1) The document discusses maternal mortality rates (MMR) in the Bundi and Bikaner districts of Rajasthan, India and initiatives to reduce MMR. 2) It provides data on population, gender ratio, MMR and other health metrics in the districts and analyzes causes of high maternal mortality such as difficult terrain, social customs, and lack of women's empowerment. 3) New initiatives discussed include tracking high risk pregnancies, strengthening primary health facilities, training auxiliary nurse midwives (ANMs), and increasing community participation through programs like SAKHI.

1. Towards Improved Maternal Health
Reducing MMR in Bundi and Bikaner
Arti Dogra
District Collector, Bikaner

2. Mamta’s Story

3. Rajasthan – Bikaner & Bundi
Data Bundi Bikaner
Population 1113725 2367745
MMR `261 263
Gender Ratio 922 903

4. • Difficult terrain prone to drought
• Early marriage
• Dominant feudal system
• Inadequate control over resources for
women
• Low literacy
• Social customs( eating last)
• Under nutrition , high levels of anaemia
Why Maternal Mortality is high

5. Rajasthan Over Time

6. Causes of Maternal Deaths

7. Maternal Deaths
District Population
Crude Birth
Rate (CBR)
2007-09
(Median
2008)
Estimated
births 2007-
09 (Median
2008)
MMR 2007-
09 (Median
2008)
Est MDs
2007-09
(Median
2008)
Avg
Reported
MDs, 2007-
08 to 2009-
10
Crude Birth
Rate (CBR)
2010
Estimated
births 2010
MMR 2010
Est MDs
2010
Reported
MDs, 2010-
11
Bikaner
2,367,745 24.9
58,957
343 202
2
24.6
58,247
263 153 11
Bundi
1,113,725 23.7
26,395
343 91
21
23.3
25,950
261 68 36
Rajasthan 68,621,012 24.7
1,694,939
331
5,610 1,089
24.4 1,674,353 264 4,420 952

8. Reported Maternal Deaths
District
Reported MDs
2007-08
Reported MDs
2008-09
Reported MDs
2009-10
Avg Reported MDs
2007-08 to 2009-10
Reported MDs
2010-11
Reported MDs
2011-12
Reported MDs
2012-13
ikaner
5 0 0
2
11 4 38
undi
23 22 17
21
36 28 16
Rajasthan 1219 987 1062
1,089
952 763 1,116

9. • Implementation of SQRS (Small Query
Reporting System)-Tracking medical activities
through SMS
• Increase the number of health facilities providing
safe delivery and newborn care
• Systematic Improvement in Labour Rooms
• Tracking of High Risk Pregnancies
• Quality improvement of MCHN Days
• Video Conferencing upto PHC Level
New Initiatives

10. Online Reporting through SMS
• Shift from reporting and analysis at the end
of the month to daily reporting
• 1 SMS within 160 characters
• Coverage to all major health related activity
like ANC Registration, Deliveries, OPD-IPD,
Maternal Deaths
• Review every day by CMHO and Block
CMHO

11. • Launched Jan 12th
, 2011
• Divided focus Health
Activities in 10 types of
Coding from R1 to R10.
• District, Block, PHCs &
Sub Center level staff
trained
• PHCs level Monitoring can
be done in real time.
SQRS Implementation

12. Process 101

13. Analysis on Inbound SMS
• Benefits
– Real Time Analysis on activities of
• ANM, MO-IC PHC, CHC, Janana and District Hospital
• Ideal for Collector, CMHO and DPM to have a Bird-Eye-
View on a particular activity
ANC Registration (Jan 01, 11 – Jan 26, 11)
Total No of ANC Registration
Total No of
BPL Registration
Total Amount
Paid to BPL
40 11 5500

14. Analysis on Inbound SMS

15. Benefits
• Real Time Reporting Solution
• Economical Reporting
• Everyday assessment of their own work
• Faster response time during Critical
Situations
• Instant Action on Absenteeism
• Ready tool for inspections and
monitoring

16. Maternal deaths

17. Maternal Deaths
Rajasthan

18. Improvement in Maternal Death
Reporting
• Reporting of maternal death through immediate SMS
• Enquiry of maternal deaths through verbal autopsy
• Block level teams of 3 people including ASHA
facilitators
• Maternal Death Audit in District Health Society
monthly
• Alternative verification

19. • To reduce maternal death (min 8-10%
pregnancies are high risk)
• High risk pregnancies should be identified &
special care , checkup , follow up
• Quality of ANC checkup for high risk lady..
• Identification of institution for safe delivery of
that lady
• Maintenance of HRP Database
High Risk Pregnancy Tracking

20. • Obstetrics Risk factor
– Previous still Birth
– Preterm baby
– Continuous abortion
– C-Section delivery
– Eclmpsia & Pre-eclampsia history
• Medical Risk Factor
– High Blood Pressure
– Heart Disease
– Diabetes
– Epilepsy
– Sever Anemia
• Physical Risk Factor
– Age
– Height
– Cervix and Uterus Problems
– Weight
Factors for detection of High
Risk Pregnancy

21. Implementation Methodology
• Sensitization of ANM, LHV, MO & Program Manager about High Risk
Pregnancy.
• High Risk booklet launched on 20th May 11 by Hon. Health Minister
• High Risk booklet in which all record of High Risk lady is maintained
by ANM.
• 4 ANC checkups are being done for High Risk lady & last checkup is
done by Doctor.
• Awareness to family members of that lady regarding high risk & special
care.
• Review in District Health Society Meeting.

22. High Risk Pregnancy Tracking
• Sensitisation of family
• HRP Circle on the house
• Lists at Gram Panchyat , CHC,PHC
• Referral and check up facility
• Verification

23. High Risk

24. Workload of PBM Hospital
Bikaner, Labour Room

25. Workload in Janana, Bundi
Alternative Needed for Janana Hospital

26. • Increase the number of primary health
facilities providing safe institutional delivery
and new born care in Bundi
• Strengthen the capacity of ANMs to manage
and refer maternal and neo-natal
complications
• Enhance community participation in
improving maternal and new born survival
ASTHA Project - Objectives

27. • Assessed
– Gaps in Labour Room Infrastructure
– Strengthen Human Resource Capacity
– Performance of Facilities
– Practices in labour room
Activities Undertaken

28. • Emphasis on good quality routine antenatal
care
• Training on basics like Delivery care
practices, pre-discharge assessment, quality
ANC.
• SBA re-orientation and training of program
managers , doctors and ANMs
Doctors and Staff Orientation

29. Success Metric Before project started ( on 28 Aug 11)
Facilities functioning 24* 7 6 10
No of ANMs / GNMs posted 39 45
No of ANMs / GNMs provided intensive
5 day training
0 31
No of doctors oriented on quality of
delivery neonatal care
0 24
Number of deliveries conducted in
previous month
277 511
Success @ ASTHA Kendra

30. Post Training Analysis

31. • Safe delivery and newborn care practice
• How to identify and report maternal deaths
• ASHAs have been instructed to report all maternal
deaths in selected blocks on phone
• verbal autopsy technique
• Monitoring High Risk Pregnancies
Asha Training

32. Improved MCHN Day
• Stress on quality ANC
• Tracking Anaemia and Blood Pressure
• Effective training and monitoring
• Identification of transport options and
possible delivery points
• Effective use of Mamta card

33. Video Conference at Health
Facilities
• Micro level monitoring
• Immediate feedback
• Prompt redressal

34. Involving the People
• SAKHI - Special program by student NSS
volunteers
• Two panchayats covered every week.
• Use of traditional music and dialect.
• Involving public represntatives

35. • Quality ANC Checkup
• Regular follow-up is being done by ANM or
Doctor.
• Facility wise interaction and engagement of
referral transport at the village level
• Maintenance of lists at CHC control room and
CMHO office
• Monthly Review at Block level and District Level
• Random checks by SDM and District Collector
Post Programme Analysis