1. NARENDRA MALHOTRA
M.D., F.I.C.O.G., F.I.C.M.C.H
• Prof. Dubrovick International university,croatia
• Indian FOGSI representative to FIGO
• President FOGSI (2008)
• Dean of I.C.M.U. (2008)
• Director Ian Donald School of Ultrasound
• National Tech. Advisor for FOGSI-G.O.I.—Mc Arthur Foundation EOC Course
• Hon Prof Ob Gyn at DMIMS,Sawangi,Advisor ART unit at MAMC & SMS Jaipur
• Editor od SAFOG journal
• Chairman publication committee of AOFOG
• Practicing Obstetrician Gynecologist at Agra. Special Interest in High Risk Obs., Ultrasound, Laparoscopy
and Infertility, ART & Genetics
• Member and Fellow of many Indian and international organisations
• FOGSI Imaging Science Chairman (1996-2000)
• Awarded best paper and best poster at FOGSI : 5 times, Ethicon fellowship, AOFOG young gyn. award,
Corion award, Man of the year award, Best Citizens of India award
• Over 30 published and 100 presented papers
• Over 50 guest lectures given in India & Abroad.Presented 10 orations.
• Organised many workshops, training programmes, travel seminars and conferences
• Editor 8 books, many chapters, on editorial board of many journals
• Editor of series of STEP by STEP books
• Revising editor for Jeatcoate’s Textbook of Gynaecology (2007) and DONALD OBS MANNUAL(2012)
• Very active Sports man, Rotarian and Social worker
MALHOTRA HOSPITALS & RAINBOW HOSPITALS
,Agra-282 010
Phone : (O) 0562-2260275/2260276/2260277, (R) 0562-2260279, (M) 98370-33335; Fax : 0562-2265194
mnmhagra3@gmail.com;drnarendra@malhotrahospitals.com;n.malhotra@rainbowhospitals.org
www.malhotrahospitals.com;www.rainbowhospitals.org
jallandhar,ludhiana,ambala,bhiwani,gwalior,allahabad,gorakhpur,kolkata,bariely,jaipur,delhi,sirsa
Neapal & Bangladesh

2. MATERNAL HEALTH ECONOMICS IN
SOUTH ASIA
WILL WE ACHIEVE
MILLINIUM DEVELOPMENT GOALS 5 ?
Narendra Malhotra
Jaideep Malhotra
Neharika Malhotra
Keshav Malhotra
www.rainbowhospitals.org
Prof Alokendu Chatterjee
Prof Rubina Sohail
www.safog.org
“Small opportunities are often the beginnings of great enterprises”
(Helen Keller)

3. "Children are our
future, and their
mothers are its
guardians.”
Kofi Annan

5. • 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
goals,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.

6. EVERY DAY A JUMBO JET FULL OF
PREGNANT WOMEN CRASHES IN THE
WORLD DAILY,KILLING OVER 400 WOMEN
DURING PREGNANCY AND CHILDBIRTH
THIS NEWS NEVER MAKES DAILY HEADLINES
WHY ??

7. “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

8. MAJORITY SOUTH ASIAN WOMEN
ARE
POOR ,
POWERLESS
&
PREGNANT

9. 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.
"Make every mother and child count"

10. Millennium Goals 2015
GOAL 1: Eradicate extreme poverty & hunger
GOAL 2: Achieve universal primary education
GOAL 3: Promote gender equality & empowering
women
GOAL 4 Reduce child mortality

11. Millennium Goals 2015
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

12. MILLINEUM DEVELOPMENT GOALS 5

13. Bangladesh
Bhutan
India
Nepal
Maldives
Pakistan
Srilanka

14. ASSESMENT OF HEALTH OF A COUNTRY
____
• Adolescent health care – routinely practiced or
not
• Pre-conception care – routinely practiced or
not
• Ante Natal Care % -- 1 visit, 3 /4 visits & by whom
• Skilled Birth Attendance – % delivered by SBA
• Institutional Delivery -- % of Inst delivery
• Post natal care -- % of PN care & when
• Functional referral system -- how much
functional & how quick; who pays for it
• MMR – current estimate i.e. for 2011

15. BANGLADESH

16. Maternal health care scenario is dismal in
all South Asian countries (except Sri Lanka)
the reasons in Bangladesh
• Political will
• Infrastructural issues, including basics
• Dr/Nurse strength—human resources
• Organisational failures
• Social evils –female education (%), early marriage
(age & %), domestic violence (%) &
attitude of your society, particularly
attitude of men, on women’s health

17. Maternal health scenario- Bangladesh
Political will -very much positive in improving MCH
Infrastructural issues- CMOC services in:
• Community clinic
• Upazilla health complex-132 (BMOC in rest UHC)
• General hospitals-3 District hospitals - 59
• MCWC-under DG family planning -63
• All medical colleges & specialized hospitals-95

18. Human Resources in Health in Bangladesh
• Doctor : Patient – 1:4000
• Nurse : Patient - 1:8000
• Nurse : Dr – 1 : 4
• Private Dr : Pt at rural area – 1: 29000
• Health care provider : Population -1:10000
• 5 physicians & 2 nurses /10000 population

19. Organizational failure
• Failure to increase the budget for MOHFW
• Health Workers shortage (specially in rural areas)
• Unable to retain trained HWs at EmONC centers
• Hard to reach areas ; Logistic ; scarcity
• Failure of monitoring
• Failure to co-ordinate between H & FP of MOHFW

20. Social evils
Female education-
• Primary education (complete)-14.3%
• Secondary education (complete) or higher-9%
• No education-27.7% Rest ???
Early marriage-
• At 13-14 yrs - 4%
• At 15-19 yrs -10.6%
• 25% become mothers before 20 years Source-(BDHS 2011)
Domestic violence- high ,mainly unrecorded.
Attitude of society towards women’s health - Unsatisfactory
• women has No decision making power -so repeated child birth.
• No regular ANC, under nutrition, anemia
• women not allowed to attend hosp even during emergency

21. Health economics
National health expenses as % of GDP- 1.03%
• Health budget - 5.4% total budget in 2011-12 & 4.9% in 2012- 2013 .
$ 16 per capita for health/yr
• Maternal health budget- 15% of total health budget
• Public expenditure as % of total health exp. 33.59%
• Private expenditure as % of total health exp. 2.29%
• External support as % of total health exp 30%
• Health insurance in Preg & child birth No provision

22. Strategies to improve Maternal health
scenario in Bangladesh
• Strengthen health facilities for EmONC services (1994)
• Demand Side Financing: Maternal Health Voucher Scheme
(DSF:2006)
• Maternal & neonatal health (MNHI) program 2007
• Free Tetanus Toxoid for women of child bearing age:2008
• Community based SBA (C-SBA) Program 2003(Target 13,500)
• Nurse midwifery training :2010 (Target 3,000)

23. Regular financial flow is maintained by
• Government’s own fund
• Aids from Donor agencies
• Development partners (USAID,DFID,CIDA,WHO,UNFPA)
• Partial cost recovery
• GOB finances 70% (93.55 billion for this fiscal year) and parallel
funders contribute remaining 30%, including 15% loans by World
Bank

24. Role of Bangladesh OBGY Society
* OGSB working on Maternal health programs along with GOB,
NGOs, UN agencies and development partners
• EmoNC-training & monitoring of doctors , paramedics
• C-SBA training and monitoring at govt .& private level
• Treatment of Eclampsia at community level
• Prevention of unsafe abortion –IPAS,FIGO
• Human resource development - LSTM, UNICEF
• F.P-Training on long acting contraceptions etc

25. Will MDG 5 targets be reached by Bangladesh
Targets & indicators Unlikely Potentially No data
5A: Reduce MMR by 75%
between 1990- 2015
Maternal mortality ratio ✓
most births attended by SBA ✓
5B: Achieve universal access to
reproductive health by 2015
Contraceptive prevalence rate ✓
Adolescent birth rate ✓
ANC (one/ four visits) ✓
Unmet need or family planning ✓
Achieving Millennium Development Goals 4 and 5 in Bangladesh
S Chowdhury,LA Banu,TA Chowdhury, S Rubayet, S Khatoon BJOG Sep, 2011

27. Per100000livebirths
CHANGING TRENDS IN MMR IN INDIA (1950-2011)
Target- M M R 109 by 2015
Source- RGI, Lancet, vol 378 ; sept, 2011

28. Unfavorable maternal health in India
Reasons ---Political Will
• Not a priority agenda for any political party
• National opinion has never focused on
maternal health as a burning issue
• We need to decide to save women’s lives

29. Unfavorable maternal health in India
Reasons -- Infrastructure
• Nearly 80% of Mat Health care provided by private sectors in India
• Dr :Pt 1:1953 or 0.5 Dr /1000 Indian (WHO-- 1/ 1000)
• Only 0.86 hospital beds per 1000 people
• Health facilities maldistributed & mostly in urban areas
• Transport & connectivity need vast improvement
Times of India, March 6, 2012 Financial Express, July 8, 2009

30. Unfavorable maternal health in India
Reasons-- Organisation
• No central theme
• Diffusion of focus from EmOC and SBA cares
• Lack of integration
• Inadequate monitoring and evaluation

31. Unfavorable maternal health in India
Reasons -- Social Issues
Female Education - Adult literacy rate: females as a % of
males, 2005-2010, is 68%
• Age at Marriage – 18% by age 15, 47% by age 18
• Domestic violence – ‘Wife beating’ justified by 51% of
men and 54% of women. violence by husband on > 40%
married Indian women
• Sexual violence -- 1 in 2 women suffer in India
NFHS III, 20005 – 6
http://www.unicef.org/infobycountry/india_statistics.html

32. Health Economics -- lop sided
State health exp as % of GDP: 1. 4%(2011)-- 3%(2022)
Public expenditure on health: 20. 3% **
Private expenditure on health: 77.4% mostly own/family exp
External Support: 2.3%
Source : National Health Accounts India (2001 – 2002), NHA Cell, MoHFW, GOI
Effect of hospitalisation – 35% pt drop to BPL , 40% borrow/sale assets,
20% (U) 28%(R)- no funds for health care. Insurance coverage -just 1%
** USA Public health exp. 50% ; West European states > 80%
(Scieber & Poullier, 1988)

33. Health Economics - Insurance
• Chiranjeevi Scheme of GOI--PPP model, where fees
paid to Drs. For Obst & other RH services
• In private insurance, most policies exclude
pregnancy and childbirth related expenses
• Corporate employees & members of certain large
groups, health policies cover pregnancy

34. Strategies to improve Maternal Health & its
financing, in India
Janani Suraksha Yojana--Encourages Inst.delivery through cash
incentives by central Govt, to Pt.& female community health
workers
• Chiranjeevi scheme – PPP model; Govt pay Private empanelled Drs
for every delivery in their hospital to encourage institutional
delivery
• Benefits from other schemes aimed at population stabilization,
reducing neonatal & infant mortality

35. Strategies to improve Maternal Health
in India
• Upgradation of physical facilities at all PHCs
• Skills upgradation of PHC workers
• Training in obst. & anesthesia skills
• Over 35000 personnel trained as health workers

36. FOGSI and maternal health
• To built a bridge between private Drs & Govt
• Catalyst to bring about changes
• Opinion creator and the leader
• Advocacy-Advocate Central & state govts for changes to policies,
laws, rules, regulations & practices to increase access to safe
abortion services in public & private sectors

37. FOGSI & Maternal Health …contd
• Emergency Obstetric Care ( EmOC )
Objective -- develop skills of non-specialist Drs.(GPs & MO), to provide
high quality EmOC services in underserved areas to prevent
maternal mortality & morbidity
• Comprehensive Abortion Care( CAC )
District level model, to deliver safe abortion services,
through public health system & expand use of MVA & MA

38. Will MDG 5 targets be reached by India ?
Target 5A Unlikely Potentially No data
Reduce MMR by 75% ✓ possible
between 1990 to 2015
Most births by SBA ✓ possible
Target 5B
Increase CPR ✓ Possible
Reduce Adolescent birth rate Unlikely
ANC 4visits ✓ 1 visit Possible
Unmet need for FP ✓ Possible
Source :--Chatterjee A, Paily VP. Achieving MDG 4 and 5 in India. BJOG 2011;118 (Suppl. 2):47–
59

40. Maternal health care scenario in Nepal –reasons
• Total Hospital Beds 6944
Community Hospital- 10-15 beds
District Hospital 50 beds
2349 person for a single bed
• Organizational failures –
Availability of electricity, drinking water ,emergency medicines etc -- are available but
sometimes there is shortage of medicine
• Social evils
Female education (%): 52% Literate
Early marriage (age & %) Median age 17.5yrs;
< 17 yrs-- 5% ; Domestic violence (15-49) (%) = 22%
• Attitude of men on women’s health --in 35% cases men decides for
women and in 65% cases she decides

41. Total health expenditure by function 2005/6

42. Total health expenditure by source 2005/6

43. CEOC/BEOC/BC-making it functional
Human resources-train/in place/transfer
Tertiary Level hospitals are too busy
Equity access/demand/need
 Flow and monitoring of fund
Sustainability-tapping local resources
Involvement of private/medical colleges health facilities
33 CEOC functioning-HR/quality
Poor Monitoring and Evaluation
Poor reporting and recording
How to reach special groups
Integration with SRH/FP
Referral mechanisms
Policy
Program
Major Challenges in Ama Surachha Program

44. NESOG ROLE
Advocacy
Work with Ministry of Health, Govt of Nepal
Identify short comings & Propose for changes
Prepare Guide books for training purposes
To cope with the demands & support Ministry of Health’s initiative

45. Will MDG 5 targets be reached by Nepal?
Target Unlikely Potentially No data
5A: Reduce MMR by 75%
between 1990 & 2015
Maternal mortality ratio ✓
most births attended by SBA ✓
5B: Achieve universal access to reproductive health by 2015
Contraceptive prevalence rate ✓
Adolescent birth rate ✓
ANC (one/ four visits) ✓
Unmet need or family planning ✓
Achieving Millennium Development Goals 4 and 5 in Nepal-- D S Malla, K Giri, C Karki, P Chaudhary
BJOG Sep, 2011

47. Present scenario of maternal health in Pakistan
• Adolescent health care – patchy
• Pre-conception care – not routinely practiced
•ANC by health prof. – 1 ANC -- 61% ; 4 & more ANC --28% ;
Urban: Rural = 48%: 20%
• Delivered by SBA --39% ; urban : rural = 60% : 30%
• Institutional delivery– 35 % ; Public 11%, Private 24%,
• Home delivery --65% ; urban : rural = 56% : 25%
•Postnatal check up -- 43%
• Referral system – informal, paid by patient’s relatives
[2006-7 PDHS,NIPS, Macro international ]

48. MMR By Province
Punjab
227
Sindh
314
Balochistan
785
NWFP
275
MMR for 3 yrs prior to survey .
MMR 260 in 2010
MMR is significantly higher in the RURAL areas and in BALOCHISTAN province
2006-07 PDHS, NIPS and Macro International
Present scenario of maternal health in
Pakistan ……contd

49. Poor Maternal Health Care in Pakistan- Reasons
Political Will In theory only
Infra structure Exists, not utilised. Inadequate
equipment;
lack of staff & quality training;
lack of public confidence
does not operate 24X7
Drs : nurses 1 : 1.4
Organisational
failure
Inferior health care in rural & urban
areas, lack of adequate community & Pvt
sector involvement, lack of strong DHS &
implementation of short / long term policy
measures.

50. Poor Maternal Health Care in Pakistan - Reasons
Social issues Poverty, rapid urbanization, sizeable
young population, large refugee
population, Male gender preference
Female education Female 46%, Total 58%. (2011)
Early marriage Age of marriage - 21.8 years. 74% girls
below 16 married in Charsadda & Mardan
Domestic violence VAW – 8539, DV - 610 cases (2011)
Better gender equality. 'Protection against
Harassment of Women at Workplace Bill
2009’adopted in 2010
Attitude of society
to women's health
Low status, not enough emphasis, not the
decision makers

51. Maternal Health Economics Pakistan
State health expenses % of GDP 3.2% of GDP
Share of maternal health 0.67% of GDP
Public expenditure 33.32%
Private expenditure 57.33%
External Support 4-16%
Health insurance for Preg &
child birth
1.64%
Employers contribution Social
security
5.07%
Philanthropy 0.92%
Population not fully covered for
health care costs
73.38 %

52. Maternal Health Economics Pakistan
Other Issues
• Limited commitment within system to generate
resources for intended purpose
•Poor correlation between spending & outcomes
• Lack of efficient & equitable use of finances
• Leakage of funds
•Inequitable allocation of revenue-- 26.81% spent on 13%
of population

53. Strategies to Improve Maternal Health Scenario
in Pakistan
Key working areas
• Strengthening health systems & promoting
interventions focusing on pro-poor policies
• Monitoring and evaluating the burden of maternal &
newborn ill-health and its socio-economic impact
• Building effective partnerships to use scarce
resources & minimize duplication in efforts.

54. Strategies to Improve Maternal Health Scenario
Pakistan
• Strengthening of MNCH, LHW and SBA programs
• Strengthening contraceptive services
• Management of unsafe abortions
• Creating awareness amongst women
• Opportunities for earning for women

55. Role of SOGP –Supportive Corporate Capacity
• Leadership role
• Advocacy
– Dissemination among faculty and students in medical and public
health institutions, information about:
• Maternal mortality, Gyn oncology. Abortion DATA
• PDHS and status of health indicators
• MDGs and way forward, emphasizing their roles
• Impart competency-based training to Drs.& Midwives
• Support research to update clinical practice

56. Role of SOGP – Supportive Corporate Capacity
• Practice best practices in clinical OB/GYN
• Collaborate with Govt to develop health care policies
• Collaborate with agencies & development partners
• Support efforts to ensure quality

57. Will MDG 5 targets be reached by Pakistan ?
Target Unlikely Potentially No data
5A: Reduce MMR by 75%
between 1990 & 2015
MMR ✓
Most births attended by SBA ✓
5B: Achieve universal access to reproductive health by 2015
Contraceptive prevalence rate ✓
Adolescent birth rate ✓
ANC (one/ four visits) ✓
Unmet need or family planning ✓
source :--Mahmud G, Zaman F, Jafarey S, Khan RL, Sohail R, Fatima S.Achieving
Millennium Development Goals 4 and 5 in Pakistan. BJOG2011;118 (Supp. 2):69–77.

59. 1.Geographical variations : North & East-21% & Estate -18%
of NMM
2. Poverty – 30% Estate, 28% Rural
3. Septic abortions- increasing (10-15%); PPH commonest
4. Contraceptive compliance - Poor
5. Inadequate health facilities few areas-EMOC, staff ,finance
6. Aftermath of ethnic conflict- IDP, single mother
7. Emerging communicable diseases- Dengue, H1N1, HIV
8. Increase Maternal mortality & morbidity due to NCD, Mental
illnesses and Suicides
9. Domestic Violence – Incidence varied 5-47% during Preg; Highest
among unmarried ,extremes of age. Adverse pregnancy
outcome 3 times high.
MMR is low in Sri Lanka but stagnant for last half decade

60. factors in Sri Lanka
• Political will
Good Political commitment to MDG 5 through Presidential task force,
Health master plan and “Mahinda Chinthanya”
• Infrastructural issues, including basics
Except north & east most people live within 5km of health facility, but
in some areas transport & road access are major problem.
Estate & some rural areas – poor social indicators like sanitation ,safe
drinking water and housing
North & East- Disruption of homes( IDP) , roads , health facilities, local
economy and community network
• Dr/Nurse strength
Medical Officers 49, Obstetrician 3, Nurses 87 & Midwifes 26 /100,000 pop
Acute shortage of HR & EMOC in some rural areas, estates & north and east

61. factors in Sri Lanka
• Organizational failure
Decentralisation of health system slow and uneven. Reorganisation of hosp &
referral system has not achieved good results. Existing health information system is
outdated .
. Social evils
Female literacy -89% Female literacy (15-24y) 99%
Female life expectancy -76yrs
Marriage by age 15 - 2% Marriage by age 18 - 12%
Poverty > 30% of estate pop & 28% rural pop are BPL
18% maternal deaths occur in Estates
. Attitude of men GBV not uncommon but generally men respect women due
religious and socio-cultural reasons

62. 0
10000
20000
30000
40000
50000
60000
70000
80000
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Total Health Expenditure (SLR Million)
Increase government spending on health at least 2.5-3.0 % of GDP.
Private spending would continue to be about 1.5-2.0 GDP so that the total expenditure would
be 4.5- 5.0 of GDP ---2011
Government to maintain health care expenses at 8% --10% of total public outlays.
Only 9% of the health budget allocated to preventive sector.
No National data available for health budget allocation for Maternal Health

63. Role of SLCOG
Advocacy and help in policy making
Training and Education ; Service provider
By 2013 all maternal death inquiries & by 2015 all severe acute maternal
morbidity audit – SLCOG to audit in the internationally accepted standard
of confidential reporting
By 2014, SLCOG aims to set standard on :--
ANC, IPC,PNC ,EmOC, Post abortion care & Contraceptive services for all
sexually capable people irrespective of age, parity & marital status

64. Will MDG 5 targets be reached in Sri Lanka ?
Target Unlikely Potentially No data
5A: Reduce MMR by 75%
between 1990 and 2015
Maternal mortality ratio ✓
Most births attended by SBA ✓
5B: Achieve universal access to reproductive health by 2015
Contraceptive prevalence rate ✓
Adolescent birth rate ✓
ANC ( 1 & 4 visits) ✓
Unmet need or family planning ✓
Senanayake H, Goonewardene M, Ranatunga A, Hattotuwa R, Amarasekera S, Amarasinghe I.
Achieving Millennium Development Goals 4 and 5 in Sri Lanka. BJOG 2011;118 (Suppl. 2):78–87.

65. All the SAFOG countries, except Sri Lanka, urgently need to expedite
their efforts many folds, to reach their MDG targets, sooner than later.
Need of the hour -- each constituent country of the South Asia, MUST
politically, financially & sincerely, work hand in hand, with the
Obstetricians of this region, to improve the health of their mothers.
More Public expenditure needed on maternal health with all round
Infrastructural improvements in health sector and more community
involvement. we need ---
POLITICAL WILL AT THE HIGHEST LEVEL
SAFOG is ready to be the most important stake holder

66. Maternal health care strategies
Improved Indirectly – by
• Improvement of FP services
• Free female education upto 12thstandard
• Safe menstrual regulation services
• Maternal nutrition project
• Increase of Maternity leave upto 6 months
• Day care center in public & private sectors

67. 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.
PRIVATE SECTOR HAS A MAJOR C.S.R
for this cause

68. how can we private sector help
• Understand that this is our problem tooo??
• Keeping mothers alive and healthy is our
responsibility to(cannot blame govt.for all ills)
• Enroll in PPP janani suraksha yojanas
• Form our own programmes to help BPL
• Charity
• Free camps and check ups and immunizations
• Awareness
• Save girl child programmes,walks,rally etc etc

70. how we are helping ..the 9th camps
pregnancy ….nines

71. Its time for society to decide whether they
want
TAJ MAHALS
or mothers and neonates
AND IT IS TIME THAT SUMMITS LIKE THIS
DISCUSS MATERNAL HEALTH IN ALL
MEETINGS
if we could have saved this beautiful queen during her 14th childbirth….there
would have been no tajmahal……………….

72. “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

73. Thank You All
Long Live SAFOG