By Sheena Shafia
"Mothers Reflect God's loving presence on earth."
Motherhood is such a blessing in woman's life, that as a loving mother, she forgets her own self for the tender love of her dear ones and trains her children to virtue. The bond between a mother and her child is a powerful component in a child's life.
But mothers who die during childbirth or before the birth of a baby leave behind their never ending stories, their children and families and numerous reasons as to why their lives ended so early.
Every time a woman in the third world becomes pregnant, her risk of dying is 200 times higher than the risk run by a woman in the developed world. Approximately 30 million women in India experience pregnancy annually, and 27 million have live births. In India every one woman dies every 5 minutes from a pregnancy-related cause.
Maternal mortality is generally defined as the death of a woman during pregnancy or delivery, or within 42 days of the end of pregnancy from a pregnancy-related cause.
The maternal mortality ratio is nothing but the maternal death per 100,000 live births in one year. The maternal mortality ratio in India is somehow near about 267 (Urban estimation), rising to 619 in rural areas where as the developed countries in contrast have a maternal mortality ratio of around 20 per 100,000 live births.
Given the high maternal mortality rate in India, the women who lose their lives as a result of pregnancy and childbirth remain invisible in general. Therefore, reliable estimates of maternal mortality in India are not available. However, WHO estimates show that out of the 529,000 maternal deaths globally each year, 136,000(25.7%) are contributed by India, most of which can be prevented. This is the highest burden for any single country.
The indirect estimate done by Bhat (Maternal mortality in India: An update. Studies in Family planning, 2002) shows that MMR is higher in eastern and central regions and is lower in north-western and southern region. Similar picture is also shown by data collected under Sample registration system by Registrar General of India in 1997.
States with high maternal mortality include Rajasthan, Madhya Pradesh, Jharkhand, Orissa, Uttar Pradesh and Bihar.
The most common responsible causes of maternal deaths are hemorrhage (ante partum or post partum), eclampsia, pre-eclampsia, infection, obstructed and prolonged labour, complications of abortion, disorders related to high blood pressure and anaemia.
Causes of maternal death (%)
Haemorrhage 30
Anaemia 19
Sepsis 16
Obstructed labor 10
Abortion 8
Toxemia 8
Others 9
MAJOR CAUSE: Anaemia is one of the major causes of maternal mortality in India. It is noted painfully that after 61 years of independence India leads iron deficiency anaemia cases in the world and more than 90% of Indian women, adolescent girls and children are anaemic. Everyone is aware that anaemia results in physical weakness, mental shortcomings, low intelligence and increased vulnerability to a number of diseases and causes adverse pregnancy outcomes and even death of expectant mother. The anaemic mothers also bear anaemic children. The Ninth Plan envisaged universal screening for anaemia in pregnant women and appropriate use of IFA tablets is also indicated .But just like other plans and policies the programme had not been operationalised fully. In none of the states were services for anaemia included as a component of antenatal care. Data from Rapid Household Survey indicated that even iron folic acid consumption is still very Low. The target during the Tenth Plan was to make every effort to fully operationalise the Ninth Plan strategy for prevention and management of anaemia. But still now it has not faced much success. Only 22.3% of pregnant women consume Iron and Folic Acid supplementation for 90 days and the percentage is less than 10% among the non-educated women compared to 50% among the well-educated. Also the disparity between rural and urban areas is significant (18% and 34.5% respectively).
OTHER CAUSE: There are various other causes of maternal mortality. Eclampsia is one of them, which is a fallout of pregnancy-induced hypertension. This usually happens due to improper antenatal care. Hypertension during the course of pregnancy can ultimately culminate in convulsions. Eclampsia if not treated with care in time may lead to the death of the mother.
Another reason of maternal death is Haemorrhage. This may once again be caused by poor antenatal care, anaemia during pregnancies or during operative deliveries.
Obstructed or prolonged labour occurs when the foetus does not deliver in the anticipated time. This may be due to the wrong position of the foetus, if it is a too large a baby or if the pelvis of the mother is narrow. In urban India, obstructed labour is generally not among the primary causes of maternal deaths anymore but in rural India, due to lack of interest in institutional delivery it is still a cause of maternal deaths. Till now, in India only 43% of deliveries involve a skilled birth attendant compared to between 86% and 99% in Mexico, China, Sri Lanka, Brazil and Thailand.
Sepsis, another major cause of maternal deaths, may arise from infections, unsafe abortions, anaemia and improper care during pregnancy. Women who do not eat nutritious food during pregnancies are susceptible to infection. In rural, India this is one of the commonest causes of maternal deaths.
INTERMEDIATE CAUSE: They include the low social status of women, lack of awareness and knowledge at the household level, inadequate resources to seek care, and poor access to quality health care. Other causes are untimely diagnosis and treatment, poor skills and training of care providers, and prolonged waiting time at the facility due to lack of trained personnel, equipment and blood. The other prominent dark chapters of our society are the early age of marriage and child bearing, child spacing, family size and fertility patterns, literacy, socio-economic status and the and the customs and beliefs.
Under the Reproductive and child health (RCH)care programme efforts were made to improve the coverage, content and quality of antenatal care in order to achieve substantial reduction in maternal and perinatal morbidity and mortality.
In the ninth plan the antenatal and intra partum care contained features like,
* Early registration of pregnancy (12 - 16 weeks);
* Minimum three Ante-Natal Check-ups;
* Screening all pregnant women for major health, nutritional and obstetric problems;
* Identification of women with health problems/complications, providing prompt and effective treatment including referral wherever required;
* Universal coverage of all pregnant women with TT immunization;
* Screening for anaemia and providing IFA tablets to prevent anaemia;
* Advice on food, nutrition and rest;
* Promotion of institutional delivery / Safe deliveries by trained personnel etc.
But according to the Household Survey 1998-99 the actual scenario was something different. A ntenatal coverage in states with poor health indices such as UP, Bihar, MP was very low. Whereas in the southern states antenatal coverage was quite good.
The main problem areas of antenatal checkups lie herewith:
* Inadequate coverage; lack of trained health personnel in antenatal screening, risk identification and referral services;
* Over crowding in PHCs/hospitals
* Lack of Emergency Obstetric services etc
One of the major goals of Government of India's Department of Health and Family Welfare is to reduce maternal mortality and morbidity. The focus has shifted from individualized interventions to attention to the reproductive health care, which includes skilled attendance at birth, operationalising Referral Units and 24 hours delivery services at Primary Health Centres and initiation of Janani Suraksha Yojna (National Maternity Benefit Scheme).
Not only that, improving women's health require a strong and sustained government commitment, a favourable policy environment, and well-targeted resources. The government's strategy should include extended care to women whom government programs do not reach. The government of India has been making policy and programmatic statements time to time and setting goals of reducing maternal mortality.
Major policy and program goals in MM ( Maternal Mortality)
1983
Health policy statement by Govt of India
MMR reduction by 200-300 by 1990 and below 200 by the year 2000
2000
National population policy
MMR reduction to less than 100 by 2010
2002
National health policy
MMR reduction to less than 100 by 2010
2002-007
Tenth Five year plan
MMR reduction to less than 200 by 2007
The challenge for the government is to help direct and improve privately provided services through appropriate regulatory arrangements and by encouraging an expansion of their scope to include promotion and prevention, in addition to curative care.
The link between pregnancy-related care and maternal mortality is well established. National programmes and plans have already stressed on the need for universal screening of pregnant women and operationalising essential and emergency obstetric care. Focused antenatal care, birth preparedness and complication readiness, skilled attendance at birth, and access to emergency obstetric care are factors that can help reduce maternal mortality.
The mind boggling high maternal mortality rate in India can be reduced by following the strategies enumerated below:
* Effective initiative from the government is required in terms of proper allocation of resources to all the health institutions specially Primary Health Centers. Even more important is to ensure that the funds actually reach the users whenever it is needed.
* Early registration of antenatal cases and effective health education of couples to make them understand the importance of antenatal check ups, hospital deliveries and small family norms.
* Local dais / birth attendants and female health workers should be imparted periodic training to update themselves with improved techniques and be incorporated as an integral part of health care system. The importance of observing proper aseptic measures while conducting deliveries should be emphasized to them.
* Prevention and early treatment of infection, ante partum and postpartum hemorrhage.
* Wide spread availability / supply of Iron – Folic acid tablets and nutritious food to the poor and remotest corners of the country.
* Treatment of illnesses like diabetes, tuberculosis and malaria during pregnancy should be ensured.
* Construction of better roads and transport facilities is required especially in the rural areas and urban slums to make the health care facilities more available and accessible to people in need.
* Providing facilities for hospital deliveries for high risk cases like severe anaemia, hypertension, diabetes and heart disease.
In conclusion it can be said that, a maternal death is often not only a result of technical incompetence or negligence, but is also caused by ineffective health system and limited knowledge, social attitudes and poor health and midwife practices by the family and community itself. Since the health of mothers is directly related to a child's health and without due attention to the causes behind high maternal mortality ratios, we are simply ignoring an important determinant of the health of our nation. In doing so, maybe we are running the risk of damaging our chances for all-encompassing prosperity in future.
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