action Committee

Taluka Level & District Level

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.

Eclampsia

(Protocol)

Hb & IQ

Anaemia FREE Pregnancy

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Community InvolvementCommunity Involvement

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OutsourcingOutsourcing

ObjectiveObjective: To develop conducive environment in all : To develop conducive environment in all

PHCs, making them clean and green, and mobilizing PHCs, making them clean and green, and mobilizing

the community through involvement of Self Help the community through involvement of Self Help

Group membersGroup members

Sweeper

Gardener

Driver/watchman

Team

“Clean PHC Green PHC”

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E-MAMTAE-MAMTA

• Mother & Child Mother & Child Online tracking systemOnline tracking system

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

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Maternal death reviews / auditMaternal death reviews / audit

Prime Show

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FOGSI InitiativesFOGSI Initiatives• EMOC EMOC at primary health centres, sub-at primary health centres, sub-

centres and district hospitals.centres and district hospitals.• certificate courses for medical officerscertificate courses for medical officers

in conducting normal deliveries as well as in conducting normal deliveries as well as caesarean sectionscaesarean sections

• conducting conducting safe abortionssafe abortions • conducting a conducting a maternal mortality auditmaternal mortality audit in in

the states the states • National National EclampsiaEclampsia registry registry

save the girl childsave the girl child campaign campaign

My Role ?(Doctor)

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Dr. Sharda Jain

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

My Role ?

DO WHAT YOU CAN, WHERE YOU ARE,

WITH WHAT YOU HAVE.

Dr. Sharda Jain

“I may not have gone where I intended to go.

But I think I have ended up where I intended to be”

Dr. Sharda Jain

Dr. Sharda Jain

Effects of Mothers’ DeathEffects of Mothers’ Death

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

Together let’s write a new future for saving mother in India.

We can do it with willpower &

hard work to respect indian women’s LIFE