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1
Minimising Maternal Minimising Maternal MortalityMortality in India in India
Evidence based ApproachEvidence based Approach
Dr. Sharda JainSec General Delhi Gynaecologist Forum
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3
Smita PatilSmita Patil
Every 5 Minute...
Maternal Death ClockMaternal Death Clock
1 woman 1 woman dies from a dies from a pregnancy-pregnancy-related related complicationcomplication
In India In India
UNICEF
6
05_
XX
X_M
M6
Near MissNear Miss Events EventsQuality Indicator of Maternal Quality Indicator of Maternal
Care Care
""A A woman who nearly died but woman who nearly died but survived asurvived a complication that complication that occurred during pregnancy, occurred during pregnancy, childbirth or within 42 days of childbirth or within 42 days of termination of pregnancy“termination of pregnancy“
W.H.O.W.H.O.
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Commitment to Reducing Commitment to Reducing Maternal Deaths (MDG- 5) Maternal Deaths (MDG- 5)
GOAL
Reduce MMR by 75 %
From 1990 - to – 2015
i.e. – 109 per lakh
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 LBSRGSRG
8SRGISRGI
Expected in 2015 - 135 per lakh LBExpected in 2015 - 135 per lakh LBMDF – 5 in 2015 is 109 per lakhMDF – 5 in 2015 is 109 per lakh
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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, INDIASRS,2007-09SRS,2007-09
Doable Goal !!
MDG - 5
Political willpower
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What Do Women Die Of ?What Do Women Die Of ?What Do Women Die Of ?What Do Women Die Of ?
They Die of simple Obstetric
Complications that Need Not Be Fatal
They Die of simple Obstetric
Complications that Need Not Be Fatal
WHO
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15% will experience an obstetric complications …This is true
world over
Nobody Knows Why This Happens.It is a Fact of Life.
Nobody Knows Why This Happens.It is a Fact of Life.
5% life threatening
Obstetric ComplicationsObstetric Complications
Most Obstetric ComplicationsMost Obstetric ComplicationsMost Obstetric ComplicationsMost Obstetric Complications
Can Neither be Can Neither be Predicted Predicted Nor Prevented…Nor Prevented…
Can Neither be Can Neither be Predicted Predicted Nor Prevented…Nor Prevented…
But if Women Receive But if Women Receive Timely Effective Timely Effective Treatment Treatment
in Time, in Time,
But if Women Receive But if Women Receive Timely Effective Timely Effective Treatment Treatment
in Time, in Time,
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…Almost All Can Be Saved…Almost All Can Be Saved
How Do We Know How Do We Know Which Women Which Women
Will Experience Complications?Will Experience Complications?
How Do We Know How Do We Know Which Women Which Women
Will Experience Complications?Will Experience Complications?
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WE CAN’T !!WE CAN’T !!
15Spirit of Every Gynaecologist
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It is necessary toIt is necessary to
ENSURE THAT EVERY ENSURE THAT EVERY PREGNANCY IS WANTEDPREGNANCY IS WANTED
CONTRACEPTIONCONTRACEPTIONKnowledge is not enough Knowledge is not enough
People have to use People have to use
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World Health Organization, World Health Organization, GenevaGeneva
Evidence – based Interventions Evidence – based Interventions
Severe Severe Bleeding Bleeding
24%24%
EclampsiEclampsiaa
12%12%
Indirect Indirect CausesCauses
20%20%OtherOther
DirectDirect
CausesCauses
8%8%
Obs-Obs-
tructetructedd
LabourLabour
8%8%
InfectionInfection
15%15%
Unsafe Unsafe
AbortionAbortion
13%13%
Oxytocin andOxytocin and
ManualManual
CompressionCompression
Iron Iron Supplements,Supplements,
Malaria Malaria IntermittentIntermittent
Treatment andTreatment and
Antiretroviral for Antiretroviral for HIVHIV
PartogramPartogram
Tetanus ToxoidTetanus Toxoid
ImmunizationImmunization
Clean DeliveryClean Delivery
AntibioticAntibioticss
Family Family Planning Planning andand
Postabortion Postabortion CareCare
MagnesiuMagnesium m SulfateSulfate
Abortion Deaths (13%)
Comprehensive Abortion CareComprehensive Abortion Care
Ensure thatEnsure that
EVERY ABORTION IS SAFEEVERY ABORTION IS SAFE..
WHO GuidelineWHO Guideline
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WHOWHO GuidelinesGuidelines
• Medical abortionMedical abortion or or vaccum aspirationvaccum aspiration
are the are the safestsafest methods methods
• MVA (MVA (Aspiration Abortion)–– It is advocated It is advocated especially especially in low resource settingsin low resource settings like PHC like PHC where reliable source of where reliable source of electricityelectricity/maintenance /maintenance is a problem ???is a problem ???
20
Three Key Points MMRThree Key Points MMR
• TimeTime - critical factor- critical factor
• Concept of THREE DELAYS.Concept of THREE DELAYS.
• Three points at which Three points at which access to care is access to care is delayeddelayed or or denieddenied or or total lacktotal lack of care of care
leads toleads to
MATERNAL DEATH MATERNAL DEATH
How Much Time How Much Time Do We Have?Do We Have?
How Much Time How Much Time Do We Have?Do We Have?
It is estimated that, It is estimated that, if untreated, death if untreated, death occurs on average in:occurs on average in:
It is estimated that, It is estimated that, if untreated, death if untreated, death occurs on average in:occurs on average in:
2 hours 2 hours from Postpartum Hemorrhagefrom Postpartum Hemorrhage
12 hours 12 hours from Antepartum from Antepartum HemorrhageHemorrhage
2 days2 days from Obstructed Laborfrom Obstructed Labor
6 days6 days from Infectionfrom Infection
2 hours 2 hours from Postpartum Hemorrhagefrom Postpartum Hemorrhage
12 hours 12 hours from Antepartum from Antepartum HemorrhageHemorrhage
2 days2 days from Obstructed Laborfrom Obstructed Labor
6 days6 days from Infectionfrom Infection21
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Janani Suraksha YojanaJanani Suraksha Yojana
JSY is a safe JSY is a safe motherhood motherhood intervention intervention under the under the
NRHMNRHM
Door step/ Door step/ Institutional deliveryInstitutional delivery /shifting from PHC – CHCs – District Hospital /shifting from PHC – CHCs – District Hospital
Education through Medical professionals & self – help groups
on risk in pregnancy and benefit of institutional delivery
24
Birth Planning Birth Planning (Home)(Home)
– Identify a Identify a skilled attendantskilled attendant – Identify appropriate Identify appropriate place of birthplace of birth, and how to get , and how to get
therethere– Identify Identify 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).– Money Money
To Avoid 3 delaysTo Avoid 3 delays
Inform mother and family aboutInform mother and family about
4 I's 4 I's • Inform Inform 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 injections T.T injections Ensur these are provided.Ensur these are provided.• Inform Inform expected dateexpected date of delivery. of delivery.• Identify Identify placeplace of delivery. of delivery.• Identify Identify health centerhealth center for referral for referral – For – For complicated complicated
delivery/cessarian Sectiondelivery/cessarian Section can be government can be government institution or accredited Private Health Institutional.institution or accredited Private Health Institutional.
ANTENATAL / INTRANATAT PLANNING
26
MALE MALE Involvement is the keyInvolvement is the key
Lack of information and Lack of information and inadequate inadequate knowledgeknowledge
Traditional Traditional practices practices
Lack of Lack of moneymoney
The First Delay - Home
Delay in deciding to seek careDelay in deciding to seek care
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
Making Emergency Obstetric Making Emergency Obstetric Care availableCare available
Emergency Referral Services (Toll free no 108)
introduced Patchy
29
Obstetric HelplineObstetric Helpline Networking of various private and public Networking of various private and public
vehicles and locally identified mobile vehicles and locally identified mobile phones forms the core infrastructure of the phones forms the core infrastructure of the helpline, which has been made financially helpline, which has been made financially sustainable by linking it with JSY.sustainable by linking it with JSY.
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Inadequate skilled attendants Poorly motivated staff Inadequate equipment and supplies Weak referral system system is not geared -system is not geared -prioritize an prioritize an
emergencyemergency & respond promptly & respond promptly
The Third Delay
Delay between arriving and receiving care at the health facility:
31
Addressing the 'third delay‘Addressing the 'third delay‘
Averting Maternal Death & Disability Averting Maternal Death & Disability Program (AMDD)Program (AMDD)
…We Need to Ensurethat Women have Access To…
Emergency Obstetric Care(EmOC)
AMDD Program Orientation
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EmOC has EmOC has 88 Key Functions Key FunctionsEmOC has EmOC has 88 Key Functions Key Functions
• Antibiotics Antibiotics (intravenous or by (intravenous or by injection)injection)
• Oxytocic Drugs Oxytocic Drugs
• Anticonvulsants Anticonvulsants • Blood TransfusionBlood Transfusion
• Manual Removal of Manual Removal of PlacentaPlacenta
• Removal of Retained Removal of Retained ProductsProducts
• Assisted Vaginal Assisted Vaginal DeliveryDelivery
• Surgery (Cesarean Surgery (Cesarean Section)Section)
32
THE GOOD NEWSTHE GOOD NEWSTHE GOOD NEWSTHE GOOD NEWS
Not all these functions need Not all these functions need hospitals hospitals and and doctorsdoctors
Well-trained Well-trained nursesnurses and and midwivesmidwives can perform most can perform most functions at Basic EmOC functions at Basic EmOC FacilitiesFacilities
33
It is An Important Point
for Resource Poor country
INDIA
It is An Important Point
for Resource Poor country
INDIA
UK / Middle EastUK / Middle East
34
Making Emergency Obstetric Care available Making 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
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PUBLIC-PRIVATE PUBLIC-PRIVATE PARTERNERSHIPPARTERNERSHIP
Life – Saving Skill
Drills
Enforcing ACCOUNTABILITYin Medical & Nursing
profession
A government INDEMNITY scheme
to cover health professionals
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We are committed to achieve the MDG 5
109 / lack Live Births
Countdown to 2015 begins……..
ASHATraining
(villages)
EquipmentsAvailability
& Maintenance
Up gradation of
PHC 24 x 7
PHC
AN care INTRANATAL
41
ANAEMIA MANAGEMENTANAEMIA MANAGEMENTMMR = 20 + 20%MMR = 20 + 20%
• Mandatory Mandatory deworming deworming • SupplementationSupplementation with with iron folic acidiron folic acid (100) (100) Vit C Vit C and and
B-12 B-12 • Use of Use of iron sucroseiron sucrose• Ensuring proper Ensuring proper measurement measurement of haemoglobin levelsof haemoglobin levels• changing changing 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”
Standardized countrywide protocol of
PPHEclampsia
Severe Anaemia &
Regular Drills
PPH
Number One causes of MMR
44
PPH BOX BALLOON TAMPONADEPPH BOX BALLOON TAMPONADE
Blood Transfusion Blood Transfusion
45
Haemorrhagic Action Haemorrhagic 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.
Eclampsia
(Drill)
Hb & IQ
Anaemia FREE Pregnancy
48
Community InvolvementCommunity Involvement
49
OutsourcingOutsourcing
ObjectiveObjective: To develop conducive environment in all : To develop conducive environment in all
PHCs, making them clean and green, and mobilizing PHCs, making them clean and green, and mobilizing
the community through involvement of Self Help the community through involvement of Self Help
Group membersGroup members
Sweeper
Gardener
Driver/watchman
Team
“Clean PHC Green PHC”
50
E-MAMTAE-MAMTA
• Mother & Child Mother & Child Online tracking systemOnline tracking system
• A GUJARAT initiative adopted by the Central Government for implementation across India
51
Maternal death reviews / auditMaternal death reviews / audit
Prime Show
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53
FOGSI InitiativesFOGSI Initiatives• EMOC EMOC 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 as in conducting normal deliveries as well as caesarean sectionscaesarean sections
• conducting conducting safe abortionssafe abortions • conducting a conducting a maternal mortality auditmaternal mortality audit in in
the states the states • National National EclampsiaEclampsia registry registry
save the girl childsave the girl child campaign campaign
My Role ?(Doctor)
.
Dr. Sharda Jain
Will - What to Change ? Why to Change ?Skill - How to Change ?
My Role ?
DO WHAT YOU CAN, WHERE YOU ARE,
WITH WHAT YOU HAVE.
Dr. Sharda Jain
“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
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.
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
PPHStep 1 General Management
• Shout for help• Rapid evaluation of Vitals• Oxygen by mask• Uterine Massage• Oxytocin 10 u IM• Site 2 large bore(16G – gray color)IV cannula• Infuse IV fluid – NS / RL run it fast• Catheterize bladder• Check the placenta-
- is it expelled
- if it is expelied – re examine & make sure it is complete• Examine vagina , perineum, and cervix for tears.
Step 2 Direct Therapy in PPH Immediately PPH- PALPATE UTERUS
Soft Uterus Contracted uterus
PlacentaExpelled
Completely Placenta retainedPartially expelled
Fundus not felt+Shock+ Pain
Atonic utB/m Massage
OxitocisCompress
MRP/ Evacuate
Inversion ImmediateRepositionOf Uterus
Complete Placenta
Trauma Cervical Vaginal
Perineal tear
Drugs Dose & route Maintenance dose Max dose Frequency Precaustion/ IC
Oxitocin IU infusion 10u/500 ml, 60 dpm
IU Infuse 10 u / 500 ml 40 dpm
Not more than 31t -
Methergin
IM / slow IU of 0.2 ml
0.2 mg after 15 min
5 doses (1 mg) 4th hourly PIH, HT, Heart disease
15 methy 1 PGF 2 a
IM 250 UG 250 ug after 15 mnts
8 doses (2 mg) 15-90 mnts Asthma heart Disease