Maternal Health

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Introduction

Government of India adopted the Reproductive, Maternal, New-born, Child and Adolescent Health (RMNCH+A) framework in 2013, It essentially aims to address the major causes of mortality and morbidity among women and children. This framework also helps to understand the delays in accessing and utilizing health care 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 various divisions are guided by central tenets of equity, universal care, entitlement, and accountability to provide ‘continuum of care’ ensuring equal focus on various life stages.

Ministry of l-lealth & Family Welfare, Government of lndia has launched a new iniiiative namely- SUMAlV- Surakshit Matritva Aashwasan" with an aim to provide assured, dignified, respectful and Quality healthcare at no cost and zero tolerance for denial of services for every woman and newborn visiting the public health facility in order to end all preventable maternal and newborn deaths and morbidities and provide,a positive birthing experience.The expected outcome of this new initiative is "Zero Prevenlable Maternal and Newborn Deaths and high qualily of maternity care delivered with dignity and respect"

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 167(SRS 2011-13);

GOAL INDICATOR	ALL INDIA STATUS (Source of data)					NHM Goal (2017)
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) for the period 2014-16 is 130maternal deaths per 100,000 live births. With this, India has achieved the Millennium Development Goal (MDG) 5 i.e. India have 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. The table displays the trend in MMR over the years. The average decline in MMR between 2007-09 and 2011-13 had been 11.3 points per year, i.e. compound rate of annual decline was5.8% whereas average compound rate of decline is 8% between 2011-13 and 2014-16.

Maternal Health Indicators (NFHS3, NFHS4)

Sr.No	Indicator	NFHS 3	NFHS 4
1	Mothers who had antenatal check-up in the first trimester (%)	43.9	58.6
2	Mothers who had at least 4 antenatal care visits (%)	37.0	51.2
3	Mothers who had full Antenatal care(%)	11.6	21
4	Mothers who received postnatal care from a doctor/nurse/LHV/ANM/midwife/otherhealth personnel within 2 days of delivery (%)	34.6	62.4
5	Institutional births (%)	38.7	78.9

Areas of work

Quality Service Provision

Quality Ante Natal care: Quality and comprehensive ANC incorporates minimum of atleast four ANCs including early registration and first ANC with first trimester. The ANC package includes physical and abdominal examinations, Hb estimation, screening for Gestational Diabetes Mellitus, Thyroid disorders, HIV/Syphilis and urine investigation, T.T/Td, Immunization, distribution of IFA tablets & Calcium (6 months during Antenatal period & 6 months during postnatal period) and counselling for nutrition etc. Early detection of high-risk pregnancies, follow up and management are important component of Antenatal care.

Essential Obstetric Care during Delivery : Government of India provide free institutional delivery at its network of health facilities including Sub-centre, primary health centres, community health centres, sub-district hospital, districts hospital etc, to reduce maternal &neonatal morbidity and mortality. In order to provide essential obstetric care services, Government of India is operationalizing the 24 X 7 PHCs services andproviding training to SNs/LHVs/ANMs under Skilled Attendance at Birth.

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

Provision of Emergency Obstetric and Neonatal Care at FRUs:Provision of Emergency Obstetric and Neonatal Care at FRUs is been done by operationalizing all FRUs in the country. While operationalizing, 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 health care providers) 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 (LSAS) 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.(EmOC).
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
Skills Labs (Daksh training)– For improving the skills of healthcare providers and to enhance their capacity for providing quality RMNCH +A services, Government of India established National and State Skills Lab.

Referral Services at both Community and Institutional level

Government of India has a thrust to establish a network for Basic patient care transportation through ambulances with an aim to reach to the beneficiary in rural area for quick service delivery.

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

Technical Guidelines and Service Delivery Guidelines:

MH Division develops and disseminates standard technical guidelines & service delivery posters for standardizing the quality of service delivery during Antenatal care, intra-natal care, postnatal care etc. from primary to tertiary level of institutions.

Training

Capacity building programme for various categories of health, works through various training programme is as follows:

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, Staff Nurses (SNs) and ANMs have been permitted 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 more than 1500 facilities in seven states of the country.

The package provides the complete set of resources to assist the States in planning and implementing the Dakshata programmes. For the realization of this, operational guidelines, learning resource package, assessment tools, 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-born 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 and high risk pregnancy detection in pregnant women on 9th of every month.

LaQshya: In order to further accelerate decline in MMR in the coming years, MoFHWhas 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

Comprehensive abortion care is an important element in the reproductive health component of the RMNCH+A strategy as 8% (2001-03 SRS) of maternal deaths in India are attributed to unsafe abortions, thereby this is indeed a very important component of RNMCH+A program. This program is implemented as per the mandates of the Medical Termination of Pregnancy Act.

Medical Termination of Pregnancy (Amendment) Act & Rules, 2021: The MTP Act, 1971 recognized the importance of providing safe, affordable, accessible and legal abortion services to women who need to terminate a pregnancy due to certain therapeutic, eugenic, humanitarian or social grounds. The Act was amended for expanding the base of beneficiaries to provide safe abortion services.

Upon the approval of The Medical Termination of Pregnancy (Amendment) Bill, 2021 in Lok Sabha and Rajya Sabha and further assent received from Hon’ble President of India, the Medical Termination of Pregnancy (Amendment) Act, 2021 had been published in the official gazette on 25th March 2021, followed by its notification for commencement on 24th September 2021. The Rules were formulated and notified for commencement on 12th October 2021.

The Medical Termination of Pregnancy (Amendment) Act, 2021 provides for:

Requirement of opinion of one registered medical practitioner for termination of pregnancy up to twenty weeks of gestation.
Requirement of opinion of two registered medical practitioners for termination of pregnancy of twenty to twenty-four weeks of gestation.
Enhancing the upper gestation limit from twenty to twenty-four weeks for vulnerable groups of women.
Non-applicability of the provisions relating to the length of pregnancy in cases where the termination of pregnancy is necessitated by the diagnosis of any of the substantial foetal abnormalities diagnosed by a Medical Board.
Strengthening the protection of privacy of a woman whose pregnancy has been terminated.
Failure of contraceptive clause extended to the woman and her partner.

Key components of the program

Comprehensive abortion care services are available across the country at the public facilities along with approved private facilities with availability of RMP, as per the purview of law (mainly at MC, DHs, SDHs and FRU CHCs along with approved private health facilities). The facility providing abortion care services are strengthened in terms of the availability of drugs, equipment and trained provider for ensuring the safety of procedure. Capacity building of MBBS doctors

Capacity building is regularly done for MBBS doctors and OBGYNs on safe abortion techniques. ANMs, ASHAs and other field functionaries are also trained for providing safe abortion counselling while keeping women privacy on forefront along with post abortion contraception counselling .

Manuals, training packages, booklets and other IEC materials are developed from time to time for strengthening the implementation of the program such as CAC Training & Service Deliver Guidelines, CAC Training Package, Handbook for ASHA, videos, leaflet & booklet for field intermediaries, and posters for community awareness generation.

Infrastructure

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

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

MCH Wings - State of the art Maternal and Child Health Wings (MCH wings) have been sanctioned at District Hospitals/District Women’s Hospitals and other high case load facilities at sub-district level, as integrated facilities for providing quality obstetric and neonatal care.

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.Maternal near miss review is also being conducted at premier institutions.

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.

Maternal Health