Maternal Health Interventions NRHM/RCH-II Maternal Health Division Ministry of Health & Family Welfare Government of India

GOALS OF NRHM Universal Health Care access affordability equity quality

Maternal Mortality-Magnitude of the Problem About 30 million pregnancies occur every year in India. 27 million deliveries 15% of these are likely to develop complications. Complications cannot be predicted. 77,000 avoidable maternal deaths per year

Maternal Mortality Maternal Mortality Ratio “ number of women who die in a year due to causes related to pregnancy and child birth for every 100, 000 live births ” Wide Variations: India 301/100,000 live births Tamil Nadu 134/100,000 live births U.P. 517/100,000 live births Sweden/USA 8-12/100,000 live births Sri Lanka 24/100,000 live births Malaysia 20/100,000 live births

Maternal Mortality Ratio over the years NSS(1957-60)* 1321 NSS(1963-64)* 1195 SRS(1972-76) 853 SRS(1977-81) 810 SRS(1982-86) 580 NFHS I (1992-93) 424** NFHS II (1998-99) 540** RGI,SRS (1997-98) 398 RGI,SRS(1999-01) 327 RGI,SRS (2001-03) 301 * Based on indirect time series estimates ** Based on small sample size Declining trend

MMR Reduction We need to accelerate

MMR Trends (RGI-SRS-2006)

Goals and targets S.No Goal Target Indicators 1 MDG-5: To improve Maternal health Reduce by 3/4ths the MMR,1990-2015. MMR Proportion of births attended by SBA Institutional delivery 2 NPP-2000 Reduce MMR to < 100/1,00,000 LB by 2010 80% Institutional Delivery 100% Safe delivery 3 NHP-2002 100/1,00,000 LB by 2015

Causes of Maternal Mortality

Strategies… over the years Pre-CSSM CSSM 1992 RCH – I RCH – II Care of Pregnant Women (Antenatal Care. Identify Comp. Refer, Safe/Inst Dely, PP Care) High risk approach Essn OC Safe Deliveries/ Institutional Deliveries TBAs TBAs/Clean delivery Instt/Safe delivery TBAs Instt/Safe delivery Skilled attendance at birth Emergency Obstetric Care - Delay model FRUs Operationali-sation of FRUs

ISSUES IN MATERNAL HEALTH SOCIAL Age at marriage Maternal Care Women’s status PROGRAMMATIC Antenatal care Skilled attendance at birth Emergency Obstetric care Adopting a Lifecycle approach to Women’s health

MH Indicators- India, NFHS II and III

ANC Status, NFHS III

INSTITUTIONAL & SAFE DELIVERIES NFHS III

Key MH Strategies in RCH-II Essential and Emergency Obstetric Care Quality ANC, PNC, Institutional and Safe Delivery. Skilled Attendance at birth (domiciliary & health facilities). Operationalise FRUs, CHCs and 24 Hrs PHC. Strengthen Referral Systems. Management of RTIs & STIs at PHCs & CHCs/FRUs. Safe Abortion Services - MVA at PHC level. Infection Management and Environment Plan (IMEP).

NRHM Accredited Social Health Activist (ASHA) – one per 1000 population Janani Suraksha Yojana Inter-sectoral Convergence. Facility Strengthening / Improving Access Strengthening of Infrastructure- IPHS Improving availability of Human Resource Untied funds at sub centres Rogi Kalyan Samitis (Hosp. Mgmt. committees) Involvement of Professional associations and medical colleges Public private partnership

Essential Obstetric Care Early Registration (12-16 wks) 3 Antenatal Check-ups Prevention & Treatment of anemia Institutional /Safe Delivery Postnatal Check-up

BasicEmOC Comp.EmOC Parenteral A/B All functions of Parent.Oxytocics Anticonvulsants Digital removal of POC MRP Assisted vaginal delivery All functions of BasicEmOC + Cs sections Blood transfusion

MMR in1960s in Thailand, Srilanka &Malaysia

Home Deliveries and Neonatal Mortality

SKILLED BIRTH ATTENDANCE Skilled Birth Attendant Enabling Environment

Issues related to Skilled attendance at Birth Reorienting Medical Officers Preservice & inservice training for SNs/LHVs/ANMs Operationalising SCs/ PHCs/CHCs/FRUs for skilled attendance at birth.(Enabling Environment)

Skilled Birth Attendance POLICY DECISIONS Empower Health Worker for some Basic Em.O.C.interventions Permission to use drugs for prevention of PPH. Permission to use drugs in emergency situations before referral Permission to perform basic procedures at community level in emergency situations

Emergency Obstetric Care Critical factor- TIME: 3 delay model. Decision to seek care Arrival at health facility Provision of adequate care at health facility 24 X 7 PHCs First Referral Units (FRUs) at sub-district level.

Janani Suraksha Yojana 100% centrally sponsored scheme Promotes institutional delivery among poor pregnant women Cash assistance to eligible women for delivery Special dispensation for 10 states with low institutional delivery ( LPS) ASHA- Link between beneficiary & govt.in LPS—other states are HPS

Policies and guidelines Operationalising FRUs. Setting up Blood Storage Units. Operationalisation of 24x7 PHCs. MTP up to 8 weeks pregnancy using MVA technique Training of MBBS Doctors in Anesthesia skills. Training of MBBS Doctors in EmOC including C-Section in partnership with FOGSI. Pregnancy care and Management of Common Obstetric Complications by MOs. AN Care and SBA for ANMs /LHV/Staff Nurses. Guidelines for RTIs and STIs including HIV/AIDS

Thrust Areas of Maternal Health Operationalising all FRUs for EmOC Establishing Blood storage Centers/ Banks All CHCs and 24 Hrs PHCs for round the clock delivery, newborn services, MTP and RTI/STI services Expediting the Implementation of SBA training Anesthesia training EmOC training Regular Quality assurance, implementation review and monitoring

MH- FUND ALLOCATION A RCH - TECHNICAL STRATEGIES & ACTIVITIES A.1 SNo Activities Sum Of SPIP (CRORES) Total Expenditure % Utilization A RCH - TECHNICAL STRATEGIES & ACTIVITIES 1832 .5 943. 9 51.51% A.1 MATERNAL HEALTH 513 .8 470 .3 91.54% A.10 PROGRAMME MANAGEMENT 89 .88 52 .93 58.89% A.11 Procurement of Pharmaceuticals & Medical Supplies 187 .85 13. 40 7.14% A.2 CHILD HEALTH 61. 95 12. 15 19.61% A.3 FAMILY PLANNING SERVICES 399 .1 160.1 40.13% A.4 New Initiatives/innovations/ interventions etc., if any 122. 74 42. 77 34.85% A.5 URBAN RCH 55. 26 20. 83 37.71% A.6 TRIBAL RCH 20. 08 4. 62 23.01% A.7 INSTITUTIONAL STRENGTHENING 200. 61 95. 59 47.65% A.8 TRAINING 83. 51 11. 27 13.50%

MIES –NRHM : MH Indicators Annual Return-Part C: Annual.xls Quarterly Return : Part Q3, Q4,Q7,Q13,Q14,Q24 Quarterly.xls Monthly Return : Part A:M-100,200, Part B : M1,2,3,5,6,7,8,9 Monthly.xls

Operating Manual- State PIPs-RCH-II Flexipool Annexure 3 b : Indicative format for current status and targets. Annexure 3b.doc Annexure 3 d: Format for Annual Work Plan Annexure 3d.xls Annexure 3 e: Detailed Budget Format Anne 3e.xls Annexure 4a : Format for Quarterly progress Report (QPR)-Physical and Financial Annex 4a.xls

Maternal Health Division- Reporting formats Maternal health activities : Monitoring Format for MH Activities.doc Anesthesia Training: Reporting Format for States for AnesthesiaTrg. Final.doc SBA Training : SBAplanmatrix( Final).doc EmOC Training : Reporting format for FOGSI Training.doc

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