Transcript Building Community Based Mechanisms

Building Community Based
Mechanisms
Workable Solutions to reduce
Maternal Mortality in India
Presentation at the
Civil Society Window on Maternal Mortality
Planning Commission of India
November 21st 2006.
by
Vd. Smita Bajpai
Programme Officer- CHETNA
Founder and board member-Dai Association-Gujarat
The concern..
Every 5 minutes, one woman in India
dies due to pregnancy and childbirth
related causes.
They die because they are not able to
access quality, affordable and skilled
care.
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The concern
A woman was brought to a rural nursing
home. Hemoglobin 3gms%. System knew she
was not going to survive. Paper work done.
She collapsed during the second blood
transfusion. (January’06)
Reported by the doctor at a meeting with CBOs of Sabarkantha District Gujarat- November 2006
The manifestation of ill health is much beyond the
institutional arena
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The concern
A woman in labour started to bleed. The Dai
was called. Realizing the emergency, she
called for a vehicle. The woman`s husband
walked for several miles to the ANM, brought
her back but the woman did not survive.
CBO representative; Barmer 2003
Physical access to emergency obstetric services is a
challenge for many women in rural areas
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Realities in India..
Most maternal deaths occur in women from
tribal/dalit communities, poor socio–economic
status, living in rural, remote regions.
Women do not have access to complete,
continued care from the public health system
Physical, socio- cultural and economic barriers
affect access to institutional health services
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Realities in India..
More than 65 % of births occur at home.
State variations –95% home births
Women prefer home births and it is a cultural
reality
Most castes / families have a culture of home
delivery by the traditional/customary Dai
At least 1 Dai is available in every village of
India to assist during births
Dais are available, accessible, affordable and accepted
for their midwifery role in communities.
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Some facts
85 % women will deliver normally
10-15 % women will develop complications
that will need medical interventions
3-5 % women will need surgical
interventions (blood/Cesarean etc.)
More chances of women having a normal delivery
However delivery complications can occur suddenly, without
any warning signals
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Some facts
20-25% deaths occur during pregnancy.
40-50% deaths occur during labour and
delivery
25-40% deaths occur after childbirth
(More during the first seven days)
It is important to focus attention during pregnancy and
also after childbirth
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Successful Models of Safe
Motherhood service delivery
MODEL 1
Home deliveries by trained
community member
Functional affordable referral
transport system
Affordable emergency
obstetric services
MODEL 3
Professional provision of
Basic Emergency Obstetric
Care
Functional affordable
referral transport system
Affordable emergency
obstetric services
MODEL 2
Home deliveries by
professionals
Functional affordable referral
transport system
Affordable emergency
obstetric services
MODEL 4
Professional provision of
Basic and Comprehensive
Emergency Obstetric Care
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Maternal Mortality Reduction in
Sweden..
Sweden’s maternal mortality declined from 567 to 227/100,000
live births over three decades (1861 to 1894). Two interventions
are credited nearly equally with this decline :
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Midwifery-assisted home births, which increased from
30% to 70% over this period
the promotion of aseptic technique in both hospital and
midwife-assisted home births.
The percentage of women birthing in a hospital increased
only slightly over this same period, from 1% to 3%.
Home births by skilled assistants lead to reduced maternal
mortality.
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Maternal Mortality Reduction in
Malaysia
MM in Malaysia declined from 630 in 1947 to 148 in
1970 and 43 in 1990
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A Government priority at Independence in 1957 was equity
of care, meaning free and accessible health services.
Midwives were placed at the village level to provide such
care, including antenatal care, home-based delivery, and
postpartum care.
By partnering with the traditional birth attendants, midwives
became the primary assistants for delivery, covering about
51% of deliveries in 1980 and 95% in 1996
Equity in health care and partnership with TBAs is essential
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Maternal Mortality Reduction
contd..
Country
Year
MMR
China (rural)
1994
115
Fortaleza, Brazil 1984
120
Gudhchiroli, India (1999)
Jhagadia, India (2006) 350
PMR
30
53
47.8
46
MMR /PMR was achieved through Model 1
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Maternal Mortality Reduction in
Tribal Area -India
With 75% home delivery, SEWA Rural could reduce
MMR by 40% and NMR by 45% in three years with
specific interventions at community level backed up by
a functional FRU.
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Empowering TBAs/ Local women volunteers ensuring
satisfactory Birth Preparedness / Complication readiness
Clean & safe normal delivery ensuring critical new born care &
postnatal follow up
Timely identification of any complications during delivery and
ensuring prompt referral to SEWA Rural’s functional FRU
Professional provision of basic and comprehensive emergency
obstetric care by SEWA Rural FRU
(Combination of Model1 and 4)
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Present Policy trends
Focus on labour and delivery with
some attention on ante natal care
Focus on institutional delivery -public
and private
Based on demography/population only
Lack considerations for infrastructure,
physical access, socio-cultural and
Geographical factors.
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Recommendations for MMR
reduction in India
Mapping of difficult, rural,tribal areas having no or
minimal access and devising realistic location
specific strategies.
Ensuring access to emergency obstetric services
to those women who need it. (15%)
Implementing community based models relevant
to the culture and geographical realities of India.
( A combination of Model 1 and 2 )
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Success contd..
Supporting TBA_ANM partnerships and
integrating TBAs in the public health system
(Evidence of success from Guatemala, Bolivia,
Indonesia)
Providing affordable referral transport
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Successful evidences for rural /
tribal areas of India
Building capacities and skills of TBAs to expand her
role as a link with the public health services:
Technical skills on her core role during labour and
childbirth, identification of complications and referrals,
Primary Health Care, Reproductive health issues,
communicable diseases etc.
Leadership/coordination skills to establish linkages
between community and public health systems
Attitudinal aspects to deal with class, caste, gender issues
Social aspects to act as a social change facilitator
We do not want to be frogs in the well but want to be fish
swimming in fresh waters
President of Dai Association- Gujarat
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The story of a Dai from Gujarat
“ It was night when a neighbor called me for
help. On reaching her house, I realised that the
woman needs hospital care. I took her to the
civil hospital which is the nearest. The staff
asked me to take the woman to the city civil
hospital. I knew that she can deliver here. I woke
up the medical officer and shared my concern. He
asked the staff to admit the woman. She delivered
a baby safely.”
A Dai from rural Mehsana at a Dai Association Board meeting
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Pioneering Effort in Gujarat
Launch of Dai Association –Gujarat
Dai-NGO-GO-INGO partnership
5000 dais-15 NGOs in 18 districts
Standardization of Traditional Midwiferycurriculum developed by NGOs- publishing
support by DHFW
Government recognition of Dais` role
through a GR
DHFW partially funding capacity building of
Dais under RCH-2
DHFW provided financial support to organize
Dai`s in 15 districts
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Cost
The Dai Association Gujarat has
developed a comprehensive capacity
building curriculum for dais to be
implemented over a period of three years.
The training cost comes to Rs.5000/- per
dai in an established training center
The GOI has a 10 day programme for
Dais focusing on clean delivery
@Rs.2100/-per Dai
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Cost
The Government of Andhra Pradesh through
Academy of Nursing Studies has implemented
a 90 day intensive training programme for
TBAs at a cost of Rs.10,000/- per Dai including
training centre cost
The working group on Local Health Traditions
has worked out a 15 crore plan to organise and
strengthen dai associations in 15 states. A Rs.
5 lakh seed money to dai association has been
recommended
The struggle for recognition, value and empowerment of
Dais continues…
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Thank you
Let us join hands to save women from
dying needless maternal deaths by
using our resources optimally and make
a significant contribution to nations’
economy and development.
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