Infant and Maternal Mortality

Millennium Development Goals (MDG) by 2015

To eradicate extreme poverty and hunger

To achieve universal primary education

To promote gender equality and empowering women

To reduce child mortality rate = 27 in 2015

To improve maternal health = 109 by 2015

To combat HIV/AIDS, malaria, and other diseases

To ensure environmental sustainability

To develop a global partnership for development

Would India achieve this goal?

Recent projections show that India would more or less reach close to the level.

Projections
The announcement by the Registrar General of India that the maternal mortality rate
(MMR) declined by 16% in 2010-12 as compared to 2007-09 is good news (212 to
178). But still lagging behind Bangladesh and Nepal.
The Infant mortality Rate (IMR) has declined nearly to the tune of 85 points from 129
in 1971 to 44 by 2011. It has further come down by two points to 42 in 2012.

Measures taken by government to achieve this goal:

Facility Based Newborn and Child Care
Neonatal mortality is one of the major contributors (2/3) to the Infant Mortality.
To address the issues of higher neonatal and early neonatal mortality, facility based
newborn care services at health facilities have been emphasized.
Setting up of facilities for care of Sick Newborn such as
a. Special New Born Care Units (SNCUs),
b. New Born Stabilization Units (NBSUs) and
c. New Born Baby Corners (NBCCs) at different levels is a thrust area under
NRHM.
a. Special Newborn Care Units (SNCU)
States have been asked to set up at least one SNCU in each district.
SNCU is 12-20 bedded units and requires 4 trained doctors and 10-12 nurses for
round the clock services.

b. Newborn Stabilization units (NBSUs)

NBSUs are established at community health centres / FRUs.

These are 4 bedded units with trained doctors and nurses for stabilization of sick
newborns.
c.

New Born Care Corners (NBCCs)

These are 1 bedded facility attached to the labour room and Operation Theatre
(OT) for provision of essential newborn care.
NBCC at each facility where deliveries are taking place should be established.
There are 8582 functional NBCC in the country so far.

Facility Based Integrated Management of Neonatal and Childhood Illness (F- IMNCI)
It is the integration of the Facility based Care package with the IMNCI package, to
empower the Health personnel with the skills to manage new born and childhood
illness at the community level as well as at the facility.
It focuses on providing appropriate skills for inpatient management of major causes of
Neonatal and Childhood mortality such as asphyxia, sepsis, low birth weight and
pneumonia, diarrhoea, malaria, meningitis, severe malnutrition in children.
This training is being imparted to Medical Officers, Staff Nurses and 24x7 PHCs
where deliveries are taking place.
The training is for 11 days.
Accredited social health activist (ASHA)
It is an effective link between the Government and the poor pregnant women in low
performing states.
Role of ASHA :
o Identify pregnant woman as a beneficiary of the scheme and report or facilitate
registration for ANC,
o Assist the pregnant woman to obtain necessary certifications wherever
necessary,
o Provide and / or help the women in receiving at least three ANC checkups
including TT injections, IFA tablets,
o Identify a functional Government health centre or an accredited private health
institution for referral and delivery,
o Counsel for institutional delivery,
o Escort the beneficiary women to the pre-determined health center and stay
with her till the woman is discharged,
o Arrange to immunize the newborn till the age of 14 weeks,
o Inform about the birth or death of the child or mother to the ANM/MO,
o Post natal visit within 7 days of delivery to track mothers health after delivery
and facilitate in obtaining care, wherever necessary,
o Counsel for initiation of breastfeeding to the newborn within one-hour of
delivery and its continuance till 3-6 months and promote family planning.

Note: Work of the ASHA or any link worker associated with Yojana would be
assessed based on the number of pregnant women she has been able to motivate to
deliver in a health institution and the number of women she has escorted to the health
institutions.
Home Based New Born Care (HBNC)
This scheme has been launched to incentivize ASHA for providing Home Based
Newborn Care.
ASHA will make visits to all newborns according to specified schedule up to 42 days
of life.
The proposed incentive is Rs. 50 per home visit of around one hour duration,
amounting to a total of Rs. 250 for five visits.
This would be paid at one time after 45 days of delivery, subject to the following:
o recording of weight of the newborn in MCP card
o ensuring BCG , 1st dose of OPV and DPT vaccination
o both the mother and the newborn are safe till 42 days of the delivery, and
o registration of birth has been done
To improve new born care practices at the community level and for early detection
and referral of sick new born babies.
The schedule of home visits by ASHA consists of at least 6 visits in case of
institutional deliveries, on days 3, 7, 14, 21, 28 & 42nd days and one additional visit
within 24 hours of delivery in case of home deliveries.
Additional visits will be made for babies who are pre-term, low birth weight or ill.
Navjat Shishu Suraksha Karyakram (NSSK)
It is a programme aimed to train health personnel in basic newborn care and
resuscitation,
It has been launched to address care at birth issues i.e. Prevention of Hypothermia,
Prevention of Infection, Early initiation of Breast feeding and Basic Newborn
Resuscitation.
Newborn care and resuscitation is an important starting point for any neonatal
program and is required to ensure the best possible start in life.
The objective of this new initiative is to have a trained health personal in Basic
newborn care and resuscitation at every delivery point.
The training is for 2 days and is expected to reduce neonatal mortality significantly in
the country.
Janani Shishu Suraksha Karyakram (JSSK)
It has provision for both pregnant women and sick new born till 30 days after birth as
follows
o Free and zero expense treatment
o Free drugs and consumables
o Free diagnostics

o Free provision of blood

o Free transport from home to health institutions
o Free transport between facilities in case of referral
o Drop back from institutions to home
o Exemption from all kinds of user charges.
The initiative would further promote institutional delivery, eliminate out of pocket
expenses which act as a barrier to seeking institutional care for mothers and sick new
borns and facilitate prompt referral through free transport.
Janani Suraksha Yojana
It aims to decrease the neo-natal and maternal deaths happening in the country by
promoting institutional delivery of babies.
It is a 100% centrally sponsored scheme
it integrates cash assistance with delivery and post-delivery care.
The success of the scheme would be determined by the increase in institutional
delivery among the poor families.
In this scheme, one important role is of the ASHA activist whose role can be of an
encouraging person in the field to encourage institutional deliveries among the poor
women.
Features of this scheme
In this scheme, the states where there is a low rate of Institutional deliveries is
classified as
o 'Low Performing States(LPS)' (the states of Uttar Pradesh, Uttaranchal,
Bihar, Jharkhand, Madhya Pradesh, Chhattisgarh, Assam, Rajasthan,
Orissa and Jammu and Kashmir), whereas the remaining states are
termed as High Performing States(HPS).
Cash Assistance for Institutional Delivery
State Category : LPS
Rural Area - Mother : Rs 1400/- ASHA : Rs 600/- Total : Rs 2000/Urban Area - Mother : Rs 1000/- ASHA : Rs 200/- Total : Rs 1200/State Category : HPS
Rural Area - Mother : Rs 700/- ASHA : Rs 200/- Total : Rs 900/Urban Area - Mother : Rs 600/- ASHA : Rs 200/- Total : Rs 800/Mother and Child Tracking System
It has been put in place which is web based to ensure registration and tracking of all
pregnant women and new born babies so that provision of regular and complete
services to them can be ensured.
Management of Malnutrition
Management of Malnutrition particularly Severe Acute Malnutrition (SAM) by
establishing Nutritional Rehabilitation Centres (NRCs).

 As breastfeeding reduces infant mortality, exclusive breastfeeding for first six months
and appropriate infant and young child feeding practices are being promoted in
convergence with Ministry of Woman and Child Development.
Iron and Folic Acid supplementation to pregnant & lactating women and children for
prevention and treatment of anaemia
Weekly Iron and Folic Acid is proposed to be initiated for adolescent population.
Universal Immunization Program (UIP)
Vaccination against seven diseases for all children.
Government of India supports the vaccine program by supply of vaccines and
syringes, cold chain equipments and provision of operational costs.
Rashtriya Kishor Swasthya Karyakram
The Government of India has started the countrys first comprehensive adolescent
health programme
It will also focus on adolescents reproductive health.
About Rashtriya Kishor Swasthya Karyakram

Focus: Health needs of 24.3 crore adolescents which makes 21% of Indias
population in India.
A holistic and participative programme instead of a doctor-driven effort.
Strategy: RMNCH+A stands for (Reproductive, Maternal, New born, Child
Health + Adolescent).
New dimensions: Mental health, nutrition, substance misuse, gender based
violence and non-communicable diseases.
Community based interventions through peer educators, and is supported by
collaborations with other Ministries and State governments, knowledge partners
and research.
Strives to make adolescents aware even before the occurrence of any disease or
problem, so that they could make informed decisions and choices.
Using new technologies and social media platforms to reach the adolescents in
their own spaces, with strategic partnerships with communities and peers.

6 Cs in this programme:
Coverage
Content
Communication
Counseling
Clinics
Convergence
Who is Adolescent?
As per RKSK programme, a person within 10-19 years of age is an adolescent.
It includes people in this age bracket in urban and rural areas and includes both girls
and boys, married and unmarried, poor and affluent, whether they are in school or out
of school.

Reasons for continuation of Maternal mortality

All the factors that contribute to preventable maternal deaths remain strongly present:

anaemia in women,

early marriages of girls,

the generally poor nutritional status of women and

The overall discrimination against girls and women.

In IMR, reduction in the post-neonatal (deaths of infants between the ages of one month
and 12 months) mortality rather than neonatal (Within one month) mortality. Why?
Neonatal - more than 70%.
Reasons

Controlling neonatal deaths necessitates advanced healthcare which often the public
health system is unable to provide.

Widespread undernourishment and anaemia levels among pregnant women in the

country lead to the birth of a considerable proportion of under-weight children.

The public health spending in India remains one of the lowest in the world despite
increased allocation during the NRHM period.

The public health system is marred by severe shortage of health functionaries,

particularly specialist doctors.

Vacant positions of doctors and paramedical staff are almost a norm in many states in
the country and regular appointments are often either neglected or delayed unduly.

States performance In MMR

HPS

LPS

Kerala (66)

Assam (328)

Maharashtra(80)

Rajasthan(255)

Tamil nadu(87)

Bihar

Some of the Reason for these differences:

Kerala (HPS)

State-sponsored Ammayum Kunjum scheme which runs alongside the

JSY.

Carries out continuous auditing and monitoring of training, quality and

results in this area.

Maharashtra(HPS)

It has earmarked free ambulance services for pregnant women while

increasing the number of ambulances available for emergency services.

It is also aiming to have doctors in the ambulances to cater to emergency

cases.

Assam(HPS)

80% of Assamese women suffer from anaemia.

Septic abortion and eclampsia (convulsions in a pregnant woman suffering

from high blood pressure perhaps followed by coma).

Insurgency has led to poor access to these health services. (Sri lanka is also
example).

State level Performance in IMR

In 2012, IMR varies from 56 in Madhya Pradesh to 12 in Kerala.
The GoI has identified nine backward states of Assam, Bihar, Chhattisgarh,
Jharkhand, Madhya Pradesh, Odisha, Rajasthan, Uttar Pradesh and Uttarakhand
needing special focus known as the empowered action group (EAG) states.
All these states recorded a percentage decline of over 4% in the last six years.
None of the states record rate of decline far below the national average indicating that
the emphasis placed on these states has produced dividends in reducing the IMR in
these states.
Between 2006 and 2011 the percentage of women delivering at the health institutions
has more than doubled in all these nine states.
However, some of these states like Jharkhand have a long way to go in ensuring near
universal institutional delivery.
ref
www.epw.in/system/files/CM_XLIX_3_180114_K_S_James.pdf

By Manikandan A