ONE of the achievements of the past half-decade or so – and to a large degree I see this as a tribute to the priorities and political leadership of the United Progressive Alliance (UPA) government – has been the increasing focus and attention being paid to the social sector. Issues of education and health, malnutrition and gender equity, poverty alleviation and infant mortality have increasingly become mainstream concerns. The ministries and departments dealing with them are no more seen as sideshows but have been bolstered by both larger outlays and intellectual capital. In terms of press coverage, the social sector has moved from page nine or twelve to page one, from feature stories to the meat of political reportage.

While this has been a gratifying phenomenon, it has also been immensely humbling. It has forced India to look inwards and scrutinize the contradictions of a society that is, justifiably, proud of its economic achievements, but has failed to solve some very basic problems. Maternal and newborn health (MNH) is one such problem.

I would go to the extent of saying that it is not a stand-alone problem, but a crosscutting one. MNH has implications for so many of our other social sector black holes: (i) Female empowerment; (ii) Poor health indices – inadequate nutrition or congenital afflictions can haunt a child for a lifetime; (iii) Damaging human capital and, therefore, taking away from potential economic gains – children who are deprived of healthy births and infancies, and women who suffer due to inadequate care during pregnancy and childbirth, often develop long-term physical or cognitive problems that constrict their ability to be productive citizens; and (iv) Population control – the certainty of a healthy child and its survival acts as an important incentive for parents to post-pone or decide against having more children

As a person from a political background, I have been no stranger to India’s rural-urban divide and socio-economic inequalities. Yet, I must confess that issues of MNH hit me hard only when I became pregnant and, later, the mother of an infant.

I still remember a particular incident that took place in the early months of my pregnancy, about 30 years ago. I was full of advice from relatives and friends and my doctor on how to take care of myself. I had even begun reading a book on childbirth and managing a new baby. It was, as can be imagined, an exciting moment in my life. It was at this time that I had to travel to a small village in the interior of Tamil Nadu.

 

In the hamlet, I happened to meet members of the community, including a pregnant woman. This was not the purpose of my visit but, given the fact that we were both expectant mothers, I began questioning her about how she was taking care of herself, ensuring nutrition for herself and the baby and whether the family was providing support and had been adequately briefed in terms of her physical needs and emotional and physiological changes.

The conversation – it was actually an impromptu interview – was an eye-opener. Both of us, the lady I was speaking to and me, were carrying but we may as well have been doing so on different planets. Perhaps because I could relate it to my immediate life and my own experience, the incident left me shaken.

In India, the information gap is something we tend to take for granted. We brush it aside as almost a cliché. The lack of information technology (IT) access for so many of our people has been encapsulated into a neat phrase called the ‘digital divide’. Yet, this knowledge gap can determine not just access to jobs or economic opportunities but sometimes a phenomenon much more basic – a chance to stay alive.

Take vaccination, recognized as crucial for saving both a mother and a baby, right from the time a pregnant woman gets her tetanus shot to the immunization programme that the baby is introduced to on day one. A few years ago, public health researchers at Chandigarh’s Post-Graduate Institute of Medical Education and Research studied immunization levels among children in the city’s middle class/urban neighbourhoods and its slums. The results were stunning. More than 80 per cent of urban mothers had immunization cards for their children, but only about 30 per cent of mothers in slums did. In urban areas, not a single child had dropped out of the immunization programme. In slums, over 40 per cent had.

It is obvious which group of mothers and children – from the Chandigarh sample quoted above – had been subjected to a rigorous MNH regimen during pregnancy and childbirth and which ones had not. The lean, scrawny and clearly undernourished woman I had encountered in that village all those years ago was not alone.

 

In 2005-06, the National Family Health Survey provided corroborative evidence of this. Over 80 per cent of mothers with at least 10 years of education had delivered children in a hospital or medical institution. Among illiterate women, institution delivery fell to 19.8 per cent.

Less than 20 per cent of Scheduled Tribe mothers had delivered children in institutions. Among Scheduled Castes, the number rose to 35 per cent and among Other Backward Castes (OBCs) to almost 40 per cent. When it came to mothers from traditionally privileged caste backgrounds, institutional deliveries were opted for by well over 50 per cent.

Institutional delivery is not a magic wand and cannot address all the risks and angularities of MNH. Yet, it is an important touchstone. As such, access to institutional delivery among various socio-economic groups does allow us to map the wider inequities prevalent in India.

 

The most striking indicators of the magnitude of India’s MNH problem are, of course, its maternal and infant mortality rates. One in five of the 600,000 women who die each year due to pregnancy related complications do so in India. So severe is India’s maternal mortality crisis that the organization Human Rights Watch (HRW) characterized it as a human rights issue in a recent report (‘Not Tally of the Anguish: Accountability in Maternal Health Care in India’).

‘In 2005, the last year for which international data is available,’ HRW’s researchers wrote, ‘India’s maternal mortality ratio was 16 times that of Russia, 10 times that of China and four times higher than in Brazil. Of every 70 Indian girls who reach reproductive age, one will eventually die because of pregnancy, childbirth or unsafe abortion, compared to one in 7,300 in the developed world. More will suffer preventable injuries, infections and disabilities, often serious and lasting a lifetime, due to failures in maternal care.’

That ‘one in 70’ figure – computing the likelihood of an adult Indian woman dying due to reasons of pregnancy – is particularly disturbing. In war-torn Lebanon, the figure is one in 290. In Libya, which has a much smaller economy than India’s, it is one in 350. Even in neighbouring Sri Lanka, it is one in 850.

One of the principal motivations of the National Rural Health Mission (NRHM) – inaugurated by the UPA government in 2005 – was to find an answer to maternal mortality. NRHM has met with some success. As per estimates for 2006, India’s maternal mortality ratio – MMR: the number of maternal deaths for every 100,000 live births – had fallen to about 250 from over 300 at the turn of the millennium.

With the NRHM having deepened in the past three years, the actual MMR should be even lower now. However, when this is posited against the Millennium Development Goal of reaching an MMR of a little over 100 by 2015, it is apparent that the journey is still young.

The other key statistical indicator for MNH is infant mortality ratio (IMR) or the number of deaths among children under the age of 12 months in a given year per 1,000 live births. Here too the NRHM and the Union Ministry for Health and Family Welfare have put together robust infrastructure in the past half-decade and this has left its impact.

According to figures released in October 2009, India’s IMR has fallen from 58 to 53 in the past five years. In the period 2004-09, there has been a nine per cent improvement in IMR numbers in rural India and 10 per cent in urban India. This indicates that progress is almost uniform and not skewed in favour of the cities, as so often happens with developmental programmes.

Public health specialists are heartened by achievements in India’s rural areas and attribute this to targeted investments made in the NRHM in the past five years. Outlay has been rewarded with outcome: recruitment of medical staff and community health workers and building of capacities have led to better IMR figures. The role of accredited social health activists (ASHAs) in community mobilization, education and behaviour change has been noteworthy.

 

So often the problem with India is that we are dealing with not one national trend but a variety of regional trends – the proverbial many Indias. This is true for MNH as well. Indeed, there are such massive regional discrepancies. Take the IMR for Chhattisgarh and Madhya Pradesh, two neighbouring states that were only a decade ago part of the same composite province. In 2008, the IMR for Chhattisgarh was 59 per 1,000 live births, but for Madhya Pradesh it was 72.

The maternal mortality graph is similarly uneven. While there has been an impressive all-India improvement between 2003 and 2006, in states such as Haryana and Punjab, the situation has actually worsened. Here, maternal mortality has to be located and contextualized within a singularly patriarchal framework that includes, for instance, the prevalence of female infanticide and the authority of caste panchayats that are male monopolies. Lower maternal mortality, then, becomes not just a health challenge but almost one of social engineering.

 

In a sense, the state that will determine how soon and how urgently India can throw off the spectre of high maternal mortality is Uttar Pradesh. Its MMR is estimated at 440 (2006 figures), the highest for any major state other than Assam. However, given absolute numbers – at 166 million (2001 Census), Uttar Pradesh has more people than any other state – the crisis in the massive province that dominates the northern Indian plains is excruciating.

In Uttar Pradesh, there is a three-sided challenge of physical infrastructure, human resources and political will. According to one estimate, the state has ‘583 fewer community health centres than Indian public health standards require.’ The report ‘No Tally of the Anguish’ had one extremely chilling finding: ‘Staff at community health centres and district hospitals visited by Human Rights Watch in Uttar Pradesh reported referring women with pregnancy complications to facilities at time more than 100 km (60 miles) away for a blood transfusion or caesarean section.’

There is a backdrop to this. For 20 years, Uttar Pradesh has been trapped in a welter of identity politics, with election-time appeals to primordial loyalties and real or imagined historical grievances. Social sector innovations and investments have not been a priority for successive state governments since the 1990s. As a result maternal and infant mortality have fallen through the cracks and become orphan issues.

To change this would require not just building new district hospitals and rural health centres, training more medical service providers and first responders, but also nurturing a new political culture that takes such a grim MNH scenario as an inspiration for determined action. Certainly, the political leaderships that have governed Uttar Pradesh in recent times have a lot to answer for. The NRHM and its modules necessitate perfect coordination between the central and state governments, and here authorities in Lucknow have often been found wanting.

 

The issue of political ownership of MNH – or even of the larger health and social sector matrix – brings us to the compelling reason why politicians and governments can no more ignore it. Indeed, the passion and resolve with which the UPA has embraced these domains have to become the standard for our polity and public discourse. India deserves as much.

This is not just a rhetorical statement but actually one rooted in a new realism. Thirty years ago, it was seen as acceptable for Indians to argue that mothers died due to inadequate care or children fell victim to ailments in infancy because, in a poor country, it was not possible to reach even essential medical care to everybody.

Today, India sees itself as an economic power. It is proud of its state-of-the-art medical facilities and institutions that have made ‘medical tourism’ a booming business, of its vaccine manufacturers who provide safety from measles and hepatitis to children in distant countries. As such, there is something morally disquieting about the fact that thousands of its own citizens, pregnant women, young mothers or vulnerable newborns, are left unprotected against and susceptible to eminently preventable illnesses and predicaments.

Money to build the sinews of a public health system and to eradicate, to the degree possible, a situation where something as beautiful and sacred as a pregnancy becomes a life-threatening gamble is available. India has run out of excuses. It has to deliver to its people.

It would also be prudent to look upon MNH as an economic investment. In the coming decades, India will have the largest population of young people in any single country. This will give it a remarkable ‘workers to dependants’ ratio that can potentially be an economic propellant. Futurists are already calling this India’s demographic dividend, the fact that by 2050 India will have 1.6 billion people and China ‘only’ 1.4 billion.

What will be the nature of this demographic dividend? Will there be a wide variation between the South – by then a mid-level prosperous economy but a greying society – and the North, still fighting inherited social sector challenges and handicapped by an absence of basic healthcare? In many ways, the progress we make on MNH in the next five years will determine the quality of our demographic dividend in the next 50. To my mind, that – more than almost anything else – will be the UPA government’s lasting legacy.