Averting Maternal Mortality Situation, Strategies and Future

1. Averting Maternal Mortality Situation, Strategies and Future Dr. Dileep Mavalankar MD, Dr. P.H. Public Systems Group Indian Institute of Management Ahmedabad

2. Maternal Mortality in India • Levels and trends • Maternal health care programs • Situation of maternal care services • Reasons for present situation • AMDD experiences and lessons • Strategies for future

3. Levels and trends of MMR • No system of recording of MM • Indirect estimates by Mari Bhat etal: • 1982-86 -MMR 580, 1992-96 - MMR 440 • NFHS - 1992 - 437 ( Urban 397, Rural 448 ) • NFHS II - 1999 - 540 ( Urban 267, Rural 619 ) • RGI - SRS 1997-8 - 408-407 • Low in south and high in eastern and central India

4. Policy Commitment for MMR Reduction • 1983 health policy: 200-300 by 1990, below 200 by 2000 • 2000 Nat population policy: 100 by 2010 • 2002 Nat health policy: 100 by 2010 • 2002-7 tenth five year plan: 200 by 2007 • Policy commitment on paper is clear but • Was there correct understanding of how to achieve reduction in MMR?

5. Maternal Health Programs • 1950-60- MCH - PHC, ANMs • 1966 - target oriented FP program started • 1985 - 1990 UIP - ( UNICEF ) • 1992-93 - CSSM ( UNICEF & world bank) - FRU - EmOC • 1997-2003 RCH ( world bank), health and FW sector (reform) program ( EC...), State health systems projects ( world bank), ORET ( Netherlands)…………. • 2004- 2009 RCH II & state health systems project ( world bank….)

6. Implementation of MH Interventions • ANC, TT immunization and IFA - key interventions. • PHC system neglected delivery care • Delivery by ANMs and doctors neglected. • TBA training - seen as key to reduce MMR • CSSM.1992- on wards : EmOC through FRUs - one of the many strategies. • 1997. RCH - isolated schemes to improve institutional delivery care. No focus on EmOC

7. Current Situation • Many interventions are not implemented properly. • Lack of specialists & trained staff in rural areas • Delegation of EmOC functions not done • Weak monitoring of implementation – FRUs operationalization, Deliveries & EmOC care, Maternal deaths. • Lack of accountability at many levels - 50% staff not staying at place of posting • Too many activities and programs - no focus on EmOC or Delivery care.

8. Staff Pyramid in a District vs. Work Load(50,000 del, 7,500 complications, 2,500 CS)

9. Are Indicators of MH Improving? • NFHS I & II - small improvement in ANC and more in TT & IFA. • Deliveries by ANMs same (11-12%) • Deliveries by doctors increased. But main increase in private hospitals. • CS rate gone up - may be in private sector. • No data on FRUs functionality, quality….

10. Design & Implementation of RCH Program • No large scale or systematic evaluation • Many problems in design: • Bunch of “schemes” not well though through • Lack of integration & coordination of inputs • Lack of monitoring of outputs and weak supervision • FRUs still not functional - no monitoring • Availability of blood remains as a problem - not many blood storage units started. • Referral transport money not much used. • Some success in Tamil Nadu and Andra Pradesh.

11. Reasons Behind the Slow Progress • Lack of institutional/management capacity - national and state level. Frequent changes.. • Lack of resources • Poor program design • Lack of focus on effective strategies - EmOC and skilled birth attendance neglected. • Lack of monitoring & evaluation. • Lack of real political and administrative will. • Inflexibility of schemes.

12. Averting Maternal Death & Disability Program (AMDD) • Global program: 50 projects in 41 countries – 50 Million $ over 5 years. • In India In: 13 districts through UNFPA (IPD) and UNICEF (BDCS). Maharashtra and Rajasthan - 3 Million $.

13. Averting Maternal Death & Disability Program (AMDD) • Key objectives are : Improving availability, utilization and quality of EmOC. • Stepwise improvements: Need assessment, training, equipment, renovation, management improvement, MIS monitoring, quality improvement, team building….

14. AMDD Program Experience • Availability is increasing - more centers are functional - more EmOC functions are done. • Utilization is gradually increasing. • Quality is also improving slowly. • Policy barriers remain - posting and transfer, delegation - who can do what. CS and anesthesia by GP, Basic EmOC by nurses and midwives….Management problems • Improving EmOC is doable – but it needs focus

15. Lessons and Future Directions • Need to focus on effective strategies - • Systematic process of planning and implementation, with propermonitoring. • Making FRUs and selected PHCs to provide 24/7 EmOC. • Increasing skilled birth attendance by ANMs, LHVs, PHC MOs. • Series of focused and coordinated implementation steps to ensure readiness - Training, supplies, R& R...

16. What is needed ? • More resources for MH and health system. • Better monitoring & recognizing performers. • Ensuring staffing in rural areas for EmOC. • Efforts to improve quality. • Addressing policy barriers - delegation & posting and transfers. • Newer thinking - social health insurance.

17. India Can Reduce MMR. But Needs Political & Societal Commitment Thanks