, 2014 • london, uk to do more! the indian perspective ... · the maternal mortality ratio (mmr)...

Phalakshi Manjrekar, MSN, RN Director of Nursing P.D. Hinduja National Hospital & Medical Research Centre, Mumbai

NIGH World Executive Committee of the Nightingale Initiative for Global Health

A teen-age mother with her newborn in Kokata, India. © 2012 ASIT KUMAR GHATAK, Courtesy of Photoshare # 8822-3.

The Indian Perspective & Its Relevance to Maternal & Child Health

“We continue to do more!”

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2nd International Conference Commonwealth Nurses Federation March 8th & 9th, 2014 • London, UK

Approximately two million children — under age 5 — die in India every year.

UNICEF’s State of the World’s Children Report, 2007

Children in Aizwal, in the Mizoram state of India await health care © 2008 Diptendu Dutta, Courtesy of Photoshare # 2009-176.

Child Mortality in India ©

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The Maternal Mortality Ratio (MMR) in India is 254 per 100,000 live births — according to Sample Registration System (SRS) Report for 2004-2006. This is a decline from the earlier ratio of 301 during 2001-2003.

Maternal Mortality in India

Women & children outside a child development center in Madhya Pradesh, India. © 2010 Anil Gulati, Courtesy of Photoshare # 330-511.

UNICEF India

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Wide disparities exist across states in India.

The MMR ranges from 95 in Kerala to 480 in Assam.

UNICEF India, Archives

Two Indian women. © 2007 Karamcheti Swathi, Courtesy of Photoshare # 131-8.

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India continues to endure about a quarter of all global maternal deaths.

A child in Ahmedabad, India, nurses her mother who is suffering from fever after giving birth 20 days ago. © 2012 Sharvari Raval, Courtesy of Photoshare # 1177-32.

Population Foundation of India

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Globally, every year, over 280,000 women die of pregnancy related causes & 99 % of these occur in developing countries…. Population Foundation of India

A pregnant woman waits for delivery outside a maternity centre in Mozambique. © 2011 Arturo Sanabria, Courtesy of Photoshare # 1515-262.

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Women wait for antenatal care (ANC) at a health centre in Nampula, Mozambique. © 2003 Arturo Sanabria, Courtesy of Photoshare # 1515-263.

…which also accounts for almost one-fourth of the world’s maternal deaths.


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India faces the enormous challenge of reducing infant mortality from 53 / 1000 live births to less than 30.


In the hills of India’s Uttaranchal state, young children take care of babies. © 2006 Shuvi Sharma, Courtesy of Photoshare # 2006-664.

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The average decline of IMR per year — between the years 2004 to 2008 — has been about 1 % per year.

Photo Attribution: http://www.examiner.com/article/neonatal-mortality-is-decreased-with-antiseptic.


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Uttar Pradesh, Bihar, Madhya Pradesh, Rajasthan, Andhra Pradesh, Orissa, Gujarat & Assam.


In 2008, the IMR was 53/1,000 live births.

Eight Indian states contribute to 75 % of infant mortality:

Photo of a young mother of the Bodo Tribe in Assam from Wikimedia Commons, photographer: Rajkumar1220, used with Creative Commons Attribution 2.0 Generic license.

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Mortality in the newborn period stands at 35/1000 live births & contributes to 65 % of all deaths in the first year of life.

Photo Attributions: © UNICEF India/2010/Graham Crouch from http://www.unicef.org.au.

Neonatal Mortality Rate

UNICEF India

Archives

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Between 2004-2008 — neonatal mortality has decreased only slightly from 37/1000 live births to 35/1000.

UNICEF India Archives

Photo Attribution: http://visual.ly/neonatal-mortality-child-survival-development-every-child-india.

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56 % of all newborn deaths occur in five Indian states — UP, Rajasthan, Orissa, MP & Andhra Pradesh.

Graphic Attrribution: http://arogyashoodh.blogspot.ca/2011/11/highest-number-of-new-born-deaths-in.html.

UNICEF India

Archives

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• pre-maturity • low birth weight • birth asphyxia • infections

Photo of a poor woman & her child in India from Wikimedia Commons, photographer Peter van der Sluijs, used with the GNU Free Documentation license.

Four major causes contribute to about 60 % of all deaths in the newborn period:

UNICEF India

Archives

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Indian Health Ministry Aims:

Maternal mortality to decrease from 254 per 1,00,000 live births to less than 100 by 2015. Ministry of Health & Family Welfare, Government of India, January 2013

A mother watches her newborn in a sub-health centre in Madhya Pradesh, India. © 2012 Anil Gulati, Courtesy of Photoshare # 1475-860.

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A small girl & her younger brother in Bittal Village, Durg District, Chhattisgarh state, India. © 2003 Pritam Kumar Nanda, Courtesy of Photoshare # 2004-167.

MMR — Address Three Causes: • Medical • Socio-economic • Health Systems

Ministry of Health & Family Welfare Government of India, January 2013

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A displaced pregnant woman in Ahmedabad, Gujarat state, India. © 2012 Sharvari Raval, Courtesy of Photoshare # 1177-1.

• Postpartum Hemorrhage – 37% • Sepsis – 11% • Unsafe Abortions – 8% • Hypertensive Disorders – 5% • Obstructive Labor – 5%

Direct Medical Causes

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Indirect Medical Causes —

• Anemia • Malaria

“Life can be tough for pregnant women in rural India.” Photo Attribution: Jane Wakefield, Technology Reporter, BBC, from http://www.bbc.co.uk/news/technology-17199877.

Ministry of Health & Family Welfare, Government of India, January 2013

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• About 70 % perinatal conditions • Respiratory Infections — 22% • Malnutrition is an underlying cause responsible for about 30% of all deaths in childhood.

Child Mortality 0-5 Years Treat the Causes:

Ministry of Health & Family Welfare, Government of India, January 2013 A family of children living on a street in Ahmedabad, India. © 2012 Sharvari Raval, Courtesy of Photoshare # 1177-35.

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Child Mortality 0-5 Years

Neonatal Causes – 52% Pneumonia – 15% Diarrheal Diseases – 11% Measles – 3% Injuries – 4% Other Causes – 15%

Indian children filmed by Al Jazeera English, posted on Wikimedia Commons, Creative Commons Attribution-Share Alike 2.0 Generic license.

WHO — Child Health Epidemiology Reference Group (CHERG) — 2012 ©

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Neonatal Deaths — Treat the Causes:

• Prematurity – 18% • Infections – 16% (pneumonia/sepsis) • Asphyxia- 10% • Congenital Anomalies – 5%


Roadside dwellers in Mumbai from Wikimedia Commons & Agência Brasil, a public Brazilian news agency. Licença Creative Commons Atribuição 3.0 Brasil exceto

quando.

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A large number of maternal & child deaths are attributable to the ‘three delays’:


• delay in deciding to seek care • delay in reaching the appropriate health facility • delay in receiving quality care once inside that facility

Indian rural women & girls from the archives of Al Jazeera English & Wikimedia Commons, Creative Commons Attribution-Share Alike 2.0 Generic license.

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Bottlenecks to treating the causes: • Lmited availability of skilled human resources — especially nurses • Low coverage of services & of skilled staff postings among marginalized communities • Inadequate supportive supervision of front-line service providers Coverage Evaluation Survey 2009, Rural Health Statistics 2011 • Concurrent Evaluation of NRHM and NRHM Progress Reports

Photo Attribution: AP File Photo from news feature — on www.thehindu.com — on long lines for maternal health services in India.

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Bottlenecks to treating the causes:

Photo Attribution: http://unicefiec.wordpress.com/2013/06/21/malaria-a-growing-concern-from-villages-to-cities/

Coverage Evaluation Survey 2009, Rural Health Statistics 2011 • Concurrent Evaluation of NRHM and NRHM Progress Reports

• Low quality of training & skill-building • Lack of focus to improve quality services • Insufficient information, education & communication on key family practices

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Reduction in Infant Mortality Ratio (IMR) to 100 per 100,000 live births by 2017.

Health Outcome Goals: Established in the 12th Five-Year Plan for India


An Auxiliary Nurse Midwife (ANM) helps a mother to learn kangaroo mother care, important for the growth of newborns in Madhya Pradesh, India. © 2012 Anil Gulati, Courtesy of Photoshare # 1475-870.

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An Indian village health worker checks a patient's blood pressure. © 2012 Pinky Patel, Courtesy of Photoshare# 4496-9.

Reduction in Maternal Mortality Ratio (IMR) to 100 per 100,000 live births by 2017.

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Reduction in Total Fertility Rate (TFR) to 2.1 by 2017.

In Birbhum, India, mothers with their infants attend a family planning & baby check-up camp organized by a local group with the help of the West Bengal Government under the National Rural Health Mission. © 2010 Sandipan Majumdar, Courtesy of Photoshare # 8510-1.

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Photo Attribution: UNFPA Website: http://www.unfpa.org/sowmy/resources/docs/photos/6_TaylorL_India.jpg

Coverage targets for key interventions for 2017:

Ministry of Health & Family Welfare, Government of India, January 2013 ©

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Increase facilities equipped for perinatal care — designated as ‘delivery points’ — by 100%.


Increase proportion of all births in government & accredited private institutions at the annual rate of 5.6 % from the baseline of 61% (SRS 2010).


A nurse weighs a newborn at a health centre in Madhya Pradesh, India. © 2010 Anil Gulati, Courtesy of Photoshare # 1475-867.

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Only 47 % of women in India likely have an institutional delivery & 53 % have had their baby’s births assisted by a skilled birth attendant.

Photo from Wikimedia Commons of a Adivasi mother & child from photographer Koustav 2007, used with GNU Free Documentation license.

Ministry of Health & Family Welfare, Government of India, January 2013 © NIGH World, 2014

Photo Attributions: theglobalmail.org. Photogragpher Mark Ralston/Getty Images

As many as 49 % of pregnant women still do not have three antenatal visits during pregnancy.

Only 46.6 % of mothers receive iron & folic acid for at least 100 days during pregnancy.

Ministry of Health & Family Welfare, Government of India, January 2013 © NIGH World, 2014


Increase proportion of pregnant women receiving antenatal care at annual rate of 6% from the baseline of 53% (CES 2009).


Women of Anjana Nagar, India, pose for a photograph after attending a women's health workshop where they learned about the benefits of pregnancy & nutrition, breast feeding, birth control & STIs. © 2004 Francey Hart, Courtesy of Photoshare # 2005-615.

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Increase proportion of mothers & newborns receiving postnatal care at annual rate of 7.5% from the baseline of 45% (CES 2009).

Mother & newborn at the Gurgaon Hospital outside of New Delhi. © 2011 Monique Jaques, Courtesy of Photoshare # 8716-2.


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A mother with her newborn are attended by skilled nursing at a hygienic health care centre in India. © 2006 Abhijit Dey, Courtesy of Photoshare # 2009-355.



Increase proportion of deliveries conducted by skilled birth attendants at annual rate of 2% from the baseline of 76% (CES 2009). © NIGH World, 2014

Most of the causes of death in the newborn period can be prevented or managed by households, communities & health facilities. But they often are unable to provide the required care… Ministry of Health & Family Welfare, Government of India, January 2013

Photo Source: Mother & baby at a nutrition rehab centre in Madhya Pradesh, from Wikimedia Commons & UK DFID, Creative Commonse Attribution 2.0 Generic license.

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A mother gives her 12-day-old infant his first traditional bath in a village near Cuduppah in Andhra Pradesh, India. This ‘tradition’ involves scrubbing the infant with soap, water & an unhygienic ritual of applying dried cow dung. © 2007 Jeevan Kuruvilla, Courtesy of Photoshare # 142-4.


Inappropriate practices such as:

• delayed initiation of breastfeeding • delayed clothing & • early bathing…

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Photo Attributions: NYTimes.com article on infant malnutrition in India — Photographer Ruth Fremson.

not seeking care when newborns are sick & applying harmful material on cord-stumps increase the risk of newborn deaths.

Inappropriate practices such as:


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Health facilities are often ill-equipped to provide essential newborn care to all newborns & special newborn care to sick newborns.

Photo Attribution: Associated Press & the DailyMail.co.uk news article about Indian children needing hospital care.


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Maternal & Child Health in India need utilization of local resources to benefit the beneficiaries. Multiple forces jointly hope to achieve the best for all the mothers & children.

A mother & newborn benefit from maternal health & family planning in Orissa. Wikimedia Commons & UK DFID, Creative Commons Attribution-Share Alike 2.0 Generic license.

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, 2014 • london, uk to do more! the indian perspective ... · the maternal mortality ratio (mmr)...

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