dr neharika malhotra MD OB GYN gave the FOGSI KAMINI RAO YUVA ORATION at AICOG 2013 at MUMBAI...............proud parents we are ....jaideep-narendra

1. NEHARIKA MALHOTRA
MD OBGYN
AWARDS RECEIVED:
 Karan Gupta Memorial award for Best Poster on Oligohydramnios in 51st AICOG held in New Delhi
Feb 2008.
 Karan Gupta Memorial award for Best Poster on Fetal growth Restriction in 52 ndAICOG held in Jaipur
Jan 2009
 Best Poster on LAVH as a minimal access surgery in YUVA FOGSI West zone , November 2009
 FOGSI-IPAS young talent research award for Best research in Medical Termination of Pregnancy in
53rd AICOG, Guwhati, Jan 2010
 Best Poster Prize at the 3 p’s Conference in Agra ,2010
 Best Paper Presentation In NARCHI conference , Nagpur, sept 2010
PUBLICATIONS:
 First author paper published on Septic Abortion in Journal of SAFOG may-august issue 2010
 Article published in FOGSI FOCUS on Contraception 2010
Extra-Curricular:
 Chapter Published in Jeffcoate 22nd edition book of Gynecology State level Swimmer
Basketball Captain in High school
 Chapter Published in FOGSI book of Obstetrics and Gynecology
School Sports Captain in Senior High school
 3rd author of paper published in SAFOG journal Professional dance training in Kathak for 7
years
 Co author of many chapters in various books(jaypee Publishers) Published many articles and poetry in various
magazines and newspaper.
Member of NGO smriti and co editor of
magazine smriti ki pehal
Worked for a save the stray animals centre

2. LET THE LIFE OF EVERY MOTHER AND NEONATE COUNT

3. “KAMINI RAO YUVA FOGSI ORATION 2012”
Neharika Malhotra
dr.neharika@gmail.com
AGRA

7. WHY ARE WE
COUNTING ?

8. MAJORITY INDIAN WOMEN ARE
POOR ,
POWERLESS
&
PREGNANT

9.  Each year more than half a million
women die from pregnancy related
causes and 10.6 million children die, 40%
of them in the first month of life.
 Almost all of these deaths are in
developing countries. Many could be pre-
vented with well-known interventions, if
only they were more widely available.
 In establishing the Millennium
Development Goals four years ago, the
international community made a
commitment to reducing maternal deaths
by three quarters, and reducing child
mortality by two thirds by the year 2015.

10. OUR INDIAN SCENARIO – SHOCKING !!!
 Imagine a woman laboring alone and giving
birth by herself in a tent in a remote village.
There is no one to help and medical care is
far away. It is winter, there is no electricity, no
heat, no soap, no running water and food is
scarce.
 What will she do if she cannot stop bleeding?
If her newborn is not breathing?
 What will happen if infection sets in for
mother or baby? Within minutes or days, both
may be dead.

12. The International Classification
of Diseases (ICD)
defines
maternal death as
“Death of a woman while
pregnant or
within 42 days of the end of the
pregnancy, from any
cause related to or aggravated
by the pregnancy or its
management, but not from
accidental or incidental
causes (ICD 9th revision)”
The gestational event could be of any
type e.g. spontaneous or induced
abortions, ectopic pregnancies, pre-
term & term pregnancies.

13. The 9th revision of ICD further divided the deaths into
the following subgroups :-
1 DIRECT MATERNAL DEATHS :
Those deaths due to obstetric complications of
pregnancy, child birth or the puerperium.
2 INDIRECT MATERNAL DEATHS :
Those deaths due to previous existing disease or
condition that developed during pregnancy &
which was not due to direct causes, but was
aggravated by the physiological effects of
pregnancy.
3 FORTUITUOS / COINCIDENTAL DIRECT
MATERNAL DEATHS :
Those deaths from unrelated causes which
happen to occur in pregnancy.

14. The 42 days originally recommended in the WHO definition
is restrictive & the 10th revision of ICD introduced the
following terms : -
1. LATE MATERNAL DEATHS : Deaths
occurring in between 42 days & 1 year after
abortion, miscarriage or delivery that is
due to direct or indirect maternal causes.
2. PREGNANCY RELATED DEATHS : Those
deaths occurring in women while pregnant
or within 42 days of termination of
pregnancy, irrespective of the cause of
death.
MATERNAL MORTALITY RATE : The risk of
women dying from puerperal causes per
1000 Live Births.
MATERNAL MORTALITY RATIO : Number
of deaths per 1,00,000 Live Births.

15. MAGNITUDE OF PROBLEM
GLOBAL SCENARIO
Annually 200 million women become
pregnant.
136 million women bear children.
UNICEF & WHO estimates that 300,000 die
annually as a result of complications of child
birth.
As per Dr Malcolm Potts “
Globally every 1 minute 1 women dies due to
pregnancy related causes”!!
99% of these deaths occur in the developing
countries! This risk is more due to unregulated
fertility.

16. Haemorrhage (including
33% anaemia)
38% Sepsis
Hypertensive disorders
Obstructed labour
Abortion
Others
8%
5% 11%
5%
Major cause of Maternal deaths in India 2000-2003;Govt. of India, SRS “Maternal mortality in India; 1997-2003, Trends,
causes and Risk factors, RGI, India, New Delhi In
collaboration with Centre for Global Health research University of Toronto, Canada

17. MATERNAL MORTALITY RATIO IN 2011

18. UNDER FIVE MORTALITY RATES 2011-2012

19. Ranking for neonatal Ranking for Ranking for TOP TEN
deaths maternal deaths stillbirths
COUNTIRES
India 1 1 1
Nigeria 2 2 3
FOR NUMBER
Pakistan 3 8 2 OF STILL
China 4 13 8 BIRTHS,NEON
DR Congo 5 3 6 ATAL
Ethiopia 6 5 5 AND
Bangladesh 7 6 4 MATERNAL
Indonesia 8 7 7
DEATHS.
Afghanistan 9 4 12
Tanzania 10 9 11

20. MAGNITUDE OF PROBLEM
INDIAN PERSPECTIVE
The average Indian woman is 100 times more
likely to die of a maternity related event than her
western counterpart.
Pregnancy for our women is an accident rather
than a choice.
Sample Registration System (1991) estimates
that Crude Death Rate is 9.8/1000.
1.1% of all deaths are maternity related.
Total deaths are 82,93,770/year of which 91,231
deaths are pregnancy related.
Maternal Mortality Rate - 3.4/1000 Live Births.

22. 55% of all maternal deaths are in Asia
(which accounts for 61% of all the
world births).
In developed countries 1% maternal
deaths occur (these countries account
for 11% of all world births).
At least 1 million children become
motherless each year.
If mother dies the risk of death for her
children who are under the age of 5, is
doubled or tripled.

23. For 1 mother that dies : 20 suffer acute
complications & 100 suffer long term
complications sequelae.
Annually 35-40 million suffer serious
acute life-threatening complications.
15-20 million have serious long term
sequelae.
10-20 million risk their lives by
subjecting themselves to clandestine
terminations of pregnancy.

24. We account for 15% of world population but
20% of all maternal deaths world wide.
Every 5 minutes 1 woman dies due
to pregnancy related causes!!
1 in every 48 women are at a risk of dying
by child birth.
MMR is 407/1,00,000 LB but National
Health Policy 2000 quotes it to be
540/1,00,000 LB.
Recent Maternal Mortality Ratio by last
year was 212.

25. PERINATAL MORTALITY :
It is defined as deaths among fetuses weighing 1000gms
or more at birth (28 wks gestation) who die before or during
delivery or within the first 7 days of delivery.
BUT FOR INTERNATIONAL ACCEPTANCE :
It is defined as deaths among fetuses weighing 500gms
or more at birth (22 wks gestation) who die before or during
delivery or within the first 7 days of delivery .
# Perinatal Mortality Rate is expressed in terms of such
deaths per 1000 total births.
PMR = Late Fetal (28 wks of gestation + more) + Early
Neonatal Death (1st week) in 1 year x 1000
Live Birth in same year

26. Purpose of Analysis of Perinatal Mortality :
• It gives a clue to the cause of death.
• It helps in identifying high risk factors and in taking
measures to prevent or reduce their incidence.
# The Perinatal Rate in India varies from state to state
according to the standard of Obstetric services available
and is more in rural area as compared to urban area.
# The Perinatal Mortality Rate in India is reported to be
47 / 1000 live births in rural and 30 / 1000 live births in
urban area and in combined 44% per 100 live births in
1999.

27. The Perinatal Mortality Rate in
developed countries is less than
10 / 1000 total birth and is
gradually decreasing due to
improved obstetric and perinatal
technologies.
National goal was to achieve a
Perinatal Mortality Rate
between 30 to 35 by year 2000.

29. STILL-BIRTH :
It is the birth of a newborn after 28th
completed week (wt 1000gms or more) when the baby does
not breath or show any signs of life after delivery.
STILL-BIRTH RATE :-
It is the number of such deaths per 1000
total births (live + still birth) .
SBR = Fetal death weighing > 1000gms at birth X 1000
Total live + still-birth weighing >1000gms at birth

30. NEONATAL DEATH :-
It is the death of the baby within 28 days
after birth . It can be either early or late.
NEONATAL MORTALITY RATE :-
It is the number of such deaths per 1000
live births.

32. Reasons for having these situations
• Health is primarily a state subject - so
there is diversity
 Spending on Health -- 0.9% of GDP for
decades.
 Even now 2 - 3% only.
(many developed nations spend 6-9%)

33. Poverty
 In 2004 -05, 27.8% Indian population lived
below one dollar/day consumption”
NSS 61st round for the year 2004-05

34. Education in 15-49 yrs old
41% women and 18% men have never been to school
NFHS 3
Illiteracy in mothers doubles the IMR

35. Age of marriage
 16% of girls 15- 19 already pregnant.
Effects--
IMR 77 in teenage pregnancy,
55 in post-teen age group‖
NFHS 3 (2005-2006); UNICEF(2006) State of World Children
Pregnancy in rural girls twice as
common as in urban ones

36. Health care
 Private and government facilities exist‖
 The poor depend on government facility‖
 Govt facility – shortage of funds,
equipments, trained staff, not enough
centres‖

37. Spending on Health
 From personal funds of patients‖
 Minimum insurance coverage‖
 87% of curative health care in India by Private
sectors‖

38. The Rural Urban Divide
Rural Urban
MMR 619 267
Skilled Birth 34 73
Attendant
IMR 50% high
IMR
in rural area

39. Analysed in the light of 3 delay model
 Delay in seeking help – poverty
illiteracy
 Delay in reaching help – Distance
No ambulance
No money to pay
 Delay in getting help - Overcrowding
Ill equipped
Understaffed

40. The
Trend

42. IN OTHER COUNTRIES

43. The vastness and diversity of India
 Area-sq miles
 India 1269219
 England 50363
 Tamilnadu50216
 Kerala 15005

44. STATE
WISE

47. Trend of % of Births attended by SBA
personnel
120
% of birth attended by
100 100
80
60
SBA
42.4 48.8 49
40 33
20
0
1992-93 1998-99 2005-06 2007-08 2015
(NFHS-1) (NFHS-2 (NFHS-3) (DLHS-3)
SBA at del 79% Inst. Del 76%
source -- CES 2009 (Coverage Evaluation Survey) Year

48. CHANGING TRENDS IN MMR IN INDIA (1950-2009)
2000 2 00 0
1800
1600 1321
1400 1195
Per 100000 live births
1200 853
810
1000 580
800 50 0
4 07
600 301 254
230 212
400 186.5**
200
0
19 19 19 19 19 19 1992 1998 2001 2006 2008 2009 2011
50- 57- 63- 72- 77- 82-
57 60 64 76 81 86
Target- M M R 109 by 2015
** Lancet 2011;Vol 378, Sept, 2011
Source-RGI

49. Goals
GOAL 1: Eradicate extreme poverty & hunger
GOAL 2: Achieve universal primary education
GOAL 3: Promote gender equality & empowering women
GOAL 4 Reduce child mortality

50. Goals
GOAL 5: Improve maternal health
GOAL 6: Combat HIV/AIDS, Malaria &
other communicable diseases
GOAL 7: Ensure environmental
sustainability
GOAL 8: Develop a global partnership for
development

51. Race To MDG 4
 Indian Planning Commission & MDG monitor (UN initiative)–
India, unlikely to achieve targets for child mortality and infant
mortality by 2015
 IMR steadily declined in India from 146 in 1951 to 58 in 2005.
still higher in rural areas & for girls
 Malnutrition accounts for nearly 50% of child deaths in India
 Significant inter-state and intra-state variations in India. (11 in
Kerala to 90 in Orissa)

52. Evaluate ICDS & District Pr. Education
Program. Improving MDG indicators lead to
successful programs
Attention to neonatal health, nutrition &
immunization, Vigil on high-risk pregnancy,
focussed antenatal, intra-natal and post-partum
period
Supply safe water & good sanitation

53. As of 2010, India’s MMR is 254 with
48% births attended by SBA
 Planning Commission projects that India will miss MMR target of
109 in 2015
 States with better socio-economic status and higher educational
levels have lower rates of MMR
 National Rural Health Mission (NRHM) started in 2005 to improve
basic health care delivery system in India—is having good impact
 Promotion of Skilled Attendance at Birth and institutional delivery
 Involving Not for Profit organisations working at national and
regional levels

58.  National Population policy 2000
* 10th 5 yr plan(2002-07)
* NRHM (2005-12)
* Janani Suraksha Yojana(JSY)
* Gujarat Chiranjeevi Scheme (GCS)
* 11th 5 yr plan (2008-12)
 Regular financial flows
NRHM allocated Rs 12,070 crore ( $2.5B)
Health budget to have 3% of GDP (current
1.4%)
Money incentives in Instn. del, Obst/
anaesthetist services

59. Vince Lombardi,
perhaps the greatest-
ever football coach,
rightly said, ―The
achievements of an
organization are the
results of the combined
efforts of each
individual.‖

60. 1. Training and building capacity
amongst maternity care
providers.
2. Establishing guidelines to
elevate clinical and ethical
practices.
3. Advocacy with the Government
on laws and administrative
practices
4. Working closely with the
Government to complement
and supplement services.
5. Partnering with other NGOs
which are aligned towards
improving the state of
reproductive health.

61. Role of FOGSI –EMOC training, catalyst
AMDD(Averting maternal deaths and disability)
EMOC kit ,EMOC skill training workshop module
12x12 initiative,24x7 initiative
Kishori project ,ankur project
Ganga yatra and Bharat jagruti yatra by FOGSI, for public awareness on
various issues
FOGSI has declared its mission for next 5 yrs as
“Maternal Mortality Reduction”.
To carry forward this mission, a national initiative
called “Save the Mother and Newborn” has been
launched.
Consortium of FOGSI-IAP (Indian Academy of
Pediatrics)-NNF (National Neonatology Forum)-SOMI
(Society of Midwives of India).

62. CONCLUSIONS
Although we have come a long way from MMR 2000 in 1950
to
254 in 2006, still it is a long way to make any global impact
Changing attitude to improve individual health by Federal
& State governments is ripping benefits now.
Financial supports/incentives by states to pregnant
mothers-to-be, are already increasing institutional
deliveries
India is short of SBA- urgent need to improve the situations

63. "Make every mother and child count"
It is a call for radical progress in
ensuring the health of women and
their children. These members of
society are often neglected because
they are vulnerable. But wherever that
happens the whole society is harmed.
Today we want to make it absolutely
clear to everyone that the health of
women, the newborn and children are
a priority for our world as a whole,
and for every society, every
community, and every family.

64. “mothers are not dying because of disease we
cannot treat.They are dying because society has to
decide whether their lives are worth saving”
-Prof Fathalla

65. A strong Political will and society
is needed to put the simple
measure in place to save lives of
women dieing in childbirth.
We are not attempting to do the
impossible. On the contrary, our
aim is to do what is well known to
be entirely possible. This
approach has the potential to
transform the lives of millions.
Giving mothers, babies and
children the care they need is an
absolute imperative.

66. Thank you for hearing me
out
“Small opportunities are often the
beginnings of great enterprises”
(Helen Keller)
So lets Us join in this journey of
making every mother and child
count !!!!
Its time for society to decide whether
they want
TAJ MAHALS
or mothers and neonates