1. MATERNAL HEALTH Some technical aspects ANC, Delivery Care and PNC
B Subha Sri,
RUWSEC, CommonHealth
Delhi, October 2012

2. Structure of presentation
Causes of Maternal Deaths
Antenatal care
Delivery care
Referral
Postpartum care
Some indirect causes
Women’s concepts of Safe Deliveries

3. Causes of maternal death - India (SRS data)

4. Why is Ante Natal Care important to prevent Maternal Deaths?
Even the best ANC cannot predict or prevent pregnancy complications, but ANC is important for women to come into and maintain contact with the health system

5. Antenatal care Aim Routine care
Identification of women with special conditions and referral to higher centre if necessary for care
Early detection of problems

6. Antenatal care Essential components
Detailed history to detect special conditions / problems
Clinical examination
Maternal height/weight
Clinical examination for anaemia
Blood pressure measurement
Abdominal examination for uterine height, fetal growth and position, fetal heart rate
Lab tests
Haemoglobin
Urine for protein
Blood group

7. Antenatal care Essential components
Medicines
Iron supplements
Tetanus toxoid
Complete antenatal card
Instructions
Birth preparedness
Danger signs
Instructions and contact for emergencies
Contraception and lactation
About maternity benefit schemes

8. Delivery care Skilled birth attendant Cleanliness and sterility
Partograph – Monitoring progress of labour on a graph
Monitoring of fetal heart rate
Active Management of Third Stage of Labour (AMTSL) – Inj oxytocin or misoprostol within 1 minute of borth of baby - Prevention of PPH
Emergency Obstetric Care – Basic / Comprehensive
Referral – Transport and accompanied transfer
Respectful care
Birth Companion
Electricity, water, clean toilets

9. Referral Timely – without delay To appropriate facility Counseling
Referral note
Transport
Accompanied

10. Postpartum care To keep in facility for 48 hours.
Monitoring for bleeding, infection.
Detect and treat problems early.
Instructions on care of herself, newborn care, danger signs
Family planning counseling
Maternity benefit schemes

11. Postpartum care Home based First visit – Within 48 hours
Second visit – Within one week
Third visit – Within 6 weeks
Identify problems in mother and baby and treat/refer early
Family planning
Immunization

12. Anaemia Commonest indirect cause of maternal death
Can cause death by itself or by complicating other causes like haemorrhage or sepsis.
Postpartum anaemia can cause long term morbidity or late maternal death.
Prevention
Early detection – Haemoglobin estimation
Treatment – Iron folic acid, Iron sucrose, Blood transfusion
Social determinant – Nutrition, ICDS

13. Malaria
Pregnancy
increases likelihood of being infected with malaria
More frequent episodes
More severe infection
Higher risk of complications
Malaria induced anaemia
Higher risk of death
Very little information in India on malaria and pregnancy
Need to integrate testing and treatment in MCH programmes, especially endemic states
Prevention

14. Tuberculosis 30% of all TB cases in the world in India.
Tuberculosis incidence and prevalence is higher in adult males than in adult females
Women perceive the stigma of TB to be worse for them than for men – delay in reporting
HIV infection higher in young women – higher chances of TB
Pregnancy with a late diagnosis of TB – increased risk of obstetric morbidity, higher miscarriage, eclampsia, intrapartum complications
Higher risk of perinatal deaths, premature births and low birth weight
Rajasthan study (ARTH) – significant cause of post partum deaths
Need for integrating MCH and RNTCP.

15. Women's perspectives – “Safe” delivery
Delivery whether at home or in an institution is “safe” when
Both the mother and the newborn survive.
There is no maternal or neonatal morbidity, both short- term and long term.
The woman and the newborn do not receive unnecessary/irrational procedures or drugs, and receive the essential/appropriate, timely care (both complicated and uncomplicated).
The woman and the newborn receive a continuum of appropriate care from antenatal to intranatal to the postnatal period. This should include safe abortion services for those women who need them.

16. Women's perspectives – “Safe” delivery
The woman and the newborn have adequate support structures at place of delivery including running water, electricity, clean toilets.
The woman and newborn have an enabling environment to a safe pregnancy and delivery including adequate nutrition, family and social support, safety at work places, access to maternity benefit and welfare schemes, birth companion
Those with complication receive emergency care and referral and transport.
Those with complication receive the appropriate technical standard of care.

17. The woman receives all the relevant information and is consulted in care give to her.
The woman and the newborn are treated with dignity.
The woman and the newborn are not discriminated in any way.
Women belonging to marginalized groups and those with special needs receive appropriate care based on their needs.
The woman and the newborn are not abused in any way