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INCREASING ACCESS TO INCREASING ACCESS TO EMERGENCY OBSTETRIC SERVICES : EMERGENCY OBSTETRIC SERVICES :
EXPERIENCES FROM RAJASTHAN, EXPERIENCES FROM RAJASTHAN, INDIAINDIA
Presenter: Presenter: Hemant DwivediHemant Dwivedi
Authors :Authors : Venkatesh SrinivasanVenkatesh SrinivasanHemant DwivediHemant DwivediDileep MavalankarDileep Mavalankar
UNITED NATIONS POPULATION FUND UNITED NATIONS POPULATION FUND (UNFPA), INDIA(UNFPA), INDIA
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Rajasthan IndiaPopulation (in million) 56.47 1027.01Population Density(per.sq.km.) 165 324Female Literacy 44.34 54.16Median Age at Marriage 15.1 16.7Total Fertility Rate (TFR) 3.78 2.85Infant Mortality Rate (IMR) 80.4 67.6Maternal Mortality Ratio 607 540
KEY DEVELOPMENT INDICATORSKEY DEVELOPMENT INDICATORS
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HEALTH SYSTEM AN OVERVIEWHEALTH SYSTEM AN OVERVIEW
Sub-Centers - with an Auxiliary Nurse Sub-Centers - with an Auxiliary Nurse Midwife (ANM) Midwife (ANM) - 5000 population- 5000 population
Primary Health Centers (PHCs) - Medical Primary Health Centers (PHCs) - Medical Officer (MO) and Paramedics - Officer (MO) and Paramedics - 30,000 30,000 populationpopulation
Community Health Centers (CHCs) - Community Health Centers (CHCs) - Specialists doctors, MOs and Paramedics - Specialists doctors, MOs and Paramedics - 125,000 population125,000 population
District Hospital - Multi Speciality District Hospital - Multi Speciality - 2 - 2 million populationmillion population
Medical College and Asso.Hospital - Medical College and Asso.Hospital - Division levelDivision level
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PROJECT DETAILS PROJECT DETAILS Averting Maternal Death and Disability (AMDD) project supported by Averting Maternal Death and Disability (AMDD) project supported by
Columbia University with a grant from the Bill and Melinda Gates Foundation.Columbia University with a grant from the Bill and Melinda Gates Foundation. Implemented as component project under UNFPA supported Integrated Implemented as component project under UNFPA supported Integrated
Population and Development (IPD) Project, Rajasthan, India from 2001-2004.Population and Development (IPD) Project, Rajasthan, India from 2001-2004. ProjectProject Area Area
Seven Districts of Rajasthan, IndiaSeven Districts of Rajasthan, IndiaPopulation covered - 13.5 millionPopulation covered - 13.5 million
Facilities CoveredFacilities Covered CEOC - 31 institutionsCEOC - 31 institutionsBEOC - 52 institutionsBEOC - 52 institutions
Project DurationProject Duration September 2000 - December 2004September 2000 - December 2004
Implementing AgencyImplementing AgencyGovernment of RajasthanGovernment of Rajasthan
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KEY FINDINGS OF BASELINE STUDY (2000)KEY FINDINGS OF BASELINE STUDY (2000)
Service Coverage (UN-Process Indicators)Service Coverage (UN-Process Indicators)
Number of institutions studied - 83Number of institutions studied - 83
% of births in facilities - 10.89 (min.>15%)% of births in facilities - 10.89 (min.>15%)
% met need of EOC - 8% (min.100%)% met need of EOC - 8% (min.100%)
% births by C-section - 0.6 (min.5-15%)% births by C-section - 0.6 (min.5-15%)
Average CFR - 1.4 (min 1%)Average CFR - 1.4 (min 1%)
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STATUS OF HEALTH SYSTEM AT BASE STATUS OF HEALTH SYSTEM AT BASE LINE SURVEY IN 2000LINE SURVEY IN 2000
High vacancies of specialists OB/GY and High vacancies of specialists OB/GY and anesthetist anesthetist
PHCs not offering complete range of PHCs not offering complete range of BEmOCBEmOC
Very few CHCs prepared to address EmOCVery few CHCs prepared to address EmOC
Only 21.5% deliveries in institutionsOnly 21.5% deliveries in institutions
Low utilization of services and confidence Low utilization of services and confidence in PHCsin PHCs
Delay in reaching institutionsDelay in reaching institutions
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PROJECT FOCUSPROJECT FOCUS
Needs Based Differential ApproachNeeds Based Differential Approach
IMPROVING ACCESS TO QUALITY SERVICESIMPROVING ACCESS TO QUALITY SERVICES
Improved functional infrastructureImproved functional infrastructure
Provided necessary equipments and suppliesProvided necessary equipments and supplies
Skill based trainings - BEOC, IP TrainingSkill based trainings - BEOC, IP Training
Development of management systemsDevelopment of management systems
INCREASE COMMUNITY AWARENESSINCREASE COMMUNITY AWARENESS
Advocacy Programs for PRIs, NGOs and Media.Advocacy Programs for PRIs, NGOs and Media.
Integrating Safe Motherhood messages into Integrating Safe Motherhood messages into existing Community level activities.existing Community level activities.
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% Vacant Positions of Health % Vacant Positions of Health Functionaries in RajasthanFunctionaries in Rajasthan
28%
7%5%
0%
5%
10%
15%
20%
25%
30%
Specialist MO ANM
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WHY FOCUS ON BEmOC?WHY FOCUS ON BEmOC?
80-85% obstetric complications do not need 80-85% obstetric complications do not need surgical interventionssurgical interventions
Focus on BEmOC will reduce nearly 33-60% Focus on BEmOC will reduce nearly 33-60% maternal deathsmaternal deaths
Skills upgradation of service provider is Skills upgradation of service provider is feasiblefeasible
Over dependence on OB & Gy specialist and Over dependence on OB & Gy specialist and anesthetist reducedanesthetist reduced
Reduces congestion at district and medical Reduces congestion at district and medical college hospitalscollege hospitals
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INITIATING BEOC SERVICESINITIATING BEOC SERVICES
Government in consultation with UNFPA Government in consultation with UNFPA decided to train MOs in BEmOC decided to train MOs in BEmOC
2 weeks training at district hospital2 weeks training at district hospital
62 teams trained BEmOC62 teams trained BEmOC
MOs gained confidence in handling cases MOs gained confidence in handling cases and expressed interest and expressed interest
Skills upgraded on manual removal of Skills upgraded on manual removal of Placenta, management of shock, judicious Placenta, management of shock, judicious use of Oxytocine, stabilizing cases of APH & use of Oxytocine, stabilizing cases of APH & PPH and ensuring referral when essentialPPH and ensuring referral when essential
Promoted use of evidence based practicesPromoted use of evidence based practices
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ORIENTATION OF CBVORIENTATION OF CBV
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MANAGEMENT INFORMATION SYSTEMMANAGEMENT INFORMATION SYSTEM
Needs assessmentNeeds assessment
Pilot testing of revised MISPilot testing of revised MIS
Revised MIS orientation and implementationRevised MIS orientation and implementation
Monitoring of progress on UN process Monitoring of progress on UN process indicatorsindicators
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Health Institutions Providing Basic andHealth Institutions Providing Basic andComprehensive Comprehensive EmOCEmOC- Rajasthan- Rajasthan
RESULTS OF THE INTERVENTIONSRESULTS OF THE INTERVENTIONS
18 1823 21
26
36
53
62
0
10
20
30
40
50
60
70
2000 2001 2002 2003
CEOCBEOC
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41944
47576 4812949502
3800040000
4200044000
4600048000
5000052000
Births2000 2001 2002 2003
Births in EmOC Institutions: Comparison of Births in EmOC Institutions: Comparison of Baseline, 2001, 2002 & 2003Baseline, 2001, 2002 & 2003
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18%
12%
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
IPD Non-IPD
% Births increase in EmOC facilities : % Births increase in EmOC facilities : Comparison with non-intervention districts in Comparison with non-intervention districts in
last 4 yearslast 4 years
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Comparison of met need of EmOC : Comparison of met need of EmOC : Intervention and non-intervention districtsIntervention and non-intervention districts
14.26
8.87.91
12.13
7.147.16
7.966.1
0
2
4
6
8
10
12
14
16
2000 2001 2002 2003
IPDNon-IPD
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0.6 0.56 0.53
00.10.20.30.40.50.6
2001 2002 2003
C-Section
C-Section in FacilitiesC-Section in Facilities
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Comparison of Average CFR in FacilitiesComparison of Average CFR in FacilitiesIntervention and non-intervention institutionsIntervention and non-intervention institutions
1.33 1.49
0.97 0.95
4.14.4
4.72
4.01
00.5
11.5
22.5
33.5
44.5
5
2000 2001 2002 2003
IPDNon-IPD
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LESSONS LEARNEDLESSONS LEARNED
BEmOC services as a feasible strategy in BEmOC services as a feasible strategy in human resource scarce settingshuman resource scarce settings
Pragmatic strategies based on local specific Pragmatic strategies based on local specific needs leads to cost effective interventionsneeds leads to cost effective interventions
Improved service provision backed up by Improved service provision backed up by community mobilization increases utilization community mobilization increases utilization of servicesof services
Operationalising EmOC services requires Operationalising EmOC services requires sustained effortssustained efforts
Demonstration project’s achievements Demonstration project’s achievements facilitates advocacy at policy levelfacilitates advocacy at policy level
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MOVING FROM PILOT TO SCALEMOVING FROM PILOT TO SCALE
Logframe of new national RH programme Logframe of new national RH programme draws on Rajasthan experience for draws on Rajasthan experience for strengthening EmOC servicesstrengthening EmOC services
Reduction in maternal morbidity and Reduction in maternal morbidity and mortality is now a priority agenda of mortality is now a priority agenda of Rajasthan Government Rajasthan Government
UN process indicator confirmed as reliable UN process indicator confirmed as reliable and accessible indicators for public health and accessible indicators for public health systems to measure programme systems to measure programme performanceperformance
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Maternal death is a personal Maternal death is a personal tragedy and social disaster.tragedy and social disaster.
Let us join our hands to avert Let us join our hands to avert it.it.
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FOR FURTHER INFORMATION….FOR FURTHER INFORMATION….
HEMANT DWIVEDIHEMANT DWIVEDISate Programme CoordinatorUNFPA Rajasthan State Office, 29, Srirampura Colony, Civil Lines, Jaipur, Rajasthan, IndiaEmail : [email protected] : 91-141-2220028/2220224Fax : 91-141-2222277
VENKATESH SRINIVASANVENKATESH SRINIVASANNational Programme OfficerUNFPA, 53, Jorbagh, New Delhi, IndiaEmail : [email protected] : 91-11-24651801Fax : 91-141-24641679