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Group 06

Dr Akhtar
Dr Nelofer
Dr Rehan
Dr Sumaida
Definition
"A maternal death is defined as the death of a
woman while pregnant or within 42 days of
termination of pregnancy, irrespective of the
duration and site of the pregnancy, from any
cause related to or aggravated by the
pregnancy or its management but not from
accidental or incidental causes.(WHO)
IN 2005, there were 5,36000 maternal
deaths world wide1
A total of 99% of maternal deaths
occur in developing countries.1
MMR in developing countries is 450
per 100,000 live births versus 09 in
developed countries.1
MMR is 276 deaths per 100,000 live births.
Main reasons are high fertility, illiteracy, lack
of skilled birth attendance, malnutrition and
inaccessibility to Emoc.
77% births occur at home. 54% are attended
by skilled attendants.3
PUNJAB: Out of all the adult women deaths,
16.3% are due to pregnancy and related
causes.(PDHS 2006-07
Lodhran is a backward district of southern
Punjab with population of 1,464,750.
Neglected by Govt in education, health and
other municipal services.
MMR is 550 per 100,000 live births and IMR is
158 per 100,000 live births.
High MMR is due to unavailability of
reproductive health services.
Unawareness and misconceptions are the
contributing factors.
Hundreds of unskilled birth attendants and
quacks provide reproductive health services.
Government,s imperfect monitoring worsens.4
NGO,s working in the area also neglect
the reproductive health issue.
Traditional knowledge and religious
misconceptions are the main hurdles.
Poverty and illiteracy contributes
towards higher MMR.4
TFR 7.1 2003-04
MMR 550 per 100,000 live 2007-08
births
CPR 23% 2007-08
Unmet need 35% 2006-07
ANC 46% 2007-08

Skilled attendant at 13.9% 2007-08


birth
Unskilled attendance 86% 2007-08

Post natal care 29% 2007-08


AIM
Improvement of maternal health status in Punjab
Objectives
To reduce MMR by 10% within three years in
District Lodhran, Punjab.
Rationale
• As there is no evidence of any initiative taken in
the past to reduce MMR in Lodhran, this project
will help to improve the maternal health status
and reduce MMR in district lodhran.
Knowledge about safe delivery practices.
Skills of health care delivery staff.
Human resource, financial constraints and
poor infrastructure.
Awareness and utilization of family
planning services.
Emoc facilities.
Availability of 24 hours health care
Family planning
• Primary prevention of maternal mortality is
examplified in the consideration of FP as a
strategy.5

• Family planning reduces number of times a


woman becomes pregnant and reduces un
wanted pregnancies.
• Even without any improvement in obstetric care
only FP services can reduce MMR upto 10%.6
It is a package of interventions focused on direct
obstetric complications that cause majority of
maternal deaths.7
It is important to pay simultaneous attention to
FP and Emoc. Ideally these two interventions
should go hand in hand.6
Increasing the proportion of deliveries with
skilled attendance is regarded as a crucial
strategy and is widely advocated by
international agencies.8
It has a preventive component of watchful
expectancy for normal deliveries as well
as referral to professional care for
emergencies.9
Through ANC early signs of morbidity and
mortality can be detected and effective
interventions are possible.10
Although there is lack of strong evidence
on the effectiveness of ANC programmes,
it still offers an opportunity for alerting the
women to risks associated with
pregnancy.11
Evidence in support of TBA training remains
inconclusive although it is recommended
that support of existing TBA programmes
should be done while giving precedence to
other programmes which are based on
stronger evidence of effectiveness.12
In light of the above mentioned evidence
from different studies :
Most effective preventive intervention is
promotion of family planning.
Most effective curative intervention is 24
hours availability of comprehensive
emergency obstetric care services.
Target population: Adult males and
females of district lodhran.
Infrastructure required:
EDO will collaborate with DPWO.
Services will be provided through RHS’A
centers, MSU,s, FW centers and RHS’B.
RHS’A MSU,s FW Centers RHS’B Total

Service 03 03 36 Not 42
outlets registered
Community level activities
Collaboration with DCO, Nazim and Counsellors.
Identification of community leaders( males as well as
females).

Group discussions:
Arrangement of separate male and female group
discussions by the , Tehsil officers and Male mobilizers
for males, in collaboration with FWW and LHW,s for
females and religious personalities of community.
Involvement of male and female doctor once in a month.
Physical availability of all the methods at the venue of
discussion
Information provided about the application, effects and
side effects of the FP methods.
Information about service outlets.
Islamic perspective of FP
Provision of incentives to all the
participants.
Presenting those couples as role models
and ambassadors who are themselves
using FP methods successfully and
limiting their families to 2 children
Arrangement of puppet shows at Tehsil as well
village level.
Arrangement of stage dramas at Tehsil and
district level.
Mass media campaign:
Arrangement of puppet shows at Tehsil as
well village level.
Arrangement of stage dramas at Tehsil and
district level.
Advertisement on local cable channels.
IEC material distribution (written and
pictorial) to the mothers, elderly influential
women, TBA,s , dais and others.
Documentary about FP methods and their
application, contraceptive surgery and
hazards of unsafe abortion
 Use of telemedicine technology at Tehsil level.
 Provision of 24hour hot line number for info
regarding FP.
 Hospital based youth clinics for males and
females (evidence from Bangladesh)
 Need based orientation in different institutes like
educational institutes, jails and factories
Development of a system of FP education at
graduate and university level: lectures will be
delivered by health personnels.
Provision of incentives and rewards to the
couples who have limited their family to two
children with spacing min three years
Depot services: a member of community will
store and supply the contraceptives and will be
responsible for distributing them.
Medicines for minor ailments will be available on
all service outlets without any user fee
Service outlets timing will be from 8am to 8pm
Responsiveness of the providers.
Registration of RHS’B.
Establishment of RTI for human resource.
Building intersectoral collaboration with MOPW, MOH,
Ministry Of Education, NIPS and Fedaral Beaureau Of
Statistics.
Ensuring the involvement of political leaders at local
as well as national level.
Task Month Time frame in
weeks
Recruitment of staff First 04

Finalizing IEC material Second 04

Training of staff(doctors, Third 12


lhw,s dais)

Arrangement of Second 04
documentaries
Task Month Time frame in weeks

Construction of rooms for fourth 12


community based youth clinics

Purchase of medicine for sixth 04


general ailment

Identification of community Sixth 04


leaders

Pilot project in Duniya pur Seventh 12

Review of limitations of project tenth 04


Implementation of the project will start at the
beginning of 2nd year and the performance of
the project will be regularly monitored and
evaluated every 06 months.
Monitoring and evaluation
A monitoring team will be established which will
comprise of DHO, DDHO and a field officer.
Regular visits will be paid at service outlets and
behaviour of staff and availability of services
will be assessed.
The project will be evaluated every 06
months by distributing a questionnaire and
determining the CPR and knowledge of
people about contraception.
Purchase of medicine 25 million

Contract staff for evening shift 20 million

IRC(institutional reimbursement cost) 2.5 million

POL 1.5 million

Mass media campaign 30 million

Incentives and rewards 10 million

miscallenous 05 million
1-(Maternal mortality in 2005: estimates developed by WHO,
UNICEF, UNFPA and the World Bank. Geneva, World Health
Organization, 2007 (http://www. who.int/reproductive-
health/publications/maternal_mortality_2005/index.html,
accessed 14 August 2008).
3-WHO unless indicated otherwise. : Pakistan Demographic and
health survey, 2007. : UNDP Report 2008. : World Bank World
Development Indicators 2007.)
4-State of reproductive health in District Lodhran; Pakistan times
26th March 2006)
5-. Royston E, Armstrong S, editors. Preventing Maternal
Deaths.Geneva: World Health Organization, 1989:1–233 .32.
Tinker A, Koblinsky M. Making motherhood safe. World
BankDiscussion Papers. Washington (DC): The World Bank, 1993.)
6-LC Chen et al. Maternal mortality in rural Bangladesh. Studies in
Family Planning 1974; 5:334-441.
7-UNICEF, World Health Organization, UNFPA. Guidelines for
Monitoring the Availability and Use of Obstetric Services. UNICEF,
World Health Organization and UNFPA. New York: UNICEF, 1997
[ISBN 92-806-3198-5].
8-Safe Motherhood Inter-Agency Group. Technical
Consultation, Ensure Skilled Attendance at Delivery, Geneva,
25– 27 April 2000, SMIAG/FCI New York.)
9- Hussein J, Hundley V, Bell J, Abbey M, Quansah Asare G,
Graham WJ. How do women identify health professionals at
birth in Ghana? Midwifery 2005;21:36– 43.)
 10-Rooney C. Antenatal Care and Maternal Health: How
Effective is It?A Review of the Evidence Maternal Health and
Safe MotherhoodProgramme Division of Family Health.
Geneva: WHO, 1992 [WHO/MSM/92.4]
11- Villar J, Ba’aqeel H, Piaggio G, et al. WHO antenatal care
randomized trial for the evaluation of a new model of routine
antenatal care.Lancet 2001;357:1551–1564)
12.- Bergstrom S, Goodburn E. The role of traditional birth
attendants in thereduction of maternal mortality. In: De
Brouwere V, Van Lerberghe W,editors. Safe Motherhood
Strategies: A Review of the Evidence.Antwerp: ITG Press,
2001 (Stud Health Serv Organ Policy 17).