Minimising Maternal
Mortality in India
Evidence based Approach
Dr. Sharda Jain
Sec General Delhi Gynaecologist Forum
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Smita Patil
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Maternal Death Clock
Every 5 Minute...
1 woman
dies from a
pregnancyrelated
complication
In India
UNICEF
Near Miss Events
Quality Indicator of Maternal Care
05_XXX_MM6
"A woman who nearly died but
survived a complication that
occurred during pregnancy,
childbirth or within 42 days of
termination of pregnancy“
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W.H.O.
Commitment to Reducing
Maternal Deaths (MDG- 5)
GOAL
Reduce MMR by 75 %
From
1990 - to – 2015
i.e. – 109 per lakh
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MMR-Indian scenario
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1940 - 20 per 1000 live births
1960 - 10 per 1000 live births
1992 - 437 per 100000 live birth
1997 - 407 per 100000 live births
2003 - 301 per 100000 live births
2006 - 254 per 100000 live births
• 2009 -212 per 1,00,000 LB
Expected in 2015 - 135 per lakh LB
MDF – 5 in 2015 is 109 per lakh
SRG
SRGI
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Maternal Mortality Ratio, INDIA
SRS,2007-09
INDIA TOTAL
Achieved MDG target
212/lakh live birth
109/lakh live birth
Kerala
81
Tamil Nadu
97
Maharashtra
104
Close proximity to MDG targets
Andhra Pradesh
134
Gujarat
148
West Bengal
145
Haryana
153
Uttar Pradesh
359
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MDG - 5
Doable Goal !!
Political willpower
What Do Women Die Of ?
They Die
of simple Obstetric
Complications
that Need Not Be Fatal
WHO
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Obstetric Complications
5%
life threatening
15% will experience an
obstetric complications
…This is true
world over
Nobody Knows Why This Happens.
It is a Fact of Life.
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Most Obstetric Complications
Can Neither be
Predicted
Nor Prevented…
But if Women
Receive Timely
Effective Treatment
in Time,
…Almost All Can Be Saved
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How Do We Know
Which Women
Will Experience Complications?
WE CAN’T !!
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Spirit of Every Gynaecologist
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It is necessary to
ENSURE THAT EVERY
PREGNANCY IS WANTED
CONTRACEPTION
Knowledge is not enough
People have to use
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World Health Organization, Geneva
Evidence – based Interventions
Magnesium
Sulfate
Family Planning
and
Postabortion Care
Antibiotics
Oxytocin and
Manual
Compression
Eclampsia
12%
Severe Bleeding
24%
Unsafe
Abortion
13%
Infection
15%
Tetanus Toxoid
Immunization
Clean Delivery
Indirect Causes
20%
Obstructed
Labour
8%
Partogram
Other
Direct
Causes
8%
Iron Supplements,
Malaria Intermittent
Treatment and
Antiretroviral for HIV
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Abortion Deaths
(13%)
Ensure that
EVERY ABORTION IS SAFE.
Comprehensive Abortion Care
WHO Guideline
WHO Guidelines
• Medical abortion or vaccum aspiration
are the safest methods
• MVA (Aspiration Abortion)– It is advocated
especially in low resource settings like PHC
where reliable source of electricity/maintenance
is a problem ???
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Three Key Points
MMR
• Time - critical factor
• Concept of THREE DELAYS.
• Three points at which access to care is
delayed or denied or total lack of care
leads to
MATERNAL DEATH
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How Much Time
Do We Have?
It is estimated that, if untreated, death
occurs on average in:
2 hours
12 hours
from Postpartum Hemorrhage
from Antepartum
Hemorrhage
2 days
from Obstructed Labor
6 days
from Infection
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Janani Suraksha Yojana
JSY is a safe
motherhood
intervention
under the
NRHM
Door step/ Institutional delivery /shifting from PHC – CHCs – District Hospital
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Education through Medical
professionals & self – help groups
on risk in pregnancy and benefit of institutional delivery
Birth Planning (Home)
– Identify a skilled attendant
– Identify appropriate place of birth, and how
to get there
– Identify support people, (who will accompany
the woman and who will take care of the
family).
– Money
To Avoid 3 delays
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Inform mother and family about
4 I's
• Inform Dates of ANC's (Anti natal care) and iron folic
acid tablate /T.T injections Ensur these are provided.
• Inform expected date of delivery.
• Identify place of delivery.
• Identify health center for referral – For complicated
delivery/cessarian Section can be government
institution or accredited Private Health Institutional.
ANTENATAL / INTRANATAT PLANNING
The First Delay - Home
Delay in deciding to seek care
 MALE Involvement is the key
Lack of information and
inadequate knowledge
Traditional practices
Lack of money
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The Second Delay
Inability to access health facilities
Out of reach health
facilities
Poor roads and
communication network
Poor community support
mechanisms
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Making Emergency Obstetric
Care available
Emergency Referral Services (Toll free no 108)
introduced
Patchy
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Obstetric Helpline
Networking of various private and public
vehicles and locally identified mobile
phones forms the core infrastructure of the
helpline, which has been made financially
sustainable by linking it with JSY.
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The Third Delay
Delay between arriving and
receiving care at the health facility:
 Inadequate skilled attendants
 Poorly motivated staff
 Inadequate equipment and supplies
 Weak referral system
 system is not geared -prioritize an
emergency & respond promptly
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Addressing the 'third delay‘
Averting Maternal Death & Disability
Program (AMDD)
…We
Need to Ensure
that Women have Access To…
Emergency Obstetric Care
(EmOC)
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AMDD Program Orientation
EmOC has
8 Key Functions
• Antibiotics
(intravenous or by
injection)
• Oxytocic Drugs
• Anticonvulsants
• Blood Transfusion
• Manual Removal of
Placenta
• Removal of Retained
Products
• Assisted Vaginal
Delivery
• Surgery (Cesarean
Section)
3232
THE GOOD NEWS
Not all these functions need
hospitals and doctors
Well-trained nurses and
midwives can perform most
functions at Basic EmOC
Facilities
UK / Middle East
It is An Important Point
for Resource Poor country
INDIA
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Making Emergency Obstetric Care available
& 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
PARTERNERSHIP
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Life – Saving
Skill
Enforcing
ACCOUNTABILITY
in Medical & Nursing
profession
A government
INDEMNITY scheme
to cover health
professionals
We are committed to achieve the MDG 5
109 / lack Live Births
Countdown to 2015 begins……..
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AN care
ASHA
Training
(villages)
Up gradation of
PHC
INTRANATAL
Equipments
Availability
&
Maintenance
24 x 7
PHC
ANAEMIA MANAGEMENT
MMR = 20 + 20%
• Mandatory deworming
• Supplementation with iron folic acid (100) Vit C and
B-12
• Use of iron sucrose
• Ensuring proper measurement of haemoglobin levels
• changing diet and lifestyle of women using slippers..,
washing hands prior to food.
ADOLESCENT ANAEMIA
Control programme
“12 by 12 initiative”
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Standardized countrywide
protocol of
PPH
Eclampsia
Severe Anaemia
&
Regular Drills
PPH
Number One causes of MMR
PPH BOX
BALLOON TAMPONADE
Blood Transfusion
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Haemorrhagic Action
Committee
Taluka Level & District Level
Blood Transfusion Arrangement
•Arrangements for the blood donation
Formation of Haemorrhagic Action camps.
Committee
•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 45
time.
Eclampsia
(Drill)
Hb
&
IQ
Anaemia FREE Pregnancy
Community Involvement
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“Clean PHC Green PHC”
Outsourcing
Driver/watchman
Sweeper
Team
Gardener
Objective: To develop conducive environment in all
PHCs, making them clean and green, and mobilizing
the community through involvement of Self Help
Group members
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E-MAMTA
• Mother & Child Online tracking system
• A GUJARAT initiative adopted by the
Central Government for implementation
across India
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Maternal death reviews / audit
Prime Show
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FOGSI Initiatives
• EMOC at primary health centres, sub-
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centres and district hospitals.
certificate courses for medical officers
in conducting normal deliveries as well as
caesarean sections
conducting safe abortions
conducting a maternal mortality audit in
the states
National Eclampsia registry
save the girl child campaign
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My Role ?
(Doctor)
Dr. Sharda Jain
Will - What to Change ?
Why .to Change ?
Skill - How to Change ?
My Role ?
Dr. Sharda Jain
DO WHAT YOU CAN,
WHERE YOU ARE,
WITH WHAT YOU HAVE.
“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
Effects of Mothers’ Death
The death of a
woman and mother
is a tragic loss to
the child, family,
community and
nation as a whole.
Dr. Sharda Jain
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
PPH
Step 1 General Management
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Shout for help
Rapid evaluation of Vitals
Oxygen by mask
Uterine Massage
Oxytocin 10 u IM
Site 2 large bore(16G – gray color)IV cannula
Infuse IV fluid – NS / RL run it fast
Catheterize bladder
Check the placenta- is it expelled
- if it is expelied – re examine & make sure it is complete
• Examine vagina , perineum, and cervix for tears.
Step 2 Direct Therapy in PPH
Immediately PPH- PALPATE UTERUS
Soft Uterus
Placenta
Expelled
Completely
Atonic ut
B/m Massage
Oxitocis
Compress
Contracted uterus
Placenta retained
Partially expelled
Fundus not felt
+Shock
+ Pain
MRP/ Evacuate
Inversion
Immediate
Reposition
Of Uterus
Complete
Placenta
Trauma
Cervical Vaginal
Perineal tear
Precaustion/
IC
Drugs
Dose & route
Maintenance dose
Max dose
Frequency
Oxitocin
IU infusion
10u/500 ml, 60
dpm
IU Infuse 10 u /
500 ml 40 dpm
Not more than 31t
-
IM / slow IU of 0.2
ml
0.2 mg after 15
min
5 doses (1 mg)
4th hourly
PIH, HT,
Heart
disease
IM 250 UG
250 ug after 15
mnts
8 doses (2 mg)
15-90 mnts
Asthma
heart
Disease
Methergin
15 methy 1
PGF 2 a