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Background

The Government of India adopted the Reproductive, Maternal, New-born, Child and Adolescent Health (RMNCH+A) framework in 2013 and it essentially looks to address the major causes of mortality among women and children. This framework also helps understand the delays in accessing and utilizing health care and services.

Based on the framework, comprehensive care is provided to women and children through five pillars or thematic areas of reproductive, maternal, neonatal, child, and adolescent health. The programmes and strategies developed by the various Divisions is guided by central tenets of equity, universal care, entitlement, and accountability to provide ‘continuum of care’ to ensure equal focus on various life stages.

Following this strategy, the Maternal Health Division strives to provide quality services to pregnant women and their newborns through various interventions and programmes, building capacity of health personnel and routine health systems strengthening activities. 

 Significant Achievements

MMR: India’s MMR at 130 (SRS 2014-16) has improved significantly from 212 (SRS 2007-09);

GOAL
INDICATOR
ALL INDIA STATUS
(Source of data)

NHP Goal (2020)
Maternal Mortality Ratio (MMR) 254 (SRS 2004-06) 212 (SRS 2007-09) 178 (SRS 2010-12) 167 (SRS 2011-13) 130 (SRS 2014-16) 100

According to the latest figure released by Registrar General of India - Sample Registration System (RGI-SRS)Maternal Mortality Ratio (MMR) is for the period 2014-16 which is 130maternal deaths per 100,000 live births. With this, India has achieved the Millennium Development Goal (MDG) 5 i.e. India achieved a reduction in MMR  by three quarters between 1990 to 2015. The target was to achieve 139 maternal deaths per 100,000 live births which now has been achieved.

The table displays the trend in MMR over the years. The average decline in MMR between 2007-09 and 2011-13 was been 11.3 points per year, i.e. 5.8% compound rate of annual decline whereas average compound rate of decline has been to 8% between 2011-13 and 2014-16.

There were nearly 12,000 fewer maternal deaths in 2016 as compared to 2013, with total number of maternal deaths for the first time reducing to 32,000, from the earlier figure of 44,000.

Maternal Health Indicators

IndicatorNFHS 4 (2015-16)NFHS 3 (2005-06)
Mothers who had antenatal check-up in the first trimester (%) 58.6 43.9
Mothers who had at least 4 antenatal care visits (%) 51.2 37.0
Registered pregnancies for which the mother received Mother and Child Protection(MCP) card (%) 89.3 NA
Mothers who received postnatal care from a doctor/nurse/LHV/ANM/midwife/otherhealth personnel within 2 days of delivery (%) 62.4 34.6
Institutional births (%) 78.9 3

Areas of work

Quality Service Provision

Quality Ante Natal care:Quality ANC includes minimum of at least 4 ANCs including early registration and 1st ANC in first trimester along with physical and abdominal examinations, Hb estimation, Gestational Diabetes Mellitus, Thyroid, HIV/Syphilis and urine investigation, 2 doses of T.T Immunization and consumption of IFA tablets & Calcium (6 months during ANC & 6 months during PNC) and counselling for nutrition. Early detection of high risk pregnancies follow up and management.

Essential Obstetric Care :This includes quality antenatal care including prevention and treatment of anaemia, institutional / safe delivery services and post-natal care. To provide essential obstetric care services, GoI is operationalizing the PHCs for 24 X 7 services and also training the SNs/LHVs/ANMs in Skilled Attendance at Birth.

Provision of Emergency Obstetric and Neonatal Care at FRUs:Provision of Emergency Obstetric and Neonatal Care at FRUs is being done by operationalizing all FRUs in the country. While operationalising, the thrust is on the critical components such as manpower, blood storage units and referral linkages etc. Availability of trained manpower (Skill Based Training for MBBS doctors) is linked with operationalization of FRUs. The initiatives being undertaken in this regard are:

Augmentation of skilled human resources for Maternal Health:

  • To overcome the shortage of skilled manpower particularly Anaesthetists and Gynaecologists, the following key skill based training programs are being implemented:
  • 18 Weeks Training Programme of MBBS Doctors in Life Saving Anaesthesia Skills for Emergency Obstetric Care.
  • 16 weeks Training programme of MBBS Doctors in Obstetric Management Skills including C-Section, in collaboration with Federation of Obstetric and Gynaecological Society of India.(CEmOC).
  • 10 days Training Programme in Basic Emergency Obstetric Care for Medical Officers (BEmOC)
  •  3 weeks Training Programme for ANMs/SNs/LHVs as Skilled Birth Attendants (SBA)Referral 

Referral Services at both Community and Institutional level:GoI has a thrust to establish a network of Basic patient care transportation ambulances with aim to reach the beneficiary in rural area within 30 minutes of the call for quick service delivery.

Presently states have been given the flexibility to establish assured referral systems to transport pregnant mothers and sick Infants, etc which includes different models including public, private partnership models.

Post natal care for mother and new born:Ensuring post-natal care within first 24 hours of delivery and subsequent home visits on 3rd, 7th, 14th and 42nd day is the important components for identification and management of emergencies occurring during post-natal period. The ANMs, LHVs and staff nurses are being oriented and trained for tackling emergencies identified during these visits.

Technical Guidelines and Service Delivery Posters

Technical Guidelines and Service Delivery Guidelines: MH Divisiondevelops and disseminates standard technical guidelines & service delivery posters for standardizing the quality of service delivery during ANC, INC, PNC, etc from tertiary to primary level of institutions.

Training

Skilled Attendance at Birth: Government of India has a commitment to provide skilled attendance at every birth both at community and Institution level. To manage and handle some common obstetric emergencies at the time of birth, a policy decision has been taken permitting Staff Nurses (SNs) and ANMs to give certain injections and also perform certain interventions under specific emergency situations to save the life of the mother.

DAKSHATA : Maternal Mortality and morbidity and perinatal mortality are major public health problems Majority have an intra partum origin and are a consequence of interventions carried out around the time of delivery. In light of this, the Government of India, in 2015, developed ‘Dakshata’ for rapidly improving the quality of care during intrapartum and immediate postpartum period across delivery points in the country.

Currently Dakshata is being implemented in approximately 1000 facilities in seven states of the country. Over the course, many new resources have been added to the implementation package to help States standardize the adoption of the programme. There are challenges of implementation, technical mentorship and synchronisation of programmes. Considering that, this initiative addresses the urgent need for improving care around childbirth, its expansion is a strategic priority. In addition, various states have been reaching out to the GoI to seek guidance for planning and implementing Dakshata in their districts. In light of this expressed need, MH Division is releasing the complete implementation package of Dakshata program for the purpose of rapidly expanding its coverage across and within states.

The package also provides the complete set of resources to assist the states in planning and implementing the Dakshata programmes within their target districts and facilities. For the realization of this, operational guidelines, learning resource package, assessment tools, and planning and budgeting tools are included in the package.

Strategies and Interventions

Flagship Programmes

JananiSurakshaYojana (JSY):JananiSurakshaYojana (JSY), a demand promotion and conditional cash transfer scheme was launched in April 2005 with the objective of reducing Maternal and Infant Mortality. It is being implemented with the objective of reducing maternal and neonatal mortality by promoting institutional delivery among poor pregnant women.

Janani Shishu Suraksha Karyakram(JSSK):Government of India has launched JananiShishuSurakshaKaryakaram (JSSK) on 1st June, 2011, which entitles all pregnant women delivering in public health institutions to absolutely free and no expense delivery including Caesarean section. The initiative stipulates free drugs, diagnostics, blood and diet, besides free transport from home to institution, between facilities in case of a referral and drop back home. Similar entitlements have been put in place for all sick new-borns accessing public health institutions for treatment till 30 days after birth. In 2013 this has been expanded to Sick infants and antenatal and postnatal complications.

Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA): Carrying forward the vision of our Hon’ble Prime Minister, the Pradhan Mantri Surakshit Matritva Abhiyan was launched in 2016 to ensure quality antenatal care to pregnant women in the country on the 9th of every month.

LaQshya: In order to further accelerate our decline in the coming years, Health Ministry has recently launched 'LaQshya - Labour room Quality improvement Initiative'. LaQshya program is a focused and targeted approach to strengthen key processes related to the labour rooms and maternity operation theatres which aims at improving quality of care around birth and ensuring Respectful Maternity Care.

Other Programmes

Comprehensive Abortion Care Services: Comprehensive and safe abortion services are provided at public health facilities including 24*7 PHCs/ FRUs (DHs/ SDHs /CHCs) including the Delivery Points.Supply of Nischay Pregnancy detection kits to sub centres for early detection of pregnancy is undertaken .

Capacity Building of Medical officers is carried out routinely in safe MTP Techniques. ANMs, ASHAs and other field functionaries are trained to provide confidential counselling for MTP and promote post-abortion care including adoption of contraception.Routine orientation and training of ASHAs to equip them with skills to create awareness on abortion issues in women and the community and facilitate women in accessing services is undertaken.

District Level Committees (DLCs) have been framed and empowered for accreditation the facilities for conducting safe abortion services under MTP Act including approval of private and NGO sector facilities for conducting MTPs.

Regular monitoring and evaluation of the services provided is conducted.

Provision of RTI/STI services: Under NHM, provision of STI/RTI care services is a very important strategy to prevent HIV transmission and promote sexual and reproductive health under the National AIDS Control Program (NACP III) and Reproductive and Child Health (RCH II). Enhanced Syndromic case management (ESCM) with minimal laboratory tests is the cornerstone of STI/RTI management under NACP III. Services are being provided to all FRUs, CHCs and at 24 X 7 PHCs.

Setting up of Blood Storage Centers (BSC) at FRUs: Timely treatment of complications associated with pregnancy is sometimes hampered due to non-availability of Blood Transfusion services at FRUs. The Drugs and Cosmetics Act has been amended to facilitate establishment of Blood Storage Centers at such FRUs.

Village Health and Nutrition Day: Organizing of Village Health & Nutrition Day (VHNDs) at Anganwadicenter at least once every month to provide ante natal/ post partum care for pregnant women, promote institutional delivery, immunization, Family Planning & nutrition are the part of various services being provided during VHNDs.

Newer Interventions: Screening of Gestational Diabetes Mellitus, screening for Hypothyroidism for high risk group during pregnancy, De-worming during pregnancy, Medical Methods of Abortion, birth companion during delivery, Maternal Near Miss programme and Technical and operational Guideline for screening for Syphilis during pregnancy are newer initiatives to improve Maternal Health services.

Infrastructure

Delivery Points: All the States & Union Territories have identified DPs above a certain minimum benchmark of performance to prioritize and direct resources in a focused manner to these facilities for filling the gaps like trained and skilled human resources, infrastructure, equipment , drugs and supplies, referral transport etc. for providing quality & comprehensive RMNCH (Reproductive, Maternal, Neonatal & Child Health) services.

Obstetric HDU/ICU: Operationalization of Obstetric ICU/HDU to handle complicated pregnancies in high case load tertiary care facilities is being conducted across country.

Information systems for Maternal Health

Maternal Death Surveillance and Response(MDSR): The process of maternal death review (MDSR) has been implemented & institutionalized by all the States since 2017. Guidelines and tools for conducting community based MDSR and Facility based MDSR have been provided to the States. The States are reporting deaths along with its analysis for causes of death.

RCH portal / MCTS Portal: Name Based Tracking of Pregnant Women and Children has been initiated by Government of India as a policy decision to track every pregnant woman , infant & child upto 5years of age by name for provision of timely ANC, Institutional Delivery, and PNC along-with immunization & other related services.

MCP Card: Ministry of Health & Family Welfare and Ministry of Women and Child Development (MOWCD) has been launched as a tool for documenting and monitoring services for antenatal, intranatal and postnatal care to pregnant women, immunization and growth monitoring of infants.