MATERNAL HEALTH Some technical aspects ANC, Delivery Care and PNC

1. B Subha Sri, RUWSEC, CommonHealth Delhi, October 2012 MATERNAL HEALTHSome technical aspectsANC, Delivery Care and PNC

2. Structure of presentation • Causes of Maternal Deaths • Antenatal care • Delivery care • Referral • Postpartum care • Some indirect causes • Women’s concepts of Safe Deliveries

3. Causes of maternal death - India(SRS data)

4. Why is Ante Natal Care important to prevent Maternal Deaths? • Even the best ANC cannot predict or prevent pregnancy complications, but ANC is important for women to come into and maintain contact with the health system

5. Antenatal care • Aim • Routine care • Identification of women with special conditions and referral to higher centre if necessary for care • Early detection of problems

6. Antenatal careEssential components • Detailed history to detect special conditions / problems • Clinical examination • Maternal height/weight • Clinical examination for anaemia • Blood pressure measurement • Abdominal examination for uterine height, fetal growth and position, fetal heart rate • Lab tests • Haemoglobin • Urine for protein • Blood group

7. Antenatal careEssential components • Medicines • Iron supplements • Tetanus toxoid • Complete antenatal card • Instructions • Birth preparedness • Danger signs • Instructions and contact for emergencies • Contraception and lactation • About maternity benefit schemes

8. Delivery care • Skilled birth attendant • Cleanliness and sterility • Partograph – Monitoring progress of labour on a graph • Monitoring of fetal heart rate • Active Management of Third Stage of Labour (AMTSL) – Injoxytocin or misoprostol within 1 minute of borth of baby - Prevention of PPH • Emergency Obstetric Care – Basic / Comprehensive • Referral – Transport and accompanied transfer • Respectful care • Birth Companion • Electricity, water, clean toilets

9. Referral • Timely – without delay • To appropriate facility • Counseling • Referral note • Transport • Accompanied

10. Postpartum care • To keep in facility for 48hours. • Monitoring for bleeding, infection. • Detect and treat problems early. • Instructions on care of herself, newborn care, danger signs • Family planning counseling • Maternity benefit schemes

11. Postpartum care • Home based • First visit – Within 48 hours • Second visit – Within one week • Third visit – Within 6 weeks • Identify problems in mother and baby and treat/refer early • Family planning • Immunization

12. Anaemia • Commonest indirect cause of maternal death • Can cause death by itself or by complicating other causes like haemorrhage or sepsis. • Postpartum anaemia can cause long term morbidity or late maternal death. • Prevention • Early detection – Haemoglobin estimation • Treatment – Iron folic acid, Iron sucrose, Blood transfusion • Social determinant – Nutrition, ICDS

13. Malaria • Pregnancy • increases likelihood of being infected with malaria • More frequent episodes • More severe infection • Higher risk of complications • Malaria induced anaemia • Higher risk of death • Very little information in India on malaria and pregnancy • Need to integrate testing and treatment in MCH programmes, especially endemic states • Prevention

14. Tuberculosis • 30% of all TB cases in the world in India. • Tuberculosis incidence and prevalence is higher in adult males than in adult females • Women perceive the stigma of TB to be worse for them than for men – delay in reporting • HIV infection higher in young women – higher chances of TB • Pregnancy with a late diagnosis of TB – increased risk of obstetric morbidity, higher miscarriage, eclampsia, intrapartum complications • Higher risk of perinatal deaths, premature births and low birth weight • Rajasthan study (ARTH) – significant cause of post partum deaths • Need for integrating MCH and RNTCP.

15. Women's perspectives – “Safe” delivery • Delivery whether at home or in an institution is “safe” when • Both the mother and the newborn survive. • There is no maternal or neonatal morbidity, both short-term and long term. • The woman and the newborn do not receive unnecessary/irrational procedures or drugs, and receive the essential/appropriate, timely care (both complicated and uncomplicated). • The woman and the newborn receive a continuum of appropriate care from antenatal to intranatal to the postnatal period. This should include safe abortion services for those women who need them.

16. Women's perspectives – “Safe” delivery • The woman and the newborn have adequate support structures at place of delivery including running water, electricity, clean toilets. • The woman and newborn have an enabling environment to a safe pregnancy and delivery including adequate nutrition, family and social support, safety at work places, access to maternity benefit and welfare schemes, birth companion • Those with complication receive emergency care and referral and transport. • Those with complication receive the appropriate technical standard of care.

17. The woman receives all the relevant information and is consulted in care give to her. • The woman and the newborn are treated with dignity. • The woman and the newborn are not discriminated in any way. • Women belonging to marginalized groups and those with special needs receive appropriate care based on their needs. • The woman and the newborn are not abused in any way