Dr Anjana SaxenaDeputy Commissioner

Maternal Health

Ministry of Health and Family Welfare

30.11.2011

1

Goals for Twelfth Plan, NPP 2000 and MDGs

Indicator Current

Level

12th

Plan

2007

2010

goals as

per

NPP

MDG

Goals

2015

Maternal Mortality

Ratio (per 100,000

live births)

212

(2007-09)

100 100 100

2

Causes of Maternal Deaths

3

Medical Causes:

Haemorrhage, Infection, Obstr

ucted Labour, HT disorder of

pregnancy

Reproductive Factors:

Parity, Unmet need of

contraception

Health Service Factor:

Access to health

Service, Lack of trained

staff, equipment and supplies

Socio-Economic

Causes:

Low Status, Low

Education, Poverty etc

Maternal

Mortality

Maternal Mortality by Causes in IndiaDirect causes :

• Severe bleeding

• Sepsis

• Unsafe Abortion

• Eclampsia

• Obstructed Labor

• Others (Ectopic Pregnancy, Severe Anemia, Embolism,Anesthesia related)

Indirect causes:

• Malaria,

• Anemia and

• Cardiac disease etc.

37%

11%5%

5%

8%

34%

Haemorrhage Sepsis Hypertensive disorders

Obstructed Labor Abortion Other Conditions

4

Source: SRS 2004-06

Iron

tablets, Antimalarials, Regular

ANC

Health service factors…

Avoiding the three delays:

In Seeking, Reaching and Obtaining

Care

MMR and Care during pregnancy(3+ANC and Institutional Delivery)

0

50

100

150

200

250

300

350

400

450

MMR (SRS-07-09)

Percentage of Institutional deliveries (DLHS-3)

Three or More ANC(DLHS-3)

Approach:

Universal supplementation with

micronutrients for pregnant, lactating

and LBW

Supplementation for women of child

bearing age including adolescents if

anaemia prevalence > 40%

Screening- only if anaemia prevalence

is mild or moderate and severe.

Strategies Of GOI:1) PMs national council on India’s nutrition challenges:

October 2008.

2) National Nutrition Policy: 1993

3) National Plan of Action for Nutrition: 1995

4) RCH program under NRHM

5) NIDDCP

6) Nutrition education

7) Other Schemes like: ICDS, SABLA, IGMSY, Midday

meal, NREGA, PDS.

8

Under RCH:

Pre conception folic acid

Provision of IFA tablet for PW and lactating mothers.

JSY

JSSK

ANC/PNC

Name Based Tracking System for Mother and Child.

VHNDs

MCP card has been developed jointly with the WCD.

Safe motherhood booklet.

SBA training for ANMs/SNs/LHVs

Strategies of GOI for quality care:

There is a package of services which includes the following:

Early Registration.

At least 3 ANCs

100 IFA Tablets to all PW/200 tabs to anemic PW (Hb%<11gms)

2 TT injections

Measurement of : Weight, Height, Blood pressure ,Bloodtests like Hb%, Bld Gp, Bld Sugar , HIV, VDRL.

Test of: Urine tests for Albumin, sugar, Abdomenexamination, FHS, Breast examination, Ultrasound.

Should receive advice on:Breast feeding, Keeping babywarm, Cleanliness, Spacing between children, Nutrition andInstitutional delivery

S.

No

Indicator DLHS-3

2007-08

CES-2009

1 Antenatal check-up in the first trimester of

Pregnancy

45 %

2 At least 1 ANC 75.2 % 89.6 %

3 Three or more antenatal check-up 49.8 % 68.7 %

4 Full ANC

(Women who received 3 ANC checkups, one

TT injection and consumed 100 + IFA

tablets)

18.8 % 26.5 %

5 Institutional Delivery 47.0 % 72.9 %

6 Skilled Birth Attendance

(Delivery by Doctor, ANM/Nurse/LHV)

52.7 % 76.2 %

Current scenario: Indicators for quality outcome of

pregnancy

Anaemia- Magnitude of Problem: The Challenge• Iron Deficiency is most common nutrition disorder in

world.

• WHO estimates the number of anaemic people worldwide to be a staggering two billion.

• Increased risk of maternal and child mortality due to severe anaemia.

• Children <2 years and pregnant women are most at risk for anemia because their requirements for iron are higher than any other group and they are most susceptible to malaria.

• Iron Deficiency is aggravated by Worm Infestation which causes blood loss and Malaria which causes haemolysis of the blood.

• Fact that every third woman in India is undernourished (35.6 percent have low Body Mass Index) and every second woman is anaemic (55.3 percent).

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Magnitude of problem…Universal in all age groups

38.6

15

1.8

55.3

39.1

14.9

1.7

55.8

0

10

20

30

40

50

60

Mild Anemia (g/dl) Moderate Anemia (g/dl) Severe Anemia (g/dl) Any Anemia (g/dl)

India

15-19

yrs

Pre

val

ence

o

f A

nem

ia

Source NFHS III (2005-06)

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Anemia in Women

Prevalence of Anemia during Pregnancy and Lactation

25.8

30.6

2.2

58.7

44.9

16.6

1.7

63.2

0

10

20

30

40

50

60

70

Mild Anemia (g/dl) Moderate Anemia (g/dl) Severe Anemia (g/dl) Any Anemia (g/dl)

Pregnant

Breastfeeding

Pre

vale

nce

o

f A

nem

ia

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Prevalence of Iron Deficiency

anaemia (NFHS-III) Higher in pregnant and breast feeding women

More in Rural areas

More in low education status

Religion has no effect on aneamia.

More in those belonging to households in the lower wealth

quintiles;

More in disadvantaged groups including scheduled tribes.

Causes of Iron Deficiency anemia Inadequate intake.

Inadequate absorption from intestines.

Closely spaced pregnancies.

High prevalence of infections and infestations.

Faulty feeding practices.

Illiteracy.

Poverty.

Socio-economic conditions.

Poor hygienic conditions

An integrated – multisectoral approach

Strategies are built into the primary health care

system and existing programs such as:

Adolescent health

Maternal and child health

Safe motherhood

Roll-back malaria

Deworming

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An integrated – multisectoral approach

Contd…

Strategies are evidence based.

With firm political commitment and strong

partnerships involving all relevant sectors.

IEC/BCC is being done for anemia prevention and

treatment

An operational surveillance system with

reliable, affordable and easy-to use methods for

assessing and monitoring anemia prevalence.

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19

Severity of Anaemia: Hb% is:

• Mild:- 10-11 gms%

• Moderate:-7-10 gms%

• Severe:- <7 gms%

Prevention Strategies under NRHM

Increased Iron Intake:100 tabs of IFA are given to all pregnant women

Moderate Anaemia: 200 tabs of IFA are given to PW and is continued Post-nataly.

Infection Control: Public health measures to control hook work infestation, malaria, and schistosomiasis;

Improved Nutritional Status: In children of 0-5 yrs supplementation of major nutrient deficiencies, diet diversification and infection prevention.

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Prevention Strategies: CounsellingIncreased Iron Intake: Dietary Modification

Increase intake of locally available food e.g. meat, livergreen leafy vegetables etc.;

Increase intake of Vitamin C rich food or other food thatenhances the absorption of Iron e.g. Fruits like Guava, citrusfruits, fermented food etc;

Reduce as much as possible consumption of Iron absorptioninhibitors e.g. Phytates and Iron binding phenoliccompounds ;

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Treatment of Iron deficiency AnaemiaOral Iron therapy

Ferrous Compound better than Ferric;

Sustained and slow release preparations – Capsule form;

Transfusion Therapy:

Cases with Hb level <5 g/dl may require hospitalisation and < 4 g/dl require blood transfusion

Slow correction is recommended;

Parental Iron Therapy

Iron Sucrose compound is most commonly used

(Dose: 100 mg of Iron in 10 ml of saline solution given over a period of 30 minutes)

Steps taken under NRHM• Deworming of anemic children with Albendazole every 6

months and IFA tabs are being distributed

• Health and nutrition education to promote dietary

diversification and rich food as well as food items that

promote iron absorption.

• To tackle the problem of anemia due to malaria

particularly in pregnant women and children, Long

Lasting Insecticide Nets (LLINs) and Insecticide Treated

Bed Nets (ITBNs) are being distributed in endemic areas.

• Tracking of Severe anemia in PW

Key thrust areas for 12th plan-RCH

Service guarantee in public health facilities

Comprehensive MCH care, Thrust on neo natal

care

Training, Birth waiting homes, Dedicated 100

beds MCH wing

Adolescent health, School

health, Operational plan for Nutrition

Meeting the Unmet Need for contraception- postpartum services, ASHA & NGOs

involvement

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Service guarantees in public health facilities: Continued

Political Commitment• Continuum of free care during ante-natal, intranatal and post-natal period

including management of complications, for every pregnant woman and free

delivery including C-section

• Ensuring for every pregnant woman free supplementation, drugs including

consumables, free diagnostics, free diet during hospital stay, free blood and

free referral transport( to and fro) with no out of pocket expenses.

• National Framework for the prevention & control of moderate and severe

anaemia among children, adolescents and pregnant and lactating mothers

• Development of Joint field operational plans in convergence with ICDS for

result oriented management of malnutrition including establishment of NRCs for

management of Severe acute malnutrition

• Up scaling the implementation and monitoring of Maternal Death Review.

• Strengthening national framework on adolescent health, currently a weak pillar

of RCH

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New Intervention Proposed:

Costing for Iron Sucrose Intervention

Estimated Pregnant women with Any Anemia is 59% as per

NFHS-3.

5% of pregnant women will require iron sucrose intervention

severe to moderate anemiaUnit Cost of 1 ampoule of Iron Sucrose@ Rs 20 per ampoule(

considering average of 5 ampoules for PW with severe and

moderate anaemia .

Total Cost for Iron Sucrose Intervention in the XII Five year

Plan will be Rs 46.22 crores .

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