1. LIFE OF EVERY MOTHER
AND NEONATE COUNTS!!!!
YUVAFOGSI
DR.KAMINIRAO ORATION
AICOG 2013 -MUMBAI
DR.D.KIRANMAI
ASST. PROFESSOR
MGMH,OMC HYDERABAD
SCIENTIFIC CONVENER
AICOG,2011
JOINT SECRETARY, OGSH

2. WORDS CAN’T DESCRIBE………..
o Health of the
mother When mothers die……….
o The health of
the child
o Human capital A NATIONS
of the nation FUTURE
Motherless HUMAN AND
children die more
frequently,
SOCIAL CAPITAL
IS CRIPPLED.
malnourished,
 less likely to
school.

3. 14TH JAN 2012
KOLKATA
 Women are not dying because of a disease
we cannot treat
 They
are dying because societies have yet to
23 APRIL 2012
RD
make the decision that their lives are
worth saving
MAMOUD FATHALLA,PRESIDENT FIGO 1997

4. IT’S A BASIC HUMAN RIGHT!
• The right to survive pregnancy and childbirth is a basic
human right
• Maternal mortality-grave violation of “Right to Life”
• Other Rights – right to liberty, security and right to freedom
from cruel, inhuman and degrading treatment
• The scale of maternal mortality is an affront to humanity .It is a
human rights violation no less than torture, disappearance, arbitrary
detention and prisoners of conscience-Mary Robinson

5. UNFPA,UNICEF 2010 DATA
TOTAL MATERNAL 284000
DEATHS -2010 DEVELOPING
2,87000 NATIONS
212
100-299
550-999.
IN INDIA 56000 WOMEN DIE EVERY YEAR NOT
OF DISEASE BUT CHILD BIRTH

6. MANY STATES, MANY DISPARITIES
ASSAM AND EAG 308
212 -2010
OTHERS
149
SOUTH STATES
127 134
81 97 SRS - 2009

7. WHERE DID INDIA GO WRONG?
1960-1990
1966- 1980
 Target oriented
family planning  Huge private sector-Not
utilized
 Ineffective interventions
ANC, High risk approach  Lack of synergy
 Lack of quality
1980-1990
 CSSM, UIP, IFA-Little impact on
MMR  Supervision
 Institutional deliveries not
monitored and neglected.  close monitoring

8. 90 percent of maternal
deaths are avoidable.
POSTPARTUM PERIOD 60%
50% in 24
HOURS-
6 CAUSES
3 DELAYS

9. THE SECRET OF SUCCESS OF SRILANKA
AND MALAYSIA…….
400 THAILAND
SRILANKA
MALAYSIA
•MIDWIVES
•SKILLED ATTENDANCE TO BIRTHS
•QUALITY
•STRENGTHENING OF COMMUNITY
HOSPITALS
30
1960-1990

10. Maternal Deaths Averted With Access To
Emergency Obstetric Services-world Bank2004
15%
15% 14%
12%
12%
10%
8% 70%
5%
7%
0%
3%
1%
EMOC SERVICES

11. The First Delay
(DECISION TO SEEK CARE)
PREGNANCY IN
RURAL INDIA
<20%
40%
60%
80%
WOMEN GIVEN COMPLETE ANCS

12. 2ND DELAY- TO REACH HEALTH CARE
• 70 % do not have a means of
transportation READY
• 40-50% percent of deaths
occur at home or on the way
• Delays occur while trying to
find money or while
transporting the patient.

13. •Availability
THE THIRD DELAY-IN RECEIVING CARE •Acceptability
•Accessibility
March 2010 •Quality
• 30% of PHC - no building Only
• 40% - no vehicle •58% Do DELIVERIES
•6%- Do MTPS
• 70 % - no linkage to district blood
bank •22% Neonatal Care
• Too far, Too little, Too Late •65% IUDS
•41% Sterilisations
IN CHCS 55.2% Obstetricians
70% Pediatricians short fall

14. TO SUMMARISE
• WE MISSED ONE CARE
Emergency Obstetric And
Neonatal Care
• WE MISSED ONE KEY
FUNCTIONARY
Skilled Professional Birth
Care for every woman
Midwife, staff nurse, doctor
• THE THREE DELAYS

15. WHAT IS THE SOLUTION???
• Focuses on 18 low
performing states, EAG
States
• 165 worst districts
APRIL 12,2005 -
2017
• To Increase the
expenditure on health from
NRHM 1.1% to 3%

16. RISK APPROACH VS EMOC APPROACH
• BASIC EmOC Functions
6+2
• Health centre –No OT • Comprehensive EmOC
Functions
1. IV /IM ANTIBIOTICS • OT/District hospitals
2. IV/IM OXYTOCICS • All six Basic EmOC functions
3. IV/IM ANTICONVULSANTS plus
4. Manual Removal of • Caesarean section
placenta • Blood transfusion
5. Assisted Vaginal delivery
6. Removal of retained
4 BEMOC & 1 CEMOC FACILITY FOR EVERY
products 5 LAKH PEOPLE

17. NRHM KEY STRATEGIES -2005-2012
IPHS
DISTRICT
FRU
JSY TRAINING
LOGISTICS
FRUS 24X7
PHC 108 Infrastructure
CEMONC CARE BUDGET
24X7 BEMOC
CAC
CENTRES BLOOD BANK
ASHA COMPREHENSIVE
ABORTION CARE
HUGE IMPROVEMENTS IN INFRASTRUCTURE,MANPOWER AND
(CAC)
ACCESS TO SERVICES
NEWBORN CARE

18. NRHM-KEY STRATEGY-
ASHA-MICROPLAN OF BIRTH
• REGISTRATION OF ANC
An ASHA for every
• 4 VISITS village-2,50,000 ASHAS
• ARRANGING FOR CASH
TRANSFER - JSY
• PLANNING PLACE OF BIRTH
• TRANSPORT
• ACCOMPANYING THE
PARTURIENT
ADDRESSES THE 1ST DELAY

19. NRHM-KEY STRATEGY
Emergency Transport System,
EMRI, HSVS,Janani Express
108 THE LIFE SAVER
• TOLL FREE 108 24x7 X365
• 22 STATES,4500 AMBULANCES
• Another 6 states -3000
ambulances- 60% of
population
• India’s largest and perhaps
most successful public private
partnership in the health
FOR THE SECOND DELAY
sector 19

20. 1ST JANANI SURAKSHA YOJANA
A 80
Trends in Institutional deliveries 2002-04 to 2007; India
N ASSAM, BIHAR ,MP, ORISSA ,RAJASTHAN ,UP
70
D Introduction of JSY
T 60
Percentage of institutional deliveries
H 50
I 40
R 30 BIHAR - 6 FOLD INC FROM
DD 20
2005-2011
E
3.19 CRORE WOMEN BENEFITED UNDER JSY
10
L
0
A 2002-2004 2005-06 2006-07 2007-08
Y Assam
Rajasthan
Bihar
Uttar Pradesh
Madhya Pradesh
India
Orissa
Trends in Institutional deliverieS 20
(NFHS III), 2006-7, 2007-8

21. INSTITUTIONAL DELIVERIES –
INDIA -2008-2010
CHATTISGARH,
JARKHAND,
UP,
BIHAR
60-80%
TAMILNADU >80%
KERALA

22. NRHM TRIGGERED INNOVATIVE SCHEMES IN STATES
• KERALA-
1ST STATE TO ACHIEVE MMR<100
• GUJARAT- INNOVATIVE CHIRANJEEVI SCHEME
• TAMILNADU- FOCUSSED ON QUALITY
• NRHM strategies
All PHCS 24x7 delivery units
MDR/verbal autopsy by collector
Rs .6000 cash benefit to poor pregnant women
• ANDHRA PRADESH
• 108, ANM Tracking, Amma lalana, Sms alerts
matrudevobhava, ayushmanbhava

23. PPH –QUICKEST OF KILLERS
2 HRS PPH
12 HRS APH
1 DAY-24 HRS RUPTURE
UTERUS
2DAYS-48HRS ECLAMPSIA
3 DAYS-72HRS OBSTRUTED
LABOR
6 DAYS-1 WEEK SEPSIS
SOURCE: maine D:safe motherhood programmes: options and issues, centre for
population and family health

24. PPH –KEY INTERVENTIONS
25%
AMTSL
600UG MISOPROSTOL
P/R , ORAL
B-LYNCH/
MODIFIED B-LYNCH 22%
PREVENTABLE
STEPWISE
DEVSCULARISATION
EMERGENCY HYSTERCTOMY

25. FIGO GUIDELINES
Prevention and treatment of PPH in low resource settings
(SMNH Committee)
http://www.figo.org/projects/prevent/pph
EVERY MOTHER SHOULD BE OFFERED AMTSL BY SBA
EVERY SBA MUST BE TRAINED IN AMTSL
BRISTOL AND HINCHING BROOKE STUDIES
-AMTSL (5.9% VS 17.9%) IN EXPECTANT MANAGEMENT
MISOPROSTOL AS ESSENTIAL DRUG FOR PPH-WHO

26. FIGO GUIDELINES-PPH-
INTERVENTIONS AT CEMOC LEVEL
Aortic compression
Ext bimanual comp Int. Bimanual Comp
Video demonstrations
NASG
EGYPT NIGERIA / ZAMBIA, ZIMBABWE Intra uterine balloon tamponade

27. Preeclampsia-Direct Cause Sepsis-Direct cause
Retraining in ANC protocols & POST NATAL CARE VISITS
skills - basic BP measurement
IPP in labor rooms and
Magnesium sulphate in post natal wards-
Eclampsia
Forty eight hour stay in PHC
IEC/ BCC messages to new mothers
on danger signs
27%
To overcome cultural taboos of
26% leaving home before one week

28. OBSTRUCTED LABOR/RUPTURE
UTERUS
8%
• PARTOGRAM -
TRAINING

29. NRHM KEY STRATEGY 13%
CAC
Unsafe abortion Women centered
Comprehensive Abortion
•22% of pregnancies- Care
induced abortions • Emergency contraception
• Medical abortion
•50% -unsafe
• Safe MTP Protocol by
MVA
•95% occur in developing
countries • CONCURRENT
• In India- 4 Million unsafe CONTRACEPTION
abortions

30. LET WOMEN DECIDE……….
80 million unintended pregnancies in 2012 in developing
world- Save the Children Report
 If all unwanted pregnancies are prevented ,
 If there is no unmet need for contraception
 Up to 1 lakh maternal deaths can be prevented –WHO 2005
 Spacing - crucial for child survival
 65% unmet need in 1st yr post partum in India
 Policy shift from permanent to temporary methods
 PPIUCD
 Spacing of 36 months after previous child birth can prevent
1.8 million child deaths (25%)

31. ANEMIA
80% IN NFHS III -complicates 80% maternal deaths
(FOGSI STUDY)
Hb % at 1st visit low
20wks,28wks, cost, effective Health Iron
, acceptable strategies fortification
34 wks iron.
Cooking in
De worming
iron utensils
IV IRON
Foot wear SUCROSE
A real boon
20%

32. India is epicenter of Childhood
Mortality
• 7.6 MILLIONS DIE EVERY
YEAR -2010
• 2 MILLIONS DIE IN INDIA
• 1 MILLION ARE NEONATES
• 50% DIE WITH IN 1 HOUR
• 75% DIE WITH IN 1 WEEK
Worldwide distribution of child death
Each dot represents 5000 deaths
Lancet 2003

33. WHY do newborns in India die?
Lancet Neonatal Survival Series 2005
Neonatal Breast feeding
resuscitation 55-87%
Neonatal
6-42%
Birth Tetanus
asphyxia and
23% others10
%
Hypothermia
management, Pre-Term Severe
Kangaroo Births Infections Community
mother care- (25%) (36%) based
18-51% pneumonia
WHO World health statistics 2007 management

34. New Child Health Initiative
by GOI Sep 2009
Navjaat Shishu Suraksha Karyakram (NSSK)
A new programme on Basic
Newborn Care and
Resuscitation, launched nationally
by GOI to address important
interventions of care at birth
GOI and IAP have signed a MoU for training
FOGSI important partner

35. HOME BASED CARE FOR MOTHER AND
NEWBORN-THE VITAL missing LINK
5 VISITS IN
ASHA
42 DAYS
RS 50/1HR
D1,3,7,10 42
VISIT
Weight BCG,OPV,DPT
monitoring Completion
Safety of
Registration both mother
of birth and child at
42 days

36. • INSPITE OF THE INITIATIVES……..STILL A LONG
WAY TO GO ……..STILL TO REACH EVERY MOTHER
AND NEONATE
3.7 2012

37. PROGRESS NOT GOOD ENOUGH
MMR BY 2015
We are 212 in 2010 153
Our goal is 100
We are 63 in 2010 Under 5
Our goal is 38 mortality
by 2015
54

38. 4th Dangerous nation for women and
children
June 22,2012
Baby Falak
Baby Afreen
Worst child sex ratio of 914:1000

39. CHILDREN BEARING CHILDREN
AND……..DYING
Save the children -2012 report
Pregnancy the
biggest killer of
teenage girls
IMR 77/1000
MMR 5 times
more in girls <15
2/3rd - before 20 yrs
1/5th - before 15 yrs
Population council of india

40. TO REACH EVERY MOTHER AND NEONATE
MEDICAL SOLUTIONS
ARE WELL KNOWN – IT
IS THE STRATEGIC
DIFFICULTIES WHICH
NEED ATTENTION

41. EVERY HELPING HAND COUNTS
IAP

42. JOIN HANDS TOGETHER
• EVERY POLITICIAN
• EVERY POLICY MAKER
• EVERY OBSTETRICIAN
• EVERY PEDIATRICIAN
• EVERY MEDICAL OFFICER
• EVERY HW
• EVERY ANM
• EVERY ASHA
TO MAKE every MOTHER AND NEWBORN count

44. THANK YOU
FOR THIS UNIQUE OPPORTUNITY
 FOGSI
 MGMH NAYAPUL, OMC
 OGSH,DR.P.KSHAH, PRESIDENT, FOGSI
 DR.S.SHANTAKUMARI
 DR.P.INDIRA DEVI
 SRI.D.V.RAIDU IAS
 SIX DECADES OF RCH IN INDIA –MS.SUJATA RAO IAS
 PROF: RATNAKUMAR,
 DILEEP MAVLANKAR-SUCCESS STORIES OF
TAMILNADU ,GUJARAT

45. REFERENCES
• WHO 2005-EVERYMOTHER AND CHILD COUNTS
• TRENDS IN MATERNAL MORTALITY1990-2010-UNFPA,WHO
• SRS 2006,2008
• NRHM-WEBSITE, WHO,mohfw.nic.in
• www.iapnrpfgm.org
• Lancet series on RCH,MATERNAL AND NEONATAL
• Presentations;
• Six decades of RCH in India –Ms.Sujata Rao IAS
• PROF: Ratnakumar, Dileep Mavlankar-success stories of
Tamilnadu ,Gujarat

47. GREETINGS FROM
HYDERABAD
FROM ONE MOTHER
TO ANOTHER

48. SONG OF YOUTH
As a young citizen of India,
armed with technology, knowledge and love for my
nation,
I realize, small aim is a crime.
I will work and sweat for a great vision,
the vision of transforming India into a developed nation
powered by economic strength with value system.
I am one of the citizens of the billion;
Only the vision will ignite the billion souls.
It has entered into me ;
The ignited soul compared to any resource,
is the most powerful resource
on the earth, above the earth and under the earth.
I will keep the lamp of knowledge burning
to achieve the vision - Developed India

49. L
LETS REDEDICATE OURSELVES TO SEE SUCH HAPPY MOTHER
AND CHILD EVERY WHERE