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INCREASING ACCESS TO INCREASING ACCESS TO EMERGENCY OBSTETRIC SERVICES : EMERGENCY OBSTETRIC SERVICES :

EXPERIENCES FROM RAJASTHAN, EXPERIENCES FROM RAJASTHAN, INDIAINDIA

Presenter: Presenter: Hemant DwivediHemant Dwivedi

Authors :Authors : Venkatesh SrinivasanVenkatesh SrinivasanHemant DwivediHemant DwivediDileep MavalankarDileep Mavalankar

UNITED NATIONS POPULATION FUND UNITED NATIONS POPULATION FUND (UNFPA), INDIA(UNFPA), INDIA

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Rajasthan IndiaPopulation (in million) 56.47 1027.01Population Density(per.sq.km.) 165 324Female Literacy 44.34 54.16Median Age at Marriage 15.1 16.7Total Fertility Rate (TFR) 3.78 2.85Infant Mortality Rate (IMR) 80.4 67.6Maternal Mortality Ratio 607 540

KEY DEVELOPMENT INDICATORSKEY DEVELOPMENT INDICATORS

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HEALTH SYSTEM AN OVERVIEWHEALTH SYSTEM AN OVERVIEW

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

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

Community Health Centers (CHCs) - Community Health Centers (CHCs) - Specialists doctors, MOs and Paramedics - Specialists doctors, MOs and Paramedics - 125,000 population125,000 population

District Hospital - Multi Speciality District Hospital - Multi Speciality - 2 - 2 million populationmillion population

Medical College and Asso.Hospital - Medical College and Asso.Hospital - Division levelDivision level

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PROJECT DETAILS PROJECT DETAILS Averting Maternal Death and Disability (AMDD) project supported by Averting Maternal Death and Disability (AMDD) project supported by

Columbia University with a grant from the Bill and Melinda Gates Foundation.Columbia University with a grant from the Bill and Melinda Gates Foundation. Implemented as component project under UNFPA supported Integrated Implemented as component project under UNFPA supported Integrated

Population and Development (IPD) Project, Rajasthan, India from 2001-2004.Population and Development (IPD) Project, Rajasthan, India from 2001-2004. ProjectProject Area Area

Seven Districts of Rajasthan, IndiaSeven Districts of Rajasthan, IndiaPopulation covered - 13.5 millionPopulation covered - 13.5 million

Facilities CoveredFacilities Covered CEOC - 31 institutionsCEOC - 31 institutionsBEOC - 52 institutionsBEOC - 52 institutions

Project DurationProject Duration September 2000 - December 2004September 2000 - December 2004

Implementing AgencyImplementing AgencyGovernment of RajasthanGovernment of Rajasthan

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KEY FINDINGS OF BASELINE STUDY (2000)KEY FINDINGS OF BASELINE STUDY (2000)

Service Coverage (UN-Process Indicators)Service Coverage (UN-Process Indicators)

Number of institutions studied - 83Number of institutions studied - 83

% of births in facilities - 10.89 (min.>15%)% of births in facilities - 10.89 (min.>15%)

% met need of EOC - 8% (min.100%)% met need of EOC - 8% (min.100%)

% births by C-section - 0.6 (min.5-15%)% births by C-section - 0.6 (min.5-15%)

Average CFR - 1.4 (min 1%)Average CFR - 1.4 (min 1%)

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STATUS OF HEALTH SYSTEM AT BASE STATUS OF HEALTH SYSTEM AT BASE LINE SURVEY IN 2000LINE SURVEY IN 2000

High vacancies of specialists OB/GY and High vacancies of specialists OB/GY and anesthetist anesthetist

PHCs not offering complete range of PHCs not offering complete range of BEmOCBEmOC

Very few CHCs prepared to address EmOCVery few CHCs prepared to address EmOC

Only 21.5% deliveries in institutionsOnly 21.5% deliveries in institutions

Low utilization of services and confidence Low utilization of services and confidence in PHCsin PHCs

Delay in reaching institutionsDelay in reaching institutions

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PROJECT FOCUSPROJECT FOCUS

Needs Based Differential ApproachNeeds Based Differential Approach

IMPROVING ACCESS TO QUALITY SERVICESIMPROVING ACCESS TO QUALITY SERVICES

Improved functional infrastructureImproved functional infrastructure

Provided necessary equipments and suppliesProvided necessary equipments and supplies

Skill based trainings - BEOC, IP TrainingSkill based trainings - BEOC, IP Training

Development of management systemsDevelopment of management systems

INCREASE COMMUNITY AWARENESSINCREASE COMMUNITY AWARENESS

Advocacy Programs for PRIs, NGOs and Media.Advocacy Programs for PRIs, NGOs and Media.

Integrating Safe Motherhood messages into Integrating Safe Motherhood messages into existing Community level activities.existing Community level activities.

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% Vacant Positions of Health % Vacant Positions of Health Functionaries in RajasthanFunctionaries in Rajasthan

28%

7%5%

0%

5%

10%

15%

20%

25%

30%

Specialist MO ANM

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WHY FOCUS ON BEmOC?WHY FOCUS ON BEmOC?

80-85% obstetric complications do not need 80-85% obstetric complications do not need surgical interventionssurgical interventions

Focus on BEmOC will reduce nearly 33-60% Focus on BEmOC will reduce nearly 33-60% maternal deathsmaternal deaths

Skills upgradation of service provider is Skills upgradation of service provider is feasiblefeasible

Over dependence on OB & Gy specialist and Over dependence on OB & Gy specialist and anesthetist reducedanesthetist reduced

Reduces congestion at district and medical Reduces congestion at district and medical college hospitalscollege hospitals

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INITIATING BEOC SERVICESINITIATING BEOC SERVICES

Government in consultation with UNFPA Government in consultation with UNFPA decided to train MOs in BEmOC decided to train MOs in BEmOC

2 weeks training at district hospital2 weeks training at district hospital

62 teams trained BEmOC62 teams trained BEmOC

MOs gained confidence in handling cases MOs gained confidence in handling cases and expressed interest and expressed interest

Skills upgraded on manual removal of Skills upgraded on manual removal of Placenta, management of shock, judicious Placenta, management of shock, judicious use of Oxytocine, stabilizing cases of APH & use of Oxytocine, stabilizing cases of APH & PPH and ensuring referral when essentialPPH and ensuring referral when essential

Promoted use of evidence based practicesPromoted use of evidence based practices

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ORIENTATION OF CBVORIENTATION OF CBV

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MANAGEMENT INFORMATION SYSTEMMANAGEMENT INFORMATION SYSTEM

Needs assessmentNeeds assessment

Pilot testing of revised MISPilot testing of revised MIS

Revised MIS orientation and implementationRevised MIS orientation and implementation

Monitoring of progress on UN process Monitoring of progress on UN process indicatorsindicators

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Health Institutions Providing Basic andHealth Institutions Providing Basic andComprehensive Comprehensive EmOCEmOC- Rajasthan- Rajasthan

RESULTS OF THE INTERVENTIONSRESULTS OF THE INTERVENTIONS

18 1823 21

26

36

53

62

0

10

20

30

40

50

60

70

2000 2001 2002 2003

CEOCBEOC

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41944

47576 4812949502

3800040000

4200044000

4600048000

5000052000

Births2000 2001 2002 2003

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

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18%

12%

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

IPD Non-IPD

% Births increase in EmOC facilities : % Births increase in EmOC facilities : Comparison with non-intervention districts in Comparison with non-intervention districts in

last 4 yearslast 4 years

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Comparison of met need of EmOC : Comparison of met need of EmOC : Intervention and non-intervention districtsIntervention and non-intervention districts

14.26

8.87.91

12.13

7.147.16

7.966.1

0

2

4

6

8

10

12

14

16

2000 2001 2002 2003

IPDNon-IPD

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0.6 0.56 0.53

00.10.20.30.40.50.6

2001 2002 2003

C-Section

C-Section in FacilitiesC-Section in Facilities

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Comparison of Average CFR in FacilitiesComparison of Average CFR in FacilitiesIntervention and non-intervention institutionsIntervention and non-intervention institutions

1.33 1.49

0.97 0.95

4.14.4

4.72

4.01

00.5

11.5

22.5

33.5

44.5

5

2000 2001 2002 2003

IPDNon-IPD

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LESSONS LEARNEDLESSONS LEARNED

BEmOC services as a feasible strategy in BEmOC services as a feasible strategy in human resource scarce settingshuman resource scarce settings

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

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

Operationalising EmOC services requires Operationalising EmOC services requires sustained effortssustained efforts

Demonstration project’s achievements Demonstration project’s achievements facilitates advocacy at policy levelfacilitates advocacy at policy level

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MOVING FROM PILOT TO SCALEMOVING FROM PILOT TO SCALE

Logframe of new national RH programme Logframe of new national RH programme draws on Rajasthan experience for draws on Rajasthan experience for strengthening EmOC servicesstrengthening EmOC services

Reduction in maternal morbidity and Reduction in maternal morbidity and mortality is now a priority agenda of mortality is now a priority agenda of Rajasthan Government Rajasthan Government

UN process indicator confirmed as reliable UN process indicator confirmed as reliable and accessible indicators for public health and accessible indicators for public health systems to measure programme systems to measure programme performanceperformance

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Maternal death is a personal Maternal death is a personal tragedy and social disaster.tragedy and social disaster.

Let us join our hands to avert Let us join our hands to avert it.it.

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FOR FURTHER INFORMATION….FOR FURTHER INFORMATION….

HEMANT DWIVEDIHEMANT DWIVEDISate Programme CoordinatorUNFPA Rajasthan State Office, 29, Srirampura Colony, Civil Lines, Jaipur, Rajasthan, IndiaEmail : unfpajpr@sify.comTelephone : 91-141-2220028/2220224Fax : 91-141-2222277

VENKATESH SRINIVASANVENKATESH SRINIVASANNational Programme OfficerUNFPA, 53, Jorbagh, New Delhi, IndiaEmail : venkatesh.srinivasan@unfpa.org.inTelephone : 91-11-24651801Fax : 91-141-24641679