1.1. Midwifery concept in maternal health 3.pptx

Midwifery concept

1. MIDWIFERY CONCEPT IN MATERNAL HEALTH Indian Healthcare System and Maternal and Neonatal Health Scenario

2. MNH Scenario in India at a G lance Population: 1.3 billion     Pregnancies: 30 million annually   Births: 26 million annually                         Source: NFHS 5, 2019-21

3. Globally more people die of poor quality of care than due to lack of access to healthcare (Lancet Commission) Source: Mortality due to low-quality health systems in the universal health coverage era: a systematic analysis of amenable deaths in 137 countries. Lancet. 2018 Nov 17;392(10160):2203-2212. 66% (in millions)

4. Situation Analysis

5. Maternal Mortality Ratio in India India has made significant progress in reduction of MMR Source: Sample Registration System (SRS)

6. Timing of Maternal Deaths Problem Statement:   Most mortality is centred around birth ( intrapartum and immediate postpartum period) Source: Ronsmans C, Graham WJ. Maternal mortality: who, when, where, and why. The Lancet. 30 September;368(9542):1189–200. Source:: JE Lawn et al.; Every newborn, progress, priorities and potential beyond survival; The Lancet   (DOI:10.1016/S0140-6736(14)60496-7).    Dakshata, MoHFW, GoI, 2015

7. Causes of Maternal & Neonatal Mortality in India Source: https://censusindia.gov.in/nada/index.php/catalog/44752 Source: Census India Most causes of maternal and neonatal mortality are preventable, if evidence-based safe practices are institutionalized

8. Timing of Neonatal Deaths Problem Statement:   Most mortality is centred around birth ( intrapartum and immediate postpartum period) Source: Ronsmans C, Graham WJ. Maternal mortality: who, when, where, and why. The Lancet. 30 September;368(9542):1189–200 Source:: JE Lawn et al.; Every newborn, progress, priorities and potential beyond survival; The Lancet   (DOI:10.1016/S0140-6736(14)60496-7)..   

9. Maternal and Newborn Health: Issues and Concerns Large inter-state and intra- district variations Persistent urban-rural differential and Gender differential in newborn mortality Four States (UP, BH, MP, RJ)- account for 70% of maternal deaths and nearly 60% newborn deaths.*  46% of all maternal deaths, 40% stillbirths and 25% of under-five deaths occur on the day of birth Maternal anemia (52%) and Low-birth Weight babies (18%)** Quality of Care & Respectful Maternity Care and Poor ANC services Convergence for Underlying Health Issues: CD and NCD with pregnancies   Persistent high level of anaemia in pregnant women and children Safe Abortion Care Services, rising C Section Rates, inadequate birth spacing Active engagement of private sector and high out of pocket expenditure Source: *MMR bulletin 2016-18, SRS 2018, ** NFHS-5 , 2019-21

10. Sustainable Development Goals (2016-2030) By 2030, a world in which every woman, child and adolescent in every setting realizes their rights to physical and mental health and well-being, has social and economic opportunities, and is fully able to participate in shaping prosperous and sustainable societies.  GUIDING PRINCIPLES  Country led  Universal   Sustainable  Human Rights-based  Equity and Gender equality enhancing  Evidence informed  Partnership driven  People centred Community owned  Accountable, Aligned with Development Effectiveness and Humanitarian Norms  The 2015-30 Global Strategy for Women’s, Children’s and Adolescents’ Health

11. Maternal and Newborn Health: Issues and Concerns Poor quality of Care: Lack of respect, empathy, and compassion from health care providers Poor infrastructure at facilities: Lack of privacy, overcrowded rooms, and inadequate amenities Unavailability of patient-centred care:  Lack of cultural competency training, failure to acknowledge women’s priorities and values   Distribution & supply of health care workforce Disparities in services utilization: Low knowledge and awareness of services, physical accessibility of care Guidelines on Midwifery Services in India, GoI, 2018

12. Critical Challenges for Reaching SDGs Ensuring Quality of Care Availability of trained Human Resources Addressing Rising C- Section Rates Improving Reach in remote areas Improving Reach for urban poor Ensuring Respectful Maternity Care Major Challenges in India

13. Major Challenges in P rovision of Quality C are Two major reasons for poor intrapartum care and outcomes : lack of trained service providers and over medicalization of pregnancy and labour Against requirement of 5,481 obstetricians at CHCs across the country, only 1,433 are in place (Rural Health Statistics, 2020-21) Rising C-Section rates: from 8.2% in 2006, 17.2% in 2015-16 to 21.5% in 2019-21 (NFHS-5) Twelve states in the country currently have C-Section rates of over 30% (NFHS-5) Involvement of nurses for midwifery care is not optimized in medical colleges

14. GoI Programs and Strategies for Improving Maternal and Newborn Outcomes   Comprehensive care for women and children adopting the life-cycle approach 5 pillars of the framework: reproductive, maternal, neonatal, child and adolescent health (RMNCH+A), launched in 2013 Program strategies in each thematic area are guided by central tenets Equity Universal care Entitlement and A ccountability

15. GoI Strategies to Improve MNH Services Entitlement for pregnant women and sick newborns till 01 year after birth Free and zero expense delivery & cesarean section Free drugs and consumables Free essential and desirable diagnostics (blood & urine tests, USG, etc.) during ante-, intra- and postnatal care Free diet & free provision of blood Free transport – home to hospital, inter hospital and drop back to home Exemption of all kinds of user charges Janani Shishu Suraksha Karyakram (JSSK ) -  2011 Initiative to assure free services to all pregnant women and sick neonates accessing public health institutions. The scheme envisages free and cashless services to pregnant women including normal deliveries and caesarean operations and also treatment of sick newborn (up to 01 year after birth) in all Government health institutions  

16. Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA) Key features : Special ANC services are provided to women in 2 nd & 3 rd trimester by specialists  on 9 th of every month at government health facilities in both urban and rural areas. A minimum package of investigations and medicines such as IFA and calcium supplements is provided to all pregnant women attending PMSMA clinics. Identification and follow-up of high-risk pregnancies is done and red stickers are added on to the MCP card of women with high-risk pregnancies. AIM: It envisages improvement in the quality and coverage of Antenatal Care (ANC) including diagnostics and counseling services as part of the Reproductive, Maternal Neonatal, Child and Adolescent Health (RMNCH+A) Strategy.

17. E-Pradhan Mantri Surakshit Matritva Abhiyan ( E-PMSMA ) E- PMSMA Check-up of pregnant women by OBGYN/Medical Officer (CEmOC/BEmOC trained) at PMSMA Clinic on the 9 th of every month. Organized at DH, SDH, CHC & U-PHC Screening for high risk factors in pregnancy Essential blood investigations and Ultra-sonography Additional 3 PMSMA visits for identified High Risk Pregnancies Essential blood Investigations and USG Collaboration opportunity with the private sector - Specialist OBGYN and USG investigations Incentives provided for OBGYN specialist, ASHA and mobility support to women identified with a high-risk pregnancy Fixed Day, Assured, Comprehensive Quality ANC Services to all Pregnant Women *HRP TRACKING* Source: NHM, GoI, 2022, https://www.nhm.gov.in/New_Update-2022-23/MH/GUIDELINES-%20MH/Guidance_Note-Extended_PMSMA_for_tracking_HRPs.pdf

18. National Health Mission ( NHM )   Launched on 05 th April 2005 as the National Rural Health Mission (NRHM) Main aim is to provide equitable, accessible and affordable health care  Many initiatives have been taken under NHM to reduce the maternal and newborn mortality and improve the quality of care:  JSY, JSSK PMSMA/E-PMSMA SUMAN Optimizing Postnatal Care  LaQshya and Midwifery

19. LaQshya Objectives :  Reduce maternal and newborn morbidity and mortality Improve quality of care during birth and immediate post-partum period Enhance satisfaction of beneficiaries, positive birthing experience and provide respectful care     Provide Respectful Maternity Care (RMC) to all pregnant women attending public health facilities A quality improvement initiative in labour room & maternity OT, aimed at improving quality of care for mothers and newborns during intrapartum and immediate post-partum period.

20. Surakshit Matritva Aashwasan (SUMAN) Services under SUMAN are: Integrates existing initiatives Respect for w omen’s autonomy, dignity, feelings, choices & preferences 100% Maternal Death Reporting and Reviews Grievance redressal mechanism Client feedback mechanism Awards to champions Community level maternal death reporting Community engagement & mega IEC/BCC Intersectoral convergence AIM: Assured, dignified and respectful delivery of quality healthcare services at no cost and zero tolerance for denial of services to any woman and newborn visiting a public health facility in order to end all preventable maternal and newborn deaths and morbidities and provide a positive birthing experience.

21. Optimizing Postnatal Care , MoHFW, GoI, 2023  Key Features: Quality screening for identification of high-risk postnatal mothers and newborns Pre-identified HRP includes postnatal mothers who were already identified and managed as HRP during their ANC/PMSMA/e-PMSMA visit High risk identified in the postnatal period includes postnatal mothers who were normal throughout their ANC period but were identified as high-risk during HBNC visits by the ASHA Concerned ASHA will refer the mother to the nearest healthcare facility under JSSK the identified high risk mother will be entitled for transport and in-facility services under JSSK Aims to strengthen the quality of postnatal care by laying emphasis on detection of danger signs in mothers and incentivization of ASHAs for prompt detection, referral & treatment of such high-risk postpartum mothers.

22. Optimizing Postnatal Care , MoHFW, GoI, 2023 contd. Tracking and management of high-risk postnatal mothers including their follow up ASHA Incentive: Pre-identified HRP: ASHA will make HBNC visits as per the schedule and shall be entitled to Rs.500/-per HRP for healthy outcome of both mother and newborn at 45th day of delivery, under e-PMSMA scheme High risk identified in postnatal period: on achieving a healthy outcome for both mother and the baby, the concerned ASHA will be incentivized @ Rs.250/-per high-risk postnatal mother, after 45th day of delivery Adequate counseling of mother and her family members during postnatal period on danger signs Robust monitoring and supervision by the field-level functionaries for the provision of PNC care & services: Line listing of postnatal high risk mothers to be captured in existing PMSMA registers/ PMSMA portal Whether the Post-natal mother confirmed as high risk by Medical Officer If yes, the status of mother and baby after 45 days of delivery Incentive paid to ASHA(Yes/No)

23. Midwifery: An Opportunity to Strengthen M aternal and Newborn Healthcare Strengthened skilled workforce: Midwives can offer maternal health services to majority of women that are high quality and evidence-based Strengthened facility resources and quality assurance: MLCUs to be established at LaQshya certified public health facilities ( initially ) Improved adherence to quality protocols and guidelines: Midwifery-led care encourages promotion and conduction of physiological normal births, reducing unnecessary interventions including avoidable Caesarean Sections Respectful & Woman Centred care: Midwifery focusses on skilled and compassionate care that empowers women through a woman- centered approach, leading to improved maternal and newborn outcomes and satisfaction

24. 24 WHO RECOMMENDATIONS TO REDUCE UNNECESSARY C- SECTIONS

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26. 26 As per NFHS -5 (2019-2021), the Caesarean section rate in Tamil Nadu is 44.9 %. WHO recommends C-section audit as one of theeffective non-clinical interventions. Despite Csection audits in place, there is not much remarkable reduction in caesarean rates with 49% of C-sections in DME institutions and 54 % of C-sections in DMS institutions Therefore, promoting normal delivery aligns not only with the principles of evidence-based medicine but also with the broader goal of ensuring maternal autonomy, informed choice, and holistic care.

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29. 29 FIVE RECOMMENDATIONS

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35. MIDWIFERY 35

36. 36 The Lancet: Midwifery Series, 2014 Midwifery is a vital solution to the challenges of providing high-quality maternal and newborn care for all women and newborn infants, in all countries

37. 37 Investing in the Midwifery Workforce Improving health service coverage and health outcomes is dependent on the availability, accessibility, acceptability and quality of human resources especially for achieving Universal Health Coverage and the Sustainable Development Goals in maternal and newborn health Nurse-midwives in India are Key Providers of Maternity Care

38. 38 The Evidence for Investing in Midwifery Education and Midwifery-Led Care When midwives are educated to international standards,  where midwifery includes the provision of family planning, and midwives are working collaboratively with medical and public health colleagues, this could avert more than 80% of all maternal deaths, stillbirths and neonatal deaths with associated improvements in quality of care. Lancet Midwifery Series 2014

39. 39 Who is a Midwife? Healthcare professional Midwife means: “with woman” Women’s advocate Specialist in normality : low risk pregnancies Looks after and supports women antenatally , intrapartum and postnatally unless deviation from the normal occurs (referral to Obstetrician) Promote health and well-being of childbearing women and their families May practice in the community, hospitals, clinics or the midwifery-led care unit (Marshall and Raynor 2020)

40. 40 Philosophy of Midwifery “Midwife” “With woman”

41. 41 Rationale for Introduction of Midwifery Services in India Lack of quality of care Lack of respectful women-centered care, Respectful Maternity Care (RMC) not part of current medical and nursing curriculum Poor experience of women pushing them to the private sector- increased out of pocket expense Inequitable services: the urban-rural divide Lack of skilled HR, especially for intra-partum care 25.8% OBGYNs* in CHCs Lack of pediatricians  Dual problems Low institutional delivery rates in some states Over- medicalization of births: rising C-section rates *Rural Health Services statistics, 2021-2022 India’s MMR is 97: Well on the way to achieving the SDG Goal 3.1 What then is the problem?

42. 42 Why does India need Midwives? Considering the need for trained human resources to provide quality care to 30 million pregnancies every year in India, it is essential to propose an alternative model of service provision for strengthening reproductive, maternal, and neonatal health services in India. Recognizing that midwifery care in India can further serve as a cost-effective and efficient model to provide quality care and reduce over-medicalization, Ministry of Health and Family Welfare developed guidelines for midwifery care in India. - Ministry of Health & Family Welfare, Government of India, 2018

43. 43 ICM Essential Competencies of Midwife

44. LAQSHYA AND MIDWIFERY 44

45. Objectives Reduce maternal and newborn morbidity and mortality Improve quality of care during delivery and immediate post-partum period Enhance satisfaction of beneficiaries, positive birthing experience and provide respectful care Provide Respectful Maternity Care (RMC) to all pregnant women attending public health facilities . 45

46. Midwifery Services & LaQshya LaQshya Alternative birthing position Birth companion stayed in mother every time especially during 2 nd stage of labour . Respectful maternity care Position of choices decision making by the mother Mobility during labor No enema No episiotomy. (except in emergency like shoulder dystocia etc.,) Monitoring as per partograph and MEOWS chart Real time partograph AMSTL Skin to skin to contact LaQshya Golden hour management Essential newborn care Retained placenta management PPH management Fourth stage of labor MIDWIFERY CARE Optimal cord clamping instead of delayed cord clamping Intrapartum exercise Mother is control over her delivery process. Preparing for birth companion (emotional support, physical support. Each mother is unique Each pregnancy is unique. 46

47. Summary Addressing nation-wide MNH challenges requires multi-level, multi-stakeholder, multi- sectoral , approaches and strategies Each of the GoI  MNH Initiatives and Programs play a vital role in the efforts to meet the nation's MNH goals  The Midwifery Initiative is an important evidence-based strategy that is a critical part of the GoI  vision to improve India's MNH outcome No one initiative will be the sole solution to address the MNH challenges in India— instead, all must be aligned with the GoI vision – we all have a part to play to realize the ultimate goal of excellent health and well-being for all women and families

48. Thank you… 48