Tamil Nadu’s initiatives to reduce MMR POPULATION India 1027 Mn Tamil Nadu 62.24 Mn

Structure of the presentation Present status of maternal health in the state Major achievements over 2007-09 Issues and concerns-comparison of maternal death data 2006-2008 Planned interventions for each of the focus areas

Demographic Profile VITAL EVENTS INDIA TAMILNADU Infant Mortality Rate 53 (SRS 2008) 31 Maternal Mortality Ratio 254 (SRS 2004-06) 79 (State HMIS-2008-09) TFR 2.7 (SRS 2007) 1.6 Institutional Deliveries 40.7 (NFHS 3) 90.4 Maternal Anaemia 57.8 53.3 Mothers who had at least 3 antenatal care visits for their last birth (%) 50.7 97.6

Trend in Maternal Mortality Rate-Tamil Nadu MMR AMTSL, LSAS training, Hiring of Specialists Blood storage facility, AN protocol, etc EMRI Before RCH RCH NRHM Source DPH & PM YEAR

Maternal Death Cause Analysis 2008-09

Improved utilization of PHCs Positioning 3 staff nurses in each PHC to provide 24x7 delivery care and training to these nurses in SBA skills Filling vacancies of medical officers and equipping the PHCs to provide BEmONC services. Using untied funds and Patient Welfare Society funds to improve ambience and user friendliness of PHCs Building bridges between PHC and community using innovative IEC techniques

IMPROVED UTILISATION OF PHCs Average OP per Day Average IP per Month Average Deliveries per Month

CONTRIBUTION IN DELIVERIES (%) Domi. PVT GH PHC HSC Up to Dec. 8

Melakkal PHC, Madurai HUD NRHM Additionalities Melakkal PHC, Madurai HUD Old Building New Building

Privacy assured during the stay at PHC RO , Solar water heater Baby warmers at PHC X-Ray Unit in PHC Communication Clean and Neat environment

Valaikappu Ceremony conducted at PHCs This programme reduces the gap by building bridges between the PHC and the community.

Making Emergency Obstetric Care available Hiring private anaesthetists and obstetricians to carry out caesarian operations Total caesarians done in secondary institutions in 2006-07-40878 Increased to 45966 (upto Jan2010) Training MBBS doctors in short term course in Life Saving Anaesthesia Skills and Emergency Obstetric Care. So far 177 doctors trained No of LSCS done by trained anesthetists - 12780

Making Emergency Obstetric Care available (contd) Emergency Referral Services (Toll free no 108) introduced AN mothers transported in Jan 2010 - 11152 Cases of inter facility transfer - 3401

Cause for concern! No major change in causes of maternal death!! Direct Cause 2006(%) 2008(%) Post partum haemorrhage 30 25.4 Pregnancy induced Hypertension 6.5 Postpartum sepsis 3.5 3.2 Septic abortion Indirect Cause Anaemia in pregnancy 5.4 4.5 No major change in causes of maternal death!!

Analysis of Maternal death (2006 & 2008) - A comparison Place of Maternal death 2006(%) 2008(%) Teaching Hospital 31 39 Transit 22 19 Private Hospital 16 18 Head quarters Hospital 15 7 Home 12 Marginal reduction in transit… increase in teaching hospital…no change in home deaths!

Analysis of period of Maternal Death- 2008(%) Out of 73 % of PN death Antenatal 22 Intranatal 5 Post natal 73 In spite of 99% institutional deliveries, 35% of the deaths are still within 24 hrs!

Haemorrhage-Direct Cause Interventions AMTSL training for the whole state-NASG of Pathfinders International also being introduced Focus on training of all nurses including secondary and tertiary institutions Ensuring safe blood availability – blood storage centres and logistics of how to use them in resource poor settings

PIH-Direct Cause Interventions Retraining to all VHNs in ante natal care protocols and skills including basic BP measurement Use of electronic BP apparatus as a validating device Model blocks to introduce calcium supplementation for antenatal women Reemphasising the use of magnesium sulphate in management of eclampsia

Sepsis-Direct cause Interventions Post natal care visits- emphasis of danger signs in home based care training IEC/ BCC messages to new mothers on danger signs and to overcome cultural taboos of leaving home before one week Ensuring forty eight hour stay in PHCs with clear discharge guidelines to be checked by the medical officer Hospital side- infection management practices in labour rooms and post natal wards- training programmes to be put in place

Obstructed /Prolonged labour (Direct cause) Interventions Training on use of partogram Emphasis on prompt referral Building district level quality control circles using the obstetricians and nurse trainers to improve delivery skills of nurses Ensuring availability of emergency services at the CEmONC centres through better networking

Anaemia management (Indirect cause) Interventions Anaemia management protocol for normal, moderate and severe anaemia cases including mandatory deworming in view of the high worm load Use of iron sucrose for severe anaemia Supplementation with Vit C and B-12 in view of the deficiencies in diet Ensuring proper measurement of haemoglobin levels IEC strategy for changing diet and lifestyle of women (using slippers..) Adolescent Anaemia Control programme - long term effect on haemoglobin and ferritin levels

Other initiatives Interventions Pregnancy cohort monitoring- focus on women at risk Verbal community death autopsy conducted by the district collector Continued focus on reduction of higher order births- strong IUD campaign for those women unwilling to accept sterilization Policy for safe abortion and ensuring availability of MVA services at least at the block level.

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