Consultative Committee of Parliament

on

Maternal Health Ms. Anuradha Gupta

Additional Secretary & Mission DirectorMinistry of Health & Family Welfare

Government of India

Magnitude

Every year

­ 2.70 crore women deliver

­ 15% (45 lakh) develop complications

­ 56000 maternal deaths happen

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.

327301

254

212

0

50

100

150

200

250

300

350

2000 2002 2003 2008

Decline in Maternal Mortality Ratio

Progress so far….

5.8%

5.5%

4.1%

% annual rate of decline

400

600

260212

Global India

1990 2008

35% decline 65 % decline

India’s Progress Vs Global Progress

Maternal deaths reduced from 149,000 in 1990 to 56,000 in 2008

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

• 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

Key factors for high MMR… contd

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

UTTAR PRADESH

270

Agra Mandal (167) Faizabad Mandal

(437)

MADHYA PRADESH

213

Gwalior (202) Shahdol (415)

ASSAMHills & Barak Valley (288) Upper Assam (436)

148

BIHAR127

Patna (241) Purnia (368)

JHARKHAND123

Uttari Chota Nagpur (197)

Palamu (320)

ODISHA

85

Northern (212) Southern (297)

CHATTISGARH Raipur (234) Bastar (291) 57

RAJASTHAN55

Jaipur (238) Ajmer (293)

Division With Minimum MMR

Division With Maximum MMR

Range

State averages mask wide intrastate disparities

Encouraging decline in High Focus States

India

Odisha

Bihar/ Jharkhand

MP/ Chhattisgarh

Rajasthan

UP/ Uttarakhand

Assam

0 10 20 30 40 50 60 70 80 90 100

42

45

51

66

70

81

90

Drop in MMR (in points) from 2004-06 to 2007-09

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

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

2005-06 2006-07 2007-08 2008-09 2009-10 2010-11 2011-12 2012-13 2013-140.0

2000.0

4000.0

6000.0

8000.0

10000.0

12000.0

14000.0

16000.0

18000.0

3926.6

6250.1

8141.39175.0

10564.411878.8

13030.7

15491.1 15874.7

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

• 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.

Maternal Health–Key Strategies

Demand Promotion through Janani Suraksha Yojana (JSY)

0.731.58

73.2990.37

100.78

107

109.37 106.57

38.29

258.22

880.17

1241.33

1473.76

1618.39 1606.00 1640.00

0

200

400

600

800

1000

1200

1400

1600

1800

0

20

40

60

80

100

120

2005-06 2006-07 2007-08 2008-09 2009-10 2010-11 2011-12 2012-13

Beneficiaries (in lakhs)

Expenditure (in crores)Launched in 2005

Building on JSY

Janani Shishu Suraksha Karyakram (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

•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

RMNCH+A

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

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

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.

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

Reaching geographies & populations with highest burden of mortality

Web-based Mother and Child Tracking System

Web-based Health Management Information System for monitoring service delivery indicators

Annual Health Survey conducted in 9 high burden states each year, both performance & outcome indicators measured

Sample Registration System : Data brought out by Registrar General of India on key outcome indicators at the national & state level

National Family Health Survey/ District Level Household Survey : All India data on key indicators through periodic surveys

MCTS

HMIS

AHS

NFHS/ DLHS

Results and accountability

SRS

Map not to scale

An illustration of the Score card for State : Bihar

Example: Priority districts for ‘pregnancy care’ Jamui, katihar, Saharsa and Sheohar

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

Purnia

Pashchim Champaran

Saran

Siwan

Gopalganj

Muzaffarpur Darbhanga

SaharsaSamastipur

Katihar

Begusarai

Kishanganj

ArariaSupaulMadhubani

SitamarhiSheohar

Purba Champaran

Madhepura

Patna

JamuiNawada

GayaAurangabad

Jehanabad

Rohtas

Kaimur (Bhabua)

Vaishali

Bhojpur

Arwal

Nalanda

SheikhpuraLakhisarai Munger

Banka

Bhagalpur

Khagaria

Buxar

High performance

Promising

Low

Very low

Composite Index

Araria Gaya Jamui Katihar Kishanganj Purba Champaran

Purnia Saharsa Sitamarhi Sheohar

Overall­Index 0.3189 0.4382 0.3650 0.3381 0.4134 0.4774 0.3788 0.3268 0.4294 0.2877

1.­Reproductive­age­group

0.1741 0.4592 0.2123 0.0740 0.2826 0.8523 0.3919 0.2313 0.3758 0.2740

2.­Pregnancy­Care

0.4442 0.4252 0.2636 0.3267 0.4312 0.3678 0.3879 0.3366 0.3840 0.2688

3.­Child­Birth 0.4053 0.4467 0.5506 0.3995 0.5193 0.4736 0.2363 0.4219 0.4358 0.1522

4.­Postnatal­mother­and­new­born­Care

0.2856 0.4439 0.4769 0.4748 0.4544 0.4071 0.3935 0.3253 0.4840 0.3608

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

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