1. IMPORTANCE OF
INSTITUTIONAL DELIVERIES
PRESENTED BY :- MANPREET KAUR
MSC NURSING 1ST YEAR
NINE ,PGIMER CHD

2. INTRODUCTION
 It is well established that giving birth in a medical
institution under the care and supervision of trained
health-care providers promotes child survival and
reduces the risk of maternal mortality. In India, both
child mortality (especially neonatal mortality) and
maternal mortality are high. India accounts for more
than one-fifth of all maternal deaths from causes
related to pregnancy and childbirth worldwide.

3. DEFINITION
 Institutional delivery refers to the childbirth at
technology-equipped medical facility under
supervision of skilled medical staff.
 In an institutional delivery, various medical tools
and technologies are used to ascertain that health
of neonate or mother is not compromised.

4. THE BACKGROUND
 Since the 1980’s successive programmes have
attempted to address the high MMR and IMR
 There have been considerable decline in India’s
MMR in the last two decades: from 398 in 1997-
98 to 212 in 2007-09
 Yet, this is far off from the MMR goal
of less than 100 per 100000 live births

5. OBJECTIVES:-
 Why this is a public health problem?
 What are the socio economic factors affecting?
 What are the role of belief and norms?
 What are the non medical causes associated?
 What are the psychological and cultural aspects?

6. A PUBLIC HEALTH PROBLEM
 MDG goal 5 :-
India has the largest number of births per year (27
million) in the world.1 With its high maternal
mortality of about 300–500 per 100 000 births This is
about 20% of the global burden hence India’s prog-ress
in reducing maternal deaths is crucial to the
global achievement of Millennium Development Goal
5 (MDG 5)

7. RISK FACTORS FOR MATERNAL MORTALITY
Socioeconomic factors
Reproductive factors
Health service factors

8. SOCIO-ECONOMIC FACTORS
 The general socioeconomic status of mothers
 Lack of education
 Poor knowledge about maternal health
 Poverty
 Poor mothers are at high risk of developing
pregnancy related complications. Almost all
maternal deaths that occur in low and middle-income
countries are mainly among the poorest of
the poor (WHO, 2005).

9. A CONCEPTUAL FRAMEWORK FOR ANALYZING
SOCIO-ECONOMIC INEQUALITIES IN HEALTH
SERVICE UTILIZATION
SOURCE: DE BROUWERE AND LERBERGHE (2001)
Socio- Economic factors
Income,wealth
Education
Employment,
Occupation
Family background
Confounders &
modifiers
Age
Place of residence
Ethnicity,
Religion
Proximate Determinants
Health status
Perception of health
problems
Autonomy, social support
Purchasing power
Insurance cover
Duties, opportunities costs
Tendency to consult,
beliefs
Health service
utilization
Frequency of visits
Type of facility
Quality received

10. REPRODUCTIVE FACTORS
 The number of pregnancies she has had in her
lifetime.
 The higher the number of pregnancies, the greater
the lifetime risk of pregnancy related deaths (WHO,
2005).
 Maternal age also has an impact on increasing the
risk of dying. Girls below 18 years and women older
than 35 years are more likely to have pregnancy
related complications that may lead to maternal
death (USAID, 2005).

11. HEALTH SERVICE FACTORS
 All pregnant women are at risk of developing
complications during any time of their pregnancies,
deliveries and postpartum periods.
 Lacks of access to emergency obstetric care and
delay for emergency referral are contributing factors
for high maternal mortality.
 Obstetrics complications are able to be treated in
health institutions that are sufficiently equipped with
supplies, medications and fully staffed with capably
trained health professionals

12. MATERNITY SERVICES UTILISATION
0 20 40 60 80 100
C sections
Skilled birth
attendents
ANC services
poor rich

13. ADVANTAGES OF INSTITUTIONAL
CHILDBIRTHS
 Antenatal care is a perquisite for a healthy delivery. Medical
facility with trained staff and advanced facilities provides all
services related to antenatal check-ups and counselling.
 In a medical institution, trained healthcare professionals
provide specific care and attention to newborn babies with
special needs in order to improve their survival chances and
reducing the risk of maternal mortality.
 Women seeking assistance of medical institution for delivery
are the ones given ample support to conceive at the right
maternal age without delaying childbearing.
 Mothers are regularly assisted for post-pregnancy care, with
medical staff discussing various aspects such as care for
umbilical cord stump, nutrition, breastfeeding and bathing.

14. ADVANTAGES OF INSTITUTIONAL
CHILDBIRTHS CONT……
 Institutional medical facilities aim for safe delivery by
labour monitoring, active management of the third stage
of delivery, immediate attention of the newborn,
postpartum monitoring, addressing complications of
mother and infant post-delivery.
 Quality of care is all-important, which is provided by
institutional medical setting.
 Institutional medical facility also provides personnel and
equipments to handle emergency circumstances which
necessitate immediate medical attention.
 Round-the-clock supervision ensures comfort for mother
with medical staff looking after nutrition and diaper
changes of her baby.

15. ADVANTAGES OF INSTITUTIONAL
CHILDBIRTHS CONT…….
 Improper care during pregnancy term can also affect
overall maternal health, specifically the reproductive
health of the woman besides the health of the newborn
baby.
 Hygienic conditions and surroundings are also important
for safe delivery, which are mostly ignored in non-institutional
setting for a delivery.
 Immunisation chart can be easily adhered to in an
institutional medical facility. Following immunisation
schedule ascertains that baby as well as mother is safe
from various health complications.
 Institutional settings provide aid to hasten labour like
intravenous (IV) drips and intramuscular injections
during labour.

16. OBSTACLE FOR LOW UTILIZATION OF
DELIVERY SERVICES
 Distance from health services;
 Costs, including user fees
 The cost of transport
 Quality of care
 Drugs availability & Supplies
 Women’s lack of autonomy indecision-making.
(The WHO (1998) and Magadi et al (2002)

18. NATIONAL RURAL HEALTH MISSION
 The National Rural Health Mission (NRHM) is a
government scheme that aims at providing valuable
healthcare services to rural households all over the
country
 National Rural Health Mission (NRHM) launched in
2005 : provide equitable , accessible and affordable
health care

19. IT SPECIALLY FOCUSES ON THE 18 STATES
Arunachal Pradesh, Assam,
Bihar, Chhattisgarh, Himachal
Pradesh, Jharkhand, Jammu and
Kashmir, Manipur, Mizoram,
Meghalaya, Madhya Pradesh,
Nagaland, Orissa, Rajasthan,
Sikkim, Tripura, Uttarkhand and
Uttar Pradesh.

20. OBJECTIVES
 Decrease the infant mortality rate to 30/1,000 live
births and maternal mortality rate to 100/1,00,000
 Universal access to public health services such as
Women’s health, child health, water, sanitation &
hygiene, immunization, and Nutrition.
 Prevent and control communicable and non-communicable
diseases.
 Control population as well as ensure gender and
demographic balance.
 Encourage a healthy lifestyle and alternative
systems of medicine through AYUSH
 Improved facilities for institutional delivery.

21. GOAL TO BE ACHIEVED BY NRHM
IMR 30/1000 LIVE
BIRTHS
MMR 100/100,000
TFR 2.1

22. GOAL CONT…….
 Improved facilities for institutional deliveries through
provision of referral , transport, escort, and
improved hospital care subsidised under the JSY
for below puberty line families

23. NRHM
 Reduction in MMR to 100/100,000 is
one of its goals
 The Janani Suraksha Yojana ( Safe
Motherhood Scheme) is the key
strategy to achieve this reduction

24. JANANI SURAKSHA YOJANA
 The government has a Janani Suraksha Yojana
(JSY) to deal with issues involved in pregnancy and
child care.

25. JSY:-
 It is a centrally sponsored scheme aimed at
reducing maternal and infant mortality rates, and
increase institutional deliveries in below poverty line
(BPL) families.
 The JSY, which falls under the overall umbrella of
National Rural Health Mission, covers all pregnant
women belonging to households below the poverty
line, above 19 years of age and up to two live
births.

26. JSY CONT……..
 The JSY, launched in 2003, modifies the existing
National Maternity Benefit Scheme or NMBS.
 While the NMBS was linked to provision of better
diet for pregnant women from BPL families, the JSY
integrates the cash assistance with antenatal care
during pregnancy period, institutional care during
delivery and immediate post-partum period in a
health centre by establishing a system of
coordinated care by field level health worker.

27. JSY
 The Yojana has identified ASHA, as an effective
link between the Government and the poor
pregnant women in low performing states.

28. CONT…………
 Counsel for institutional delivery.
 Escort the beneficiary women to the pre-determined
health center and stay with her till the woman is
discharged.
 Arrange to immunize the newborn till the age of 14
weeks.
 Inform about the birth or death of the child or mother
to the ANM/MO.
 Post natal visit within 7 days of delivery to track
mother’s health after delivery and facilitate in obtaining
care, wherever necessary.
 Counsel for initiation of breastfeeding to the newborn
within one-hour of delivery and its continuance till 3-6
months and promote family planning.

29. IMPORTANT FEATURES OF JSY:
 The scheme focuses on the poor pregnant woman
with special dispensation for states having low
institutional delivery rates namely the states of Uttar
Pradesh, Uttaranchal, Bihar, Jharkhand, Madhya
Pradesh, Chhattisgarh, Assam, Rajasthan, Orissa
and Jammu and Kashmir. While these states have
been named as Low Performing States (LPS), the
remaining states have been named as High
performing States (HPS).

30. TRACKING EACH PREGNANCY:
 Each beneficiary registered under this Yojana
should have a JSY card along with a MCH card.
ASHA/AWW/ any other identified link worker under
the overall supervision of the ANM and the MO,
PHC should mandatorily prepare a micro-birth
plan. This will effectively help in monitoring
Antenatal Check-up, and the post delivery care.

31. JSY :THE PACKAGE OF INCENTIVES
Low performing states High performing states
Institutiona
l delivery
package
Rs.1400 ($23)to mothers in
rural areas
Rs.1000 ($16) in urban
areas
Rs. 600 ($10) to ASHAs
Home
delivery
package
Rs. 500 ($8) to
mothers- being BPL ,
above 19 yrs of ages.
Institution
al
delivery
package
Mothers : Rs. 700 ($12) in
rural areas
Rs.600 ($10) in urban
areas
Rs.200 ($ 4) and 350 ( $6)
in tribal areas) to ASHAs
Home
delivery
package
Rs. 500 ($8)to
mothers- being BPL
, above 19 yrs of
ages.

32. DISBURSEMENT OF CASH ASSISTANCE:
a. The mother and the ASHA should get their entitled
money at the heath centre immediately on arrival
and registration for delivery.
b. Generally the ANM/ ASHA should carry out the
entire disbursement process. However, till ASHA
joins, AWW or any identified link worker, under the
guidance of the ANM may also do the
disbursement.

33. PAYMENT TO ASHA:
 First payment for the transactional cost at the
health centre on reaching the institution along with
the expectant mother.
 The second payment should be paid after she has
made postnatal visit and the child has been
immunized for BCG.
 All payments to ASHA would be done by the
ANM only. : It must be ensured that ASHA gets her
second payment within 7 days of the delivery, as
that would be essential to keep her sustained in the
system.

34. ROLE OF ASHA OR OTHER LINK HEALTH WORKER
ASSOCIATED WITH JSY:-
 Identify pregnant woman as a beneficiary of the
scheme and report or facilitate registration for ANC
 Assist the pregnant woman to obtain necessary
certifications wherever necessary,
 Provide and / or help the women in receiving at
least three ANC checkups including TT injections,
IFA tablets,
 Identify a functional Government health centre or
an accredited private health institution for referral
and delivery

35. RATIONALE
 Institutional deliveries would help the pregnant
woman access a team of skilled birth attendants
more reliably and it would also improve her access :
 emergency obstetric care
 reduced maternal and neonatal mortality
The scheme offers
a package of
financial incentives
to pregnant women
to improve access
to institutional
deliveries.

36. IMPACT OF JANANI SURAKSHA YOJANA ON
INSTITUTIONAL DELIVERY RATE: AN
OBSERVATIONAL STUDY IN INDIA
 The data were analyzed for two years before
implementation of JSY (2003-2005) and compared
with two years following implementation of JSY
(2005-2007). Overall, institutional deliveries
increased by 42.6% after implementation, including
those among rural, illiterate and primary-literate
persons of lower socioeconomic strata.

37. POSSIBLE IEC STRATEGY
 To associate NGO and Self Help Groups for
popularizing the scheme among women’s group
and also for monitoring of the implementation.
 To provide wide publicity to the scheme by:
 Promoting JSY as a component of total package
of services under RCH along with programmes like
Pulse polio programme.
 Printing and distributing JSY guidelines, pamphlets,
notices in local languages at SC/PHCs/CHCs/
District Hospitals/ DM’s and Divisional
Commissioner’s office and even in at the accredited
Pvt. Nursing Homes, in abundance.

38. MATERNAL MORTALITY IN 1990-2013
 F:Maternal mortality in 1990.docx

39. LET US ENSURE THESE BASIC HEALTH RIGHTS
FOR EVERY MOTHER AND HER CHILD ..AS INDIA
MOVES TOWARDS UNIVERSAL HEALTH COVERAGE

40. REFERENCES
 Park.K.2009. Park’s Textbook of Preventive and
Social Medicine. Twentieth edition. M/s Banarsidas
Bhanot publishers, Jabalpur, India. Pp 379-381.
 http://reports.nrhmcommunityaction.org/more.htm.

41. THANKS