IMPORTANCE OF

INSTITUTIONAL DELIVERIES

PRESENTED BY :- MANPREET KAUR

MSC NURSING 1ST YEAR

NINE ,PGIMER CHD

INTRODUCTION

It is well established that giving birth in a medical

institution under the care and supervision of trained

health-care providers promotes child survival and

reduces the risk of maternal mortality. In India, both

child mortality (especially neonatal mortality) and

maternal mortality are high. India accounts for more

than one-fifth of all maternal deaths from causes

related to pregnancy and childbirth worldwide.

DEFINITION

Institutional delivery refers to the childbirth at

technology-equipped medical facility under

supervision of skilled medical staff.

In an institutional delivery, various medical tools

and technologies are used to ascertain that health

of neonate or mother is not compromised.

THE BACKGROUND

Since the 1980’s successive programmes have

attempted to address the high MMR and IMR

There have been considerable decline in India’s

MMR in the last two decades: from 398 in 1997-

98 to 212 in 2007-09

Yet, this is far off from the MMR goal

of less than 100 per 100000 live births

OBJECTIVES:-

Why this is a public health problem?

What are the socio economic factors affecting?

What are the role of belief and norms?

What are the non medical causes associated?

What are the psychological and cultural aspects?

A PUBLIC HEALTH PROBLEM

MDG goal 5 :-

India has the largest number of births per year (27

million) in the world.1 With its high maternal

mortality of about 300–500 per 100 000 births This is

about 20% of the global burden hence India’s prog-

ress in reducing maternal deaths is crucial to the

global achievement of Millennium Development Goal

5 (MDG 5)

RISK FACTORS FOR MATERNAL MORTALITY

Socioeconomic factors

Reproductive factors

Health service factors

SOCIO-ECONOMIC FACTORS

The general socioeconomic status of mothers

Lack of education

Poor knowledge about maternal health

Poverty

Poor mothers are at high risk of developing

pregnancy related complications. Almost all

maternal deaths that occur in low and middle-

income countries are mainly among the poorest of

the poor (WHO, 2005).

A CONCEPTUAL FRAMEWORK FOR ANALYZING

SOCIO-ECONOMIC INEQUALITIES IN HEALTH

SERVICE UTILIZATION

SOURCE: DE BROUWERE AND LERBERGHE (2001)Socio- Economic factors

Income,wealth

Education

Employment,

Occupation

Family background

Confounders &

modifiers

Age

Place of residence

Ethnicity,

Religion

Proximate Determinants

Health status

Perception of health

problems

Autonomy, social support

Purchasing power

Insurance cover

Duties, opportunities costs

Tendency to consult,

beliefs

Health service

utilization

Frequency of visits

Type of facility

Quality received

REPRODUCTIVE FACTORS

The number of pregnancies she has had in her

lifetime.

The higher the number of pregnancies, the greater

the lifetime risk of pregnancy related deaths (WHO,

2005).

Maternal age also has an impact on increasing the

risk of dying. Girls below 18 years and women older

than 35 years are more likely to have pregnancy

related complications that may lead to maternal

death (USAID, 2005).

HEALTH SERVICE FACTORS

All pregnant women are at risk of developing

complications during any time of their pregnancies,

deliveries and postpartum periods.

Lacks of access to emergency obstetric care and

delay for emergency referral are contributing factors

for high maternal mortality.

Obstetrics complications are able to be treated in

health institutions that are sufficiently equipped with

supplies, medications and fully staffed with capably

trained health professionals

MATERNITY SERVICES UTILISATION

0 20 40 60 80 100

ANC services

Skilled birth

attendents

C sections

poor rich

ADVANTAGES OF INSTITUTIONAL

CHILDBIRTHS

Antenatal care is a perquisite for a healthy delivery. Medical facility with trained staff and advanced facilities provides all services related to antenatal check-ups and counselling.

In a medical institution, trained healthcare professionals provide specific care and attention to newborn babies with special needs in order to improve their survival chances and reducing the risk of maternal mortality.

Women seeking assistance of medical institution for delivery are the ones given ample support to conceive at the right maternal age without delaying childbearing.

Mothers are regularly assisted for post-pregnancy care, with medical staff discussing various aspects such as care for umbilical cord stump, nutrition, breastfeeding and bathing.

ADVANTAGES OF INSTITUTIONAL

CHILDBIRTHS CONT……

Institutional medical facilities aim for safe delivery by

labour monitoring, active management of the third stage

of delivery, immediate attention of the newborn,

postpartum monitoring, addressing complications of

mother and infant post-delivery.

Quality of care is all-important, which is provided by

institutional medical setting.

Institutional medical facility also provides personnel and

equipments to handle emergency circumstances which

necessitate immediate medical attention.

Round-the-clock supervision ensures comfort for mother

with medical staff looking after nutrition and diaper

changes of her baby.

ADVANTAGES OF INSTITUTIONAL

CHILDBIRTHS CONT…….

Improper care during pregnancy term can also affect overall maternal health, specifically the reproductive health of the woman besides the health of the newborn baby.

Hygienic conditions and surroundings are also important for safe delivery, which are mostly ignored in non-institutional setting for a delivery.

Immunisation chart can be easily adhered to in an institutional medical facility. Following immunisationschedule ascertains that baby as well as mother is safe from various health complications.

Institutional settings provide aid to hasten labour like intravenous (IV) drips and intramuscular injections during labour.

OBSTACLE FOR LOW UTILIZATION OF

DELIVERY SERVICES

Distance from health services;

Costs, including user fees

The cost of transport

Quality of care

Drugs availability & Supplies

Women’s lack of autonomy indecision-making.

(The WHO (1998) and Magadi et al (2002)

NATIONAL RURAL HEALTH MISSION

The National Rural Health Mission (NRHM) is a

government scheme that aims at providing valuable

healthcare services to rural households all over the

country

National Rural Health Mission (NRHM) launched in

2005 : provide equitable , accessible and affordable

health care

IT SPECIALLY FOCUSES ON THE 18 STATES

Arunachal Pradesh, Assam,

Bihar, Chhattisgarh, Himachal

Pradesh, Jharkhand, Jammu and

Kashmir, Manipur, Mizoram,

Meghalaya, Madhya Pradesh,

Nagaland, Orissa, Rajasthan,

Sikkim, Tripura, Uttarkhand and

Uttar Pradesh.

OBJECTIVES

Decrease the infant mortality rate to 30/1,000 live births and maternal mortality rate to 100/1,00,000

Universal access to public health services such as Women’s health, child health, water, sanitation & hygiene, immunization, and Nutrition.

Prevent and control communicable and non-communicable diseases.

Control population as well as ensure gender and demographic balance.

Encourage a healthy lifestyle and alternative systems of medicine through AYUSH

Improved facilities for institutional delivery.

GOAL TO BE ACHIEVED BY NRHM

IMR 30/1000 LIVE

BIRTHS

MMR 100/100,000

TFR 2.1

GOAL CONT…….

Improved facilities for institutional deliveries through

provision of referral , transport, escort, and

improved hospital care subsidised under the JSY

for below puberty line families

NRHM

Reduction in MMR to 100/100,000 is

one of its goals

The Janani Suraksha Yojana ( Safe

Motherhood Scheme) is the key

strategy to achieve this reduction

JANANI SURAKSHA YOJANA

The government has a Janani Suraksha Yojana

(JSY) to deal with issues involved in pregnancy and

child care.

JSY:-

It is a centrally sponsored scheme aimed at

reducing maternal and infant mortality rates, and

increase institutional deliveries in below poverty line

(BPL) families.

The JSY, which falls under the overall umbrella of

National Rural Health Mission, covers all pregnant

women belonging to households below the poverty

line, above 19 years of age and up to two live

births.

JSY CONT……..

The JSY, launched in 2003, modifies the existing

National Maternity Benefit Scheme or NMBS.

While the NMBS was linked to provision of better

diet for pregnant women from BPL families, the JSY

integrates the cash assistance with antenatal care

during pregnancy period, institutional care during

delivery and immediate post-partum period in a

health centre by establishing a system of

coordinated care by field level health worker.

JSY

The Yojana has identified ASHA, as an effective

link between the Government and the poor

pregnant women in low performing states.

CONT…………

Counsel for institutional delivery.

Escort the beneficiary women to the pre-determinedhealth center and stay with her till the woman isdischarged.

Arrange to immunize the newborn till the age of 14weeks.

Inform about the birth or death of the child or motherto the ANM/MO.

Post natal visit within 7 days of delivery to trackmother’s health after delivery and facilitate in obtainingcare, wherever necessary.

Counsel for initiation of breastfeeding to the newbornwithin one-hour of delivery and its continuance till 3-6months and promote family planning.

IMPORTANT FEATURES OF JSY:

The scheme focuses on the poor pregnant woman

with special dispensation for states having low

institutional delivery rates namely the states of Uttar

Pradesh, Uttaranchal, Bihar, Jharkhand, Madhya

Pradesh, Chhattisgarh, Assam, Rajasthan, Orissa

and Jammu and Kashmir. While these states have

been named as Low Performing States (LPS), the

remaining states have been named as High

performing States (HPS).

TRACKING EACH PREGNANCY:

Each beneficiary registered under this Yojana

should have a JSY card along with a MCH card.

ASHA/AWW/ any other identified link worker under

the overall supervision of the ANM and the MO,

PHC should mandatorily prepare a micro-birth

plan. This will effectively help in monitoring

Antenatal Check-up, and the post delivery care.

JSY :THE PACKAGE OF INCENTIVES

Low performing states High performing states

Institutiona

l delivery

package

Rs.1400 ($23)to mothers in

rural areas

Rs.1000 ($16) in urban

areas

Rs. 600 ($10) to ASHAs

Home

delivery

package

Rs. 500 ($8) to

mothers- being BPL ,

above 19 yrs of ages.

Institution

al

delivery

package

Mothers : Rs. 700 ($12) in

rural areas

Rs.600 ($10) in urban

areas

Rs.200 ($ 4) and 350 ( $6)

in tribal areas) to ASHAs

Home

delivery

package

Rs. 500 ($8)to

mothers- being BPL

, above 19 yrs of

ages.

DISBURSEMENT OF CASH ASSISTANCE:

a. The mother and the ASHA should get their entitled

money at the heath centre immediately on arrival

and registration for delivery.

b. Generally the ANM/ ASHA should carry out the

entire disbursement process. However, till ASHA

joins, AWW or any identified link worker, under the

guidance of the ANM may also do the

disbursement.

PAYMENT TO ASHA:

First payment for the transactional cost at the

health centre on reaching the institution along with

the expectant mother.

The second payment should be paid after she has

made postnatal visit and the child has been

immunized for BCG.

All payments to ASHA would be done by the

ANM only. : It must be ensured that ASHA gets her

second payment within 7 days of the delivery, as

that would be essential to keep her sustained in the

system.

ROLE OF ASHA OR OTHER LINK HEALTH WORKER

ASSOCIATED WITH JSY:-

Identify pregnant woman as a beneficiary of the

scheme and report or facilitate registration for ANC

Assist the pregnant woman to obtain necessary

certifications wherever necessary,

Provide and / or help the women in receiving at

least three ANC checkups including TT injections,

IFA tablets,

Identify a functional Government health centre or

an accredited private health institution for referral

and delivery

RATIONALE

Institutional deliveries would help the pregnant

woman access a team of skilled birth attendants

more reliably and it would also improve her access :

emergency obstetric care

reduced maternal and neonatal mortality

The scheme offers

a package of

financial incentives

to pregnant women

to improve access

to institutional

deliveries.

IMPACT OF JANANI SURAKSHA YOJANA ON

INSTITUTIONAL DELIVERY RATE: AN

OBSERVATIONAL STUDY IN INDIA

The data were analyzed for two years before

implementation of JSY (2003-2005) and compared

with two years following implementation of JSY

(2005-2007). Overall, institutional deliveries

increased by 42.6% after implementation, including

those among rural, illiterate and primary-literate

persons of lower socioeconomic strata.

POSSIBLE IEC STRATEGY

To associate NGO and Self Help Groups forpopularizing the scheme among women’s groupand also for monitoring of the implementation.

To provide wide publicity to the scheme by:

Promoting JSY as a component of total packageof services under RCH along with programmes likePulse polio programme.

Printing and distributing JSY guidelines, pamphlets,notices in local languages at SC/PHCs/CHCs/District Hospitals/ DM’s and DivisionalCommissioner’s office and even in at the accreditedPvt. Nursing Homes, in abundance.

MATERNAL MORTALITY IN 1990-2013

F:\Maternal mortality in 1990.docx

LET US ENSURE THESE BASIC HEALTH RIGHTS

FOR EVERY MOTHER AND HER CHILD ..AS INDIA

MOVES TOWARDS UNIVERSAL HEALTH COVERAGE

REFERENCES

Park.K.2009. Park’s Textbook of Preventive and

Social Medicine. Twentieth edition. M/s Banarsidas

Bhanot publishers, Jabalpur, India. Pp 379-381.

http://reports.nrhmcommunityaction.org/more.htm.

THANKS