MATERNAL HEALTH Some technical aspects ANC, Delivery Care and PNC B Subha Sri, RUWSEC, CommonHealth Delhi, October 2012

Structure of presentation Causes of Maternal Deaths Antenatal care Delivery care Referral Postpartum care Some indirect causes Women’s concepts of Safe Deliveries

Causes of maternal death - India (SRS data)

Why is Ante Natal Care important to prevent Maternal Deaths? Even the best ANC cannot predict or prevent pregnancy complications, but ANC is important for women to come into and maintain contact with the health system

Antenatal care Aim Routine care Identification of women with special conditions and referral to higher centre if necessary for care Early detection of problems

Antenatal care Essential components Detailed history to detect special conditions / problems Clinical examination Maternal height/weight Clinical examination for anaemia Blood pressure measurement Abdominal examination for uterine height, fetal growth and position, fetal heart rate Lab tests Haemoglobin Urine for protein Blood group

Antenatal care Essential components Medicines Iron supplements Tetanus toxoid Complete antenatal card Instructions Birth preparedness Danger signs Instructions and contact for emergencies Contraception and lactation About maternity benefit schemes

Delivery care Skilled birth attendant Cleanliness and sterility Partograph – Monitoring progress of labour on a graph Monitoring of fetal heart rate Active Management of Third Stage of Labour (AMTSL) – Inj oxytocin or misoprostol within 1 minute of borth of baby - Prevention of PPH Emergency Obstetric Care – Basic / Comprehensive Referral – Transport and accompanied transfer Respectful care Birth Companion Electricity, water, clean toilets

Referral Timely – without delay To appropriate facility Counseling Referral note Transport Accompanied

Postpartum care To keep in facility for 48 hours. Monitoring for bleeding, infection. Detect and treat problems early. Instructions on care of herself, newborn care, danger signs Family planning counseling Maternity benefit schemes

Postpartum care Home based First visit – Within 48 hours Second visit – Within one week Third visit – Within 6 weeks Identify problems in mother and baby and treat/refer early Family planning Immunization

Anaemia Commonest indirect cause of maternal death Can cause death by itself or by complicating other causes like haemorrhage or sepsis. Postpartum anaemia can cause long term morbidity or late maternal death. Prevention Early detection – Haemoglobin estimation Treatment – Iron folic acid, Iron sucrose, Blood transfusion Social determinant – Nutrition, ICDS

Malaria Pregnancy increases likelihood of being infected with malaria More frequent episodes More severe infection Higher risk of complications Malaria induced anaemia Higher risk of death Very little information in India on malaria and pregnancy Need to integrate testing and treatment in MCH programmes, especially endemic states Prevention

Tuberculosis 30% of all TB cases in the world in India. Tuberculosis incidence and prevalence is higher in adult males than in adult females Women perceive the stigma of TB to be worse for them than for men – delay in reporting HIV infection higher in young women – higher chances of TB Pregnancy with a late diagnosis of TB – increased risk of obstetric morbidity, higher miscarriage, eclampsia, intrapartum complications Higher risk of perinatal deaths, premature births and low birth weight Rajasthan study (ARTH) – significant cause of post partum deaths Need for integrating MCH and RNTCP.

Women's perspectives – “Safe” delivery Delivery whether at home or in an institution is “safe” when Both the mother and the newborn survive. There is no maternal or neonatal morbidity, both short- term and long term. The woman and the newborn do not receive unnecessary/irrational procedures or drugs, and receive the essential/appropriate, timely care (both complicated and uncomplicated). The woman and the newborn receive a continuum of appropriate care from antenatal to intranatal to the postnatal period. This should include safe abortion services for those women who need them.

Women's perspectives – “Safe” delivery The woman and the newborn have adequate support structures at place of delivery including running water, electricity, clean toilets. The woman and newborn have an enabling environment to a safe pregnancy and delivery including adequate nutrition, family and social support, safety at work places, access to maternity benefit and welfare schemes, birth companion Those with complication receive emergency care and referral and transport. Those with complication receive the appropriate technical standard of care.

The woman receives all the relevant information and is consulted in care give to her. The woman and the newborn are treated with dignity. The woman and the newborn are not discriminated in any way. Women belonging to marginalized groups and those with special needs receive appropriate care based on their needs. The woman and the newborn are not abused in any way