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PREVENTIVE STRATEGY FOR REDUCTION IN MMR PRESENTATION GROUP 01 DR KAUSAR DR TASNEEM DR KHURRAM DR KHALID
Introduction According to the World Health Organization, "A maternal death is defined as the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes.”
The
target of 75% reduction in maternal mortality ratios by 2015 is one of the three health related UN Millennium Development Goals, Half
a million deaths worldwide.
90%
in developing world.
Every minute worldwide
380 women become pregnant.
Amongst these, 190 are unplanned.
110 have pregnancy-related complications
40 have unsafe abortion.
1 woman dies from a pregnancy related complication.
Situation in Pakistan . Pakistan,
the 6th most populous country of the world continues to have high infant and maternal mortality rates. Pakistan MMR 276/100,000 live births GOP, has consistently allocated high priority to safe motherhood programmes in successive national health policies during last two decades. Reproductive
MHC
Overall
health service package of 1999 emphasized
progress has been slow
District Profile
Located in the centre of country at an almost equal distance from Karachi & Peshawar. Total area is 43494 km2 Geographically, lies in the upper Indus plain. A railway line connects Khanewal with FSD & Multan. It is basically an agricultural area Administratively divided into 4 tehsils,168 union councils.
Demographic & Health Indicators Population
2.39 million
Rural/ Urban %
82.5/17.5%
Male/female literacy rate
75/52%
Growth Rate
2.4%
Health Facilities
125
TFR
3
IMR
86/1000
MM Ratio
160/100000
Antenatal care coverage by skilled attendant
34%
% Deliveries by skilled attendant in HF
15.5%
CPR
24%
Health Department khanewal
EDO assissted by DHMT.
1 DHQ hospital,4 THQ hospitals,4 RHCs ,82 BHUs,MCHCs 10, Dispensaries 24.
Public health sector manpower,sanctioned posts 1355, filled posts 1106.
Posts of MOs, LHVs, Dais, at THQ, RHCs, BHUs, level are not completely filled.
POSSIBLE AREAS OF INTERVENTIONTO REDUCE MMR IN KHANEWAL DISTRICT
Reduce the likelihood that women will become pregnant.
Reduce the likelihood that a pregnant woman will experience a serious complication of pregnancy or child birth.
Improve the outcome for women with complication.
Reduce the likelihood that women will become pregnant Target population Unmet need for pregnancy Women with high parity In very young women Women with chronic disease like heart disease and epilepsy Intervention Family planning programs with involvement of TBAs mobile clinics and religious leaders Motivation of health providers to participate in F.P program delay the age at marriage
Reduce the likelihood that a pregnant woman will experience a serious complication of pregnancy or child birth. Intervention:
Creating awareness and demand for services
Advice on seeking antenatal care
Increase knowledge about dangerous signs during pregnancy among general population
Improve decision making at household level in case of emergency
Training courses for health provider according to standard protocol
Focus on T.T.
Training of TBAs for active management of third stage of labour.
Provision of community operated emergency transport.
Availability of female lady doctors at all BHU
Availability of 24 hours skilled care at BHU
Focus on post partum care.
Availability of all maternal services within ½ hr of travel.
Improve the outcome for women with complication
Development of the comprehensive and basic emergency obstetric care
Knowledge of dangerous sign of postpartum
Improve the referral system
Strict rules and laws regulation for unsafe abortion
Curative Intervention: Improvements in the capacity of existing health facilities to treat complications in pregnancy and childbirth
It is an essential element in reducing maternal mortality 1 A study in Matlab, Bangladesh has provided support for community based EmOC programs Three years of the maternity-care program, which included services to manage life-threatening complications, demonstrated a significant reduction in direct obstetric mortality compared with the three previous years of no intervention 2
Preventive Intervention:
Focus on the apparent delay in decision making to seek medical care. Aim :To reduce MMR in Khaniwal. District. Objective: To enhance the knowledge about obstetrics emergency to prevent delay in decision making for seeking emergency care in Khaniwal District. Sub objectives: 1. Increase awareness regarding reproductive health seeking behavior 2. To train the TBAs about danger signs of pregnancy 3. Increase awareness among TBAs about timely referral
Priority
The location of women when they deliver, who is attending them and how quickly they can be transported to referral –level care are thus crucial factors in determining interventions that are needed and feasible 3
90% deliveries take place at home and 80% death occur at home.4
01in 20 women with complications of pregnancy or childbirth reaches a facility with emergency obstetrical care.5
% 0f wom en by place of deliv ery 80 70
percentage%
60 50 rural
40
urban
30 20 10 0 at home
B HU/RHC /MC H
D HQ/THQ
PVT HOS P /C LINIC
knowledge about maternal life threating condition among different groups of participants women husband family mem total
A
bl ee h. di bl ng oo d. su ha g em ar or ra ge ob s. la bo ur in fe ct io n
percentage
60 50 40 30 20 10 0
participants
person who made decision to seek health care 60
percentage %
50 40 30 20 10 0 Self
husband
mother in law
other family member
m easures taken
TBA/DAI
Others
Package include
Awareness program regarding life-threatening condition of pregnant women to identify the danger signs of pregnancy to facilitates timely decision for seeking health care. These delays are interrelated and occur for a wide variety of economic, social, cultural and political reasons. Each must be addressed if death or severe illness is to be averted. For example, improving access to care without improving health service responsiveness and ability to manage life-threatening complications will not reduce maternal deaths. However, many of the poorest women may have no contact with formal health services. There is a need to better understand their needs and the barriers they face in using services. These barriers can be within the household as well as at the point of care. Invest in human resources, particularly midwifery but also referral level skills.
Target population: 1. 2. 3. 4. 5.
Pregnant women Husband Influential family member Dai TBAs Health providers
Distribution plan
Identification of pregnant women and social mobilization by LHW to include pregnant women in area Identification of dai and TBAs in the areas by community members. Detailed mapping of the district will be done to identify health provider at BHU and private doctor who are mainly responsible to refer the pregnant women to emergency obstetrics care. Cont…
Distribution plan
Greater public awareness is a powerful tool in reducing maternal mortality.Civil society groups have an important role in drawing attention to the problem and in strengthening government accountability through engagement with Parliament and in consultations around poverty reduction strategies Support for women’s groups can raise the visibility of the problem and stimulate action .Violence is responsible for a sizable proportion of maternal deaths.pregnant women who suffer due to delay in decision are more likely to have more complications and may lead to death. Education, particularly of girls, empowers women to make informed choices and increases demand for improved services. Better-educated women marry later, have fewer, healthier and better educated children and make more effective use of health services. Maternal health should be introduced into school curricula and into contacts with adolescents in formal and informal settings. Effective communications and transport are critical to success. New technologies, including mobile and satellite phones, can speed calls for assistance and warn referral facilities.
IMPLEMENTATION OF MY DISTRIBUTION PLAN:
The intersectoral collaborative meetings involving the mobilization of community which will help in implementing the programme effectively. Male mobilizer from the union council for interactions and councelling with husbands regarding their responsibilities in case of emergency and the way, how to manage at time of delivery leading to complication due to delay in decision making.so their Effective communications, money and transport arrangements with mobile and satellite phones, can speed calls for assistance and warn referral facilities. Provide ambulance in distant areas where health facility services are far away with collaboration of funds given by EDO, District nazim and influential members of the community. Meeting sessions in dominant family members including male and female regarding dangerous signs of pregnancy and the consequences of delay in decision making for seeking medical care.
IMPLEMENTATION OF MY DISTRIBUTION PLAN:
Educating the pregnant women through IEC materials regarding the dangerous signs in pregnancy and during labour. And improving their decision power and inhibition, which prevent women from consulting at health center. Improve knowledge, counseling and emergency practices skills of LHW’s by group discussions under supervision of Obstetricians and gynecologist. Educating Dais and TBAs regarding life threatening condition during pregnancy through pictorial material and improve their moral responsibilities during patient handling, timely identification of obstetric complication and immediate referral decision.
SUPERVISION TEAMS
For the supervision of health facilities: The team will comprise of DOC, DHO and 1 elected representative For supervision of enrollment activities: The team will comprise of EDO , DDHO, one community representative. Collection, analysis, and reporting of data: Monthly records of the activities carried out will be submitted by the health facilities and analyses and report on monthly basis will go to the EDO health that can change or let continue the activities based on the evidence given by the thorough record keeping. Monitoring & Evaluation: Evaluation will be done through outcome indicators
Outcome indicators: 1. 2.
3. 4. 5.
Percentage of pregnant women enrolled in the health insurance plan. Percentage of knowledge among pregnant women, Dais and TBAs through questionnaire filling regarding the dangerous signs in pregnancy and during labour. Percentage of pregnant women facing complication due to delay in decision at home level. Met need for EMOC services defined as proportion of all obstetric complications treated at EMOC centers. Percentage of pregnant women referred by Dais or TBAs on time without development of serious complication.
At the end of the plan along with quantification, qualitative formative study will be done to see the effect through people’s eyes.
ASSUMPTIONS
Delay in decision explains
1.
Educating the pregnant women through IEC materials regarding the dangerous signs in pregnancy and during labour. And improving their decision power and inhibition, which prevent women from consulting at health center Low status of women can be improved through providing financial support regarding health service provision and behavior change Improve knowledge, counseling and emergency practices skills of LHWs by group discussions under supervision of Obstetricians and gynecologist Insufficient resources can be overcome by providing transport and by guiding the husband to manage money for time of complication.involvement of husband from start will result in better compliance of the plan. Lack of awareness regarding dangerous signs can be improved by providing education to household members, health providers, influential personnel and pregnant women.
2. 3. 4.
5.
PROJECT BUDGET Budget allocated for ambulances and maintenance Number of facilities Budget allocated per facility Total budget available
LINE ITEM FOR 4 TEHSILS
AMBULANCE
PETROL & MAINT.
TOTAL
NO/TEH SIL
08 million 92 01 million 100million.
MILLION/MONT H/ TEHSIL
01
0.041
MILLION/YE AR/ TEHSIL
TOTAL MILLION FOR 4 TEHSIL
1.5
06
0.5
02
02
08
LINE ITEM
NO/FACILI TY
MILLION/MONTH/ FACILITY
MILLION/YEAR/ FACILITY
3
0.00216
0.26
1
0.001
0.12
0.00125
0.15
0.0083
0.1
0.016
0.2
0.0041
0.05
0.00583
0.07
0.0041
0.05
0.04274
1
SALARIES(New hired staff) LHV, DAIs, TBAs Monitoring & evaluation staff
STATIONARY & EDU MATERIAL
PILOT PROJECT
1 VISIT/MONTH
PROG FOR COMMUNITY ORIE 2/MONTH UTILITY
TA/DA
Misc
TOTAL
THANKS
Introduction According to the World Health Organization, "A maternal death is defined as the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes.”
The
target of 75% reduction in maternal mortality ratios by 2015 is one of the three health related UN Millennium Development Goals, Half
a million deaths worldwide.
90%
in developing world.
Every minute worldwide
380 women become pregnant.
Amongst these, 190 are unplanned.
110 have pregnancy-related complications
40 have unsafe abortion.
1 woman dies from a pregnancy related complication.
Situation in Pakistan . Pakistan,
the 6th most populous country of the world continues to have high infant and maternal mortality rates. Pakistan MMR 276/100,000 live births GOP, has consistently allocated high priority to safe motherhood programmes in successive national health policies during last two decades. Reproductive
MHC
Overall
health service package of 1999 emphasized
progress has been slow
District Profile
Located in the centre of country at an almost equal distance from Karachi & Peshawar. Total area is 43494 km2 Geographically, lies in the upper Indus plain. A railway line connects Khanewal with FSD & Multan. It is basically an agricultural area Administratively divided into 4 tehsils,168 union councils.
Demographic & Health Indicators Population
2.39 million
Rural/ Urban %
82.5/17.5%
Male/female literacy rate
75/52%
Growth Rate
2.4%
Health Facilities
125
TFR
3
IMR
86/1000
MM Ratio
160/100000
Antenatal care coverage by skilled attendant
34%
% Deliveries by skilled attendant in HF
15.5%
CPR
24%
Health Department khanewal
EDO assissted by DHMT.
1 DHQ hospital,4 THQ hospitals,4 RHCs ,82 BHUs,MCHCs 10, Dispensaries 24.
Public health sector manpower,sanctioned posts 1355, filled posts 1106.
Posts of MOs, LHVs, Dais, at THQ, RHCs, BHUs, level are not completely filled.
POSSIBLE AREAS OF INTERVENTIONTO REDUCE MMR IN KHANEWAL DISTRICT
Reduce the likelihood that women will become pregnant.
Reduce the likelihood that a pregnant woman will experience a serious complication of pregnancy or child birth.
Improve the outcome for women with complication.
Reduce the likelihood that women will become pregnant Target population Unmet need for pregnancy Women with high parity In very young women Women with chronic disease like heart disease and epilepsy Intervention Family planning programs with involvement of TBAs mobile clinics and religious leaders Motivation of health providers to participate in F.P program delay the age at marriage
Reduce the likelihood that a pregnant woman will experience a serious complication of pregnancy or child birth. Intervention:
Creating awareness and demand for services
Advice on seeking antenatal care
Increase knowledge about dangerous signs during pregnancy among general population
Improve decision making at household level in case of emergency
Training courses for health provider according to standard protocol
Focus on T.T.
Training of TBAs for active management of third stage of labour.
Provision of community operated emergency transport.
Availability of female lady doctors at all BHU
Availability of 24 hours skilled care at BHU
Focus on post partum care.
Availability of all maternal services within ½ hr of travel.
Improve the outcome for women with complication
Development of the comprehensive and basic emergency obstetric care
Knowledge of dangerous sign of postpartum
Improve the referral system
Strict rules and laws regulation for unsafe abortion
Curative Intervention: Improvements in the capacity of existing health facilities to treat complications in pregnancy and childbirth
It is an essential element in reducing maternal mortality 1 A study in Matlab, Bangladesh has provided support for community based EmOC programs Three years of the maternity-care program, which included services to manage life-threatening complications, demonstrated a significant reduction in direct obstetric mortality compared with the three previous years of no intervention 2
Preventive Intervention:
Focus on the apparent delay in decision making to seek medical care. Aim :To reduce MMR in Khaniwal. District. Objective: To enhance the knowledge about obstetrics emergency to prevent delay in decision making for seeking emergency care in Khaniwal District. Sub objectives: 1. Increase awareness regarding reproductive health seeking behavior 2. To train the TBAs about danger signs of pregnancy 3. Increase awareness among TBAs about timely referral
Priority
The location of women when they deliver, who is attending them and how quickly they can be transported to referral –level care are thus crucial factors in determining interventions that are needed and feasible 3
90% deliveries take place at home and 80% death occur at home.4
01in 20 women with complications of pregnancy or childbirth reaches a facility with emergency obstetrical care.5
% 0f wom en by place of deliv ery 80 70
percentage%
60 50 rural
40
urban
30 20 10 0 at home
B HU/RHC /MC H
D HQ/THQ
PVT HOS P /C LINIC
knowledge about maternal life threating condition among different groups of participants women husband family mem total
A
bl ee h. di bl ng oo d. su ha g em ar or ra ge ob s. la bo ur in fe ct io n
percentage
60 50 40 30 20 10 0
participants
person who made decision to seek health care 60
percentage %
50 40 30 20 10 0 Self
husband
mother in law
other family member
m easures taken
TBA/DAI
Others
Package include
Awareness program regarding life-threatening condition of pregnant women to identify the danger signs of pregnancy to facilitates timely decision for seeking health care. These delays are interrelated and occur for a wide variety of economic, social, cultural and political reasons. Each must be addressed if death or severe illness is to be averted. For example, improving access to care without improving health service responsiveness and ability to manage life-threatening complications will not reduce maternal deaths. However, many of the poorest women may have no contact with formal health services. There is a need to better understand their needs and the barriers they face in using services. These barriers can be within the household as well as at the point of care. Invest in human resources, particularly midwifery but also referral level skills.
Target population: 1. 2. 3. 4. 5.
Pregnant women Husband Influential family member Dai TBAs Health providers
Distribution plan
Identification of pregnant women and social mobilization by LHW to include pregnant women in area Identification of dai and TBAs in the areas by community members. Detailed mapping of the district will be done to identify health provider at BHU and private doctor who are mainly responsible to refer the pregnant women to emergency obstetrics care. Cont…
Distribution plan
Greater public awareness is a powerful tool in reducing maternal mortality.Civil society groups have an important role in drawing attention to the problem and in strengthening government accountability through engagement with Parliament and in consultations around poverty reduction strategies Support for women’s groups can raise the visibility of the problem and stimulate action .Violence is responsible for a sizable proportion of maternal deaths.pregnant women who suffer due to delay in decision are more likely to have more complications and may lead to death. Education, particularly of girls, empowers women to make informed choices and increases demand for improved services. Better-educated women marry later, have fewer, healthier and better educated children and make more effective use of health services. Maternal health should be introduced into school curricula and into contacts with adolescents in formal and informal settings. Effective communications and transport are critical to success. New technologies, including mobile and satellite phones, can speed calls for assistance and warn referral facilities.
IMPLEMENTATION OF MY DISTRIBUTION PLAN:
The intersectoral collaborative meetings involving the mobilization of community which will help in implementing the programme effectively. Male mobilizer from the union council for interactions and councelling with husbands regarding their responsibilities in case of emergency and the way, how to manage at time of delivery leading to complication due to delay in decision making.so their Effective communications, money and transport arrangements with mobile and satellite phones, can speed calls for assistance and warn referral facilities. Provide ambulance in distant areas where health facility services are far away with collaboration of funds given by EDO, District nazim and influential members of the community. Meeting sessions in dominant family members including male and female regarding dangerous signs of pregnancy and the consequences of delay in decision making for seeking medical care.
IMPLEMENTATION OF MY DISTRIBUTION PLAN:
Educating the pregnant women through IEC materials regarding the dangerous signs in pregnancy and during labour. And improving their decision power and inhibition, which prevent women from consulting at health center. Improve knowledge, counseling and emergency practices skills of LHW’s by group discussions under supervision of Obstetricians and gynecologist. Educating Dais and TBAs regarding life threatening condition during pregnancy through pictorial material and improve their moral responsibilities during patient handling, timely identification of obstetric complication and immediate referral decision.
SUPERVISION TEAMS
For the supervision of health facilities: The team will comprise of DOC, DHO and 1 elected representative For supervision of enrollment activities: The team will comprise of EDO , DDHO, one community representative. Collection, analysis, and reporting of data: Monthly records of the activities carried out will be submitted by the health facilities and analyses and report on monthly basis will go to the EDO health that can change or let continue the activities based on the evidence given by the thorough record keeping. Monitoring & Evaluation: Evaluation will be done through outcome indicators
Outcome indicators: 1. 2.
3. 4. 5.
Percentage of pregnant women enrolled in the health insurance plan. Percentage of knowledge among pregnant women, Dais and TBAs through questionnaire filling regarding the dangerous signs in pregnancy and during labour. Percentage of pregnant women facing complication due to delay in decision at home level. Met need for EMOC services defined as proportion of all obstetric complications treated at EMOC centers. Percentage of pregnant women referred by Dais or TBAs on time without development of serious complication.
At the end of the plan along with quantification, qualitative formative study will be done to see the effect through people’s eyes.
ASSUMPTIONS
Delay in decision explains
1.
Educating the pregnant women through IEC materials regarding the dangerous signs in pregnancy and during labour. And improving their decision power and inhibition, which prevent women from consulting at health center Low status of women can be improved through providing financial support regarding health service provision and behavior change Improve knowledge, counseling and emergency practices skills of LHWs by group discussions under supervision of Obstetricians and gynecologist Insufficient resources can be overcome by providing transport and by guiding the husband to manage money for time of complication.involvement of husband from start will result in better compliance of the plan. Lack of awareness regarding dangerous signs can be improved by providing education to household members, health providers, influential personnel and pregnant women.
2. 3. 4.
5.
PROJECT BUDGET Budget allocated for ambulances and maintenance Number of facilities Budget allocated per facility Total budget available
LINE ITEM FOR 4 TEHSILS
AMBULANCE
PETROL & MAINT.
TOTAL
NO/TEH SIL
08 million 92 01 million 100million.
MILLION/MONT H/ TEHSIL
01
0.041
MILLION/YE AR/ TEHSIL
TOTAL MILLION FOR 4 TEHSIL
1.5
06
0.5
02
02
08
LINE ITEM
NO/FACILI TY
MILLION/MONTH/ FACILITY
MILLION/YEAR/ FACILITY
3
0.00216
0.26
1
0.001
0.12
0.00125
0.15
0.0083
0.1
0.016
0.2
0.0041
0.05
0.00583
0.07
0.0041
0.05
0.04274
1
SALARIES(New hired staff) LHV, DAIs, TBAs Monitoring & evaluation staff
STATIONARY & EDU MATERIAL
PILOT PROJECT
1 VISIT/MONTH
PROG FOR COMMUNITY ORIE 2/MONTH UTILITY
TA/DA
Misc
TOTAL
THANKS
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