maternal death review – as a tool for system strengthening · health & family welfare dept,...

1Health & Family Welfare Dept, Govt of Gujarat www.gujhealth.gov.in

Maternal Death Review – As a tool for System Strengthening

- Dr. N.B. Dholakia - Additional Director (FW)

Taj Mahal Built by Mughal emperor Shah Jahan in memory of his favorite wife, Mumtaz Mahal.

-Taj Mahal means "crown of buildings“

-a UNESCO World Heritage Site

-A monument of grief

-Mumtaz Mahal died during the birth of their fourteenth child

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The risk of a woman dying from a complication related to pregnancy or childbirth Developed Countries - 1 in 2800, India - 1 in 100


Celebrities who died during Child Birth

3

• Mumtaz Mahal (1631), wife of Mughal emperor Shah Jahan. Her memorial is the Taj Mahal

• Gowri Lakshmi Bayi (1815), Maharani of Travancore• Smita Patil (1986), an Indian actress and wife of Raj

Babbar

The WHO estimates that 800 women die every day from preventable causes related to pregnancy and childbirth. More than 3.5 million children died in 2011 from preventable causes. Nearly all of the deaths occur in developing countries

http://en.wikipedia.org/wiki/Mumtaz_Mahal

http://en.wikipedia.org/wiki/Mughal_Empire

http://en.wikipedia.org/wiki/Shah_Jahan

http://en.wikipedia.org/wiki/Shah_Jahan

http://en.wikipedia.org/wiki/Taj_Mahal

http://en.wikipedia.org/wiki/Gowri_Lakshmi_Bayi

http://en.wikipedia.org/wiki/Maharajah_of_Travancore

http://en.wikipedia.org/wiki/Smita_Patil



http://en.wikipedia.org/wiki/Raj_Babbar

http://en.wikipedia.org/wiki/Raj_Babbar


State’s Targets for MDGs 4 and 5:

Health Indicators

Current StatusTarget 2015

MDGTarget 2017

12th Plan

Reduction inMMR

148 (2007-09SRS)

100 <90

Reduction inIMR

41 (SRS 2011) 29 24

Under 5Mortality RateU5MR

52 (SRS 2011) 42 35

Total FertilityRate

2.4 (SRS 2011) 2.2 2.1


Maternal Mortality Ratio, India, SRS 2007-09

81 97 104134 145 148 153

172 178212

258 261 269

318

359390

0

50

100

150

200

250

300

350

400

450


MMR SRS 2007-09

212

148

261

145

104 97 85

196

100

210

102

61 5635

226198

313

188

146 138 127

0

50

100

150

200

250

300

350


Maternal and Neonatal MortalityMagnitude of the Problem in Gujarat

About 14,14,000 pregnancies per year

12,86,000 deliveries per year

15% are likely to develop complications

All Complications cannot be predicted

Estimated 1900 maternal deaths per year (5-6 maternal deaths per day)

38,500 Neonatal deaths per year (106 neonatal deaths every day )

7

88

Process of MDR in Gujarat


Summary Status of Maternal Deaths Reporting in Gujarat (April 11 to March 12)

• Out of Estimated Maternal deaths, Verbal Autopsy of 47% was carried out

• Out of Verbal Autopsy carried out, data of 91% available

• 88% of Maternal deaths reviewed by CDHO

• 76% of Maternal Deaths reviewed by Collector

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Estimated Maternal Deaths (Excluding

Corporation)

Maternal Deaths reported by HMIS

Verbal Autopsy Carried Out

Verbal Autopsy Data Available

Maternal Deaths Reviewed by CDHO

Maternal Deaths Reviewed by

Collector

1449

806 686 625 601 519

1-3 deaths

4-6 deaths

>7 deaths

Maternal Deaths Reported in Gujarat (April 11 to March 12)

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District-wise reporting of maternal deaths (% = Reported Deaths/Estimated Deaths*100)

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• State Average 47%

• More reporting of deaths means - more maternal deaths reviewed by CDHO and Collector - more actions taken!!

• Promote reporting of deaths

1925

2930313131

3435

3739

4143

45474749

556264

7071

787879

97140

MehsanaAmreli

Sabarkantha Valsad

Bharuch Navsari

SuratJunagadh

RajkotPanchmahal

BhavnagarKheda

BanaskanthaJamnagar

PatanGujarat

Porbandar Gandhinagar

AnandKutch

AhmedabadTapi

SurendranagarVadodara

Dahod Narmada

Dang

District-wise maternal deaths reviewed by CDHO(% = Deaths reviewed by CDHO/ Reported Deaths*100)

12

8

55

68

81 83 85 86 88 88 88 91 91100 100 100 100 100 100 100 100 100 100 100 100 100 100 100

• 88% of the Deaths reported are reviewed by CDHO


District-wise maternal deaths reviewed by Collector (% = Deaths reviewed by Collector/ Reported Deaths*100)

13

0

1017

48

5868

75 7680 81 83 83 85 86 86 88 89 90

96 100 100 100 100 100 100 100 100


Place of Delivery (n=490)

14

192

107

6945 45

14 14 40

50

100

150

200

250

Private Hospital

Home District hospital

Trust hospital CHC During Transportation

PHC Sub-center

Freq

uenc

y


Who conducted Home Delivery (n=107)

15

57

22

15

58

Trained Dai Relative Untrained Dai Doctor/FHW Others


Place of Death (n=616)

16

0 20 40 60 80 100 120 140 160

PHC

On the way to home

CHC

Trust Hospital

Home

On the way to hospital

Private Hospital

District Hospital

15

2162

88135

146158


Time of Death (n=610)

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Time of Death of those who delivered (n=491)

Ante-Partum

11619%

Intra-Partum346%

Post-partum46075%

221

79 87

54

249 17

Day of Delivery

Second Day First Week (3-7 days)

Second Week Third Week Fourth Week Fifth Week


Cause of Death (n=602)

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Others20434%

PPH20434%

Sepsis89

15%

PIH59

10%

Obstructed laborer/Ruptured

Uterus244%

APH223%


Other Causes of Death (n=164)

19

111111

222

33

466

77

810

1111

1517

2123

AbortionEpilepsy

Hyperemesis GravidarumHysteria

PROMVenous Thrombosis

DiarrhoeaEctopic Pregnancy

Surgical/Anaesthetic ComplicationAccidental/Incidental

GI CausesHepatic Failure

Drug/Blood Transfusion ReactionPUO

Cerebral CausesRespiratory Causes

Renal FailureIUFD with DIC

Cardiac CausesJaundice

Pulmonary EmbolismSickle Cell AnemiaInfectious Causes

Severe Anaemia

Pathway Analysis (n=616)

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Home

1st Facility

2nd Facility

3rd Facility

4th Facility

5th Facility

6th Facility

7th Facility

616

542

306

107

24

4

2

0

43 died at home (7%)

31 died en route (5%) 148 died at 1st Facility (27%)

21 returned home & died (4%)67 died en route (12.4%)

26 died en route (8.5%)

12 died en route (11%)

1 died en route (%)

156 died at 2nd Facility (51%)

17 returned home & died (6%)63 died at 3rd Facility (59%)

8 returned home & died (7.5%)19 died at 4th Facility (79%)

1 returned home & died (4%)1 died at 5th Facility (25%)

1 returned home & died (25%)

1 died at 6th Facility (50%)


Utilization of ANC Services

21

413

46 30 667

4 22

Sub-center PHC CHC District hospital Private Trust hospital More than 1 facility

01%1

11%

216%

325%

3+47%

Site of ANC services taken (n=588)

No. of ANC visits during current pregnancy (n=590)


MDR leading to State Level Actions

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All 26 District Collectors and CDHOs are reviewing all thematernal deaths This has resulted in series of corrective actionsto avert maternal deaths.

Special 4 wheel drive vehicles launched to reach out togeographically difficult terrains(12 vehicles in five districts).

Inter-Facility Transfer (IFT) services launched to address referralservices from one hospital to another further reducingtransportation delays.

Essential drugs required for delivery and management of itscomplications made available in facilities conducting delivery


MDR leading to State Level Actions

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Districts were sensitized and directed to implement use ofpartograph.

Technical Series for capacity building initiated on AcuteManagement of Third Stage of Labor (AMTSL), Use of Partographand Use of Magnesium Sulphate.

Pool of 30 MDR resource persons created at State level. Newer approaches to help to understand why women die:

Confidential Enquiries into Maternal Deaths to be piloted


4 Wheel Drive

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PPP – Chiranjeevi Yojana strengthend

Chiranjeevi YojAna

-Asia Innovation Award (Singapore)

-Prime Minister’s Award for Administrative Excellence April 2009

-Unicef report 2009

Policy InterventionsHigh Priority Talukas

/AreasTribal /Backward /Desert / Saltpan /Coastal

/urban slums

Rational Deployment of HR

Enhance Supportive Supervision

Use of Technology - GIS Mapping,

e-Mamta, m-Health

Integration and Convergence with

Other Departments, NGO, SHG, community participation etc

Life Cycle Approach

High Priority Talukas

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Let us join hands to save our mothers and children.

We make a living by what we get;

We make a life by what we give!

Dr N.B.Dholakia, Department of Health & FW Government of Gujarat, Gandhinagar,Gujarat

9099075152

[email protected]

Project “Ability Gujarat”

Department of Health and Family WelfareGovernment of Gujarat

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What is Disability

A Disability is a functional limitation or restriction of an individual’sability to perform an activity.

Disability includes (As per Gazette of India):1. Locomotors disability2. Low vision3. Blindness4. Hearing impairment5. Mental retardation6. Mental illness7. Multiple Disability


It’s the time for a futuristic approachto empower PwD’s using ICT…….

“Ability Gujarat”

32


Background of the Initiative

Total disabled population in Gujarat (as per census 2011) is 12,68,257

To address this gap, a web based application named “Ability Gujarat”

is developed to allow scientific assessment of disabilities.

The project has been designed to cover the entire state of Gujarat.

The key component of the project is to identify Persons with Disability

(PwDs) and undertake issuance of “Disability Certificates” to the

individuals within a specified time period.

GOALIssue

Certificate to Individual


Ability Gujarat is a web based application. Theobjective of the application isIdentification, Registration and issuance ofDisability Certificate to PwDs (Person withDisability).

The application aims at registering all disabledpeople of Gujarat and creating a centralized datarepository at State level which in turn willstreamline the process of disability assessmentand certification

About the Initiative – Ability Gujarat

Total Registrations done - 4,70,000

Project Conceptualization – Jan 2012

Project Inauguration – 10-July-2012

Total Certificates Issued - 1,00,000


Objective

Short Term Objectives

Creation of a database for PwD’s

Identification, Online Issuance of Certificate to PwD’s

To generate a computerized Database of all persons with Disabilities. (Online Registration of PwD’s)

Long Term Objectives

Creation and regular updation of a comprehensive databank of PwD’s in Gujarat Promotion and prevention of disability to ensure equal opportunities, protection of rights and full

participation To provide Disability Certificate by Web Based Application (e– Certificate for Disability)


Features of Ability Gujarat

Scientific assessment of degree of the disability based on guidelines andformulae.

Generation of a computer based Disability Certificate with unique ID. The database thus generated will be hosted in the Public Domain which

can be accessed online. Query Module will help us to retrieve the information in desired format. Online analytical reports of various parameters related to PwDs can be

generated


Integration with Stakeholders

Health & Family Welfare Department

Social Justice & Empowerment Department

Education Department – Sarva Shiksha Abhiyan

NGO & Community Based Organization

National & State Corporation for Physically Handicapped

Commissioner of Persons with Disability


Transformation Strategy

Persons with Disability (PwDs) can avail the benefits of “Ability Gujarat” project through following work flow :

Action Plan

• Development of Web Application

• Rollout of project & Completion

• Development of Ready Reckoner for MBBS MOs

• Formation of Disability Certification Cell

1 234Fixed time

frame

Micro Plan

Nodal Officer &

State Team

H&FWD

39


Flow of the Project

PwD (Person with Disability) Registration

Physical Assessment

Certificate Issuance / Rejection

1

2

3


PwD Registration Flow

Ways for PwD Registration

Direct Registration using website (Self & NGOs help)

Manual process fill the form and send it via post (disability

cell will enter the data)

Health Workers fill manual form and data entry operators

do the registration

1 2 3

Registration Done, PwD ID generated (FORM I)

Centralized Data Base


Physical Assessment Flow

PwD visits near by PHC, CHC, Health Centre with Form I for Physical Assessment

PwD guided to concerned Specialty Doctor

Doctor performs Physical Assessment and verifies legal documents


Disability Certificate Issuance/Rejection

Once Physical Assessment of PwD is done . The Certificate is either issued or denied

Form 2, 3 & 4 (Obvious & Non-

Obvious)

Form 5 (Rejection)


Inauguration Ceremony

Inaugurated by Hon. Minister of Health and Minister of Social Justice and Empowerment


Inauguration Ceremony

PwD Certificate issued by Hon. Minister of Health and Minister of Social Justice and Empowerment


Monitoring & Supervision

Disability Certification cell at Commissionerate

Respective RDDs (At Regional level)

CDHO,CDMO , Superintendent SDH (At District Level)

BHO (At Block level)


Positive Outcomes

A Centralized database for all PwDs of the State created along with type of

disabilities

Duplication and fraudulent activities have been reduced.

State Disability Cell established to provide value added services to PwDs.

The gap between service providers & those who are in need has reduced due to

better resource mobilization by Health Department

Till Date 4.7 Lakh Registration done with in 1 Year of Short Time till 1st August 2013.


Positive Outcome in Camp

Specially designed query module to identify the location and type of disability of PwDs which makes

it easy to organize camps to maximize Coverage of Certificate issued to PwD’s.


Key Reports

S.No Types of Reports

1 PwD Details - Education Wise

2 PwD Details - Age Wise

3 PwD Details - Employment Status wise

4 PwD Details - Gender Wise

5 Disability Wise PwD Report

6 Report by age, gender and type of Disability Wise

7 Reports of Facility wise Certificate Issued

IMP

IMP


Benefits of Ability Gujarat

Centralized database will be helpful for effective campapproach

Efficient services at hospitals due to digitalization of records Real-time Information about PwDs Easy to avail disability certificate due to Fixed Day and Fixed

time approach Reduced per visit time and Less waiting time for the

certificate Longer life of Disability records Improvement in the quality of life of PwDs


Sustainability

Centralized database which is helpful for effective camp approach.

Efficient services at hospitals due to digitalization of records.

Minimal infrastructure, easy to use software for grass root workers.

Involvement of regular staff from State, district, block and PHC.

Scientific assessment for degree of the disability based on guidelines and

formulae.

The application is on the public as well as government network GSWAN for easy connectivity at all the Government Public Health Institutes.


Application Screen – Home PageStep 1: PwD open our application www.ability.gujarat.gov.in

http://www.ability.gujarat.gov.in/


Application Screen - RegistrationStep 2: After Clicking on Registration link application will show three options to register PwD on “Ability Gujarat” Portal


Application Screen - RegistrationStep 3: Enter Registration details in the PwD Registration Page


Application Generated PwD Certificate


Points that make the project Replicable

The overall process of PwD registration, assessment and issuance of certificate is made

so easy that it can be easily adopted by any State to actually target the PwD population of

the State.

As the approach and methodology adopted for reaching out to the PwDs has been

successful and appreciated by the PwDs and NGOs, the same approach can be replicated

else where.

The application has a robust query / reporting facility which helps in generating statistics

through which State authorities can easily track the PwDs and organize camps with

defined goals.


Summarizing Key BenefitsBefore Ability Gujarat:

non reliability, less effective and lowquality information

After Ability Gujarat Now:Reliable, Accurate, Valid, High Quality,

Effective Useable Information

Information at District Level Information at State Level

Manual Reporting- reliability issue Digital online reporting-Reliable Reports

Paper Certificates issued at District Level Digital certificates on Web Portal -downloadable form.

Data collation from manual records took weeks Real time day to day information-online

Missing MIS : No. of PwD Certificate Issued, Disability type wise ,district and gender wise, age wise counts.

Digitally extracted information- exhaustive MIS with slicing and dicing as per requirement

Beneficiary wise report of services at the State/District level not available-only count

Beneficiary wise Reports digitally be viewed at the State and District level also.

Data on Certificate Issued fits/services rendered not available

Data on certificates issued and Service rendered to beneficiaries available.


District wise online RegistrationsSr No District Name Male Female Eunuch Total

1 Ahmedabad 16969 10461 19 274402 Amreli 10872 8608 9 194893 Anand 14562 9872 66 245004 Banaskantha 8506 4693 24 132235 Bharuch 12657 9195 35 218876 Bhavnagar 21947 10510 6 324637 Dahod 9672 6974 15 166618 Gandhinagar 8042 4700 1 127439 Jamnagar 7384 5008 26 1241810 Junagadh 11749 8414 13 2017611 Kachchh 4588 2763 9 736012 Kheda 15232 8609 9 2385013 Mahesana 8951 3907 1 1285914 Narmada 7511 5409 10 1293015 Navsari 5827 3493 6 932616 Panchmahal 16470 8439 63 2497217 Patan 4754 2897 17 766818 Porbandar 2203 1466 7 367619 Rajkot 16344 11985 43 2837220 Sabarkantha 20614 13401 53 3406821 Surat 21898 10912 14 3282422 Surendranagar 3758 1858 22 563823 Tapi 2617 1808 1 442624 The Dang 943 637 0 158025 Vadodara 18402 11141 72 2961526 Valsad 6735 3965 10 10710

Total 279,207 171,125 551 450,883

Period : 10-07-2012 to 23-07-2013


District wise Disability type report

District Name BlindnessLow

VisionLeprosy

CuredLocomotors

Disability

Hearing & Speech

Impairment

MentalRetardation

Mental Illness

MultipleDisability

Ahmadabad 1261 1055 357 16171 1209 1026 1002 5230Amreli 1286 2461 387 8355 1888 1356 1355 2396Anand 2777 2949 1126 9028 1718 1093 1580 4260Banaskantha 1053 905 155 6521 1161 862 878 1812Bharuch 2031 4509 1221 6966 2769 388 393 2929Bhavnagar 732 927 760 22942 1762 714 3161 1463Dahod 1289 2474 471 7132 2141 1135 1033 1826Gandhinagar 732 856 230 7298 641 731 760 1612Jamnagar 762 825 171 5518 1155 767 1302 1935Junagadh 1421 2673 323 8975 1664 1557 1803 1767Kachchh 717 225 118 3344 720 467 553 1216Kheda 2017 1695 323 11881 1635 600 1619 4172Mahesana 637 298 12 4619 384 288 153 6462Narmada 1382 1407 642 4023 939 109 857 3571Navsari 681 574 754 3740 843 70 882 1997Panchmahal 3463 431 363 14962 2303 838 657 2008Patan 782 1232 154 3477 605 215 509 704Porbandar 244 147 61 1867 247 267 380 462Rajkot 1966 2133 530 13711 2412 1585 2046 4019Sabarkantha 2202 2911 476 16615 2572 2100 2438 4824

Surat 2669 600 324 19680 3376 315 688 5202Surendranagar 526 461 74 2147 589 170 391 1273Tapi 411 261 151 2318 360 3 246 714The Dang 257 188 39 448 148 3 51 446Vadodara 2518 2876 1608 13613 2271 398 1900 4467Valsad 678 910 1153 3348 1055 217 535 2816

Total 34,508 36064 11,977 218,699 36,567 17,274 27,772 68,022

Period : 10-07-2012 to 23-07-2013


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maternal death review – as a tool for system strengthening · health & family welfare dept,...

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