anc-highrisk identification

Dr. SWARNA REDDY.E.B.,CAS.,AREA HOSPITAL, A P V V P,SRIKALAHASTHI, CHITTOOR-Dt. : 

Dr. SWARNA REDDY.E.B.,CAS.,AREA HOSPITAL, A P V V P,SRIKALAHASTHI, CHITTOOR-Dt. DISTRICRT ACTION PLAN TO REDUCE M M R THROUGH DETECTION OF HIGH-RISK MOTHERS IN CHTTOOR-Dt, ANDHRA PRADESH

What Is Safe Motherhood? : 

2 “ A woman’s ability to have a SAFE and healthy pregnancy and childbirth. ” What Is Safe Motherhood? Pregnancy and childbirth are natural processes. They are however not risk free. High risk ANC – 15% The tragedy of maternal mortality largely neglected in developing Countries. Every minute of everyday, somewhere in the world, a woman dies as a result of complications arising during pregnancy and childbirth. Death of a woman during pregnancy is a tragedy both for her family and the society.

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15th January 2009 Workshop on Reducing Maternal Mortality in Benue State Definition of Maternal Death: WHO-A maternal death is death of a Woman while pregnant or within 42 days of termination of pregnancy irrespective of the duration and the site of the pregnancy, from any course related to or aggravated by the pregnancy or it management but not from accidental or incidental causes.

ANTE NATAL CARE : 

ANTE NATAL CARE Antenatal or prenatal care is care of the woman during the Pregnancy Early registration of pregnancies (12 – 16 weeks) Minimum 3 antenatal visits (20,32,36 weeks) check-ups Anaemia prophylaxis ( Iron and Folic acid tablets) Two doses of TT Minimum investigations( Ht,Wt, B.P,Hb%,Blood group, Rh typing, Urine examination,VDRL,HIV (TRIDOT TEST) Identification of high risk group, Early detection of complication of pregnancy & timely , safely referral to FRU Treatment of worm infestation with Mebendazole Health education on diet, breast feeding, care of breast, personnel hygiene during pregnancy,& family planning

Some facts : 

5 Some facts CBR+10% = ANC’S 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 380 women become pregnant 190 women face unplanned or unwanted pregnancy 110 women experience a pregnancy related complication 40 women have an unsafe abortion 1 woman dies from a pregnancy-related complication

Maternal Mortality: A Global Tragedy : 

6 Maternal Mortality: A Global Tragedy Annually, 585,000 women die of pregnancy related complications 99% in developing world ~ 1% in developed countries Delay in decision to seek care Lack of understanding of complications Acceptance of maternal death Low status of women Socio-cultural barriers to seeking care Delay in reaching care Mountains, islands, rivers — poor organization Delay in receiving care Supplies, personnel Poorly trained personnel with punitive attitude Finances

Maternal Health Services : 

7 Maternal Health Services Good quality maternal health services are not universally available and accessible > 35% receive no antenatal care ~ 50% of deliveries unattended by skilled provider ~ 70% receive no postpartum care during 1st 6 weeks following delivery Historical Review Traditional birth attendants Antenatal care Risk screening Current Approach Skilled attendant at delivery

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8 Current Approach to Reduction of Maternal Mortality The flawed assumption: Most life-threatening obstetric complications can be predicted or prevented

HIGH RISK-FACTORS : 

HIGH RISK-FACTORS PRE-CONCEPTUAL PROBLEMS physical, Social PROBLEMS-PREVIOUS PREGNANCY LBW, Over-weight, Birth-defects, LSCS, Stilbirth, Rh-Incompatibility, Mis-carriage, Post-term PROBLEMS-DURING PREGNANCY Drugs, Radiation, Infection, Chemicals, Pregnancy Complications PHYSICAL FACTORS: Age at Delivery-<19 Yrs; >36 Yrs(Elderly Primi). Short stature (< 145 cms) , weight<40=>80MEDICAL FACTORS: APH,PPH ,Grand multi-para, Multiple pregnancyAbnormal presentations,polyhydromniosAnemia, Rh-IncompatibilityPIH , EclampsiaPrevious LSCS,Retained placenta,Prolonged labour H/O CONSANGUINITYRecurrent abortions , ECTOPIC PREGNANCYDiabetes, jaundiceHeart disease ,HypothyroidismAssociated Infections-MALARIA, TB, RTI’S, HIV

OBJECTIVE : 

OBJECTIVE TO INCREASE DETECTION RATE OF HIGH- RISK MOTHERS FROM CURRENT LEVEL 5% OF ANC TO 10% OF ANC IN THE YEAR 2010-11

OBJECTIVE : 

OBJECTIVE PROFILE

AP Profile : 

Number of Sub-centres … 12522 Number PHCs … 1570 Number 24-hrs MCH Centres … 800 Community Health Centres … 167 District Hospital under APVVP … 19 Area Hospital under APVVP … 58 Teaching Hospitals … 11 AP Profile Estimated Population as on 1.10.2007 … 837.08 lakhs 0-5 years children … 93.73 lakhs Density of population ... 277 per sq km Sex Ratio (Females/ 1000 males) ... 978 Literacy Rate Total … 60.47% Male … 73.32% Female … 50.43%

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Peddatippasamudram B.Kothakota Molakalacheruvu Buchinayanikandriga Forest K.V.B. Puram Narayanvanam Satyavedu Forest Varadaiah palem Nindra Nagalapuram Erpedu Pitchatur Nagari Vijayapuram Puttur Karvetinagaram Vadamalpet Tirupati (R) Vedurukuppam Ramachadrapuram S.R.Puram G.D.Nellore Renigunta Tottambedu Srikalahasthi Tirupati(U) Palasamudram Putalapattu Penumuru Chittoor Chandragiri Chinnagottigallu Yerravaripalem Pakala Pulicherla Rompicherla Tavanampalle Irala Piler Sadum Kambamvaripalle Bangarupalem Kalikiri Gudipala Yadamarri Kalakada Nimmanapalli Vayalpadu Gurramkonda Somala Chowdepalli Peddapanjani Punganur Madanapalli Ramasamudram Peddamandyam Kurabalakota Thamballapalle Gangavaram Palamaner Baireddypalle V.Kota Santhipuram Ramakuppam Gudupalli Kuppam MEDICAL INSTITUTIONS IN CHITTOOR DISTRICT ANANTHAPUR DISTRICT KARNATAKA TAMILNADU KADAPA DISTRICT Empedu Sub Centres - 644

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HEALTH PROFILE:

OBJECTIVE : 

OBJECTIVE SITUATIONAL ANALYSIS

Global Causes of Maternal Mortality : 

19 Current Approach to Reduction of Maternal Mortality Global Causes of Maternal Mortality

Maternal Mortality Ratio : 

Maternal Mortality Ratio Andhra Pradesh Southern States 1992-93 & 1998-99 – Estimates by IIHFW 2001-03 – SRS (2001-03) 1992-93 & 1998-99 – Estimates by IIHFW 2001-03 – SRS (2001-03)

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Percentage of currently married among women aged 15-19 High value districts Low value districts Mahabubnagar – 43 Nizamabad – 28 Nalgonda – 42 Cuddapah – 28 Kurnool – 41 Karimnagar – 28 Anantapur – 39 Chittoor – 28 Vizianagaram – 38 Hyderabad – 11 State average Total – 34 Rural – 43 Urban – 20

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Antenatal Checkup in Andhra Pradesh % ANTENATAL CHECK-UP CHITTOOR-DT

Women* Who Received 3+ ANC Visits in A.P : 

Women* Who Received 3+ ANC Visits in A.P * For last births in the past 3 years Percent

Percentage of women registered in first trimester : 

75% or more Visakhapatnam (94.8)Vizianagaram (82.7)Srikakulam (81.6) Warangal (79.8)Karimnagar (78.8) East Godavari (76.1) 61% to 74% West Godavari (73.4)Khammam (73.4)Nizamabad (68.5) Nellore (68.3)Krishna (66.3)Prakasam (63.6) Adilabad (61.9)Kadapa (61.0) Below 60% Nalgonda (59.5)Chittoor (56.1)Hyderabad (58.7) Guntur (56.2)Medak (54.4)Kurnool (48.6) Anantapur(43.8)Mahabubnagar (35.8)Ranga Reddy (34.8) State Average Total: 63.2 Rural: 60.0 Urban: 67.4 Percentage of women registered in first trimester CHITOOR-DT BASELINE SURVEY

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HIGH-RISKS-IDENTIFIED IN CHITTOOR-DT

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major causes of maternal deaths-Chittoor-Dt.

SWOT Analysis : 

SWOT Analysis Coordinated activity of ASHA,AWW& ANM CEmONC CENTERS All PHC, APVVP Hospitals have Lab Technicians. ASHA’S, 108 & 104 Fixed day services Gynaecologist are available in APVVP. Health Personnel are aware of High Risk Pregnancies. IEC Activities- Caring out IEC Activities on regular basis. Co-operation from Private Doctors & Nursing Homes , NGO’S who are doing a lot to the society. STRENGTH WEAKNES Non availability of safe delivery MTP services. Family Planning Activity. Ill equipped and under staffed Laboratory Services poor Referral System (Gynecology, Anesthetists services) Illiteracy & poverty, Ignorance Lack of Gynecologist at PHC Level. Under reporting separating – by public and Health Staff. Legal Marriage is not followed Unsafe family planning methods Unsafe delivery & MTP procedure

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Adolescent Education & Age at Marriage PC PNDT ACT-1994. Safe Family Planning Methods. Safe delivery & MTP procedures Availability of Health Staff & Lt’s. Health Camps. School Health -Nutrition education Family Health awareness camps at regular intervals Inter Sectoral Co-ordination from education NGO’s , Mahila Sangh IEC Activities. OPPORTUNITIES THREATS Ignorant attitude . Seeking Health care by Quacks & Traditional Birth Attendants. Illiteracy & Poverty. Poor Involvement of community members. Non co-operation by huband Cultural Myths & Practices

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STRATEGIES Capacity buildings in all levels. Pre-conceptional care. Early registration of ANC cases by ASHA’S ,104(FDS) & ANM’S & Preparation of EDD list=GIVE TO 108,. Improving AWARENESS regarding High-risk’s, available facilities & Free transport facilities to FRU. Establishment of HIGH-RISK Screening camps. Educate the husband & Adolescent girls. Provision of the safe MTP services. Strengthening the referral system. Proper IEC activity level. Distribution of IFA & ALBENDAZOLE tablets to all adolescent girls. Implementation of marriage act properly. Proper implementation of family planning programme. Co-ordination with other Departments.

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1.activity Capacity building – training of manpower, village link worker, ASHA’S,AWW,ANM, staff nurses, OT assistants, medical officers .

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Detection of high –risks –ANM- ASHA’S-104(FDS) Identify the High-risks and list them in village register. Organize screening camps for confirming the High-risk (refer to base hospital). Transport the High-risk to the base hospital. Free surgery / Necessary intervention at base hospital. Follow-up of operated cases, carrying out for better patient compliance. 2.activity

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Pre Conceptional Care Examination Pre Marital It is one of the components of maternal health care Family History Immunization Physical Examination Health Education Investigation Prevention 3.ACTIVITY

HOWEVER, GIRL- CHILD EDUC. REMAINS FUNDAMENTAL;- : 

HOWEVER, GIRL- CHILD EDUC. REMAINS FUNDAMENTAL;- EDUCATED GIRL;- Marries later & thus acquires maturity for parental responsibilities; Has fewer children; Provides better care and nutrition for self/ children; Makes better judgement to seek medical attention sooner for self/children.

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Immunization

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Effective IEC campaign mainly – Demand generation of HIGH-RISK SEEKING CARE. Awareness of screening camp places. Awareness of facilities – base hospitals. To improve the quality of services at Govt., NGO and private sectors. By improving facilities Maximum utilization of services. Minimizing the complications. To improve transport facilities at Govt., NGO and private sector. No. of vehicles will be utilized to transport the HIGH-RISK patients from screening camp to base hospital. 4.activity

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ACTION 5: Lab services to be provided round the clock ACTION 6: Strengthening transport services and referral linkages Provision of emergency care has to be supported by Appropriate referral transport from periphery to functioning FRU Also from FRU to tertiary level hospitals and establish proper referral system Providing government procured vehicles should not be seen as the only option for referral transport linkage The option of providing funds to facility incharges together with administrative and financial powers to make local arrangements is a recommended option

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ACTION 7: Establishing Inter-sectoral co-ordination Co-ordinating with non-government Organisations Public private partnerships Emergency services ACTION 8: Monitoring / Reviewing of performance every month to strengthen and improve the quality of service. MIAN AIM BEING PREPARING THE HIGH-RISK MOTHER TO BE AWARE OF THE AWAILABLE SERVICES INFORM HER THE IMPORTANCE OF SERVICE NECESSITY FOR HER WELL-BEING PREPARE HER TO SEEK SERVICE IN APPROPRIATE TIME AND PLACE

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Janani Suraksha Yojana (JSY): Free Bus passes: 2nd A N M A S H A ‘ S 70,700 Women Health Volunteers (ASHA’S) identified and selected @ one per 1000 rural population positioned; ASHA’S are preventive healthcare resource persons-of-first-resort in all maternal and child health matters. They are the link-persons between the community and the service providers in their respective villages; Contd.. Interventions for Reducing MMR

Changes after the implementation of ASHA Programme : 

Changes after the implementation of ASHA Programme Early Registration of Pregnant Women has improved. Overall Registration of Pregnant Women has gone up Antenatal coverage with TT injection has gone up. Distribution of IFA tablets has gone up. Dissemination of health information has increased. Risk identification is done even at the village by ASHAs Follow up of high risk pregnant women has become better since ASHAs make sure that they are checked up by the ANM and Doctor.

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Strengthening of First Referral Units with CEMONC Services (Comprehensive Emergency Obstetric and Neonatal Care)

Other interventions for promoting health and medical facilities : 

Other interventions for promoting health and medical facilities Contd.. Enhancing functioning of 24/7 PHCs

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Progress of 108 Services (EMRI): 692 ambulances positioned Highlights Total Lives Saved – 48,268 Served 4.41 lakh Pregnancy cases Average Base to Scene time – 15 min. 93% of the population covered 92% of the Geographical covered Average Population covered per Ambulance - 1 lakh Average Mandals covered per Ambulance - 1.4 Progress of 108 Ambulance Services 108 Ambulance Services

Fixed Day Health Services (104) : 

Fixed Day Health Services (104) Health Services through Mobile Health Units Target groups: Pregnant women, infants, children and people with chronic diseases. No.of Vans in service … 474 Total Van Days … 32,584

Other interventions for promoting health and medical facilities : 

Other interventions for promoting health and medical facilities Blood Banks & Blood Storage centres: Untied Funds for Sub-centres: Hospital Development Societies (Rogi Kalyana Samithi): Village Health and Sanitation Committees (Gram Panchayat Health Committee): Contd..

BUDGET REQUIREMENT : 

BUDGET REQUIREMENT POPULATION: =3745875 No of ANC’S =90649 IN CHITTOOR-Dt. HIGH RISK CASES (15% OF A.N.C) =13598 PER YEAR BUDGETTE AVAILABLE: UNDER NRHM BUDGET REQUIREMENT:

GANTT CHART : 

GANTT CHART

Summary : 

Current Approach to Reduction of Maternal Mortality Summary WHO 1999. Systematic medical supervision of woman during pregnancy. TOO AVOID EARLY LATE FREQUENT

Slide 49: 

Acknowledgements: Organisers: All Faculty Members for the opportunity to make this presentation Patients: Whose symptoms become a source of our learning ALL OF YOU: For your patient listening, participation & involvement AND MY SINCERE THANKS TO Dr. A.BALASUBRAMANYAM, Medical Superintendent, Area Hospital, Srikalahasthi for nominating me for this excellent course.

Thank you : 

Thank you