1.

DELIVERING THE MCH SERVICES

&

2. MATERNAL MORTALITY

DR (COL) RAKESH ARYA

• UNDER FIVE Children plus women in the reproductive
age group (15-44 years) = 32.4 % of the total
population in India.

• Women of child bearing age constitute 22.2%

• Children under 15 are about 35.3% of total population.

• MCH (mother and child health) CARE is a method of

delivering health care to a special population which is
especially vulnerable to disease, disability or death.
• The MCH services encompass the
1. CURATIVE,

2. PREVENTIVE AND

3. SOCIAL ASPECTS

I - OBSTETRICS,
II - PEDIATRICS,

III - FAMILY WELFARE,

IV - NUTRITION,

V - CHILD DEVELOPMENT
AND VI - HEALTH EDUCATION.
MCH CARE Is A Huge Umbrella.

• All Activities Which Promote Health And Prevent Or Solve

Health Problems Of Mother And Children

• Whether Curative, Diagnostic, Preventive Or

Rehabilitative.

• Whether Carried Out In Health Centers Or In The Home

• Whether By Primary Health Care Workers, Traditional

Dais, Or Highly Trained Specialists.

 SPECIFIC OBJECTIVES OF MCH

1. Reduction Of Morbidity And Mortality Rates

For Mothers And Children.

2. Promotion Of The Physical And Psychological

Development Of The Child Within The Family

3. Promotion Of Reproductive Health.

 COMPONENTS OF MCH CARE
• Include The Following Sub-areas

A. Maternal Health
B. Family Planning
C. Child Health
D. School Health
E. Handicapped Children
F. Care Of The Children In Special Settings
eg Day Care Centres.
 Maternal And Child Health Services

• Prenatal / Antenatal Care Services

• Intra natal Care Services

• Post natal Care Services

• Under Five Child Health Services

• Child Guidance Clinics

 CONTENT OF MCH CARE
• Cannot Be Modelled On Patterns Of Other Countries.

• Services should be flexible, and adapted to the local

demographic, social traditions, cultures and economic
needs and resources.

• Factors like urbanization, migration, changing

patterns of women's work and status have far-
reaching effects on childbearing and child-rearing.
• PRE INDEPENDENCE --- BHORE COMMITTEE.

1952 India Launched Family Planning Programme

1974, Integration Of F P Services With MCH Services.

1978 M T P Act

1978 Launching Of EPI

1982 Upgraded To UIP.

1992 The Umbrella Of CSSM.

Oct 97 RCH Programme Phase I.

Apr 05, RCH-II Was Launched For 5-year (Extended To 2012).

2013 RCH-II WAS RENAMED ‘RMNCH-A PROGRAMME’

 RECENT TRENDS IN MCH CARE

• MCH care was traditionally designed / provided as

vertical programs with "standard“ technical content

-- modelled from a few developed countries.

• Applied in our socio-economic situations, such vertical

programs were not successful , and unable to solve
the priority problems of the majority of mothers and
children.
 Recent trends in MCH care

1. Integration Of Care

2. Risk Approach

3. Manpower Changes

4. Primary Health Care

5. Reproductive And Child Health

 1. Integration of care
• Conventional MCH services tended to be fragmented into
ANC, PNC, infant care, FP / FW etc. Components were
dealt by different staff or departments.

• Integration implies that all those involved in maternity

care must work as a UNIFIED team.
• Obstetric and Pediatric units should be closely linked with
community physicians, health and social workers.

• This approach helps to promote continuity of care as well

as improves efficiency and effectiveness of MCH care.
 2. Risk approach
• A managerial tool for improving the coverage and
efficient better use of scarce resources.

• Based on the early detection of high-risk factors.

• All high risk mothers and children are given

additional and more skilled care.

• Essential care for all others (no risk group)

• Care Appropriate To The Need For Every One

 3. Manpower changes
• Earlier category of “M C H workers" (e.g., A N Ms, H Vs)
at the peripheral level is gradually being phased out.

• A wide range of workers are now forming the team for

M C H work.

(i) Professionals : Specialists, doctors, nurses,

paramedicals

(ii) Field workers : M P Ws, Health Guides, S B As, Bal

Sevikas, Anganwadi Workers, ASHA
 4. Primary health care
• MCH care is an indispensable priority element of primary
health care in every country.

• Primary health care has all the elements necessary to

make a positive impact on the health of mothers and
children

• MCH care………. family planning, ……..control of infections,

nutritional measures……….health education
• all closely related.
 5. R C H APPROACH
• PEOPLE HAVE ABILITY TO REGULATE THEIR FERTILITY ,

• WOMEN ARE ABLE TO GO THROUGH PREGNANCY AND

THEIR BIRTH SAFELY,

• THE OUTCOME OF PREGNANCY IS SUCCESSFUL IN TERMS

OF SURVIVAL

• AND COUPLES ARE ABLE TO HAVE SEXUAL RELATIONS

FREE OF FEAR OF PREGNANCY AND OF CONTRACTING
DISEASE.
 ORGANIZATION OF MCH/FP SERVICES

• THE PRESENT STRATEGY IS TO PROVIDE M C H

SERVICES AS AN INTEGARTED PACKAGE

THROUGH THE EXISTING PRIMARY HEALTH

CARE SYSTEM.
 ORGANIZATION OF MCH SERVICES

• IN RURAL AREAS is based on the complex of CHCs, PHCs and their

SCs.

• Trained health personnels are crucial in reducing M and I

mortality in rural areas. T B As/ S B As / are now available in
most villages.

• ICDS projects are providing a package of basic health services

eg. Supplementary nutrition, immunization, health check-up, referral,

nutrition and health education, and non-formal education services to
mother and children.
IN URBAN AREAS

• Urban Health Centers

• In urban areas, the general trend is towards

institutional delivery.

• In larger cities, almost 90 per cent of deliveries take

place in maternity hospitals and maternity homes.

• Specialist services are available at district hospitals.

 INDICATORS OF MCH CARE
1. MATERNAL MORTALITY RATIO

2. MORTALITY IN INFANCY AND CHILDHOOD

a) Perinatal mortality rateb.

b) Neonatal mortality rate
c) Post-neonatal mortality rate
d) Infant mortality rate
e) Under-5 mortality rate
f) Child survival rate.
 Assessment of MCH services

• Done on the basis of MCH indicators

MATERNAL MORTALITY
 SOME FACTS

• 20-25% deaths occur during pregnancy.

• 40-50% deaths occur during labor and delivery

• 25-40% deaths occur within 7 days after childbirth

It is important to focus attention

during pregnancy and
also after childbirth
 GLOBAL BURDEN

• 19/20 countries with high MMR – Sub Saharan Africa

• MMR 400 / 1 lakh live births

• 1 death per minute

• 1% in developed countries

• Two countries account for a third of global maternal

deaths; India at 17 % and

Nigeria at 14 %
 INDIAN SCENARIO
• One Indian woman dies from complications related to
pregnancy and childbirth every seven minutes

• The M M R in India stands at approx 150 per 100,000

live births.

• Kerala with MMR of 110

• Uttar Pradesh with MMR of 517.

• WHO commends India for its groundbreaking
progress in recent years in reducing the MATERNAL
MORTALITY RATIO (MMR) by 77%,

• from 556 per 100 000 live births in 1990

• to 160 per 100 000 live births in 2016

• Target of an MMR of 100 by 2020,

below 70 by 2030.
 MATERNAL MORTALITY ( WHO )

• Death Of A Woman Who Is Pregnant

Or Within 42 Days Of Termination Of Pregnancy,

• Irrespective Of The Site Or Duration Of Pregnancy,

• From Any Cause Related To Or Aggravated By The

Pregnancy Or Its Management

• But Not From Accidental Or Incidental Causes.

 Most of these causes can be readily addressed
if skilled health personnel are on hand and
key drugs, eqpt and referral facilities are available.
ANAEMIA, MALARIA, T B, HIV, CVS, LIVER, RENAL,
 CAUSES OF MATERNAL MORTALITY

• 20 % - indirect
• 80 % - direct

Major direct causes

• Haemorrhage
• Infection (sepsis)
• Eclampsia
• Unsafe Abortion
• Obstructed Labour
 SOCIAL ISSUES
• Early / Late Marriage
• Urban - Rural Divide
27% wedded before 18

• Short Birth Intervals-

• Lack Of Women
30% Births At < 2 yr
Interval Empowerment

• High Parity- 25% Births

In Parity 4 / • Gender Discrimination
More

• Inadequate Diet • Desire For Selective Sex

- Female Feticide
• Illiteracy
 ECONOMIC ISSUES

• Lack Of Money / Job Constraints

• Lack Of Transport And Communication

• Delay In Taking Decision To Shift

• Improper Dietary Habits

 MCH CARE DELIVERY ISSUES
• Lack of ANC

• Lack of skilled care at birth

• Poor rate of institutional deliveries

• Lack of access to Emergency Obstetric Care (EmOC).

• Delay in diagnosis / wrong diagnosis

• Lack of blood and blood products

• Lack of essential drugs

• Junior staff dealing with high risk cases without supervision

 ‘DELAY’ MODEL for high MMR & IMR

• DELAY……….. In Seeking Care

• DELAY …….….In Transport To Appropriate

Health Facility

• DELAY …………In Provision Of Adequate Care

 DELAY
ONSET TIME AND DEATH

• APH - 12 hours

• PPH – 02 hours

• Rupture Uterus - 24 hours

• Eclampsia – 48 hours

• Infection – 06 days
 IMPACT OF MATERNAL DEATHS
• Motherless children more likely to die within 2 years of
maternal death

• 10 X higher chance of neonatal death

• 7 X higher chance of death for infants older than one month

• 3 X higher chance of death for UNDER FIVE children.

• Enrolment in school for younger children is delayed and older

children often leave school to support their family.
MEASUREMENT OF MATERNAL MORTALITY

• There are three main measures of maternal

mortality

1. MATERNAL MORTALITY RATIO,

2. MATERNAL MORTALITY RATE

3. LIFETIME RISK OF MATERNAL DEATH.

(a) MATERNAL MORTALITY RATIO :

Number of maternal deaths during a given time

period per 100,000 live births during the same time-period.

(b) MATERNAL MORTALITY RATE :

Number of maternal deaths in a given period per

100,000 women of reproductive age during the same time-

period.
• Adult lifetime risk of maternal death :

The probability of dying from a maternal cause

during a woman's reproductive lifespan.
 PREVENTIVE MEASURES FOR MMR
1. Early registration of pregnancy. Min 4 A N Cs.

2. Dietary supplementation, including correction of

anaemia.

3. Prevention of infection and haemorrhage during

puerperium

4. Prevention of complications, e.g., eclampsia,

mal-presentations, ruptured uterus

5. Trt of medical conditions, e.g., HTN, DM, TB, etc.

 PREVENTIVE MEASURES FOR MMR
7. Anti-malaria and tetanus prophylaxis

8. Clean delivery practice. with the help of trained

local dais and female health workers

9. Institutional deliveries for women with bad

obstetric history and risk factors.

10. Promotion of family planning - to control the

number of children to not more than two, and
spacing of births.

11. Safe abortion services.

 PREVENTION OF MATERNAL MORTALITY

Health Education

• Age at marriage

• Spacing / Limitation of births

• Awareness of antenatal care
• Utilization of RCH services
• Nutritional education
• Importance of Immunization
 PREVENTION OF MATERNAL MORTALITY

Safe Abortion services

• Sex education and contraception

• Adolescent clinics

• MTP under LA

• Teaching MTP to RMP

 PREVENTION OF MATERNAL
MORTALITY

Health delivery infrastructure

• Provision of RCH services at remote rural areas /

urban slums

• Improved staffing

• Facilities for Essential / Emergency obstetric care

• Training of traditional birth attendants (TBAs )

 PREVENTION OF MATERNAL
MORTALITY
• ADOPTION OF SMALL FAMILY NORM

• PREVENTION OF ANAEMIA …………….. CONCEPT OF

100 TABLETS

– At Puberty

– At The Time Of Marriage

– During Pregnancy

– During Lactation
 PREVENTION OF MATERNAL MORTALITY

Non health strategies

• Poverty Eradication

• Improvement Of Literacy

• Women’s Empowerment Measures

• Improved Communications

• Improved Transport Facilities

 RCH I and RCH II
• M C H care was a part of F W programme from its
inception as a separate vertical intervention.

• In 1992, the C S S M Programme integrated all the

schemes for better compliance.

• More recently, R C H Programme was launched in

1997, which integrated family planning, C S S M
Programme, Preventive management of STD/ RTI,
AIDS, and a client approach to health care.

• This programme has entered into phase II, with

reorientation to make it consistent with N R H M.
 RCH –PHASE II (01/1/05)
• The focus is to reduce M n C mort and morb with emphasis

on rural health care. THE MAJOR STRATEGIES ARE

1. ESSENTIAL OBSTETRIC CARE

A. Institutional Delivery
B. Skilled Attendance At Delivery

2. EMERGENCY OBSTETRIC CARE

A. At First Referral Units (FRU) At PHCs AND CHCs
B. At Distt Hosps for round the clock
Delivery Services
 ESSENTIAL OBSTETRIC CARE
First Level

• Registration Of Pregnancy In The First 12 - 16 Wks

• At Least 4 Pre natal Check Ups

• Assistance During Delivery. ( Skilled Birth Attendant

or Institutional)

• At Least 3 Post natal Check Ups

 ESSENTIAL OBSTETRIC CARE

• Such care has three functions-

1. Birth takes place in the best of circumstances

2. Resolve complications as they arise
3. To respond to life-threatening emergencies

• Organized in midwife led birthing centers, combining

cultural proximity in a non-medicalized setting, with
professional skilled care, the necessary equipment, and
the potential for emergency evacuation.
 EMERGENCY OBSTETRIC CARE
Back Up

• Ideally Provided In A Hospital Setting –

Specialist Doctors, Skilled General Practitioners Or

Midlevel Technicians With The Appropriate Skills.

• Linked With First Level Care

• 24 Hrs Availability

• Emergency & Non-emergency Conditions

 EMERGENCY OBSTETRIC CARE

There Are 3 Critical Elements Of This Type Of Care

1. Availability Of Surgical Interventions

2. Facility For Newborn Care

3. Blood Storage Facility X 24 Hrs

• If So Equipped, Such Centers Are Known As

First Referral Units ( F R Us )

• To Be Made Available At PHC / CHC / SDH.

 FIRST REFERRAL UNIT
MINIMUM SERVICES OF FULLY FUNCTIONAL FRUs

1. Normal & Assisted Delivery Services 24 X 7.

2. Emergency Surgical Obstetric Care incl Caesarean.

3. New Born Care

4. Emergency Care Of Sick Children

5. Full Range Of F P Services incl Laparoscopic

6. Safe Abortion Services

 Continued……..

7. Treatment of STI \ RTI

8. Blood storage facility

9. Essential laboratory services

10. Referral ( transport) services

TRIBUTE TO MATERNAL MORTALITY
• Ideal requirement for fully functional FRU includes- ƒ
• Availability of all three Specialists (Gynecologist, Pediatrician,
Anesthetists). ƒ
• Availability of Blood Bank/Blood Storage Unit.
• Availability of Blood Bank/Blood Storage Unit. ƒ
• Functional Operation Theatre. ƒ
• Essential Laboratory Services. ƒ
• Referral (transport) Services. ƒ
• Functional Labour room with providing services of Normal,
Complicated & Caesarean section deliveries. ƒ
• New Born care services. ƒ
• Family planning & Safe abortion care services (Both Medical & Surg
) ical .
 Causes

• Maternal deaths mostly occur from the third trimester to

• the first week after birth (with the exception of deaths due to
• complications of abortion}. Studies show that mortality risks
• for mothers are particularly elevated within the first two days
• after birth. Most maternal deaths are related to obstetric
• complications including postpartum haemorrhage,
• infections, eclampsia and prolonged or obstructed labour -
• and complications of abortion. Most of these direct causes of
• maternal mortality can be readily addressed if skilled health
• personnel are on hand and key drugs, equipment and
• referral facilities are available
• India is among those countries which have a
very high maternal mortality ratio. According
to the estimates the MMR has reduced from
212 per lac live births in 2007-09 to 178 per
lac live births in 2010-12, a reduction of 34
points over a period of three years period.
States of Kerala, Maharashtra and Tamil Nadu
have already achieved the goal of a MMR of
100 per lac live births.
• Social correlates
• A number of social factors influence maternal mortality.
• The important ones are : (a) Women's age : The optimal
• child-bearing years are between the ages of 20 and 30 years.
• The further away from this age range, the greater the risks of
• a woman dying from pregnancy and childbirth. (b) Birth
• interval : Short birth intervals are associated with an
• increased risk of maternal mortality. (c) Parity: High parity
• contributes to high maternal mortality.
• Not only are these three variables interrelated, but there
• are also other factors which are involved, e.g., economic
• circumstances, cultural practices and beliefs, nutritional
• status, environmental conditions and violence against
• women. The social factors often precede the medical causes
• and make pregnancy and child-birth a risky venture.
 Preventive and social measures

• High maternal mortality reflects not only in inadequacy

• of health care services for mothers, but also a low
standard
• of living and socio-economic status of the community.
In the
• world as a whole, the problem of maternal mortality is
• principally one of applying existing obstetric knowledge
• through antenatal, intranatal and postnatal services
rather
• than developing new skills.
 key lessons:
• 1. Every pregnancy faces risk. There is no reliable way to
predict which women will develop complications.
• 2. Time between complication and death is very short (e.g.
2 hours in postpartum haemorrhage).
• 3. Therefore, skilled care should be available to all women
during the maternal period, especially during childbirth.
• 4. Antenatal high-risk screening approach and TBA training
alone are not effective in reducing maternal mortality.
• 5. Improved access to good quality maternal health services
is necessary.
• 6. There is a need to prevent unwanted pregnancy and
address unsafe abortion.
• Expected outcomes from the Mission : IMR
reduced to 30/1000 live births by 2012.
Material Mortality reduced to 100/100,000 by
2012.