INCREASING ACCESS TO EMERGENCY OBSTETRIC SERVICES : EXPERIENCES FROM RAJASTHAN, INDIA

Presenter: Authors :

Hemant Dwivedi Venkatesh Srinivasan Hemant Dwivedi Dileep Mavalankar

UNITED NATIONS POPULATION FUND (UNFPA), INDIA

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KEY DEVELOPMENT INDICATORS

Population (in million) Rajasthan 56.47

Population Density(per.sq.km.) 165 Female Literacy 44.34

Median Age at Marriage 15.1

Total Fertility Rate (TFR) Infant Mortality Rate (IMR) Maternal Mortality Ratio 3.78

80.4

607 India 1027.01

324 54.16

16.7

2.85

67.6

540

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HEALTH SYSTEM AN OVERVIEW



Sub-Centers - with an Auxiliary Nurse Midwife (ANM) - 5000 population



Primary Health Centers (PHCs) - Medical Officer (MO) and Paramedics - 30,000

population



Community Health Centers (CHCs) - Specialists doctors, MOs and Paramedics - 125,000

population



District Hospital - Multi Speciality - 2 million

population



Medical College and Asso.Hospital - Division level

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PROJECT DETAILS

 Averting Maternal Death and Disability (AMDD) project supported by Columbia University with a grant from the Bill and Melinda Gates Foundation.

     Implemented as component project under UNFPA supported Integrated Population and Development (IPD) Project, Rajasthan, India from 2001-2004.

Project Area

Seven Districts of Rajasthan, India Population covered - 13.5 million

Facilities Covered

CEOC - 31 institutions BEOC - 52 institutions

Project Duration

September 2000 - December 2004

Implementing Agency

Government of Rajasthan 5

KEY FINDINGS OF BASELINE STUDY (2000) Service Coverage (UN-Process Indicators)



Number of institutions studied - 83

 

% of births in facilities - 10.89 (min.>15%) % met need of EOC - 8% (min.100%)

 

% births by C-section - 0.6 (min.5-15%) Average CFR - 1.4 (min 1%)

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STATUS OF HEALTH SYSTEM AT BASE LINE SURVEY IN 2000



High vacancies of specialists OB/GY and anesthetist



PHCs not offering complete range of BEmOC



Very few CHCs prepared to address EmOC



Only 21.5% deliveries in institutions



Low utilization of services and confidence in PHCs



Delay in reaching institutions

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PROJECT FOCUS

Needs Based Differential Approach

IMPROVING ACCESS TO QUALITY SERVICES



Improved functional infrastructure



Provided necessary equipments and supplies



Skill based trainings - BEOC, IP Training



Development of management systems INCREASE COMMUNITY AWARENESS



Advocacy Programs for PRIs, NGOs and Media.



Integrating Safe Motherhood messages into existing Community level activities.

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30% 25% 20% 15% 10% 5% 0%

% Vacant Positions of Health Functionaries in Rajasthan

28% 7% 5% Specialist M O ANM

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WHY FOCUS ON BEmOC?

    

80-85% obstetric complications do not need surgical interventions Focus on BEmOC will reduce nearly 33-60% maternal deaths Skills upgradation of service provider is feasible Over dependence on OB & Gy specialist and anesthetist reduced Reduces congestion at district and medical college hospitals

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INITIATING BEOC SERVICES

     

Government in consultation with UNFPA decided to train MOs in BEmOC 2 weeks training at district hospital 62 teams trained BEmOC MOs gained confidence in handling cases and expressed interest Skills upgraded on manual removal of Placenta, management of shock, judicious use of Oxytocine, stabilizing cases of APH & PPH and ensuring referral when essential Promoted use of evidence based practices

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ORIENTATION OF CBV

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MANAGEMENT INFORMATION SYSTEM



Needs assessment



Pilot testing of revised MIS



Revised MIS orientation and implementation



Monitoring of progress on UN process indicators

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RESULTS OF THE INTERVENTIONS 70 Health Institutions Providing Basic and Comprehensive EmOC- Rajasthan 62 60 53 50 40 36 30 18 26 18 23 21 CE O C B E O C 20 10 0 2000 2001 2002 2003

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Births in EmOC Institutions: Comparison of Baseline, 2001, 2002 & 2003

52000 50000 48000 46000 44000 42000 40000 38000 41944 47576 48129 49502 2000 Birt hs 2001 2002 2003 15

% Births increase in EmOC facilities : Comparison with non-intervention districts in last 4 years 18% 18% 16% 14% 12% 10% 8% 6% 4% 2% 0% 12% IP D Non-IP D

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16 Comparison of met need of EmOC : Intervention and non-intervention districts 14 14.26

12.13

12 10 8.8

7.91

8 6 6.1

7.96

7.16

7.14

IP D Non-IP D 4 2 0 2000 2001 2002 2003

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0.6

0.5

0.4

0.3

0.2

0.1

0 0.6

2001

C-Section in Facilities

0.56

2002 0.53

2003 C-Section

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5 Comparison of Average CFR in Facilities Intervention and non-intervention institutions 4.72

4.5

4.4

4 4.1

4.01

3.5

3 2.5

2 1.5

1.33

1.49

IP D Non-IP D 1 0.5

0 0.97

0.95

2000 2001 2002 2003

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LESSONS LEARNED



BEmOC services as a feasible strategy in human resource scarce settings



Pragmatic strategies based on local specific needs leads to cost effective interventions



Improved service provision backed up by community mobilization increases utilization of services



Operationalising EmOC services requires sustained efforts



Demonstration project’s achievements facilitates advocacy at policy level

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MOVING FROM PILOT TO SCALE

  

Logframe of new national RH programme draws on Rajasthan experience for strengthening EmOC services Reduction in maternal morbidity and mortality is now a priority agenda of Rajasthan Government UN process indicator confirmed as reliable and accessible indicators for public health systems to measure programme performance

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Maternal death is a personal tragedy and social disaster.

Let us join our hands to avert it.

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FOR FURTHER INFORMATION….

HEMANT DWIVEDI Sate Programme Coordinator UNFPA Rajasthan State Office, 29, Srirampura Colony, Civil Lines, Jaipur, Rajasthan, India Email : [email protected]

Telephone : 91-141-2220028/2220224 Fax : 91-141-2222277 VENKATESH SRINIVASAN National Programme Officer UNFPA, 53, Jorbagh, New Delhi, India Email : [email protected]

Telephone : 91-11-24651801 Fax : 91-141-24641679

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