State Capability Enhancement Framework in Practice: How WKH is reducing MMR
Meghalaya’s West Khasi Hills district, one of the remotest districts in the state, had been recording one of the highest instances of maternal deaths between the year 2020-2021 among 11 other districts. As per the State HMIS data (Figure 1), between January to August 2020, the district recorded 15 maternal deaths and the number subsequently increased to 18 recorded maternal deaths between January to August 2021. It was observed that merely targeting clinical dimensions for saving lives of high risk pregnant women was not enough to address the systemic challenges underlying the maternal deaths.
As part of building State Capability to tackle this challenge, targeted interventions under Rescue Mission were initiated in May 2020. Reproductive, maternal, neonatal, child and adolescent health reviews have been taking place on a weekly basis with all the districts. The intent was to analyze the existing maternal and child health scenario in all districts and to diagnose the underlying problems contributing to high MMR and IMR. They were also aimed at breaking down the psychological barrier among district health teams by creating a dedicated platform for regular iterations, and to eventually increase reporting of maternal and infant death cases, without fear of facing penalties.
Problem diagnosis through the SCEF Approach
“Following the dedicated review meetings, we learnt that several factors contributed to the maternal deaths in our district. Some important factors involved late registration for AnteNatal Checkups (ANC), multigravida, teenage pregnancies, delay in detection of pregnancy related danger signs, bad condition of roads and uneven distribution of health facilities often located very far from villages, among other issues”. – Dr. Rapborlang Laloo, District Maternal and Child Health Officer, West Khasi Hills District, Meghalaya
The regular maternal death audits revealed that almost 70 per cent of maternal deaths were attributed to PostPartum Hemorrhage leading to excessive bleeding and eventual death of the mothers after delivery. Following this revelation, the district initiated the distribution of a tablets to even the community members, while educating them on its use and dosage. This greatly helped to reduce the instances of maternal deaths, as per information received from the District MCH Officer.
It was seen that each of these factors required targeted intervention, and more so, a collaborative approach. A major deliverable needed to bring down the maternal deaths identified by the district team was to ensure that preventable deaths should be avoided. For the purpose, the following steps were taken:
- Mass mobilization of the Community and gaining their support.
- Regular Follow-Up of pregnant mothers by AWW and ASHAs.
- Inter-departmental Convergence where the issue of MMR was viewed as not only the responsibility of the Health Department, but also the Social Welfare and Community & Rural Development Departments.
- Personal visits to pregnant women by Health Supervisors, with a focus on mandatory visits to check on High Risk Pregnant Women.
- Providing access to health care services by promoting Health Sub-Centres to delivery points.
- Co-opting Traditional Birth Attendants (TBAs) into the health systems by training them in identifying danger signs and encouraging them to refer high risk pregnant women to health facilities.
- Providing more access to contraception and safe abortion services to prevent unwanted pregnancies (especially Teenage pregnancies, women with complications etc.).
- In 2021, the district witnessed a sharp increase in the number of maternal deaths. This was when the need for intensive review meetings with the ANMs was realized.
Another major factor that aided in bringing down the district maternal deaths was operationalising the sub centers. Out of the 46 sub-centres in the district, only 12 were conducting the deliveries at the facilities. As of now, out of the 46 sub centers, 35 have begun performing institutional deliveries.
The Result
Following the above mentioned interventions, between the years 2021-2022, the district maternal deaths went down drastically, as seen from (Figure1) above. The district team intensified the quarterly review meetings with ANMs. The result was that not only was there a visible decline in maternal mortality but the full immunization coverage in the district also improved. Community ownership and inter-sectoral convergence helped to improve the health seeking behavior of the community. Intensive support from line departments including the social welfare and community & rural development departments furthermore helped to improve the health indicators.
“Frequent supportive supervision, analysis of feedback provided by the frontline workers and action taken by the district motivated the frontline health care workers. Sharing of responsibility across all cadres of the workforce and inter departmental convergence created a sense of ownership amongst the healthcare providers towards achieving a common objective.”– Dr. Rapborlang Laloo, District Maternal and Child Health Officer, West Khasi Hills District, Meghalaya.
