Consultative Committee of Parliament on Maternal Health

1. Consultative Committee of Parliament onMaternal Health Ms.Anuradha Gupta Additional Secretary & Mission Director Ministry of Health & Family Welfare Government of India

2. Magnitude • Every year • 2.70 crore women deliver • 15% (45 lakh) develop complications • 56000 maternal deaths happen

3. Maternal Mortality • Maternal Deaths (deaths during pregnancy and child birth) are a key outcome indicator of maternal health. • Maternal Mortality Ratio (MMR) is the number of maternal deaths per 1 lakh live births. • MMR in India is 212 as per SRS 2007-09; further data from RGI is expected by the end of this year. • MDG 5 Target for India is to reduce MMR to 150 by 2015. • 12th Plan Goal is to reduce MMR to 100 by 2017.

4. Progress so far…. 4.1% 5.5% 5.8% % annual rate of decline

5. India’s Progress Vs Global Progress 65 % decline 35% decline Maternal deaths reduced from 149,000 in 1990 to 56,000 in 2008

6. Key factors for high MMR • Early age at marriage • 47% of married women aged 20-24 years married at ≤ 18 years • Attributable to lack of women empowerment • Early child bearing • 16% women (1 in 6) aged 15-19 years begin to give birth • Inadequate contraception and lack of spacing between births • 57.6% of births have less than 36 months’ spacing • Prevalence of contraception among 15-24 years is 18.6% only

7. Key factors for high MMR… contd • High Parity • 15% of all births are third order births and more than one fifth (21.9%) are fourth or higher order births • Poor nutritional status of women across life stages • 55.8% of adolescent girls (15-19 years), 58.7% of pregnant women and 63.2 % of lactating women are anemic • Persistent home deliveries in certain geographies • About 50 lakh women still deliver at home • Barriers to institutional care - Out of pocket payments - Customs and traditions - Climatic and geographical difficulties

8. MMR: Wide variations • Five States account for about three fourths of MMR • Out of 56000 maternal deaths every year, UP alone contributes 20090 deaths (36%) • Bihar (7132), Rajasthan (5708), MP(5241) and Assam (2769) account for 37.2% of deaths

9. State averages mask wide intrastate disparities Division With Maximum MMR Division With Minimum MMR Range ASSAM Upper Assam (436) Hills & Barak Valley (288) CHATTISGARH 148 Raipur (234) Bastar (291) BIHAR UttariChota Nagpur (197) Palamu (320) Jaipur (238) Patna (241) Purnia (368) Ajmer (293) 123 127 55 RAJASTHAN JHARKHAND ODISHA Northern (212) Southern (297) 85 MADHYA PRADESH Gwalior (202) Shahdol (415) 213 UTTAR PRADESH FaizabadMandal (437) Agra Mandal (167) 270 57

10. Encouraging decline in High Focus States

11. National Rural Health Mission- An important milestone • Launched in 2005 • Enhanced focus on Reproductive and Child Health • Augmented financial resources and local flexibility • Brought new focus on health systems strengthening • Laid emphasis on decentralization and communitisation • Introduced Accredited Social Health Activist (ASHAs) • Prioritized rural, marginalized & vulnerable populations • Encouraged innovations in service delivery

12. Stepped up Investment for RCH & Health Systems (Rs in Crores)

13. Maternal Health–Key Strategies • Strengthening of outreach and facility based services • Early registration of pregnancy • Quality Antenatal, Intranatal and Post natal care • Detection of high risk pregnancies and their timely management • IFA supplementation, nutrition counselling and Tetanus Toxoid vaccination • Village Health and Nutrition Day (VHND) as an important platform of service delivery • Operationalisation of health facilities • 24X7 PHCs- up from 1263 in 2005 to 8228 in 2013 • First Referral Units (FRUs)- up from 940 in 2005 to 2584 in 2013

14. Maternal Health–Key Strategies • Over 1.5 lakh human resource added which includes 70523 ANMs, 34384 Staff Nurses, 8808 MOs, 2919 Specialists • Over 3200 MOs trained in Life Saving Anesthesia Skills and Emergency Obstetric Care skills • More than 69000 ANMs/Nurses trained as Skilled Birth Attendants • 1.66 Crore women delivered in public and accredited health facilities in 2012-13, out of which 22.50 lakh (13.5%) were C-Sections.

15. Demand Promotion through JananiSurakshaYojana (JSY) Launched in 2005

16. Building on JSY JananiShishuSurakshaKaryakram (JSSK) • Launched on 1st June, 2011 • Entitles all pregnant women to absolutely free deliveries including C sections and sick newborns to free treatment at government health facilities • Free entitlements including drugs and consumables, diagnostics, blood, diet and free transport from home to health institution and drop back • Now expanded to cover antenatal & post natal complications and sick infants • Over Rs 2000 crores being provided to States annually • Supply of free drugs to pregnant women has registered a dramatic increase • 18000 ambulances added of which over 13000 are connected to 102/108 toll free number and are GPS fitted

17. RMNCH+A • A paradigm shift from Reproductive and Child Health to Reproductive, Maternal, Neonatal, Child and Adolescent health • Integrated approach to ensure continuum of care across lifecycle • Brings new focus on 24 crore adolescents: reaching out to them in their own spaces besides facilities

18. RMNCH+A Two important initiatives under RMNCH+A: • National Iron + Initiative to prevent and control anaemia - Includes Weekly Iron Folic Acid Supplementation for 13 crore adolescents • Emphasis on spacing • Door step delivery of contraceptives by >8.8 lakh ASHAs • 200,000 ANMs being trained for IUCD services at 150,000 sub centres • Post partum IUCD /FPS to reach > 1.66 crore women accessing public health facilities

19. New initiatives • About 16000 health facilities with case loads above the benchmarks identified as “Delivery Points” • These are being prioritized for physical, financial and human resources to offer quality services • 468 Maternal and Child Health Wings sanctioned during 2012-13 and 2013-14 at high case load facilities • These would add 28000 additional beds for mothers and children • Major focus brought on strengthening pre-service and in-service training of ANM and GNM for improving quality of services

20. New initiatives… contd.. • Maternal Death Review introduced in all States • Analysis of deaths both at facility and community level • A web enabled Mother and Child Tracking System put in place to ensure and monitor service delivery to mothers and children • More than 4.7 crore mothers and over 3.9 crore children already registered.

21. Reaching geographies & populations with highest burden of mortality Identification of 184 High Priority Districts (HPDs), based on ‘composite health index’ across States Differential planning for HPDs 30% higher financial allocation; differential norms for HR, infrastructure; incentives for HR Harmonisation of technical assistance All partners to work with States to accelerate progress on RMNCH+A

22. Results and accountability MCTS HMIS AHS SRS NFHS / DLHS

23. An illustration of the Score card for State : Bihar • Weak Performance on following indicators: • Pregnant women received 3 ANC check-ups • Pregnant women given 100 IFA • Pregnant women receiving TT2 or Booster • Possible Corrective Actions: • Close tracking/ follow up after first ANC registration; greater use of MCTS • Monitor IFA supplies; frontline workers to counsel/ follow up regarding consumption of IFA • Monitor supplies for TT; use MCTS for tracking Example: Priority districts for ‘pregnancy care’ Jamui, katihar, Saharsa and Sheohar Map not to scale

24. In conclusion • Accelerated decline in mortality is encouraging • Strategies and tools are becoming sharper • Quality of services is a key priority • Focus now on addressing intrastate inequities and reaching the unreached • Urban poor to be covered under the recently launched National Urban Health Mission (NUHM) • Emphasis on results and accountability

25. THANK YOU