Initiatives Taken to Improve Maternal Health in Bikaner, Rajasthan.

Towards Improved Maternal Health

Reducing MMR in Bundi and Bikaner

Arti Dogra

District Collector, Bikaner

Mamta’s Story

Rajasthan – Bikaner & Bundi

Data Bundi Bikaner

Population 1113725 2367745

MMR `261 263

Gender Ratio 922 903

• Difficult terrain prone to drought• Early marriage• Dominant feudal system• Inadequate control over resources for women• Low literacy • Social customs( eating last)• Under nutrition , high levels of anaemia

Why Maternal Mortality is high

Rajasthan Over Time

Causes of Maternal Deaths

Maternal Deaths

District Population

Crude Birth Rate (CBR)

2007-09 (Median

2008)

Estimated births 2007-09 (Median

2008)

MMR 2007-09 (Median

2008)

Est MDs 2007-09 (Median

2008)

Avg Reported

MDs, 2007-08 to 2009-

10

Crude Birth Rate (CBR)

2010

Estimated births 2010

MMR 2010Est MDs

2010

Reported MDs, 2010-

11

Bikaner2,367,745 24.9

58,957

343 202 2

24.6 58,247

263 153 11

Bundi1,113,725 23.7

26,395

343 91 21

23.3 25,950

261 68 36

Rajasthan 68,621,012 24.7 1,694,939

331 5,610

1,089

24.4 1,674,353 264 4,420 952

Reported Maternal Deaths

DistrictReported MDs

2007-08Reported MDs

2008-09Reported MDs

2009-10Avg Reported MDs 2007-08 to 2009-10

Reported MDs 2010-11

Reported MDs 2011-12

Reported MDs 2012-13

Bikaner5 0 0

2

11 4 38

Bundi23 22 17

21

36 28 16

Rajasthan 1219 987 1062 1,089

952 763 1,116

• Implementation of SQRS (Small Query Reporting System)-Tracking medical activities through SMS

• Increase the number of health facilities providing safe delivery and newborn care

• Systematic Improvement in Labour Rooms• Tracking of High Risk Pregnancies• Quality improvement of MCHN Days• Video Conferencing upto PHC Level

New Initiatives

Online Reporting through SMS

• Shift from reporting and analysis at the end of the month to daily reporting

• 1 SMS within 160 characters• Coverage to all major health related activity like

ANC Registration, Deliveries, OPD-IPD, Maternal Deaths

• Review every day by CMHO and Block CMHO

• Launched Jan 12th, 2011• Divided focus Health

Activities in 10 types of Coding from R1 to R10.

• District, Block, PHCs & Sub Center level staff trained

• PHCs level Monitoring can be done in real time.

SQRS Implementation

Process 101

Analysis on Inbound SMS

• Benefits– Real Time Analysis on activities of

• ANM, MO-IC PHC, CHC, Janana and District Hospital• Ideal for Collector, CMHO and DPM to have a Bird-Eye-

View on a particular activity

ANC Registration (Jan 01, 11 – Jan 26, 11)

Total No of ANC RegistrationTotal No of

BPL RegistrationTotal AmountPaid to BPL

40 11 5500

Analysis on Inbound SMS

Benefits

• Real Time Reporting Solution• Economical Reporting• Everyday assessment of their own work• Faster response time during Critical Situations• Instant Action on Absenteeism • Ready tool for inspections and monitoring

Maternal deaths

Maternal Deaths

Rajasthan

Improvement in Maternal Death Reporting

• Reporting of maternal death through immediate SMS• Enquiry of maternal deaths through verbal autopsy• Block level teams of 3 people including ASHA

facilitators• Maternal Death Audit in District Health Society

monthly• Alternative verification

• To reduce maternal death (min 8-10% pregnancies are high risk)

• High risk pregnancies should be identified & special care , checkup , follow up

• Quality of ANC checkup for high risk lady..• Identification of institution for safe delivery of

that lady• Maintenance of HRP Database

High Risk Pregnancy Tracking

• Obstetrics Risk factor– Previous still Birth– Preterm baby– Continuous abortion– C-Section delivery– Eclmpsia & Pre-eclampsia history

• Medical Risk Factor– High Blood Pressure– Heart Disease– Diabetes– Epilepsy– Sever Anemia

• Physical Risk Factor– Age– Height– Cervix and Uterus Problems– Weight

Factors for detection of High Risk Pregnancy

Implementation Methodology

• Sensitization of ANM, LHV, MO & Program Manager about High Risk Pregnancy.

• High Risk booklet launched on 20th May 11 by Hon. Health Minister

• High Risk booklet in which all record of High Risk lady is maintained by ANM.

• 4 ANC checkups are being done for High Risk lady & last checkup is done by Doctor.

• Awareness to family members of that lady regarding high risk & special care.

• Review in District Health Society Meeting.

High Risk Pregnancy Tracking

• Sensitisation of family

• HRP Circle on the house

• Lists at Gram Panchyat , CHC,PHC

• Referral and check up facility

• Verification

High Risk

Workload of PBM Hospital Bikaner, Labour Room

Workload in Janana, BundiAlternative Needed for Janana Hospital

• Increase the number of primary health facilities providing safe institutional delivery and new born care in Bundi

• Strengthen the capacity of ANMs to manage and refer maternal and neo-natal complications

• Enhance community participation in improving maternal and new born survival

ASTHA Project - Objectives

• Assessed– Gaps in Labour Room Infrastructure– Strengthen Human Resource Capacity – Performance of Facilities– Practices in labour room

Activities Undertaken

• Emphasis on good quality routine antenatal care

• Training on basics like Delivery care practices, pre-discharge assessment, quality ANC.

• SBA re-orientation and training of program managers , doctors and ANMs

Doctors and Staff Orientation

Success Metric Before project started ( on 28 Aug 11)

Facilities functioning 24* 7 6 10

No of ANMs / GNMs posted 39 45

No of ANMs / GNMs provided intensive 5 day training

0 31

No of doctors oriented on quality of delivery neonatal care

0 24

Number of deliveries conducted in previous month

277 511

Success @ ASTHA Kendra

Post Training Analysis

• Safe delivery and newborn care practice• How to identify and report maternal deaths • ASHAs have been instructed to report all maternal

deaths in selected blocks on phone• verbal autopsy technique• Monitoring High Risk Pregnancies

Asha Training

Improved MCHN Day

• Stress on quality ANC

• Tracking Anaemia and Blood Pressure

• Effective training and monitoring

• Identification of transport options and possible delivery points

• Effective use of Mamta card

Video Conference at Health Facilities

• Micro level monitoring

• Immediate feedback

• Prompt redressal

Involving the People

• SAKHI - Special program by student NSS volunteers

• Two panchayats covered every week. • Use of traditional music and dialect.• Involving public represntatives

• Quality ANC Checkup • Regular follow-up is being done by ANM or Doctor.• Facility wise interaction and engagement of referral transport

at the village level• Maintenance of lists at CHC control room and CMHO office• Monthly Review at Block level and District Level• Random checks by SDM and District Collector

• Motto:Healthy Mother & child

Post Programme Analysis