Transcript Document 7286595

MDG 5:. Reduce by three quarters,
between 1990 and 2015, the maternal
mortality ratio
MATERNAL HEALTH INDICATORS
1) MMR
2) SBA
3) CPR
4) TFR
5) ANTENATAL COVERAGE

Indicators Definitions
199091
200102
200607
200708
2008- MTDF
09
Target
2009-10
MDG
Target
2015
Maternal
Mortality
Ratio
No. of mothers
dying due to
complications of
pregnancy and
delivery per
100,000 live births
533*
350
276
na
na
300
140
Proportion
of births
attended
by skilled
birth
attendants
Proportion of
18
deliveries attended
by skilled health
personnel (MOs,
midwives, LHVs)
40
37
40
41
60
>90
Contracept
ive
prevalence
rate
Proportion of
12
eligible couples for
family planning
programmes using
one of the
contraceptive
28
29.6
30.2
30.8
51
55
Indicator Definitions
s
199091
200102
200607
200708
2008 MTDF
MDG
-09
Target Target
2009-10 2015
Total
Fertility
Rate
Average number of 5.4
children a woman
delivered during
her reproductive
age
na
4.1
3.85
3.75
2.7
2.1
Proportion
of women
15-49
years
who had
given birth
during last
3 years
Proportion of
15
women (15-49)
who delivered
during the last 3
years and
received at least
one antenatal care
during their
pregnancy period
from either
public/private care
providers
35
53
56
58
70
100
To reduce maternal and child deaths and
illnesses by improving their health status
particularly of the poor and the
marginalized.
Sr.
No
1
Indicators
Current
MDG
Status
Target
(MICS 2011) 2015
97/1000Lb
104
45
58/1000Lb
Figure not
available
25
Infant Mortality Rate
81/1000Lb
77
40
Maternal Mortality Ratio
227/10000
0Lb
Figure not
available
140
5
% of deliveries attended by
skilled birth attendants at
home/ Health Facilities
38%
59%
>90%
6
Contraceptive Prevalence
Rate
33%
35%
55%
2
3
4
Under Five Mortality Rate
Base Line
(PDHS
survey
2006-07)
Newborn Mortality Rate
GENERAL (SOCIOECONOMIC AND CULTURAL
FACTORS)
A) Poor hygiene and sanitary conditions
B) Unsafe drinking water
C) Poverty
D) Low literacy (Female)
E) Low level of Health awareness
F) Urban Vs Rural disparity regarding development and
provision of resources
G) Poor nutritional status of mother
H)
I)
J)
L)
Mothers age and parity
Interval between births
Level of women empowerment
Natural disasters
•
Facility Level









Staff absenteeism & Frequent postings / transfers
Gender and skill imbalances
Urban -Rural disparities for availability of health professionals
Lack of clearly defined referral mechanisms
Inappropriate locations
Poor maintenance of Health Facilities
Insufficient funding and issues of supplies
Management issues including supervision & monitoring
Non availability of necessary equipment, medicines and
supplies
 Community
Level
The most underserved pockets of population still not covered
by Lady Health Workers (60 % coverage)
 Insufficient availability of skilled birth attendants
 About 48% of the deliveries being conducted by TBAs,
 Community Midwifery program recently introduced.
Currently 6000 CMWs trained but there are deployment
issues
 Low confidence in public health facilities
 Socio-cultural diversity coupled with low literacy and lack of
awareness resulting in inappropriate behaviors and practices
related to maternal health

A) LOW SBA RATE
B) LOW LEVEL OF ANTENATAL COVERAGE
C) T.T IMMUNIZATION COVERAGE FOR PREGNANTS IS
LOW
D) LOW CPR AND HIGH TFR
E) HIGH PREVELENCE OF ANEMIA
F) LOW REFERRAL RATES OF COMPLICATED CASES
DURING ANTENATAL AND AT THE TIME OF DELIVERY
G) LOW PROPORTIONATE OF ASSISTED VAGINAL
DELIVERY AND C-SECTION VS NORMAL DELIVERY IN
HEALTH FACILITIES
H) HIGH INCIDENCE OF SEPTIC ABORTIONS
Care



Before Pregnancy
HTSP
Family Planning
Improved Nutrition
Care During Pregnancy
• Maternal immunization for tetanus toxoid
• Nutritional support (including iron and folate supplementation)
• Birth planning including transportation
• Counseling on breast feeding
• Recognition of danger signs and treatment or referral as needed
• Where appropriate—
- Presumptive malaria treatment
- Syphilis screening and treatment
- Voluntary counseling and testing for HIV
Care During Childbirth
• Skilled
birth attendance at delivery
• Clean delivery: hand-washing, clean
space, clean cord care
• Recognition of danger signs (for
mother) and treatment or referral as
needed
Continued & Routine Visits with a
Trained Health Care Provider
Early postnatal visit
 Recognition of danger signs (e.g., fever) for
mother with treatment or referral as needed
 Post partum family planning

WHO has made these recommendations for making
maternal health a viable program area at the country
level:
1. Specify specific goals for reduction in maternal
mortality rates.
2. Write and adopt a national policy supporting a
countrywide maternal health strategy.
3. Conduct advocacy among multiple partners at the
highest levels to mobilize resources.
4. Adopt a country strategy providing options for
programs in districts with different health infrastructures
and mortality situations
5. Mainstream maternal health through coordination between maternal
and child survival and other health areas, as well as cooperation with
other sectors.
6. Develop partnerships among governments, NGOs, professional
bodies, academia, and developmental partners at regional and country
levels.
7. Establish universal registration of births and deaths. Reach
consensus on key indicators for maternal health. (Use these data for
supportive supervision within the health system.)
8. Include key indicators within national surveys and national health
management information systems.
9. Strengthen maternal care capacity through systematic training,
skills development, and logistics.
10.Conduct operations research to establish an evidence base for
innovative programs
PC-1 Allocation
Releases
GOP
DFID
TOTAL
TOTAL
Expenditu
re
-
-
-
-
2007-08 1341.461
92.75
-
92.75
71.852
2008-09 2454.234
127.2
628.708
755.908
425.089
2009-10 1534.538
99.676
350.416
450.092
347.624
2010-11 1413.047
205.962
-
205.962
500.939
2011-12 1323.469
424.824
169.591
594.415
496.502
Year
2006-07
Original Revised
21.871
Total
8088.621
2012-13
-
950.412 1148.715 2099.127 1842.006
1457.186 571.227
829.072
1400.299
233.631
1- The released amounts has been mentioned in the year when these were released
from the Finance Department Govt. of the Punjab.
2.
The end of 2011-12 26% fund (Rs. 2099.127 M) were released against total
allocation of Rs. 8088.621 M.
3.
The Govt. of Pakistan decided to continue funding till June 2015 @ funds
released in 2010-11. Revised / New PC-I (2012-15) having total cost 3558.180
Million is under the process of approval at CDWP.
4.
DFID share Rs. 642.026 Million per year (One Year allocation up to 2014 is
already available in program for the year 2011-12 released 2012-13) & GOP
(PSDP) share Rs. 544.034 million per year up to 2015.
5.
356 Million of DFID, 136.017 Million of GOP under the process of release from
Finance Department Punjab
INTRODUCTION OF A
CADRE OF CMWS TO
INCREASE SKILLED
BIRTH ATTENDANTS
(SBA) RATE
Target :
Total Recruited:
Passed Out:
Deployed CMWs:
6346
5717
4367
3947
350000
329152
300000
250000
200000
151046
150000
100000
43250
45617
50000
10028
1323
43
422
0
ANC Visit Deliveries postnatal FP service
visit
provide
Referral
cases
Referral
Newborn
Maternal
Deaths
Newborn
Deaths
Status of Civil Work and Renovation Works in DHQs,
THQs, under National MNCH Program, Punjab
CMW School
Sr #
Target
Approved
Completed
In Progress
Still Not
1
34
33
27
5
1
Note: 3 CMW Schools Completed in that priod 1/1/13 to 30/6/13.
DHQs Hospital
Sr #
Target
Approved
Completed
In Progress
Still Not
1
34
33
26
4
3
Note: 4 Renovation Work Completed DHQ Hospitals in that priod 1/1/13 to 30/6/13.
THQs Hospital
Sr #
Target
Approved
Completed
In Progress
Still Not
1
76
63
46
4
13
Note: 3 Renovation Work Completed THQ Hospitals in that period 1/1/13 to 30/6/13.
DHQ Hospital Bahawalnagar
THQ Hospital, Haroonabad
THQ Hospital Mankera
THQ Hospital Shahpur
CMW SCHOOL ATTOCK
CMW SCHOOL JHELUM
CMW SCHOOL BAHAWALNAGAR
Type of
Training
Duration
IMNCI
11/07 Days
Staff
Doctors, LHV, Disp. , Nurse /Staff Nurse ,
MT/HT/FMT
Target
Progres
s
1647
7464
IMNCI (TOT)
05 Days
Doctors/Consultant /Pediatrician
/Gynecologists etc
EmONC
12 Days
WMO, Gyneo, LHV,
Basic EmONC
06 Days
Nurse /Staff Nurse
ENC
04 Days
Doctors, CMW Tutor Principal, LHV, Nurse,
CMWs
MIS Software
02 Days
PHSs, SOs, COs
138
MNCH MIS Tool
02 Days
CMWs, LHSs, LHVs
5109
CMW Tutor TOT
01 Month
Revised CMWs
Curriculum
04 Days
174
6698
515
1200
468
CMW Tutor
99
CMW tutors, Clinical Instructors, Gynecologist,
WMO,
114
24/7 Comprehensive Emergency Obstetric and Neonatal Care (CEmONC) Services
Target
Progress
Comments
• All DHQ
Hospitals to
provide
comprehensive
EmONC
services .
• All 89 THQ
hospitals to
provide
comprehensive
EmONC
services.
• All
DHQ
Hospitals
are
providing
Comprehensive EmONC services.
• All
THQ
Hospital
are
providing
Comprehensive & Basic EmONC services
except the following.
1. Attock (Hazro)
2. Bahawalpur (Khairpur)
3. Bhakkar (Kallor Kot, Mankera & Darya Khan)
4. Sialkot (Pasror)
5. Khushab (Nosherah, Nur Pur Thal)
6. Jhang (Shorkot, Ahmad Pur Sial)
7. Lahore (Shahdra)
8. Mianwali (Esa Khail, Kala Bagh & Piplan)
9. Multan (Jalal Pur Pir wala)
10.Pakpattan (Arif wala)
11.Rawalpindi (Murree)
Most of the THQ
Hospitals have no
Anesthetist and
Blood Transfusion
Units. Some THQs
are providing
Comprehensive
EmONC services
without
Gynecologist,
BTOs and
Anesthetist with
local adjustments /
alternates.
24/7 Basic Obstetric and Neonatal Care (BEmONC) Services
Target
291 RHCs of
Punjab
Progress
All RHCs are
providing 24/7
Basic EmONC
services.
Comments
Procurement of IT Equipment for:
1. MCH Cell
2. Nursing Schools
 Procurement of Furniture for
1. MCH Cell
2. Hostel / Classroom Furniture
 Procurement of Transports
1. Toyota Van
2. Jimny Jeep
Procurement of Medical Equipment.
1. CTG Machines
52
2. CMWs Kits
Procurement of Teaching Aids for School of Nursing.
1. Midwifery Training Material
 Procurement of Medicine for 11 Districts.
Procurement of Safe Delivery Kits for 36 Districts.
Procurement of Printing Material
1. IMNCI Books
2. EmONC Books
3. CMW Tools
4. CMW Manual

36
26
36
26
52
36
3000
30 Sets
PROBLEMS/ ISSUES
1) RELATED TO PROGRAM
2) CHALLENGES FACED BY THE CMWS








Insufficient training, CMW Tutor issue
Procedural Issues in Deployment and
Certification:
Inadequate skill sets and referrals:
Financial issues:
Mobility and security problems:
Acceptance by the communities:
Lack of Coordination with the other service
providers:
De-motivation:
RECOMMENDATIONS
In light of all the problems described above, the
following remedial measures are suggested:
Community integration for better uptake:
2. Improve Skill-set:
3. Clearer Job Descriptions and Coordination:
4. Health Facility Linkages:
5. Alternate financial viability models:
6. Revisit the CMW Strategy:
1.
WAY FORWARD
1) CONTINUATION IN THE TRAINING PROGRAM OF CMW--TO INCREASE COVERAGE UPTO 5000 AS WELL AS URBAN
SLUMS AND INCREASING THE OVERALL POOL OF SBAs
2) INCREASING THE NUMBER OF BASIC EMOC AND
COMPREHENSIVE EMOC CENTRES (RHS+ Model), THEIR
EVEN DISTRIBUTION, UTILIZATION RATES IN DEALING
COMPLICATIONS AND STRENGTHENING THEIR REFERRAL
LINKAGES
3) PREPARATION OF TRAINED HUMAN RESOURCE IN
PROVIDING MCH SERVICES.
4) PROMOTING THE CONCEPT OF TASK SHARING
5) INCENTIVE BASED PACKAGES
6) STRONG POLITICAL COMMITMENT AND INTERSECTORAL
COORDINATION
WAY FORWARD (Contd)
7) MOBILE RURAL AMBULANCE SERVICES
8) MIS SYSTEM WITH PROPER ANALYSIS AND
FEEDBACK
9) INTRODUCING HEALTH FACILITY BASED
MATERNAL DEATH AUDIT AND ITS REVIEW,
STRENGTHENING VERBAL AUTOPSY
10) PROVISION OF SERVICES IN INTEGRATED
FORM
WAY FORWARD Contd-----11) SUPPORTING EVIDENCE BASED, COST EFFECTIVE
AND HIGH IMPACT INTERVENTIONS e.g.
Assuring availability of antibiotics, Oxytocics, IV fluids and
Oxygen
Infection prevention
Use of Misoprostol and Magnesium sulphate
THANK YOU