The problem

EVERY minute in our world 380 women become pregnant; 190 women face an unplanned or unwanted pregnancy; 110 women experience a pregnancy-related complication; 40 women have an unsafe abortion; and one woman dies of pregnancy-related complications!

Aseptic delivery (safe birth) should be the right of every woman. Yet, complications of pregnancy and childbirth are the greatest threat to a woman’s life and health in developing countries. Nearly 600,000 women die each year in such circumstances, 99 per cent of the deaths occurring in developing countries.

In India, every five minutes one woman dies from complications related to pregnancy and childbirth. This adds up to a total of 121,000 women per year, or one in five fatalities globally. As it happens, almost all of these deaths can be prevented.¹ 

Causes of maternal deaths in India are similar to those elsewhere and include haemorrhage or bleeding (38 per cent), sepsis (11 per cent), pregnancy-induced high blood pressure disorders (five per cent), obstructed labour (five per cent), abortion (eight per cent) and other conditions (34 per cent).

These deaths are preventable and the interventions are highly cost effective. As per global estimates, basic maternal care can cost as little as US$ 2 per person in developing countries. The total cost of saving a mother or infant through care during pregnancy, delivery and after delivery is approximately US$ 230, while the benefits to the family, to the community and to society at large cannot be measured.² Over one-half of all infant (children under one year) deaths can also be prevented through simple interventions and practices at home.

How does India fare against such challenges? In this country, maternal deaths are as high as 301/100,000 live births and neonatal (a newborn up to first 28 days of life) deaths are 39 for every 1,000 live births. About 65 per cent of all births occur at home, of which more than half are assisted by traditional birth attendants and only less than 18 per cent are assisted by health professionals (NFHS-3, 2005-06).³ Though over the past six years there has been a slow decline in maternal and newborn deaths, greater individual and collective action is required.

In a sense, every pregnancy faces a risk. Fifteen per cent of pregnant women develop life-threatening complications. For every woman who dies, 30 develop lifelong illness and injuries related to pregnancy and childbirth. These long-term disabling illnesses leave a deep impact on the woman and her family.

It is critical that women, their families and their healthcare providers recognize the danger signs in mothers and newborns early and refer them to an institution where they can get appropriate care. These deaths and disabilities can be prevented through primary and simple health and nutrition interventions and use of essential obstetric care.

Reduction of deaths of women has been an area of concern and governments have set time-bound targets:

* In 1994, the International Conference on Population and Development in Cairo recommended reduction in maternal deaths by at least 50 per cent of the 1990 level by the year 2000 and a further half by 2015.

* The Millennium Development Goals (MDGs) set the target of achieving 200 maternal deaths per 100,000 live births by 2007 and 109 per 100,000 live births by 2015.

Within India, there are significant geographical differentials. The Sample Registration System (SRS) 1997-2003 report estimates nearly two-thirds of the maternal deaths in the country are reported to occur in the ‘Empowered Action Group’ (EAG) states (Bihar, Jharkhand, Orissa, Madhya Pradesh, Chhattisgarh, Rajasthan, Uttar Pradesh, Uttarakhand) and in Assam.

The study shows that the maternal mortality ratio was in the vicinity of 400 in 1997-98 but came down to about 300 in 2001-03, thus registering a decline of 24 per cent during this period. The decline is impressive but a lot still needs to be done to achieve the MDG targets.

Progress on priority health outcomes in the country depends to a large extent on advance at the district and state levels. Maternal death is an important indicator of the reach of effective clinical health services to the poor, and is regarded as one of the composite measures to assess a country’s overall progress. For this reason, India’s National Rural Health Mission (NRHM) considers EAG states as focus states.

With its size and diversity, India has wide variations in the status of women. In 2001-03, the lifetime risk of a woman dying as a result of childbirth was 1.8 per cent in the EAG states and Assam, 0.4 per cent in the southern states, and 0.6 per cent in other states. Women with poor nutrition or having anaemia are far more likely to have a poor outcome of their pregnancy – such as having a premature labour and a baby with less than normal weight, bleeding and infections after childbirth. Almost half of Indian women in their reproductive period suffer from anaemia as a result of poor nutrition since childhood and adolescence, compounded by repeated and frequent pregnancies and childbirths.

Also, data on urban deaths suggests that haemorrhage is a much less common cause of maternal death in these settings, reflecting better access to emergency obstetrical care. Low level of education among women increases the risk of maternal death appreciably. Cultural beliefs or a woman’s status in society can prevent a pregnant woman from getting the care she needs. To improve maternal health, gaps in the capacity and quality of health systems and barriers to accessing health services must be identified and tackled.

Safe motherhood is also a matter of newborn and infant survival. Poor maternal health reduces a newborn’s chances of survival. Almost eight million deaths of newborns each year in developing countries can be avoided with improved maternal health, adequate nutrition during pregnancy and appropriate management of deliveries.⁴ These deaths are largely the result of lack of newborn care and caused by the same factors responsible for the death and disability of so many new mothers.

The means to prevent most maternal deaths and disabilities and deaths of infants are well-known, simple and cost little. The single most critical intervention for safe motherhood is to ensure a skilled attendant (doctors, midwives and nurses trained in midwifery and proficient in the skills necessary to manage normal deliveries and identify danger signs and refer complicated cases to a higher level of care) is present and assists every birth.

The government of India has been making efforts to meet the challenge of a rapid reduction in maternal and newborn deaths. The programme on Reproductive and Child Health (RCH) initiated in 1997 is one such effort. It aims to ensure women have access to information and services for reproductive health care.

Under the Janani Suraksha Yojana (JSY), the monetary incentive to women getting institutional deliveries has succeeded in mobilizing women to the hospital for delivery. Even so, the quality of services influencing the pregnancy outcome for the health of the mother and her newborn is debatable. Infrastructure is not prepared for the pressure of increased demand.

How then can India help its most vulnerable citizens, mothers and their newborn children, emerge from this situation? What are the ten things we must know, recognize and internalize?

One, empower women, ensure their choices. Gender inequalities and discrimination limit women’s choices and contribute directly to their ill health and death. Legal reform and community mobilization can help women safeguard their reproductive health by enabling them to understand their needs, and to seek appropriate services with confidence and without delay.

Two, every pregnancy faces risks. Every pregnant woman, even if she is well-nourished and well-educated, can develop sudden, life-threatening complications that require high-quality midwifery care. Attempts to predict these problems have not been successful, since most complications are unexpected.

It is a sobering lesson that a majority of women with poor pregnancy outcomes do not fall into any high-risk category. Hence educating women and their families about easy and simple recommended home care and behaviour, including early identification of danger signs, may be effective in saving lives.

Three, focus on the lack of skilled attendants during childbirth. It is critical to ensure that a health provider with the skills to conduct a safe, normal delivery – and identify and refer complications – is present during childbirth.

Unfortunately, there is a chronic shortage of such providers in poor and rural communities. Research has shown that even trained traditional birth attendants (TBAs) have not significantly reduced a woman’s risk of dying during childbirth, largely because TBAs are unable to identify and refer pregnancy complications.

Four, address the lack of access to quality maternal and newborn health services. A large number of women in developing countries do not have such access and cannot get to or afford quality care. Cultural customs and beliefs also prevent women from understanding the importance of health services and seeking them.

Usually mothers-in-law and/or husbands are the ones to take the decision for the woman. Often these decision-makers do not feel it necessary to have the delivery in a health facility or are unaware of its benefits. Besides, the cost and/or the distance of the health facility may be a limiting factor to access.

Five, safe motherhood is non-negotiable – a matter of social justice and human rights.⁵ Throughout the world women face poverty, discrimination and gender inequalities. These factors contribute to poor reproductive health and unsafe motherhood even before a pregnancy occurs, and make it worse once pregnancy and childbirth have begun.

High levels of maternal mortality are a symptom of the neglect of women’s most fundamental human rights. Such neglect affects most acutely the poor, the disadvantaged and the powerless. Protecting and promoting women’s rights, empowering women to make informed choices and reducing social and economic inequalities are the keys to safe motherhood.

Six, safe motherhood has to be seen as an important socio-economic investment. When a mother dies or is disabled, her children’s health, well-being and survival are threatened. Her family loses her contribution to household management and the care she provides for children and other family members. The economy loses her productivity.

Investments in safe motherhood reduce household poverty, save families and governments the cost of treatment and other services and strengthen the health system. An investment in safe motherhood is an investment in the emotional, physical, social and economic well-being of women, their children, families and communities.

Seven, very young mothers are more likely to die. Adolescent pregnancy is alarmingly common in many countries, including India. Every year young women under the age of 20 give birth to 15 million babies. Girls aged 15-19 are twice as likely to die from childbirth as women in their twenties; those under age 15 are five times as likely to die. Early childbearing is so frequent in India, especially in the EAG states, and carries several health risks. Pregnancy-related complications, it must be noted, are the main cause of death for 15-19 year old girls worldwide.

Eight, deaths from the consequences of unsafe abortions are the most easily preventable. Each year, women around the world experience 75 million unwanted pregnancies. Approximately 50 million unwanted pregnancies are terminated and some 20 million of these are unsafe abortions performed by persons lacking the necessary skills or in an environment lacking the minimal medical standards or both. About 95 per cent of unsafe abortions take place in developing countries, causing deaths of more than 200 women daily.⁶ 

With a simple and cost-effective basket of options of very effective modern methods of contraception to choose from, it is a shame that almost 13 per cent of couples are not able to meet the need of planning their families. Although nearly 60 per cent of women and men around the world now use modern contraceptives, an estimated 350 million couples lack information about contraceptives and access to a full range of methods and services. Between 120 and 150 million married women who want to limit or space future pregnancies are not using a contraceptive method.⁷ 

Nine, many women and newborns do not receive the care they need. Many women in developing countries, including India, do not receive care during pregnancy, almost half give birth without a skilled attendant and the vast majority of women and newborns do not receive any care after delivery.

Many pregnant women do not receive the services because there are no services close to their homes. Distance from available health services, lack of transport and cost of services keep millions of women from seeking care even when complications arise. In addition, health workers often treat women in an insensitive manner and do not pay attention to their concerns and privacy. These negative interactions with health-care providers are also barriers to seeking care. Some women do not use the services because they do not like how the care is provided or because the health services are of poor quality.

Good healthcare during the critical period of labour and delivery is the single most important intervention for preventing maternal and newborn deaths and illnesses.

Care during the 42 days after the delivery, the postpartum period, enables health workers to check that mother and baby are doing well and to detect and manage any problems early. Less than 30 per cent of new mothers and infants in developing countries receive postpartum care. In developed countries, the number is 90 per cent.

Ten, newborns are a part of the mother. Deaths of newborns during the first month of life (neonatal mortality) contribute to more than 60 per cent of infant (child up to one year) deaths and about 40 per cent of under-five death rates in several countries of Southeast Asia. The direct causes of neonatal deaths are neonatal tetanus, sepsis/infections, difficulty in breathing at birth, birth injury, low birth weight/ prematurity and congenital abnormalities.

Except congenital abnormalities, neonatal deaths are quite amenable to reduction since effective and affordable interventions are available. Skilled attendance at birth is strongly associated with lower neonatal deaths. Its maximal influence is in reduction of deaths during the first 24 hours after birth, a period that sees 40 per cent of all neonatal deaths.

Neonatal health and deaths are multi-factorial. Mainstreaming should involve programmes dealing with future mothers (education, empowerment of women, nutrition and socio-economic status), family planning, adolescent health, immunization and child health and development.

Death due to tetanus infection in newborns is decreasing due to improved immunization coverage of pregnant mothers, but it still continues to be a public health problem. The high proportion of home deliveries conducted by untrained traditional birth attendants and relatives or family members is a reflection of the lack of health services and, if present, a poor demand for them.

Moreover, traditional practices like administration of pre-lacteal feeds and late initiation of first breastfeed and colostrum (the initial thick milk), immediate bathing the baby after birth, inconsistent methods of keeping the baby warm and not seeking prompt and appropriate care for the sick baby, especially the girl child, are some social factors adversely influencing newborn survival.

In India, and especially in the state of Uttar Pradesh, delivery is considered to be an unclean process and hence not enough attention is paid to the cleanliness of the place of birth during the delivery process, for cutting the umbilical cord and for its care. All these unhealthy practices leave the mother and newborn susceptible to infection.

The social customs of delaying breastfeeding until some ritual or ceremony celebrating the birth of the baby has been carried out – for instance, on the sixth day of birth – is also harmful. It deprives the baby of the benefits of the colostrum, which protects it from infections, and of the breast milk, which is sufficient nutritional requirement.

During the first six months feeding only breast milk (exclusive breastfeeding) is enough for the baby. Yet, the knowledge of exclusive breastfeeding is low among pregnant women, their mothers-in-law and healthcare providers. Hence, its practice is also low, leaving the baby either undernourished or prone to infection from unnecessary top feeds through the bottle.

In the larger reckoning, the incidence of maternal and newborn deaths is one of the signs of major inequity in the world, reflecting the gap between the rich and the poor. An astonishing 99 per cent of maternal deaths occur in developing countries, where 85 per cent of the population lives. More than half of these deaths occur in Sub-Saharan Africa and a third in South Asia.

In developing countries there are 450 maternal deaths per 100,000 live births, versus nine in developed countries. Because women in developing countries have many pregnancies on average, their lifetime risk more accurately reflects the overall burden of these women. A woman’s lifetime risk of maternal death is one in 7,300 in developed countries compared to one in 75 in developing countries.⁸ 

In addition to the differences between countries, there are also large disparities within countries – between people with high and low incomes and between rural and urban populations.

Why do mothers die? Women die from a wide range of complications in pregnancy, childbirth or the postpartum period. Most of these complications develop because of their pregnant status and some because the pregnancy aggravates an existing disease. Globally, about 80 per cent of maternal deaths are due to causes mentioned earlier.

Among the indirect causes, 20 per cent of maternal deaths are due to diseases that complicate pregnancy or are aggravated by the pregnancy, such as malaria, anemia, and HIV. Women also die of poor health at conception and a lack of adequate care needed for a healthy outcome of pregnancy for themselves and their babies.⁹ 

Most of the maternal and newborn deaths are avoidable and the interventions to save mothers and provide care during pregnancy, child birth and post-partum period are known. Early identification of complications and prompt and appropriate treatment can make the difference between life and death. Pregnant women and their family members, especially women in their homes and community-level health-care providers, should be taught how to identify these danger signs and where to seek appropriate care promptly.

Regular checkups by a trained person at least four times during pregnancy can help identify problems early. Care during labour to identify slow or obstructed progress of labour and prompt referral where operative facilities are available, may save the lives of the mother and her newborn.

Appropriate care for both by the community-level provider after returning home is the final link in the continuum of care and ensuring a healthy outcome of pregnancy. The most important effort will be to let the woman, her family and community be empowered to use safe practices and take appropriate decisions for maternal and newborn health.

This wide spectrum of issues related to ensuring good health of mothers and their newborns is beyond the capacity of any one person or programme. It is a shared enterprise to which all of society must contribute. In a sense, every human birth is a miracle; and a mother and her child are the makers of that miracle. To sustain that miracle and to keep both mother and baby safe is a social obligation. Each one of us has a stake in it.

ANJALI NAYYAR and RASHMI PACHAURI RAJAN

 

Footnotes:

1. Safe Motherhood at Home: Realities, Perspectives and Challenges, A Symposium Report, November 2000, The White Ribbon Alliance for Safe Motherhood/India.

2. Safe Motherhood: Helping to Make Women’s Reproductive Health and Rights a Reality. Inter-agency Group for Safe Motherhood – Family Care International, UNFPA, UNICEF, The World Bank, WHO, IPPF, The Population Council, 2000.

3. National Family Health Survey-3, Volume 1, 2005-06. International Institute for Population Sciences, Mumbai, India.

4. Perinatal Mortality: A Listing of Available Information. WHO, Geneva, 1996.

5. R.J. Cook, Advancing Safe Motherhood Through Human Rights. Presentation at Safe Motherhood Technical Consultation, Sri Lanka, October 1997.

6. Abortion: A Tabulation of Avoidable Data on the Frequency and Mortality of Unsafe Abortion, 3rd edition. WHO, Geneva, 1998.

7. N. Sadik, The State of the World’s Population 1997. UNFPA, New York, 1997.

8. Maternal Mortality in 2005: Estimates developed by WHO, UNICEF, UNFPA and the World Bank, Geneva, World Health Organization, 2007 (http://www.who.int/reproductive-health/publications/maternal_mortality_2005/index.html, accessed August 2008).

9. WHO Report 2005, Make Every Mother and Child Count. World Health Organization, Geneva, 2005 (http://www.who.int/whr/2005/en,accessed August 2008).