2. SOME FACTS
85 % women will deliver normally
10-15 % women will develop complications
3-5 % women will need surgical interventions
(blood/Cesarean etc.)
More chances of women having a normal delivery
However delivery complications can occur suddenly, without any
warning signals
2
3. SOME FACTS
20-25% deaths occur during pregnancy.
40-50% deaths occur during labour and
delivery
25-40% deaths occur after childbirth
(More during the first seven days)
It is important to focus attention during pregnancy and also
after childbirth
3
4. GLOBAL BURDEN
5,29,000 deaths / yr or 400/ 1 lakh live births
1 death per minute
1% in developed countries
Range – 24 to 830 / 100,000 live births
19/20 countries with high MMR – Sub
Saharan Africa
5. LIFETIME RISK FOR A WOMAN
Continent Risk of Losing a Risk of dying due to
neonate maternal cause
AFRICA 1 In 5 1 in 16
ASIA 1 in 11 1 in 132
LATIN AMERICA 1 in 21 1 in 188
DEVELOPED 1 in 125 1 in 2976
COUNTRIES
6. SCENARIO IN INDIA
An Indian woman dies from
complications related to pregnancy
and childbirth.
Every seven minutes
The maternal mortality ratio in India
stands at approx 200 per 100,000 live
births.
It has some high performing states
like Kerala with MMR of 110 and
poorly doing states like Uttar Pradesh
7. MATERNAL MORTALITY
Death of a woman who is pregnant or within
42 days of termination of
pregnancy, irrespective of the site or duration
of pregnancy, from any cause related to or
aggravated by the pregnancy or its
management
8. MATERNAL MORTALITY
Death of a woman who is pregnant or within
42 days of termination of
pregnancy, irrespective of the site or duration
of pregnancy, from any cause related to or
aggravated by the pregnancy or its
management
9. MATERNAL MORTALITY
Death of a woman who is pregnant or within
42 days of termination of pregnancy,
irrespective of the site or duration of
pregnancy, from any cause related to or
aggravated by the pregnancy or its
management
10. MATERNAL MORTALITY
Death of a woman who is pregnant or within
42 days of termination of pregnancy,
irrespective of the site or duration of
pregnancy, from any cause related to or
aggravated by the pregnancy or its
management
11. MATERNAL MORTALITY
Death of a woman who is pregnant or within
42 days of termination of
pregnancy, irrespective of the site or duration
of pregnancy, from any cause related to or
aggravated by the pregnancy or its
management
12. DIRECT OBSTETRIC DEATHS
The deaths resulting from obstetric
complications of the pregnant state
(pregnancy, labour and the puerperium), from
interventions, omissions, or incorrect
treatment, or from a chain of events
resulting from any of the above are called
direct obstetric deaths.
Indirect obstetric deaths
Those resulting from previous existing disease or disease that
developed during pregnancy and that was not due to direct
obstetric causes but was aggravated by the physiological effects
of pregnancy.
13. Late maternal death
Late maternal is death of a woman from direct or indirect obstetric
causes, more than 42 days but less than one year, after
termination of pregnancy.
Pregnancy related death
defined as : the death of a woman while pregnant or within
42 days of termination of pregnancy, irrespective of the
cause of death.
To facilitate the identification of maternal death in circumstances
in which cause of death attribution is inadequate, ICD-10
introduced a new category, that of “pregnancy-related death”.
14. MEASUREMENT OF MATERNAL MORTALITY
There are three main measures of maternal
mortality-
maternal mortality ratio,
maternal mortality rate
lifetime risk of maternal death.
15. MATERNAL MORTALITY RATIO
This represents the risk associated with each
pregnancy, i.e. the obstetric risk.
It is calculated as the number of maternal
deaths during a given year per 100,000 live
births during the same period. This is usually
referred to as rate though it is a ratio.
16. NOTE - MMR
The appropriate denominator for the maternal
mortality ratio would be the total number of
pregnancies (live births, fetal deaths or stillbirths,
induced and spontaneous abortions, ectopic and
molar pregnancies).
However, this figure is seldom available and thus
number of live births is used as the denominator.
In countries where maternal mortality is high
denominator used is per 1000 live births but as this
indicator is reduced with better services, the
denominator used is per 1,00,000 live births to avoid
figure in decimals.
17. ‘DELAY’ MODEL
Delay in seeking care
Delay in transport to appropriate health
facility
Delay in provision of adequate care
18. DELAY
Onset, time and death
APH-12 hours
PPH – 02hours
Rupture uterus- 24 hours
Eclampsia – 48 hours
Infection – 06 days
19. CAUSES OF MATERNAL MORTALITY
20 % - indirect
80 % - direct
Four Major causes
Haemorrhage
Infection (sepsis)
Eclampsia
Obstructed
Labour
22. WOMEN ARE DYING IN INDIA DUE TO
Marriage and childbirth at an early age.
Lack of access to Emergency Obstetric Care
(EmOC).
Inadequate nutrition
Due to six medical causes-
Hemorrhage, sepsis, unsafe abortion, obstructed
labour, eclampsia, pre-existing anemia, malaria
Absence of skilled personnel at delivery
Short birth intervals- 30% births at < 24 months
interval
High parity- 25% births in parity 4 or more
Lack of blood transfusion facilities in rural areas
23. IMPACT OF MATERNAL DEATHS
Children who lost their mothers are more likely
to die within two years of maternal death
10 times the chance of death for the neonate
7 times the chance of death for infants older
than one month
3 times the chance of death for children 1 to5
years
Enrolment in school for younger children is
delayed and older children often leave school to
support their family.
24. WHAT IS COMMON TO ALL THESE
CAUSES ?
They all are preventable to a great extent
25. IF THEY ARE ALL PREVENTABLE THEN
WHY NOT?
The reasons are
Social
Economical
Medical
26. SOCIAL ISSUES
Early marriage
Gender discrimination
Illiteracy
Desire for selective sex of child- female feticide
Domestic violence
27. ECONOMIC ISSUES
Lack of money
Lack of timely transport and communication
Delay in taking decision to shift
Improper dietary habits
28. MEDICAL ISSUES
Lack of ANC
Lack of emergency obstetric care
Lack of blood and blood products
Lack of essential drugs
Junior staff dealing with high risk cases without
supervision
Delay in diagnosis / wrong diagnosis
29. PREVENTION OF MATERNAL MORTALITY
Health Education
Age at marriage
Utilization of RCH services
Awareness of antenatal care
Nutritional education
Importance of Immunization
Spacing / Limitation of births
30. PREVENTION OF MATERNAL MORTALITY
Safe Abortion services
Sex education and contraception
(Adolescent clinics)
Roleof MVA
MTP under LA
Teaching MTP to RMP
31. PREVENTION OF MATERNAL MORTALITY
Health delivery infrastructure
Provision of RCH services at remote rural areas /
urban slums
Improved staffing
Facilities for Essential / Emergency obstetric
care
Training of traditional birth attendants (
TBAs )
32. PREVENTION OF MATERNAL MORTALITY
Health care delivery
Emergency management of Eclampsia / Third
stage complications at PHC level
Flying squad services
34. PREVENTION OF MATERNAL MORTALITY
Prevention of anaemia
Concept of 100 tablets
at puberty
at the time of marriage
during pregnancy
during lactation
35. PREVENTION OF MATERNAL MORTALITY
Non health strategies
Povertyeradication
Improvement of literacy
Women‟s empowerment measures
Improved communications
Improved transport facilities
36. ACTIONS FOR SAFE MOTHERHOOD
Legislative & Policy actions
Society & Community
Health sector
38. SOCIETY & COMMUNITY
National, regional and district safe motherhood
committees
Health facility and community committee
Raising awareness on danger signs
provisioning of DDK for clean deliveries
TBAs - remote and inaccessible areas.
Improving maternal nutrition
Addressing certain diseases like malaria, TB,
RTI/STI, HIV/AIDS and Hepatitis.
Preventing unwanted births and reducing unsafe
abortions
39. HEALTH SECTOR ACTIONS
Antenatal clinics
EOC -Skilled Birth attendance
Postnatal care
Abortion services
FRUs –EmOC
Iron & FA, inj TT
Family planning services
40. FIRST LEVEL MATERNAL CARE
Such care has three functions-
birth takes place in the best of circumstances
resolve complications as they arise
To respond to life-threatening emergencies
organized in midwife led birthing
centres, combining cultural proximity in a non-
medicalized setting, with professional skilled
care, the necessary equipment, and the
potential for emergency evacuation.
41. BACKUP CARE
ideally provided in a hospital where doctors –
specialists, skilled general practitioners or mid-
level technicians with the appropriate skills
Linked with first level care
24 hrs availability
Emergency & non-emergency conditions
Both 1st level services & backup care to be
rolled out simultaneously
42. INITIATIVES IN INDIA
FP program – 1952
AIHPP - 1969
MTP Act -1971
Family welfare -1977
CSSM -1992
RCH
JSY
Vandemataram scheme
EmOC
EOC
43. ESSENTIAL OBSTETRIC CARE
Registration of pregnancy in the first 12-
16 wks
At least 3 prenatal check ups
Assistance during delivery.( Skilled Birth
Attendant)
At least 3 postnatal check ups.
44. EMERGENCY OBSTETRIC CARE
Inputs
A total of 1748 FRUs - provisioning of drug kits, laparoscope, blood
transfusion and employing contractual staff like PHN/ANM/Lab Asst and
anaesthesiologist.
24 Hour Delivery Services at PHCs/CHCs
For this doctor could be paid Rs 200/- per delivery & other staff could be hired on contractual
basis.
Referral Transport to Indigent Families through Panchayats
In category C districts of eight weakly performing states, issue addressed by providing financial
assistance to Panchayats through District Family Welfare Officers.
Blood Supply to FRUs/PHCs
MTP services
Inputs
(a) Need based training in MTP by NIHFW.
(b) Supply of MTP equipment to District Hospitals, CHCs & PHCs where trained staff is
available.
(c) Assistance for engaging doctors trained in MTP to the PHCs once a week on fixed
days for performing MTP (Pay Rs 500/- day). These doctors will also provide ANC
and PNC services to patients during their visit.
(d) Supply of MTP equipment to Private clinics if they have OT & trained doctors.
46. JSY- ELIGIBILITY
LPS States All pregnant women delivering in Government
health centres like Sub-centre, PHC/CHC/ FRU /
general wards of District and state Hospitals or
accredited private institutions
HPS States BPL pregnant women, aged 19 years and above
LPS & HPS All SC and ST women delivering in a
government health centre like Sub-centre,
PHC/CHC/ FRU / general ward of District and
state Hospitals or accredited private institutions
47. Cash Assistance
Cat Rural Area Total Urban Area Total
Mother’s ASHA’s Rs. Mother’s ASHA’s Rs.
Package
Package Package Package
LPS 1400 600 2000 1000 200 1200
HPS 700 700 600 600
48. SPECIAL DISPENSATION FOR LPS STATES:
Age restriction removed
Restricting benefits of JSY up to 2 births
removed
No need for any marriage or BPL certification
49. MICRO BIRTH PLAN
-
Inform the mother and the family about 4 Is, namely
Inform dates of 3 ANC & TT Injection (s) and
ensure these are provided,
Identify the health centre for all referral,
Identify the Place of Delivery,
Inform expected date of delivery
50. VANDE MATARAM SCHEME
Public Private Partnership with the involvement of
Federation of Obstetric and Gynachological Society of India
and Private Clinics.
Voluntary scheme wherein any Obstetric and Gynaecologist,
maternity home, nursing home can volunteer themselves in
joining the scheme. Any lady doctor/MBBS doctor providing
safe motherhood services can also volunteer to join this
scheme.
The enrolled „Vandematram‟ doctors will display
„Vandematram‟ logo in their clinic. Iron and Folic Acid
Tablets, oral pills, TT injections etc. will be provided by the
respective District Medical Officers to the „Vandematram‟
doctors/clinics for free distributions to beneficiaries.
51. CHALLENGES IN MATERNAL HEALTH
Establishing data base on maternal mortality
High risk pregnancy behavior-too early, too
many, too close
Urban-Rural divide
Poor rate of institutional deliveries
Lack of skilled care at birth
Poor implementation of programs
Lack of women empowerment
52. TEN ACTION MESSAGES FOR SAFE MOTHERHOOD
Advance Safe Motherhood Through Human Rights
Empower Women: Ensure Choices
Safe Motherhood is a Vital Economic and Social
Investment
Delay Marriage and First Birth
Every Pregnancy Faces Risks
Ensure Skilled Attendance at Delivery
Improve Access to Quality Reproductive Health
Services
Prevent Unwanted Pregnancy and Address Unsafe
Abortion
Measure Progress
The Power of Partnership
53. FINAL MESSAGE
Child birth – a miracle of life should not
become a nightmare of death
55. Perinatal Mortality Rate : This includes both late foetal deaths (stillbirths)
and early neonatal deaths. The important thing to consider is the weight 1000gm
and more at birth or a gestation of 28 weeks if birth weight is not available and if
both weight
and gestation are not available, body length (Crown to heel) of at least 35 cm
should be used.
The preferred criterion is birth weight. The denominator used in calculation of
perinatal mortality is 1000 live births (suits nations with poor recording of still
births) but for more precise comparison the denominator includes all live births
weighing
1000 gm or more. Perinatal mortality is a sensitive indicator of essential maternal
and newborn care provided at childbirth.
The factors responsible for stillbirths and early neonatal deaths are often similar.
This indicator also assumes importance in view of the fact that many of the early
neonatal deaths are recorded as stillbirth in developing nations thereby inflating
figures for stillbirths but showing figures for early neonatal deaths lower than the
factual. This anomaly is taken care of by Perinatal Mortality Rate. The Perinatal
period comprises just 0.5 % of the average lifespan but has more deaths in this
period than next 30-40 years of life.
Notas del editor
The highlight is that most of the states recording unfavorable maternal mortality rates are the ones with the highest number of birth rates and huge population bases with poor health infrastructure. There are a number of reasons India has such a high maternal mortality ratio. Marriage and childbirth at an early age, lack of adequate health care facilities, inadequate nutrition and absence of skilled personnel, all contribute to pregnancies proving fatal. The common causes of maternal mortality in India are anaemia, haemorrhage, sepsis, obstructed labour, abortion, and toxaemia. Maternal morbidities are the anaemias, chronic malnutrition, pelvic inflammations, liver and kidney diseases. In addition, the pathological processes of some preexisting diseases, such as chronic heart diseases, hypertension, kidney diseases and pulmonary tuberculosis are aggravated by pregnancy and childbirth.
The factors underlying the direct causes of maternal deaths operate at several levels. The low social and economic status of girls and women is a fundamental determinant of maternal mortality in many developing countries including India. Low status limits the access of girls and women to education and good nutrition as well as to the economic resources to pay for health care or family planning services. Lack of decision making power in terms of family planning puts them to repeated childbearing. Excessive physical work coupled with poor diet leads to poor maternal outcomes. Many deliveries in rural areas are either conducted by relatives or traditional birth attendant or at times none. In India three out of every five births take place at home; only two in five births take place in a health facility. However, the percentage of births in a health facility has increased steadily. Less than half of births took place with assistance from a health professional, and more than one third were delivered by a Traditional Birth Attendant. The remaining 16 percent were delivered by a relative or other untrained person. A disposable delivery kit (DDK) was used only in 20% of births taking place at home. Most women receive no postnatal care at all. (13)NutritionalPoor nutrition before and during pregnancy contributes in a variety of ways to poor maternal health, obstetric problems and poor pregnancy outcomes. Stunting predisposes to cephalopelvic disproportion and obstructed labour. Anemia may predispose to infection during pregnancy and childbirth, obstetric hemorrhage and are poor operative risks in the event if surgery is required. Severe vitamin A deficiency make women more vulnerable to obstetric complications. Iodine deficiency increases the risk of stillbirths and spontaneous abortions. Lack of dietary calcium appears to increase the risk of pre-eclampsia and eclampsia during pregnancy.
can investigate maternal deaths and implement strategies for improvement in areas such as referral, emergency transport, deployment and support of health care providers and cost sharing.
InputsA total of 1748 FRUs have been identified & equipped under CSSM programme. Some of the FRUs are lacking in manpower or infrastructure. Under RCH programme, a provision has been kept for strengthening these FRUs through provisioning of drug kits, laparoscope, blood transfusion and employing contractual staff like PHN/ANM/Lab Asst and anaesthesiologist. 24 Hour Delivery Services at PHCs/CHCsUnder RCH program, arrangements have been made that a doctor on call duty, a nurse and cleaning staff are available beyond normal working hours to encourage people to seek deliveries in PHCs/CHCs. For this doctor could be paid Rs 200/- per delivery & other staff could be hired on contractual basis.Referral Transport to Indigent Families through PanchayatsIn category C districts of eight weakly performing states, communication infrastructure is weak and economic status of families in remote villages is poor. Because of this, even if there is a complication identified during pregnancy or delivery, the women have the delivery conducted in the village and frequently through untrained Dais. This is one of the causes of high maternal mortality and morbidity. This has been addressed by providing financial assistance to Panchayats through District Family Welfare Officers.Blood Supply to FRUs/PHCsDept of family welfare will be taking up pilot projects with the assistance of European Commission under the RCH programme for setting up of regular and reliable supply of blood to PHCs/CHCs by linking them with the nearest blood bankMTP servicesMTP by untrained or experienced persons is responsible for high maternal mortality and morbidity. Therefore, increasing and improving facilities for MTP is an important component of the RCH programme at PHC level. Inputs(a) Need based training in MTP by NIHFW.(b) Supply of MTP equipment to District Hospitals, CHCs & PHCs where trained staff is available.(c) Assistance for engaging doctors trained in MTP to the PHCs once a week on fixed days for performing MTP (Pay Rs 500/- day). These doctors will also provide ANC and PNC services to patients during their visit. (d) Supply of MTP equipment to Private clinics if they have OT & trained doctors.