Birth is by far the greatest joy for a family. In India, especially in rural areas, the flowering of this joy is largely dependent on the timely availability of high quality obstetric and newborn care services. Ensuring this is a huge challenge for the country.
One state that has led the nation in building a strong foundation of public health services is Tamil Nadu. In rural areas, it has extended health services successfully through a network of District and Taluk level hospitals, Primary Health Centers and Health Sub-Centers.
Tamil Nadu has also been a trendsetter in the provision of maternal and neonatal care. The state has made major progress in improving maternal and child health (MCH) outcomes. According to the most recent National Family Health Survey (NFHS-3) carried out in 2005-2006, there has been 35 percent reduction in the Infant Mortality Rate (IMR) from 48 deaths per 1,000 in 1999 to 31 deaths in 1,000 live births in 2006 although additional efforts are needed to bring Tamil Nadu’s IMR closer to its better-performing neighbors, such as Sri Lanka (IMR 18.8/1,000) and the state of Kerala (IMR is 14/1,000).
These improvements are in part due to a significant increase in overall vaccination coverage of children between 12 and 23 months. The overall nutrition status of children under age 3 has also improved, with an 18 percent reduction in underweight children.
Maternal and infant health in Tamil Nadu
Despite the fact that the state’s Maternal Mortality Ratio (MMR) continues to be 25 times higher than in developed countries, according to the Sample Registration System, MMR has decreased from 167 deaths per 100,000 live births in 1999 to 111 deaths per 100,000 live births in 2006.
All roads point to a new sunrise on Tamil Nadu’s rural horizon called CEmONC – The Comprehensive Emergency Obstetric & Newborn Care Services initiative.
Launched in the year 2004 under the World Bank supported Tamil Nadu Health Systems Project (TNHSP), and implemented in three phases, CEmONC is a landmark initiative that aims at providing every kind of maternal and newborn care, responding to all emergency situations at any time, on any day. At least two hospitals in each district have been fully equipped to function as CEmONC Centers. The commitment is to ensure a level of access, facilities and expertise that will prevent any maternal or neonatal death.
"We have been working on the issue of maternal death for almost 15 years now. We felt that the issue had to be transported from the private domain to the public. That it should no longer be considered a private tragedy but a public scandal. That is what we set about doing. We said, let us look at what causes maternal death and how can we prevent it," said Sheela Rani Chunkath former-Health Secretary, Government of Tamil Nadu and currently, Chairman & MD, Tamil Nadu Industrial Investment Corporation Limited.
The answer that emerged was that there were three kinds of delays which prevented pregnant rural women from receiving the timely treatment they needed in an emergency situation.
"The maternal death review gave a lot of information about the various delays. Delays at the family level, delays in getting the transport and delays in getting care at the facility level," said Dr. Padmanabhan, former Deputy Director, Reproductive and Child Health, Department of Health and Family Welfare, Government of Tamil Nadu.
Making a success of CEmONC
CEmONC provides a comprehensive solution to all these delays. To reduce the first delay, pregnant women and their family members continue to be sensitized to the advantages of institutional delivery, facilities available, need for regular antenatal checkups and early admission in case of emergency. More than 99.5 percent of deliveries in the state now take place in medical institutions.
For the second delay-lack of transport-the answer is the anytime any place ambulance service of the National Rural Health Mission which functions all over the state and can be summoned by dialing 108. Using this service, a woman anywhere in the state can reach a CEmONC center within half an hour.
"We have linked up the CEmONC services with the 108 emergency services – the emergency ambulance services which would take the pregnant mother in complicated labor to the nearest CEmONC center," said Dr Vijayakumar, Project Director of the Tamil Nadu Health Systems Project.
Besides the ambulance service, the core components of a CEmONC Centre, all of them fully equipped, well-maintained and open 24 hours, are – Obstetric and Pediatric Casualty; Operation theatre; Labor ward; antenatal, post natal and post operative wards; blood bank; neonatal ICU; lab, diagnostic and scan facilities. To maintain high standards of hygiene and stem the spread of infection, an effective system of color-coded bins has been put in place for management of bio-medical waste.
Adequate numbers of staff-specialists, nurses and paramedics-have been posted to the centers and trained in all CEmONC procedures.
"TNHSP has been instrumental in establishing a network of specialist emergency obstetric and neonatal care cen¬ters which service the entire population of the state. Beyond service delivery, the CEmONCs have institutionalized standardized human resource compliment; skill upgradation methodologies; excellent quality of care; data systems; and monitoring and evaluation mechanisms. This entire package has been catalytic in the enthusiastic uptake of CEmONC services by all representative populations in the state-especially the vulnerable groups," said Preeti Kudesia, Senior Public Health Specialist, World Bank and former Task Team Leader of TNHSP.
For a mother-to-be, institutional care begins with antenatal registration and check-ups at the nearest Health Sub Centre, Primary Health Centre or hospital. PHC and HSC staff are trained to handle normal deliveries and in early recognition of complications for early referral to a CEmONC center.
"Pregnant women come for ANC from 12th week of pregnancy, with one check-up every month. I deliver babies day or night. I have all the facilities here and can do normal deliveries. If there is a problem, I refer the case to the Medical Officer. If it cannot be handled at the PHC, then they call 108 and refer it to a CEmONC," said K.B. Kalaiarasi, Village Health Nurse, Health Sub Center.
With the patient on the way, the trained technician in the ambulance informs the CEmONC center of the case details, blood group and expected time of arrival. This is why the center is ready to receive the patient for immediate care, to the level of emergency surgery, if needed.
CEmONC Centers provide special care to HIV positive mothers, working with the Prevention of Parent to Child Transmission Program. Couples are counseled on the need to test for HIV, delivery in hospital and safety precautions.
"It is only because of all the counseling that I had my baby safely. Otherwise, I was thinking, I don’t want this baby…It was their treatment and counseling that comforted me and gave me the confidence that I could have my baby and make sure that he did not get HIV. I owe it all to the people here," said an HIVpositive mother.
The concerted effort to take CEmONC to vulnerable and isolated communities has resulted in a significant rise in the number of scheduled caste and scheduled tribe women availing of the 108 ambulance service and opting for institutional delivery.
From 66 in 2004, the number of designated CEmONC Centers will soon reach the target figure of 125. There will then be one CEmONC center for every 5 lakh population in the state. And the maximum time taken for a woman in labor to reach the nearest center will decrease – from half an hour to 15 minutes. Quality of CEmONC service is maintained through a rigorous certification process for each center, repeated every two years.
Cardiovascular Diseases Prevention and Treatment
Another major pilot intervention under this Project has been the prevention and treatment of cardiovascular diseases known as CVD. The crude mortality death rate due to cardiovascular diseases in Tamil Nadu is the highest in the country. A pilot project was carried out in two blocks in the districts of Sivaganga and Virudhunagar in Tamil Nadu between 2007 and 2009. The aim was to create awareness of the risk factors relating to cardiovascular diseases and an early detection and treatment of hypertension. Any person above the age of 30 years is screened for hypertension in the primary health center or a general hospital in these two districts.
Result: The awareness about CVD among the communities in the two districts has increased dramatically. More new cases being detected early, is a positive development for the community – it means that combative measures can be followed early-on. Plans are afoot to scale up this program to other districts in a phased manner.
Health Management Information Systems
Hospital Management Systems (HMS) is another important aspect of this Project. It helps to streamline the functioning of the hospital by automating processes and aiding proper management of data. All activities like registration of the patient to preparation of discharge summary, including online entry of diagnosis and prescription by the doctor as well as maintenance of drug inventory in pharmacies are managed through the HMS. Forty one hospitals across five districts are currently linked with the online system. Real time data is available 24x7 at these 41 hospitals.