maternal death review- national perspective-wb-2011
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Maternal Death Review…
A National Perspective
Maternal Deaths… unacceptable numbers
About 28 million pregnancies per year in India
26 million live births 15% of pregnancies likely to develop
complications 67 000 maternal deaths in a year
Maternal Deaths…Causes
• Direct obstetric and non-obstetric causes - hemorrhage, sepsis, eclampsia, obstructed labour, abortion related, anemia etc
• Underlying/contributory causes - Social, behavioral, cultural, economic factors
• The “three delays”:– Delay in decision making– Delay in reaching the appropriate health
facility– Delay in receiving health care at the facility
MDG Goals,Targets and Indicators …MDG 5…MDG Goals,Targets and Indicators …MDG 5…NRHM /RCH goals in lineNRHM /RCH goals in line
Goal Target Indicators AchievementsMDG-5: To improve Maternal health
Reduce by 3/4ths the MMR, 1990-2015. (From 424 (NFHS-I) to approx.106 per 1,00,000 Live-Births in 2015).
NRHM/RCH II-Reduce to 100/1,00,000 Live-births
MMR
Proportion of births attended by SBA.
Institutional delivery.
MMR : 254 per 100,000 live births( RGI-SRS 2004-06)UN Interagency Estimates(2008) : 230/100,000 LB
52.6 %Safe Delivery47% Institutional Delivery
76%Safe Delivery72.9% Institutional Delivery(UNICEF Coverage Evaluation Survey 2009)
MMR…we need to accelerate pace of decline
0
100
200
300
400
500
600
MMR 2001-03
MMR 2004-06
RCH /NRHM/
MDG goal
MMR Trends…variation across States
Source:RGI SRS
2/3rds deaths
Burden of Maternal Deaths...
2001-03 2004-06
Assam 490 480
U.P. / Uttarakhand 517 440
Rajasthan 445 388
M.P. / Chhattisgarh 379 335
Bihar / Jharkhand 371 312
Orissa 358 303
Karnataka 228 213
Punjab 178 192
Haryana 162 186
Andhra Pradesh 195 154
West Bengal 194 141
Maharashtra 149 130
Tamil Nadu 134 111
Kerala 110 95
Policy and Programmes...Goals and Targets
National Population Policy 2000
MULTI-PRONGED
APPROACH..
MATERNAL HEALTH STRATEGIES
Demand Promotion-
( Janani Suraksha Yojana)
Provision of services
Public sector
1. Essential and Emergency
Obstetric Care•Quality ANC, INC, Safe and
Institutional delivery•Skilled birth attendance•Multi-skilling
2.Operationalize FRU s & 24*7 PHCs
3. Services for RTIs & STIs –
convergence with the NACP
4. Safe abortion services- New
Guidelines
5. Strengthen referral systems
6.Village Health and Nutrition Day..
Mother-Child Protection Card
Provision of Services : Private sector•Accreditation of Pvt. Health Facilities for
RCH services and SBA training•Fixed package for outsourcing services
• Maternal Death Review• Pregnancy and Child Tracking –web based system• Prioritising resources for identified “delivery points” or MCH Centres
New
10
NRHM…Overarching Umbrella
Intersectoral Convergence
Accredited Social Health Activist (ASHA) – one per 1000 population
Facility Strengthening / Improving Access
Strengthening of Infrastructure- IPHS
Improving availability of Human Resource - Contractual Appointments
Availability of funds at facilities-Untied funds ,Annual Maintenance Grants, Grants to Rogi Kalyan Samitis.
Village Health and Nutrition Days
Village Health and Sanitation Committees
Public-private Partnerships.
Flexible Funding through NRHM/RCH Flexi-pool.
Innovative Strategies
CommunitisationDecentralisation
FlexibleFunding
Maternal Death Review
Policy on Maternal Death Reviews …spelt out in implementation framework of RCH II
Strengthen Monitoring/Records/Audit procedures
• Monitor State and Regional level MMR
• Introduce mother-child linked card
• Conduct review of maternal deaths at the hospital and community levels
• Develop tools for maternal death review and reporting
Maternal Death Reviews Maternal Death Reviews Initiatives…fragmentedInitiatives…fragmented
Why conduct MDR?
Reduce maternal mortality and morbidity Improve quality of obstetric care Understand determinants of maternal death Provide stimulus for action at all levels Take corrective action to fill the gaps in service
provision
Prerequisite: A commitment to act upon the findings Not for punitive action
MDR ProcessMDR ProcessFive approaches to help understand why women die ...
• Maternal deaths in the community (CBMDR)
• Maternal deaths in facilities (FBMDR)
• Confidential enquiries into maternal deaths
• Learning from women who survived: “near miss” cases
• Evidence-based clinical audit
All these approaches...
Identify cases (maternal deaths) Review cases confidentially and no blame Look for avoidable factors Promote change in practices Review the outcome of these changes Refine and develop
The maternal death surveillance cycle..
Identify casesIdentify cases
Recommendations Recommendations for actionfor action
Collect informationCollect information
Analyse resultsAnalyse results
Implement,Implement,evaluate and refineevaluate and refine
No Punitive Action
Challenges... to roll out the process
Creating awareness in community... Need for effective BCC/IEC
Mobilising communities and the health system Resolving infrastructure and human resource issues Building partnerships between govt. systems and
others (prof. bodies ,tech. agencies ,NGOs ) Resolving ethical issues Developing guidelines and simple implementable
tools Orientation of a wide range of functionaries --policy
makers, programme officers, frontline HWs, community workers, PRIs...capacity building of the states
Each maternal death Each maternal death is …………is ………… a tragedy a tragedy
Bigger tragedy, Bigger tragedy, however, however, is……................ is……................ failing to learn failing to learn lessons from her lessons from her death!!death!!
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