THE 2009 State of World Children (Unicef) reminds us of the grim reality in South Asia. An overwhelming proportion of deliveries are conducted at home and that too not by a skilled personnel. In this region, unlike China which stands out, the Indian picture is not only dismal but downright embarrassing. This is mainly because health sector reforms in the country have not yet paid adequate attention to the need for trained midwives who can serve women in rural areas.

The hard reality is that we need thousands of trained midwives in our villages and cities, in slums and hamlets. If we cannot get doctors to serve in rural areas, maybe the only way out is to create a cadre of well-trained nurse midwives who could provide services and even set up private practice in rural areas. If we are serious about expanding the pool of trained midwives, then we have no alternative but to fix our elementary and secondary education system and ensure that more girls from all areas, especially rural and tribal areas, complete secondary education, make sure schools offer biology and science and, above all, that they are taught regularly and get a real opportunity to learn.

For almost thirty years now women’s health advocates and concerned public health professionals have argued that there is no magic technological fix that can reduce maternal mortality. We need more providers closer to women – that’s the bottom line. Yes, a complex range of societal, systemic and attitudinal issues frame women’s ability to access maternal healthcare services – as illustrated in the table below.

As a start we need to acknowledge that the healthcare system cannot fix structural inequalities that are prevalent in our society and the economy. We are also aware that it is unrealistic to expect healthcare service providers to become social activists. But it is possible to ensure that there are trained service providers who are sensitive to the predicament of poor women, that services are available within accessible distance (both physical as well as social), and that women are treated with dignity, care and kindness when they approach a health facility or a service provider.

What then should be the priorities of a maternal health programme? The starting point is to ask whether everyone, right from the medical officer to the health secretary in GOI, has a shared understanding of the goals of the maternal and child health programme. This is important because the larger vision gets fragmented into ‘tasks’ and ‘outputs’ as communicated down the line. As a result, not everyone is aware of the larger policy context and why the government decided on specific programmes or projects. The larger goal of reaching an essential package of services (maternal and child health, contraception and management of related diseases) to the poor and the vulnerable is often missed out. Articulating and communicating the larger goal and vision of the programme, enabling workers at all levels to identify what they can do and what they are expected to do towards achievement of the larger goal, is the first step.

 

There is one issue on which most practitioners agree, i.e., we cannot turn the entire system around in one go. While the larger goal is important and has to be kept in mind, it is important to set intermediary goals. Reducing maternal mortality and infant mortality may be the immediate and identifiable goal of a programme. This is rarely contested and it is therefore possible to build a consensus among political parties, religious leaders, community leaders, women’s organizations and indeed the health professionals.

 

Maternal mortality is a very sensitive indicator of the value society places on the lives of women. Equally infant and child mortality is yet another area that demands greater responsiveness and sensitivity of the health delivery system. Access to contraception is thus at the heart of both maternal health as well as the well-being of children (preventing frequent births that affect nutrition and growth of children as well as the health of women). These complementary goals are a litmus test for measuring the effectiveness of a health programme. Gearing the entire system and getting the support of education ministry, medical and nursing council and other stakeholders could be a doable and achievable intermediary goal. Such an approach could create a window of opportunity and generate the momentum for change.

What then are the basic minimum or non-negotiable conditions to sincerely reduce maternal mortality? Ensure accessibility to facilities and providers in our villages and hamlets, in urban slums and in remote areas. We need many more trained providers. These grassroots providers need to be linked up to referral services. And most importantly, lay down quality standards with respect to technology, skills as well as treatment protocols.

While broader issues of gender inequality may be common to most regions of the country, there are wide variations on how it manifests on the ground. Women’s mobility, early marriage, son preference, a distorted sex ratio have been debated a lot in India. The important issue here is that these factors do not affect women alone; they also affect the institutional environment, leading to professional inequality where some cadres are more under-resourced (training, support, backup given to ANMs or ASHA) in some areas than others. Equally, issues of safety and security affect women providers more in some areas than others.

 

The effectiveness of the maternal and child health programme in the country is inextricably linked to the overall functioning of the health delivery system. Programme specific solutions may have limited impact as generic health system issues of functionality of health centres, skills of and support to frontline workers, supplies and logistics, all these impact on the efficiency of the system (institutional environment).

One of the most cited challenges is the percolation of contradictory messages/targets down the line. Often maternal and child health services are seen as being in competition with contraception services, when the two are inextricably linked. Equally, the campaign mode for immunization or special RCH camps is positioned in competition with regular and routine services. This has been highlighted in the Planning Commission review of the Ninth Plan as the biggest challenge facing the programme. The important issue here is that campaigns and special camps need not be seen in competition with routine services, but as complementary.

It is now acknowledged that quality and cost of services in the public sector influences quality in the private sector; they are linked. Where the public sector is dysfunctional, the private sector is exploitative. Conversely, where the public sector is functioning and is of reasonable quality, both cost and quality in the private sector is usually reasonable. Poor quality of care and poor accessibility of public sector services affect women who either opt out of health services altogether or selectively access services in the informal private sector.

 

Finally, and most importantly, the health department needs to forge a close working relationship with education. There must be a planned strategy to enable girls from rural, remote, tribal and from urban areas to complete secondary education. The government could leverage existing government programme like Kasturba Gandhi Balika Vidyalaya to enable girls from the most deprived sections of our society to not only finish class 10 and 12, but help them enrol in a nursing training programme. The health ministry, the medical council and the education ministry have to work together – develop a time-bound plan to increase the number of midwives across the country.

This has to be planned across three ministries and 32 state governments. Can this be done in a mission mode whereby we as a nation commit to break the cycle of maternal deaths?

 

This may have a ripple effect – creating more opportunities for women and help break the inter-generational cycle of illiteracy and low educational levels among women. Adolescents account for 23 per cent of population – 230 million in the 10-19 age group. It is important to remember that if we are able to influence the educational status of women, this will help enhance the pool of providers, and also influence health seeking behaviour. If we can pull this off, the next decade will witness rapid improvement on all fronts: health, girls education, mortality, morbidity and population growth. It is here that the maternal and child health programme needs to forge partnerships across departments, especially education.

* This brief note draws upon a paper prepared along with Dr. Sharad Iyengar, Kirti Iyengar and Pavitra Menon titled ‘Mainstreaming Gender Within India’s Reproductive and Child Health (RCH 2) Programme’, UNFPA, January 2004.