Istitutional deliveries

1. IMPORTANCE OF INSTITUTIONAL DELIVERIES PRESENTED BY :- MANPREET KAUR MSC NURSING 1 ST YEAR NINE ,PGIMER CHD

2. INTRODUCTION It is well established that giving birth in a medical institution under the care and supervision of trained health-care providers promotes child survival and reduces the risk of maternal mortality. In India, both child mortality (especially neonatal mortality) and maternal mortality are high. India accounts for more than one-fifth of all maternal deaths from causes related to pregnancy and childbirth worldwide.

3. DEFINITION Institutional delivery refers to the childbirth at technology-equipped medical facility under supervision of skilled medical staff. In an institutional delivery, various medical tools and technologies are used to ascertain that health of neonate or mother is not compromised.

4. The background Since the 1980’s successive programmes have attempted to address the high MMR and IMR There have been considerable decline in India’s MMR in the last two decades: from 398 in 1997-98 to 212 in 2007-09 Yet, this is far off from the MMR goal of less than 100 per 100000 live births

5. Objectives:- Why this is a public health problem? What are the socio economic factors affecting? What are the role of belief and norms? What are the non medical causes associated? What are the psychological and cultural aspects?

6. A Public Health Problem MDG goal 5 :- India has the largest number of births per year (27 million) in the world.1 With its high maternal mortality of about 300–500 per 100 000 births This is about 20% of the global burden hence India’s prog­ress in reducing maternal deaths is cru­cial to the global achievement of Millen­nium Development Goal 5 (MDG 5)

7. Risk factors for maternal mortality Socioeconomic factors Reproductive factors Health service factors

8. Socio-economic factors The general socioeconomic status of mothers Lack of education Poor knowledge about maternal health Poverty Poor mothers are at high risk of developing pregnancy related complications. Almost all maternal deaths that occur in low and middle-income countries are mainly among the poorest of the poor (WHO, 2005).

9. A Conceptual Framework for Analyzing Socio-Economic inequalities in Health service utilization Source: De Brouwere and Lerberghe (2001) Socio- Economic factors Income,wealth Education Employment, Occupation Family background Confounders & modifiers Age Place of residence Ethnicity, Religion Proximate Determinants Health status Perception of health problems Autonomy, social support Purchasing power Insurance cover Duties, opportunities costs Tendency to consult, beliefs Health service utilization Frequency of visits Type of facility Quality received

10. Reproductive factors The number of pregnancies she has had in her lifetime. The higher the number of pregnancies, the greater the lifetime risk of pregnancy related deaths (WHO, 2005). Maternal age also has an impact on increasing the risk of dying. Girls below 18 years and women older than 35 years are more likely to have pregnancy related complications that may lead to maternal death (USAID, 2005).

11. Health service factors All pregnant women are at risk of developing complications during any time of their pregnancies, deliveries and postpartum periods. Lacks of access to emergency obstetric care and delay for emergency referral are contributing factors for high maternal mortality. Obstetrics complications are able to be treated in health institutions that are sufficiently equipped with supplies, medications and fully staffed with capably trained health professionals

12. Maternity services utilisation

13. Advantages of Institutional Childbirths Antenatal care is a perquisite for a healthy delivery. Medical facility with trained staff and advanced facilities provides all services related to antenatal check-ups and counselling . In a medical institution, trained healthcare professionals provide specific care and attention to newborn babies with special needs in order to improve their survival chances and reducing the risk of maternal mortality. Women seeking assistance of medical institution for delivery are the ones given ample support to conceive at the right maternal age without delaying childbearing. Mothers are regularly assisted for post-pregnancy care, with medical staff discussing various aspects such as care for umbilical cord stump, nutrition, breastfeeding and bathing.

14. Advantages of Institutional Childbirths cont…… Institutional medical facilities aim for safe delivery by labour monitoring, active management of the third stage of delivery, immediate attention of the newborn, postpartum monitoring, addressing complications of mother and infant post-delivery. Quality of care is all-important, which is provided by institutional medical setting. Institutional medical facility also provides personnel and equipments to handle emergency circumstances which necessitate immediate medical attention. Round-the-clock supervision ensures comfort for mother with medical staff looking after nutrition and diaper changes of her baby.

15. Advantages of Institutional Childbirths cont……. Improper care during pregnancy term can also affect overall maternal health, specifically the reproductive health of the woman besides the health of the newborn baby. Hygienic conditions and surroundings are also important for safe delivery, which are mostly ignored in non-institutional setting for a delivery. Immunisation chart can be easily adhered to in an institutional medical facility. Following immunisation schedule ascertains that baby as well as mother is safe from various health complications. Institutional settings provide aid to hasten labour like intravenous (IV) drips and intramuscular injections during labour.

16. Obstacle for low utilization of delivery services Distance from health services; Costs, including user fees The cost of transport Quality of care Drugs availability & Supplies Women’s lack of autonomy indecision-making. (The WHO (1998) and Magadi et al (2002)

17. National rural health mission The National Rural Health Mission (NRHM) is a government scheme that aims at providing valuable healthcare services to rural households all over the country National Rural Health Mission (NRHM) launched in 2005 : provide equitable , accessible and affordable health care

18. It specially focuses on the 18 States Arunachal Pradesh, Assam, Bihar, Chhattisgarh, Himachal Pradesh, Jharkhand, Jammu and Kashmir, Manipur, Mizoram, Meghalaya, Madhya Pradesh, Nagaland, Orissa, Rajasthan, Sikkim, Tripura, Uttarkhand and Uttar Pradesh.

19. Objectives Decrease the infant mortality rate to 30/1,000 live births and maternal mortality rate to 100/1,00,000 Universal access to public health services such as Women’s health, child health, water, sanitation & hygiene, immunization, and Nutrition. Prevent and control communicable and non-communicable diseases. Control population as well as ensure gender and demographic balance. Encourage a healthy lifestyle and alternative systems of medicine through AYUSH Improved facilities for institutional delivery.

20. GOAL TO BE ACHIEVED BY NRHM IMR 30/1000 LIVE BIRTHS MMR 100/100,000 TFR 2.1

21. Goal cont……. Improved facilities for institutional deliveries through provision of referral , transport, escort, and improved hospital care subsidised under the JSY for below puberty line families

22. NRHM Reduction in MMR to 100/100,000 is one of its goals The Janani Suraksha Yojana ( Safe Motherhood Scheme) is the key strategy to achieve this reduction

23. Janani Suraksha Yojana The government has a Janani Suraksha Yojana (JSY) to deal with issues involved in pregnancy and child care.

24. JSY:- It is a centrally sponsored scheme aimed at reducing maternal and infant mortality rates, and increase institutional deliveries in below poverty line (BPL) families. The JSY, which falls under the overall umbrella of National Rural Health Mission, covers all pregnant women belonging to households below the poverty line, above 19 years of age and up to two live births.

25. JSY Cont…….. The JSY, launched in 2003, modifies the existing National Maternity Benefit Scheme or NMBS. While the NMBS was linked to provision of better diet for pregnant women from BPL families, the JSY integrates the cash assistance with antenatal care during pregnancy period, institutional care during delivery and immediate post-partum period in a health centre by establishing a system of coordinated care by field level health worker.

26. JSY The Yojana has identified ASHA, as an effective link between the Government and the poor pregnant women in low performing states.

27. Cont………… Counsel for institutional delivery.    Escort the beneficiary women to the pre-determined health center and stay with her till the woman is discharged.      Arrange to immunize the newborn till the age of 14 weeks.      Inform about the birth or death of the child or mother to the ANM/MO.      Post natal visit within 7 days of delivery to track mother’s health after delivery and facilitate in obtaining care, wherever necessary.      Counsel for initiation of breastfeeding to the newborn within one-hour of delivery and its continuance till 3-6 months and promote family planning.

28. Important Features of JSY: The scheme focuses on the poor pregnant woman with special dispensation for states having low institutional delivery rates namely the states of Uttar Pradesh, Uttaranchal, Bihar, Jharkhand, Madhya Pradesh, Chhattisgarh, Assam, Rajasthan, Orissa and Jammu and Kashmir. While these states have been named as Low Performing States (LPS), t he remaining states have been named as High performing States (HPS) .

29. Tracking Each Pregnancy: Each beneficiary registered under this Yojana should have a JSY card along with a MCH card. ASHA/AWW/ any other identified link worker under the overall supervision of the ANM and the MO, PHC should mandatorily prepare a micro-birth plan . This will effectively help in monitoring Antenatal Check-up, and the post delivery care.

30. JSY :The package of Incentives Low performing states High performing states Institutional delivery package Rs.1400 ($23)to mothers in rural areas Rs.1000 ($16) in urban areas Rs. 600 ($10) to ASHAs Home delivery package Rs. 500 ($8) to mothers- being BPL , above 19 yrs of ages. Institutional delivery package Mothers : Rs. 700 ($12) in rural areas Rs.600 ($10) in urban areas Rs.200 ($ 4) and 350 ( $6) in tribal areas) to ASHAs Home delivery package Rs. 500 ($8)to mothers- being BPL , above 19 yrs of ages.

31. Disbursement OF CASH assistance: a. The mother and the ASHA should get their entitled money at the heath centre immediately on arrival and registration for delivery.   b. Generally the ANM/ ASHA should carry out the entire disbursement process. However, till ASHA joins, AWW or any identified link worker, under the guidance of the ANM may also do the disbursement.

32. Payment to ASHA: First payment for the transactional cost at the health centre on reaching the institution along with the expectant mother. The second payment should be paid after she has made postnatal visit and the child has been immunized for BCG. All payments to ASHA would be done by the ANM only . : It must be ensured that ASHA gets her second payment within 7 days of the delivery, as that would be essential to keep her sustained in the system.  

33. Role of ASHA or other link health worker associated with JSY:- Identify pregnant woman as a beneficiary of the scheme and report or facilitate registration for ANC     Assist the pregnant woman to obtain necessary certifications wherever necessary,    Provide and / or help the women in receiving at least three ANC checkups including TT injections, IFA tablets,    Identify a functional Government health centre or an accredited private health institution for referral and delivery

34. Rationale Institutional deliveries would help the pregnant woman access a team of skilled birth attendants more reliably and it would also improve her access : emergency obstetric care reduced maternal and neonatal mortality The scheme offers a package of financial incentives to pregnant women to improve access to institutional deliveries.

35. Impact of Janani Suraksha Yojana on institutional delivery rate: an observational study in India The data were analyzed for two years before implementation of JSY (2003-2005) and compared with two years following implementation of JSY (2005-2007). Overall, institutional deliveries increased by 42.6% after implementation, including those among rural, illiterate and primary-literate persons of lower socioeconomic strata.

36. Possible IEC strategy   To associate NGO and Self Help Groups for popularizing the scheme among women’s group and also for monitoring of the implementation.  To provide wide publicity to the scheme by:   Promoting JSY as a component of total package of services under RCH along with programmes like Pulse polio programme . Printing and distributing JSY guidelines, pamphlets, notices in local languages at SC/PHCs/CHCs/ District Hospitals/ DM’s and Divisional Commissioner’s office and even in at the accredited Pvt. Nursing Homes, in abundance.

37. Maternal mortality in 1990-2013 F:\Maternal mortality in 1990.docx

38. Let us ensure these basic health rights for every mother and her child ..as India moves towards universal health coverage

39. REFERENCES Park.K.2009. Park’s Textbook of Preventive and Social Medicine. Twentieth edition. M/s Banarsidas Bhanot publishers, Jabalpur, India. Pp 379-381. http://reports.nrhmcommunityaction.org/more.htm.

40. THANKS