maternal mortality neonatal mortality high risk pregnancy

1. MATERNAL MORTALITY AND NEONATAL
MORTALITY
 WHO definitions of maternal death, namely the death of a woman
while pregnant or within 42 days of terminating a pregnancy,
irrespective of the site and duration of the pregnancy, from any cause
related to or aggravated by the pregnancy or its management, but not
from accidental or incidental causes.

2. .Perinatal mortality & morbidity
 It is defined as death among fetuses weighing 1000g or more at birth(28 week
POG) who die before or during delivery or within first 7 days of delivery.
 Expressed in terms of such deaths per 1000 total births.
 Current rate-
 PERINATAL MORBIDITY- It means major illness of neonate from birth to first
fore weeks of life. Causes- prematurity, LBW, birth asphyxia and trauma,
congenital malformations

3. Predisposing factors-
 Epidemiological –age, parity, low socioeconomic status, poor nutrition
 Medical disorders- anaemia, diabetes, fever(malaria), HIV, thyroid disorders
 Obstetric causes- APH, Hypertensive disorders, Rh isoimmunization, cervical
incompetence, dystocias, multiple pregnancy, congenital malformations,
IUGR, PPROM
 UNEXPLAINED

4. Prevention-
 Pre pregnancy health care and counselling
 Genetic councelling
 Regular ANC visits
 Detection and management of medical disorders
 Screening of high risk pts
 Careful labor monitoring
 Skilled birth attendant- 3 cleans are to be maintained
 Provision of referral neonatal services
 Health care education to mother about care of newborn- breastfeeding,
prevention of hypothermia
 Family planning services

5. Interventions :
Causes Percent Intervention
Infections (sepsis,
meningitis, pneumonia,
neonatal tetanus, cong
syphilis)
33% Tetanus toxoid, warmth,
screening for infection,
clean delivery, exclusive
breastfeeding, early
recognition and
treatment of infection
Birth asphyxia , trauma,
hypothermia
28% Skilled birth attendant,
labor monitor, warmth
Preterm birth /LBW 24% Breastfeeding , infection
control, referral
Congenital malformations 15% Prenatal diagnosis and
genetic councelling

6. Stillbirths
 It is birth of a newborn after 28th completed week(>1000g) when baby does
not breathe or show any sign of life after delivery.
 It includes- antepartum deaths(macerated) and intrapartum deaths(fresh SB).
 SB Rate- number of such death per 1000 total birth(live + stillbirth).

7. Neonatal deaths-
 It is Death of infant within 28 days after birth.
 NMR – Number of such deaths per 1000 live births.
 Majority of death occurs in 48 hrs.
 CAUSES- within 7 days are almost obstetric related cause(perinatal death)
 About 2/3 deaths are related to prematurity.

8.  The Government of India is a signatory to the United Nations (UN)
 Sustainable Development Goals (SDGs), which adopted a global maternal mortality
ratio (MMR) target of fewer than 70 deaths per 100 000 live births by 2030
 Requires the reliable quantification of maternal deaths and trends and an
understanding of the major causes of these deaths at the subnational level
 India, similar to many countries with high maternal mortality, officially registers only a
fraction of births, deaths and vital events. Maternal deaths are concentrated in remote
rural areas and are among the least likely to be recorded
 India, however, has had a functioning Sample Registration System (SRS) to monitor
fertility and mortality covering over 1 million nationally representative homes for more
than five decades

9.  The UN estimates that about 24 million children were born in 2017 in India,
and about 35 000 mothers died during childbirth or shortly thereafter, giving an
MMR of 145 per 100 000 live births
 presented 12% of global maternal deaths
 World Health Organization (WHO), the worldwide MMR - fallen substantially
from 342 in the year 2000 to 211 in 2017, reducing global maternal deaths
from 451 000 to 295 000 during this period
 About 40% of this absolute decline was derived from fewer maternal deaths in
India

10. Where do maternal deaths occur
 The high number of maternal deaths in some areas of the world reflects inequalities in
access to quality health services and highlights the gap between rich and poor
 The MMR in low income countries in 2017 is 462 per 100 000 live births versus 11 per
100 000 live births in high income countries.
 In 2017, according to the Fragile States Index, 15 countries were considered to be “very
high alert” or “high alert” being a fragile state (South Sudan, Somalia, Central African
Republic, Yemen, Syria, Sudan, the Democratic Republic of the Congo, Chad, Afghanistan,
Iraq, Haiti, Guinea, Zimbabwe, Nigeria and Ethiopia), and these 15 countries had MMRs in
2017 ranging from 31 (Syria) to 1150 (South Sudan).
 The risk of maternal mortality - highest for adolescent girls under 15 years old and
complications in pregnancy and childbirth are higher among adolescent girls age 10-19
(compared to women aged 20-24) (2,3).
 Women in less developed countries have, on average
 many more pregnancies than women in developed countries
 their lifetime risk of death due to pregnancy is higher
 A woman’s lifetime risk of maternal death is the probability that a 15 year old woman will
eventually die from a maternal cause.
 In high income countries, this is 1 in 5400, versus 1 in 45 in low income countries

11. Fragile States Index is an assessment of 178 countries based
on 12 cohesion, economic, social and political indicators,
resulting in a score that indicates their susceptibility to
instability. Further information about indicators and
methodology is available at: https://fragilestatesindex.org/

12. Why do women die?
Women die as a result of complications during and following pregnancy
and childbirth
Most of these complications develop during pregnancy and most are
preventable or treatable
Other complications may exist before pregnancy but are worsened during
pregnancy, especially if not managed as part of the woman’s care

13. Why do women die?
The major complications that account for nearly 75% of all maternal
deaths are :
•severe bleeding (mostly bleeding after childbirth)
•infections (usually after childbirth)
•high blood pressure during pregnancy (pre-eclampsia and eclampsia)
•complications from delivery
•unsafe abortion.
The remainder are caused by or associated with infections such as
malaria or related to chronic conditions like cardiac diseases or
diabetes

14.  Key facts
• Every day in 2017, approximately 810 women died from preventable
causes related to pregnancy and childbirth.
• Between 2000 and 2017, the maternal mortality ratio (MMR, number of
maternal deaths per 100,000 live births) dropped by about 38% worldwide.
• 94% of all maternal deaths occur in low and lower middle-income
countries.
• Young adolescents (ages 10-14) face a higher risk of complications and
death as a result of pregnancy than other women.
• Skilled care before, during and after childbirth can save the lives of
women and newborns.

15. How can women’s lives be saved?
 Most maternal deaths are preventable as the health-care
solutions to prevent or manage complications are well known
 All women need access to high quality care in pregnancy,
and during and after childbirth.
 Maternal health and newborn health are closely linked
 It is particularly important that all births are attended by
skilled health professionals, as timely management and
treatment can make the difference between life and death for
the mother as well as for the baby

16. How can women’s lives be saved?
 Severe bleeding after birth can kill a healthy woman within hours if she is unattended.
 Injecting oxytocics immediately after childbirth effectively reduces the risk of bleeding
 Infection after childbirth can be eliminated if good hygiene is practiced and if early signs of infection are
recognized and treated in a timely manner
 Pre-eclampsia should be detected and appropriately managed before the onset of convulsions
(eclampsia) and other life-threatening complications.
 Administering drugs such as magnesium sulfate for pre-eclampsia can lower a woman’s risk of
developing eclampsia
 To avoid maternal deaths, it is also vital to prevent unwanted pregnancies. All women, including
adolescents, need access to contraception, safe abortion services to the full extent of the law, and
quality post-abortion care

17. Why do women not get the care they need?
 Poor women in remote areas are the least likely to receive adequate health care. This is especially true for
regions with low numbers of skilled health workers, such as sub-Saharan Africa and South Asia.
 The latest available data suggest that in most high income and upper middle income countries, more than
90% of all births benefit from the presence of a trained midwife, doctor or nurse. However, fewer than half of
all births in several low income and lower-middle-income countries are assisted by such skilled health
personnel (5)
 The main factors that prevent women from receiving or seeking care during pregnancy and childbirth are:

• poverty
• distance to facilities
• lack of information
• inadequate and poor quality services
• cultural beliefs and practices.
 To improve maternal health, barriers that limit access to quality maternal health services must be identified
and addressed at both health system and societal levels.

18.  The Sustainable Development Goals and Maternal Mortality
 In the context of the Sustainable Development Goals (SDG), countries have
united behind a new target to accelerate the decline of maternal mortality by
2030. SDG 3 includes an ambitious target: “reducing the global MMR to less
than 70 per 100 000 births, with no country having a maternal mortality rate of
more than twice the global average”.

19.  WHO response
 Improving maternal health is one of WHO’s key priorities. WHO works to contribute to the reduction of
maternal mortality by increasing research evidence, providing evidence-based clinical and
programmatic guidance, setting global standards, and providing technical support to Member States on
developing and implementing effective policy and programmes.
 As defined in the Ending Preventable Maternal Mortality Strategy (6), WHO is working with partners in
supporting countries towards:
• addressing inequalities in access to and quality of reproductive, maternal, and newborn health care
services;
• ensuring universal health coverage for comprehensive reproductive, maternal, and newborn health
care;
• addressing all causes of maternal mortality, reproductive and maternal morbidities, and related
disabilities;
• strengthening health systems to collect high quality data in order to respond to the needs and priorities
of women and girls; and
• ensuring accountability in order to improve quality of care and equity.

20.  Maternal mortality is considered a key health indicator and the direct causes of maternal deaths are well
known and largely preventable and treatable.
 The major complications that account for nearly two-thirds of all maternal deaths are severe bleeding (mostly
bleeding after childbirth), infections (usually after childbirth), high blood pressure during pregnancy (pre-eclampsia
and eclampsia), complications from delivery and unsafe abortions.
 Maternal Mortality Ratio(MMR) of India for the period 2016-18, as per the latest report of the national Sample
Registration system (SRS) data is 113/100,000 live births, declining by 17 points, from 130/ 100,000 live births in
2014-16.
 This translates to 2,500 additional mothers saved annually in 2018 as compared to 2016. Total estimated annual
maternal deaths declined from 33800 maternal deaths in 2016 to 26437 deaths in 2018.
 Pregnancy-related complications are the number one cause of death among girls between 15 and 19 years of age.
Because adolescent girls are still growing themselves, they are at greater risk of complications if they become
pregnant. Moreover, child brides are less likely to receive proper medical care while pregnant or to deliver in a health
facility, compared to women married as adults.

21.  All women need access to antenatal care in pregnancy, skilled care during childbirth, and care
and support in the weeks after childbirth. All births should be assisted by skilled health
professionals, as timely management and treatment can make the difference between life and
death for both the mother and the baby.
 The Government of India has been focusing on initiatives to improve maternal health indicators. Much
progress has been made in ending preventable maternal deaths in the past two decades: Globally the
number of women and girls who die each year due to issues related to pregnancy and childbirth has
dropped considerably, from 451,000 in 2000 to 295,000 in 2017, a 38 per cent decrease.
 However, coverage of life-saving health interventions and practices remains low due to gaps in
knowledge, policies and availability of resources. In a few areas there is a gap between the rich and
the poor and an urban and rural divide. Access to health services is often dependent on a families’ or
mother’s economic status and where they reside.

22.  UNICEF works with the Ministry of Health and Family Welfare (MoHFW), Ministry of Women and Child Development
(MWCD), NITI Aayog and state governments to support planning, budgeting, policy formulation, capacity building,
monitoring, and demand generation. It supports the capacities of health managers and supervisors at district and
block-level to plan, implement, monitor and supervise effective maternal health care services with a focus on high-
risk pregnant women and those in hard-to-reach, vulnerable and socially disadvantaged communities. UNICEF
supports the implementation of various interventions by Government of India, including:
 Reaching every mother: UNICEF supports the implementation of MoHFW policy that every delivery should be
attended by a skilled health care provider in a health care facility.
 Continuum of Care: Improving the health and nutrition of mothers-to-be and providing quality maternal and new-
born health services through a continuum of care approach. This includes improving access to family planning,
antenatal care during pregnancy, improved management of normal delivery by skilled attendants, access to
emergency obstetric and neonatal care when needed, and timely post-natal care for both mothers and newborns.

23.  Antenatal care: All pregnant mothers must register for antenatal care at the nearest health facility as soon as aware
of the pregnancy to assure healthy progress of their pregnancy and timely identify high risk issues affecting their
health or their baby’s well-being.
 The Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA) launched by MoHFW, provides a fixed day for
assured, comprehensive and quality antenatal care free of cost to pregnant women on 9th of every month. This
Programme strengthens antenatal care detection and follow up of high risk pregnancies, contribute towards
reduction of maternal deaths and reduce the MMR of India.
 Janani Shishu Suraksha Karyakaram (JSSK): this scheme encompasses free maternity services for women and
children, a nationwide scale-up of emergency referral systems and maternal death audits, and improvements in the
governance and management of health services at all levels.
 To achieve the global goal of improving maternal health and to save women’s lives we need to do more to reach
those who are most at risk, such as women in rural areas, urban slums, poorer households, adolescent mothers,
women from minorities and tribal, Scheduled Caste and Scheduled Tribe groups.

24.  As per the Sample Registration System (SRS) Bulletin of Registrar General of India
(RGI), the Infant Mortality Rate (IMR) has reduced from 37 per 1000 live births in
2015 to 30 per 1,000 live births in 2019 at National Level.

 The State/ UT wise details of Infant Mortality Rate (IMR) for the period from 2015 to
2019 are as follows:

25. o. National/ State/ UT Infant Mortality Rate (per 1000 live births)
2015 2016 2017 2018 2019
ALL INDIA 37 34 33 32 30
1 Andhra Pradesh 37 34 32 29 25
2 A&N Islands 20 16 14 9 7
3 Arunachal Pradesh 30 36 42 37 29
4 Assam 47 44 44 41 40
5 Bihar 42 38 35 32 29
6 Chandigarh 21 14 14 13 13
7 Chhattisgarh 41 39 38 41 40
8 D&N Haveli 21 17 13 13 11
9 Daman & Diu 18 19 17 16 17
10 Delhi 18 18 16 13 11
11 Goa 9 8 9 7 8
12 Gujarat 33 30 30 28 25
13 Haryana 36 33 30 30 27
14 Himachal Pradesh 28 25 22 19 19
15 J & K including Ladakh 26 24 23 22 20
16 Jharkhand 32 29 29 30 27
17 Karnataka 28 24 25 23 21
18 Kerala 12 10 10 7 6
19 Lakshadweep 20 19 20 14 8
20 Madhya Pradesh 50 47 47 48 46
21 Maharashtra 21 19 19 19 17
22 Manipur 9 11 12 11 10
23 Meghalaya 42 39 39 33 33
24 Mizoram 32 27 15 5 3
25 Nagaland 12 12 7 4 3
26 Odisha 46 44 41 40 38
27 Puducherry 11 10 11 11 9
28 Punjab 23 21 21 20 19
29 Rajasthan 43 41 38 37 35
30 Sikkim 18 16 12 7 5
31 Tamil Nadu 19 17 16 15 15
32 Telangana 34 31 29 27 23
33 Tripura 20 24 29 27 21
34 Uttar Pradesh 46 43 41 43 41
35 Uttarakhand 34 38 32 31 27
36 West Bengal 26 25 24 22

26. As per the Sample Registration System (SRS) Report of Registrar
General of India (RGI), the Maternal Mortality Rate (MMR) has
reduced from 8.1 in 2015-17 to 7.3 in 2016-18 at National Level.
The Status of MMR at National level and State level as per SRS
2015-17 and 2016-18 are as follows:
Status of Maternal Mortality Rate (MMR)
India/ States 2015-17 2016-18
ALL INDIA 8.1 7.3
Andhra Pradesh 3.6 3.6
Assam 15.2 14.0
Bihar 16.9 15.1
Jharkhand 6.1 5.6
Gujarat 6.0 5.1
Haryana 7.7 7.0
Karnataka 7.3 4.9
Kerala 1.9 2.1
Madhya Pradesh 17.5 15.9
Chhattisgarh 11.0 12.1
Maharashtra 3.3 2.6
Odisha 11.1 9.7
Punjab 6.8 7.0
Rajasthan 16.8 14.5
Tamil Nadu 4.8 3.2
Telangana 3.8 3.6
Uttar Pradesh 20.1 17.8
Uttarakhand 5.9 6.4
West Bengal 5.0 5.0
Other States 4.7 4.5
Source: Sample Registration System (SRS) of Registrar General of India (RGI)

27. In order to bring down Infant Mortality Rate (IMR) and Maternal
Mortality Rate (MMR), the Ministry of Health and Family Welfare
(MoHFW) is supporting all States/UTs in implementation of
Reproductive, Maternal, New-born, Child, Adolescent health and
Nutrition (RMNCAH+N) strategy under National Health Mission
(NHM) based on the Annual Program Implementation Plan (APIP)
submitted by States/ UTs. The interventions taken up by Govt. are:

28. Interventions for improving Maternal Mortality
Rate (MMR):
• Janani Suraksha Yojana (JSY), a demand promotion and conditional cash transfer
scheme was launched in April 2005 with the objective of reducing Maternal and Infant
Mortality by promoting institutional delivery among pregnant women.
• Janani Shishu Suraksha Karyakram (JSSK) aims to eliminate out-of-pocket expenses
for pregnant women and sick infants by entitling them to free delivery including
caesarean section, free transport, diagnostics, medicines, other consumables, diet and
bloodin public health institutions.
• Surakshit Matratva Ashwasan (SUMAN) aims to provide assured, dignified, respectful
and quality healthcare at no cost and zero tolerance for denial of services for every
woman and newborn visiting the public health facility to end all preventable maternal
and newborn deaths.
• Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA) provides pregnant women
fixed day, free of cost assured and quality Antenatal Care on the 9thday of every month.

29. • Laqshya aims to improve the quality of care in labour room and maternity operation
theatres to ensure that pregnant women receive respectful and quality care during
delivery and immediate post-partum period.
• Comprehensive Abortion Care services are strengthened through trainings of health
care providers, supply of drugs, equipment, Information Education and Communication
(IEC) etc.
• Midwifery programme is launched to create a cadre for Nurse Practitioners in
Midwifery who are skilled in accordance to International Confederation of Midwives
(ICM) competencies and capable of providing compassionate women-centred,
reproductive, maternal and new-born health care services.
• Delivery Points-Over 25,000 ‘Delivery Points’ across the country are strengthened in
terms of infrastructure, equipment, and trained manpower for provision of
comprehensive RMNCAH+N services.
• Functionalization of First Referral Units (FRUs)by ensuring manpower, blood storage
units, referral linkages etc.
• Setting up of Maternal and Child Health (MCH) Wings at high caseload facilities to
improve the quality of care provided to mothers and children.

30. • Operationalization of Obstetric ICU/HDU at high case load tertiary care facilities
across country to handle complicated pregnancies.
• Capacity building is undertaken for MBBS doctors in Anesthesia (LSCS) and Obstetric
Care including C-section (EmOC) skills to overcome the shortage of specialists in these
disciplines, particularly in rural areas.
• Maternal Death Surveillance Review (MDSR) is implemented both at facilities and at
the community level. The purpose is to take corrective action at appropriate levels and
improve the quality of obstetric care.
• Monthly Village Health, Sanitation and Nutrition Day (VHSND) is an outreach
activity for provision of maternal and child care including nutrition.
• Regular activities are conducted for early registration of ANC, regular ANC,
institutional delivery, nutrition, and care during pregnancy etc.
• MCP Card and Safe Motherhood Booklet are distributed to the pregnant women for
educating them on diet, rest, danger signs of pregnancy, benefit schemes and
institutional deliveries.

31. Interventions for improving Infant Mortality
Rate (IMR):
• Facility Based New-born Care:Sick New-born Care Units (SNCUs) are established at
District Hospital and Medical College level, New-born Stabilization Units (NBSUs) are
established at First Referral Units (FRUs)/ Community Health Centres (CHCs) for care of
sick and small babies.
• Community Based care of New-born and Young Children : Under Home Based New-
born Care (HBNC) and Home-Based Care of Young Children (HBYC) program, home
visits are performed by ASHAs to improve child rearing practices and to identify sick
new-born and young children in the community.
• Mothers’ Absolute Affection (MAA):Early initiation and exclusive breastfeeding for first
six months and appropriate Infant and Young Child Feeding (IYCF) practices are
promoted under Mothers’Absolute Affection (MAA).
• Social Awareness and Actions to Neutralize Pneumonia Successfully (SAANS) initiative
implemented since 2019 for reduction of Childhood morbidity and mortality due to
Pneumonia.

32. • Universal Immunization Programme (UIP) is implemented to provide vaccination to
children against life threatening diseases such as Tuberculosis, Diphtheria, Pertussis, Polio,
Tetanus, Hepatitis B, Measles, Rubella, Pneumonia and Meningitis caused by Haemophilus
Influenzae B. The Rotavirus vaccination has also been rolled out in the country for
prevention of Rota-viral diarrhoea. Pneumococcal Conjugate Vaccine (PCV) has been
introduced in all the States and UTs.
• Rashtriya Bal Swasthya Karyakaram (RBSK): Children from 0 to 18 years of age are
screened for 30 health conditions (i.e. Diseases, Deficiencies, Defects and Developmental
delay) under Rashtriya Bal SwasthyaKaryakaram (RBSK) to improve child survival. District
Early Intervention Centres (DEICs) at district health facility level are established for
confirmation and management of children screened under RBSK.
• Nutrition Rehabilitation Centres (NRCs)are set up at public health facilities to treat and
manage the children with Severe Acute Malnutrition (SAM) admitted with medical
complications.
• .

33. • Intensified Diarrhoea Control Fortnight / Defeat Diarrhoea (D2) initiative
implemented for promoting ORS and Zinc use and for reducing diarrhoeal deaths.
• Anaemia Mukt Bharat (AMB) strategy as a part of POSHAN abhiyan aims to
strengthen the existing mechanisms and foster newer strategies to tackle anaemia which
include testing & treatment of anaemia in school going adolescents & pregnant women,
addressing non nutritional causes of anaemia and a comprehensive communication
strategy.
• Capacity Building: Several capacity building programs of health care providers are
taken up for improving maternal and child survival and health outcomes.