Maternal Death Review…

A National Perspective

Maternal Deaths… unacceptable numbers

About 28 million pregnancies per year in India

26 million live births 15% of pregnancies likely to develop

complications 67 000 maternal deaths in a year

Maternal Deaths…Causes

• Direct obstetric and non-obstetric causes - hemorrhage, sepsis, eclampsia, obstructed labour, abortion related, anemia etc

• Underlying/contributory causes - Social, behavioral, cultural, economic factors

• The “three delays”:– Delay in decision making– Delay in reaching the appropriate health

facility– Delay in receiving health care at the facility

MDG Goals,Targets and Indicators …MDG 5…MDG Goals,Targets and Indicators …MDG 5…NRHM /RCH goals in lineNRHM /RCH goals in line

Goal Target Indicators AchievementsMDG-5: To improve Maternal health

Reduce by 3/4ths the MMR, 1990-2015. (From 424 (NFHS-I) to approx.106 per 1,00,000 Live-Births in 2015).

NRHM/RCH II-Reduce to 100/1,00,000 Live-births

MMR

Proportion of births attended by SBA.

Institutional delivery.

MMR : 254 per 100,000 live births( RGI-SRS 2004-06)UN Interagency Estimates(2008) : 230/100,000 LB

52.6 %Safe Delivery47% Institutional Delivery

76%Safe Delivery72.9% Institutional Delivery(UNICEF Coverage Evaluation Survey 2009)

MMR…we need to accelerate pace of decline

0

100

200

300

400

500

600

MMR 2001-03

MMR 2004-06

RCH /NRHM/

MDG goal

MMR Trends…variation across States

Source:RGI SRS

2/3rds deaths

Burden of Maternal Deaths...

2001-03 2004-06

Assam 490 480

U.P. / Uttarakhand 517 440

Rajasthan 445 388

M.P. / Chhattisgarh 379 335

Bihar / Jharkhand 371 312

Orissa 358 303

Karnataka 228 213

Punjab 178 192

Haryana 162 186

Andhra Pradesh 195 154

West Bengal 194 141

Maharashtra 149 130

Tamil Nadu 134 111

Kerala 110 95

Policy and Programmes...Goals and Targets

National Population Policy 2000

MULTI-PRONGED

APPROACH..

MATERNAL HEALTH STRATEGIES

Demand Promotion-

( Janani Suraksha Yojana)

Provision of services

Public sector

1. Essential and Emergency

Obstetric Care•Quality ANC, INC, Safe and

Institutional delivery•Skilled birth attendance•Multi-skilling

2.Operationalize FRU s & 24*7 PHCs

3. Services for RTIs & STIs –

convergence with the NACP

4. Safe abortion services- New

Guidelines

5. Strengthen referral systems

6.Village Health and Nutrition Day..

Mother-Child Protection Card

Provision of Services : Private sector•Accreditation of Pvt. Health Facilities for

RCH services and SBA training•Fixed package for outsourcing services

• Maternal Death Review• Pregnancy and Child Tracking –web based system• Prioritising resources for identified “delivery points” or MCH Centres

New

10

NRHM…Overarching Umbrella

Intersectoral Convergence

Accredited Social Health Activist (ASHA) – one per 1000 population

Facility Strengthening / Improving Access

Strengthening of Infrastructure- IPHS

Improving availability of Human Resource - Contractual Appointments

Availability of funds at facilities-Untied funds ,Annual Maintenance Grants, Grants to Rogi Kalyan Samitis.

Village Health and Nutrition Days

Village Health and Sanitation Committees

Public-private Partnerships.

Flexible Funding through NRHM/RCH Flexi-pool.

Innovative Strategies

CommunitisationDecentralisation

FlexibleFunding

Maternal Death Review

Policy on Maternal Death Reviews …spelt out in implementation framework of RCH II

Strengthen Monitoring/Records/Audit procedures

• Monitor State and Regional level MMR

• Introduce mother-child linked card

• Conduct review of maternal deaths at the hospital and community levels

• Develop tools for maternal death review and reporting

Maternal Death Reviews Maternal Death Reviews Initiatives…fragmentedInitiatives…fragmented

Why conduct MDR?

Reduce maternal mortality and morbidity Improve quality of obstetric care Understand determinants of maternal death Provide stimulus for action at all levels Take corrective action to fill the gaps in service

provision

Prerequisite: A commitment to act upon the findings Not for punitive action

MDR ProcessMDR ProcessFive approaches to help understand why women die ...

• Maternal deaths in the community (CBMDR)

• Maternal deaths in facilities (FBMDR)

• Confidential enquiries into maternal deaths

• Learning from women who survived: “near miss” cases

• Evidence-based clinical audit

All these approaches...

Identify cases (maternal deaths) Review cases confidentially and no blame Look for avoidable factors Promote change in practices Review the outcome of these changes Refine and develop

The maternal death surveillance cycle..

Identify casesIdentify cases

Recommendations Recommendations for actionfor action

Collect informationCollect information

Analyse resultsAnalyse results

Implement,Implement,evaluate and refineevaluate and refine

No Punitive Action

Challenges... to roll out the process

Creating awareness in community... Need for effective BCC/IEC

Mobilising communities and the health system Resolving infrastructure and human resource issues Building partnerships between govt. systems and

others (prof. bodies ,tech. agencies ,NGOs ) Resolving ethical issues Developing guidelines and simple implementable

tools Orientation of a wide range of functionaries --policy

makers, programme officers, frontline HWs, community workers, PRIs...capacity building of the states

Each maternal death Each maternal death is …………is ………… a tragedy a tragedy

Bigger tragedy, Bigger tragedy, however, however, is……................ is……................ failing to learn failing to learn lessons from her lessons from her death!!death!!