Registration of Subject For

PROFORMA

REGISTRATION OF SUBJECT FOR

DISSERTATION

MS PYNHUNLANG KHARSATI

I YEAR M.Sc. NURSING

OBSTETRICAL AND GYNAECOLOGICAL NURSING

YEAR 2013-2015.

PADMASHREE COLLEGE OF NURSING

GURUKRUPA LAYOUT, NAGARBHAVI

BANGALORE-560072.

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

6. BRIEF RESUME OF THE INTENDED WORK

6.1 INTRODUCTION :

We need nothing less than a revolution in our attitudes towards conception, pregnancy, birth and parenting. ~Sophie Style

Pregnancy is special--let's make it safe" is the slogan of the 1998 World Health Day.

Evidence-based maternity care means practices that have been shown by the highest quality, most current medical evidence to be most beneficial to mothers and babies (reducing incidences of injuries, complications, and death), with care tailored to the individual. 1

Midwives continue to be members of a highly skilled workforce with the scope to provide world-class maternity care from the provision of direct care through to Board level contributions. Midwives are the lead professional for all healthy women with straightforward pregnancies. For women with complex pregnancies they will work as the key coordinator of care within the multidisciplinary team, liaising closely with obstetricians, general practitioners, health visitors/public health practitioners and maternity support workers/maternity care assistants and social care contexts. They have the capacity to initiate and to respond to change. Midwives embrace a greater public health role. Midwives continue to provide the majority of care to pregnant women and therefore will maintain and develop their competence and are champions of care in the hospital and community. increased focus on social models of care with women and families' needs at the very heart of midwifery and maternity care. Midwives deliver innovative evidence-based, cost-effective, quality care across integrated health when appropriate, consults where necessary and manages a woman’s health and social needs.

A midwife’s focus is to enable all women and their families to have a positive and safe experience of pregnancy, birth and early parenting. A social model of maternity care where women, rather than the organisation, are at the centre is a key feature of midwifery care .One-to-one support in established labour results in better outcomes for women and this is a key role of the midwife. 2

No mother, anywhere in the world, should have to risk her life and that of her baby by going through childbirth without expert care. But every year 48 million women give birth without someone present who has recognised midwifery skills. More than 2 million women give birth completely alone, without even a friend or relative present to help them, making these some of the most dangerous moments of their livesNo mother, anywhere in the world, should have to risk her life and that of her baby bygoing through childbirth without expert care. But every year 48 million women give birth without someone present who has recognised midwifery skills.More than 2 million women give birth completely alone, without even a friend or relative present to help them, making these some of the most dangerous moments of their lives. 3

Every mother will remember the feelings of anticipation, excitement, fear and joy she had before she gave birth. Everyone can imagine what a pregnant woman – a friend, a sister, a wife or partner – will go through as she approaches one of the most significant moments of her life. Now imagine giving birth without anyone in the room with any midwifery training – it can become a dangerous event. No mother, anywhere in the world, should have to risk her life and that of her baby by going through childbirth without expert care, but every year 48 million women give birth without someone with the proper medical skills present. Each year there are 358,000 maternal deaths, and 814,000 newborn babies die during childbirth. A million more babies are lost earlier in delivery – stillborn but having been alive in the mother’s wombhours or even just minutes earlier.More than 3 million babies die before they are amonth old.Complications that kill hundreds of thousands of women and babies in developing countries are managed effectively in richer countries by a midwife or health worker with the right skills, the right equipment and the support of a health system. Women in the poorest countries are least likely to have a skilled attendant during birth, are much more likely to lose their newborn, and are most likely to die themselves during childbirth.3

6.2 NEED FOR THE STUDY :

Half a million women die each year around the world in pregnancy. It's not biology that kills them so much as neglect.

Nicholas D. Kristof

MATERNAL HEALTH

Maternal mortality and morbidity and perinatal mortality are major public health problems in India. It has long been recognized that majority of perinatal deaths have intrapartum origin and result as a consequence of interventions carried out around the time of delivery. 4

Recent decades have seen a rapid expansion in the development and use of a range of practices designed to start, augment, accelerate, regulate or monitor the physiological process of labour, with the aim of improving outcomes for mothers and babies, and sometimes of rationalising work patterns in institutional birth. In the last few decades, questions are increasingly raised to the value or desirability of such high levels of intervention. In 1996, a technical working group of the World Health Organization (WHO) made a number of recommendations based on a similar range of practices. Cochrane Collaboration uses scientific methods to determine which practices, drugs or procedures are best for treating diseases. It also examines practices during labor and delivery and examines which practices are best for women and newborns. Reproductive health library has compiled evidence on most of these practices. As a result of this research on evidence based care, modern labor and delivery care has undergone some dramatic changes over the last couple of decades. 4

In 2005, Government of India developed guidelines for doctors and ANMs/ LHVs on care during antenatal period, labour and delivery and postpartum period. These guidelines are in accordance with evidence based practices. Despite this, and despite the rapidly increased emphasis on the use of evidence-based medicine, many of these practices remain common, without due consideration of their value to women or their newborns. Many providers continue to use a range of unhelpful, untimely, inappropriate and/or unnecessary interventions, all too frequently poorly evaluated. 4

This guideline aims to examine the evidence for or against some of the commonest practices and to establish recommendations, based on the best available evidence. This guideline gives recommendations on those interventions which are or should be used to support the processes of normal birth. There are many variations across institutions in the quality of care, the sophistication of services available and the status of the provider for normal birth. 4

This guideline examines the evidence for 8 key practices in labour-delivery care:

1. Augmentation of labour

2. Routine episiotomy

3. 24 hour discharge

4. Active management of third stage of labor (AMTSL)

5. Monitoring of labour and partograph

6. Position for delivery

7. Breastfeeding < 1 hour

8. Drying & wrapping of newborn 4

Women die as a result of complications during and following pregnancy and childbirth. Most of these complications develop during pregnancy. Other complications may exist before pregnancy but are worsened during pregnancy. The major complications that account for 80% of all maternal deaths are, severe bleeding (mostly bleeding after childbirth), infections (usually after childbirth), high blood pressure during pregnancy (pre-eclampsia and eclampsia) and unsafe abortion,Every day, approximately 800 women die from preventable causes related to pregnancy and childbirth. 5

99% of all maternal deaths occur in developing countries. 5

Maternal mortality is higher in women living in rural areas and among poorer communities. Skilled care before, during and after childbirth can save the lives of women and newborn babies. 5

Safe motherhood goes beyond individual women, but it also has a communal and public health goal. The survival and well-being of mothers and children is central to family and community life and social flourishing. Reducing maternal mortality is an attainable goal for countries around the world. Statistics show that among the women who die of pregnancy related causes, 25% of the women die during pregnancy, 16% die during delivery and 61% die after delivery, with most of these deaths occurring within one week. Hence in total, about 75 % of all maternal deaths are those, associated directly or indirectly with some sort of health care facility. Delivery and the week immediately after, is the most critical stage for every pregnancy, and this is the stage where quality of care available does matter. 2

Of the 8.1 million children who die each year before the age of five, one in ten dies

during their birth and does not live to see the end of their first day. To stop this appalling suffering the world needs more midwives and skilled birth attendants so every woman and her baby are given the care and support they need. No child is born to die Midwives and skilled birth attendants play a vital role in saving the lives of mothers and babies. The International Confederation of Midwives (ICM) defines a midwife as“a person who having been regularly admitted to a midwifery educational programme, duly recognized in the country in which it is located, has successfully completed the prescribed course of studies in midwifery and has acquired the requisite qualifications to be registered and/or legally licensed to practice midwifery ”.A skilled birth attendant is an “accredited health professional, such as a midwife, doctor or nurse, who has been…trained to proficiency in the skills needed to manage normal, uncomplicated pregnancies, childbirth and the immediate postnatal period, and in the identification, management and referral of complications in women and newborns”. Midwives are the only people in a health service whose education and training are dedicated to the care of pregnant women, new mothers and their newborn babies. The ideal is for every birth to be attended by a certified midwife, because in an under-staffed, over-stretched health service a health worker with a wider remit is more likely to have competing demands from other patients and less time to dedicate to mothers and newborn babies. However, the significant contribution that skilled birth attendants make to saving the lives of mothers and babies must be recognized. Midwives and skilled birth attendants cannot operate effectively in isolation. 3

Globally:

WHO adopted the Millennium Development Goals in 2000 and one of the goals is to reduce the maternal mortality ratio by three quarters between 1990 and 2015 and to achieve, by 2015, universal access to reproductive health. To meet the goal, WHO promotes skilled care at every birth and has developed training for midwives.

Maternal mortality ratio (MMR) is defined as the death of a woman while pregnant or within 42 days of termination of pregnancy and is received by dividing the number of maternal deaths per 100 000 live birth Every year, nearly 600 000 women worldwide between the age of 15 and 49 die due to complications from pregnancy and childbirth and 99 percent of the maternal deaths occur in developing countries. It is estimated that up to 80 percent of these deaths are possible to prevent. In developing countries the MMR varies between 240 and 730 depending on the region and the numbers are twenty times higher than in developed countries where 8-17 maternal deaths occur per 100 000 live births. 6

The life time risk of dying from pregnancy related complications for a woman in developing countries is one in 75 compared to one in 7 300 in developed countries. 6

In India :

India is likely to miss the Millennium Development Goal (MDG) related to maternal health as one maternal death is being reported every 10 minutes in the country now.
India recorded around 57,000 maternal deaths in 2010, which translate into a whopping six every hour and one every 10 minutes, UN data in this regard says.
The current Maternal Mortality Rate (MMR) of India is 212 per one lakh live births, whereas the country`s MDG in this respect is 109 per one lakh live births by 2015.
The MMR challenge for India was highlighted at the launch of the Millennium Development Goals Report of the UN Secretary General. The 2012 report, which assesses the regional progress on eight MDGs the world promised to meet, states that although progress has been made on improvements in maternal health, actual targets remain far from sight. India has reduced MMR significantly from 437 per one lakh live births in 1999 to 212 now, but needs to hasten the pace under National Rural Health Mission to achieve related MDG.The MDG Report 2012 points out that an estimated 2,87,000 maternal deaths occurred in 2010 worldwide. This represents a decline of 47 per cent from 1990 when the MDGs were set."Of the total maternal death burden worldwide, the sub- Saharan Africa accounts for 56 per cent and South Asia accounts for 29 per cent. Together the two regions made up for 85 per cent of the global maternal death burden in 2010.. As per the latest MMEIG (Maternal Mortality Estimation Inter-Agency Group-WHO,UNICEF,UNFPA, World Bank) report titled “Trends in Maternal Mortality: 1990 to 2010” India is ranked 126 out of 180 countries when countries are arranged in ascending order of MMR.About half of the total maternal deaths occur because of hemorrhage and sepsis. A large number of deaths are preventable through safe deliveries and adequate maternal care. 7

KARNATAKA:

While its three southern neighbours have managed to lower the maternal mortality rate, Karnataka has struggled to bring it down below 150 per 1,00,000, according to the latest data. The sample registration system (SRS) data for 2007-09 has revealed that MMR –the number of women between 18 and 49 dying due to maternal causes—has remained 178 for 1,00,000 cases in Karnataka. Though numbers have actually fallen from 213 during 2004-06, MMR in Karnataka is still the highest amongst the three southern states of Andra Pradesh, Tamil Nadu and Kerala that respectively registered 134,97and81 cases during the same period. 8