Maternal Death Review…

A National Perspective
Maternal Deaths… unacceptable
numbers

 About 28 million pregnancies per year in India

 26 million live births
 15% of pregnancies likely to develop
complications
 67 000 maternal deaths in a year
Maternal Deaths…Causes

• Direct obstetric and non-obstetric causes

- hemorrhage, sepsis, eclampsia, obstructed
labour, abortion related, anemia etc
• Underlying/contributory causes
- Social, behavioral, cultural, economic factors
• The “three delays”:
– Delay in decision making
– Delay in reaching the appropriate health
facility
– Delay in receiving health care at the facility
MDG Goals,Targets and Indicators …MDG 5…
NRHM /RCH goals in line

Goal Target Indicators Achievements

MDG-5: To Reduce by 3/4ths the MMR, MMR MMR : 254 per 100,000
improve 1990-2015. live births
Maternal (From 424 (NFHS-I) to ( RGI-SRS 2004-06)
health approx.106 per 1,00,000 Live- UN Interagency
Births in 2015). Estimates(2008) :
Proportion of 230/100,000 LB
NRHM/RCH II-Reduce to births attended by
100/1,00,000 Live-births SBA. 52.6 %Safe Delivery
47% Institutional
Institutional Delivery
delivery.
76%Safe Delivery
72.9% Institutional
Delivery
(UNICEF Coverage
Evaluation Survey 2009)
MMR…we need to accelerate pace
of decline
 MMR Trends…variation across States

600
2/3rds deaths
500
MMR 2001-03
400
MMR 2004-06
300 RCH /NRHM/
MDG goal
200

100

Source:RGI SRS
 Burden of Maternal Deaths...

2001-03 2004-06
Assam 490 480
U.P. / Uttarakhand 517 440
Rajasthan 445 388
M.P. / Chhattisgarh 379 335
Bihar / Jharkhand 371 312
Orissa 358 303
Karnataka 228 213
Punjab 178 192
Haryana 162 186
Andhra Pradesh 195 154
West Bengal 194 141
Maharashtra 149 130
Tamil Nadu 134 111
Kerala 110 95
Policy and Programmes...Goals and Targets
National Population Policy 2000
MATERNAL HEALTH STRATEGIES
Provision of services
Public sector
1. Essential and Emergency
MULTI-
Demand Obstetric Care
PRONGED
Promotion- •Quality ANC, INC, Safe and
APPROACH
( Janani Institutional delivery
Suraksha
..
•Skilled birth attendance
Yojana)
•Multi-skilling
2.Operationalize FRU s & 24*7 PHCs
3. Services for RTIs & STIs –
convergence with the NACP
4. Safe abortion services- New
Provision of Services : Private sector
Guidelines
•Accreditation of Pvt. Health Facilities for
5. Strengthen referral systems
RCH services and SBA training
6.Village Health and Nutrition Day..
•Fixed package for outsourcing services
Mother-Child Protection Card

• Maternal Death Review

New • Pregnancy and Child Tracking –web based system
• Prioritising resources for identified “delivery points” or
MCH Centres
 NRHM…Overarching Umbrella
Flexible
Communitisation Funding
Decentralisation

 Intersectoral Convergence
Accredited Social Health Activist (ASHA) –
one per 1000 population
Facility Strengthening / Improving Access
Strengthening of Infrastructure- IPHS

Improving availability of Human Resource - Contractual Appointments

Availability of funds at facilities-Untied funds ,Annual Maintenance

Grants, Grants to Rogi Kalyan Samitis.

Village Health and Nutrition Days

Village Health and Sanitation Committees

Public-private Partnerships.

 Flexible Funding through NRHM/RCH Flexi-pool. 10

Maternal Death Review
Policy on Maternal Death Reviews …spelt out in
implementation framework of RCH II

Strengthen Monitoring/
Records/Audit procedures

• Monitor State and Regional

level MMR
• Introduce mother-child linked
card
• Conduct review of maternal
deaths at the hospital and
community levels
• Develop tools for maternal
death review and reporting
 Maternal Death Reviews
Initiatives…fragmented
 Why conduct MDR?
 Reduce maternal mortality and morbidity
 Improve quality of obstetric care
 Understand determinants of maternal death
 Provide stimulus for action at all levels
 Take corrective action to fill the gaps in service
provision

Prerequisite:
A commitment to act upon the findings
 Not for punitive action
MDR Process
Five approaches to help understand why women
die ...
• Maternal deaths in the
community (CBMDR)

• Maternal deaths in
facilities (FBMDR)

• Confidential enquiries into

maternal deaths

• Learning from women who

survived: “near miss” cases

• Evidence-based clinical
 All these approaches...

 Identify cases (maternal deaths)

 Review cases confidentially and no blame
 Look for avoidable factors
 Promote change in practices
 Review the outcome of these changes
 Refine and develop
The maternal death surveillance cycle..

Identify cases

Implement, Collect information

evaluate and refine

Recommendations
for action
Analyse results

No Punitive Action
Challenges... to roll out the process

 Creating awareness in community... Need for

effective BCC/IEC
 Mobilising communities and the health system
 Resolving infrastructure and human resource issues
 Building partnerships between govt. systems and
others (prof. bodies ,tech. agencies ,NGOs )
 Resolving ethical issues
 Developing guidelines and simple implementable tools
 Orientation of a wide range of functionaries --policy
makers, programme officers, frontline HWs,
community workers, PRIs...capacity building of the
states
Each maternal death is
…………
a tragedy

Bigger tragedy,
however,
is……................
failing to learn lessons
from her death!!