Dr. KANUPRIYA CHATURVEDI Maternal & Newborn Health WITH reference to INDIA & RAJASTHAN Dr. KANUPRIYA CHATURVEDI

KEY ISSUES Maternal & Newborn Health :Where we stand Creating a supporting environment Continuum of care across time & location Risks & opportunities Strengthening health systems The Rate of Progress

Maternal & Newborn Health :Where we stand

Maternal & Newborn Health :Where we stand Global Scenario Regional distribution Maternal mortality ratio & Maternal mortality rate Direct causes Conceptual framework

Global scenario-Maternal health 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 Nearly 4 million newborns die {40% of under 5 deaths} within 28 days of birth Three quarters of neonatal deaths occur during first 7 days 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 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

Maternal mortality ratio per 100,000 births Uttar Pradesh 517 2001-2003 India: 301 Kerala 110 per 100,000 live births Less than equal to 150 151 - 300 More than 300 Missing Data Source: SRS

Medical causes of maternal deaths in India Other Conditions 34% Hemorrhage 38% Abortion 8% Sepsis 11% Obstructed Labour 5% Hypertensive Disorders 5% Medical causes of maternal deaths in India Source: SRS

Medical Causes of Neonatal Deaths-India Diarrhoea Asphyxia Preterm Tetanus Other Congenital Infection Source: Lawn JE Cousen SN for CHERG (Nov 2006)

Share of under-five mortality in India Infant deaths within 7 days of birth 40% Neonatal deaths 50% Infant deaths 76% 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% Source : SRS 2007

Infant Mortality Rates by State

Infant Mortality Rate-Rajasthan

Infant Mortality Rate by Demographic Characteristics

Childhood Mortality Rates by Sex

Steady Decline in Infant Mortality Rates India

Creating a supporting environment

Creating a supportive environment for women & children 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 Timing of births Safe motherhood Child development Breast feeding Nutrition & growth Immunization Diarrhoea Coughs, colds & more serious illnesses Hygiene Malaria HIV and AIDS Injury prevention Disasters & emergencies

Quality education & a decent living Studies show that educated women; 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 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 Specific factors 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 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 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 * For last births in the past 3 years

Deliveries at institutions / by skilled birth attendants 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 Andhra Pradesh, Haryana, Himachal Pradesh, Jammu & Kashmir, Karnataka, Manipur, Orissa, Punjab, Sikkim, Uttaranchal Note: This could not be checked as latest run gives information for last five years, whereas for NFHS-2 it has been calculated for last 3 years.

Institutional deliveries –Rajasthan

Post natal care for mothers Percentage of women having at least one postnatal care within two days of delivery 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 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 Based on reported birth weight data: 30% in NFHS 2 and 34% in NFHS 3 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 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 Basic health care Quality maternal care Newborn &child health care Adequate nutrition Improved water & sanitation Hygiene practices

Critical points for service delivery Adolescence, Pre-pregnancy, Pregnancy, Birth Infancy, Childhood Post-partum, Neonatal

Supportive environment Protection from abuse, exploitation, violence & discrimination Equal participation in home community, social & political life Women empowerment Respect for rights of women & children Quality education Decent standard of living Greater involvement of men

The continuum of care across time & location- ‘Risks & opportunities’ Across time-{ Key points} Adolescence Pre pregnancy Pregnancy Birth Post natal Neo natal Across location-{ Key points} Household level Community level Outreach services Outpatient services Facility based care

Key actions Enhance nutrition of adolescent girls Improve quality of reproductive health services Ensure adequacy of antenatal care Ensure skilled assistance during pregnancy & childbirth

Key actions 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 Enhancing data collection & analysis Enhancing human resources, training & supervision Fostering social mobilization Ensuring equitable & sustainable financing

Contd. Strengthening infrastructure, transportation, logistics ,supplies & referral process Improving the quality of care 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 4.1 3 2.2 Industrialized countries 6 1.9 1.7 0.2 Developing countries 74 4 1.6 Least developed countries 130 2.5 4.7 1.3 WORLD 68 1.8 2.4 2.6

Comprehensive Programming for Reducing Maternal Mortality Delays 3rd Delay: Receipt of adequate and appropriate treatment 2 nd Delay: Identifying and reaching medical facility 1 st Decision to seek care Building Partnerships Quality of care Socio economic & cultural factors Access to services Factors Accessibility of facilities Mobilise: men, women, family & community Link community to services · 24 - hour quality EmOC Accountability Strategies Political commitment, Poverty, Political will and Leadership

What will make it happen 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