Dr. KANUPRIYA CHATURVEDI

1. Maternal & Newborn Health WITH reference to INDIA & RAJASTHAN Dr. KANUPRIYA CHATURVEDI

2. KEY ISSUES • Maternal & Newborn Health :Where we stand • Creating a supporting environment • Continuum of care across time & location • Risks & opportunities • Strengthening health systems • The Rate of Progress

3. Maternal & Newborn Health :Where we stand

4. Maternal & Newborn Health :Where we stand • Global Scenario • Regional distribution • Maternal mortality ratio & Maternal mortality rate • Direct causes • Conceptual framework

5. Global scenario-Maternal health • Each year, more than half million women die from causes related to pregnancy & childbirth • For every such death there are 20 others who suffer pregnancy related illnesses or other adverse outcome (obstetric fistula, uterine prolapse) • Around 10 million women annually suffer from complications of pregnancy • On average, each day~1500 women die from causes related to pregnancy & child birth • 80% of maternal deaths could be avoided by access to essential maternity & basic health services

6. Global Scenario-Neonatal Health • Nearly 4 million newborns die {40% of under 5 deaths} within 28 days of birth • Three quarters of neonatal deaths occur during first 7 days • For every newborn death ,20 others suffer birth injury, complications of preterm birth or other neonatal conditions • A child born in a least developed country is 14 times more likely to die within first 28 days of life as compared to industrialized country

7. The big divide • The divide between industrialized countries &developing regions –is perhaps greater than on any other issue • Average lifetime risk of maternal death for a woman in least developed country is >300 times than in industrialized country • In developing world a woman has 1 in 76 lifetime risk of maternal death as compared to 1 in 8000 in industrialized countries • Global MMR stood at 430/lakh live births in 1990,and at 400/lakh in 2005

8. per 100,000 live births Less than equal to 150 151 - 300 More than 300 Missing Data Maternal mortality ratio per 100,000 births Uttar Pradesh 517 2001-2003 India: 301 Kerala 110 Source: SRS

9. Other Conditions Hemorrhage 34% 38% Abortion 8% Sepsis 11% Obstructed Hypertensive Labour 5% Disorders 5% Medical causes of maternal deaths in India Source: SRS

10. Medical Causes of Neonatal Deaths-India Diarrhoea Asphyxia Preterm Tetanus Other Congenital Infection Source: Lawn JE Cousen SN for CHERG (Nov 2006)

11. Share of under-five mortality in India 40% Infant deaths within 7 days of birth Neonatal deaths 50% Infant deaths 76% Infant deaths between 7 days of birth and within 28 days 10% Infant deaths between 28 days and within one year of birth 26% Child deaths between one year and within five years of birth 24% Source : SRS 2007

12. Infant Mortality Rates by State

13. Infant Mortality Rate-Rajasthan

14. Infant Mortality Rate by Demographic Characteristics

15. Childhood Mortality Rates by Sex

16. Steady Decline in Infant Mortality Rates India

18. Creating a supporting environment

19. Creating a supportive environment for women & children • Millennium development Goals • Promoting a healthy behavior • Securing a quality education • Preventing child marriage • Ante natal care coverage • Skilled delivery care coverage

20. Timing of births Safe motherhood Child development Breast feeding Nutrition & growth Immunization Diarrhoea Coughs, colds & more serious illnesses Hygiene Malaria HIV and AIDS Injury prevention Disasters & emergencies Promoting a healthy behavior

21. Quality education & a decent living • Studies show that educated women; • Are more likely to delay marriage • Ensure that their children are immunized • Are better informed about nutrition • Undertake improved birth spacing practices

22. Age at marriage-India Percentage of women aged 20-24 married before age 18 Early marriage leads to early childbearing thereby enhancing maternal health risks Source: NFHS

23. Antenatal Coverage -Rajasthan

25. Continuum of care across time & location: Risks & opportunities

27. First 28 Days of life • Specific factors • Limited access to skilled care providers • Home births [Associated with half of newborn deaths] • Inadequate recognition of newborn illnesses • Insufficient care seeking • A limited repertoire of interventions for early neonatal disorders [ e.g. birth asphyxia, premature births ] • A lack of consensus on interventions and delivery strategies

28. Nutrition among women Percentage of ever-married women age 15-49 with any anaemia and Body Mass Index (BMI) below 18.5 kg/m2 High percentage of women with anaemia and low BMI results in higher risk of low birth weight and peri-natal deaths Source: NFHS

29. Antenatal care Percentage of ever-married women age 15-49 years having at least one ante-natal care There has been a significant increase in ante-natal care in the last 7 years. Further increases are seen in the latest DLHS results Source: NFHS

30. Women* Who Received Antenatal Care * For last births in the past 3 years

31. Deliveries at institutions / by skilled birth attendants Institutional births have shown significant improvement in the DLHS results Source: NFHS

32. Trends in Institutional Deliveries by State

33. Institutional deliveries –Rajasthan

34. Post natal care for mothers Percentage of women having at least one postnatal care within two days of delivery Only 37% of women received postnatal check-ups within the recommended period of two days of delivery Source: NFHS

35. Initiation of breastfeeding within an hour Percentage of children born in the last three years who started breastfeeding within one hour of birth Only one in four children in India are breastfed within 1 hour of birth Source: NFHS

36. Birth weight Percentage of children with reported birth weight less than 2.5 kg Based on reported birth weight data: 30% in NFHS 2 and 34% in NFHS 3 Every year at least six million children in India are born with low birth weight which gives them a disadvantaged start in life Source: NFHS

38. Strengthening health systems

40. Proposed action framework Central premise “.. Essential services for mothers, newborns and children are most effective when delivered in an integrated package • at critical points in life cycle, • in a dynamic health system, • in an environment supportive of women’s rights”

41. Basic health care Quality maternal care Newborn &child health care Adequate nutrition Improved water & sanitation Hygiene practices Essential Services for mothers newborn & children

42. Adolescence, Pre-pregnancy, Pregnancy, Birth Infancy, Childhood Post-partum, Neonatal Critical points for service delivery

43. Respect for rights of women & children Quality education Decent standard of living Greater involvement of men Protection from abuse, exploitation, violence & discrimination Equal participation in home community, social & political life Women empowerment Supportive environment

44. Across time-{ Key points} Adolescence Pre pregnancy Pregnancy Birth Post natal Neo natal Across location-{ Key points} Household level Community level Outreach services Outpatient services Facility based care The continuum of care across time & location-‘Risks & opportunities’

45. Key actions • Enhance nutrition of adolescent girls • Improve quality of reproductive health services • Ensure adequacy of antenatal care • Ensure skilled assistance during pregnancy & childbirth

46. Key actions • Provide access to quality Basic and Comprehensive Emergency Obstetric • Initiation of breastfeeding within one hour of birth • Newborn care when required • Expand post-natal care for mothers & newborns • Promote safe water & hygiene practices at households and in facilities

47. Strengthening health systems to improve maternal & newborn health • Enhancing data collection & analysis • Enhancing human resources, training & supervision • Fostering social mobilization • Ensuring equitable & sustainable financing

48. Contd. • Strengthening infrastructure, transportation, logistics ,supplies & referral process • Improving the quality of care • Global health initiatives{Strengthening collaberation

49. The Rate of Progress

50. The Rate of Progress