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PREVENTIVE STRATEGY

FOR REDUCTION IN MMR

PRESENTATION
GROUP 01
DR KAUSAR
DR TASNEEM
DR KHURRAM
DR KHALID
Introduction

According to the World Health Organization, "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.”

The target of 75% reduction in maternal mortality ratios


by 2015 is one of the three health related UN Millennium
Development Goals,

Half a million deaths worldwide.

90% in developing world.


Every minute worldwide
 380 women become pregnant.

 Amongst these, 190 are unplanned.

 110 have pregnancy-related complications

 40 have unsafe abortion.

 1 woman dies from a pregnancy related


complication.
Situation
. in Pakistan
Pakistan, the 6th most populous country of the world
continues to have high infant and maternal mortality rates.
Pakistan MMR 276/100,000 live births
GOP, has consistently allocated high priority to safe
motherhood programmes in successive national health
policies during last two decades.

Reproductive health service package of 1999 emphasized


MHC

Overall progress has been slow


District Profile
 Located in the centre of country at an almost
equal distance from Karachi & Peshawar.
 Total area is 43494 km2
 Geographically, lies in the upper Indus plain.
 A railway line connects Khanewal with FSD &
Multan.
 It is basically an agricultural area
 Administratively divided into 4 tehsils,168 union
councils.
Demographic & Health Indicators
Population 2.39 million
Rural/ Urban % 82.5/17.5%
Male/female literacy rate 75/52%
Growth Rate 2.4%
Health Facilities 125
TFR 3
IMR 86/1000
MM Ratio 160/100000
Antenatal care coverage by skilled attendant 34%

% Deliveries by skilled attendant in HF 15.5%

CPR 24%
Health Department khanewal
 EDO assissted by DHMT.

 1 DHQ hospital,4 THQ hospitals,4 RHCs ,82 BHUs,MCHCs 10,


Dispensaries 24.

 Public health sector manpower,sanctioned posts 1355, filled posts


1106.

 Posts of MOs, LHVs, Dais, at THQ, RHCs, BHUs, level are not
completely filled.
POSSIBLE AREAS OF INTERVENTIONTO REDUCE
MMR IN KHANEWAL DISTRICT
 Reduce the likelihood that women will become pregnant.

 Reduce the likelihood that a pregnant woman will


experience a serious complication of pregnancy or child
birth.

 Improve the outcome for women with complication.


Reduce the likelihood that women will become
pregnant
Target population
 Unmet need for pregnancy
 Women with high parity
 In very young women
 Women with chronic disease like heart disease and epilepsy

Intervention
 Family planning programs with involvement of TBAs
mobile clinics and religious leaders
 Motivation of health providers to participate in F.P program
 delay the age at marriage
Reduce the likelihood that a pregnant woman will
experience a serious complication of pregnancy or
child birth.
Intervention:
 Creating awareness and demand for services
 Advice on seeking antenatal care
 Increase knowledge about dangerous signs during
pregnancy among general population
 Improve decision making at household level in case of
emergency
 Training courses for health provider according to standard
protocol
 Focus on T.T.
 Training of TBAs for active management of third stage of labour.
 Provision of community operated emergency transport.

 Availability of female lady doctors at all BHU

 Availability of 24 hours skilled care at BHU

 Focus on post partum care.

 Availability of all maternal services within ½ hr of travel.


Improve the outcome for women with
complication
 Development of the comprehensive and basic emergency
obstetric care

 Knowledge of dangerous sign of postpartum

 Improve the referral system

 Strict rules and laws regulation for unsafe abortion


Curative Intervention:
Improvements in the capacity of existing health facilities to treat
complications in pregnancy and childbirth

 It is an essential element in reducing maternal mortality 1


 A study in Matlab, Bangladesh has provided support for
community based EmOC programs Three years of the
maternity-care program, which included services to manage
life-threatening complications, demonstrated a significant
reduction in direct obstetric mortality compared with the
three previous years of no intervention 2
Preventive Intervention:
Focus on the apparent delay in decision
making to seek medical care.

Aim :To reduce MMR in Khaniwal. District.

Objective: To enhance the knowledge about obstetrics emergency to


prevent delay in decision making for seeking emergency care in
Khaniwal District.

Sub objectives:
1. Increase awareness regarding reproductive health seeking
behavior
2. To train the TBAs about danger signs of pregnancy
3. Increase awareness among TBAs about timely referral
Priority
 The location of women when they deliver, who is
attending them and how quickly they can be transported
to referral –level care are thus crucial factors in
determining interventions that are needed and feasible 3

 90% deliveries take place at home and 80% death occur at


home.4

 01in 20 women with complications of pregnancy or


childbirth reaches a facility with emergency obstetrical
care.5
% 0f wom en by place of deliv ery

80

70

60

50
percentage%

rural
40
urban
30

20

10

0
at home B HU/RHC /MC H D HQ/THQ PVT
HOS P /C LINIC
knowledge about maternal life
threating condition among different
groups of participants

60
percentage

50 women
40 husband
30
20 family mem
10 total
0
ng

em ar

ur
ge

n
io
g

bo
di

ra

ct
su
ee

la
or

fe
d.

s.
bl

in
oo

ob
A

ha
bl
h.

participants
person who made decision to seek health care

60

50

40
percentage %

30

20

10

0
Self husband mother in other family TBA/DAI Others
law member
m easures taken
Package include
 Awareness program regarding life-threatening condition of pregnant
women to identify the danger signs of pregnancy to facilitates timely
decision for seeking health care.
 These delays are interrelated and occur for a wide variety of
economic, social, cultural and political reasons. Each must be
addressed if death or severe illness is to be averted. For example,
improving access to care without improving health service
responsiveness and ability to manage life-threatening complications
will not reduce maternal deaths. However, many of the poorest
women may have no contact with formal health services. There is a
need to better understand their needs and the barriers they face in
using services. These barriers can be within the household as well as
at the point of care. Invest in human resources, particularly
midwifery but also referral level skills.
Target population:
1. Pregnant women
2. Husband
3. Influential family member
4. Dai TBAs
5. Health providers

Distribution plan
 Identification of pregnant women and social mobilization by LHW to include
pregnant women in area
 Identification of dai and TBAs in the areas by community members.
 Detailed mapping of the district will be done to identify health provider at
BHU and private doctor who are mainly responsible to refer the pregnant
women to emergency obstetrics care.
 Cont…
Distribution plan
 Greater public awareness is a powerful tool in reducing maternal mortality.Civil society groups
have an important role in drawing attention to the problem and in strengthening government
accountability through engagement with Parliament and in consultations around poverty
reduction strategies
 Support for women’s groups can raise the visibility of the problem and
stimulate action .Violence is responsible for a sizable proportion of maternal
deaths.pregnant women who suffer due to delay in decision are more likely
to have more complications and may lead to death.
 Education, particularly of girls, empowers women to make informed choices
and increases demand for improved services. Better-educated women marry
later, have fewer, healthier and better educated children and make more
effective use of health services.
 Maternal health should be introduced into school curricula and into contacts
with adolescents in formal and informal settings.
 Effective communications and transport are critical to success. New
technologies, including mobile and satellite phones, can speed calls for
assistance and warn referral facilities. 
 
IMPLEMENTATION OF MY
DISTRIBUTION PLAN:
 The intersectoral collaborative meetings involving the mobilization of
community which will help in implementing the programme effectively.
 Male mobilizer from the union council for interactions and councelling with
husbands regarding their responsibilities in case of emergency and the way,
how to manage at time of delivery leading to complication due to delay in
decision making.so their Effective communications, money and transport
arrangements with mobile and satellite phones, can speed calls for assistance
and warn referral facilities.
 Provide ambulance in distant areas where health facility services are far away
with collaboration of funds given by EDO, District nazim and influential
members of the community.
 Meeting sessions in dominant family members including male and female
regarding dangerous signs of pregnancy and the consequences of delay in
decision making for seeking medical care.
IMPLEMENTATION OF MY
DISTRIBUTION PLAN:
 Educating the pregnant women through IEC materials regarding the
dangerous signs in pregnancy and during labour. And improving their
decision power and inhibition, which prevent women from consulting
at health center.
 Improve knowledge, counseling and emergency practices skills of
LHW’s by group discussions under supervision of Obstetricians and
gynecologist.
 Educating Dais and TBAs regarding life threatening condition during
pregnancy through pictorial material and improve their moral
responsibilities during patient handling, timely identification of
obstetric complication and immediate referral decision.
SUPERVISION TEAMS
 For the supervision of health facilities:
The team will comprise of DOC, DHO and 1 elected representative
 For supervision of enrollment activities:
The team will comprise of EDO , DDHO, one community representative.
 Collection, analysis, and reporting of data:
Monthly records of the activities carried out will be submitted by the health
facilities and analyses and report on monthly basis will go to the EDO health
that can change or let continue the activities based on the evidence given by
the thorough record keeping.
 Monitoring & Evaluation:
Evaluation will be done through outcome indicators
Outcome indicators:
1. Percentage of pregnant women enrolled in the health insurance plan.
2. Percentage of knowledge among pregnant women, Dais and TBAs through
questionnaire filling regarding the dangerous signs in pregnancy and during
labour.
3. Percentage of pregnant women facing complication due to delay in decision at
home level.
4. Met need for EMOC services defined as proportion of all obstetric complications
treated at EMOC centers.
5. Percentage of pregnant women referred by Dais or TBAs on time without
development of serious complication.

At the end of the plan along with quantification, qualitative formative study will be
done to see the effect through people’s eyes.
ASSUMPTIONS
 Delay in decision explains
1. Educating the pregnant women through IEC materials regarding the dangerous
signs in pregnancy and during labour. And improving their decision power and
inhibition, which prevent women from consulting at health center
2. Low status of women can be improved through providing financial support
regarding health service provision and behavior change
3. Improve knowledge, counseling and emergency practices skills of LHWs by group
discussions under supervision of Obstetricians and gynecologist
4. Insufficient resources can be overcome by providing transport and by guiding the
husband to manage money for time of complication.involvement of husband from
start will result in better compliance of the plan.
5. Lack of awareness regarding dangerous signs can be improved by providing
education to household members, health providers, influential personnel and
pregnant women.
PROJECT BUDGET

Budget allocated for ambulances and maintenance 08 million


Number of facilities 92
Budget allocated per facility 01 million
Total budget available 100million.

MILLION/MONT MILLION/YE
LINE ITEM FOR NO/TEH H/ AR/ TOTAL MILLION
4 TEHSILS SIL TEHSIL TEHSIL FOR 4 TEHSIL

AMBULANCE 01 1.5 06

PETROL &
MAINT. 0.041 0.5 02

TOTAL 02 08
NO/FACILI
LINE ITEM TY MILLION/MONTH/ MILLION/YEAR/
FACILITY FACILITY

SALARIES(New hired
staff)

LHV, DAIs, TBAs 3 0.00216 0.26

Monitoring & evaluation


staff
1 0.001 0.12
STATIONARY & EDU

MATERIAL
0.00125 0.15

PILOT PROJECT 1
VISIT/MONTH 0.0083 0.1

PROG FOR
COMMUNITY ORIE
2/MONTH 0.016 0.2

UTILITY
0.0041 0.05

TA/DA
0.00583 0.07

Misc
0.0041 0.05

TOTAL 0.04274 1
 THANKS