Post on 09-Mar-2018
transcript
Dr. KANUPRIYA CHATURVEDI
Maternal & Newborn HealthWITH reference to INDIA & RAJASTHAN
KEY ISSUES Maternal & Newborn Health :Where we stand
Creating a supporting environment
Continuum of care across time & location
Risks & opportunities
Strengthening health systems
The Rate of Progress
Maternal & Newborn Health :Where we stand
Maternal & Newborn Health :Where we stand
Global Scenario Regional distribution Maternal mortality ratio & Maternal
mortality rate Direct causes Conceptual framework
Global scenario-Maternal health
Each year, more than half million women die from causes related to pregnancy & childbirth
For every such death there are 20 others who suffer pregnancy related illnesses or other adverse outcome (obstetric fistula, uterine prolapse)
Around 10 million women annually suffer from complications of pregnancy
On average, each day~1500 women die from causes related to pregnancy & child birth
80% of maternal deaths could be avoided by access to essential maternity & basic health services
Global Scenario-Neonatal Health Nearly 4 million newborns die {40% of under 5
deaths} within 28 days of birth
Three quarters of neonatal deaths occur during first 7 days
For every newborn death ,20 others suffer birth injury, complications of preterm birth or other neonatal conditions
A child born in a least developed country is 14 times more likely to die within first 28 days of life as compared to industrialized country
The big divide The divide between industrialized countries
&developing regions –is perhaps greater than on any other issue
Average lifetime risk of maternal death for a woman in least developed country is >300 times than in industrialized country
In developing world a woman has 1 in 76 lifetime risk of maternal death as compared to 1 in 8000 in industrialized countries
Global MMR stood at 430/lakh live births in 1990,and at 400/lakh in 2005
517
149
228
110134
195
445
172
517
379
162
178
371
358379
371490
194
2001-2003
Source: SRS
India: 301Kerala
110
Uttar Pradesh517
Maternal mortality ratio per 100,000 births
per 100,000 live births Less than equal to 150151 - 300More than 300Missing Data
Other Conditions
34% Hemorrhage 38%
Abortion 8%
Sepsis 11%Obstructed Labour 5% Hypertensive
Disorders 5%
Medical causes of maternal deaths in India
Source: SRS
Medical Causes of Neonatal Deaths-India
23%
3%
6%
24%
6%
2%
35%
Diarrhoea
Preterm
Congenital
Infection
Asphyxia
Other
Tetanus
Source: Lawn JE Cousen SN for CHERG (Nov 2006)
Infant deaths within 7 days of birth
Infant deaths between7 days of birth and within 28 days
Infant deaths between 28 days and within one year of birth
Child deaths between oneyear and within five years of birth
40%
10%
26%
24%
Neonatal deaths50%
Infant deaths76%
Share of under-five mortality in India
Source : SRS 2007
Infant Mortality Rates by State
73 71 70 6966 65 65
62 6157
54 5250 48
45 45 43 42 42 4240 38 38 36 34 34
30 30
15 15
0
10
20
30
40
50
60
70
80
UP
CH
MP JH AS
OR RJ
BH AR IN AP
TR GJ
WB
MG JK KA PJ UT
HR DL
MH NA
HP
MZ
SK TN MN
GO KE
Infant Mortality Rate-Rajasthan
Infant Mortality Rate by Demographic Characteristics
7256
5077
8062
4764
3730
5086
0 10 20 30 40 50 60 70 80 90 100
40-4930-3920-29
< 20MOTHER'S AGE AT BIRTH
7 or more 4-6 2-3
1BIRTH ORDER
4 years or more3 years2 years
< 2 yearsPREVIOUS BIRTH INTERVAL
Childhood Mortality Rates by Sex
37
21
58
23
79
41
15
56
14
70
0
10
20
30
40
50
60
70
80
90
NeonatalMortality
PostneonatalMortality
Infant Mortality Child Mortality Under-fiveMortality
Female Male
Steady Decline in Infant Mortality Rates India
79
68
57
0
10
20
30
40
50
60
70
80
NFHS-1 NFHS-2 NFHS-3
Creating a supporting environment
Creating a supportive environment for women & children Millennium development Goals Promoting a healthy behavior Securing a quality education Preventing child marriage Ante natal care coverage Skilled delivery care coverage
Promoting a healthy behavior Timing of births Safe motherhood Child development Breast feeding Nutrition & growth Immunization Diarrhoea
Coughs, colds & more serious illnesses
Hygiene Malaria HIV and AIDS Injury prevention Disasters &
emergencies
Quality education & a decent living
Studies show that educated women;
Are more likely to delay marriage Ensure that their children are immunized Are better informed about nutrition Undertake improved birth spacing
practices
45%
50%
54%
1992-93 1998-98 2005-06
Percentage of women aged 20-24 married before age 18
Age at marriage-India
Early marriage leads to early childbearing thereby enhancing maternal health risks
Source: NFHS
Antenatal Coverage -Rajasthan
Continuum of care across time & location: Risks & opportunities
First 28 Days of life Specific factors
Limited access to skilled care providers Home births [Associated with half of newborn
deaths] Inadequate recognition of newborn illnesses Insufficient care seeking A limited repertoire of interventions for early
neonatal disorders [ e.g. birth asphyxia, premature births ]
A lack of consensus on interventions and delivery strategies
Nutrition among women
36%
56%
33%
52%
0
20
40
60
Any anemia BMI below normal
1998-98 2005-06
Percentage of ever-married women age 15-49 with any anaemia and Body Mass Index (BMI) below 18.5 kg/m2
High percentage of women with anaemia and low BMI results in higher risk of low birth weight and peri-natal deaths
Source: NFHS
65%59%
83%
66%60%
87%
77%72%
91%
30
40
50
60
70
80
90
100
Urban Rural Total
1992-93 1998-98 2005-06
Antenatal carePercentage of ever-married women age 15-49 years having at least one ante-natal care
There has been a significant increase in ante-natal care in the last 7 years. Further increases are seen in the latest DLHS results
Source: NFHS
Women* Who Received Antenatal Care
65
83
5966 60
867277
91
Total Urban Rural
NFHS-1 NFHS-2 NFHS-3
* For last births in the past 3 years* For last births in the past 3 years
Institutional delivery
4134
26
2005-061998-981992-93
Delivery assisted by health personnel
4942
35
2005-061998-991992-93
Deliveries at institutions / by skilled birth attendants
Institutional births have shown significant improvement in the DLHS results
Source: NFHS
Percentage point change between NFHS-2 and NFHS-3 StatesRemained unchanged (2 states)
Arunachal Pradesh, Nagaland
Increased less than 7 percentage point (7 states)
Assam, Chhattisgarh, Delhi, Goa, Jharkhand, Tripura, West Bengal
Increased by 7-14 percentage points(10 states)
Bihar, Gujarat, Maharashtra, Madhya Pradesh, Meghalaya, Rajasthan, Tamil Nadu, Kerala, Uttar Pradesh , Mizoram
Increased by 15 or more percentage points (10 states)
Andhra Pradesh, Haryana, Himachal Pradesh, Jammu & Kashmir, Karnataka, Manipur, Orissa, Punjab, Sikkim, Uttaranchal
Trends in Institutional Deliveries by State
Institutional deliveries –Rajasthan
Post natal care for mothers
37.3
61.0
28.632.4
23.0
Total Urban Rural ScheduledCaste
ScheduledTribe
Percentage of women having at least one postnatal care within two days of delivery
Only 37% of women received postnatal check-ups within the recommended period of two days of delivery
Source: NFHS
Only one in four children in India are breastfed within 1 hour of birth
Initiation of breastfeeding within an hour
23%16%
10%
0
20
40
60
80
100
1992-93 1998-98 2005-06
Percentage of children born in the last three years who started breastfeeding within one hour of birth
Source: NFHS
23%
21%
23% 23%
19%
22%
Total Urban Rural
1998-99 2005-06
Every year at least six million children in India are born with low birth weight which gives them a disadvantaged start in life
Based on reported birth weight data: 30% in NFHS 2 and 34% in NFHS 3
Birth weightPercentage of children with reported birth weight less than 2.5 kg
Source: NFHS
Strengthening health systems
Proposed action framework
Central premise “.. Essential services for mothers, newborns and children are most effective when delivered in an integrated package at critical points in life cycle, in a dynamic health system, in an environment supportive of
women’s rights”
Essential Services for mothers newborn & children
Basic health care
Quality maternal care
Newborn &child health care
Adequate nutrition
Improved water & sanitation
Hygiene practices
Critical points for service delivery Adolescence, Pre-pregnancy, Pregnancy, Birth
Infancy, Childhood Post-partum, Neonatal
Supportive environment Respect for rights of
women & children
Quality education
Decent standard of living
Greater involvement of men
Protection from abuse, exploitation, violence & discrimination
Equal participation in home community, social & political life
Women empowerment
The continuum of care across time & location-‘Risks & opportunities’
Across time-{ Key points}
Adolescence Pre pregnancy Pregnancy Birth Post natal Neo natal
Across location-{ Key points}
Household level Community level Outreach services Outpatient services Facility based care
Key actions
• Enhance nutrition of adolescent girls
• Improve quality of reproductive health services
• Ensure adequacy of antenatal care
• Ensure skilled assistance during pregnancy & childbirth
Key actions• Provide access to quality Basic and Comprehensive
Emergency Obstetric
• Initiation of breastfeeding within one hour of birth
• Newborn care when required
• Expand post-natal care for mothers & newborns
• Promote safe water & hygiene practices at households and in facilities
Strengthening health systems to improve maternal & newborn health
Enhancing data collection & analysis
Enhancing human resources, training &
supervision
Fostering social mobilization
Ensuring equitable & sustainable financing
Contd. Strengthening infrastructure, transportation,
logistics ,supplies & referral process
Improving the quality of care
Global health initiatives{Strengthening
collaberation
The Rate of Progress
The Rate of Progress
Countries/Territories
U5MR [2007]
Average annual Rate of
reduction ( %) [1990-2007]
GDP/Capita Annual
Growth Rate (%) [1990-
2007]
TFR [2007]
Average annual Rate of reduction
( %) [1990-2007]
India 72 [Rank-49]
2.9 4.5 2.8 2
S.E.Asia 78 2.8 4.1 3 2.2Industrializ
ed countries
6 3 1.9 1.7 0.2
Developing countries
74 1.9 4 2.8 1.6
Least developed countries
130 1.9 2.5 4.7 1.3
WORLD 68 1.8 2.4 2.6 1.3
Comprehensive Programming for Reducing Maternal Mortality
Political commitment, Poverty, Political will and Leadership
Delays
3rd Delay: Receipt of
adequate and appropriate treatment
2nd Delay: Identifying and
reaching medical facility
1st Delay: Decision to seek care
Quality of care
Socio economic & cultural factors
Access to services
Factors
Accessibility of facilities
Quality of care
Mobilise: men, women, family & community
Link community to services
24-hour quality EmOC
Accountability
Strategies
Building Partnerships
What will make it happen
Building synergy and partnerships
Generating and sustaining strong political leadership for health of women and children
Mobilizing resources for maternal and newborn health
Empowering families and communities for promoting health and accessing healthcare