We continue to do more! 2 nd International Conference Commonwealth Nurses Federation March 8 th & 9 th, 2014 London, UK The Indian Perspective & Its Relevance to Maternal & Child Health Phalakshi Manjrekar, MSN, RN Director of Nursing P.D. Hinduja National Hospital & Medical Research Centre, Mumbai NIGH World Executive Committee of the Nightingale Initiative for Global Health A teen-age mother with her newborn in Kokata, India. 2012 ASIT KUMAR GHATAK, Courtesy of Photoshare # 8822-3.
Child Mortality in India Approximately two million children under age 5 die in India every year. UNICEF s State of the World s Children Report, 2007 Children in Aizwal, in the Mizoram state of India await health care 2008 Diptendu Dutta, Courtesy of Photoshare # 2009-176.
Maternal Mortality in India The Maternal Mortality Ratio (MMR) in India is 254 per 100,000 live births according to Sample Registration System (SRS) Report for 2004-2006. This is a decline from the earlier ratio of 301 during 2001-2003. Women & children outside a child development center in Madhya Pradesh, India. 2010 Anil Gulati, Courtesy of Photoshare # 330-511. UNICEF India Archives
Wide disparities exist across states in India. The MMR ranges from 95 in Kerala to 480 in Assam. UNICEF India, Archives Two Indian women. 2007 Karamcheti Swathi, Courtesy of Photoshare # 131-8.
India continues to endure about a quarter of all global maternal deaths. Population Foundation of India A child in Ahmedabad, India, nurses her mother who is suffering from fever after giving birth 20 days ago. 2012 Sharvari Raval, Courtesy of Photoshare # 1177-32.
Globally, every year, over 280,000 women die of pregnancy related causes & 99 % of these occur in developing countries. Population Foundation of India A pregnant woman waits for delivery outside a maternity centre in Mozambique. 2011 Arturo Sanabria, Courtesy of Photoshare # 1515-262.
which also accounts for almost one-fourth of the world s maternal deaths. Population Foundation of India Women wait for antenatal care (ANC) at a health centre in Nampula, Mozambique. 2003 Arturo Sanabria, Courtesy of Photoshare # 1515-263.
India faces the enormous challenge of reducing infant mortality from 53 / 1000 live births to less than 30. Population Foundation of India In the hills of India s Uttaranchal state, young children take care of babies. 2006 Shuvi Sharma, Courtesy of Photoshare # 2006-664.
The average decline of IMR per year between the years 2004 to 2008 has been about 1 % per year. UNICEF India, Archives Photo Attribution: http://www.examiner.com/article/neonatal-mortality-is-decreased-with-antiseptic.
In 2008, the IMR was 53/1,000 live births. Eight Indian states contribute to 75 % of infant mortality: Uttar Pradesh, Bihar, Madhya Pradesh, Rajasthan, Andhra Pradesh, Orissa, Gujarat & Assam. UNICEF India, Archives Photo of a young mother of the Bodo Tribe in Assam from Wikimedia Commons, photographer: Rajkumar1220, used with Creative Commons Attribution 2.0 Generic license.
Neonatal Mortality Rate Mortality in the newborn period stands at 35/1000 live births & contributes to 65 % of all deaths in the first year of life. UNICEF India Archives Photo Attributions: UNICEF India/2010/Graham Crouch from http://www.unicef.org.au.
Between 2004-2008 neonatal mortality has decreased only slightly from 37/1000 live births to 35/1000. UNICEF India Archives Photo Attribution: http://visual.ly/neonatal-mortality-child-survival-development-every-child-india.
56 % of all newborn deaths occur in five Indian states UP, Rajasthan, Orissa, MP & Andhra Pradesh. UNICEF India Archives Graphic Attrribution: http://arogyashoodh.blogspot.ca/2011/11/highest-number-of-new-born-deaths-in.html.
Four major causes contribute to about 60 % of all deaths in the newborn period: pre-maturity low birth weight birth asphyxia infections UNICEF India Archives Photo of a poor woman & her child in India from Wikimedia Commons, photographer Peter van der Sluijs, used with the GNU Free Documentation license.
Indian Health Ministry Aims: Maternal mortality to decrease from 254 per 1,00,000 live births to less than 100 by 2015. Ministry of Health & Family Welfare, Government of India, January 2013 A mother watches her newborn in a sub-health centre in Madhya Pradesh, India. 2012 Anil Gulati, Courtesy of Photoshare # 1475-860.
MMR Address Three Causes: Medical Socio-economic Health Systems Ministry of Health & Family Welfare Government of India, January 2013 A small girl & her younger brother in Bittal Village, Durg District, Chhattisgarh state, India. 2003 Pritam Kumar Nanda, Courtesy of Photoshare # 2004-167.
Direct Medical Causes Postpartum Hemorrhage 37% Sepsis 11% Unsafe Abortions 8% Hypertensive Disorders 5% Obstructive Labor 5% Ministry of Health & Family Welfare Government of India, January 2013 A displaced pregnant woman in Ahmedabad, Gujarat state, India. 2012 Sharvari Raval, Courtesy of Photoshare # 1177-1.
Indirect Medical Causes Anemia Malaria Ministry of Health & Family Welfare, Government of India, January 2013 Life can be tough for pregnant women in rural India. Photo Attribution: Jane Wakefield, Technology Reporter, BBC, from http://www.bbc.co.uk/news/technology-17199877.
Child Mortality 0-5 Years Treat the Causes: About 70 % perinatal conditions Respiratory Infections 22% Malnutrition is an underlying cause responsible for about 30% of all deaths in childhood. Ministry of Health & Family Welfare, Government of India, January 2013 A family of children living on a street in Ahmedabad, India. 2012 Sharvari Raval, Courtesy of Photoshare # 1177-35.
Child Mortality 0-5 Years Neonatal Causes 52% Pneumonia 15% Diarrheal Diseases 11% Measles 3% Injuries 4% Other Causes 15% WHO Child Health Epidemiology Reference Group (CHERG) 2012 Indian children filmed by Al Jazeera English, posted on Wikimedia Commons, Creative Commons Attribution-Share Alike 2.0 Generic license.
Neonatal Deaths Treat the Causes: Prematurity 18% Infections 16% (pneumonia/sepsis) Asphyxia- 10% Congenital Anomalies 5% Ministry of Health & Family Welfare Government of India, January 2013 Roadside dwellers in Mumbai from Wikimedia Commons & Agência Brasil, a public Brazilian news agency. Licença Creative Commons Atribuição 3.0 Brasil exceto quando.
A large number of maternal & child deaths are attributable to the three delays : delay in deciding to seek care delay in reaching the appropriate health facility delay in receiving quality care once inside that facility Ministry of Health & Family Welfare, Government of India, January 2013 Indian rural women & girls from the archives of Al Jazeera English & Wikimedia Commons, Creative Commons Attribution-Share Alike 2.0 Generic license.
Bottlenecks to treating the causes: Lmited availability of skilled human resources especially nurses Low coverage of services & of skilled staff postings among marginalized communities Inadequate supportive supervision of front-line service providers Coverage Evaluation Survey 2009, Rural Health Statistics 2011 Concurrent Evaluation of NRHM and NRHM Progress Reports Photo Attribution: AP File Photo from news feature on www.thehindu.com on long lines for maternal health services in India.
Bottlenecks to treating the causes: Low quality of training & skill-building Lack of focus to improve quality services Insufficient information, education & communication on key family practices Coverage Evaluation Survey 2009, Rural Health Statistics 2011 Concurrent Evaluation of NRHM and NRHM Progress Reports Photo Attribution: http://unicefiec.wordpress.com/2013/06/21/malaria-a-growing-concern-from-villages-to-cities/
Health Outcome Goals: Established in the 12th Five-Year Plan for India Reduction in Infant Mortality Ratio (IMR) to 100 per 100,000 live births by 2017. Ministry of Health & Family Welfare, Government of India, January 2013 An Auxiliary Nurse Midwife (ANM) helps a mother to learn kangaroo mother care, important for the growth of newborns in Madhya Pradesh, India. 2012 Anil Gulati, Courtesy of Photoshare # 1475-870.
Health Outcome Goals: Established in the 12th Five-Year Plan for India Reduction in Maternal Mortality Ratio (IMR) to 100 per 100,000 live births by 2017. Ministry of Health & Family Welfare, Government of India, January 2013 An Indian village health worker checks a patient's blood pressure. 2012 Pinky Patel, Courtesy of Photoshare# 4496-9.
Health Outcome Goals: Established in the 12th Five-Year Plan for India Reduction in Total Fertility Rate (TFR) to 2.1 by 2017. Ministry of Health & Family Welfare, Government of India, January 2013 In Birbhum, India, mothers with their infants attend a family planning & baby check-up camp organized by a local group with the help of the West Bengal Government under the National Rural Health Mission. 2010 Sandipan Majumdar, Courtesy of Photoshare # 8510-1.
Coverage targets for key interventions for 2017: Increase facilities equipped for perinatal care designated as delivery points by 100%. Ministry of Health & Family Welfare, Government of India, January 2013 Photo Attribution: UNFPA Website: http://www.unfpa.org/sowmy/resources/docs/photos/6_taylorl_india.jpg
Coverage targets for key interventions for 2017: Increase proportion of all births in government & accredited private institutions at the annual rate of 5.6 % from the baseline of 61% (SRS 2010). Ministry of Health & Family Welfare, Government of India, January 2013 A nurse weighs a newborn at a health centre in Madhya Pradesh, India. 2010 Anil Gulati, Courtesy of Photoshare # 1475-867.
Only 47 % of women in India likely have an institutional delivery & 53 % have had their baby s births assisted by a skilled birth attendant. Ministry of Health & Family Welfare, Government of India, January 2013 Photo from Wikimedia Commons of a Adivasi mother & child from photographer Koustav 2007, used with GNU Free Documentation license.
As many as 49 % of pregnant women still do not have three antenatal visits during pregnancy. Only 46.6 % of mothers receive iron & folic acid for at least 100 days during pregnancy. Ministry of Health & Family Welfare, Government of India, January 2013 Photo Attributions: theglobalmail.org. Photogragpher Mark Ralston/Getty Images
Coverage targets for key interventions for 2017: Increase proportion of pregnant women receiving antenatal care at annual rate of 6% from the baseline of 53% (CES 2009). Ministry of Health & Family Welfare, Government of India, January 2013 Women of Anjana Nagar, India, pose for a photograph after attending a women's health workshop where they learned about the benefits of pregnancy & nutrition, breast feeding, birth control & STIs. 2004 Francey Hart, Courtesy of Photoshare # 2005-615.
Coverage targets for key interventions for 2017: Increase proportion of mothers & newborns receiving postnatal care at annual rate of 7.5% from the baseline of 45% (CES 2009). Ministry of Health & Family Welfare, Government of India, January 2013 Mother & newborn at the Gurgaon Hospital outside of New Delhi. 2011 Monique Jaques, Courtesy of Photoshare # 8716-2.
Coverage targets for key interventions for 2017: Increase proportion of deliveries conducted by skilled birth attendants at annual rate of 2% from the baseline of 76% (CES 2009). Ministry of Health & Family Welfare, Government of India, January 2013 A mother with her newborn are attended by skilled nursing at a hygienic health care centre in India. 2006 Abhijit Dey, Courtesy of Photoshare # 2009-355.
Most of the causes of death in the newborn period can be prevented or managed by households, communities & health facilities. But they often are unable to provide the required care Ministry of Health & Family Welfare, Government of India, January 2013 Photo Source: Mother & baby at a nutrition rehab centre in Madhya Pradesh, from Wikimedia Commons & UK DFID, Creative Commonse Attribution 2.0 Generic license.
Inappropriate practices such as: delayed initiation of breastfeeding delayed clothing & early bathing Ministry of Health & Family Welfare Government of India, January 2013 A mother gives her 12-day-old infant his first traditional bath in a village near Cuduppah in Andhra Pradesh, India. This tradition involves scrubbing the infant with soap, water & an unhygienic ritual of applying dried cow dung. 2007 Jeevan Kuruvilla, Courtesy of Photoshare # 142-4.
Inappropriate practices such as: not seeking care when newborns are sick & applying harmful material on cord-stumps increase the risk of newborn deaths. Ministry of Health & Family Welfare Government of India, January 2013 Photo Attributions: NYTimes.com article on infant malnutrition in India Photographer Ruth Fremson.
Health facilities are often ill-equipped to provide essential newborn care to all newborns & special newborn care to sick newborns. Ministry of Health & Family Welfare Government of India, January 2013 Photo Attribution: Associated Press & the DailyMail.co.uk news article about Indian children needing hospital care.
Maternal & Child Health in India need utilization of local resources to benefit the beneficiaries. Multiple forces jointly hope to achieve the best for all the mothers & children. A mother & newborn benefit from maternal health & family planning in Orissa. Wikimedia Commons & UK DFID, Creative Commons Attribution-Share Alike 2.0 Generic license.