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Maternal Death Review«A National Perspective

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Maternal Deaths« unacceptablenumbers

About 28 million pregnancies per year in India26 million live births15% of pregnancies likely to developcomplications67 000 maternal deaths in a year

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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 delaysµ:² Delay in decision making² Delay in reaching the appropriate health

facility² Delay in receiving health care at the facility

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MDGMDG Goals,TargetsGoals,Targets and Indicators «MDG 5«and Indicators «MDG 5«NRHM /RCH goals in lineNRHM /RCH goals in line

Goal Target Indicators Achievements

MDG-5: ToimproveMaternalhealth

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 to100/1,00,000 Live-births

MMR

Proportion of births attended bySBA.

Institutionaldelivery.

MMR : 254 per 100,000live births( RGI-SRS 2004-06)UN Interagency

Estimates(2008) :230/100,000 LB

52.6 %Safe Delivery47% InstitutionalDelivery

76%Safe Delivery72.9% Institutional Delivery(UNICEF CoverageEvaluation Survey 2009)

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MMR«we need to accelerate paceof decline

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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

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Bu rden of Maternal Deaths...

2001-03 2004-06

Assam 490 480

U.P. / Utta r akhand 517 440

Rajasthan 445 388

M.P. / C hhattisga r h 379 335

Biha r / J ha r khand 371 312

O r issa 358 303

Ka r nataka 228 213

P u njab 178 192

Haryana 162 186

Andh r a P r ad e sh 195 154We st Be ngal 194 141

Maha r asht r a 149 130

Tamil Nad u 134 111

Ker ala 110 95

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Policy and Programmes...Goals and TargetsN

ational Popu

lation Policy 2000

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MULTI-PRO NGE D

APPROACH..

MATE RN AL H E ALTH STRAT EG IE S

DemandPromotion-

( JananiS u raksha

Yojana)

Provision of servicesP u blic sector

1. E ssential and E mergencyObstetric Care

Qu ality A N C, I N C, Safe andInstit u tional deliverySkilled birth attendanceMu lti-skilling

2.Operationalize FRU s & 24*7 PHCs3. Services for RTIs & STIs ±convergence with the NACP 4. Safe abortion services- New Guidelines

5. Strengthen referral systems6. Village Health and N u trition Day..Mother-Child Protection Card

Provision of Services : Private sector Accreditation of Pvt. Health Facilities for

RCH services and S B A trainingFixed package for o u tso u rcing services

Maternal Death ReviewPregnancy and Child Tracking ±web based systemPrioritising reso u rces for identified ³delivery points´ or

MCH Centres

New

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10

NRHM«Overarching Umbrella

Intersectoral Convergence

Accredited Social Health Activist (ASHA) ² 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 MaintenanceGrants, 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

Co mm unitisati onDece nt r alisati on

Flex ibleFunding

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Maternal Death Review

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Policy on Maternal Death Reviews «spelt out inimplementation framework of RCH II

Strengthen Monitoring/Records/Audit procedures

Monitor State and Regionallevel MMRIntroduce mother-child linkedcardConduct review of maternal

deaths at the hospital andcommunity levelsDevelop tools for maternaldeath review and reporting

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Maternal Death ReviewsMaternal Death ReviewsInitiatives«fragmentedInitiatives«fragmented

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W hy conduct MDR?

Reduce maternal mortality and morbidity Imp rove qu ality of o bst e tr ic c a reUnd er stand de ter minants of mat er nal de ath P rov ide stim u lus for a c tion at all leve lsTak e correc tive a c tion to f ill the gaps in s erv iceprov ision

P rerequisite:A commitment to act upon the findings

No t for punitive a c tion

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MDR ProcessMDR ProcessFive approaches to help understand why women

die ... Maternal deaths in thecommunity (CBMDR)

Maternal deaths infacilities (FBMDR)

Confidential enquiries intomaternal deaths

Learning from women whosurvived: ´near missµ cases

Evidence-based clinicalaudit

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All these approaches...Identify cases (maternal deaths)Review cases confidentially and no blameLook for avoidable factorsPromote change in practicesReview the outcome of these changesRefine and develop

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The maternal death surveillance cycle..

Identify casesIdentify cases

RecommendationsRecommendations

for actionfor action

Collect informationCollect information

Analyse res u ltsAnalyse res u lts

Implement,Implement,

eval u ate and refineeval u ate and refine

No Punitive Action

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Challenges... to roll out the process

Creating awareness in community... Need foreffective BCC/IECMobilising communities and the health systemResolving infrastructure and human resource issuesBuilding partnerships between govt. systems andothers (prof. bodies ,tech. agencies ,NGOs )Resolving ethical issuesDeveloping guidelines and simple implementable toolsOrientation of a wide range of functionaries --policymakers, programme officers, frontline HWs,community workers, PRIs...capacity building of thestates

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