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

2. 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

3. Maternal & Newborn Health :Where we stand

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

5. 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

6. 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

7. 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

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

9. 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

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

11. 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

12. Infant Mortality Rates by State

13. Infant Mortality Rate-Rajasthan

14. Infant Mortality Rate by Demographic Characteristics

15. Childhood Mortality Rates by Sex

16. Steady Decline in Infant Mortality Rates India

18. Creating a supporting environment

19. 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

20. 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

21. 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

22. Age at marriage-India
Percentage of women aged married before age 18
Early marriage leads to early childbearing thereby enhancing maternal health risks
Source: NFHS

23. Antenatal Coverage -Rajasthan

25. Continuum of care across time & location: Risks & opportunities

27. 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

28. Nutrition among women
Percentage of ever-married women age 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

29. Antenatal care
Percentage of ever-married women age 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

30. Women* Who Received Antenatal Care
* For last births in the past 3 years

31. Deliveries at institutions / by skilled birth attendants
Institutional births have shown significant improvement in the DLHS results
Source: NFHS

32. 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 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.

33. Institutional deliveries –Rajasthan

34. 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

35. 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

36. 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

38. Strengthening health systems

40. 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”

41. Essential Services for mothers newborn & children
Basic health care
Quality maternal care
Newborn &child health care
Adequate nutrition
Improved water & sanitation
Hygiene practices

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

43. 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

44. 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

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

46. 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

47. Strengthening health systems to improve maternal & newborn health
Enhancing data collection & analysis
Enhancing human resources, training & supervision
Fostering social mobilization
Ensuring equitable & sustainable financing

48. Contd.
Strengthening infrastructure, transportation, logistics ,supplies & referral process
Improving the quality of care
Global health initiatives{Strengthening collaberation

49. The Rate of Progress

50. The Rate of Progress Countries/ Territories U5MR [2007]
Average annual Rate of reduction ( %) [ ]
GDP/Capita Annual Growth Rate (%) [ ]
TFR [2007]
Average annual Rate of reduction ( %) [ ]
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

51. 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

52. 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