Progress in Obstetrics & Gynaecology (Volume 1) Narendra Malhotra, Arun Nagrath, Manjula Singh
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1Obstetrics
  • Safe Motherhood – Is it Achievable? Deoki Nandan
  • Screening for Trisomies in the 21 st Century Narendra Malhotra, Jaideep Malhotra
  • Managing Down’s Syndrome Babies Ajay Kalra
  • The Uterine Cervix in Pregnancy and Labour Shalini Rajaram, Banchita Sahu
  • Antiphospholipid Antibodies and the Antiphospholipid Syndrome Vineeta Das, Amita Mishra
  • Epilepsy and Pregnancy MMSingh, MPSingh
  • Pain Relief in Labour Uma Srivastava, Aditya Kumar
  • Destructive Operations and their Role in Modern Obstetric Practice Zakia Arshad, Hasibul Hasan Shirazee
  • Elective Caesarean Section Rooma Sinha
  • Obstetrical Hysterectomy Barun Sarkar, Manjula Singh2

Safe Motherhood— Is It Achievable?1

Deoki Nandan
“No country sends its soldiers to war to protect their country without seeing to it that they will return safely, and yet mankind for centuries has been sending women to battle to renew human resource without protecting them”
—Fred Sai, former president of the International Planned Parenthood Federation
 
INTRODUCTION
In all parts of the world, Motherhood i.e. the role of women as mothers is considered respectful and birth of a new baby is celebrated as an occasion. Thus, Motherhood should be a time of celebration and joy as much as for a woman, as is for her family and her community. It is also considered a feeling of fulfillment for a women. However for women in developing countries, the reality of motherhood poses some serious concerns, where pregnancy and childbirth are still a perilous journey. For these women, motherhood is often marred by unforeseen complications of pregnancy and childbirth. Some even die in the prime time of their lives and in great distress.
Safe Motherhood not only underscores good care of the mother, but also towards care of her newborn baby. Thus, it is a package of health care for both mother and baby. The importance of safe motherhood practices and child survival cannot be exaggerated in a country like ours, which has witnessed high maternal, infant and child mortality. It can be stressed upon that healthy children don’t just happen, there are at least five prerequisites for it, viz Healthy Mother, Healthy Birth, Healthy Development, Healthy Diet and Healthy Environment.
A mother’s death carries profound consequences and is more than personal tragedy not only for her family, especially her surviving children, but also for her community and country. Adding more to this social dimension of maternal death-as a woman dies during her most productive years, her death has a strong social and economic impact as her family loses her love, her nurturing and her productivity inside and outside the home and community loses a productive worker and a primary care giver. In some developing countries, if the mother dies, the risk of death for her children under age of five years is doubled or even tripled.4
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Understanding the Problem (Magnitude)
Global
Worldwide, complications of pregnancy and childbirth are the leading causes of death among women of reproductive age group i.e. 15-49 years. According to the recent estimates by WHO and UNICEF, nearly 5,85,000 women die each year worldwide from complications related to pregnancy and childbirth, leaving behind them at least one million motherless children. This means that every minute of every day, somewhere in the world, a woman die as a result of complications related to pregnancy and childbirth. For each woman who dies, an estimated 100 women survive childbearing but suffer from life long illness or serious disease, disability and physical damage caused by pregnancy-related complications.
Unfortunately, about 99 per cent of these deaths occur in developing countries alone, of which 55 per cent occur in Asia (which accounts for 61% of world’s birth). In contrast to this, developed countries with 11 per cent of all births have less than 1 per cent of maternal deaths. This is tragic as these deaths are not caused by disease, but occurred during or after a natural process of delivery of the child. The risk of dying of pregnancy-related complications is highest in Eastern and Western Africa and in some parts of Asia, where in some countries the maternal mortality ratios are even more than 1,000 deaths per 100,000 live births.
Women’s Lifetime Risk of Dying of Pregnancy
Region
Risk of Dying
Africa
1 in 16
Asia
1 in 65
Latin America and Caribbean
1 in 130
Europe
1 in 1,400
North America
1 in 3,700
All Developing Countries
1 in 48
All Developed Countries
1 in 1,800
In developing countries woman’s lifetime risk of dying of pregnancy-related 5 complications is forty times higher than that of her counterparts in developed countries. Maternal death and disability are the leading cause of healthy life years lost for developing country women of reproductive age group (15-49 years). It accounts for the loss of more than 28 million disability-adjusted life years (DALYs i.e years of life lost due to premature death) and at least 18 per cent of the burden of disease.
 
Regional
As far as the Indian situation is concerned, the gift of Motherhood is most of the time by accident and not by choice. A World Bank publication ‘Improving Women’s Health in India’ observes, “The average Indian woman is almost 100 times more likely to die of a maternity related cause than her counterpart in the industrial world”. Women in India, like their sisters in other developing countries, rely heavily on men to meet their health care needs.
According to Sample Registration System (SRS) estimates, 1.1 per cent of all deaths in India in 1991 were due to maternal causes. At a crude death rate of 9.8 per 1000 in 1991, an estimated 8293770 deaths occurred, out of which 91231 were related to pregnancy related causes. Based on these numbers it can be estimated that maternal mortality rate would be around 62.9 per 100,000 women in the reproductive age group of 15 to 45 years (or a maternal mortality ratio of 3.4 per 1000 deliveries).
While our country has only 15 per cent of the world’s population, it accounts for over 20 per cent of the world maternal deaths. In India, every five minutes one woman die of complications related to pregnancy and childbirth. This adds up to a total of 1,21,000 women per year. Illiteracy, poverty, poor nutrition, inadequate or non-existent of women friendly health care and repeated childbearing in unsafe and unhygienic conditions combine together to multiply the health risk that women face in their life-term in the country.
The situation of women living in India, during pregnancy and childbirth can be briefed as follows:
  • Each year nearly 22,000 of maternal deaths following nutritional anemia, preventable by a timely antenatal check up. According to WHO reports, about 90 per cent of pregnant women in India are anaemic and the average weight gain of pregnant women is just 7 kg.
  • Over 80 per cent of maternal deaths in India, and elsewhere in the world are due to six medical causes, which can be treated in a hospital or First Referral Unit that has emergency facilities for obstetric care and skilled medical personnel.
  • Only 60 per cent of rural pregnant women whereas 86 per cent of urban pregnant women in India receive at least one antenatal checkup.
  • In India, only 34 per cent of deliveries take place in health institutions. In rural areas, three out of four births take place at home.
  • As a matter of fact every pregnancy poses a potential risk, however 15 per cent of the women develop life-threatening complications?6
  • Skilled personnel attend only 42 per cent of deliveries in India.
  • Sixty per cent of all maternal deaths occur after delivery; yet less than 17 per cent women in India receive any postpartum care.
  • Contraceptive prevalence rate in India is only 48 per cent which is abysmally low.
  • Nearly 7 million abortions take place in India annually and for each legal abortion, there are at least 10 illegal induced abortions.
  • Only 52 per cent of women are involved in decision making for their own health care.
The National Average Maternal Mortality Ratio for the year 1998, as estimated by Registrar General of India is 407 per 100,000 live births. The two National Family Health Surveys (NFHS I and II), conducted during 1992-93 and 1998-99 revealed that MMR was 437 and 540 per100,000 live births respectively. In India, there is a wide regional difference in maternal mortality and morbidity. Estimated maternal mortality ratios in major states of India (1997) show that MMR is highest in the state of Uttar Pradesh (707 per 100,000 live births) followed by Rajasthan (677 per 100,000 live births) Madhya Pradesh (498 per 100,000 live births) and Bihar (451 per 100,000 live births). This highlights that these four states, situated in the centre of the country contribute the largest share of death among women.
Many research studies have been undertaken to find out the causes and solutions of maternal mortality in the country. One such study which needs a mention i.e., an ICMR Supported Community Based Study conducted by Dr Deoki Nandan and Dr Badri N. Saxena in the two districts viz. Agra and Farrukhabad, in the state of Uttar Pradesh (which have highest MMR). They found that maternal mortality ratio was 582 per 100,000 live births in Agra district and 886 per 100,000 live births in Farrukhabad district. Of these, about half (50.5%) deaths occurred at home and about one fourth (22.3%) of the cases died in Govt. hospital, PHC/Subcentre; one sixth (15.5%) deaths occurred during transit and more than one tenth (11.7%) occurred in private hospitals. As for the causes they found that more than half (54.5%) of deaths occurred due to direct causes; haemorrhage, retained placenta and ruptured uterus accounted for 37 per cent of the deaths, sepsis for 11.7 per cent and prolonged or obstructed labour for 2.9 per cent deaths.
 
Causes of Unsafe Motherhood
“Motherhood and Childhood are entitled to special care and assistance.”
—Article 25, 1948 Universal Declaration of Human Rights
Evidences have shown that motherhood can be safer for all women. What remains is, for governments to commit for making safe motherhood a priority. Making motherhood a safer time in women’s lives requires commitment at all levels: at home, in the community, in the clinic, in the country and at the international level. Researches show that women’s lives can be saved and their suffering reduced if health systems could address serious and life threatening complications of pregnancy and childbirth when they occur. One of the best way to do this is to make sure that women receive good care at delivery. By year 1991, only 46.3 per cent of deliveries in the country were attended by trained birth attendants or skilled health personnel’s. This clearly depicts that a lot is required to be done to ensure safe motherhood.
Provision of skilled care means ensuring the availability of health professionals such as doctors, nurses, or midwives can manage normal deliveries and treat the life threatening complications of pregnancy and childbirth.7 Thus skilled care for pregnant women during delivery is an indispensable ingredient of safe motherhood programs. Skilled care, however can only be effective in the context of health systems, that address women’s health needs and the obstacles women face en rout to emergency care.
Most of the maternal deaths take place due to the natural process of pregnancy and childbirth which are largely avoidable. Broadly, causes of maternal mortality/morbidity can be classified into two groups—Medical and Social Causes.
 
Medical Causes
 
Obstetric Causes
  • Haemorrhage
  • Infection
  • Toxaemias of pregnancy
  • Obstructed labour
  • Unsafe abortion
 
Non-obstetric Causes
  • Anaemia
  • Associated diseases, e.g. Cardiac, Renal, Hepatic, Metabolic and Infectious
  • Malignancy
  • Accidents
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8Approximately 45 per cent of all maternal deaths occur in the first 24 hours after delivery. About 80 per cent of maternal deaths are due to direct causes i.e. obstetric complications of pregnancy, labour and puerperium, as a result of interventions or incorrect treatment. The single most common cause, accounting for a quarter of all maternal deaths is obstetric haemorrage, generally occurring postpartum which can lead to death very rapidly in the absence of prompt life saving care. Puerperal infections, often the consequence of poor hygiene during delivery, or untreated reproductive tract infections account for about 15 per cent of maternal mortality.
Long-term consequences of pregnancy-related complications include uterine prolapse, pelvic inflammatory disease, fistula, incontinence, infertility, and pain during sexual intercourse.
 
Social Causes
The existence of skilled care alone however, does not guarantee its use following the low social status of women in some societies. A number of social factors, alone and in combination, influence maternal mortality. Few important social factors are—Age at childbirth, Parity, Too close pregnancies, Family size, Malnutrition, Poverty, Illiteracy, Ignorance and Prejudices, Lack of maternity services, Shortage of health manpower, Delivery by untrained dais Poor environmental sanitation, Poor communication and transport facilities, Social customs etc. These social factors are interrelated and their interplay often precedes the medical causes and makes pregnancy and childbirth a risky venture.
Besides women face multiple delays in seeking and receiving life saving care when they need it. These delays because of their origin from the existing social set-up are rightly termed as “Social Delays”.
These social delays are:
Delay one
Failure to recognize the signs of life threatening complications.
Delay two
Postponement of decision to seek care.
Failure to recognize signs of complications, failure to perceive severity of illness, cost considerations, previous negative experiences with the health care system and transportation difficulties are factors that result in delayed decisions to seek care.
Delay three
Delay in reachingappropriate health care facility.
The lengthy distance to a facility or provider, the condition of roads and the lack of available transportation are factors that commonly create a delay in reaching care.
Delay four
Substandard or slow care at health facility.
The uncaring and callous attitude of providers, the shortage of supplies and basic equipment’s, the non-availability of health care personnel and the poor skills of health care providers are factors contributing to a delay in receiving care.
9
 
Gaps in the Present Strategy
Maternal Mortality Rate (along with Infant Mortality Rate) is a critical indicator which precisely advocates the need for strengthening the health status of a community or country. The unfavorable sex ratio of 933 women per 1000 men (Census India 2001) is an alarming manifestation of the lower status of women in our society. The causes that lead to avoidable maternal deaths, most in the prime of their lives, originate long before their pregnancies and extend far beyond the realm of medical care. Throughout the world, women suffer from poverty, discrimination and gender inequalities. These factors significantly contribute to poor reproductive health and unsafe motherhood even before a pregnancy occurs.
But the question still remains unanswered i.e.—Why maternal mortality remains so high in India while, infant mortality has gone down from about 146 in 1951s to about 72 per 1000 live births by year 1998?
Since late 1950s, Government of India has been developing a network of Primary Health Care (PHC) Centres and sub centres manned by qualified doctors and Auxiliary Nurse Midwives (ANMs) respectively with a view to provide MCH services. But since then, major focus of the PHC system has shifted from providing basic MCH services to family planning (in 1950-60s), ANC with high risk approach, training of traditional birth attendants (in 1970-80s), immunization programme (in 1980-90s) and HIV/AIDS and reproductive health (in 1990s) with consequent less focus on intra-natal care.
Under Primary Health Care Approach, Primary Health Centres were created on a population of 30,000 in rural areas and sub centres over a population of 5,000. On each subcentre, Auxiliary Nurse Midwife (ANM) is posted, and she is expected to cater nearly 5 villages. But since then population has increased manifold but number of ANMs is still the same, besides most of them are non-functional. As a result, most of the population, particularly of remote areas is not being properly served.
In 1992, Government of India embarked ‘Child Survival and Safe Motherhood Programme’, which provided facilities to identify First Referral Units (FRUs). These FRUs equipped with good infrastructure were supposed to provide comprehensive emergency obstetric care including cesarean section and blood transfusion. Unfortunately, due to some reasons not many FRUs could become functional, and those, which worked, were also not able to meet the requirement.
Over viewing the scenario in rural area, majority of deliveries are conducted by traditional birth attendants, most of which are not formally trained and are not competent enough to provide appropriate maternal services. Considering the current birth rate of 26.4 per 1000 population (1998), any birth attendant would encounter single maternal death in a period of 10-20 years and is therefore a rare event for her. For this reason traditional birth attendants cannot emphasize over the magnitude of maternal mortality and the need to bring it down. Therefore traditional birth attendants should be motivated and properly trained on various aspects of antenatal, intranatal, and postpartal care.10
 
Safe Motherhood Initiatives and Progress
 
Global
All men and women have the right to “…be informed and to have access to safe, effective, affordable and acceptable methods of family planning of their choice… and [have] the right of access to appropriate health care services that will enable women to go safely through pregnancy and childbirth and provide couples with the best chance of having a healthy infant…”
—Paragraph 7.2, Programme of Action, International Conference on Population and Development, Cairo, 1994.
  • In response to high maternal mortality rates, Global Safe Motherhood Initiative was launched at a conference held in Nairobi (Kenya) in 1987. The campaign has been sponsored by the World Health Organization, the World Bank, the United Nations Population Fund and UNICEF.
The global Safe Motherhood Initiative (SMI) was launched to improve maternal health and cut the number of maternal deaths to half by the year 2000. It is led by a unique alliance of co-sponsoring agencies working together to raise awareness, set priorities, stimulate research, mobilize resources, provide technical assistance and share information. Their cooperation and commitment have helped governments and non-governmental partners from more than 100 countries take action for safer motherhood. During the Initiative’s first decade, these safe motherhood partners developed model programs, tested new technologies and conducted research in a wide range of countries and settings.
The SMI’s target has subsequently been adopted by most developing countries. Under the Safe Motherhood Initiative, countries have developed programs to reduce maternal mortality and morbidity. The strategies adopted to make motherhood safe vary countries to countries and include:
  1. Providing family planning services,
  2. Providing post-abortion care,
  3. Promoting antenatal care,
  4. Ensuring skilled assistance during childbirth
  5. Improving essential obstetric care, and
  6. Addressing the reproductive health needs of adolescents.
    • The Safe Motherhood Initiative held a milestone meeting in Sri Lanka in 1997—”Safe Motherhood at 10”—which reviewed progress to date and identified immediate priorities for action.
    • The White Ribbon Alliance for Safe Motherhood is a global movement, launched in May 1999 in the United States, with the objective of making Safe Motherhood a priority of international organizations, governments and the private sector. It is led by a partnership of international organizations, including the United Nations Children’s Fund (UNICEF), the United Nations Population Fund (UNFPA), the World Health Organization, the World Bank, Family Care International (FCI) and others. Partnerships in 15 countries have sponsored awareness-raising campaigns and events.
The White Ribbon Alliance (WRA) complements the work of the 11 International Safe Motherhood Initiative. The goals of WRA are raising awareness about the need to ensure safe pregnancy and childbirth; Building alliances through wide-ranging, intersectoral partnerships with non-traditional groups (such as teachers and religious organizations) and Acting as a catalyst for action to address the tragedy of maternal deaths and sustain current safe motherhood efforts.
  • The ongoing international efforts for safer motherhood were further strengthened when Safe Motherhood was named the Theme of World Health Day (April 7th 1998—Pregnancy is special; let us make it safe.). As part of World Health Day, an International Symposium on Safe Motherhood was held in Washington. D.C. and was attended by key representatives of governments, international aid agencies, and NGOs. The message of the symposium was clear: motherhood can and should be made safe.
  • In 1996, Nepal’s Save the Children Alliance and MCH Products named March 8th (International Woman’s Day) as National Clean Delivery Day.
  • On October 12, 1999, the International Planned Parenthood Federation, Population Concern and Marie Stopes International released 6,000 balloons at Trafalgar Square, London with a view to represent the 6,00,000 women, who die every year of complications due to pregnancy and childbirth.
  • The tragedy of maternal death for individual women, their families, communities and countries; and the knowledge that most of these deaths could be prevented has led to numerous international agreements this incorporates all for action to ensure safe motherhood. These are:
    • Convention on the Rights of the Child (1990)
    • Convention on the Elimination of All Forms of Discrimination Against Women (1992)
    • World Conference on Human Rights Programme of Action (1993)
    • The International Conference on Population and Development Programme of Action (1994)
    • Fourth World Conference on Women Platform for Action (1995)
    • World Summit on Social Development Programme of Action (1995)
    • The Joint WHO/UNFPA/UNICEF/World Bank Statement on Reduction of Maternal Mortality (1999)
 
National Scenario
“State Parties shall ensure to women appropriate services in connection with pregnancy, confinement and the post natal period, granting free services where necessary, as well as adequate nutrition during pregnancy and lactation.”
—Article 12.2, Commission for the Elimination of All Forms of Discrimination Against Women (CEDAW), ratified by India.
  • 12In 1952, India was the first country to launch a nation wide Family Planning Programme. During the years 1966-69 the programme took firmer roots and the family planning infrastructure (e.g. primary health centres, subcentres, urban family planning centres, district and state bureaus) were strengthened. During the fourth five-year plan (1969-74) the programme was given top priority and was made an integral part of MCH activities of PHCs and their subcentres.
  • In 1969, an All India Post Partum Programme was launched, which is a hospital based, maternity centered approach to family planning. The primary objective of the programme is to improve the health of mother and children through MCH and Family Welfare Programme. Following this, the Medical Termination of Pregnancy (MTP) Act was introduced in the year 1972. The 42nd Amendment of the Constitution has made ‘Population Control and Family Planning’ a concurrent subject and the provision has been made effective from January 1977.
  • Following the acceptance of Primary Health Care approach for the achievement of Health for All by the year 2000, National Health Policy was formulated in 1982 (approved in 1983). It laid down the long-term demographic goal of Net Reproduction Rate (NRR) of one to be achieved by year 2000 (which implies a 2-child family norm). This could be achieved through the attainment of a birth rate of 21 per 1000 population, death rate of 9 per 1000 population and a Couple Protection Rate (CPR) of 60 per cent.
  • Government of India launched Child Survival and Safe Motherhood (CSSM) Programme in August 1992, with financial assistance from World Bank and UNICEF for the improvement of newborn care and maternal care at community level. It included immunization, prevention and treatment of anaemia, antenatal care and early identification of maternal complications, deliveries by trained personnel, promotion of institutional deliveries, management of obstetric emergencies and birth spacing.
  • Reproductive and Child Health Programme was launched on the basis of principles of reproductive health following International Conference on Population and Development (ICPD) held in Cairo in 1994. RCH Programme was formally launched on 15th October 1997. This programme integrates all interventions of fertility regulation, maternal and child health with reproductive health for both men and women. The RCH programme has a special significance for India. The RCH approach, which incorporates family planning in its wider context extends to promotion of women’s status, gender equity and reproductive rights to counter the existing social situations which promote gender sterotypes. It relied on client oriented, demand driven, high quality services based on the needs of community through decentralized participatory planning and community needs assessment approach.
  • 13Continuing towards the goal of improving women’s health India formed its National Population Policy (NPP)—2000. It reaffirms the commitment of the government towards target free approach in administering family planning services.
    The new NPP is more than just a matter of fertility and mortality rates. t ddeals with women education; empowering women for improved health and nutrition; child survival and health; the unmet needs for family welfare services; health care for the under served population groups; adolescent health and education; increased participation of men in planned parenthood and collaboration with and commitments from Non-Government Organizations and the Private Sector
In the context of Safe Motherhood, NPP-2000 considers certain operational strategies for empowerment of women. This includes
  • Creating an enabling environment for women and children to benefit from products and services disseminated under the RCH Programme.
  • Improving district, sub-district and panchayat-level health management with coordination and collaboration between district health officer, sub-district health officer and the panchayats for planning and implementation activities. Strengthening the referral networks and Community Health Centres to provide comprehensive emergency obstetric and neonatal care.
  • Improving the accessibility and quality of maternal and child health services, and improving the technical skills of maternal and child health care providers.
  • Using the maternal and child health local area monitoring system including, monitoring the incidence and coverage of antenatal visits, deliveries assisted by trained health care personnel and post-natal visits, among other indicators.
  • Developing a health package for adolescents and expanding the availability of safe abortion care.
 
The White Ribbon Alliance for Safe Motherhood—India
The White Ribbon makes a statement:
“Unsafe Motherhood is unacceptable!”
The White Ribbon Alliance of India (WRAI) was launched in November 1999, and its goals like those of global alliance, are to increase awareness, build alliances and act as a catalyst for action. WRAI is an alliance and not a non-governmental organization or a project and it functions with the involvement of 41 organizations, which include NGOs, UN agencies, donor agencies, individuals etc. WRAI is now functioning under decentralized process through identification of a facilitator or a facilitating organization at state/district levels.
The white ribbon is dedicated to women who have died during pregnancy and childbirth, and to all those, whose lives could have been saved. All 14these deaths could have been prevented through health and nutritional interventions and use of essential obstetric care. The White Ribbon Alliance draws attention to these needless and tragic loss of lives and unites individuals, organizations and communities to increase awareness of the need to promote Safe Motherhood. The white colour not only symbolizes grief or death, but also hopes.
WRAI through its organizational partners have launched a National Campaign on 8th March 2001, with a goal to provide information to women, husbands and families about actions that they can take to prevent maternal and neonatal death.
“Safe Motherhood: Families can make a difference.”
Strategies and activities planned by WRAI during the National Campaign 2001 are:
  • Information dissemination across the country.
  • Linking up with the Government.
  • Press Campaigns
  • Events by local organizations like organizing marches, rallies, information fairs and capacity building exercises.
  • March to Taj Mahal was held on 7th April 2001 on the occasion of World Health Day. This March and assemblage at Taj Mahal was symbolic, given the fact that Mumtaz Mahal died during childbirth. It also helped draw public attention to the actions that could prevent maternal deaths in the future.
 
Why is the Safe Motherhood Programme Important?
  • Majority of the deaths associated with pregnancy and childbirth are preventable. If treatment practices are streamlined and community awareness about availability and accessibility to the treatment facilities are improved, maternal and peri-natal mortality will decline rapidly.
  • Appropriate therapy started early is effective. Early identification and timely referral of cases is operationally feasible.
  • Obstetric emergencies are difficult to treat and account for a high case fatality. Early recognition and treatment of maternal complications will reduce the need for emergency obstetric interventions and reduce the maternal and peri-natal mortality. It will also reduce the number of cases requiring surgery, blood transfusions and hospitalization.
  • Safe Motherhood is also a matter of infant survival. Poor maternal health reduces a newborn’s chances of survival. Each year, an estimated 75 per cent of perinatal deaths i.e. almost 8 million perinatal deaths (stillbirths and deaths within the first week) are largely the result of the same factors that cause the death and disability of their mothers as well as lack of newborn care. These can be avoided by improved maternal health, adequate nutrition during pregnancy and appropriate management of deliveries.
  • The saving of the life of mother will have an immense social impact for the family and community. It will also have an indirect impact on the under five-child15 mortality rate which is nearly four times higher in families with a maternal death.
  • Essential maternal care and early treatment of maternal complications is cost-effective. This will lead to considerable savings on drug expenditure and hospitalization. The savings can be used for further improving maternal and newborn care and for upgrading facilities for emergency obstetric care. Thus, investments on safe motherhood is an investment in the emotional, physical, social and economic well being of woman, her children, her families and her communities.
 
Essential Services for Safe Motherhood
“Health is a personal and social state of balance and well being in which a woman feels strong, active, creative, wise and worthwhile; where her own body’s power of healing is intact; where all her diverse capacities and rhythms are valued; where she may make choices, express herself and move about freely.”
—Women and Health Programme, India, 1996
Safe Motherhood means ensuring that all women have access to the information and care they need to go safely through pregnancy and childbirth. Services for safe motherhood should be readily available through a network of linked community health care providers, clinics and hospitals. These services include:
  1. Community education on safe motherhood.
  2. Antenatal care and counseling, including the promotion of maternal nutrition
  3. Skilled assistance during childbirth
  4. Care for obstetric complications, including life-threatening emergencies.
  5. Postpartum care
  6. Services to prevent and manage the complications of unsafe abortion
  7. Family planning counseling, information and services
  8. Reproductive health education and services for adolescents.
Woman can save her life during childbirth when she is able to plan her pregnancy, give birth under the supervision of a skilled attendant and has access to high quality treatment if pregnancy complications occur. These improvements are feasible even in low-income settings as are prevalent in our country, but this then requires continuous and qualitative improvement in existing health system.
 
10 Action Messages for Safe Motherhood
Emerging from the Sri Lanka Technical Consultation held in year 1997, the International Safe Motherhood Initiative has defined 10 key action messages for safe motherhood. These are:
  1. 16Advance safe motherhood through human rights
  2. Empower women: Ensure choices
  3. Make a vital and social investment in safe motherhood
  4. Delay marriage and first birth
  5. Recognize that every pregnancy faces risks
  6. Ensure skilled attendance at delivery
  7. Improve access to quality reproductive health services
  8. Prevent unwanted pregnancy and address unsafe abortion
  9. Measure progress
  10. Utilize the power of partnerships
 
What can be done?
 
Modification of the Policies
Pioneering research done at Columbia University, School of Public Health has shown that the best and most cost effective strategy for reduction in maternal mortality is to provide Emergency Obstetric Care (EOC) services, within the reach of all pregnant women. This is because it is not possible to predict or prevent complications of pregnancy and childbirth, but there is generally a short time of 2 hours to 4 days before a woman dies, so in many situations she can be saved by effective EOC services.
In the light of this evidence, the national and state governments must actively change the policies that constrain access to emergency obstetric care services in rural areas. Government must strive for the best possible services and must establish simple but safe standards of services which can be provided by basic medical officer and nurses, and not insist on services to be provided only by specialists at remote hospitals.
Most doctors at PHCs and hospitals in remote/rural areas do not provide even basic emergency obstetric care. Doctors should be trained to undertake basic surgery needed in the areas including caesarian section and even other emergency abdominal surgery. They must also be trained to provide anaesthesia in rural hospitals. Such doctors should be posted at sub-district level hospitals where there are no specialists.
Another important aspect for the adequate utilization of services is to provide quality services to the beneficiaries. The quality of routine health care services, which daily serve?
 
Gender Roles and Safe Motherhood
Most women in our country similar to those in other developing countries continue to suffer due to unjustifiable social structure gender roles, gender relatives and gender sterotypes have decision role in reproductive lives of the women. If gender roles, gender relation and gender sterotypes all addressed with seriousness and fairness, then only the safe motherhood can be ensured. They are often not able to take correct decisions when complications of pregnancy and childbirth develop rather; they are not empowered for self-care and to make decisions about seeking maternity care. In addition, lack of17 support from men and other members of the family leads to poor utilization of prenatal, natal and post-natal services by pregnant women. According to National Family Health Survey II (NFHS II), only 52 per cent of women are involved in or assurence of decision making on their own health care. Poor nutrition, little education, limited or absence of decision making power, few resources and inadequate access to social services further contributes to this.
At this point male members of the family and community members are placed in the decision-making roles. But then men are not able to make proper decisions regarding care seeking at the time of complications because they do not understand the dangers involved during pregnancy and childbirth. Culturally there is very little inter spouse communication. The way male child is brought-up in our poor families, he is not able to visualize/sympathize with the suffering and trauma that a woman goes through during pregnancy and delivery.
Researches have suggested that one way to work towards reducing maternal mortality is to educate men and other male family members about the danger signs and what to do about them. If possible, man should be asked to accopany has wife in the labour room (in case of individual delivery). So as to witness his wife delivering, this develop an insight/undressing about the complications/risks involved in the delivering of the child. If implemented, this may probably prove a major breakthrough in ensuring safe motherhood. By this they could play a pivotal lifesaving role during pregnancy and childbirth.
 
Social Mobilization for Safe Motherhood
Creating enabling environment for community action and individual behaviour change is at the heart of reducing avoidable maternal and neonatal deaths. This is only possible by galvanizing sustained participation of a variety of stakeholders, including communities, service institutions and providers, civil society groups, media, marketing and commercial networks, policy makers, donor groups and many more.
Social Mobilization involves planned actions and processes to reach, influence and involve all relevant segments of society across all sectors from the national to the community level. Creating for an enabling environment and fortering positive behaviour and social change. There are four components of social mobilization which are Community Mobilization; Social Marketing; Behaviour Change Communication and Advocacy.
  1. Community Mobilization This uses deliberate, participatory processes to involve local institutions, local leaders, community groups and members of the community to organize for collective action towards a common purpose. Community mobilization is characterized by respect for the community and its needs.
  2. Social Marketing This promotes and sells products or services, which are considered to have a social value, using a variety of outlets and marketing approaches. Social Marketing may not always be a component of social mobilization.
  3. 18Behaviour Change Communication (BCC) It is designed to achieve measurable objectives, reach and involve specific audiences and position health practices persuasively as a benefit in the minds of the intended audience. BCC recognizes that behaviour change is a process and people usually go through several intermediate steps before they attempt to change their behaviour.
    Steps to Behaviour Change
    zoom view
  4. Advocacy It means systematically enabling key players to understand what safe motherhood means and how to operationalize it. It is a process that involves a series of actions conducted by organized citizens in order to transform power relationships. The purpose of advocacy is to achieve specific policy changes, program changes or allocation of resources that benefit the population involved in this process. These changes can take place in the public or private sector. Effective advocacy is done according to a strategic plan and within a reasonable time frame. Advocacy is commonly mistaken for a ‘campaign’, but in fact campaign is one method of advocacy.
Since social mobilization tries to make sweeping changes in the society, it involves many stakeholders at the same time and success depends on identifying the appropriate partners for a coalition. Coalition can be here defined as an action oriented group of organizations working together in a coordinated fashion toward a common goal. It can be emphasized that good leadership is critical to successful coalition building.
 
Combating the Social Delays
As has been already discussed that behind most of the maternal deaths few social delays are functional which have their origin from uneducated/unaware community. Reducing maternal deaths requires well-coordinated and sustained efforts. Diminishing these social delays requires policy commitment and actions at the local and national levels. To make motherhood safer and to combat these delays, maternal health experts have made certain policy options. These are:
Delay one
  • Increase awareness in the communities about the signs of life threatening complications.
  • Educating women, their partners and their families about when and where to seek care for complications.
Delay two
  • Encouraging families and communities to develop plans of action in case of obstetric emergencies.
  • Raising women’s status so that they are empowered to make critical health decisions.
  • 19Enhancing links between communities and health care providers.
  • Improving relationships between traditional healers and skilled health care providers.
  • Improving the interpersonal communication skills of health care providers.
  • Educating women and their families where to seek care services in case of complications.
  • Encouraging the use of health care facilities by adolescents, single or married women and ethnic and linguistic groups who are reluctant to use services because of socio-cultural barriers.
Delaythree
  • Encouraging communities to create emergency transportation plans.
  • Upgrading roads and transportation systems.
  • Enhancing referral systems between communities and health care providers.
  • Establishing maternity waiting homes.
Delay four
  • Upgrading the quality of care at health facilities, including improving provider’s technical and interpersonal skills, motivation and performance.
  • Training health facility staff to recognize and admit patients with life threatening complications.
  • Ensuring adequate and sustainable supplies of emergency medicines, essential equipment’s, blood and staffing levels at health facilities.
  • Providing 24-hour service at facilities that provide emergency obstetric care.
  • Enhancing referral systems between communities and health facilities.
 
Birth Preparedness and Complication Readiness
Preparing for birth and complications reduces delays
Vast majority of maternal deaths in our country occurs either at home or on the way to the health facility. Obstetric emergencies cannot be predicted and any pregnancy can take a turn for the worst and escalate into a life-threatening situation, regardless of the woman’s health status and the place in which she gives birth. When the birth occurs at home, as the majority of them do, the women and their families are not aware of the signs of an obstetric emergency, what to do and where to seen treatment?
It is therefore important to educate families and communities about care of pregnant women. If family members are planning to conduct delivery at home, they should be told about ‘Five Cleans’, as majority of maternal deaths and illness, caused due to infections can be prevented by adopting the practice of ‘five cleans’ in childbirth and delivery practices. These ‘five cleans’ are: Clean Delivery Surface, Clean Hands, Clean Cord tie, Clean Blade and Clean Cord Stump.
20Along with this, the family members and community should also be educated and made aware for recognizing danger signs during and following pregnancy, arranging finance and transportation and identifying health facilities with essential obstetric care in case of emergency. These arrangements must be made well in advance, only then the delays in seeking, reaching or receiving care can be reduced and averted. This is the essence of Birth Preparedness and Complication Readiness.
Birth preparedness and complication readiness is a comprehensive matrix, which promotes, empowering approach to maternal and newborn well being and it includes the woman and her family, as well as the community, health care providers, facilities that serve them and the policies that affect care for the woman and the newborn.
The matrix encompasses the responsibilities, actions, practices and skills needed to help ensure the safety and well being of the woman and her newborn throughout pregnancy, labour, childbirth and the postpartum period. A key element of birth preparedness is identifying a skilled provider, who can support a woman during labour and childbirth and manage complications that may arise or refer for higher level care.
The detailed “Birth Preparedness and Complication Readiness Matrix” is given in Annexure-2
Birth Preparedness and Complication Readiness is a shared responsibility
 
A Newer Approach for Safer Motherhood: MCHN Project
Along with the ongoing efforts for the achievement of safer motherhood, a newer approach has been tried and successfully running in 5 districts of Uttar Pradesh viz. Agra, Lucknow, Allahabad, Varanasi and Jhansi. This has been named as “Community Based Maternal and Child Health Nutrition (MCHN) Project” and is being supported by UNICEF. The project is based on multi-sectoral coordination (i.e. Health, Education, ICDS, Panchayat Raj Institution and Development sectors) with full community participation and involvement.
Under this project, mobilizers (exclusively females) are selected from the same community, and are trained for 3 days on various aspects of maternal and child health, nutrition, sanitation and hygiene. These mobilizers, who are the soul of this project, are named as ‘Bal Parivar Mitra’ (previously named as Community Health, Nutrition and Sanitation Mobilizers or CHNSMs). One mobilizer is selected over 30-40 households, with the single criterion that, they are decision-makers or are capable of influencing/modifying the current health related practices in their community. They are not paid any honorarium for their work and they perform the task with the spirit of social work keeping in view the upliftment of the community.
These mobilizers are expected to give advice about good practices related to health and nutrition for mothers and children. They work in coordination 21with Auxiliary Nurse Midwife and Anganwadi Worker and specifically concentrate on five high risk groups viz. Pregnant women, Lactating mothers, Newly married couples, Children less then 2 years of age and malnourished children less then 6 years of age. They particularly stress on antenatal care for pregnant women, safe delivery practices (including five cleans) and postpartal care. These mobilizers are then followed up on a monthly or quarterly basis, so as to analyze their activities, solve their problems and to provide them feedback.
As on date, the mobilizers are successfully functioning in their respective communities and are successful in replacing the many old/unhealthy practices with healthy ones. They are working with a single humanitarian target to improve health status of women and children.
 
Thematic Approach for Achievement of Safe Motherhood
Six evidence-based priority themes, ranked according to existing evidence for the potential contribution of each theme to maternal mortality reduction, in order of relative emphasis are:
 
Theme One: Birth Preparedness/Planning for a Safer Birth—Rule of Seven
Lack of awareness of the danger signs of obstetric emergencies, and lack of appreciation of the need for rapid and appropriate response when emergencies occur, are the major contributing factors in many maternal and newborn deaths. There are seven key elements of preparing a household plan for safer birth (i.e. Rule of Seven). These include
  1. Preferred birth location;
  2. Preferred birth attendant;
  3. Knowledge of location of closest appropriate care facility
  4. Obtain funds for birth-related expenses
  5. Identify companion to accompany to facility
  6. Arrange transport for facility-based birth or in case of obstetric emergency
  7. Identify compatible blood donors in case of hemorrhage.
 
Theme Two: Early Postpartum Care for Mother and Newborn
It has been proved by systematic global review of maternal mortality data that an overwhelming majority of maternal and newborn deaths occur during the immediate and early postpartum period. This theme highlights the benefits of routine early postpartum care, recognition of danger signs of maternal and newborn postpartum emergencies, and the specific elements of care for mother and newborn that can be lifesaving if initiated early.
 
Theme Three: The “Clean Chain” —Cleanliness, Asepsis, and Infection Control at Household and Facility Level
Sepsis is one of the most avoidable causes of maternal death, through systematic prevention efforts. To cultivate22 a “culture of cleanliness” at all levels of care, the clean chain must be promoted not only among home birth attendants and families, but among health professionals as well. There is clear evidence that doctors and other facility-based maternal care providers often do not maintain hygienic practice during delivery, and that modern medical practice in health facilities can contribute significantly to maternal and newborn sepsis. For facility-based deliveries, the clean chain includes establishing and posting protocols for hand washing and disinfection; clean surfaces and practices; hand washing and aseptic techniques and use of “clean delivery” indicators on regular basis as part of supervision and monitoring.
Promotion of “clean chain” home birth practices for all birth attendants includes “Five cleans” viz ensuring clean hands, clean delivery surface, clean cord cut, clean cord tie and clean cord stump. At household level, “clean chain” includes promotion of maternal personal hygiene during pregnancy, birth and postpartum; newborn hygiene, “clean feeding” (exclusive breast-feeding), and clean immediate environment for the newborn.
Clean birth is a safe “lead-in” for promoting change in other elements of birth practice that are potentially harmful, but more likely to be controversial. These other harmful birth practices, which also occur at both facility-based and home births, include use of oxytocics, and prolonged and excessive obstetric manipulation.
 
Theme Four: Reducing the “Delays” in Care seeking for Obstetric and Newborn Emergencies
Since the delay concept was first introduced, the overwhelming number of pregnancy-related deaths where delay was an important factor has been clearly documented in many countries. Delay in recognition and treatment frequently results in death and timely recognition with prompt treatment of obstetric and newborn complications can be lifesaving.
A critical factor in maternal and newborn deaths is the unpredictable nature of most life-threatening obstetric complications, their extremely rapid onset, and the potential for rapid progression to fatal outcome. Promotion of the three delays and their specific manifestations will increase awareness at the household and community level and among both health professionals and traditional birth attendants (TBAs), and encourage the development of locally appropriate solutions.
A major focus of this theme is reinforcing the need for rapid recognition of the emergency condition, rapid on-site stabilization or treatment by a trained health professional or rapid movement of women and newborns experiencing emergencies to the appropriate care facility for care by a trained health professional. This theme ties into, and reinforces, the emergency readiness aspects of both the birth preparedness and postpartum care themes.
 
Theme Five: Improved Patterns of Antenatal Care Use
There are two key contributing factors to antenatal care (ANC) use patterns that are common in our country, as also in most developing nations-1) a dominant and often intractable belief that 23 antenatal care is not required unless there is a problem, and 2) perceived poor quality of public care.
Regular, good quality antenatal care undoubtedly contributes to improved maternal and newborn health. Antenatal care remains valued as an important “point of contact” with pregnant women, to screen for medical problems such as pre-eclampsia and maternal infection, provide TT immunization and iron-folate supplementation, and to introduce and reinforce healthy behaviors, including birth preparedness. ANC use is often initiated late in pregnancy, and commonly lowest among primiparas and grand multiparas over age thirty-five, women with highest potential risk of obstetric problems.
 
Theme Six: Strengthening the Community Response and Social Support Networks
A decade of maternal health communication experience has shown that communication interventions that target primarily women themselves are less successful. Informing and motivating family and community influentials is essential to effectively change behaviors to reduce maternal and newborn. In the event of obstetric emergency, the capacity of women to make independent care-seeking decisions is understandably compromised. At this critical juncture, the ability of family influentials and the birth attendant to make timely, informed emergency care decisions can be lifesaving.
This theme will thus reinforce the overarching theme of total community involvement and community responsibility for healthier mothers and newborns, as well as Theme One.
 
CONCLUSION
Studies have shown that maternal mortality has not declined as significantly as general mortality or infant mortality in India in spite of ongoing efforts. NFHS II data have shown that the maternal mortality ratio i.e. the number of pregnancy related deaths per 1,00,000 births is 540, indicating no reduction in the rate of maternal deaths in the last 6 years. Hidden in this average is the grave concern that maternal mortality is far greater in rural areas (619, according to NFHS II) than in urban areas.
Yet, in spite of not so encouraging results of on going activities to improve women’s health status, the goal of Safe Motherhood is still achievable and not beyond the reach. To prevent the avoidable deaths and suffering among women, individual and collective action is urgently required and it is necessary that the issue of Safe Motherhood is visualized from the point view of fundamental human right, social justice and fairness.
In order to achieve safe motherhood, a multi-dimensional, multi-structural and multi-faceted approach is required. First, it is required to generate the political commitment to reallocate resources to implement the available strategies. Lot of dedication and priority reallocation are required to strengthen community-based maternal health care delivery system, upgrade existing facilities, create relevant new ones if necessary and use appropriate technologies at all levels so 24that women have better care at lower costs.
An effort should be made to motivate the community to undertake Social Audit i.e. to find out the immediate and underlying causes of maternal deaths in their respective areas and to seek for methods to deal with them by mutual discussions and agreement. This can be helpful in incorporation of Assessment, Analysis and Action (AAA) Approach to the ongoing activities to curtail maternal mortality.
As is seen in most Indian households, male members are sole decision-makers and it is essential to make them aware about appropriate care for the pregnant women, and not consider women as the second sex, the lesser sex, the weaker sex. The community and particularly women themselves must be mobilized and involved in planning and implementing policies, programmes and projects, so that their needs and preferences are explicitly taken into account. A range of information, education and communication activities must be utilized through culturally appropriate channels to reach communities, women, men, boys and policy makers.
It should be felt that achievement of safe motherhood is not only the responsibility of health sector, in fact others like education sector, development sector, Panchayat Raj Institution. etc. should also be actively involved in the ongoing efforts. The importance of safe motherhood should be emphasized to medical students since beginning, and they should be adequately trained about all aspects (medical/surgical) of maternal care. In addition to this, mixed strategies with full involvement of electronic and print media should be developed.
On the basis of cumulative experiences gleaned from other developed nations, it can be concluded that, the dream of Safe Motherhood could be brought into reality only by the concerted efforts of community, health-care providers and policy makers. A commitment at all levels should be developed to reduce inequities, improve women’s autonomy and ensure that motherhood is a safe, joyful and rewarding experience.
 
BIBLIOGRAPHY
  1. Advocacy for Reproductive Health and Women’s Empowerment in India: A Ford Foundation Report; July 1997
  1. Awareness, Mobilization and Action for Safe Motherhood: A Field Guide; White Ribbon Alliance for Safe Motherhood; Washington D.
  1. Birth Preparedness and Complication Readiness: A Matrix of Shared Responsibility; Maternal and Neonatal Health Program; Baltimore.
  1. D Nandan, Badri N, Saxena: “Maternal Morbidity and Mortality patterns in Uttar Pradesh.” Indian Journal of Community Medicine 1: 10-15, 1997.
  1. Govt. of India (2000), Annual Report 1999-2000, Ministry of Health and Family Welfare, New Delhi.
  1. Making Motherhood Safer-Overcoming Obstacles on the Pathway to Care by Elizabeth I. Ransom and Nancy V. Yinger; Population Reference Bureau, USA; February 2002.
  1. National Population Policy–2000; Department of Family Welfare, Ministry of Health and Family Welfare, Government of India, New Delhi.
  1. 25 Social Mobilization for Safe Motherhood, Workshop Report; The White Ribbon Alliance for Safe Motherhood; Bhopal, India; August 2001
  1. Safe Motherhood at Home - Realities, Perspectives and Challenges; A Symposium Report; June 2001
  1. State of India’s Health; Voluntary Health Association of India; 1992
  1. The White Ribbon Alliance for Safe Motherhood/India; 2nd Edition, December 2000
 
ANNEXURE 1
 
DEFINITIONS
  • Safe Motherhood This term covers a broad range of direct and indirect efforts to reduce deaths and disabilities resulting from pregnancy and childbirth. Direct efforts include those to ensure that every woman has access to a full range of high quality, affordable sexual and reproductive health services—especially maternal care and treatment of obstetric emergencies to reduce deaths and disability, indirect efforts include delaying the age of marriage and first pregnancy and limiting the number of pregnancies.
  • Maternal MortalityRate According to WHO it is defined as—“The death of a woman while pregnant or within 42 days of termination of pregnancy irrespective of the duration or site of pregnancy, from any cause related to or aggravated by pregnancy or its management but not from accidental or incidental causes.”
  • Maternal Mortality Rate (MMR) thus measures the risk of women dying from puerperal causes. MMR is expressed as a rate per 1000 live births. Denominator includes all deliveries and abortions.
  • Maternal Mortality Ratio Number of maternal deaths per 100,000 live births.
  • Late Maternal Death is the death of a woman from direct or indirect obstetric causes more than 42 days but less than one year after termination of pregnancy.
  • Pregnancyrelated death is the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the cause of death.
  • International Classification of Diseases (ICD) has divided maternal deaths into two groups viz.
    Direct ObstetricDeaths resulting from obstetric complications of the pregnant state (pregnancy, labour and puerperium) from interventions, omissions, incorrect treatment or from a chain of events resulting from any of the above.
    Indirect Obstetric Deaths resulting from previous existing disease or diseases that developed during pregnancy and which was not due to direct obstetric causes but which was aggravated by physiologic effects of pregnancy.
  • Maternal Morbidity Illness or disability occurring as a result of or in relation to pregnancy and childbirth.
  • SkilledBirth Attendant A midwife, nurse, nurse-midwife or doctor who has undergone a prescribed course and is registered or legally licensed to practice. This excludes Traditional Birth Attendant (TBA), even if trained.
  • 26Obstetric Emergency A severe, life-threatening condition that is related to pregnancy or delivery that requires urgent medical intervention, in order to prevent the likely death of the woman. Major signs of Obstetric Emergency are Heavy bleeding; High fever; Convulsions; Loss of consciousness and Placenta not coming out even after 30 minutes of delivery of the baby.
    An Obstetric Emergency:
    • May occur any time during pregnancy, delivery or upto six weeks after childbirth, may occur suddenly without any warning.
    • Is life threatening
    • Requires urgent action
    • The patient must be taken to a hospital or First Referral Unit (FRU) without delay
  • Perinatal Death Death of a fetus occurring between the time a fetus weighs at least 500 gm (or after 28 completed weeks of gestation) and the seventh day after birth of a live-born infant.
  • Stillbirth A baby that is delivered dead, in medical terms it is defined as the death of a fetus weighing at least 500 gm (or after 28 completed weeks of gestation) before the complete expulsion or extraction from its mother.
  • NeonatalDeath Death of a live-born infant any time between birth to 28 days.
  • Disability Adjusted Life Years (DALYs) It is a measure of the burden of disease in a defined population and effectiveness of the interventions. It express years of life lost to premature death and years lived with disability (adjusted for the severity of disability). One DALY is—‘one lost year of healthy life’.27
 
ANNEXURE 2
BIRTH PREPAREDNESS AND COMPLICATION READINESS MATRIX
Policy maker
Facility
Provider
Community
Family
Woman
PREGNANCY
  • Promotes health and survival of pregnant women and newborns and promotes, ensures and facilitates skilled antenatal care and an emergency referral system.
  • Ensures resource allocation so that adequate level of resources support antenatal care for safe childbirth and facilitates emergency referral services by families, community, individuals and advocacy groups.
  • Use information to support systems that update service delivery and cadre specific guidelines.
  • Coordinates donor support
  • Ensures that protocols are in place for clinical management, blood donation, anesthesia, surgical interventions, infection prevention and physical infrastructure.
  • Advocates the policy through all possiible venues (e.g. national campaigns, press conferences, community talks, local coalitions and supportive facili~ lities.
  • Provides essential drugs and equipments
  • Follows infection prevention principles and practices.
  • Maintains a functional emergency system including:
    • Communication
    • Transportation
    • Safe blood supply
    • Emergency funds-Follows service delivery guidelines related to appropriate and effective management during the antenatal period and involve community in quality of care.
  • Provide job aids to assist providers in performing appropriate antenatal care
  • Ensures availability of a skilled provider 24 hours a day, 7 days a week
  • Reviews case management of maternal and neonatal morbidity and mortality.
  • Is gender and culturally sensitive, client centered and friendly
  • Provides skilled ANC, ; including health promotion, disease prevention, detecting and managing complication, screening for and managing HIV /AIDS, tuberculosis and STDs.
  • Assisting the woman to prepare for birth and provide items needed for clean birth.
  • Counseling/educating the woman family about danger signs, nutrition, family planning, breastfeeding and HIV/ AIDS.
  • Plan for reaching provider at the time of delivery and identification of skilled provider.
  • Identification of people to provide care for children / household, help in transportation and accompany to health facility.
  • Complication readiness plan in case of emergency including funds, transportation, blood donors and referral facilities.
  • Promote and educate about concept of birth preparedness and dispels misconception and harmful practices that create obstacles.
  • Respects community's expectations and works within that setting.
  • Supports and values the use of antenatal care and supports special treatment for woman during pregnancy.-Recognizes danger signs and implements the complication readiness plan.-Supports mother and baby friendly decisior making for normal births and obstetric emergencies-Has access to health facilities along with community financing plan, functional transportation system and blood donation system for obstetric emergencies-Conducts dialogue with providers and works together with them to ensure quality of care
  • Support the facility that serves the community
  • Educates members of the community for the promotion of birth preparedness and complication readiness and dispels misconceptions and harmful practices.
  • Advocates for policy that support skilled health care
  • Advocates for skilled health care for woman and supports and values woman's use of antenatal care facilities.
  • Makes plan with woman for normal birth and complications
  • Recognizes danger i signs and facilitates implementing the complication readiness plan.
  • Identifies decision making process in case of obstetric emergencies
  • Identifies skilled provider for childbirth and means to contact or reach the provider.
  • Knows transportation systems, where to go in case of emergency and support persons to accompany and stays with family-Supports provider and woman in reaching referral site if needed-Knows how to access community and facility emergency funds-Elas personal savings for costs associated with emergency care or normal delivery-Knows how and when to access community blood donor system and also identifies blood donors.
  • Attends at least four antenatal visits (obtains money, transport)
  • Makes a birth plan with provider, husband and family.
  • Decides and acts on, where she wants to give birth with the help of skilled health care provider
  • Identifies a skilled provider for birth and knows how to contact or reach the provider.
  • Recognize danger signs and implements the complication readiness plan in case of complication.
  • Knows transportation systems, where to go in case of emergency and supports persons to accompany and stay with family
  • Speaks out and acts on behalf of her and her28 child's health, safety and survival
  • Knows about community and facility emergency funds available
  • Has personal savings and can access in case of need.
29
Policy maker
Facility
Provider
Community
Family
Woman
LABOUR AND CHILD BIRTH
  • Create an environment that supports the survival of pregnant women and newborns.
  • Promotes improved care during labor and childbirth and ensures that skilled care policies for labor and childbirth are evidence based, in place and politically endorsed.
  • Support systems that routinely update service vice delivery and cadre-specific guidelines and promotes/ facilitates the adoptation of evidence based practices.
  • Supports policies for complication management based on appropriate, epidemiological, financial, and sociocultural data.
  • Ensures that adequate levels of resources are dedicated to skilled care at birth and an effective emergency referral system exists.
  • Advocates birth preparedness and complication readiness through all possible venues (e.g. national campaigns, community talks, press conferences, local coalitions and supportive facilities).
  • Is equipped, staffed, and managed to provide skilled care for the pregnant women and newborn.
  • Has required essential drugs and equipments.
  • Follows infection prevention principles and practices.
  • Has appropriate space for birthing.
  • Has a functional emergency system, indu-ding:
    • Communication
    • Transportation
    • Safe blood supply
    • Emergency funds
  • Has service delivery guidelines for relevant and appropriate management of labor and childbirth.
  • Has job aids to assist providers in performing labor and childbirth procedure.
  • Ensures availability of a skilled provider 24 hours a day, 7 days a week.
  • Is gender and culturally sensitive, client-centered and friendly and involves community in quality of care.
  • Reviews case management of maternal and neonatal morbidity and mortality.
  • Provides skilled care for normal/complicated pregnancies, births, and the postpartum period.
  • Provides skilled care during labour and childbirth, including:
    • Assessing/monitoring women during labour using the partograph
    • Providing emotional and physical support through labour and childbirth
    • Conducting a clean and safe delivery including active management of 3rd stage of labour
    • Recognizing complications and providing appropriate management
    • Informing woman and family of existence of emergency facility(if available)
    • Referring to higher levels of care when appropriate
  • Supports the community she serves
  • Respects community's expectations and works within that setting
  • Educates community about birth preparedness and complication readiness
  • Promotes concept of birth preparedness and dispels misconceptions and harmful practices that could prevent birth prepare preparedness and complication readiness.
  • Advocates and facilitates preparedness and readiness actions.
  • Supports and values use of skilled provider at childbirth
  • Supports implementing the woman’s birth preparedness plan
  • Makes sure that the woman is not alone during labour, childdbirth and immediate postpartum period
  • Supports the woman in reaching place and provider of her choice
  • Recognizes danger signs and supports implementing the complication readiness plan
  • Supports mother and baby-friendly decision making in case of obstetric emergencies
  • Can access facility and community emergency funds, can support timely transportation of woman and have a functional blood donor system
  • Dialogues and works together with provider on expectations and supports the facility that serves the community
  • Advocates for policies that support skilled healthcare
  • Supports pregnant woman’s plans during pregnancy, childbirth and the postpartum period.
  • Advocates for skilled health care for woman
  • Recognizes normal labour and facilitates implementing birth preparedness plan
  • Supports woman in reaching place and provider of choice
  • Supports provider and woman in reaching referral site, if needed
  • Agrees with woman on decision making process in case of obstetric emergency
  • Recognizes danger signs and facilitates implementing the complication readiness plan
  • Discusses with and supports woman’s labour and birthing decisions
  • Knows about transportation facilities, where to go in case of emergency, and support persons to stay with family
  • Knows how to access community and facility emergency funds
  • Has personal savings for costs associated with emergency care or normal birth
  • Purchases necessary drugs or supplies
  • Prepares for birth, values and seeks skilled care during pregnancy, childbirth and the postpartum period.
  • Chooses provider and place of birth in antenatal period
  • Recognizes normal labour and understands birth preparedness plan
  • Recognizes danger signs and understands complication readiness plan
  • Knows transportation systems, where to go in case of emergency, and support persons to stay with family
  • Can access community and facility emergency funds
  • Has personal savings and can access in case of need.30
31
Policy maker
Facility
Provider
Community
Family
Woman
POSTPARTUM AND NEWBORN
  • Promotes improved postpartum and newborn care and ensures that skilled postpartum and newborn care policies are evidence based, in place and politically endorsed
  • Promotes and facilitates the adoption of evidence based practices
  • Supports policies for management of postpartum and newborn complications using appropriate, epidemiological, financial, and socio-cultural data
  • Ensures adequate levels of resource (financial, material, human) are dedicated to supportting the skilled management of postpartum and newborn care and the effectiveness of an emergency referral system
  • Encourages and facilitates participation in policy making and resource allocation for safe childbirth and emergency referral services by families community, individuals, and advocacy groups
  • Coordinates donor support for improved postpartum and newborn care
  • Is equipped, staffed, and well managed to provide skilled care for the postpartal woman and newborn.
  • Has all essential drugs and equipment
  • Follows infection prevention principles and practices
  • Has a functional emergency system, including:
    • Communication
    • Transportation
    • Safe blood supply
    • Emergency funds
  • Has service delivery guidelines on care of newborn and mother during postpartum period.
  • Has job aids to assist providers in performing appropriate postpartum and newborn care
  • Ensures availability of a skilled provider 24 hours a day, 7 days a week.
  • Is gender and culturally sensitive, client centered and friendly and involves community in quality of care
  • Reviews case management of maternal and neonatal morbidity and mortality.
  • Provides skilled newborn and postpartum care including:
    • Recognizing complications in the newborn and postpartum woman and providing appropriate management
    • Promoting health and preventing disease in the woman, including: Provision of contraceptive counseling and services
  • Promoting health and preventing disease in the newborn, including:
    • Thermal protection
    • Promotion of breast feeding
    • Eye care
    • Cord care
    • Immunization
  • Providing appropriate counseling and education for woman and family about danger signs and self-care for the postpartum woman and newborn
  • Informing woman and family of existence of emergency funds
  • Referring to higher levels of care when required
  • Respects community’s expectations and works within the setting
  • Educates/promotes in community about complication readiness and dispels misconceptions and harmful practices that could prevent complication readiness.
  • Advocates and facilitates preparedness and readiness actions.
  • Supports and values women’s use of postpartum and newborn care
  • Supports and values use of skilled provider during postpartum period
  • Supports appropriate and healthy norms for women and newborns during the postpartum period
  • Makes sure that the woman is not alone during the postpartum period
  • Recognize danger signs and supports implementing the complication readiness plan
  • Supports mother and baby friendly decision making in case of newborn emergencies
  • Supports timely transportation of woman and newborn to referral site, if needed
  • Can access facility and community emergency funds
  • Dialogues and works together with provider on expectations
  • Supports the facility that serves the community
  • Educates community members about complication readiness
  • Advocates for policies that support skilled health care
  • Promotes concept of and dispels misconceptions and harmful practices that could prevent complications readiness
  • Supports pregnant woman’s plans during pregnancy childbirth and the postpartum period.
  • Advocates for skilled healthcare for woman
  • Supports the woman’s use of postpartum and newborn care, adjusts responsibilities allow her attendance
  • Recognizes complications signs and facilitates implementing the complication rea diness plan
  • Agrees with woman on decision making process in case of postpartum or newborn emergency
  • Knows transportation systems, where to go in case of emergency, and support persons to stay with family
  • Supports provider, woman and newborn in reaching referral site if needed
  • Knows how to access community and facility emergency funds
  • Has personal savings for costs associated with postpartum and new born care
  • Purchases drugs or supplies needed for normal or emergency postpartum and newborn care
  • Knows how and when to access community blood donor system and identifies blood donor
  • Prepares for birth, values and seeks skilled care during pregnancy childbirth and the postpartum period.
  • Seeks postpartum and newborn care at least twice at 6 days and at 6 weeks postpartum (obtains money, transport)
  • Recognizes danger signs and implements the complications readiness plan
  • Speaks out and acts on behalf of her and her child’s health, safety and survival
  • Know transportation system, where to go in case of emergency, and support persons to stay with family
  • Can access community and facility emergency funds
  • Has personal savings and can access in case of need.
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