LIFE OF EVERY MOTHER AND NEONATE

COUNTS!!!! YUVAFOGSI 2012 –MADURAI

DR.KAMINIRAO ORATION

DR.D.KIRANMAI

ASST. PROFESSOR

MGMH,OMC HYDERABAD

JOINT SECRETARY, OGSH

My mother!You come to me like heavens caring arms……………………………..Your caring hands ,tenderly removing the pain,Your love , your care, your faith gave me the strengthTo face the world void of fear

APJ ABDULKALAM

Women are not dying because of a disease we cannot treat

They are dying because societies have yet to make the decision that their lives are worth saving MAMOUD FATHALLA,PRESIDENT FIGO

1997

14TH JAN 2012 KOLKATA

23RD APRIL 2012

When mothers die……….

WORDS CAN’T DESCRIBE………..o Health of the mother o The health of the child o Human capital of the nationMotherless children die more frequently,

malnourished,

less likely to school.

A NATIONS FUTURE HUMAN AND SOCIAL CAPITAL IS CRIPPLED.

• WHY SHOULD “WE’ CARE?

• MCH indicators - human development index .

• Maternal mortality - a proxy indicator of functioning of a health system.

• An issue of Human rights.

Do our mothers and children count?

WHERE DO WE STAND?

WHAT WENT WRONG?

WHAT HAS TO BE DONE ?CURRENT STRATEGIES

FUTURE

100-299

550-999.

TOTAL MATERNAL

DEATHS -20102,87000

UNFPA,UNICEF 2010 DATA

284000 DEVELOPING

NATIONS

IN INDIA 56000 WOMEN DIE EVERY YEAR NOT OF DISEASE BUT CHILD BIRTH

212

India and Nigeria 1/3 of world’s maternal

deaths

134th among 182

in the human

development index -

2009.Budget /expenditure

on health

INDIA THE SUPERPOWER

INDUSTR

Y SPORTS

DEFENCE

MANY STATES, MANY DISPARITIES

ASSAM AND EAG

OTHERS

81 97

127SRS - 2009

149

134

SOUTH STATES

308

212 -2010

WHERE DID INDIA GO WRONG?1960-1990

1966- 1980 Target oriented family planning Ineffective interventions ANC,

High risk approach

1980-1991 CSSM, UIP, IFA ANM & MOs - accountable -

target oriented programs - FP & UIP-Little impact on MMR PHC/SC DELIVERIES- not

monitored and neglected.

Huge private sector-Not utilized

Lack of synergy

Lack of quality supervision, close monitoring

2000-2009

• MIDWIVES

• SKILLED ATTENDANCE TO

BIRTHS

• QUALITY

• STRENGTHENING OF

COMMUNITY HOSPITALS

THAILANDSRILANKAMALAYSIA

1960-1990

400

30

THE SECRET OF SUCCESS OF SRILANKA AND MALAYSIA…….

90 percent of maternal deaths are

avoidable.

ANEMIA

6 CAUSES

3 DELAYS

POSTPARTUM PERIOD 60%

50% in 24 HOURS-

Maternal Deaths Averted With Access To Emergency Obstetric Services-world Bank2004

hemorrhage

eclampsia

infections

obstructe

d labor

safe aborti

on servi

ces

AMTSL

IRON DEFICIENCY

TETANUS

0%2%4%6%8%

10%12%14%16% 15%

12%14%

8%

12%

7%

3%1%

70%

The three delaysDelay.. Delay.. Delay..

The First Delay (DECISION TO SEEK CARE)

•

PREGNANCY IN RURAL INDIA

A PREGNANT WOMAN WALKING 5 KMS TO REACH PHC DAYS BEFORE HER EDD

2ND DELAY- TO REACH HEALTH CARE

• 70 % do not have a means of transportation READY

• 40-50% percent of deaths occur at home or on the way

• Delays occur while trying to find money or while transporting the patient.

THE THIRD DELAY-IN RECEIVING CARE

UNTIMELY

INEFFECTIVE

UNDER STAFFED

UNTRAINED/INADEQUATELY EQUIPPED

LACK OF INFRASTRUCTURE

UNRESPONSIVE/DISCRIMINATORY SERVICES

ABUSE/NEGLECT/POOR QUALITY

TO SUMMARISE

• WE MISSED ONE CARE Emergency Obstetric And

Neonatal Care• WE MISSED ONE KEY

FUNCTIONARY Skilled Professional Birth

Care for every woman Midwife, staff nurse, doctor

• THE THREE DELAYS

• Focuses on 18 low performing states, EAG States• 165 worst districts• To Increase the expenditure on health from 1.1% to 3%

•ADDRESSES THREE DELAYS

•PROVIDES EMONC CARE•INFRASTRUCTURE•LOGISTICS•STAFF

APRIL 12,2005 -2017

WHAT IS THE SOLUTION???

6+2

RISK APPROACH VS EMOC APPROACH

6 BASIC EmOC Functions Health centre –No OT

1. IV /IM ANTIBIOTICS2. IV/IM OXYTOCICS3. IV/IM

ANTICONVULSANTS4. Manual Removal of

placenta5. Assisted Vaginal

delivery6. Removal of retained

products

Comprehensive EmOC Functions

OT/District hospitals All six Basic EmOC

functions plus Caesarean section Blood transfusion

4 BEMOC & 1 CEMOC FACILITY FOR EVERY 5 LAKH PEOPLE

NRHM KEY STRATEGIES -2005-2012

24X7 BEMOC CENTRESCOMPREHENSIVE ABORTION CARE (CAC)NEWBORN CARE

FRUS 24X7 CEMONC CARECACBLOOD BANKHUGE IMPROVEMENTS IN INFRASTRUCTURE,MANPOWER AND

ACCESS TO SERVICES

PHC

DISTRICTFRU

IPHS

JSY

108

ASHA

NRHM-KEY STRATEGY-ASHA-MICROPLAN OF BIRTH

• REGISTRATION OF ANC

• 4 VISITS

• ARRANGING FOR CASH TRANSFER - JSY

• PLANNING PLACE OF BIRTH

• TRANSPORT

• ACCOMPANYING THE PARTURIENTADDRESSES THE 1ST DELAY

Trends in Institutional deliveries 2002-04 to 2007; India

0

10

20

30

40

50

60

70

80

2002-2004 2005-06 2006-07 2007-08

Perc

en

tag

e o

f in

sti

tuti

on

al d

eliveri

es

Assam Bihar Madhya Pradesh Orissa

Rajasthan Uttar Pradesh India

Trends in Institutional deliverieS (NFHS III), 2006-7, 2007-8 22

Introduction of JSY

JANANI SURAKSHA YOJANA EVEN BIMARU TURNS HEALTHY

3.19 CRORE WOMEN BENEFITED UNDER JSY

BIHAR - 6 FOLD INC FROM 2005-2011

1ST AND THIRD DELAY

23

NRHM-KEY STRATEGYEmergency Transport System

• TOLL FREE 108 24x7 X365

• 12 STATES,2919 AMBULANCES

• SAVING LAKHS OF LIVES IN CRUCIAL GOLDEN HOUR

108 THE LIFE SAVER

FOR THE SECOND DELAY

NRHM TRIGGERED INNOVATIVE SCHEMES IN STATES

KERALA- 1ST STATE TO ACHIEVE MMR<100

GUJARAT- INNOVATIVE CHIRANJEEVI SCHEME TAMILNADU- FOCUSSED ON QUALITY NRHM strategies

All PHCS 24x7 delivery units MDR/verbal autopsy by collector Rs .6000 cash benefit to poor pregnant women ANDHRA PRADESH 108, ANM Tracking, Amma lalana, Sms alerts, matrudevobhava, ayushmanbhava

NOT A RESORT-IT’S A PHC!!!

Trend in Maternal Mortality Rate-Tamil Nadu M

MR

YEAR

0

20

40

60

80

100

120

140

160145

109

79

2000-20012004-2005

Source DPH & PM

Before RCH RCHNRHM

AMTSL, LSAS training, Hiring of Specialists

Blood storage facility, AN protocol, etc

EMRI

2008-2009

GPS MAPPING TO IDENTIFY SUITABLE HOSPITALS

At least two fully equipped and operational Em OC centers in each of the 32 districts which can be reached within 1

hour from any part of the district

TAMILNADU

TAMILNADU AND INDIA

CHILD BIRTH A JOYFUL EVENT –CAN TURN INTO

TRAGEDY

POST PARTUM PERIOD

ACCOUNTS FOR 60% OF MATERNAL

AND 50% OF CHILD

MORTALITY

PPH –QUICKEST OF KILLERS2 HRS PPH

12 HRS APH

1 DAY-24 HRS RUPTURE UTERUS

2DAYS-48HRS ECLAMPSIA

3 DAYS-72HRS OBSTRUTED LABOR

6 DAYS-1 WEEK SEPSIS

SOURCE: maine D:safe motherhood programmes: options and issues, centre for population and family health

PPH –KEY INTERVENTIONSAMTSL

600UG MISOPROSTOL P/R , ORAL

B-LYNCH/ MODIFIED B-LYNCH

STEPWISE DEVSCULARISATION

EMERGENCY HYSTERCTOMY

22% PREVENTABLE

25%

FIGO GUIDELINESPrevention and treatment of PPH in low resource settings

(SMNH Committee)

http://www.figo.org/projects/prevent/pph

EVERY MOTHER SHOULD BE OFFERED AMTSL BY SBA

MISOPROSTOL AS ESSENTIAL DRUG FOR PPH-WHO

BRISTOL AND HINCHING BROOKE STUDIES-AMTSL (5.9% VS 17.9%) IN EXPECTANT MANAGEMENT

EVERY SBA MUST BE TRAINED IN AMTSL

FIGO GUIDELINES-PPH-INTERVENTIONS AT CEMOC LEVEL

Ext bimanual comp Aortic compression

NASG

Intra uterine balloon tamponadeEGYPT NIGERIA / ZAMBIA, ZIMBABWE

Int. Bimanual Comp

Video demonstrations

Preeclampsia-Direct Cause Sepsis-Direct cause

POST NATAL CARE VISITS

IPP in labor rooms and post natal wards-

Forty eight hour stay in PHC

IEC/ BCC messages to new mothers on danger signs

To overcome cultural taboos of leaving home before one week

Retraining in ANC protocols & skills - basic BP measurement

Magnesium sulphate in Eclampsia

27%26%

OBSTRUCTED LABOR/RUPTURE UTERUS

• PARTOGRAM - TRAINING

8%

NRHM KEY STRATEGY CAC

Women centered Comprehensive Abortion

Care• Emergency contraception• Medical abortion• Safe MTP Protocol by

MVA• CONCURRENT

CONTRACEPTION

13%

Unsafe abortion

•22% of pregnancies-induced abortions

•50% -unsafe

•95% occur in developing countries• In India- 4 Million unsafe abortions

LET WOMEN DECIDE……….80 million unintended pregnancies in 2012 in developing

world- Save the Children Report

If all unwanted pregnancies are prevented , If there is no unmet need for contraception

Up to 1 lakh maternal deaths can be prevented –WHO 2005

Spacing - crucial for child survival

Spacing of 36 months after previous child birth can prevent 1.8 million child deaths (25%)

Policy shift from permanent to temporary methods PPIUCD

ANEMIA80% IN NFHS III -complicates 80% maternal deaths (FOGSI STUDY)

Hb % at 1st visit

20wks,28wks,

34 wks

low cost,

effective,

acceptable iron.

De wormin

gCooking in iron

utensilsFoot wear

IV IRON

SUCROSE

A real boon Health

strategies

Iron fortificati

on

20%

WHAT ABOUT ME?

Worldwide distribution of child deaths

Each dot represents 5000 deaths Lancet 2003

India is epicenter of Childhood Mortality

• 7.6 MILLIONS DIE EVERY YEAR -2010

• 2 MILLIONS DIE IN INDIA• 1 MILLION ARE NEONATES

• 50% DIE WITH IN 1 HOUR • 75% DIE WITH IN 1 WEEK

Birth asphyxia

23%

NeonatalTetanus and others10%

Severe Infections

(36%)Pre-Term

Births (25%)

WHY do newborns in India die?

WHO World health statistics 2007

Neonatalresuscitation

6-42%

Breast feeding 55-87%

Hypothermia management,

Kangaroo mother care-

18-51%

Community based

pneumonia management

Lancet Neonatal Survival Series 2005

New Child Health Initiative by GOI Sep 2009

A new programme on Basic Newborn Care and Resuscitation,

launched nationally by GOI to address important interventions

of care at birth

Navjaat Shishu Suraksha Karyakram (NSSK)

GOI and IAP have signed a MoU for trainingFOGSI important partner

NRHM INITIATIVES FOR NEW BORN AND CHILDHEALTH

IMNCI 433 DTS-4,92,611 TRAINED

Navjat Sishu Suraksha karyakram 50000 trained

Special Newborn Care Units (SNCU) 293

Newborn Stabilization Units(NBSU) 1134

Newborn Care Corners (NBCC) Home based new born care

HOME BASED CARE FOR MOTHER AND NEWBORN-THE VITAL missing LINK

ASHA5 VISITS

IN 42 DAYS

D1,3,7,10 42

RS 50/1HR

VISIT

Weight monitori

ng

BCG,OPV,DPT

Completion

Registration of birth

Safety of both mother

and child at 42 days

Home visits for young infants: Objectives

KANGAROO MOTHER

CARE

IDENTIFY ILLNESS,

REFERRAL

EXCLUSIVE BREAST FEEDING

CORD CAREHAND

WASHING

Expected outcomes

41% of institutional deliveries

90% trained15-30% reduction in

NNMR

Greater impact in states with higher

neonatal mortality

INSPITE OF THE INITIATIVES……..STILL A LONG WAY TO GO ……..STILL TO REACH EVERY MOTHER

AND NEONATE

3.7 2012

MMR BY 2015

153We are 212 in 2010Our goal is 100

PROGRESS NOT GOOD ENOUGH

We are 63 in 2010Our goal is 38

Under 5 mortality by 2015

54

30% of PHC - no building

40% - no vehicle

70 % - no linkage to district blood bank

Blood bank sources vital but neglected

Too far, Too little, Too Late

PHCSOnly•58% Do DELIVERIES

•6%- Do MTPS

•22% Neonatal Care

•65% IUDS

•41% Sterilisations

55.2% Obstetricians 70% Pediatricians short fall CHC

YET TO REACH EVERY MOTHER AND NEONATE

SEX SELECTIVE ABORTIONS

Worst child sex ratio of 914:1000

4th Dangerous nation for women and children

Baby Falak

Baby Afreen

Sex selective abortions

June 22,2012

CHILDREN BEARING CHILDREN AND……..DYING

Pregnancy the biggest killer of teenage girls

MMR 5 times more in girls <15

IMR 77/1000

2/3rd - before 20 yrs1/5th - before 15 yrs

Population council of india

Save the children -2012 report

OTER KEY ISSUES FEMALE FETICIDE

FEMALE INFANTICIDE

POVERTY

DOMESTIC VIOLENCE

SEXUAL ABUSE/RAPE

ILLITERACY

DISCRIMINATION AT WORK PLACE

PNDT

DOMESTIC VIOLENCE ACT

GENDER EQUITY

EDUCATION

EMPOWER MENT

SCHEMES FOR GIRL CHILD

MATERNITY LEAVE

TO REACH EVERY MOTHER AND NEONATE

MEDICAL SOLUTIONS ARE WELL KNOWN – IT

IS THE STRATEGIC DIFFICULTIES WHICH

NEED ATTENTION

EVERY HELPING HAND COUNTS

IAP

JOIN HANDS TOGETHER

EVERY POLITICIAN EVERY POLICY MAKER EVERY OBSTETRICIAN EVERY PEDIATRICIAN EVERY MEDICAL OFFICER EVERY HW EVERY ANM EVERY ASHA

TO MAKE every MOTHER AND NEWBORN count

LONG ROAD AHEAD, BUT

• THERE IS NO REASON WHY WE SHOULD LAG BEHIND

THANK YOU FOR THIS UNIQUE

OPPORTUNITYFOGSIMGMH NAYAPUL, OMCOGSH,DR.P.KSHAH, PRESIDENT, FOGSIDR.S.SHANTAKUMARIDR.P.INDIRA DEVISRI.D.V.RAIDU IASSIX DECADES OF RCH IN INDIA –MS.SUJATA RAO IASPROF: RATNAKUMAR, DILEEP MAVLANKAR-SUCCESS STORIES OF

TAMILNADU ,GUJARAT

REFERENCES

• WHO 2005-EVERYMOTHER AND CHILD COUNTS• TRENDS IN MATERNAL MORTALITY1990-2010-UNFPA,WHO• SRS 2006,2008• NRHM-WEBSITE, WHO,mohfw.nic.in• www.iapnrpfgm.org• Lancet series on RCH,MATERNAL AND NEONATAL• Presentations;• Six decades of RCH in India –Ms.Sujata Rao IAS• PROF: Ratnakumar, Dileep Mavlankar-success stories of

Tamilnadu ,Gujarat

GREETINGS FROM HYDERABAD

FROM ONE MOTHER TO ANOTHER

SONG OF YOUTH As a young citizen of India,

armed with technology, knowledge and love for my nation,

I realize, small aim is a crime.

I will work and sweat for a great vision,

the vision of transforming India into a developed nation

powered by economic strength with value system.

I am one of the citizens of the billion;

Only the vision will ignite the billion souls.

It has entered into me ;

The ignited soul compared to any resource,

is the most powerful resource

on the earth, above the earth and under the earth.

I will keep the lamp of knowledge burning

to achieve the vision - Developed India

L

LETS REDEDICATE OURSELVES TO SEE SUCH HAPPY MOTHER AND CHILD EVERY WHERE