India has taken several big strides over the past decade to reduce maternal mortality. The results are beginning to show. A decade ago, close to 75,000 women died every year during child birth or due to pregnancy-related causes. By 2010, this number had fallen to 50,000. The country’s maternal mortality ratio fell from 301 per 100,000 live births in 2003 to 212 in 2009. The pace is gaining momentum, but is it enough to reach the United Nations Millennium Development Goal of 109 by 2015? The chances are good, provided the State makes a special effort to reach disadvantaged communities.
The National Rural Health Mission (NRHM) and the Janani Suraksha Yojana (JSY) have contributed positively in improving the reach of healthcare to women. According to the 2009 Coverage Evaluation Survey, nearly three out of four births were taking place in institutions — up from less than 40% in 2005-06. More than two-thirds (69%) of pregnant women received at least three antenatal checkups, and around 90% received more than two tetanus toxoid injections.
Despite the overall progress, wide disparities and inequities in women’s access to healthcare continue to persist. Sadly, access to health services still depends upon where one lives, how educated one is, how rich one is, and to which community one belongs. For instance, as against the national average of 73% of women who gave birth in institutions, the proportion was 54% among women who had no education, 55% among women belonging to the lowest wealth quintile, 57% among Scheduled Tribes, and 68% among rural women.
Those of us working in the field know that the poorest among women, those belonging to Scheduled Castes and Scheduled Tribes in many parts of the country have still to be brought into the fold of an inclusive healthcare system. For example, 26 maternal deaths took place in the Barwani district hospital in Madhya Pradesh over a period of eight months in 2010. Tragically, 21 of these 26 women belonged to Scheduled Tribes. Even more alarming is that an enquiry commissioned by the government found all the 26 maternal deaths to be avoidable.
The Population Foundation of India, supported by the United Nations Population Fund (UNFPA), the Woodrow Wilson International Center for Scholars and the Maternal Health Task Force, recently convened around 70 leading development practitioners and public health experts for a consultation on maternal health. Participants included SK Sikdar, Abhay Bang, Sharad Iyengar, K Srinath Reddy, AK Shiva Kumar, Gita Sen, H Sudershan and Leela Visaria.
Seven strong conclusions emerged from the deliberations. One, we must recognise maternal morbidity as a serious health issue. For each woman who dies, an estimated 20 more suffer from infection, injury and disability during pregnancy and childbirth. Some women die, while for others, life is a living death experience. These complications range from fistula, uterine prolapse, painful sexual intercourse, reproductive tract damage and infections, anaemia and even infertility. Maternal morbidity, like maternal mortality, can be easily prevented.
Two, we must integrate maternal health, reproductive health and family planning — now delivered as vertical programmes — into a universal health coverage plan that recognises woman’s health as a basic right. For example, anaemia among girls needs to be addressed at a younger age. Waiting till they are pregnant and then treating them for the condition may be too late. Similarly, a substantial number of maternal deaths can be prevented by merely meeting the unmet need for family planning and providing access to safe abortion services. The government of India has taken a right step by announcing a comprehensive strategy on reproductive, newborn, child and adolescent health (RMNCH+A).
Three, we must focus on the marginalised. Within an overall framework of universal health coverage, the State needs to adopt special and differentiated strategies to reach women in remote rural areas, those belonging to tribal communities, and the more disadvantaged groups in society.
Four, we must improve the quality of care by putting in place adequate guidelines, protocols, checklists and introducing a system of accreditation for facilities and services for both the public and private sector. Five, address the shortage of human resources. Despite the more than 10-fold increase in institutional births over the past five years, there has not been a matching increase in staff strength. Skills of field functionaries such as auxiliary nurse and midwives (ANMs) have been lost as they have been instructed not to conduct deliveries. Many healthcare providers trained in the Indian systems of medicine fail to recognise clinical symptoms of an obstetric emergency.
Six, ensure greater accountability from the highest level instead of holding the frontline health worker or the Accredited Social Health Activist (ASHA) responsible. A greater involvement of the communities in monitoring the health services, which has begun under the NRHM, needs scaling up with adequate budget allocation. Seven, gaps in knowledge must be addressed. Better monitoring and evaluation systems need to be introduced. A community perspective should be brought into the assessment of service delivery. A robust methodology should be developed for measuring morbidity and collecting real time data. More regular studies on maternal mortality and morbidity should be planned.
The last mile is always the most exhausting, exasperating and difficult to cover. The State needs to give a big push to maternal health.
Poonam Muttreja is Executive Director, Population Foundation of India
The views expressed by the author are personal