MATERNAL HEALTH

Maternal Health includes the health of a woman before and during pregnancy, at childbirth and during post-partum period.

Maternal mortality is a sensitive indicator and helps to understand the health care system of a country and also indicates the prevailing socio-economic scenario. WHO estimated that 94% of maternal death occurs in developing countries. India’s MMR has declined from 130 per 1 lakh live births in 2014-2016 to 97 per 1 lakh live births in 2018 – 20 (ref: SRS) and accomplished the National Health Policy (NHP) target for MMR of less than 100/lakh live births and is on the right track to achieve the SDG target of MMR less than 70/ lakh live births by 2030. The no of maternal death in the state (Mizoram) has reduced from 26 in the financial year 2018-19 to 13 in the financial year 2019-20.

The common causes of maternal death in India are (ref: ‘Global causes of maternal death: a WHO systematic analysis’ 2014)-

Hemorrhage	27%
Hypertension	14%
Sepsis	11%
Other direct causes	10%
Complications of unsafe abortion *	8%
Embolism	3%
Indirect causes	28%

 

1.    Ante Natal Care: Ensuring quality ANC has been an ongoing activity since the inception of RCH in Mizoram. This includes early registration of Pregnancy at the nearest health facility, at least 4 ANC check-ups, Immunization with injection TT, Folic Acid, IFA & Calcium supplementation etc. To ensure quality antenatal care the Government of India has launched PMSMA scheme which expanded to Extended-PMSMA.

a.    PMSMA (Pradhan Mantri Surakshit Matriva Abhiyan): PMSMA has been launched by Ministry of Health & Family Welfare (MoHFW), GOI since 2016. The program aims to provide assured, comprehensive and quality antenatal care, free of cost, universally to all pregnant women (in 2^nd& 3^rd trimester) on the 9^th of every month in public facilities.

Key Features of PMSMA: -

                                          i.    PMSMA is based on premise that if pregnant women in India is examined by physician and appropriately investigated at least once during the PMSMA and then appropriately followed up – the process can result in reduction in the number of maternal and neonatal deaths in our country.

                                        ii.    ANC services will be provided by OBGY Specialist / Radiologist/ Physician with support from private sector doctors to supplement the effort of Government sectors.

                                       iii.    A minimum package of ANC services (including investigation and drugs) would be provided to the beneficiaries on th 9^th day of every month at identified public health facilities (PHC/CHC/DH/Urban health facilities etc) in both urban and rural areas in addition to routine ANC at the health facility /outreach.

                                       iv.    It is envisaged that a minimum package of investigations including one ultrasound during the 2^nd trimester of pregnancy and medicines such as IFA Supplements, Calcium etc would be provided to all pregnant women attending PMSMA clinic.

                                        v.    Pregnant women would be given Mother & Child Protection Card and Safe motherhood booklets.

                                       vi.    One of the critical components of PMSMA is identification and follow up of High-Risk Pregnancies. A sticker indicating the condition and risk factor of pregnant women would be added on to MCP card for each visit. Green sticker- for women with no risk factor detected and Red Sticker- for women with high-risk pregnancy.

                                      vii.    A National Portal for PMSMA and mobile application have been developed to facilitate the engagement of private/voluntary sector.

b.    Extended - PMSMA: Extended PMSMA was introduced later in order to detect more HRP and to follow up and for a better outcome of the pregnancy.  This initiative includes Identification of HRP by incentivization of HRPs detected during PMSMA session up to 3 follow up for pregnant mother and ASHA, additional day for PMSMA, strengthen the provision of Qualified service provider for PMSMA by capacity building, deputing OBGY/trained doctors where trained doctor is not available and tele-consultation.

 

2.    Intra Natal Care: To promote safe delivery in the hands of skilled birth attendant, with the aim of achieving 100% institutional delivery.

 

3.    Post Natal Care: After Delivery, Health Worker/ ASHA pay visit to the mother and give them advice and necessary treatment if needed.

 

The following schemes/ programmes/initiatives are implemented as per the GOI guidelines to ensure save delivery as well as post-delivery follow up for both the mother and the newborns: -

a.    Janani Suraksha Yojana (JSY): It is a safe motherhood intervention under the National Health Mission (NHM). It is a 100% centrally sponsored scheme and integrates cash assistance with delivery and post-delivery care and is being implemented with specific aims and objectives of reducing maternal mortality and neonatal mortality by promoting institutional delivery especially among poor pregnant women.

In Mizoram it is being implemented since May 2005. Since then incentives has been given to every pregnant woman delivering at Public Health Institutions such as District Hospitals, Community Health Centres, Primary Health Centres, Urban Health Centres Sub Centres and Accredited Private Hospitals.

Eligibility Criteria for Financial Assistance:

                                          i.    Registering at any Sub Centre during 1^st Trimester

                                        ii.    At least 4 ANC checkups and

                                       iii.    TT injection during pregnancy.

 

b.    Janani Shishu Suraksha Karyakram (JSSK): Government of India has launched Janani Shishu Suraksha Karyakaram (JSSK) on 1st June, 2011 in view to eliminate difficulty being faced by the pregnant women and parents of sick new- born along-with high expenditure on delivery and treatment of sick- new-born. It is an initiative to provide completely free and cashless services to pregnant women including normal deliveries and caesarean Sections.

The scheme was launched in Mizoram in June 2011 and has been implemented since then. The following are the Free Entitlements for pregnant women:   

1. Free and cashless delivery
2. Free C-Section
3. Free drugs and consumables
4. Free diagnostics
5. Free diet during stays in the health institutions
6. Free provision of blood
7. Exemption from user charges
8. Free transport from home to health institutions
9. Free transport between facilities in case of referral
10. Free drop back from Institutions to home after 48hrs stay

The scheme aims to eliminate out of pocket expenses incurred by the pregnant women and sick new borns upto 1 year while accessing services at Government health facilities.

LaQshya (Labour Room Quality Improvement Initiative): Ministry of Health & Family Welfare, Government of India launched LaQshya programme on 11^th December 2017 with the objectives of reducing maternal mortality and morbidity by improving quality of care in labour room and Maternity Operation Theatre (OT) in Public health facility.

Goal – To reduce preventable maternal and new-born mortality, morbidity and still births associated with the care around delivery in Labour room and maternity OT and ensure respectful maternity care.

Strategies:

• Reorganizing /aligning Labour room & Maternity OT layout and workflow as per ‘Labour room standard Guidelines’ and ‘Maternal &Newborn Health Toolkit’ issued by MoHFW , Government of India.
• Ensuring that at least all Government medical colleges and hospital Case-load district hospitals have dedicated Obstetrics HDU as per GoI MPHFW Guidelines for management of complicate pregnancies that requires life saving critical care.
• Ensuring strict adherence to clinical protocols for management and stabilization of the complications before referral to higher centres.

## Currently, 8 District Hospitals have State Laqshya Certification and Mamit District Hospital and Lunglei District Hospital have achieved National Laqshya Certification during 2021-22.

SUMAN (Surakshit Matriva Aashwasan): Union H&FMW Minister, Dr. Harsh Vardhan launched the SUMAN scheme along with other state Heath Minister on 10^th October 2019. 50 public facilities (DH/SDH/CHC/UPHC/PHC/HWC) are notified for different level of service given till 2022-23 in Mizoram.

AIM: - Assured, dignified, respectful and quality healthcare at no cost and zero tolerance for denial of services for every woman and new-born visiting public health facility in order to end all preventable maternal and newborn deaths and morbidities and provide a positive birthing experience.

Beneficiaries Of the initiatives are: -

• All pregnant women
• All mothers up to six months post-delivery.
• All Sick infants.

Service Guarantee Under SUMAN: -

All pregnant Women/Newborns visiting public health facilities are entitled to the following free services:

• Provision of at least 4 ANC (including 1 check-up during 1^st trimester and atleast 1 check up under PMSMA & 6 home based newborn care visits.
• Safe Motherhood Booklet & Mother & Child Protection Card.
• Comprehensive Abortion Care services in line with the MTP Act.
• Quality care by trained personnel (including SBA /Midwife).
• Free and zero expense access for identification and management of maternal Complications.
• Free transport from home to health institutions (Dial 102/108), assurance referral services with scope of reaching health facilities within 1 hour of any critical case emergency and drop back from institution to home after due discharge (minimum 48hrs)
• Free and Zero Expense delivery and C- Section facility in case of complications at public Health Facility.
• Respectful care with privacy and dignity.
• Choice for delayed cord clamping beyond 5 minutes/up to delivery of placenta in case of uncomplicated pregnancy.
• Free and Zero expenses for sick infants.
• Birth registration certificates from healthcare Facilities.
• Conditional Cash transfers/ direct benefit transfers under various central and state specific schemes.
• Post-partum family planning counselling.
• Time bound redressal of grievances through a responsive call centre/helpline.
• Early initiation and support for breast feeding.

DAKSHATA: The MoHFW, GoI has developed an initiative Dakshata to improve quality of care at the delivery points of the country through focused programmes which includes concise training package for competency enhancement for Medical Officers, Nurses and ANM; developing a system of post-training follow up and mentoring ; ensuring availability of essential commodities, supplies and equipments in Labour Rooms; strengthening the capacity of the facilities and system to measure quality of care on a regular basis.

Goal:- To improve the quality of maternal and newborn care during the intra and immediate post-partum period, though providers who are competent and confident (Dakshata).

Training of Health Care Providers:

Skilled Birth Attendance (SBA) Training: Staff Nurses and Health workers (ANM) at facilities conducting deliveries are being trained in SBA for their skill enhancement.

Basic Emergency Obstetric Care (BEmOC) Training: Medical Officers at Level 2 Facilities (24X7 PHCs and Non-FRU CHCs) are being trained in BEmOC.

Emergency Obstetric Care (EmOC) & Life Saving Anaesthetic Skill (LSAS): Medical Officers at Level 3 Facilities (FRU CHC & DH) where Specialists are not available, are being trained at EmOC & LSAS.

Comprehensive Abortion Care (CAC): Provision of comprehensive safe abortion services at public health facilities including 24*7 PHCs/ FRUs (DHs/ SDHs /CHCs) with a focus on "Delivery Points". Medical Officers at these facilities are also being trained in CAC to ensure safe abortion services as per new amendment of Medical Termination of Pregnancy Act 2021.

Provision of RTI/STI Services: RTI/STI Clinics are being set up at District Hospitals. Such Clinics are in the process of functioning at Sub District levels as well. Training of Service Providers are being held across the state proper management as well as timely referral. HIV and Syphilis Dual Kit is distributed in facilities for screening during ANC.

 

Performance Based Incentives

The following performance-based incentives have been started in the High Priority Districts namely Lunglei, Lawngtlai, Saiha & Mamit as pilot projects: -

• Incentive for Line listing of severely anaemic pregnant mothers: - Incentive for ANM @ Rs. 100 for line listing and follow up of every case of Pregnant woman with severe anaemia are being given.

Other Incentive: E - PMSMA: - Incentive for HRP mother detected in PMSMA session and ASHA @Rs 100/case up to 3 follow up and Rs 500 for ASHA for healthy outcome of Mother and baby on 45^th day of delivery.

Maternal Death Review: Every maternal death is audited and reviewed by the District MDR Committee