WHAT is a greater tragedy than dying while giving life? Yet, an astounding number of women in India die each year due to causes related to pregnancy and childbirth. India has the highest burden of maternal mortality in the world. Of the global toll of 529,000 maternal deaths each year, India accounts for one-fourth (136,000); one woman dies every five minutes! India’s maternal mortality ratio (MMR) of 450¹ per 100,000 live births is fifty times higher than that of many developed countries and several times higher than that of Sri Lanka (58), Malaysia (62), Vietnam (150), and other countries in Asia. In fact, maternal mortality statistics reflect the largest disparity between the developing and developed world of any health indicator; one out of every 17 women in the least developed countries dies from pregnancy and childbirth-related complications, compared to one out of every 4,000 women in developed countries.

One might ask why the maternal mortality ratio has not declined in India? Why has the Maternal and Child Health Programme not been effective even though it was incorporated in India’s first and subsequent five year plans? Strikingly, even today, about 47 per cent of births take place at home and, at best, 39 per cent are assisted by trained health professionals. Why is the programme not making a difference?

The reality is that maternal mortality, a neglected tragedy, affects women who are doubly disadvantaged by both poverty and gender. The causes of maternal mortality are deeply rooted in the adverse social, cultural, political and economic environment that society creates for women. Poor health in women is an outcome of the disadvantage and discrimination that they suffer from birth through childhood, adolescence and adult life. And unless these underlying determinants are addressed, it will not be possible to make a difference. Maternal mortality, however, represents a mere tip of the iceberg. For every woman who dies, many more suffer permanent injury or chronic disability following complications from pregnancy and delivery.

 

Maternal mortality ratio (MMR) reflects a woman’s risk of dying each time she becomes pregnant. The risk is high in developing countries because of women’s poor health during pregnancy and the low quality of obstetric care available to them. Women’s life-time risk of maternal death, which is also affected by the total number of children women bear, is much higher – almost 40 times higher – in the developing than the developed world. Family planning is, therefore, an important part of efforts to improve maternal and child survival. Delaying and spacing births helps women bear children during their healthiest years and enables them to have the desired number of children. Research has shown that babies born less than two years after the next oldest sibling are more than twice as likely to die in the first year as those born after an interval of three years.

Investment in family planning can reap immediate health benefits by preventing as many as one in every three maternal deaths by allowing women to delay motherhood, space births, avoid unintended pregnancies and abortions, and stop childbearing when they have reached their desired family size; save lives of newborns and infants; save adolescent lives by preventing pregnancy during adolescence; and reduce deaths from AIDS by preventing parent-to-child transmission of HIV infection by the correct use of condoms. It is estimated that if women had only the number of pregnancies they wanted and at the intervals they desired, maternal mortality would drop by about one-third. Access to safe and voluntary family planning counselling and services can significantly reduce unintended pregnancies and abortions and, thereby, save women’s lives.

Each year, approximately seven million unwanted pregnancies are terminated in India. Abortion is one of the most easily preventable and treatable causes of maternal mortality. About 12 per cent of maternal deaths are due to unsafe abortion which also results in morbidity, chronic disability and sterility. Expanding family planning services is an important strategy for decreasing pregnancy-related mortality and morbidity. However, even with vigorous family planning programmes, there will always be some unwanted pregnancies and, therefore, a demand for abortion. High levels of maternal mortality associated with clandestine, unsafe abortions can be prevented by enhancing women’s access to safe abortion services. Yet, the vast majority of abortions in India are unsafe despite the fact that abortion was legalized in the country more than 30 years ago.

 

There is clear evidence that health problems that begin in childhood and adolescence affect the health status of women during their reproductive years and also impact on the health of their newborns. Discrimination against the girl child can significantly retard her growth and development. The long-term negative impacts of childhood malnutrition are well-known. Stunted women are at a higher risk of obstructed labour, an important cause of maternal mortality. Millions of girls in India are undernourished and enter their reproductive years anemic. Anemia lowers their capacity for physical work and their ability to cope with infection. Maternal mortality is significantly higher in women who are anemic. Interventions to reduce malnutrition, especially anemia, must, therefore, begin long before girls reach reproductive age.

In India, girls marry and get pregnant at very young ages. Early pregnancy can set into motion an intergenerational cycle of ill health and growth failure because infants born to adolescent mothers are more likely to have a low birth weight, be premature, injured at birth, or stillborn. In India, even today 46 per cent of girls are married before 18 years (the legal age of marriage) and 33 per cent of first order births take place in adolescents. After marriage, a girl must prove her fertility as soon as possible by bearing a child, preferably a son. Research worldwide has established that early and closely spaced childbearing increase the risk of dying for both the mother and the child. When age at marriage increases and childbearing is delayed, there is a dual benefit with improvements in the health and survival of women and children coupled with significant reductions in fertility.

 

Malnutrition plays a major underlying role. Even today more than half of Indian women are anemic during pregnancy. The impact of malnutrition is reflected in maternal undernutrition including anemia, high prevalence of low birth weight and high levels of stunting. Anemia is an important underlying cause of maternal mortality. Malnutrition is associated with more than 50 per cent of childhood deaths and directly affects the severity of diseases such as measles and diarrhea.

There are important linkages between maternal and infant mortality. In India, two-thirds of deaths among infants occur in the first month of life, the neonatal period. Each year, 20 per cent of the world’s infants (26 million) are born in India; 1.2 million die before completing the first four weeks of life, a figure amounting to 30 per cent of the 3.9 million neonatal deaths worldwide. The current neonatal mortality rate of 44 per 1,000 live births accounts for nearly two-thirds of all infant mortality and half of under-five child mortality in India. Over one-third of all neonatal deaths occur on the first day of life, almost half within three days, and nearly three-fourths in the first week of life. These deaths are largely the result of the same factors that cause the death and disability of their mothers – poor health, undernutrition, inadequate health care, and poor hygiene and management of delivery as well as lack of newborn care.

 

The irony is that maternal and neonatal deaths are preventable and treatable. The major causes of morbidity and mortality are well-known and many proven life-saving interventions exist. Saving these lives does not require extraordinary interventions or technology. Interventions to prevent maternal and neonatal deaths have been successfully implemented in both developed and developing countries. Then why is this problem so difficult to address in India?

The importance of promoting safe motherhood in the developing world was recognized by the global community many decades ago. Voices to save mothers’ lives were first raised at the Conference on Safe Motherhood in Nairobi in 1987. Advocates for safe motherhood clearly articulated that maternal deaths are preventable and that it is the responsibility of national governments to prevent this tragic loss of life. Strong arguments were made to generate the political will to prevent poor women from dying due to pregnancy-related causes.

However, it was only when reduction of maternal mortality was included among the Millennium Development Goals in 2000 that serious efforts began to be made by the international community to save women’s lives in developing countries where 99 per cent of all maternal deaths take place. Today, there is, perhaps for the first time, a real outcry to lower maternal mortality. But the problem is that little has been done to strengthen health service systems in many developing countries and so women do not have access to quality services.

 

To reduce maternal mortality, every woman must have access to a skilled birth attendant even if she delivers at home. But should life-threatening complications arise, she should be able to reach a referral facility in time. Referral facilities should be well-equipped and have qualified staff to manage complications. All pregnant women, by virtue of their pregnant status, face some level of risk. Research shows that around 40 per cent have some complication and about 15 per cent need obstetric care to manage complications that are potentially life-threatening to mother or infant.

Such complications are often sudden in onset and unpredictable. In these cases, essential emergency obstetric care must be available to save the woman’s life. Emergency obstetric care must be available in institutions that have the equipment, supplies and qualified and trained staff to undertake immediate surgical interventions if needed. Time too is of the essence because delay in reaching a facility and in receiving emergency care can result in the loss of a life. Not only is the mother’s life likely to be endangered but the life of the newborn is also at risk.

In India, birth is believed to be a normal event that does not require medical intervention. Poor women, especially in rural areas, fear hospitals. They have family and social support at home and see no benefit in incurring transportation and other costs to give birth in health facilities. There are ample data that document the poor quality of services provided in government health facilities. The rude behaviour of service providers, the lack of equipment and drugs at these facilities, and unaffordable costs (in supposedly ‘free’ government institutions) are serious deterrents.

According to the National Family Health Survey-3, in 2005-2006, two out of five births in India took place in institutions; 51 per cent of women received antenatal care at least three times during pregnancy but only 56 per cent received antenatal care during the first trimester of pregnancy. National-level statistics mask significant differentials between urban and rural areas as well as between regions and states. There are also significant differentials by socio-economic status. In 2005-2006, no more than 31 per cent of all rural births in India were conducted in institutions; 39 per cent were delivered by trained birth attendants. In Kerala and Tamil Nadu, 99 and 86 per cent of births, respectively took place in institutions. In Uttar Pradesh, on the other hand, only 22 per cent of the women delivered their last child in an institutional setting.

 

In 2005-2006, only 36 per cent of the mothers received a postnatal check-up within two days of birth as recommended; most women received no postnatal care. Yet, the majority of maternal deaths take place during the postnatal period. A meta-analysis summarizing the global literature shows that more than 60 per cent of maternal deaths occur in the postpartum period; 45 per cent occur within one day of delivery, more than 65 per cent within a week, and more than 80 per cent within two weeks. In developing countries, 80 per cent of postpartum deaths caused by obstetric factors occur within one week. Thus, the first 24 hours and the first week are high-risk periods, and the risk remains significant until the second week after delivery.

 

Since most deaths occur in the postpartum period and life-threatening complications cannot be predicted, encouraging institutional delivery has begun to be seen as an important strategy for preventing maternal and neonatal mortality. In response, a nationwide programme, the Janani Suraksha Yojana, was launched in April 2005 to reduce maternal and infant mortality. This programme encourages institutional delivery so that women can receive care during delivery and the postpartum period.

Under this programme, in low performing states, all pregnant women, irrespective of parity and economic status, who undergo institutional delivery in a government health facility or an accredited private facility are given Rs 1,400 in rural areas and Rs 1,000 in urban areas. Additionally, accredited social health activists (ASHAs) who assist pregnant women in accessing maternal health services are provided an incentive amount of Rs 600 and Rs 200 in rural and urban areas, respectively. In high performing states in contrast, the programme is restricted to women who have two live births, women who are 19 years or older and women from families registered as below the poverty line. In both low and high performing states, poor pregnant women, aged 19 years and above, who prefer to deliver at home are entitled to cash assistance of Rs 500 per delivery for upto two live births.

ASHAs serve as the link between the health service system and the pregnant women. They are entrusted with a number of responsibilities including registering pregnant women and ensuring that they receive antenatal care. They are expected to develop micro birth plans, ensure that women are transported to referral government or accredited private facilities for delivery, provide postnatal care to the mother, and care to her newborn child.

In just two years, between 2006-07 and 2007-08, programme beneficiaries are estimated to have doubled; 55.7 lakh women benefited from the programme during 2007-08 compared to 27.6 lakh in 2006-7. Expenditure increased, correspondingly, from Rs 258.22 crore in 2006-07 to Rs 754.2 crore in 2007-08. Evaluations of this programme suggest that it has indeed succeeded in increasing the number of institutional deliveries and use of antenatal care services in some states.

In the few years separating 2002-2004 and 2007-2008, just before and after the programme’s 2005 launch, the proportion of deliveries taking place in health care institutions increased dramatically in Madhya Pradesh (from 29% to 47%), Rajasthan (from 30% to 46%) and Andhra Pradesh (from 59% to 72%). In these three states, the proportion of mothers participating in the programme as of 2007-2008 stood at one-quarter (Andhra Pradesh) to one-third (Madhya Pradesh and Rajasthan). Thus, there has been a significant increase in institutional deliveries, especially among poor women who rarely gave birth at a facility before.

 

However, little is known about the programme’s quality of care. Women are going for institutional deliveries in large numbers but hospitals and health centres are poorly equipped to take on the increased demand for services. Consequently, women are discharged too soon after delivery and do not receive care during the postnatal period when maternal and neonatal death rates are the highest. Is the programme then achieving its intended objectives? This experience underscores that there are fundamental problems related to the health service system. These range from basic issues of inadequate space and poor sanitation to a lack of trained manpower and inadequate equipment and supplies for managing deliveries and providing emergency obstetric care. These systemic problems must be urgently addressed.

 

Several issues regarding the disbursement of funds are also emerging. India has had long years of experience with family planning incentives and targets which skewed and distorted the data and were eventually discontinued because they were found to be counter-productive. There are lessons to be drawn from the family planning programme experience of the 1970s and 1980s. Some of those lessons may be useful in the design and implementation of Janani Suraksha Yojana so that heavy investments that are being made do, in fact, yield the desired benefits.

The role gender plays deserves special mention. There are large numbers of ‘missing girls’ in India. There has been a sharp decline of 35 points in the child sex ratio for girls between the 1981 and the 2001 Census. While neonatal and infant mortality rates in boys and girls favour girls or are comparable, the child mortality rate is significantly higher for girls. This is a reflection of the status society affords to women. There is strong son preference with concomitant neglect of girls at the household, community and societal levels. These inequities continue throughout women’s lives. Gender interplays with caste, class, religion, age, geographical location economic and health status to further intensify womens’ vulnerability.

In recent years, India has begun to witness a feminization of the HIV epidemic. New infections are increasingly occurring in women with a corresponding increase in parent-to-child transmission of infection. While there are proven interventions, the national programme for the prevention of parent-to-child transmission (PPTCT) initiated in 2000 has yet to be scaled up to cover 156 priority districts that have more than one per cent HIV prevalence among women receiving antenatal care. If pregnant women are to be provided with both reproductive health and HIV and AIDS services, there is a clear need to coordinate efforts being made by the National AIDS Control Organization (NACO) and the Reproductive and Child Health (RCH) Programme included under the National Rural Health Mission (NRHM).

 

While the needless suffering and death of a woman when giving life to the next generation is sufficient cause for action in itself, there are also other significant social and economic costs. When a woman dies, her family and community are considerably affected in economic and social terms. Reproductive health programmes, including maternal health, are among the most cost-effective investments in health. Providing women in low-income countries with care during pregnancy, delivery and after birth, as well as postpartum family planning and neonatal care would cost about $3 each year per person. Basic antenatal, delivery and postpartum care alone can cost as little as $2 per person. Therefore, even in resource poor settings, improving maternal health is possible. What is needed is strong political commitment and a reallocation of resources.

Making safe motherhood a reality for women is a challenge that calls for a reconceptualization of the problem and its solution. Significant changes must be made in the way maternal health care is provided and the priorities that national governments and donors accord to this programme. While organizing quality services that are accessible to poor women is important, it is not sufficient. Safe motherhood will not be achieved until women are empowered and their human rights – including their rights to quality services and information during and after pregnancy and childbirth – are realized.

 

Safe motherhood is non-negotiable. It should be redefined as a human rights issue. It must be defined as a social injustice that reflects society’s failure to value and protect women. Women should not die just because they are women! The government must be made accountable. It must recognize and acknowledge its responsibility for providing special care that women need, starting from birth, continuing through childhood and adolescence, as well as during pregnancy and childbirth.

Defining maternal death as a ‘social injustice’ as well as a ‘health disadvantage’ would obligate the government to address the causes of poor maternal health through its political, health and legal systems. India is committed to achieving the millennium development goals by the year 2015. A country that can now compete economically and technologically with the most developed nations in the world must certainly ensure that it also achieves these important social goals. It must put in place the health infrastructure and the systems that are necessary for ensuring the prevention of death and disability among women and children.

 

Footnote:

1. For 2005-2006, MMR ranged from the Government of India’s estimate of 301 to the World Health Organization’s estimate of 450.