MDG 5:. Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio

MATERNAL HEALTH INDICATORS1) MMR2) SBA3) CPR4) TFR5) ANTENATAL COVERAGE

Indicators Definitions 1990-91

2001-02

2006-07

2007-08

2008-09

MTDFTarget2009-10

MDGTarget2015

MaternalMortality Ratio

No. of mothersdying due tocomplications ofpregnancy anddelivery per100,000 live births

533* 350 276 na na 300 140

Proportion of birthsattended by skilledbirth attendants

Proportion ofdeliveries attendedby skilled healthpersonnel (MOs,midwives, LHVs)

18 40 37 40 41 60 >90

Contraceptiveprevalence rate

Proportion of eligible couples forfamily planningprogrammes usingone of thecontraceptive

12 28 29.6 30.2 30.8 51 55

Total Fertility Rate

Average number ofchildren a womandelivered during her reproductive age

5.4 na 4.1 3.85 3.75 2.7 2.1

Proportion of women 15-49 yearswho had given birthduring last 3 years

Proportion ofwomen (15-49) who delivered during the last 3 years andreceived at leastone antenatal careduring theirpregnancy periodfrom eitherpublic/private care providers

15 35 53 56 58 70 100

Indicators

Definitions 1990-91

2001-02

2006-07

2007-08

2008-09

MTDFTarget2009-10

MDGTarget2015

To reduce maternal and child deaths and illnesses by improving their health status particularly of the poor and the marginalized.

Sr. No

Indicators

Base Line (PDHS survey

2006-07)

Current Status (MICS

2011)

MDG Target

2015

1 Under Five Mortality Rate 97/1000Lb 104 45

2Newborn Mortality Rate

58/1000LbFigure not available

25

3 Infant Mortality Rate 81/1000Lb 77 40

4Maternal Mortality Ratio 227/10000

0LbFigure not available

140

5% of deliveries attended by skilled birth attendants at home/ Health Facilities

38% 59% >90%

6Contraceptive Prevalence Rate

33% 35% 55%

GENERAL (SOCIOECONOMIC AND CULTURAL FACTORS)

A) Poor hygiene and sanitary conditions

B) Unsafe drinking water

C) Poverty

D) Low literacy (Female)

E) Low level of Health awareness

F) Urban Vs Rural disparity regarding development and provision of resources

G) Poor nutritional status of mother

H) Mothers age and parityI) Interval between birthsJ) Level of women empowermentL) Natural disasters

• Facility Level Staff absenteeism & Frequent postings / transfers Gender and skill imbalances Urban -Rural disparities for availability of health professionals Lack of clearly defined referral mechanisms Inappropriate locations Poor maintenance of Health Facilities Insufficient funding and issues of supplies Management issues including supervision & monitoring Non availability of necessary equipment, medicines and

supplies

Community Level The most underserved pockets of population still not covered

by Lady Health Workers (60 % coverage) Insufficient availability of skilled birth attendants

About 48% of the deliveries being conducted by TBAs, Community Midwifery program recently introduced.

Currently 6000 CMWs trained but there are deployment issues

Low confidence in public health facilitiesSocio-cultural diversity coupled with low literacy and lack of

awareness resulting in inappropriate behaviors and practices related to maternal health

A) LOW SBA RATE

B) LOW LEVEL OF ANTENATAL COVERAGE

C) T.T IMMUNIZATION COVERAGE FOR PREGNANTS IS LOW

D) LOW CPR AND HIGH TFR

E) HIGH PREVELENCE OF ANEMIA

F) LOW REFERRAL RATES OF COMPLICATED CASES DURING ANTENATAL AND AT THE TIME OF DELIVERY

G) LOW PROPORTIONATE OF ASSISTED VAGINAL DELIVERY AND C-SECTION VS NORMAL DELIVERY IN HEALTH FACILITIES

H) HIGH INCIDENCE OF SEPTIC ABORTIONS

Care Before Pregnancy HTSP Family Planning Improved Nutrition

Care During Pregnancy• Maternal immunization for tetanus toxoid

• Nutritional support (including iron and folate supplementation)

• Birth planning including transportation

• Counseling on breast feeding

• Recognition of danger signs and treatment or referral as needed

• Where appropriate—

- Presumptive malaria treatment

- Syphilis screening and treatment

- Voluntary counseling and testing for HIV

Care During Childbirth

• Skilled birth attendance at delivery• Clean delivery: hand-washing, clean space, clean cord care

• Recognition of danger signs (for mother) and treatment or referral as needed

Continued & Routine Visits with a Trained Health Care Provider

Early postnatal visit Recognition of danger signs (e.g., fever)

for mother with treatment or referral as needed

Post partum family planning

WHO has made these recommendations for making maternal health a viable program area at the country level:

1. Specify specific goals for reduction in maternal mortality rates.

2. Write and adopt a national policy supporting a countrywide maternal health strategy.

3. Conduct advocacy among multiple partners at the highest levels to mobilize resources.

4. Adopt a country strategy providing options for programs in districts with different health infrastructures and mortality situations

5. Mainstream maternal health through coordination between maternal and child survival and other health areas, as well as cooperation with other sectors.

6. Develop partnerships among governments, NGOs, professional bodies, academia, and developmental partners at regional and country levels.

7. Establish universal registration of births and deaths. Reach consensus on key indicators for maternal health. (Use these data for supportive supervision within the health system.)

8. Include key indicators within national surveys and national health management information systems.

9. Strengthen maternal care capacity through systematic training, skills development, and logistics.

10.Conduct operations research to establish an evidence base for innovative programs

Year

PC-1 Allocation Releases  

Original Revised GOP DFID TOTALTOTAL

Expenditure

2006-07 21.871   - - - -

2007-08 1341.461   92.75 - 92.75 71.852

2008-09 2454.234   127.2 628.708 755.908 425.089

2009-10 1534.538   99.676 350.416 450.092 347.624

2010-11 1413.047   205.962 - 205.962 500.939

2011-12 1323.469   424.824 169.591 594.415 496.502

Total 8088.621   950.412 1148.715 2099.127 1842.006

2012-13 - 1457.186 571.227 829.072 1400.299 233.631

1- The released amounts has been mentioned in the year when these were released from the Finance Department Govt. of the Punjab.

2. The end of 2011-12 26% fund (Rs. 2099.127 M) were released against total allocation of Rs. 8088.621 M.

3. The Govt. of Pakistan decided to continue funding till June 2015 @ funds released in 2010-11. Revised / New PC-I (2012-15) having total cost 3558.180 Million is under the process of approval at CDWP.

4. DFID share Rs. 642.026 Million per year (One Year allocation up to 2014 is already available in program for the year 2011-12 released 2012-13) & GOP (PSDP) share Rs. 544.034 million per year up to 2015.

5. 356 Million of DFID, 136.017 Million of GOP under the process of release from Finance Department Punjab

INTRODUCTION OF A CADRE OF CMWS TO

INCREASE SKILLED BIRTH ATTENDANTS

(SBA) RATE

Target : 6346Total Recruited: 5717 Passed Out: 4367Deployed CMWs: 3947

Status of Civil Work and Renovation Works in DHQs, THQs, under National MNCH Program, Punjab

CMW SchoolSr # Target Approved Completed In Progress Still Not

1 34 33 27 5 1

Note: 3 CMW Schools Completed in that priod 1/1/13 to 30/6/13.

DHQs HospitalSr # Target Approved Completed In Progress Still Not

1 34 33 26 4 3

Note: 4 Renovation Work Completed DHQ Hospitals in that priod 1/1/13 to 30/6/13.

THQs HospitalSr # Target Approved Completed In Progress Still Not

1 76 63 46 4 13

Note: 3 Renovation Work Completed THQ Hospitals in that period 1/1/13 to 30/6/13.

DHQ Hospital Bahawalnagar

THQ Hospital, Haroonabad

THQ Hospital Mankera

THQ Hospital Shahpur

CMW SCHOOL ATTOCK CMW SCHOOL BAHAWALNAGAR

CMW SCHOOL JHELUM

Type of Training

Duration Staff Target Progres

s

IMNCI 11/07 DaysDoctors, LHV, Disp. , Nurse /Staff Nurse , MT/HT/FMT

7464

1647

IMNCI (TOT) 05 Days Doctors/Consultant /Pediatrician /Gynecologists etc

174

EmONC 12 Days WMO, Gyneo, LHV, 6698 515

Basic EmONC 06 Days Nurse /Staff Nurse

ENC 04 Days Doctors, CMW Tutor Principal, LHV, Nurse, CMWs

1200 468

MIS Software 02 Days PHSs, SOs, COs   138

MNCH MIS Tool 02 Days CMWs, LHSs, LHVs   5109

CMW Tutor TOT 01 Month CMW Tutor   99

Revised CMWs Curriculum

04 Days CMW tutors, Clinical Instructors, Gynecologist, WMO,

  114

24/7 Comprehensive Emergency Obstetric and Neonatal Care (CEmONC) Services

Target Progress Comments

• All DHQ Hospitals to provide comprehensive EmONC services .

• All 89 THQ hospitals to provide comprehensive EmONC services.

• All DHQ Hospitals are providing Comprehensive EmONC services.

• All THQ Hospital are providing Comprehensive & Basic EmONC services except the following.

1. Attock (Hazro)

2. Bahawalpur (Khairpur)

3. Bhakkar (Kallor Kot, Mankera & Darya Khan)

4. Sialkot (Pasror)

5. Khushab (Nosherah, Nur Pur Thal)

6. Jhang (Shorkot, Ahmad Pur Sial)

7. Lahore (Shahdra)

8. Mianwali (Esa Khail, Kala Bagh & Piplan)

9. Multan (Jalal Pur Pir wala)

10.Pakpattan (Arif wala)

11.Rawalpindi (Murree)

Most of the THQ Hospitals have no Anesthetist and Blood Transfusion Units. Some THQs are providing Comprehensive EmONC services without Gynecologist, BTOs and Anesthetist with local adjustments / alternates.

24/7 Basic Obstetric and Neonatal Care (BEmONC) Services

Target Progress Comments

291 RHCs of Punjab

All RHCs are providing 24/7 Basic EmONC services.

Procurement of IT Equipment for:1. MCH Cell 36 2. Nursing Schools 26

Procurement of Furniture for 1. MCH Cell 36 2. Hostel / Classroom Furniture 26

Procurement of Transports 1. Toyota Van 522. Jimny Jeep 36

Procurement of Medical Equipment. 1. CTG Machines 522. CMWs Kits 3000

Procurement of Teaching Aids for School of Nursing.1. Midwifery Training Material 30 Sets

Procurement of Medicine for 11 Districts.Procurement of Safe Delivery Kits for 36 Districts.Procurement of Printing Material

1. IMNCI Books 2. EmONC Books3. CMW Tools 4. CMW Manual

PROBLEMS/ ISSUES

1) RELATED TO PROGRAM

2) CHALLENGES FACED BY THE CMWS

Insufficient training, CMW Tutor issueProcedural Issues in Deployment and Certification: Inadequate skill sets and referrals: Financial issues: Mobility and security problems: Acceptance by the communities:Lack of Coordination with the other service providers: De-motivation:

RECOMMENDATIONS

In light of all the problems described above, the following remedial measures are suggested:

1. Community integration for better uptake:2. Improve Skill-set:3. Clearer Job Descriptions and Coordination:4. Health Facility Linkages:5. Alternate financial viability models: 6. Revisit the CMW Strategy:

WAY FORWARD

1)CONTINUATION IN THE TRAINING PROGRAM OF CMW--- TO INCREASE COVERAGE UPTO 5000 AS WELL AS URBAN SLUMS AND INCREASING THE OVERALL POOL OF SBAs2)INCREASING THE NUMBER OF BASIC EMOC AND COMPREHENSIVE EMOC CENTRES (RHS+ Model), THEIR EVEN DISTRIBUTION, UTILIZATION RATES IN DEALING COMPLICATIONS AND STRENGTHENING THEIR REFERRAL LINKAGES 3)PREPARATION OF TRAINED HUMAN RESOURCE IN PROVIDING MCH SERVICES.4)PROMOTING THE CONCEPT OF TASK SHARING5)INCENTIVE BASED PACKAGES6)STRONG POLITICAL COMMITMENT AND INTERSECTORAL COORDINATION

WAY FORWARD (Contd)

7) MOBILE RURAL AMBULANCE SERVICES8) MIS SYSTEM WITH PROPER ANALYSIS AND FEEDBACK9) INTRODUCING HEALTH FACILITY BASED MATERNAL DEATH AUDIT AND ITS REVIEW, STRENGTHENING VERBAL AUTOPSY10) PROVISION OF SERVICES IN INTEGRATED FORM

WAY FORWARD Contd------

11) SUPPORTING EVIDENCE BASED, COST EFFECTIVE AND HIGH IMPACT INTERVENTIONS e.g.

Assuring availability of antibiotics, Oxytocics, IV fluids and

OxygenInfection prevention

Use of Misoprostol and Magnesium sulphate

THANK YOU