1. 1
Minimising Maternal MortalityMinimising Maternal Mortality
in Indiain India
Evidence based ApproachEvidence based Approach
Lecture - 1Lecture - 1
Dr. Sharda Jain
Director :-
Chairman PCH OBST/ Gynae Dpt.
Secretary General of Delhi Gynaecologist Forum

2. 2

3. 3
Smita PatilSmita Patil

4. Every 5 Minute...
Maternal Death ClockMaternal Death Clock
1 woman1 woman
dies from adies from a
pregnancy-pregnancy-
relatedrelated
complicationcomplication
In IndiaIn India
UNICEF

6. 6
05_XXX_MM6
Near MissNear Miss EventsEvents
Quality Indicator of Maternal CareQuality Indicator of Maternal Care
""AA woman who nearly died butwoman who nearly died but
survived asurvived a complication thatcomplication that
occurred during pregnancy,occurred during pregnancy,
childbirth or within 42 days ofchildbirth or within 42 days of
termination of pregnancy“termination of pregnancy“
WHOWHO

7. 7
Commitment to ReducingCommitment to Reducing
Maternal Deaths (MDG- 5)Maternal Deaths (MDG- 5)
GOAL
Reduce MMR by 75 %
From 1990 - to – 2015
i.e. – 109 per lakh

8. MMR-Indian scenarioMMR-Indian scenario
• 1940 - 20 per 1000 live births1940 - 20 per 1000 live births
• 1960 - 10 per 1000 live births1960 - 10 per 1000 live births
• 1992 - 437 per 100000 live birth1992 - 437 per 100000 live birth
• 1997 - 407 per 100000 live births1997 - 407 per 100000 live births
• 2003 - 301 per 100000 live births2003 - 301 per 100000 live births
• 2006 - 254 per 100000 live births2006 - 254 per 100000 live births
• 2009 -212 per 1,00,000 LB2009 -212 per 1,00,000 LB
SRGSRG
8
SRGISRGI
Expected in 2015 - 135 per lakh LBExpected in 2015 - 135 per lakh LB
MDF – 5 in 2015 is 109 per lakhMDF – 5 in 2015 is 109 per lakh

9. 9
INDIA TOTALINDIA TOTAL
Achieved MDG targetAchieved MDG target
212/lakh live birth212/lakh live birth
109/lakh live birth109/lakh live birth
KeralaKerala 8181
Tamil NaduTamil Nadu 9797
MaharashtraMaharashtra 104104
Close proximity to MDG targetsClose proximity to MDG targets
Andhra PradeshAndhra Pradesh 134134
GujaratGujarat 148148
West BengalWest Bengal 145145
HaryanaHaryana 153153
Uttar PradeshUttar Pradesh 359359
Maternal Mortality Ratio, INDIAMaternal Mortality Ratio, INDIA
SRS,2007-09SRS,2007-09

10. Doable Goal !!
MDG - 5
Political willpower

11. 11
What Do Women Die Of ?What Do Women Die Of ?
They Die
of simple Obstetric
Complications
that Need Not Be Fatal

12. 12
15% will experience an
obstetric complications
…This is true
world over
Nobody Knows Why This Happens.
It is a Fact of Life.
5%
life threatening
Obstetric ComplicationsObstetric Complications

13. Most Obstetric ComplicationsMost Obstetric Complications
Can Neither beCan Neither be
PredictedPredicted
Nor Prevented…Nor Prevented…
But if WomenBut if Women
Receive TimelyReceive Timely
Effective TreatmentEffective Treatment
in Time,in Time,
13
…Almost All Can Be Saved

14. How Do We KnowHow Do We Know
Which WomenWhich Women
Will Experience Complications?Will Experience Complications?
14
WE CAN’T !!

15. 15
Spirit of Every Gynaecologist

16. 16
It is necessary toIt is necessary to
ENSURE THAT EVERYENSURE THAT EVERY
PREGNANCY IS WANTEDPREGNANCY IS WANTED
CONTRACEPTIONCONTRACEPTION
Knowledge is not enoughKnowledge is not enough
People have to usePeople have to use

17. 17
World Health Organization, GenevaWorld Health Organization, Geneva
Evidence – based InterventionsEvidence – based Interventions
Severe BleedingSevere Bleeding
24%24%
EclampsiaEclampsia
12%12%
Indirect CausesIndirect Causes
20%20%
OtherOther
DirectDirect
CausesCauses
8%8%
Obs-Obs-
tructedtructed
LabourLabour
8%8%
InfectionInfection
15%15%
UnsafeUnsafe
AbortionAbortion
13%13%
Oxytocin andOxytocin and
ManualManual
CompressionCompression
Iron Supplements,Iron Supplements,
Malaria IntermittentMalaria Intermittent
Treatment andTreatment and
Antiretroviral for HIVAntiretroviral for HIV
PartogramPartogram
Tetanus ToxoidTetanus Toxoid
ImmunizationImmunization
Clean DeliveryClean Delivery
AntibioticsAntibiotics
Family PlanningFamily Planning
andand
Postabortion CarePostabortion Care
MagnesiumMagnesium
SulfateSulfate

18. Abortion Deaths
(13%)
Comprehensive Abortion CareComprehensive Abortion Care
Ensure thatEnsure that
EVERY ABORTION IS SAFEEVERY ABORTION IS SAFE..
WHO GuidelineWHO Guideline

19. 19
WHOWHO GuidelinesGuidelines
• Medical abortionMedical abortion oror vaccum aspirationvaccum aspiration
are theare the safestsafest methodsmethods
• MVA (MVA (Aspiration Abortion)–– It is advocatedIt is advocated
especiallyespecially in low resource settingsin low resource settings like PHClike PHC
where reliable source ofwhere reliable source of electricityelectricity/maintenance/maintenance
is a problem ???is a problem ???

20. 20
Three Key Points MMRThree Key Points MMR
• TimeTime - critical factor- critical factor
• Concept of THREE DELAYS.Concept of THREE DELAYS.
• Three points at whichThree points at which access to care isaccess to care is
delayeddelayed oror denieddenied oror total lacktotal lack of careof care
leads toleads to
MATERNAL DEATHMATERNAL DEATH

21. How Much TimeHow Much Time
Do We Have?Do We Have?
How Much TimeHow Much Time
Do We Have?Do We Have?
It is estimated that,It is estimated that, if untreated, deathif untreated, death
occurs on average in:occurs on average in:
2 hours2 hours from Postpartum Hemorrhagefrom Postpartum Hemorrhage
12 hours12 hours from Antepartumfrom Antepartum
HemorrhageHemorrhage
2 days2 days from Obstructed Laborfrom Obstructed Labor
6 days6 days from Infectionfrom Infection
21

22. 22
Janani Suraksha YojanaJanani Suraksha Yojana
JSY is a safeJSY is a safe
motherhoodmotherhood
interventionintervention
under theunder the
NRHMNRHM
Door step/Door step/ Institutional deliveryInstitutional delivery /shifting from PHC – CHCs – District Hospital/shifting from PHC – CHCs – District Hospital

23. Education through Medical
professionals & self – help groups
on risk in pregnancy and benefit of institutional delivery

24. 24
Birth PlanningBirth Planning (Home)(Home)
– Identify aIdentify a skilled attendantskilled attendant
– Identify appropriateIdentify appropriate place of birthplace of birth, and how to get, and how to get
therethere
– IdentifyIdentify support peoplesupport people,, (who will accompany the(who will accompany the
woman and who will take care of the family).woman and who will take care of the family).
– MoneyMoney
To Avoid 3 delaysTo Avoid 3 delays

25. Inform mother and family aboutInform mother and family about
4 I's4 I's
• InformInform Dates of ANC'sDates of ANC's (Anti natal care) and iron folic(Anti natal care) and iron folic
acid tablate /acid tablate /T.T injectionsT.T injections Ensur these are provided.Ensur these are provided.
• InformInform expected dateexpected date of delivery.of delivery.
• IdentifyIdentify placeplace of delivery.of delivery.
• IdentifyIdentify health centerhealth center for referralfor referral – For– For complicatedcomplicated
delivery/cessarian Sectiondelivery/cessarian Section can be governmentcan be government
institution or accredited Private Health Institutional.institution or accredited Private Health Institutional.
ANTENATAL / INTRANATAT PLANNING

26. 26
 MALEMALE Involvement is the keyInvolvement is the key
Lack of information andLack of information and
inadequateinadequate knowledgeknowledge
TraditionalTraditional practicespractices
Lack ofLack of moneymoney
The First Delay - Home
Delay in deciding to seek careDelay in deciding to seek care

27. 27
The Second DelayThe Second Delay
Out of reach health
facilities
Poor roads and
communication network
Poor community support
mechanisms
Inability to access health facilities

28. 28
Making Emergency ObstetricMaking Emergency Obstetric
Care availableCare available
Emergency Referral Services (Toll free no 108)
introduced Patchy

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Obstetric HelplineObstetric Helpline
Networking of various private and publicNetworking of various private and public
vehicles and locally identified mobilevehicles and locally identified mobile
phones forms the core infrastructure of thephones forms the core infrastructure of the
helpline, which has been made financiallyhelpline, which has been made financially
sustainable by linking it with JSY.sustainable by linking it with JSY.

30. 30
 Inadequate skilled attendants
 Poorly motivated staff
 Inadequate equipment and supplies
 Weak referral system
 system is not geared -system is not geared -prioritize anprioritize an
emergencyemergency & respond promptly& respond promptly
The Third Delay
Delay between arriving and
receiving care at the health facility:

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Addressing the 'third delay‘Addressing the 'third delay‘
Averting Maternal Death & DisabilityAverting Maternal Death & Disability
Program (AMDD)Program (AMDD)
…We Need to Ensure
that Women have Access To…
Emergency Obstetric Care
(EmOC)
AMDD Program Orientation

32. 32
EmOC hasEmOC has 88 Key FunctionsKey Functions
• AntibioticsAntibiotics
(intravenous or by(intravenous or by
injection)injection)
• Oxytocic DrugsOxytocic Drugs
• AnticonvulsantsAnticonvulsants
• Blood TransfusionBlood Transfusion
• Manual Removal ofManual Removal of
PlacentaPlacenta
• Removal of RetainedRemoval of Retained
ProductsProducts
• Assisted VaginalAssisted Vaginal
DeliveryDelivery
• Surgery (CesareanSurgery (Cesarean
Section)Section)
32

33. THE GOOD NEWSTHE GOOD NEWS
Not all these functions needNot all these functions need
hospitalshospitals andand doctorsdoctors
Well-trainedWell-trained nursesnurses andand
midwivesmidwives can perform mostcan perform most
functions at Basic EmOCfunctions at Basic EmOC
FacilitiesFacilities
33
It is An Important Point
for Resource Poor country
INDIA
UK / Middle EastUK / Middle East

34. 34
Making Emergency Obstetric Care availableMaking Emergency Obstetric Care available
& functional At CHC/ Dist. Hospital& functional At CHC/ Dist. Hospital
Hiring private
ANAESTHETISTS &
OBSTETRICIANS to carry
out caesarian operations
Total : 45966 (upto Jan2010)
Training MBBS DOCTORS
in short term course in Life
Saving ANAESTHESIA Skills
and Emergency Obstetric
Care (EOC).
Total LSCS - 12780

35. 35
PUBLIC-PRIVATEPUBLIC-PRIVATE
PARTERNERSHIPPARTERNERSHIP

36. Life – Saving
Skill
Drills

37. Enforcing
ACCOUNTABILITY
in Medical & Nursing
profession

38. A government
INDEMNITY scheme
to cover health
professionals

39. 39
We are committed to achieve the MDG 5
109 / lack Live Births
Countdown to 2015 begins……..

40. ASHA
Training
(villages)
Equipments
Availability
&
Maintenance
Up gradation of
PHC
24 x 7
PHC
AN care INTRANATAL

41. 41
ANAEMIA MANAGEMENTANAEMIA MANAGEMENT
MMR = 20 + 20%MMR = 20 + 20%
• MandatoryMandatory dewormingdeworming
• SupplementationSupplementation withwith iron folic acidiron folic acid (100)(100) Vit CVit C andand
B-12B-12
• Use ofUse of iron sucroseiron sucrose
• Ensuring properEnsuring proper measurementmeasurement of haemoglobin levelsof haemoglobin levels
• changingchanging diet and lifestylediet and lifestyle of women using slippers..,of women using slippers..,
washing hands prior to food.washing hands prior to food.
ADOLESCENT ANAEMIAADOLESCENT ANAEMIA
Control programmeControl programme
““12 by 12 initiative”12 by 12 initiative”

42. Standardized countrywide
protocol of
PPH
Eclampsia
Severe Anaemia

43. PPH
Number One causes of MMR

44. 44
PPH BOX BALLOON TAMPONADEPPH BOX BALLOON TAMPONADE
Blood TransfusionBlood Transfusion

45. 45
Haemorrhagic ActionHaemorrhagic Action
CommitteeCommittee
Formation of Haemorrhagic Action
Committee
Taluka Level & District Level
Blood Transfusion Arrangement
•Arrangements for the blood donation
camps.
•Keeping all the donor cards at the PHC
level.
•When pt. required blood , can be
provided without replacement
immediately.
•This arrangement done at Karvan PHC.
•This innovative step saved three
mothers by transfusing blood at the time.

46. Eclampsia
(Protocol)

47. Hb & IQ
Anaemia FREE Pregnancy

48. 48
Community InvolvementCommunity Involvement

49. 49
OutsourcingOutsourcing
ObjectiveObjective: To develop conducive environment in all: To develop conducive environment in all
PHCs, making them clean and green, and mobilizingPHCs, making them clean and green, and mobilizing
the community through involvement of Self Helpthe community through involvement of Self Help
Group membersGroup members
Sweeper
Gardener
Driver/watchman
Team
“Clean PHC Green PHC”

50. 50
E-MAMTAE-MAMTA
• Mother & ChildMother & Child Online tracking systemOnline tracking system
• A GUJARAT initiative adopted by the
Central Government for implementation
across India

51. 51
Maternal death reviews / auditMaternal death reviews / audit
Prime Show

52. 52

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FOGSI InitiativesFOGSI Initiatives
• EMOCEMOC at primary health centres, sub-at primary health centres, sub-
centres and district hospitals.centres and district hospitals.
• certificate courses for medical officerscertificate courses for medical officers
in conducting normal deliveries as well asin conducting normal deliveries as well as
caesarean sectionscaesarean sections
• conductingconducting safe abortionssafe abortions
• conducting aconducting a maternal mortality auditmaternal mortality audit inin
the statesthe states
• NationalNational EclampsiaEclampsia registryregistry
save the girl childsave the girl child campaigncampaign

54. My Role ?
(Doctor)
.
Dr. Sharda Jain
Will - What to Change ?
Why to Change ?
Skill - How to Change ?

55. My Role ?
DO WHAT YOU CAN,
WHERE YOU ARE,
WITH WHAT YOU HAVE.
Dr. Sharda Jain

56. “I may not have gone
where I intended to go.
But I think I have
ended up where I
intended to be”
Dr. Sharda Jain

57. Dr. Sharda Jain
Effects of Mothers’ DeathEffects of Mothers’ Death
The death of a
woman and mother
is a tragic loss to
the child, family,
community and
nation as a whole.

58. Together let’s write a new future for
saving mother in India.
We can do it with willpower &
hard work to respect indian women’s LIFE