Maternal Mortality
7
1 Notes www.iasscore.in Any health or health related problem which affects a vast majority of people and hampers the progress of an area or nation or which damages normal lifestyle of people and moreover which is preventable at least to a certain extent, can be called a public health problem. In India, Maternal Mortality Rate has become a major public health problem. MMR is defined as death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of pregnancy, from any cause related to or aggravated by pregnancy or its management but not from accidental or incidental causes. Present Situation The right to survive pregnancy and childbirth is a basic human right. Under international law, the government of India bears a legal obligation to ensure that women do not die or suffer complications as a result of preventable pregnancy-related causes. The staggering scale and continuing occurrence of maternal deaths and morbidity in India reveals the government’s failure to protect women’s reproductive rights, and comply with international law. But the present situation of India has been described as below: • India has recorded a decline in maternal mortality rates between 1990 and 2013 but along with Nigeria it accounted for one third of the global maternal deaths. • According to World Health Organization’s Trends in maternal mortality estimates 1990 to 2013, an estimated 289,000 women died in 2013 from complications in pregnancy and childbirth, down from 523,000 in 1990. • Although the MMR dropped but, India is far behind the target of 103 deaths per live births to be achieved by 2015 under the United Nations-mandated Millennium Development Goals (MDGs). • The MMR in southern states fell 17% from 127 to 105, closer to the MDGs. Assam and Uttar Pradesh/ Uttarakhand were the worst performing states, with an MMR of 328 and 292, respectively. Kerala and Tamil Nadu have surpassed the MDG with an MMR of 66 and 90, respectively. • According to the Annual Health Survey (AHS), which covers nine states, India has made headway in institutionalizing child deliveries, i.e., taking place in hospitals. More than 40% of child deliveries in Chhattisgarh and 79% in Madhya Pradesh were institutional in 2012, compared with 34.9% in Chhattisgarh and 76.1% in Madhya Pradesh in 2011. • The states covered by the AHS are Rajasthan, Uttarakhand, Uttar Pradesh, Madhya Pradesh, Bihar, Jharkhand, Chhattisgarh, Odisha and Assam. • More than 85% of the total births took place in government institutions in Madhya Pradesh and Odisha in 2011, and this was more than 60% in the other states surveyed, except Jharkhand, according to the latest AHS data. • Total fertility ratio (TFR), or the average number of children given birth by a woman, reach a preferred level of 2.1 in only 29 out of 284 AHS districts, whereas in 2011 it was 20 districts, according to the AHS data. MATERNAL MORTALITY AND ROLE PLAYED BY MIDWIVES
description
essay
Transcript of Maternal Mortality
1
Not
es
www.iasscore.in
Any health or health related problem which affects a vast majority of people and hampers the progress of anarea or nation or which damages normal lifestyle of people and moreover which is preventable at least to acertain extent, can be called a public health problem. In India, Maternal Mortality Rate has become a majorpublic health problem. MMR is defined as death of a woman while pregnant or within 42 days of terminationof pregnancy, irrespective of the duration and site of pregnancy, from any cause related to or aggravated bypregnancy or its management but not from accidental or incidental causes.
Present Situation
The right to survive pregnancy and childbirth is a basic human right. Under international law, the governmentof India bears a legal obligation to ensure that women do not die or suffer complications as a result ofpreventable pregnancy-related causes. The staggering scale and continuing occurrence of maternal deaths andmorbidity in India reveals the government’s failure to protect women’s reproductive rights, and comply withinternational law.
But the present situation of India has been described as below:
• India has recorded a decline in maternal mortality rates between 1990 and 2013 but along with Nigeriait accounted for one third of the global maternal deaths.
• According to World Health Organization’s Trends in maternal mortality estimates 1990 to 2013, anestimated 289,000 women died in 2013 from complications in pregnancy and childbirth, down from523,000 in 1990.
• Although the MMR dropped but, India is far behind the target of 103 deaths per live births to be achievedby 2015 under the United Nations-mandated Millennium Development Goals (MDGs).
• The MMR in southern states fell 17% from 127 to 105, closer to the MDGs. Assam and Uttar Pradesh/Uttarakhand were the worst performing states, with an MMR of 328 and 292, respectively. Kerala andTamil Nadu have surpassed the MDG with an MMR of 66 and 90, respectively.
• According to the Annual Health Survey (AHS), which covers nine states, India has made headway ininstitutionalizing child deliveries, i.e., taking place in hospitals. More than 40% of child deliveries inChhattisgarh and 79% in Madhya Pradesh were institutional in 2012, compared with 34.9% in Chhattisgarhand 76.1% in Madhya Pradesh in 2011.
• The states covered by the AHS are Rajasthan, Uttarakhand, Uttar Pradesh, Madhya Pradesh, Bihar,Jharkhand, Chhattisgarh, Odisha and Assam.
• More than 85% of the total births took place in government institutions in Madhya Pradesh and Odishain 2011, and this was more than 60% in the other states surveyed, except Jharkhand, according to thelatest AHS data.
• Total fertility ratio (TFR), or the average number of children given birth by a woman, reach a preferredlevel of 2.1 in only 29 out of 284 AHS districts, whereas in 2011 it was 20 districts, according to the AHSdata.
MATERNAL MORTALITY ANDROLE PLAYED BY MIDWIVES
Not
es
2
www.iasscore.in
Causes of High MMR in India
Medical Causes
• The most common direct medical causes of maternal death around the world are hemorrhage, obstructedlabor, infection (sepsis) and hypertensive disorders related to pregnancy, such as eclampsia. These conditionsare largely preventable and once detected, they are treatable.
• Complications from unsafe abortion are another common and preventable direct cause of maternal death.The NFHS-3 and other studies confirm the widespread prevalence of these causes of maternal mortalityin India.
• In India as well as globally, a significant portion of maternal deaths are ascribed to “indirect causes.”“Indirect causes” are those conditions or diseases that can lead to complications in pregnancy or whichare aggravated by pregnancy. In India, common “indirect causes” of maternal death are anemia, malariaand HIV/AIDS. Anemia and unsafe abortion are deserving of special note, as these two causes of maternaldeath are more common in India than they are in much of the world. The percentage of maternal deathscaused by hemorrhage is greater in India than in the rest of the world and has been attributed to higherrates of anemia in Indian women. Pregnant women who are anemic, face multiple health risks in additionto the risk of maternal death. Anemic women are increasingly susceptible to communicable diseases suchas tuberculosis (TB) and malaria, which are associated with adverse outcomes during and after pregnancy.Anemic women face the further risk of falling into a cycle of multiple pregnancies in their efforts to havechildren that survive, since nutritional deficiencies during pregnancy notably reduce the chances of infantsurvival. In India, anemia is far more prevalent in women than in men, with the NFHS-3 reporting that55% of women have anemia, as compared to only 24% of men.
• Complications from unsafe abortion account for a significant proportion of maternal deaths in India.According to the government, around 9% of total maternal deaths are caused by unsafe abortion,butmedical experts put the figure at almost 18%; higher than the global average of 13%. Although abortionis legally permitted on several grounds, each year approximately 6.7 million abortions occur outside ofgovernment-recognized health centers, often in unhygienic conditions or by untrained abortion providers.This problem disproportionately affects adolescents, as unsafe abortions account for half of all maternaldeaths of women aged 15-19. Most women in India are not able to obtain legal abortions for multiplereasons, including a dearth of information about safe abortion services; inconsistent and prohibitive costs;a shortage of trained providers and adequate equipment; lack of confidentiality and informal demands forspousal consent; poor access to facilities; and lack of knowledge about the legal status of abortion – onestudy showed that only 9% of Indian women knew that abortion was legal.
Socioeconomic factors
• A higher incidence of mortality and morbidity is found to occur among woman and girls who are pooror low-income, less educated and belong to socially disadvantaged castes and tribes.
• Child marriage puts young girls and adolescents at significant risk of pregnancy-related complications andmortality.
• Pregnant women living with HIV/AIDS experience an increased risk of pregnancy-related fatalities due tooutright discrimination.
• The affordability of reproductive health services for women is a major concern. The burden of high out-of-pocket expenses for reproductive health care has been identified as a leading cause of poor reproductive
3
Not
es
www.iasscore.in
health outcomes among low-income women in South Asian countries, including India. This trend may beattributed to the fact that the government spends less than 1% of its Gross Domestic Product (GDP) onhealth which in turn has led to insufficient access to health care services and poor quality of care.Consequently, hospitalization is frequently a cause of debt among the poor, which in turn leads to increasedpoverty. In terms of barriers faced specifically by poor women to maternal health care, studies point totheir increased likelihood of receiving a lower quality of care than rich women, which serves as a deterrentagainst seeking institutional health care, leading to higher risk of pregnancy-related complications andmortality. Consequently, in India, the poorest women have significantly less access to antenatal health carethan rich women.
• Education level has been noted by experts as one of the most important indicators of women’s statusrelated to maternal mortality, in light of its affects on fertility rates and access to employment and healthcare. Female education and female literacy rates are strongly correlated to high rates of maternal mortalityaround the world. Some national-level comparisons show that literacy is a stronger predictor of maternalhealth than economic wealth. Lack of education adversely affects women’s health by limiting their knowledgeabout nutrition, birth spacing and contraception. This is particularly evident in India, where a woman’slevel of education strongly correlates to many indices of maternal health, including fertility rate, utilizationof prenatal care, met need for contraception and higher age at first birth. Furthermore, studies in Indiashow that education level is a key determinant of the quality of care received by women in health caresettings, and that illiterate women tend to experience significantly lower interpersonal quality of care inhealth facilities.
Health-System Related Factors
• Essential reproductive health services are not available to the majority of women in India. The NationalHuman Rights Commission (NHRC) reports that a mere 30% of the population receives services throughthe public health system. The unavailability of basic reproductive health services including contraceptives,pre- and post-natal care and emergency obstetric care, as well as delays in seeking institutional care andthe poor quality of care provided in government hospitals, have contributed dramatically to maternaldeaths.
• High maternal mortality rates correlate strongly with inadequate access to family planning information andservices. Unwanted pregnancies expose women to significant risks to their maternal health, includingcomplications from unsafe abortions and high-risk pregnancies. Studies show that women facing unwantedpregnancies are far more likely to seek induced abortions, including illegal abortions, and are much lesslikely to receive adequate pre-natal care.
• Less than 50% of women give birth with the assistance of a skilled attendant and only 40% of deliveriesoccur in an institutional setting. Although the WHO recommends that women receive four antenatalcheckups during pregnancyand the Indian government has promised to ensure that women are providedfour checkups through the NRHM, less than three-quarters of women in India receive any antenatalexamination at all. Access to maternal health care varies greatly by state. In West Bengal over 90% ofwomen receive at least one prenatal examination, while in Bihar that number is only 34%.
• Most maternal deaths are attributable to the ‘three delays’: the delay in deciding to seek care, the delayin reaching the appropriate health facility, and the delay in receiving quality care once inside an institution.The first delay, the delay in deciding to seek care, can occur due to inadequate resources, poor access tohigh-quality health care and lack of awareness at the household level of the importance of maternal healthcare. The second delay refers to lack of access to obstetric care. Lack of access can mean that appropriatefacilities do not exist or are not physically accessible; or it can mean that financial, socio-cultural or
Not
es
4
www.iasscore.in
infrastructural barriers – such as impassable roads or lack of transportation options prohibit women frompromptly gaining access to an existing facility. The third delay typically results from untimely diagnosisand treatment, poor skills and training of care providers, prolonged waiting time at the facility, shortageof equipment and blood, multiple referrals to different health facilities, and shortages in electricity or watersupply.
Steps taken by Government
The government has launched the reproductive and Child Health Programme Phase II (RCH-II) under theumbrella of the National Rural Health Mission (NRHM), aims to improve access for rural people, especiallypoor women and children to equitable, affordable accountable and effective primary health care, with a specialfocus on 18 States, with the ultimate objective of reducing Infant Mortality, Maternal Mortality and TotalFertility Rates.
The key strategies and interventions under the NRHM for reduction of Maternal Mortality Ratio are:
• Janani Suraksha Yojana (JSY), a cash benefit scheme to promote Institutional Delivery with a special focuson Below Poverty Line (BPL) and SC/ST pregnant women;
• Operationalizing round the clock facilities for delivery services in the 24X7 Primary Health Centres(PHCs) and First Referral Units (FRUs) including District Hospitals, Sub-district Hospitals, CommunityHealth Centres and other institutions.
• Augmenting the availability of skilled manpower thorough various skill- based trainings of Skilled BirthAttendants; training of MBBS Doctors in Life Saving Anesthetic Skills and Emergency Obstetric Careincluding Caesarean Section.
• Provision of Ante-natal and Post-natal Care services including prevention and treatment of Anaemia bysupplementation with Iron and Folic Acid tablets during pregnancy and lactation.
• Organizing Village Health and Nutrition Days (VHNDs) at anganwadi Centres to impart health andnutrition education to pregnant and lactating mothers.
• Systems strengthening of health facilities through flexible funds at Sub Centres (PHCs) and CommunityHealth Centres (CHCs) and District Hospitals.
• Provision of early detection of pregnancy, regular check-up of blood pressure, hemoglobin, fetal growthfree of cost.
• Regular home visit by Accredited Social Health Activist (ASHA) and sensitizing mothers about the needof taking one extra meal, eight hours sleep at night and two hours rest at day time, early detection ofcomplication of pregnancy etc. ASHAs educate the mothers about the need of institutional delivery anddelivery by skilled birth attendant.
• Provision of arrangement of mothers’ meeting every month at Anganwadi center.
• Establishment of First Referral Units (FRUs) at block level having provision of normal delivery, caesariansection and assisted vaginal delivery. FRUs are equipped with gynecologists, pediatricians, anesthetists andblood transfusion facility.
• Under Vande Mataram scheme gynecologists who are not in Governmental service, if treat pregnant ladiesat Government facilities free of cost, then they receive a particular amount of incentive from the Governmentand also get Vande Mataram certificate.
5
Not
es
www.iasscore.in
• Some NGOs are working for pregnant ladies in hard to reach areas like hilly areas and delta islands likeSundarban.
• Government of India has launched Janani Shishu Suraksha Karyakaram (JSSK). The initiative entitles allpregnant women delivering in public health institutions to absolutely free and no expense delivery, includingcaesarean section. The entitlements include free drugs and consumables, free diet up to 3 days duringnormal delivery and up to 7 days for C-section, free diagnostics, and free blood whenever required. Thisinitiative also provides for free transport from home to institution, between facilities in case of a referraland drop back home. Similar entitlements have been put in place for all sick newborns accessing publichealth institutions for treatment till 30 days after birth. This has now been expanded to cover sick infants.
Role of Midwife in Reducing Maternal Mortality
One of the key components of the National Rural Health Mission is to provide every village in the countrywith a trained female community health activist ASHA, midwives. Selected from the village itself and accountableto it, the ASHA will be trained to work as an interface between the community and the public health system.Following are the key components of ASHA :
• They are empowered with knowledge and a drug-kit to deliver first-contact healthcare, thus every ASHAis expected to be a fountainhead of community participation in public health programmes in her village.
• ASHA is the first port of call for any health related demands of deprived sections of the population,especially women and children, who find it difficult to access health services.
• ASHA is a health activist in the community who create awareness on health and its social determinantsand mobilise the community towards local health planning and increased utilisation and accountability ofthe existing health services.
• She is a promoter of good health practices and will also provide a minimum package of curative care asappropriate and feasible for that level and make timely referrals.
• ASHA provide information to the community on determinants of health such as nutrition, basic sanitation& hygienic practices, healthy living and working conditions, information on existing health services and theneed for timely utilisation of health & family welfare services.
• She counsel women on birth preparedness, importance of safe delivery, breast-feeding and complementaryfeeding, immunization, contraception and prevention of common infections including Reproductive TractInfection/Sexually Transmitted Infections (RTIs/STIs) and care of the young child.
• ASHA mobilise the community and facilitate them in accessing health and health related services availableat the Anganwadi/sub-centre/primary health centers, such as immunisation, Ante Natal Check-up (ANC),Post Natal Check-up supplementary nutrition, sanitation and other services being provided by the government.
• She act as a depot for essential provisions being made available to all habitations like Oral RehydrationTherapy (ORS), Iron Folic Acid Tablet (IFA), chloroquine, Disposable Delivery Kits (DDK), Oral Pills &Condoms, etc.
Activities performed by ASHAs
• Mobilizing pregnant mothers for ANC and escorting them for Institutional delivery.
• Mobilizing Children & mothers for immunization.
• Conducting home visits & surveys.
Not
es
6
www.iasscore.in
• DOTS Provider
• Collecting blood slides.
• Salt testing & water testing.
• Conducting VHSC meetings.
• Organizing VHND & other health activities in the village.
• Motivator of family planning.
• Depot holder of basic drugs.
• Promoter of healthy lifestyle.
• Assisting ANM in Home Deliveries.
Issues in Implementation
• Corruption is widespread in providing health care facilities. The inability of pregnant woman to pay theinformal demands for money in exchange for services has been identified as a leading cause of maternalmortality. It appears that JSY is wrongly being seen as a scheme to cover out-of-pocket costs for institutionaldelivery, which is supposed to be free, rather than as a cash assistance program for nutritional and othersupport. There also have been reports of ANMs selling state-provided medicines illegally and pocketingthe earnings.
• Many institutions are increasing promotion of institutional delivery without first addressing or improvingthe quality of care, which has led to poor services and medical care. Often institutions are not fully staffedor do not offer services for evening births, leading to women being turned away or being sent to privatehospitals where they may incur huge medical costs. Health centers also have a lack of workable toiletsand basic sanitation facilities. Further, referral systems are weak or non-existent, leading women to beshuttled back and forth between providers with no continuity of care.
• Health workers are not adequately trained, which leads to mismanagement of delivery cases, such as thewidespread, unsupervised use of oxytocin injections before delivery.
• Certain provisions of the NRHM are problematic insofar as they fail to take into account circumstancesthat deny women the ability to control when, under what circumstances and how often they becomepregnant. For instance, in JSY making cash incentives conditional on consent for sterilization is a form ofcoerced sterilization, as women who belong to BPL households are not likely to have the financial abilityto reject the cash payment, even if they prefer a non-permanent method of birth control. The implicationsof these provisions for women’s well-being and basic human rights have been overlooked by policymakersand need to be addressed.
New Initiatives
• Maternal Death Review
The process of maternal death review (MDR) has been implemented & institutionalized by all the Statesas a policy since 2010. Guidelines and tools for conducting community based MDR and facility basedMDR have been provided to the States. The States are reporting deaths along with its analysis for causesof death.
7
Not
es
www.iasscore.in
• Delivery Points (DPs)
All the States & Union Territories have identified DPs above a certain minimum benchmark of performanceto prioritize and direct resources in a focused manner to these facilities for filling the gaps like trained andskilled human resources, infrastructure, equipments, drugs and supplies, referral transport, etc., for providingquality & comprehensive RMNCH (Reproductive, Maternal, Neo-natal & Child Health) services.
• Web Enabled Mother and Child Tracking System
Name Based Tracking of Pregnant Women and Children has been initiated by Government of India as a policydecision to track every pregnant woman, infant & child upto 3 yrs, by name for provision of timely ANC,Institutional Delivery, and PNC along with immunization & other related services.
• A Joint MCP Card
Ministry of Health & Family Welfare and Ministry of Women and Child Development (MOWCD) has beenlaunched as a tool for documenting and monitoring services for ante-natal, intra-natal and post-natal care topregnant women, immunization and growth monitoring of infants.
• Tracking of severe Anaemia during pregnancy & child birth by SCs and PHCs
Severe anemia is a major cause for pregnancy related complications that may lead to maternal deaths. Effectivemonitoring of these cases by the ANM as well as the Medical Officer in charge of PHC has been started toline list these cases and provide necessary treatment.
• Technical Guidelines & Service Delivery Posters
GoI has developed & disseminated standard technical guidelines & service delivery posters for standardizingthe quality of service delivery during ANC, INC, PNC, etc from tertiary to primary level of institutions.
