a truly cherished moment....Dr.Kamini Rao oration 2013 mumbai. Dr.Kiranmai devineni Hyderabad

1. LIFE OF EVERY MOTHER
AND NEONATE COUNTS!!!!
YUVAFOGSI 2012 –MADURAI
DR.KAMINIRAO ORATION
DR.D.KIRANMAI
ASST. PROFESSOR
MGMH,OMC HYDERABAD
JOINT SECRETARY, OGSH

2. My mother!
You come to me like
heavens caring arms
……………………………..
Your caring hands ,
tenderly removing the
pain,
Your love , your care,
your faith gave me the
strength
To face the world void of
fear
APJ ABDULKALAM

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. 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.

5. Do our mothers and children count?
• WHY SHOULD “WE’ CARE?
• MCH indicators - human
development index .
• Maternal mortality - a proxy indicator
of functioning of a health system.
• An issue of Human rights.

6. WHERE DO WE STAND?
WHAT WENT WRONG?
WHAT HAS TO BE DONE ?
CURRENT STRATEGIES
FUTURE

7. 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

8. INDIA
THE SUPERPOWER
Budget /expenditure
on health
INDUSTRY
India and Nigeria
1/3 of world’s
maternal deaths
SPORTS
134th among 182 in
the human
DEFENCE development index
- 2009.

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

10. WHERE DID INDIA GO WRONG?
1960-1990
2000-2009
 Huge private sector-Not
1966- 1980 utilized
 Target oriented
family planning  Lack of synergy
 Ineffective interventions ANC,
High risk approach  Lack of quality supervision,
1980-1991 close monitoring
 CSSM, UIP, IFA
 ANM & MOs - accountable -
target oriented programs - FP
& UIP-Little impact on MMR
 PHC/SC DELIVERIES- not
monitored and neglected.

11. 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

12. 90 percent of maternal
deaths are avoidable.
POSTPARTUM PERIOD
60%
50% in 24
HOURS-
6 CAUSES
3 DELAYS

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

14. The three delays
Delay.. Delay.. Delay..
The First Delay
(DECISION TO SEEK CARE)
•
A PREGNANT WOMAN
WALKING 5 KMS TO REACH
PHC DAYS BEFORE HER EDD
PREGNANCY IN
RURAL INDIA

15. 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.

16. THE THIRD DELAY-IN RECEIVING CARE
UNTIMELY
INEFFECTIVE
UNDER STAFFED
UNTRAINED/INADEQUATELY EQUIPPED
LACK OF INFRASTRUCTURE
UNRESPONSIVE/DISCRIMINATORY SERVICES
ABUSE/NEGLECT/POOR QUALITY

17. 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

18. WHAT IS THE SOLUTION???
•ADDRESSES THREE DELAYS
•PROVIDES EMONC CARE
•INFRASTRUCTURE
•LOGISTICS
•STAFF
• Focuses on 18 low
APRIL 12,2005 - performing states, EAG States
2017 • 165 worst districts
• To Increase the expenditure
on health from 1.1% to 3%

19. 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
3. IV/IM functions plus
ANTICONVULSANTS  Caesarean section
4. Manual Removal of  Blood transfusion
placenta
5. Assisted Vaginal delivery
6. Removal of retained
products 4 BEMOC & 1 CEMOC FACILITY
FOR EVERY 5 LAKH PEOPLE

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

21. NRHM-KEY STRATEGY-
ASHA-MICROPLAN OF BIRTH
• REGISTRATION OF ANC
• 4 VISITS
• ARRANGING FOR CASH
TRANSFER - JSY
• PLANNING PLACE OF BIRTH
• TRANSPORT
• ACCOMPANYING THE
PARTURIENT
ADDRESSES THE 1ST DELAY

22. JANANI SURAKSHA YOJANA
EVEN BIMARU TURNS HEALTHY
Trends in Institutional deliveries 2002-04 to 2007; India
80
70
Introduction of JSY
60
Percentage of institutional deliveries
50
40
30
BIHAR - 6 FOLD INC
20
FROM 2005-2011
10
0 3.19 CRORE WOMEN BENEFITED UNDER JSY
2002-2004 2005-06 2006-07 2007-08
1ST AND THIRD DELAY
As s am Bihar Madhya Prades h Oris s a
Rajas than Uttar Prades h India
Trends in Institutional deliverieS
(NFHS III), 2006-7, 2007-8 22

23. NRHM-KEY STRATEGY
Emergency Transport System
108 THE LIFE SAVER
• TOLL FREE 108 24x7 X365
• 12 STATES,2919 FOR THE SECOND DELAY
AMBULANCES
• SAVING LAKHS OF LIVES
IN CRUCIAL GOLDEN HOUR
23

24. 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

25. NOT A RESORT-IT’S A PHC!!!

26. Trend in Maternal Mortality Rate-Tamil Nadu
160
140
145
120 109
MMR
100
80 AMTSL,
79
LSAS Blood
training, storage
60 facility, AN
Hiring of
Specialists protocol, EMRI
40 etc
20
2000-2001
2004-2005 2008-2009
0
Before RCH RCH
NRHM
Source DPH & PM
YEAR

27. GPS MAPPING TO IDENTIFY SUITABLE HOSPITALS
TAMILNADU
At least two fully equipped and operational Em OC
centers in each of the 32 districts which can be reached within 1
hour from any part of the district

28. TAMILNADU AND INDIA

29. CHILD BIRTH A JOYFUL EVENT –
CAN TURN INTO TRAGEDY
POST
PARTUM
PERIOD
ACCOUNTS
FOR 60% OF
MATERNAL
AND 50% OF
CHILD
MORTALITY

30. 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

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

32. 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

33. 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

34. 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

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

36. 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

37. 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
 Spacing of 36 months after previous child birth can prevent
1.8 million child deaths (25%)
 Policy shift from permanent to temporary methods
 PPIUCD

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

39. WHAT ABOUT ME?

40. 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

41. 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

42. 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

43. NRHM INITIATIVES FOR NEW BORN AND
CHILDHEALTH
IMNCI 433 DTS-4,92,611 TRAINED
Navjat Sishu Suraksha karyakram 50000 trained
Special Newborn Care Units (SNCU) 293
Newborn Stabilization Units(NBSU) 1134
Newborn Care Corners
Home based (NBCC)
new born care

44. 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

45. Home visits for young
infants: Objectives
KANGAROO IDENTIFY
MOTHER ILLNESS,
CARE REFERRAL
EXCLUSIVE CORD CARE
BREAST HAND
FEEDING WASHING

46. Expected outcomes
41% of institutional
deliveries Greater impact in
90% trained states with higher
15-30% reduction in neonatal mortality
NNMR

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

48. 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

49. YET TO REACH EVERY MOTHER AND
NEONATE
 30% of PHC - no building PHCS
Only
•58% Do DELIVERIES
 40% - no vehicle
•6%- Do MTPS
 70 % - no linkage to district
blood bank •22% Neonatal Care
•65% IUDS
 Blood bank sources vital but
neglected •41% Sterilisations
 Too far, Too little, Too Late
55.2% Obstetricians
CHC 70% Pediatricians short fall

50. 4th Dangerous nation for women and
children
June 22,2012
Baby Falak
Baby Afreen
Worst child sex ratio of 914:1000

51. 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

52. OTER KEY ISSUES
 FEMALE FETICIDE  PNDT
 FEMALE INFANTICIDE  DOMESTIC VIOLENCE ACT
 POVERTY  GENDER EQUITY
 DOMESTIC VIOLENCE  EDUCATION
 SEXUAL ABUSE/RAPE  EMPOWER MENT
 ILLITERACY  SCHEMES FOR GIRL CHILD
 DISCRIMINATION AT  MATERNITY LEAVE
WORK PLACE

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

55. EVERY HELPING HAND COUNTS
IAP

56. 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

57. LONG ROAD AHEAD, BUT
• THERE IS NO REASON WHY WE SHOULD LAG
BEHIND

58. 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

59. 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

60. GREETINGS FROM
HYDERABAD
FROM ONE MOTHER
TO ANOTHER

61. 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

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