1. 1 INCREASING ACCESS TO EMERGENCY OBSTETRIC SERVICES : EXPERIENCES FROM RAJASTHAN, INDIA Presenter: Hemant Dwivedi Authors : Venkatesh Srinivasan Hemant Dwivedi Dileep Mavalankar UNITED NATIONS POPULATION FUND (UNFPA), INDIA

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3. 3 KEY DEVELOPMENT INDICATORS

4. 4 HEALTH SYSTEM AN OVERVIEW  Sub-Centers - with an Auxiliary Nurse Midwife (ANM) - 5000 population  Primary Health Centers (PHCs) - Medical Officer (MO) and Paramedics - 30,000 population  Community Health Centers (CHCs) - Specialists doctors, MOs and Paramedics - 125,000 population  District Hospital - Multi Speciality - 2 million population  Medical College and Asso.Hospital - Division level

5. 5 PROJECT DETAILS  Averting Maternal Death and Disability (AMDD) project supported by Columbia University with a grant from the Bill and Melinda Gates Foundation.  Implemented as component project under UNFPA supported Integrated Population and Development (IPD) Project, Rajasthan, India from 2001-2004. u Project Area Seven Districts of Rajasthan, India Population covered - 13.5 million u Facilities Covered CEOC - 31 institutions BEOC - 52 institutions u Project Duration September 2000 - December 2004 u Implementing Agency Government of Rajasthan

6. 6 KEY FINDINGS OF BASELINE STUDY (2000) Service Coverage (UN-Process Indicators)  Number of institutions studied - 83  % of births in facilities - 10.89 (min.>15%)  % met need of EOC - 8% (min.100%)  % births by C-section - 0.6 (min.5-15%)  Average CFR - 1.4 (min 1%)

7. 7 STATUS OF HEALTH SYSTEM AT BASE LINE SURVEY IN 2000  High vacancies of specialists OB/GY and anesthetist  PHCs not offering complete range of BEmOC  Very few CHCs prepared to address EmOC  Only 21.5% deliveries in institutions  Low utilization of services and confidence in PHCs  Delay in reaching institutions

8. 8 PROJECT FOCUS Needs Based Differential Approach IMPROVING ACCESS TO QUALITY SERVICES  Improved functional infrastructure  Provided necessary equipments and supplies  Skill based trainings - BEOC, IP Training  Development of management systems INCREASE COMMUNITY AWARENESS  Advocacy Programs for PRIs, NGOs and Media.  Integrating Safe Motherhood messages into existing Community level activities.

9. 9 % Vacant Positions of Health Functionaries in Rajasthan

10. 10 WHY FOCUS ON BEmOC?  80-85% obstetric complications do not need surgical interventions  Focus on BEmOC will reduce nearly 33-60% maternal deaths  Skills upgradation of service provider is feasible  Over dependence on OB & Gy specialist and anesthetist reduced  Reduces congestion at district and medical college hospitals

11. 11 INITIATING BEOC SERVICES  Government in consultation with UNFPA decided to train MOs in BEmOC  2 weeks training at district hospital  62 teams trained BEmOC  MOs gained confidence in handling cases and expressed interest  Skills upgraded on manual removal of Placenta, management of shock, judicious use of Oxytocine, stabilizing cases of APH & PPH and ensuring referral when essential  Promoted use of evidence based practices

12. 12 ORIENTATION OF CBV

13. 13 MANAGEMENT INFORMATION SYSTEM  Needs assessment  Pilot testing of revised MIS  Revised MIS orientation and implementation  Monitoring of progress on UN process indicators

14. 14 Health Institutions Providing Basic and ComprehensiveEmOC - Rajasthan RESULTS OF THE INTERVENTIONS

15. 15 Births in EmOC Institutions: Comparison of Baseline, 2001, 2002 & 2003

16. 16 % Births increase in EmOC facilities : Comparison with non-intervention districts in last 4 years

17. 17 Comparison of met need of EmOC : Intervention and non-intervention districts

18. 18 C-Section in Facilities

19. 19 Comparison of Average CFR in Facilities Intervention and non-intervention institutions

20. 20 LESSONS LEARNED  BEmOC services as a feasible strategy in human resource scarce settings  Pragmatic strategies based on local specific needs leads to cost effective interventions  Improved service provision backed up by community mobilization increases utilization of services  Operationalising EmOC services requires sustained efforts  Demonstration project’s achievements facilitates advocacy at policy level

21. 21 MOVING FROM PILOT TO SCALE  Logframe of new national RH programme draws on Rajasthan experience for strengthening EmOC services  Reduction in maternal morbidity and mortality is now a priority agenda of Rajasthan Government  UN process indicator confirmed as reliable and accessible indicators for public health systems to measure programme performance

22. 22 Maternal death is a personal tragedy and social disaster. Let us join our hands to avert it.

23. 23 FOR FURTHER INFORMATION…. HEMANT DWIVEDI Sate Programme Coordinator UNFPA Rajasthan State Office, 29, Srirampura Colony, Civil Lines, Jaipur, Rajasthan, India Email : unfpajpr@sify.com Telephone : 91-141-2220028/2220224 Fax : 91-141-2222277 VENKATESH SRINIVASAN National Programme Officer UNFPA, 53, Jorbagh, New Delhi, India Email : venkatesh.srinivasan@unfpa.org.in Telephone : 91-11-24651801 Fax : 91-141-24641679