Institutional Delivery and Maternal Mortality : How are they related

A Study Says

Increased childbirth at Indian health facilities led to no matching reduction in maternal deaths

To reduce maternal and neo-natal deaths, India launched a cash transfer programme in 2005 that provides monetary incentives for women to give birth in health facilities instead of at home. While the programme successfully increased the use of health facilities for child birth, it did not reduce maternal deaths as much, especially in poor areas. This is according to a doctoral dissertation published at Umeå University.
Doctoral student Bharat Randive at the Department of Public Health and Clinical Medicine found that the so called Janani Suraksha Yojana (JSY) programme successfully increased births at facilities, but due to its implementation in a fragile health system context, it was less effective at reducing fatalities.
“The cash transfer programmes are by themselves inadequate to improve health outcomes,” says Bharat Randive. “While the programme can improve service utilisation, it will not reduce maternal and neo-natal deaths unless the socioeconomic inequalities in access to facility-based care are also addressed and the care is of good quality. Emergency obstetric care, which is essential to save lives of pregnant women and babies, is grossly unavailable at public facilities in the poor states of India that form a global hotspot for avoidable maternal deaths.”
In his research, Bharat Randive looked at nine Indian states and compared access to care and health outcomes in rich and poor areas. The poor areas of these nine less developed states had 135 more maternal deaths for every 100,000 births and the decline in maternal deaths during the programme in these areas was four times slower than in the rich areas.
As all facilities in the JSY programme are not equipped to provide higher level care, obstetric referral services, which are expected to be saving lives of women and newborns, are important for JSY success. However the findings indicate poor quality of referral services. The referrals were associated with higher chances of adverse outcomes at birth and there were a high number of deaths even when women were referred from facilities within the desired two-hour transfer time. At its implementation, key government officials and non-government stakeholders were critical of the appropriateness of the cash transfer programme and highlighted the importance of strong health systems and good quality services for the programme to succeed at reducing mortality.
Bharat Randive lives in Pune, India. In addition to his doctoral studies, Bharat worked as Senior Programme Associate for the MATIND project at R.D. Gardi Medical College in Madhya Pradesh, India.

This is being reported as 

Increased hospital births not reducing maternal deaths in India

Relationship between Institutional Delivery and Maternal Mortality follow Logarithm Scale and not linear scale 

So
Increased childbirth at Indian health facilities led to no matching reduction in maternal deaths

If we increase Institution delivery by 30 % from 20 % to 50 %, MMR will not reduce 30 % from 200 per lakh to 120 per lakh

The reduction will be of course less, but When Institution deliveries are increased to more than 80 %, there will be rapid reduction in MMR

But

That does not mean <<Increased hospital births not reducing maternal deaths in India>>

More Discussion at https://www.facebook.com/spine.brain.surgeon/posts/10153950590544828

Perambalur brings maternal deaths to near-zero

From http://timesofindia.indiatimes.com/city/chennai/Perambalur-brings-maternal-deaths-to-near-zero/articleshow/50544518.cms

CHENNAI: In the hinterland of Tamil Nadu, a doctor-turned collector has achieved something that could turn health policies on their head. Daraz Ahmed's intervention programme has brought down maternal death to near-zero in four years.

The maternal mortality ratio (MMR) in India during 2011-2013 was 167 per 100,000 live births, down from 327 during 1999-2001. In Tamil Nadu, during the same period, it was brought down from 167 to 79, and is believed to be 72 now.

Maternal mortality ratio is the number of women in the 15-49 age group who die from pregnancy-related causes within 42 days of pregnancy termination per 100,000 live births.

For a year since October 2014, Peramabalur registered no maternal death, but this record was broken when a woman died in November 2015 soon after labour. If extrapolated for 100,000 deliveries, Perambalur's MMR will be 10.

Soon after assuming office, Ahmed ensured that all pregnant women with anaemia took iron tablets, and every other woman with highrisk pregnancies underwent caesarean sections. Half the 10,000 deliveries between October 2014 and December 2015 were through C-sections.

Experts feel Perambalur's success can be a case study , but are not sure about its scalability as medical opinion may be divided on elective caesarean, and not everyone may be able to bear the extra cost. "We ask all states to segregate high risk women and do intensive intervention to ensure they have a safe delivery . But it may not be possible to replicate a similar model across the country because most places don't have the resources. In most places, the decision to do a C-section is taken during labour or closer to the due date," said National Rural Health Mission managing director C K Mishra.

Ahmed's measures have achieved quick results. "Maternal deaths are inevitable but our aim is to stop all preventable ones," said Ahmed.

Caesarean section comes with its share of risks -another reason why only 10% of deliveries in the country are such. Ahmed and his team of doctors say they planned C sections when they knew the risks were higher in normal delivery.

"Ours is a small district.Our anganwadi workers and village health nurses know almost every family they work with. They know it when a woman skips her first period.They bring them for antenatal check-up. We identify risks early; for up to 30% of the women we plan a C-section while they are in the second trimester because we know chances of normal delivery are slim. We understand surgeries carry risk, but we have been able to reduce not just risks of surgery but risks of maternal death as well," said Ahmed.

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