INDIA grapples with public health issues and problems that often transcend the ability of local communities to find a remedy. Preventable maternal mortality¹ and morbidity is a public health emergency. Every five minutes somewhere across the country, one woman dies from pregnancy and childbirth related complications (close to 80,000 a year, and possibly around 20 to 30 times that figure suffer ill health and near misses). 60 per cent of all maternal deaths occur during, or soon after delivery, but only one woman in six receives postnatal care. These deaths are almost wholly preventable.

For every 1000 live births, like brief candles, the lives of 39 neonates (less than 28 day old newborn infants) are snuffed out because skilled care was unavailable at the critical time. This is particularly unacceptable since simple, cost effective measures for nurturing neonates are available.² There is no effective, reliable and comprehensive civil registration system for accurately reporting births and deaths; so women are dying in childbirth and during pregnancy, mostly unnoticed, in a nation largely unconcerned. As many of these deaths are not registered, they remain uncounted and unreported. No one recalls a single riot anywhere in the country simply because one more woman has demised in a community health centre during childbirth. Yet, strikes for higher emoluments by sundry constituencies get prime coverage in the print and electronic media! The age profile of women who have died in maternal deaths across India (Table 1) only confirms that this is nothing short of a scandal.

During the 1990s, the maternal mortality ratio (MMR)³ hovered between 540 and 570 maternal deaths for every 100,000 live deliveries. In the current decade, India’s MMR at 254⁴ (SRS 2006) has improved significantly from 301⁵ (SRS 2003). Though infant mortality rate (IMR)⁶ at 55 (SRS 2007) has improved from 60 (SRS 2003), all India averages camouflage the striking and serious inter-state diversities.⁷

Typically, a maternal death marks a tragic ending of an already complex story operating at different levels – individual, household, community and health system, with different elements – socio-economic, cultural and medical. In these circumstances we need to comprehend more clearly both the proximate and the root causes of maternal deaths (Table 2).

The National Population Policy 2000, India, states that ‘maternal mortality is not merely a health disadvantage. It is a matter of social injustice.’ Gita Sen cautions that since the rate of maternal deaths has fallen only 1% a year over the period 1990-2005 ‘tackling these (the root causes) may well require sustained policy effort over generations.’⁸

 

Maternal and Newborn Health (MNH) has moved up in our public health policy agenda. The NRHM (April 2005) not only sets out MNH as a priority concern, it has secured huge resources and has got going on the ground. There are great expectations from the NRHM. Reports from Common Review Missions and rapid assessment studies indicate that numerous interventions are gaining visibility, although the ground reality does not appear to be wholly encouraging with respect to maternal and neonatal well-being.

Programmes and projects that deliver maternal and neonatal health services are neither designed nor delivered in a coordinated manner. We are not handling maternal well-being along a continuum of four inextricably, inter-dependant stages: (i) pre-conception – girls and young women need education, nutrition, good health and counselling on how to negotiate their own decisions, as well as information about the options available to prevent unwanted births; (ii) pregnancy – women need at least four antenatal consultations and examination by a competent health professional, appropriately qualified for the task in hand, as well as support from family members; (iii) delivery or abortion – during this intranatal stage, women need a skilled birth attendant, and referrals to more specialized health services in the event of complications; (iv) post-partum care when the health of both mother and infant are fragile and need monitoring and supervision, with counsellling on family planning and breastfeeding.

There is a different requirement at each stage, and we need integrated strategies to provide a continuum of care. The NRHM programme on maternal health continues to focus on institutional delivery without adequately strengthening each individual intervention or knitting these interventions together to implement a continuum of care through the prenatal, antenatal, intranatal and the postnatal stages.

 

There is a crippling crisis in the availability of appropriately trained human resources for the tasks in hand. Mistakes have been made in the past. Over the years there have been policy shifts in respect of the core competencies of health professionals made available closest to household levels. The Auxiliary Nurse Midwife was initially recruited as a temporary worker (from among local women with a primary education), and trained for a short period before being assigned to health sub-centres for specific duties, to function under supervision. The Mudaliar Committee (1961) recommended that the ANM be continued as an auxiliary cadre in frontline facilities, as a community based health professional focusing on maternal and child health. The Kartar Singh Committee (1975), expanded the role of the ANM into a multipurpose health worker. She commenced looking after primary health care, including disease control.

 

A second policy change followed in 1977 wherein maternal and child health (MCH) was integrated into family planning to become family welfare. This had major repercussions because simultaneously, as if on cue, the Indian Nursing Council (INC) reduced the ANM training course from a duration of 24 months to 18 months. By 1995, the technical supervision being earlier provided by the ANM had significantly declined. In lieu of skill upgradation, and continual refresher training for the ANM, what we saw in the field was that over time these policy shifts brought about a huge deterioration in the practice and training of the ANM’s midwifery skills. By the 1980s, the community perception of ANMs changed from MCH care providers to family planning and immunization workers.

Below the ANM, the Trained Birth Attendants (TBAs) learnt on the job as it were. They were not put through rigorous, formal and standardized training. Retraining them now is not going to make any material difference to maternal mortality. The WHO has repeatedly cautioned that it is only a skilled birth attendant (SBA) present during childbirth, who can address the wide array of complications. A skilled birth attendant is a midwife, nurse, nurse-midwife or doctor who has undergone a prescribed course and is registered or legally licensed to practice. This excludes traditional birth attendants (TBAs), even if trained. The fact is that out there in the field neither the ANM nor the TBA, nor the medical officer is a skilled birth attendant in the strict sense of the word.

 

The ASHA⁹ recruited under the NRHM is not intended to fulfil this function. She cannot, by any yardstick, stand in for a qualified, skilled MCH¹⁰ community worker. Our medical education is also not equipping fresh graduates for public health in general, and for maternal and child health care in particular. In these circumstances, the government must without delay put in place a community midwife cadre. Our frontline health infrastructure cannot handle an additional 27-28 million deliveries a year, and an exclusive focus on institutional deliveries for routine, non-EmOC childbirth may not be the panacea we are looking for.

Current field reports convey the impressive increase in institutional deliveries, but also draw attention to the appalling quality of care being dispensed to pregnant women, which could well be instrumental in turning them away from undertaking the tedious, uncertain, and sometimes humiliating trek to the institutional facility. Across the country, pregnant women and their gatekeepers are crying out for safe birthing facilities, closer home.

 

There have been recurrent health system failures, with accountability deficits all the way through. The fact is that without a functioning health system that minimally includes an adequate supply of drugs for obstetric first aid, emergency obstetric care, and referral systems, even a skilled birth attendant can do little. A policy shift in the implementation of abortion now allows termination of pregnancy up to 49 days, and comprehensive safe abortion guidelines stand finalized. However, the 6th Joint Review Mission (ending May 2009), and led by Ministry of Health and Family Welfare, has reported that drugs prescribed through the public procurement system for use during abortion are found unavailable.

Emergency transport and communication are vital for any emergency health service. Somehow, these matters were left to state governments, and even where ambulances are purchased by states, their maintenance and management is grossly neglected. In early 2008 in Uttar Pradesh, 45 per cent CHCs did not have the funds to operate the one ambulance they had. Table 3 indicates availability of emergency services across key states in late 2008.

Blood banking services are a vital but neglected and wholly underfunded area. A 1996 Supreme Court judgement mandated stringent infrastructure requirements for licensing blood banks. While this improved blood safety, it depleted the availability of blood for medical emergencies across rural India. In 2001, the central government modified policy to allow blood storage facilities in First Referral Units. However, even now, many comprehensive EmOC centres are not connected to blood banks. In obstetric emergencies while blood is free, patients have to pay the processing charges, and this itself becomes a barrier. Poor women refrain from accessing blood when they need it most, in an emergency.

 

Neonatal care was not recognized as a public health issue for a long time, and wholly inadequate attention was paid to it in both maternal and child health programmes. Consequently, at ground levels, low skilled birth attendance and negligible postnatal care have been major weaknesses. The 6th Joint Review Mission led by Ministry of Health and Family Welfare (May-July 2009) has reported that a programme for essential newborn care has been initiated, although the overall policy, operational plans and revised guidelines have not been disseminated for newborn care such as for resuscitation, management of sick newborns and appropriate use of equipment like baby warmers, weighing machines etc.

The role of the ASHA in facilitating newborn care in the postnatal period is not clearly defined, inclusive of monitoring breastfeeding during and after discharge from hospital. Standard protocols are not in place for providing in-patient care for sick infants/children, such as those with severe diarrhoea and pneumonia. With the exception of Madhya Pradesh, Gujarat and Maharashtra, and despite high levels of malnutrition, services for management of severely malnourished children do not exist. The utilization of facilities for sick children is not monitored. The fact remains that the best institutional delivery may fail to save the mother and newborn unless they are skilfully cared for in the immediate postnatal period (24-72 hours).

 

Let us now turn to steps that will promote issues related to successful implementation, and more sustainable outcomes.

1. Focus on the three critical strategies for reducing maternal and neonatal mortality: better access to skilled birth attendants, emergency obstetric care reasonably close at hand, and improved referral systems. There are no shortcuts to this roadmap.

2. Comprehend that access to MNH services is as much determined by physical and operational access, as by availability of information, financial costs and the quality of these services. The government must very quickly develop, field-test and then mandate for regular monitoring a basket of indicators covering the most critical social determinants of health care and policy barriers (like ANMs not being allowed to use oxytocin till policy was modified), taking care that with reference to specific jurisdictions, the indicators must include measures of availability, access, service use, outcome and impact (with reference to specific jurisdictions like a block, a district, etc).

3. Require that health care providers, public and private, report all pregnancy related deaths, including that of neonates. Make maternal death investigation a mandatory component of the NRHM, include these in the annual state project implementation plans, and integrate the findings from maternal death investigation into state policy and planning under the NRHM. Before the start of the financial year 2010-11, issue guidelines for investigating maternal deaths investigation, which could inter alia, identify health system shortcomings in addressing both the socio-economic and medical causes of maternal deaths, as well as that of underlying determinants like nutrition. The ‘Maternal and Perinatal Death Inquiry and Response’ (MAPEDIR) across districts with high MMR and IMR is a good beginning.

 

Institute social audits to ensure continuous public vigilance, because social audits serve to supplement administrative monitoring. Bring centre-stage the social audit of every maternal and perinatal death. Train sarpanches to do social audit, and then review the findings through gram sabhas. This will eventually assist in the forward movement from paid health workers to community level pressure groups, and help sustain the changes coming about on the ground.

4. Continually upgrade and certify on priority basis, within each district, a reasonable number of geographically well distributed comprehensive obstetric care facilities, highly visible and easily accessible by all, on an equal basis.

5. Implement the civil registration system. The NRHM could, along with panchayati raj institutions, partner with the home departments of state governments to see this through.

6. Continually upgrade interventions at programme level to plug accountability deficits: (i) Deposit the incentive money, wherever feasible, directly into the beneficiary held post office/bank accounts, in order to pre-empt the diversion of these resources to unauthorized end users. An additional 45 million households have been brought within the purview of the banking system/post office deposits (through the NREGA). (ii) Disburse the incentive money to the ASHA only after she has facilitated the administration of BCG vaccine to the newborn, and also ensured registration of birth.

7. Expand the continuum of care to enforce the Child Marriage Act 2006, and make registration of marriage compulsory. Disseminate aggressively appropriate messages for young women/their elders/their peer groups through gram sabhas over community radio and via the vernacular print and electronic media. Educate them about the vicious cycle of illiteracy and early marriages and how this girl child, not yet fully grown, is unprepared to stumble into childbearing, unspaced pregnancies, and low birth-weight, chronically malnourished babies, among whom a large proportion will remain stunted and wasted.

 

Disseminate through these messages the lifelong benefits of basic schooling, organize distance learning if necessary, and skill building for every daughter and daughter-in-law within a village, and then reward consistency and achievement with a guarantee of wage employment. Success on this front will sustainably liberate women from repeatedly producing malnourished children in favour of having fewer and healthier infants, which in turn, will enable mother and children to access higher social and economic opportunity.

8. Install early response mechanisms in addition to a grievance redressal ombudsman to enhance accountability. Women have complaints and concerns about the treatment they receive at health care facilities. They have no avenues to turn to. First, install an emergency telephone helpline which is accessible to rural women with little or no formal education, and which will be responded to 24/7, around the clock, with instantaneous interventions to avert preventable maternal deaths, and/or distress. Obstacles do arise, such as a woman facing an obstetric emergency is refused admission into a health facility; meets with improper demands for payment as a condition for delivery of supposedly free health care services; encounters closed government health facilities; absentee doctors; and unavailable medicines. These matters will all come into the public domain, and immediately alert the authorities.

 

On a more permanent footing, it is entirely feasible to set up a regional investigative authority such as an ombudsman to enquire into complaints. This nuanced health intervention will very quickly boost consumer confidence, improve trust in the health system, hold to account those responsible for violations, will prevent repetition of the same behaviour in future, and act as a deterrent against possible backsliding.

9. Address the crisis in human resources by calling upon practitioners in the non-government and private corporate sectors to loan their skills and services to government health centres for two days every month for remuneration at public sector levels. The success of the Chiranjeevi Scheme across Gujarat is one model.

10. Finally, involve the gram panchayats for tracking unreached households for maintaining oversight over health facilities and frontline workers.

 

Footnotes:

1. Maternal mortality refers to women who died for reasons attributable to pregnancy, childbirth, and within six weeks of delivery.

2. Neonatal mortality refers to newborns who die within the first twenty eight days.

3. MMR refers to the number of women who die for reasons attributable to pregnancy and childbirth within six weeks after delivery.

4. SRS 2006 (Sample Registration Survey conducted by the Office of Registrar General of India).

5. SRS 2003.

6. Infant Mortality Rate refers to the number of infant deaths (under one year of age), per 1000 live births.

7. IMR refers to the number of children who die within the first year of life.

8. Gita Sen (2008), 10th Annual Sol Levine Lecture on Society and Health, Harvard School of Public Health, published in Social Science and Medicine 69(7), October 2009.

9. Accredited Social Health Activist.

10. Maternal and Child Health.

 

References:

Registrar General of India, GOI, ‘Special Bulletin on Maternal Mortality in India, 2004-06’, April 2009.

Registrar General of India and Centre for Global Health Research, ‘Maternal Mortality in India 1997-2003: Trends, Causes and Risk Factors’, 2006.

World Health Organization, ‘National Level Monitoring of the Achievement of Universal Access to Reproductive Health: Conceptual and Practical Considerations and Related Indicators’, 2008.

WHO, ‘Operationalizing the Neonatal Health Care Strategy in South-East Asia Region’, June 2006.

‘Maternal Mortality: Who, When, Where and Why’, The Lancet, September 2006.

‘NRHM: Sprint, Marathon or Stroll’, Yojana, October 2009.

Ministry of Health and Family Welfare, GOI, ‘India: Partnership for Population Stabilization’, 2009.

Ministry of Health and Family Welfare, GOI, ‘Janani Suraksha Yojana: Guidelines for Implementation’.

Population Foundation of India, ‘Infant and Child Mortality in India: District Level Estimates’, May 2008.

Human Rights Watch, ‘No Tally of the Anguish’, October 2009.

Benita Sharma and Aruna Kanchi, ‘Effective Use of Gender Responsive Budgeting (GRB) Tools and Strategies in the Context of Aid Effectiveness Agenda: India Country Report’, 2007.

Jansankhya Sthirata Kosh (National Population Stabilisation Fund), ‘Population Stabilization in India: Where Are We?’, June 2009.

UNICEF, ‘Maternal and Perinatal Death Inquiry and Response’.

‘Reproductive Health in China: Improve the Means to the End’, The Lancet, November 2008.

International Centre for Diarrhoeal Disease Research, Bangladesh, ‘Maternal Health Situation in India: A Case Study’, April 2009.