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Detecting the high-risk mother
" A billboard by Shivpuri district administration cautioning against under-age marriages. Shivpuri is Madhya Pradesh is one among the 15 districts implementing MAPEDIR "

By Patralekha Chatterjee

Shivpuri, Madhya Pradesh:  In Madhya Pradesh, the number of mothers who had at least 3 antenatal care visits prior to their delivery has increased from 27.1 percent in 1998-99 to 40.2 percent in 2005-06, according to the preliminary findings of latest National Family Health Survey.

For pregnant women in the villages of this vast, sprawling, picturesque state in central India, however, there is a reality beyond numbers. At 379 per 100,000 live births, the maternal mortality ratio in the state remains among the highest in the country.

Shivpuri and Guna are the two districts in Madhya Pradesh piloting MAPEDIR (Maternal and Perinatal Death Inquiry & Response). In Shivpuri, a recent collective brainstorming session of MAPEDIR interviewers helped dispelled many myths and provided important insights into how best to detect the ‘high-risk’ mother in time.

54 maternal deaths were investigated till February 2007 from various blocks in Shivpuri as part of the ongoing MAPEDIR. The preliminary analysis of the data is throwing up new, interesting findings that can be used as local evidence to spur district-level action.   
A common misconception: only those women who had multiple pregnancies were “high risk”. But while sharing their experiences, public health nurses, ANMs, lady health visitors and NGO field staff who are tracking maternal deaths in the district discovered that even those who had had just one child or were expecting their first child could be potentially at high risk of maternal death due to sudden complications. 

 “For us, the biggest lesson is not to fall into the trap of preconceived notions. For example, the MAPEDIR data shows that accessing antenatal care is no guarantee against maternal death.  More than 80 percent of the maternal deaths that have been investigated in the district show that the dead women had accessed antenatal care in some form.  Most of the deaths in the district are taking place within 24 hours of delivery underscoring the need to also strengthen  post natal care,” says Rajesh Srivastav, an UNICEF field operative in Shivpuri.

An important issue is the quality of antenatal and post natal care and not the number of checkups, points out the team of interviewers tracking maternal deaths in Shivpuri. “Today, typically, ANC care consists of a weight check, tetanus toxoid injections and distribution of iron folic tablets. The blood pressure of the expecting woman is not taken. Nor are haemoglobin tests conducted to detect the extent of anemia during routine ANC check ups. There are other practical problems on the ground -- village women are resistant to undergoing urine tests, or carrying urine samples to a health centre. That combined with the lack of a proper place to conduct all necessary tests for a pregnant woman tells you something about how overstretched we are,” says Usha Joshi, an auxiliary nurse-midwife (ANM) and one among the team of trained MAPEDIR interviewers in the district.

“What is urgently needed is a village level motivator across the district – someone who can constantly monitor a pregnant woman’s state of health, alert health workers in case of potential complications. In places where “ASHAS” or such village-level motivators have been recruited, trained and are functioning effectively, there is tangible progress. But every village in Shivpuri does not have an ASHA (accredited social health activist) as of now. The newly recruited ASHAS are yet to be fully accepted by the communities. In such villages where illiteracy, superstition and lack of awareness are high, more women are at high risk of maternal death. The good news is that MAPEDIR is bringing to light many of these issues and strengthening the maternal death reporting system and health services for mothers,” adds Joshi.

This initiative is part of the UNICEF Maternal Mortality Advocacy Project funded by United Kingdom’s Department for International Development (DFID).

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