Maternal & Newborn Health
WITH reference to
INDIA & RAJASTHAN
Dr. KANUPRIYA CHATURVEDI
KEY ISSUES
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Maternal & Newborn Health :Where we stand
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Creating a supporting environment
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Continuum of care across time & location
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Risks & opportunities
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Strengthening health systems
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The Rate of Progress
Maternal & Newborn
Health :Where we stand
Maternal & Newborn Health
:Where we stand
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Global Scenario
Regional distribution
Maternal mortality ratio & Maternal
mortality rate
Direct causes
Conceptual framework
Global scenario-Maternal health
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Each year, more than half million women die from causes
related to pregnancy & childbirth
For every such death there are 20 others who suffer
pregnancy related illnesses or other adverse outcome
(obstetric fistula, uterine prolapse)
Around 10 million women annually suffer from
complications of pregnancy
On average, each day~1500 women die from causes
related to pregnancy & child birth
80% of maternal deaths could be avoided by access to
essential maternity & basic health services
Global Scenario-Neonatal Health
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Nearly 4 million newborns die {40% of under 5 deaths}
within 28 days of birth
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Three quarters of neonatal deaths occur during first 7
days
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For every newborn death ,20 others suffer birth injury,
complications of preterm birth or other neonatal
conditions
A child born in a least developed country is 14 times
more likely to die within first 28 days of life as
compared to industrialized country
The big divide
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The divide between industrialized countries &developing
regions –is perhaps greater than on any other issue
Average lifetime risk of maternal death for a woman in least
developed country is >300 times than in industrialized
country
In developing world a woman has 1 in 76 lifetime risk of
maternal death as compared to 1 in 8000 in industrialized
countries
Global MMR stood at 430/lakh live births in 1990,and at
400/lakh in 2005
Uttar Pradesh
517
178
Maternal mortality ratio
per 100,000 births
2001-2003
517
162
517
445
490
371
371
379
194
172
379
358
149
195
Kerala
110
228
India: 301
per 100,000 live births
Less than equal to 150
110
134
151 - 300
More than 300
Missing Data
Source: SRS
Medical causes of maternal deaths in
India
Other
Conditions
34%
Hemorrhage
38%
Abortion 8%
Obstructed
Labour 5%
Source: SRS
Sepsis 11%
Hypertensive
Disorders 5%
Medical Causes of Neonatal Deaths-India
Diarrhoea
2%
Asphyxia
23%
Preterm
35%
Tetanus
3%
6%
Other
6%
Congenital
24%
Infection
Source: Lawn JE Cousen SN for CHERG (Nov 2006)
Share of under-five mortality in India
Neonatal deaths
50%
Infant deaths within 7 days of birth
40%
Infant deaths
76%
Source : SRS 2007
Infant deaths between
7 days of birth and within 28 days
10%
Infant deaths between 28 days
and within one year of birth
26%
Child deaths between one
year and within five years of birth
24%
Infant Mortality Rates by
State
80
73
70
71 70
69
66 65 65
62 61
57
60
54
52
50
50
48
45 45
43 42 42 42
40
40
38 38
36
34 34
30 30
30
20
15 15
KE
GO
MN
TN
SK
MZ
HP
NA
MH
DL
HR
UT
PJ
KA
JK
MG
WB
GJ
TR
AP
IN
AR
BH
RJ
OR
JH
MP
CH
UP
0
AS
10
Infant Mortality RateRajasthan
Infant Mortality Rate by
Demographic Characteristics
PREVIOUS BIRTH INTERVAL
< 2 years
2 years
3 years
4 years or more
86
50
30
37
BIRTH ORDER
1
2-3
4-6
7 or more
64
47
62
80
MOTHER'S AGE AT BIRTH
< 20
20-29
30-39
40-49
77
50
56
72
0
10
20
30
40
50
60
70
80
90
100
Childhood Mortality Rates by Sex
90
79
80
70
70
58
60
50
40
37
56
41
30
23
21
15
20
14
10
0
Neonatal
Mortality
Postneonatal
Mortality
Infant Mortality
Female
Male
Child Mortality
Under-five
Mortality
Steady Decline in Infant Mortality
Rates India
80
79
68
70
57
60
50
40
30
20
10
0
NFHS-1
NFHS-2
NFHS-3
Creating a supporting
environment
Creating a supportive environment
for women & children
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Millennium development Goals
Promoting a healthy behavior
Securing a quality education
Preventing child marriage
Ante natal care coverage
Skilled delivery care coverage
Promoting a healthy behavior
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Timing of births
Safe motherhood
Child development
Breast feeding
Nutrition & growth
Immunization
Diarrhoea
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Coughs, colds &
more serious
illnesses
Hygiene
Malaria
HIV and AIDS
Injury prevention
Disasters &
emergencies
Quality education & a decent
living
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Studies show that educated women;
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Are more likely to delay marriage
Ensure that their children are immunized
Are better informed about nutrition
Undertake improved birth spacing practices
Age at marriage-India
Percentage of women aged 20-24 married before age 18
54%
50%
45%
1992-93
1998-98
2005-06
Early marriage leads to early childbearing thereby enhancing
maternal health risks
Source: NFHS
Antenatal Coverage -Rajasthan
Continuum of care across
time & location: Risks &
opportunities
First 28 Days of life
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Specific factors
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Limited access to skilled care providers
Home births [Associated with half of newborn
deaths]
Inadequate recognition of newborn illnesses
Insufficient care seeking
A limited repertoire of interventions for early
neonatal disorders [ e.g. birth asphyxia, premature
births ]
A lack of consensus on interventions and delivery
strategies
Nutrition among women
Percentage of ever-married women age 15-49 with any anaemia and
Body Mass Index (BMI) below 18.5 kg/m2
60
56%
52%
36%
40
33%
20
0
Any anemia
BMI below normal
1998-98
2005-06
High percentage of women with anaemia and low BMI results in
higher risk of low birth weight and peri-natal deaths
Source: NFHS
Antenatal care
Percentage of ever-married women age 15-49 years having at least one ante-natal care
100
90
87%
91%
83%
77%
80
72%
65% 66%
70
59% 60%
60
50
40
30
Urban
Rural
1992-93
1998-98
Total
2005-06
There has been a significant increase in ante-natal care in the last
7 years. Further increases are seen in the latest DLHS results
Source: NFHS
Women* Who Received
Antenatal Care
77
65
83
86
91
72
66
59
Total
Urban
NFHS-1
* For last births in the past 3 years
NFHS-2
60
Rural
NFHS-3
Deliveries at institutions /
by skilled birth attendants
Institutional delivery
41
34
Delivery assisted by
health personnel
49
42
35
26
1992-93
1998-98
2005-06
1992-93
1998-99
2005-06
Institutional births have shown significant improvement in the
DLHS results
Source: NFHS
Trends in Institutional Deliveries by
State
Percentage point change between
NFHS-2 and NFHS-3
States
Remained unchanged
(2 states)
Arunachal Pradesh, Nagaland
Increased less than 7 percentage
point
(7 states)
Assam, Chhattisgarh, Delhi, Goa,
Jharkhand, Tripura, West Bengal
Increased by 7-14 percentage points
(10 states)
Bihar, Gujarat, Maharashtra,
Madhya Pradesh, Meghalaya,
Rajasthan, Tamil Nadu, Kerala,
Uttar Pradesh , Mizoram
Increased by 15 or more percentage
points
(10 states)
Andhra Pradesh, Haryana,
Himachal Pradesh, Jammu &
Kashmir, Karnataka, Manipur,
Orissa, Punjab, Sikkim,
Uttaranchal
Institutional deliveries –Rajasthan
Post natal care for mothers
Percentage of women having at least one postnatal care within two days of delivery
61.0
37.3
28.6
32.4
23.0
Total
Urban
Rural
Scheduled
Caste
Scheduled
Tribe
Only 37% of women received postnatal check-ups within the
recommended period of two days of delivery
Source: NFHS
Initiation of breastfeeding within an hour
Percentage of children born in the last three years who started
breastfeeding within one hour of birth
100
80
60
40
23%
20
10%
16%
0
1992-93
1998-98
2005-06
Only one in four children in India are breastfed within 1 hour of birth
Source: NFHS
Birth weight
Percentage of children with reported birth weight less than 2.5 kg
23%
23% 23%
Based on reported
birth weight data:
30% in NFHS 2 and
34% in NFHS 3
22%
21%
19%
Total
Urban
1998-99
Rural
2005-06
Every year at least six million children in India are born with
low birth weight which gives them a disadvantaged start in life
Source: NFHS
Strengthening health
systems
Proposed action framework
Central premise “.. Essential services
for mothers, newborns and children
are most effective when delivered in
an integrated package
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at critical points in life cycle,
in a dynamic health system,
in an environment supportive of
women’s rights”
Essential Services for mothers
newborn & children
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Basic health care
Quality maternal
care
Newborn &child
health care
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Adequate nutrition
Improved water &
sanitation
Hygiene practices
Critical points for service delivery
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Adolescence,
Pre-pregnancy,
Pregnancy,
Birth
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Infancy,
Childhood
Post-partum,
Neonatal
Supportive environment
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Respect for rights of
women & children
Quality education
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Decent standard of living
Greater involvement of
men
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Protection from abuse,
exploitation, violence &
discrimination
Equal participation in home
community, social & political
life
Women empowerment
The continuum of care across
time & location‘Risks & opportunities’
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Across time-{
Key points}
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Across location-{
Key
points}
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Adolescence
Pre pregnancy
Pregnancy
Birth
Post natal
Neo natal
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Household level
Community level
Outreach services
Outpatient services
Facility based care
Key actions
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•
Enhance nutrition of adolescent girls
•
Improve quality of reproductive health services
•
Ensure adequacy of antenatal care
•
Ensure skilled assistance during pregnancy &
childbirth
Key actions
•
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Provide access to quality Basic and Comprehensive
Emergency Obstetric
Initiation of breastfeeding within one hour of birth
•
Newborn care when required
•
Expand post-natal care for mothers & newborns
•
Promote safe water & hygiene practices at households
and in facilities
Strengthening health systems to
improve maternal & newborn health
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Enhancing data collection & analysis
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Enhancing human resources, training & supervision
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Fostering social mobilization
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Ensuring equitable & sustainable financing
Contd.
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Strengthening infrastructure, transportation,
logistics ,supplies & referral process
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Improving the quality of care
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Global health initiatives{Strengthening
collaberation
The Rate of Progress
The Rate of Progress
Countries/
Territories
U5MR
[2007]
Average annual
Rate of reduction (
%) [1990-2007]
GDP/Capita
Annual Growth
Rate (%)
[1990-2007]
TFR
[2007]
Average annual
Rate of reduction (
%) [1990-2007]
India
72
[Rank-49]
2.9
4.5
2.8
2
S.E.Asia
78
2.8
4.1
3
2.2
Industrialized
countries
6
3
1.9
1.7
0.2
Developing
countries
74
1.9
4
2.8
1.6
Least
developed
countries
130
1.9
2.5
4.7
1.3
WORLD
68
1.8
2.4
2.6
1.3
Comprehensive Programming for Reducing
Maternal Mortality
nd
Decision to
seek care
2 Delay:
Identifying and
reaching medical
facility
Receipt of
adequate and
appropriate
treatment
Socio economic
& cultural
factors
Factors
Access to
services
Accessibility of
facilities
Quality of care
Quality of care
Strategies
Mobilise: men,
women, family
& community
Link community
to services
 24-hour
quality EmOC
 Accountability
Political commitment, Poverty, Political will and Leadership
Building Partnerships
Delays
1st Delay:
3rd Delay:
What will make it happen
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Building synergy and partnerships
Generating and sustaining strong political
leadership for health of women and children
Mobilizing resources for maternal and newborn
health
Empowering families and communities for
promoting health and accessing healthcare