By Aeman Nishath
Recently, a woman in Iowa was referred to a university hospital during childbirth because of possible complications. At the university hospital it was decided that a cesarean section should be done. After the cesarean section was completed and the woman was resting in her hospital room, she went into shock and died. An autopsy showed that, during the cesarean section, the surgeon had accidentally nicked the woman's aorta, the biggest artery in the body, which led to internal hemorrhage, shock, and death.
A cesarean section can save the life of the mother or her baby, or both. A cesarean section can kill a mother or her baby, or both. Every procedure or technology used during pregnancy and birth carries risks for the mother and baby. Whether or not to use any procedure or technology will be a judgment based on balancing the chances that it will make things better against the chances that it will make things worse.
We live in the age of technology. Since long before human beings landed on the moon, we have believed that technology can solve all of our problems. It should come as no surprise that doctors and hospitals are using more and more technology and invasive interventions on pregnant and birthing women. Has all this technology solved the problems surrounding birth? Let's look at the record. Is the increasing use of technology saving the lives of more pregnant and birthing women? In fact, the risk of a woman in this country dying from maternal mortality (i.e., causes related to pregnancy) has not decreased in more than 25 years. Each year, nearly 1,000 women die during pregnancy, during birth, or in the first week after giving birth. Nearly half of these deaths could have been prevented with better access to higher-quality maternity care. Hundreds of thousands of other women experience medical complications from pregnancy.2
The data also suggest an increase in recent years in the number of women dying during pregnancy and birth in the US.3 We have known for some time that maternal mortality in the US is underreported--in one state in one year, a third of the maternal deaths had not been reported.4 But the latest evidence suggests that "The actual pregnancy-related death rate could be more than twice as high as that reported for 1990."5
WHY ARE MORE AMERICAN WOMEN DYING?
It is difficult to pinpoint why more American women are dying before, during, and after giving birth--the data give only the leading or immediate cause of death, not the underlying causes. But if we look at the six leading causes of pregnancy-related deaths in the US, three--hemorrhage, anesthesia, infection--are often the result of invasive obstetric interventions.6 For example: Although the immediate cause of death is frequently given as "hemorrhage," in many cases the hemorrhage is associated with cesarean section (as in the case cited in the first paragraph). There is good research, both in the US and the United Kingdom, showing that the maternal mortality rate for cesarean section is four times higher than for vaginal birth.7-9 The rate of maternal mortality is still twice as high as for vaginal birth even when the cesarean section is routine, or "elective"; i.e., it is not an emergency procedure. With nearly twice as many cesarean sections as are necessary being done today in the US, the procedure could be a significant part of the reason for the country's rising rate of maternal mortality.10
Another possible cause of rising pregnancy-related deaths in the US is the markedly increasing use of epidural blocks for normal labor pain. Administering an epidural block doubles the risk that the woman will die; "anesthesia complications" are documented as one of the leading causes of maternal mortality in the US.11
There is good reason to believe that other obstetric technologies also contribute to the rising number of women who die during childbirth in this country. Data from the Centers for Disease Control (CDC) show that in the past ten years the number of women given powerful and dangerous drugs to induce labor has gone from 10 percent of all births to 20 percent.12 In the same ten years, the drug Cytotec, not approved by the FDA for labor induction because of insufficient scientific evaluation of risk--a warning often ignored by doctors--has become the single most popular labor-inducing drug. New scientific data show that inducing labor with Cytotec causes a marked increase in uterine rupture, an obstetric catastrophe in which a quarter of all babies die, many women die as well, and, of the women who survive, almost none can ever have another baby.
Why has the rate of Cytotec-induced labor doubled when the ability of women's bodies to begin labor has not decreased? Further CDC data show that the answer is doctor convenience. In those same ten years, the number of births taking place Monday through Friday greatly increased.13 Like taking prenatal X-rays in the 1930s, prescribing the drug di-ethyl-stillbesterol (DES) to pregnant women in the 1950s, and thalidomide in the 1960s, inducing labor with Cytotec in the 1990s is another obstetric intervention that has gone into widespread use without adequate scientific evaluation, with tragic consequences for thousands of women and babies.
The scientific evidence strongly suggests that the increasing use of obstetric interventions and technologies--cesarean section, epidural anesthesia, and drugs to induce labor--is not saving more women's lives, but ending them. Medical care was responsible for some of the earlier decreasing mortality of pregnant and birthing women, not because of high-tech interventions but because of basic medical advances, such as the discovery of antibiotics and the ability to give safe blood transfusions. There has never been any scientific evidence that such high-tech interventions as the routine use of electronic fetal monitoring during labor decrease the mortality rate of women.14 There is also no scientific evidence to prove that the fall in maternal mortality was because birth was moved into the hospital.15 The evidence does show that, as long as a system is in place that can transport women in labor within 30 minutes to a facility where antibiotics, blood transfusions, and necessary cesarean sections are available, there should be very little maternal mortality. For example, in the Netherlands, a third of all births are planned homebirths attended by midwives that refer women to doctors when necessary. The rate of maternal mortality in the Netherlands is far lower than in the US.
THE IMPORTANCE OF QUALITY CARE
The US spends twice as much as any other country on maternity care, and yet 15 other countries have lower rates of maternal mortality. There are at least two reasons for this, both having to do with access to quality care. More than 40 million Americans have no health insurance; many of these are women needing maternity care. If a woman applies for Medicare support for her maternity care, she must have means testing, which necessitates that she jump through many bureaucratic hoops before she can receive care. This can be a disaster. Furthermore, women receiving publicly funded care go to overcrowded hospitals staffed by interns and residents who are overworked and insufficiently trained.16 In addition, when poor women qualify for their maternity care to be funded by Medicare, they may be referred to a private practitioner, and receive this care in the doctor's private offices and private hospitals. There they often receive less attention than the women whose care is being funded by private insurance instead of public funds, in part because of the cultural and socioeconomic gaps between the poor women and their doctors. The delays and crowding, and lack of understanding and skill of some doctors, can all lead to pregnancy-related deaths.
The second reason the US has a higher rate of maternal mortality than 15 other countries is the way birthing women are cared for here. American doctors insist that women need to be in the hospital when giving birth, yet these same doctors who need to provide maternity care for them are not in the hospital when the women actually give birth, but in their offices doing prenatal checkups on healthy women, or in another hospital doing gynecological surgery, or at home eating dinner.17 So when the birthing woman who is in the hospital (or transported to the hospital) needs urgent attention for developing complications, the obstetrician is often not there, must be called, and may come too late. Research shows that, in more than 70 percent of cases, the main factor in the death of babies at birth is the doctor's absence.18
The US and Canada are the only countries in the world in which obstetricians provide primary birth care for the majority of normal births. The American obstetrician tries to be all things to women: a primary provider of maternity care for healthy pregnant and birthing women; a provider of preventive care for women; a specialist in women's diseases; and a highly skilled surgeon. No other doctor anywhere in healthcare tries to maintain competence at all of these levels and in so many areas because it is unreasonable to expect this from one human being. It's unlikely that an obstetrician can perform a six-hour gynecological surgical procedure on a woman with extensive cancer, then rush to his or her office and do the best job of quietly, patiently counseling a pregnant woman about her sex life. If you are considering a hospital birth with an obstetrician as your primary birth attendant, ask the doctor how much time he or she will spend with you during your labor. One of the reasons a midwife, rather than an obstetrician, is generally a better choice to attend your hospital birth is that, assuming a normal pregnancy, midwives have been shown statistically to be safer birth attendants than doctors.19 This is, in part, because the midwife is there in the hospital with you throughout your labor, while the obstetrician is not.
For more than 50 years now the US has had a system of maternity care that often boils down to this: A woman goes into labor, goes to the hospital, and is admitted by the labor and delivery (L&D) nurse, who examines her. The L&D nurse then calls the obstetrician, who gives orders over the telephone to the nurse. The obstetrician may or may not come by the hospital during the labor to check the woman. It is the job of the L&D nurse to monitor the labor and call the obstetrician when the birth is imminent so that the doctor does not have to hang around the hospital waiting for the birth.
During my 15 years as Director of Women's and Children's Health for the World Health Organization, I frequently visited the industrialized countries of Europe. I observed that in the 15 countries that lose fewer pregnant and birthing women than the US does--including those countries with the world's lowest rates of maternal mortality--obstetricians remain in the hospitals, ready to jump in and treat serious complications. In those countries, it is the midwives who are out in the community, giving prenatal and postnatal checkups, and who are also in the hospitals as the only health professionals at the births of 80 to 90 percent of women who give birth without serious complications.
It cannot be overemphasized that American women's lack of access to quality, immediate obstetrical attention in the hospital is a major reason so many of them die unnecessarily during pregnancy and childbirth. Put differently, every one of the 15 countries that have lower rates of maternal mortality has universal healthcare coverage for all pregnant and birthing women (with no bureaucratic hoops to jump through), and all obstetricians are hospital-based, ready to care for these women should they develop complications. Furthermore, maternal mortality is not higher in those countries where there are large numbers of planned homebirths with midwives, because there is a system in place for transporting birthing mothers to the hospital, and for managing complications with mutual respect and collaboration between out-of-hospital midwives and hospital staff.
Data from many states in the US show maternal mortality to be four times higher for African-American women than for Caucasian women, and nearly twice as high for Hispanic women.20 The markedly greater risk that African-American and Hispanic women will die during pregnancy and childbirth is because this group includes a higher proportion of uninsured women, poor women, and women who go to hospitals with insufficient and/or poorly trained staff. In short, African-American and Hispanic women have less access to quality maternity care.
WHERE'S THE DATA?
Occasionally, a group of obstetricians tries to get a handle on maternal deaths in their locale. In a study of ten hospitals in the greater Chicago area, reported in 2000, the maternal mortality rate there was twice as high as reported by the CDC.21 Furthermore, on investigation of each case, these Chicago obstetricians found that 37 percent of the deaths were preventable. In the preventable cases, mistakes by doctors and nurses were determined to be the cause of death more than 80 percent of the time. Unfortunately, as is nearly always the case, the study made no attempt to determine how many of the deaths were related to obstetric interventions such as induction of labor, epidural block, and cesarean section. Lamenting that state maternal mortality committees, which carefully review all maternal deaths, are now largely defunct in the US, the study urged that these committees be revived to investigate causes and develop programs of intervention and education.
There is an urgent need for careful auditing of every single maternal death in the US, with a thorough analysis of causes--including underlying causes--and presentation of the results to the public. The Federal Aviation Authority could not set policies for safe flying if they were unaware of half of the planes falling from the skies, and couldn't retrieve the "black boxes" of most of those planes they knew had fallen. But this is analogous to the CDC trying to set policy for safe motherhood when they have limited data on maternal mortality. Federal policy prohibits the CDC from making surveys of what is happening in all states with maternal deaths.22 At the state level, there are enormous pressures from state and local medical societies to prevent adequate investigation of all maternal deaths.23 It's not easy to get information about the nearly 1,000 women who die each year in the US around the time of birth. To begin with, it's difficult to track maternal deaths, as death certificates in only 16 states include a question concerning whether the deceased had been pregnant within a year of her death. Although some states have regulations requiring that such deaths be reported, in no state can anyone, including scientists who want to study why these women die, gain access to information about individual cases of maternal death. If there is an investigation of a maternal death by a hospital, it is a longstanding policy that this happen behind closed doors, which protects the doctor and hospital involved. There is no public accountability. Public knowledge of pregnancy-related deaths does not fit well into any HMO or healthcare facility's marketing efforts. Employees of most hospitals know that their job security often depends on their willingness to keep silent, and the tribal loyalty of doctors is a powerful deterrent to accessing information. The CDC is doing everything it can to push states to improve their maternal death audits. It has had some successes, but today only a few states conduct thorough audits of all maternal deaths, and only one state, Massachusetts, has a law, passed after intense lobbying by consumer groups, mandating that newspapers report maternal deaths.
We know that at least half of these maternal deaths are not reported anywhere, that nearly all of these women die in the hospital, not at home, and that, with adequate medical attention, close to half of these women need not have died. The possibility of liability due to inadequate medical attention has doctors terrified of litigation, and reluctant to release information concerning maternal mortality. American women need to know that their chance of dying around the time of birth is increasing. They have a right to know why.
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Sunday, April 26, 2009
Death in Birth
By Richard Lee
In a hospital ward in Freetown, the capital of Sierra Leone, Fatmata Conteh, 26, lay on a bed, having just given birth to her second child. She had started bleeding from a tear in her cervix, the blood forming a pool on the floor below. Two doctors ran in and stitched her up, relatives found blood supplies, and nurses struggled to connect a generator to the oxygen tank. One nurse jammed an intravenous needle into Conteh's arm, while another hooked a bag of blood to a rusted stand, and a third slapped an oxygen mask over her face. In the corner of the room, a tiny baby--3 hours old--lay on a bed, wailing, swaddled in bright-colored African fabric. "Listen! You must feel happy to hear your baby cry," said a nurse, pleading with Conteh to find strength. Three visiting members of a neighborhood church began chanting over Conteh: "Jesus, put blood into this woman! Thank you, Lord!" But as their chants grew louder, the nurses stepped back from the bed. Conteh was dead.
Some version of that scene is repeated around the world about once a minute. Death in childbirth is not just something you find in a Victorian novel. Every year, about 536,000 women die giving birth. In some poor nations, dying in childbirth is so common that almost everyone has known a victim. Take Sierra Leone, a West African nation with just 6.3 million people: women there have a 1 in 8 chance of dying in childbirth during their lifetime. The same miserable odds apply in Afghanistan. In the U.S., by contrast, the lifetime chance that a woman will die in childbirth is about 1 in 4,800; in Britain, 1 in 8,200; and in Sweden, 1 in 17,400. Deaths are heavily weighted to the poorest and most isolated in each country, which means that many politicians remain largely ignorant of the scale of the tragedy. "Often the people in the cities do not know what is happening in their own rural areas," says Sarah Brown, wife of British Prime Minister Gordon Brown and patron of the White Ribbon Alliance, a global advocacy organization that works with governments to lower maternal mortality rates. Brown--who lost a baby 10 days after giving birth in 2001--says that when she tells heads of state and their spouses how many women die in childbirth, "they are aghast."
The Gains Not Made
They have reason to be. For here is the truly ghastly reality of maternal mortality: in 20 years--two decades that have seen spectacular medical breakthroughs--the ratio of maternal deaths to babies born has barely budged in poor countries. To be sure, maternal health has seen advances, with new drugs to treat deadly postpartum bleeding and pregnancy-related anemia. But in many places, such gains are dwarfed by a multitude of problems: scattershot care, low pay for health workers and a scarcity of midwives and doctors. In Mozambique, where women have a 1 in 45 lifetime chance of dying in childbirth, there are just 3 doctors per 100,000 people; in all of Sierra Leone, there are 64 government doctors, only five of whom are gynecologists. Millions of families have never seen a doctor or nurse and give birth at home with traditional birthing helpers, while those who make it to a clinic--some being carried on bicycles or in hammocks--often find patchy electricity, dirty water and few drugs or nurses. Explaining the task of reducing maternal deaths, Sierra Leone's Minister of Health, Saccoh Alex Kabia, who returned home last year after decades of working as a surgeon in Atlanta, says, "The whole health sector is in a shambles."
Many hope that maternal death rates in poor nations will naturally fall over time, as they did in much of the world in the 20th century. They well might. But international officials say governments often lack the political will--as well as the money--to tackle the issue, perhaps because there are too few women politicians to push it. Monir Islam, director of the maternal-health program of the World Health Organization in Geneva, calls governments' low level of investment in reducing deaths in childbirth a "sinful neglect."
In an attempt to jolt officials into action, governments at the U.N. General Assembly in 2000 chose to make a drastic reduction in maternal mortality one of the eight Millennium Development Goals (MDGS)--a series of targets in a program that channels aid to key issues, including education and clean water--to be met by 2015. The MDGS hold people "to a golden standard for progress," says Jamie Drummond, executive director of the antipoverty organization DATA. When world leaders gather in New York City this month to take stock of the MDGS, their speeches are likely to tout the many achievements since 2000: millions more African children now attend school and sleep under mosquito nets; thousands of new water wells have been dug. Yet though maternal health care underpins many other development goals (healthy mothers are more likely to ensure that their children are well fed and educated), the total number of women dying in childbirth has remained virtually unchanged in eight years.
Why? Health officials are clear in their answers. Aside from lack of money and political will, they also face entrenched traditions and fatalistic attitudes to maternal mortality, especially in very poor communities. "People think that dying in childbirth is not preventable," says Nadira Hayat, Afghanistan's Deputy Minister of Health. "They say it is up to God."
So it seemed before dawn one Sunday in August in Kora Olia, a remote village in Afghanistan's northeastern province of Badakhshan, where maternal mortality is about four times the country's already high rate. Nine months pregnant, Harakatmo, 19, began bleeding heavily. Her husband and mother-in-law were concerned, but the local doctor was far away, and expensive, so they waited. When Harakatmo was still bleeding the next morning, they sent a horseman to fetch a village health worker, but Harakatmo's bleeding continued. Panicked, her husband strapped her to a makeshift stretcher and carried her down the steep track from their home until he found a police truck to take them to a clinic several miles away. The doctor there urged the family to rush Harakatmo to Badakhshan's only hospital, in Faizabad, the provincial capital. Harakatmo's husband hired a ramshackle minivan for the journey--a five-hour ride along rutted dirt roads. On the way, they stopped while Harakatmo's mother-in-law delivered the baby. It was already dead; the tiny corpse was wrapped in a cloth and placed next to Harakatmo. Lying in the hospital that evening, she said she considered herself lucky. "When I left my house this morning, I thought I would die."
More will die if health-care systems are not reformed. In the first half of this year, 889 babies were delivered in Freetown's crumbling Princess Christian Maternity Hospital. During that period, 70 women died giving birth, and about eight more women have died since--an astonishing death rate of about 9%. Yet far from being overstretched, the hospital most days feels desultory, with nurses lingering in near empty wards because people cannot afford to pay for care. Emergency maternity care is supposed to be free in Sierra Leone, but in reality, patients are asked to pay for every item, including cotton swabs, gauze and syringes--this in a country where the average income is about $200 a year. If transfusions are needed, relatives have to donate blood to replace what is used.
One morning I watched a fierce argument between nurses and the relatives of a woman whose unborn baby was already dead inside her. As she sat on a bed awaiting an emergency C-section, her relatives pleaded that they could not afford 400,000 leones (about $135) for the operation. Finally the woman's aunt handed some 250,000 leones (about $85) to a nurse, who counted the banknotes before jamming them into her pocket, explaining to me that the money was "for drugs and to pay the doctor." Since nurses and doctors earn about $150 a month, "the staff is struggling to survive," says Peter Sikana, technical adviser for the U.N. Population Fund in Sierra Leone.
The scribbled notes from nurses in patient records, many of them in school exercise books paid for by relatives, describe their battles to keep women alive. In one such note, a nurse describes a woman, 18, who arrived at the hospital in late July suffering convulsions days after a traditional birth attendant delivered her baby at home. Four days later, the nurse wrote, "All due nursing care rendered but in vain. May her soul rest in peace." Six weeks later, I find the woman's father sitting outside the tiny family home atop an escarpment that overlooks Freetown. Holding the newborn baby, he says his daughter gave birth at home because "the terrain is too rough to reach the hospital." By the time he carried her, half conscious, down the slope to the hospital, she was too sick to be saved. Even for women who give birth in a hospital, survival is no sure thing. Another woman, 20, was admitted in late July in early labor and began having seizures hours after giving birth. Through the night the nurses scrawled frantic notes, including this one at 1:30 a.m.: "Dr. was tried ... via mobile [phone] to no avail." The woman died two hours later. I find her husband grinding peanuts in a Freetown market. "She delivered a healthy baby," he says, showing me a photograph of his wife, a tall woman with a confident, beaming smile.
Hope, for Some
Though many die in hospitals, researchers say the riskiest births are those without any nurse, midwife or doctor in attendance--about 35% of all the world's births. In addition to age-old problems like unclean instruments and poor-quality water--in Sierra Leone, I visited a traditional birth attendant who said she had delivered hundreds of babies in a windowless room in a slum of cramped shanties, with no indoor plumbing--there are new hazards. Afghanistan, for example, has seen growing sales of over-the-counter oxytocin, an injectable hormone that is used to stanch postpartum bleeding and speed labor but that can kill if administered incorrectly. Shamisa, a midwife, says that recently a heavily pregnant woman was brought to her rural Badakhshan clinic in a coma after being given a range of drugs by a pharmacist; both she and the baby died.
After millions of deaths and years of muddled government policies, a groundswell of distress at maternal mortality rates is at last stirring action. At the July G-8 summit of industrialized nations in Hokkaido, Japan, leaders for the first time discussed maternal deaths as a crucial obstacle to development. And there has been progress. Some poor countries have shown rapid results from investments in maternal health: in Honduras, for example, maternal mortality rates dropped about 50% from 1990 to '97 after officials opened scores of rural clinics and trained thousands of midwives. Nepal and Sri Lanka have trained midwives in emergency obstetrics. In the Indian states of Assam, Madhya Pradesh and Orissa, pregnant women now get 1,400 rupees ($32) to spend on whatever maternity services they choose--even a taxi ride to a clinic to give birth. Afghanistan has built 1,465 clinics and trained about 19,000 community health workers since the Taliban was ousted in 2001. The incidence of this worldwide tragedy can be reduced.
Even in Sierra Leone there are glimmers of hope. Aid organizations recently began training traditional birth attendants; several towns now demand that they deliver babies in clinics, where nurses can monitor their work. An hour east of Freetown, I visited a village where local elders had just passed a law requiring all women to give birth at a clinic or face fines of about $8--more than the clinic fee. And the World Bank, UNICEF and the British government's Department for International Development have agreed to jointly invest $262 million over the next three years to overhaul Sierra Leone's shambolic health system. "We will lose two or three more generations," says Geert Cappelaere, UNICEF's representative in Freetown. "But the core message is one of hope."
For some, that hope has come too late. A week after Conteh's death, her relatives gathered to name her baby girl after the dead mother. Weeping, Conteh's parents and her boyfriend hugged and kissed the infant, a bittersweet reminder of their loss. They are not alone. In the time it has taken to read this story, about 20 more women have died in childbirth.
In a hospital ward in Freetown, the capital of Sierra Leone, Fatmata Conteh, 26, lay on a bed, having just given birth to her second child. She had started bleeding from a tear in her cervix, the blood forming a pool on the floor below. Two doctors ran in and stitched her up, relatives found blood supplies, and nurses struggled to connect a generator to the oxygen tank. One nurse jammed an intravenous needle into Conteh's arm, while another hooked a bag of blood to a rusted stand, and a third slapped an oxygen mask over her face. In the corner of the room, a tiny baby--3 hours old--lay on a bed, wailing, swaddled in bright-colored African fabric. "Listen! You must feel happy to hear your baby cry," said a nurse, pleading with Conteh to find strength. Three visiting members of a neighborhood church began chanting over Conteh: "Jesus, put blood into this woman! Thank you, Lord!" But as their chants grew louder, the nurses stepped back from the bed. Conteh was dead.
Some version of that scene is repeated around the world about once a minute. Death in childbirth is not just something you find in a Victorian novel. Every year, about 536,000 women die giving birth. In some poor nations, dying in childbirth is so common that almost everyone has known a victim. Take Sierra Leone, a West African nation with just 6.3 million people: women there have a 1 in 8 chance of dying in childbirth during their lifetime. The same miserable odds apply in Afghanistan. In the U.S., by contrast, the lifetime chance that a woman will die in childbirth is about 1 in 4,800; in Britain, 1 in 8,200; and in Sweden, 1 in 17,400. Deaths are heavily weighted to the poorest and most isolated in each country, which means that many politicians remain largely ignorant of the scale of the tragedy. "Often the people in the cities do not know what is happening in their own rural areas," says Sarah Brown, wife of British Prime Minister Gordon Brown and patron of the White Ribbon Alliance, a global advocacy organization that works with governments to lower maternal mortality rates. Brown--who lost a baby 10 days after giving birth in 2001--says that when she tells heads of state and their spouses how many women die in childbirth, "they are aghast."
The Gains Not Made
They have reason to be. For here is the truly ghastly reality of maternal mortality: in 20 years--two decades that have seen spectacular medical breakthroughs--the ratio of maternal deaths to babies born has barely budged in poor countries. To be sure, maternal health has seen advances, with new drugs to treat deadly postpartum bleeding and pregnancy-related anemia. But in many places, such gains are dwarfed by a multitude of problems: scattershot care, low pay for health workers and a scarcity of midwives and doctors. In Mozambique, where women have a 1 in 45 lifetime chance of dying in childbirth, there are just 3 doctors per 100,000 people; in all of Sierra Leone, there are 64 government doctors, only five of whom are gynecologists. Millions of families have never seen a doctor or nurse and give birth at home with traditional birthing helpers, while those who make it to a clinic--some being carried on bicycles or in hammocks--often find patchy electricity, dirty water and few drugs or nurses. Explaining the task of reducing maternal deaths, Sierra Leone's Minister of Health, Saccoh Alex Kabia, who returned home last year after decades of working as a surgeon in Atlanta, says, "The whole health sector is in a shambles."
Many hope that maternal death rates in poor nations will naturally fall over time, as they did in much of the world in the 20th century. They well might. But international officials say governments often lack the political will--as well as the money--to tackle the issue, perhaps because there are too few women politicians to push it. Monir Islam, director of the maternal-health program of the World Health Organization in Geneva, calls governments' low level of investment in reducing deaths in childbirth a "sinful neglect."
In an attempt to jolt officials into action, governments at the U.N. General Assembly in 2000 chose to make a drastic reduction in maternal mortality one of the eight Millennium Development Goals (MDGS)--a series of targets in a program that channels aid to key issues, including education and clean water--to be met by 2015. The MDGS hold people "to a golden standard for progress," says Jamie Drummond, executive director of the antipoverty organization DATA. When world leaders gather in New York City this month to take stock of the MDGS, their speeches are likely to tout the many achievements since 2000: millions more African children now attend school and sleep under mosquito nets; thousands of new water wells have been dug. Yet though maternal health care underpins many other development goals (healthy mothers are more likely to ensure that their children are well fed and educated), the total number of women dying in childbirth has remained virtually unchanged in eight years.
Why? Health officials are clear in their answers. Aside from lack of money and political will, they also face entrenched traditions and fatalistic attitudes to maternal mortality, especially in very poor communities. "People think that dying in childbirth is not preventable," says Nadira Hayat, Afghanistan's Deputy Minister of Health. "They say it is up to God."
So it seemed before dawn one Sunday in August in Kora Olia, a remote village in Afghanistan's northeastern province of Badakhshan, where maternal mortality is about four times the country's already high rate. Nine months pregnant, Harakatmo, 19, began bleeding heavily. Her husband and mother-in-law were concerned, but the local doctor was far away, and expensive, so they waited. When Harakatmo was still bleeding the next morning, they sent a horseman to fetch a village health worker, but Harakatmo's bleeding continued. Panicked, her husband strapped her to a makeshift stretcher and carried her down the steep track from their home until he found a police truck to take them to a clinic several miles away. The doctor there urged the family to rush Harakatmo to Badakhshan's only hospital, in Faizabad, the provincial capital. Harakatmo's husband hired a ramshackle minivan for the journey--a five-hour ride along rutted dirt roads. On the way, they stopped while Harakatmo's mother-in-law delivered the baby. It was already dead; the tiny corpse was wrapped in a cloth and placed next to Harakatmo. Lying in the hospital that evening, she said she considered herself lucky. "When I left my house this morning, I thought I would die."
More will die if health-care systems are not reformed. In the first half of this year, 889 babies were delivered in Freetown's crumbling Princess Christian Maternity Hospital. During that period, 70 women died giving birth, and about eight more women have died since--an astonishing death rate of about 9%. Yet far from being overstretched, the hospital most days feels desultory, with nurses lingering in near empty wards because people cannot afford to pay for care. Emergency maternity care is supposed to be free in Sierra Leone, but in reality, patients are asked to pay for every item, including cotton swabs, gauze and syringes--this in a country where the average income is about $200 a year. If transfusions are needed, relatives have to donate blood to replace what is used.
One morning I watched a fierce argument between nurses and the relatives of a woman whose unborn baby was already dead inside her. As she sat on a bed awaiting an emergency C-section, her relatives pleaded that they could not afford 400,000 leones (about $135) for the operation. Finally the woman's aunt handed some 250,000 leones (about $85) to a nurse, who counted the banknotes before jamming them into her pocket, explaining to me that the money was "for drugs and to pay the doctor." Since nurses and doctors earn about $150 a month, "the staff is struggling to survive," says Peter Sikana, technical adviser for the U.N. Population Fund in Sierra Leone.
The scribbled notes from nurses in patient records, many of them in school exercise books paid for by relatives, describe their battles to keep women alive. In one such note, a nurse describes a woman, 18, who arrived at the hospital in late July suffering convulsions days after a traditional birth attendant delivered her baby at home. Four days later, the nurse wrote, "All due nursing care rendered but in vain. May her soul rest in peace." Six weeks later, I find the woman's father sitting outside the tiny family home atop an escarpment that overlooks Freetown. Holding the newborn baby, he says his daughter gave birth at home because "the terrain is too rough to reach the hospital." By the time he carried her, half conscious, down the slope to the hospital, she was too sick to be saved. Even for women who give birth in a hospital, survival is no sure thing. Another woman, 20, was admitted in late July in early labor and began having seizures hours after giving birth. Through the night the nurses scrawled frantic notes, including this one at 1:30 a.m.: "Dr. was tried ... via mobile [phone] to no avail." The woman died two hours later. I find her husband grinding peanuts in a Freetown market. "She delivered a healthy baby," he says, showing me a photograph of his wife, a tall woman with a confident, beaming smile.
Hope, for Some
Though many die in hospitals, researchers say the riskiest births are those without any nurse, midwife or doctor in attendance--about 35% of all the world's births. In addition to age-old problems like unclean instruments and poor-quality water--in Sierra Leone, I visited a traditional birth attendant who said she had delivered hundreds of babies in a windowless room in a slum of cramped shanties, with no indoor plumbing--there are new hazards. Afghanistan, for example, has seen growing sales of over-the-counter oxytocin, an injectable hormone that is used to stanch postpartum bleeding and speed labor but that can kill if administered incorrectly. Shamisa, a midwife, says that recently a heavily pregnant woman was brought to her rural Badakhshan clinic in a coma after being given a range of drugs by a pharmacist; both she and the baby died.
After millions of deaths and years of muddled government policies, a groundswell of distress at maternal mortality rates is at last stirring action. At the July G-8 summit of industrialized nations in Hokkaido, Japan, leaders for the first time discussed maternal deaths as a crucial obstacle to development. And there has been progress. Some poor countries have shown rapid results from investments in maternal health: in Honduras, for example, maternal mortality rates dropped about 50% from 1990 to '97 after officials opened scores of rural clinics and trained thousands of midwives. Nepal and Sri Lanka have trained midwives in emergency obstetrics. In the Indian states of Assam, Madhya Pradesh and Orissa, pregnant women now get 1,400 rupees ($32) to spend on whatever maternity services they choose--even a taxi ride to a clinic to give birth. Afghanistan has built 1,465 clinics and trained about 19,000 community health workers since the Taliban was ousted in 2001. The incidence of this worldwide tragedy can be reduced.
Even in Sierra Leone there are glimmers of hope. Aid organizations recently began training traditional birth attendants; several towns now demand that they deliver babies in clinics, where nurses can monitor their work. An hour east of Freetown, I visited a village where local elders had just passed a law requiring all women to give birth at a clinic or face fines of about $8--more than the clinic fee. And the World Bank, UNICEF and the British government's Department for International Development have agreed to jointly invest $262 million over the next three years to overhaul Sierra Leone's shambolic health system. "We will lose two or three more generations," says Geert Cappelaere, UNICEF's representative in Freetown. "But the core message is one of hope."
For some, that hope has come too late. A week after Conteh's death, her relatives gathered to name her baby girl after the dead mother. Weeping, Conteh's parents and her boyfriend hugged and kissed the infant, a bittersweet reminder of their loss. They are not alone. In the time it has taken to read this story, about 20 more women have died in childbirth.
THE HEARTBRAKE
Women are dying in childbirth in the same numbers as they were decades ago. The slow progress is an outrage, argues HNN's Editorial Director Sarah Williams.
Habibu is lying on matting on the mud floor of her hut. The contractions are coming thick and fast now. The pain is intense, but she draws comfort from the memory that, the previous three times, this agony gave way to the peaceful, exhausted bliss of holding her baby in her arms.
Her husband’s mother is on hand to help – she has, after all, given birth many times herself and seen many more children born. Water has been brought from the pump and sits in two large bowls ready to be used – one to wash the baby and the other to wash everything and everyone else; pieces of old cloth have been gathered over the months before so as to soak up any blood and bodily fluid. A kerosene lamp has been borrowed from a neighbour to cast any light needed on this dark West African night.
The delivery itself seems to go well: a girl, Mama says, now to be heard crying. Habibu lies back and gives herself up to the pleasure of there no longer being any sharp pain, only exhaustion and discomfort, and to the satisfaction of having brought another life into the world.
It is a while before Mama realizes that blood is still pumping out of Habibu, forming a widening crimson pool on the mat and the floor. She uses the rags to try to staunch the flow; to no avail. There is no sign of the placenta being delivered, as would normally happen within minutes of birth. Mama waits in hope for further precious minutes before realizing that the blood flow is not going to stop and that there is serious danger. Alarmed now, she summons her son, who sets out on his bicycle to try to contact the nurse at the government clinic 12 kilometres away.
By the time the nurse arrives, two hours have passed and it is too late for Habibu, whose life has drained away with her blood. There is nothing the nurse can do for the woman. Instead she tends to the newborn baby, while cursing under her breath the fees she has to charge for attending a birth at the clinic – fees that mean so many women opt to go it alone. She knows she could easily have saved her – an injection of oxytocin, perhaps, or a manual delivery of the placenta – but knows just as clearly that this desperate experience will be repeated on many other nights and days over the months and years to come.
The specifics of this story are fictional, though I name its victim Habibu in honour of a woman I knew in a Burkina Faso village who died in childbirth. She had just remarried after years of hardship raising children as a widow and had been looking forward to cementing her new marriage with a baby. She could and should have attended the nearest health centre for antenatal checks and for her delivery – the last time I visited it, the maternity unit at that health centre had yet to lose a mother during childbirth. But she opted not to do so – in part because her previous children had been safely delivered at home, but also because such supervision costs money, and even the smallest sums are hard to find in a subsistence farming family.
Just one story – but one that is repeated an average of 1,500 times every day around the world, and with particular terrible regularity in Africa and South Asia. In other cases, the complication might be not postpartum haemorrhage but an obstructed labour that demands, but does not receive, a caesarean section. In many such instances the baby will die along with the mother; in others, the mother will survive but will have lost her child. And for every one woman that dies, another 20 suffer injury, infection or disability that can even leave them shunned by their family and community.
In the vast majority of these cases, the deaths are eminently preventable. While the number of child deaths worldwide has consistently fallen – from around 13 million in 1990 to 9.7 million in 2006 – the maternal mortality toll has remained stubbornly similar. For decades, the international estimate of the number of maternal deaths each year has hovered just over the half-million mark.
You might assume from this that maternal deaths are somehow mysterious, untouchable by medical science or development interventions. Yet nothing could be farther from the truth. Not only could the number of maternal deaths be radically reduced, but it could also be done within a few years if only there were sufficient will.
This was one reason why, when the Millennium Development Goals were set in 2000, arguably the most ambitious of all the targets set was in relation to maternal mortality. Whereas the target was to cut poverty in half and to cut child mortality by two-thirds, the aspiration was to slash the maternal mortality ratio by three-quarters. The chart overleaf shows just how far the world is falling short.
This is where the gulf between rich and poor worlds is at its widest and most obscene. The lifetime risk of maternal death is just 1 in 8,000 in the Global North compared with 1 in 76 in the Global South. At the national extremes, an Irish woman has a 1 in 47,600 chance of dying from a pregnancy-related cause compared with a staggering 1 in 7 chance of death for a woman in Niger.
No matter how good the supervision or the medical facilities, some deaths in childbirth will always occur. But the statistics indicate clearly how much less hazardous it is for a woman in the West now to have a baby than it was for previous generations. There is no point in pretending that Ireland’s remarkable safety record could be replicated overnight all over the world. But the Millennium Development Goal could certainly still be achieved – even now, with only 6 years of the 25 left to run, when such pathetic progress has been made to date. And, were we to do so, 400,000 women every year would be saved from unnecessary death – and their husbands, children and families from unimaginable grief.
Given this, there are just two big questions to ask. How might these lives be saved? And, if we know how to save them, why isn’t it happening?
The ‘how’ is surprisingly straightforward. The best way to reduce maternal mortality (as well as the deaths of newborn babies) is to ensure that all births are attended by skilled health workers – trained midwives, nurses or doctors. At the moment only 59 per cent of births in the developing world are attended. The lowest rates of skilled attendance are in South Asia (41 per cent) and sub-Saharan Africa (43 per cent) and it is no coincidence that these are also the regions with the highest incidence of both maternal and neonatal mortality. If you live in the countryside in one of those regions, moreover, you’re about half as likely to have your birth attended as if you live in a city.
Ensuring that skilled workers are there during the delivery will cut out many of the unnecessary deaths. To save even more lives, a suitably equipped maternity centre needs to be within reasonable striking distance (less than two hours’ journey away) if some major obstetric complication arises.
Of course there are all kinds of other factors involved that would further reduce maternal mortality – among them better nutrition for pregnant women, better access to contraception, antenatal and postnatal visits, teaching each pregnant woman and her family about the danger signs. But, in the simplest terms, if every birth were attended by a skilled health worker the numbers of maternal deaths would tumble.
If it is that simple, that attainable, why is it not happening? Is this not something the whole world could agree on as an uncontentious objective? Isn’t motherhood, like apple pie, supposed to be an unchallengeable good?
Actually, the stubborn lack of progress on maternal mortality suggests that the root cause lies in women’s disadvantaged position in most countries and cultures. In countries with similar levels of economic development, maternal mortality tends to be inversely proportional to women’s status – in other words, the worse women are treated in society in general, the more likely they are to die in childbirth.1
Against this background of discrimination, often handed down from generation to generation by cultural tradition, initiatives to enhance maternal health need to go hand in hand with measures to promote women’s rights and to protect girls and women from violence, exploitation and abuse. Getting girls into school is a fast track to improving maternal health (and the health of their children) later; it also helps to protect them from child marriage, with its inevitable consequences of premature pregnancy and motherhood. The evidence is clear that educated adolescents are more likely to wait until they are out of their teenage years, when pregnancy risks are highest, to begin a family, and are more likely to have healthy babies. Pregnancy and childbirth-related deaths are the leading cause of mortality for girls aged 15-19 worldwide, killing 70,000 every year. Girls who give birth at even younger ages than 15 are even more at risk due to their physical immaturity, being five times more likely to die in childbirth than women in their twenties.2
Because there is such a close link between women’s oppression and maternal mortality, we need to treat maternal health as a fundamental human right – especially if we are to reach the poorest and most socially excluded women. The Convention to Eliminate Discrimination Against Women (CEDAW), which has been ratified by 185 countries, requires that governments ‘ensure to women appropriate services in connection with pregnancy, confinement and the post-natal period, granting free services where necessary, as well as adequate nutrition during pregnancy and lactation’. Very few developing countries are currently delivering on this commitment.
So women’s oppression is part of the background. But don’t go away thinking that this means there’s little that can be done about maternal mortality. The scandal is that mothers are dying unnecessarily because the world is unprepared to stump up the relatively meagre resources required to protect them.
That maternal deaths could be reduced by making sure all deliveries were attended has been known for decades – certainly ever since the international conference at Alma Ata in 1978 that propounded the notion of Primary Healthcare. The Alma Ata vision was of relatively low-cost outreach workers in communities, building on the model of ‘barefoot doctors’ pioneered in Maoist China. But those health workers and midwives at work out in the community were always supposed to be backed up by clinics – and beyond them hospitals to which they could refer patients.
This eminently sensible model of an integrated healthcare system that could have transformed the lives of people right across the Majority World was abandoned almost entirely because those pulling the purse-strings of ‘development’ considered this to be too expensive.
It was replaced in the 1980s by the disastrous idea that the funding gap in health should be met by getting the ‘consumers’ themselves to pay user fees. The legacy of that approach is still killing women all over Africa and South Asia, where the poor inevitably take their chances rather than pay for care, just as Habibu did.
A great deal of time and many millions of lives have been lost in the intervening decades since the vision of the Alma Ata Declaration was articulated, but we have returned to the same point. An integrated health system that would allow the MDGs to be met, and would transform maternal, neonatal and child health worldwide, is still achievable – provided the necessary resources are invested.
We could not get overnight to the point where all births are attended and have access to emergency obstetric care when needed – especially given the drain of doctors and nurses away from the countryside and even from Majority to Minority Worlds. There is at present a shortage of 2.3 million doctors, nurses and midwives spread across 57 countries.3 But ultimately it is still a question of resources: if we spent the money required to create health systems that functioned properly, we could still solve this problem in time to meet the MDG target.4
Back in 2003, global development assistance to maternal and neonatal health stood at $663 million a year. It was estimated then that an extra $6.1 billion would be required each year by 2015 to increase coverage to desired levels.5 To put this in perspective, the economic impact of maternal and newborn deaths has been estimated at $15 billion per year in lost productivity, while global military spending passes the $6-billion mark every one-and-a-half days.6
As global recession takes hold and the economic meltdown continues, it will be argued that such resources cannot easily be found. Yet with what ease are hundreds of billions of dollars found to bail out banks, to insure the financial system against its bad debts! Why could we not, over the last two decades, have found the much smaller sums necessary to bail out poor countries by investing in the kind of health services they so badly needed? Why could we not, long ago, have spent the sums necessary to insure young women and their families the world over against death and disability?
This article began by telling the story of Habibu, before sweeping off into the realms of statistics and health policies to make its case. But it is all too easy in discussing the global situation to forget that every single one of the 536,000 mothers who die in childbirth each year has her own story just like Habibu’s. Like her, they approached their labour full of expectation and hope for the new life that they were about to bring into the world, only to die for want of the care that should have been their right – and that mothers in the rich world routinely expect. We should hold stories like theirs in the forefront of our minds as we consider in the months and years ahead exactly what kind of world economy we are now to remake.
Habibu is lying on matting on the mud floor of her hut. The contractions are coming thick and fast now. The pain is intense, but she draws comfort from the memory that, the previous three times, this agony gave way to the peaceful, exhausted bliss of holding her baby in her arms.
Her husband’s mother is on hand to help – she has, after all, given birth many times herself and seen many more children born. Water has been brought from the pump and sits in two large bowls ready to be used – one to wash the baby and the other to wash everything and everyone else; pieces of old cloth have been gathered over the months before so as to soak up any blood and bodily fluid. A kerosene lamp has been borrowed from a neighbour to cast any light needed on this dark West African night.
The delivery itself seems to go well: a girl, Mama says, now to be heard crying. Habibu lies back and gives herself up to the pleasure of there no longer being any sharp pain, only exhaustion and discomfort, and to the satisfaction of having brought another life into the world.
It is a while before Mama realizes that blood is still pumping out of Habibu, forming a widening crimson pool on the mat and the floor. She uses the rags to try to staunch the flow; to no avail. There is no sign of the placenta being delivered, as would normally happen within minutes of birth. Mama waits in hope for further precious minutes before realizing that the blood flow is not going to stop and that there is serious danger. Alarmed now, she summons her son, who sets out on his bicycle to try to contact the nurse at the government clinic 12 kilometres away.
By the time the nurse arrives, two hours have passed and it is too late for Habibu, whose life has drained away with her blood. There is nothing the nurse can do for the woman. Instead she tends to the newborn baby, while cursing under her breath the fees she has to charge for attending a birth at the clinic – fees that mean so many women opt to go it alone. She knows she could easily have saved her – an injection of oxytocin, perhaps, or a manual delivery of the placenta – but knows just as clearly that this desperate experience will be repeated on many other nights and days over the months and years to come.
The specifics of this story are fictional, though I name its victim Habibu in honour of a woman I knew in a Burkina Faso village who died in childbirth. She had just remarried after years of hardship raising children as a widow and had been looking forward to cementing her new marriage with a baby. She could and should have attended the nearest health centre for antenatal checks and for her delivery – the last time I visited it, the maternity unit at that health centre had yet to lose a mother during childbirth. But she opted not to do so – in part because her previous children had been safely delivered at home, but also because such supervision costs money, and even the smallest sums are hard to find in a subsistence farming family.
Just one story – but one that is repeated an average of 1,500 times every day around the world, and with particular terrible regularity in Africa and South Asia. In other cases, the complication might be not postpartum haemorrhage but an obstructed labour that demands, but does not receive, a caesarean section. In many such instances the baby will die along with the mother; in others, the mother will survive but will have lost her child. And for every one woman that dies, another 20 suffer injury, infection or disability that can even leave them shunned by their family and community.
In the vast majority of these cases, the deaths are eminently preventable. While the number of child deaths worldwide has consistently fallen – from around 13 million in 1990 to 9.7 million in 2006 – the maternal mortality toll has remained stubbornly similar. For decades, the international estimate of the number of maternal deaths each year has hovered just over the half-million mark.
You might assume from this that maternal deaths are somehow mysterious, untouchable by medical science or development interventions. Yet nothing could be farther from the truth. Not only could the number of maternal deaths be radically reduced, but it could also be done within a few years if only there were sufficient will.
This was one reason why, when the Millennium Development Goals were set in 2000, arguably the most ambitious of all the targets set was in relation to maternal mortality. Whereas the target was to cut poverty in half and to cut child mortality by two-thirds, the aspiration was to slash the maternal mortality ratio by three-quarters. The chart overleaf shows just how far the world is falling short.
This is where the gulf between rich and poor worlds is at its widest and most obscene. The lifetime risk of maternal death is just 1 in 8,000 in the Global North compared with 1 in 76 in the Global South. At the national extremes, an Irish woman has a 1 in 47,600 chance of dying from a pregnancy-related cause compared with a staggering 1 in 7 chance of death for a woman in Niger.
No matter how good the supervision or the medical facilities, some deaths in childbirth will always occur. But the statistics indicate clearly how much less hazardous it is for a woman in the West now to have a baby than it was for previous generations. There is no point in pretending that Ireland’s remarkable safety record could be replicated overnight all over the world. But the Millennium Development Goal could certainly still be achieved – even now, with only 6 years of the 25 left to run, when such pathetic progress has been made to date. And, were we to do so, 400,000 women every year would be saved from unnecessary death – and their husbands, children and families from unimaginable grief.
Given this, there are just two big questions to ask. How might these lives be saved? And, if we know how to save them, why isn’t it happening?
The ‘how’ is surprisingly straightforward. The best way to reduce maternal mortality (as well as the deaths of newborn babies) is to ensure that all births are attended by skilled health workers – trained midwives, nurses or doctors. At the moment only 59 per cent of births in the developing world are attended. The lowest rates of skilled attendance are in South Asia (41 per cent) and sub-Saharan Africa (43 per cent) and it is no coincidence that these are also the regions with the highest incidence of both maternal and neonatal mortality. If you live in the countryside in one of those regions, moreover, you’re about half as likely to have your birth attended as if you live in a city.
Ensuring that skilled workers are there during the delivery will cut out many of the unnecessary deaths. To save even more lives, a suitably equipped maternity centre needs to be within reasonable striking distance (less than two hours’ journey away) if some major obstetric complication arises.
Of course there are all kinds of other factors involved that would further reduce maternal mortality – among them better nutrition for pregnant women, better access to contraception, antenatal and postnatal visits, teaching each pregnant woman and her family about the danger signs. But, in the simplest terms, if every birth were attended by a skilled health worker the numbers of maternal deaths would tumble.
If it is that simple, that attainable, why is it not happening? Is this not something the whole world could agree on as an uncontentious objective? Isn’t motherhood, like apple pie, supposed to be an unchallengeable good?
Actually, the stubborn lack of progress on maternal mortality suggests that the root cause lies in women’s disadvantaged position in most countries and cultures. In countries with similar levels of economic development, maternal mortality tends to be inversely proportional to women’s status – in other words, the worse women are treated in society in general, the more likely they are to die in childbirth.1
Against this background of discrimination, often handed down from generation to generation by cultural tradition, initiatives to enhance maternal health need to go hand in hand with measures to promote women’s rights and to protect girls and women from violence, exploitation and abuse. Getting girls into school is a fast track to improving maternal health (and the health of their children) later; it also helps to protect them from child marriage, with its inevitable consequences of premature pregnancy and motherhood. The evidence is clear that educated adolescents are more likely to wait until they are out of their teenage years, when pregnancy risks are highest, to begin a family, and are more likely to have healthy babies. Pregnancy and childbirth-related deaths are the leading cause of mortality for girls aged 15-19 worldwide, killing 70,000 every year. Girls who give birth at even younger ages than 15 are even more at risk due to their physical immaturity, being five times more likely to die in childbirth than women in their twenties.2
Because there is such a close link between women’s oppression and maternal mortality, we need to treat maternal health as a fundamental human right – especially if we are to reach the poorest and most socially excluded women. The Convention to Eliminate Discrimination Against Women (CEDAW), which has been ratified by 185 countries, requires that governments ‘ensure to women appropriate services in connection with pregnancy, confinement and the post-natal period, granting free services where necessary, as well as adequate nutrition during pregnancy and lactation’. Very few developing countries are currently delivering on this commitment.
So women’s oppression is part of the background. But don’t go away thinking that this means there’s little that can be done about maternal mortality. The scandal is that mothers are dying unnecessarily because the world is unprepared to stump up the relatively meagre resources required to protect them.
That maternal deaths could be reduced by making sure all deliveries were attended has been known for decades – certainly ever since the international conference at Alma Ata in 1978 that propounded the notion of Primary Healthcare. The Alma Ata vision was of relatively low-cost outreach workers in communities, building on the model of ‘barefoot doctors’ pioneered in Maoist China. But those health workers and midwives at work out in the community were always supposed to be backed up by clinics – and beyond them hospitals to which they could refer patients.
This eminently sensible model of an integrated healthcare system that could have transformed the lives of people right across the Majority World was abandoned almost entirely because those pulling the purse-strings of ‘development’ considered this to be too expensive.
It was replaced in the 1980s by the disastrous idea that the funding gap in health should be met by getting the ‘consumers’ themselves to pay user fees. The legacy of that approach is still killing women all over Africa and South Asia, where the poor inevitably take their chances rather than pay for care, just as Habibu did.
A great deal of time and many millions of lives have been lost in the intervening decades since the vision of the Alma Ata Declaration was articulated, but we have returned to the same point. An integrated health system that would allow the MDGs to be met, and would transform maternal, neonatal and child health worldwide, is still achievable – provided the necessary resources are invested.
We could not get overnight to the point where all births are attended and have access to emergency obstetric care when needed – especially given the drain of doctors and nurses away from the countryside and even from Majority to Minority Worlds. There is at present a shortage of 2.3 million doctors, nurses and midwives spread across 57 countries.3 But ultimately it is still a question of resources: if we spent the money required to create health systems that functioned properly, we could still solve this problem in time to meet the MDG target.4
Back in 2003, global development assistance to maternal and neonatal health stood at $663 million a year. It was estimated then that an extra $6.1 billion would be required each year by 2015 to increase coverage to desired levels.5 To put this in perspective, the economic impact of maternal and newborn deaths has been estimated at $15 billion per year in lost productivity, while global military spending passes the $6-billion mark every one-and-a-half days.6
As global recession takes hold and the economic meltdown continues, it will be argued that such resources cannot easily be found. Yet with what ease are hundreds of billions of dollars found to bail out banks, to insure the financial system against its bad debts! Why could we not, over the last two decades, have found the much smaller sums necessary to bail out poor countries by investing in the kind of health services they so badly needed? Why could we not, long ago, have spent the sums necessary to insure young women and their families the world over against death and disability?
This article began by telling the story of Habibu, before sweeping off into the realms of statistics and health policies to make its case. But it is all too easy in discussing the global situation to forget that every single one of the 536,000 mothers who die in childbirth each year has her own story just like Habibu’s. Like her, they approached their labour full of expectation and hope for the new life that they were about to bring into the world, only to die for want of the care that should have been their right – and that mothers in the rich world routinely expect. We should hold stories like theirs in the forefront of our minds as we consider in the months and years ahead exactly what kind of world economy we are now to remake.
Saturday, April 25, 2009
Waning Motherhood - The Cursed Bliss in India
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.
"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.
'They Still Die in Labor Room'
By Samiya Anwar & M H Ahssan
Taj Mahal- One of the seven wonders of the world, One of the Greatest monuments, dedicated to the memory of the Queen Mumtaz , by her husband Emperor Sahajahan, is a testimony and a grim reminder of the tragedy of maternal mortality, that can befall any women in childbirth. The probability of an Indian mother dying during childbirth is roughly 10 times that of her Chinese counterpart. Reducing the Maternal Mortality Ratio (MMR) by three-quarters in 10 years is now a Millennium Development Goal. Why is MMR in India so high and how far are we from the goal? HNN unravels the many challenges to saving mothers' lives.
Maternal Death - A Tragic Reality
Women, undoubtedly is the most beautiful piece of creation. She is not just a female, she is more than it. She is definitely a special handiwork of God. That is why she is wanted, she is loved. Men love women. Isn’t so and why not they are always surrounded by women. First it is a woman, to whom they are born. Then they grow with women as sisters. They are married to women. And also women are the one who reproduces the generations. Yes, because women are the reason for the offspring and growth of society.
But the same women are put to menace for procreation of mankind. They are often treated as reproducing machines. Not cared, left as scraps or doormats at homes women die anonymously especially the poor. For women it is a joyful start to a life as the mother and for a child a whole new life. It is really indecent that there is no man or women who take care of them or good medical facilities when the women are in need of special care and attention during and after pregnancy. Hence they either develop complications in the womb or die soon after child birth. Lack of education and short of medical facilities would be the cause. Many stories of women dying with maternal deaths are largely untold and unheard.
This is a social issue and heeds attention. Thanks to the television channels for wonderfully presenting the shows on social problems. Balika Vadhu, is such a social serial on Colors, which had so far portrayed the maternal deaths of young women. It is a mirror of Indian Society. The Indian Government estimates that 301 women die annually for every 100,000 live births. In some states the maternal mortality ratio is even higher -- 358 in Orissa, 371 in Bihar, and 379 in Madhya Pradesh. It is also estimated that few rural women chooses to remain passive. Laajwanti (name changed) a rural girl barely 16 has no complaints; however, she says “It’s a woman’s duty to produce as many children she can. They are God’s gift.” It is been observed that the maternal mortality rate has risen faster as there is pressure on girls to produce as soon they reach puberty. It is a shame to our country which is developing but not the people. We’re still backward. Right!
As the new data analysis tool reveals an estimated 80,000 pregnant women or new mothers die each year in India often from preventable causes including hemorrhage, eclampsia, sepsis and anemia. Since many deaths happen in the anonymity of women's homes or on the way to seek help at a medical facility, they often go unrecorded. It is absurd because we know about such practices, we have heard it, we have also listen to the news channels and read in several newspapers but still there is no official complaint.
Over 67% of maternal deaths in eight districts in Orissa were among SC/ST groups. Illiteracy is as much a factor as lack of primary health care. After achieving so many laurels in academics, still we’re not fully educated. Though the enrolment in schools has risen from past, our country yet suffers from problems due to lack of information and knowledge. Also in Purulia, West Bengal, 48% of the women who had died had no formal schooling. That’s a real embarrassment. In Bihar’s Vaishali, we can see 42% of the deaths occurred due to Haemorrhage, the most common cause of delivery-related deaths, with almost all hemorrhages occurring after delivery. Many women who delivered at home also died from postpartum hemorrhage. Eclampsia, a serious complication during pregnancy that is attributed to under-developed arteries in the placenta, was the second most common cause of death (17% in Dholpur, 19% in Purulia, and 27% in Guna/Shivpuri). However, the standard treatment for eclampsia, magnesium sulfate, was often not available in these places. These are the shocking findings of an ongoing survey across six states being conducted in co-ordination with the United Nations Childrens’ Fund (Unicef). India is still quite far from achieving the Millennium Development Goal of reducing maternal mortality rate (MMR) by three quarters by 2015. On an average, there are at least 301 women dying annually for every 100,000 live births. In some states the MMR is even higher—358 in Orissa, 371 in Bihar and 379 in Madhya Pradesh.
Causes may be:
- Early marriage,Hidden pregnancy, history of abortion, etc
- Financial disasters, No medical facilities
- Smoking, drinking and drugs (urban women)
- Lack of knowledge (like the example I gave about Laajwanti above)
Maternal death is a sensitive issue of human race. We need to curb the social ailments from the society. It is like terrorism killing the number of innocent lives in the dark of ignorance. Though it is hard to eliminate fully from the society we can generate proper awareness about the loss of humanity with every mother dying during and post pregnancy.
Maternal mortality: This India story is a shame!
Over 67% of maternal deaths in eight districts in Orissa were among SC/ST groups. Illiteracy is as much a factor as lack of primary health care. In Purulia, West Bengal , 48% of the women who had died had no formal schooling.
Haemorrhage is the most common cause of delivery-related deaths, with almost all haemorrhages occurring after delivery. In Bihar’s Vaishali, 42% of the deaths occurred due to this. Many women who delivered at home also died from postpartum haemorrhage.
Eclampsia, a serious complication during pregnancy that is attributed to under-developed arteries in the placenta, was the second most common cause of death (17% in Dholpur, 19% in Purulia, and 27% in Guna/Shivpuri). However, the standard treatment for eclampsia, magnesium sulfate, was often not available in these places.
These are the shocking findings of an ongoing survey across six states being conducted in co-ordination with the United Nations Childrens’ Fund (Unicef). India is still quite far from achieving the Millennium Development Goal of reducing maternal mortality rate (MMR) by three quarters by 2015. On an average, there are at least 301 women dying annually for every 100,000 live births. In some states the MMR is even higher—358 in Orissa, 371 in Bihar and 379 in Madhya Pradesh.
A new tool, Maternal and Perinatal Death Inquiry and Response (MAPEDIR), has been developed to analyse the underlying medical and social reasons behind maternal death and is being used across 16 districts in Rajasthan, Madhya Pradesh, West Bengal, Jharkhand, Orissa and Bihar providing an ongoing, systematic collection of data to reconstruct and analyse the cases of 1,600 women—the highest number of audited maternal deaths in the world. MAPEDIR also informs health officials about the challenges local women face in accessing reproductive health care.
“The tragic reality is that too often maternal deaths are not visible. They don’t leave any trace behind, and their deaths are not accounted for. Unicef is committed to continue working with the National Rural Health Mission to promote surveillance as a key strategy to lower maternal and child mortality,” Chris Hirabayashi, Unicef India deputy director of programmes, said at a meeting with health officials from the six states who are using MAPEDIR.
“Unless we know the main reasons for maternal deaths we cannot take effective measures to tackle them. The traditional system did not deal with the issues adequately. Now using MAPEDIR, we can know if the death are due to delays in decision making at household level or lack of transport or delay at the facility or a cumulative of all three,” S P Yadav, director of medical and health services in Rajasthan said.
A team made up of state government health and nutriti on officials and NGO members, headed by a member of the local village council or Panchayati Raj Institution, conducts interviews with surviving family members at community-level with technical support from Unicef and funds from the United Kingdom’s department of international development (DFID) work under MAPEDIR.
Social and economic factors like the low status of women in communities, the poor understanding of families on when to seek care, lack of transport, poor roads, the cost of seeking care, multiple referrals to different health facilities and a delay in life-saving measures in rural areas have been listed out by Unicef as the reasons behind the high MMR.
Many of these deaths happen in the anonymity of women’s homes or on the way to a medical facility and so they often go unrecorded. An estimated 80,000 pregnant women or new mothers die each year in India often from preventable causes including hemorrhage, eclampsia, sepsis and anemia.
Who cries when mothers die?
Munna was nine months pregnant. She did experience pains few days back, when her husband and mother-in-law rushed her to the nearest primary health centre in Kushwai of the District Shahdol in the State of Madhya Pradesh in India. They had to make her travel by bus from their village, and then in pain Munna had to walk, which she could barely to reach the health centre.
But unfortunately the kushwai health centre, where they had come with lot of hopes, did not had a medical doctor for last one and half years. One male health worker mans the centre. Though, he puts in his best but that may not be enough for women like Munna and others who need medical support.
Inspite of reaching the primary health centre, she did not get any help. She has to travel another eight kilometers to Burhar, the place where there is a community health centre. The centre is fortunately newly built and has facilities for delivery. Munna did develop some complications during the delivery but fortunately survived to see her new born.
She was lucky but thousands of women which die in the state are not. App 10,000 women die every year in Madhya Pradesh during pregnancy or within 42 days after pregnancy. Majority of these could be prevented. Medically these deaths may be due to hemorrhage, infection, eclampsia or unsafe abortion or any of three delays. But fact is there exists a yawning gap in our health system which stands in between life and death of women in the state. This gap has linkage to availability and access to health services, infrastructure, awareness among communities of not only the services but even recognizing danger signs, issue of how where they can access the services etc. Studies also tells us that for every maternal death in India, 20 more women suffer from the impaired health.
But if the situation at ground is like this, and has been there. What is the state’s response to an issue like this? Does it impact the political leaders, their discourse? Does issue of women dying in the state is debated in discussions where funds are allocated or decisions are made? Does state’s machinery care for it? Does civil society raise its concern?
To answer some of these questions a dip stick assessment was done in year 2004 at various levels within civil society, debates in the state assembly, media analysis. Outcomes were revealing. First of all the issue concerned only few in health department. There were only handful of civil society partners, and their major role was to support service delivery system. As such there was no push or urgency to bring change. Interestingly, the issue had never being debated on the floor of the state assembly, a place where elected representatives ‘of the people, for the people and by the people’ decide. It did not impact them, many of them were not even aware of the fact that state has this high number of maternal deaths? An issue like this was never raised by the political leaders in the debates which happen there – an issue of total neglect at the highest political body. Media covered ‘event news’ around the safe motherhood day, probably they never got the right information too.
That was a starting point, but nevertheless situation has changed today. Today state recognizes it as a major issue when it comes to women and children. State calls for an action. It is on high priority list of the political head of the state, state party is being questioned on the number of deaths, gaps on the infrastructure and many related points. Today more than 150 civil society organizations are raising concern on the issue and demanding urgency and urgency of action in the state.
How it happened and what does it impact and what strengths does it generate? Movements don't just happen; the energy that underlies them must be marshaled, channeled, and focused. The principal means by which this is achieved in our society, and within our political tradition, is through advocacy networks and coalitions.
Networks like Madhya Pradesh Voluntary Health Association, Madhya Pradesh Jan Adhikar Manch and Collective for advocacy, resource and training, Madhya Pradesh Samaj Sewa Sanstha, Mahila Chetna Manch, and many others have not only contributed to help bring the issue at an individual level but as a part of informal collation added to that force which helped bringing the agenda on political normative framework. Some of the strengths which this informal network helped bring were the numbers of civil society partners raising concern on the issue spread across different regions of the state. From a handful few now it is more than 150 civil society partners in the state working in all divisions to bring the issue to forefront. The turn around is also in their way of working from being a service delivery partners or a social mobilization partners in supportive and submissive role in a new avatar of advocacy partner. In this new role civil society speaks on the issue of right to health, its violation, demands state’s accountability to provide for safemotherhood. In this new business influencing people who make decisions which impact human lives is the key.
The primary target of the civil society was to bring the issues which impact lives of women at the villages, blocks and districts to the agenda of the people who make or influence decisions, i.e. state assembly debates, political leaders, members of legislative assembly, ministers, media, rights commission etc. They had been to some part successful. ex-pression of this concern was undertaken by directly meeting and sensitizing political leaders. The evidences highlighting gap were shared with political leaders, urging them to rise above politics and give a strong call for action. These non governmental organizations wrote memorandums, shared information and collected evidences for the same purpose. Media engagement also supported by providing an enabling environment for change. Strong evidences i.e. case of maternal deaths which can be presented, health system gaps were highlighted which added pressure on the state and the leaders to react. Resultant of this solid gains achieved. Today questions on maternal mortality are being raised in the state assembly, the highest policy making body of the state. It is not just few many voices are being publicly heard on the issue. There is a increased concern within media.
From nowhere it came to a point where state publicly acknowledge the problem, and its commitment to act. Many new polices and schemes have been announced and that too in the rapid succession. This amount of concern and even expressed publicly by leaders had never been seen earlier in the state on the issue of maternal mortality. But that is not enough today empowered civil society and media is always looking with eagle’s eye on the new measures of the state and vocally points out the gaps This is a positive sign, where people are voicing their opinion. But it is not easy as said. Political leaders have started picking up real cases of deaths, gaps in infrastructure in the state, violation of rights, gaps in policies and seeking answers to what is being done by the state to response to the situation.
Advocacy experts tell us that ‘people centered advocacy’ is the best, i.e. position when people who suffer can speak for themselves. A step has been taken in the same direction by the engaged networks. Madhya Pradesh Jan Adhikar Manch in their work with communities helped to bring the issue to debate in various gram sabhas which were held by panchayats in Gwalior – Chambal division. Similarly women who had participated in various women conventions hosted by Madhya Pradesh Samaj Sewa Sanstha came forward and wrote about the problems women face in rural areas when it comes to issue of safemotherhood and why do women die in their villages while giving birth. As per sources of Madhya Pradesh Samaj Sewa Sanstha more than 200 women have written to the Chief Minister. On a simple fifty paise post card, they wrote by theselves and it was send to the Chief Minister. It looks simple but powerful, if it gets to his eyes. Recently a large number of women from villages across Madhya Pradesh have joined a signature (or thumb-impression) campaign to press for their right to health and to call upon the Government to ensure that the dream of safe motherhood becomes a reality. As a part of a special drive to raise concern on this crucial issue, more than 20,000 women from different villages of the State are now in the process of signing (or placing their thumb impression) on a various banners demanding the right to health and calling upon the State to ensure that the dream of safe motherhood becomes a reality. Madhya Pradesh Voluntary Health Association, Madhya Pradesh Samaj Sewa Sanstha are the civil society partners who are collecting these signatures/thumb impressions of women. They say that they do so after they are adequately sensitizing them on the issue of maternal mortality. Then if they feel that some concrete action is needed to improve the situation, they come and sign. Plan is to present the banners with their signatures to policy makers.
One might say that this is good effort, which indeed it is to bring the agenda of maternal mortality on to the political and action framework but it is still a long way to go. This is true. But if one looks back one and half years where there was hardly any concern, hardly anyone called for action, except few that too ‘within the box’. The focus was limited. From nowhere it has come somewhere, which is an important achievement by any means. Need of the day is to provide possible answers to the state, which is willing to listen. Answers which can help deliver results, within the context of the field realties and socio – cultural aspects – a new call to many!
Lhamu, a mother of twelve, lives in a remote village in Western Tibet. Three of her children died within a month of birth and the four year old strapped to her back looked as small as a one year old. She gave birth all alone, at home, all twelve times. But Lhamu was lucky. She didn't die. One in 33 women dies during childbirth in Tibet. Malnutrition, abject poverty and lack of any health care – however basic—plagues Lhamu's family, as it does much of Tibet. Tibet – vast lonely stretches of dead habit with nary a creature on its harsh plains and no economy to speak of. It can't be as bad here in new economy India, right?
Think again.
One in 48 women in India is at risk of dying during childbirth. The Maternal Mortality Ratio (MMR) in India is a high 407 per 100,000 live births, according to the National Health Policy 2002. Other sources put the MMR at a higher 540 (NHFS and UNICEF data, 2000). Reducing the Maternal Mortality Ratio (MMR) by three-quarters by 2015 is a Millennium Development Goal (MDG) for all countries including India. Achieving this means reducing the MMR to 100 by 2015. Part of the problem is this measurement – MMR data is just not there and if it is, it varies widely depending on what method was used to get it.
Studies show MMR among scheduled tribes (652) and scheduled castes (584) is higher than in women of other castes (516, according to one study). It is higher among illiterate women (574) than those having completed middle school (484). The key determinant seems to be access to healthcare. Less-developed villages had a significantly higher MMR (646) than moderately or well-developed villages (501 and 488 deaths, respectively).
"It is very sad that the numbers are so high even 57 years after independence," avers Dr H Sudarshan who is Vigilance Director (Health) of the anti-corruption body Karnataka Lokayukta. "Not only are the numbers from the Sample Registration System (SRS) high, they are also incomplete. We do not know how many mothers actually died during childbirth and why. Underreporting is rampant and people hide MMR numbers in fear of repercussions. We need state-wise and within states, district-wise data," says Sudarshan who was also Chairman of the Karnataka Health Task Force which made wide-ranging recommendations based on a 2-3 year detailed study conducted in the state. Regardless, the UN MMR numbers for India (540) are several times higher than those for other developing countries like China (56), Brazil (260), Thailand (44), Mexico (83) or even Sri Lanka (92).
Medical reasons
So what exactly leads to such a high MMR? The main reasons for maternal deaths related to pregnancy are anaemia, post-partum bleeding and septic abortions with anaemia being the most rampant. "Antenatal care is most important," declares Sudarshan, "and that is just not being done. This kind of care checks for high risk pregnancies."
Public health advocate Dr Mira Shiva agrees, "Hypertension and the toxemias of pregnancy can only be detected with antenatal care. There is a total neglect of a mother's health in India. [The situation] is disgusting because a big chunk of all this is preventable. The medical establishment is busy with micronutrients but that is not the answer. Giving one iron tablet to a woman during her pregnancy is too late." Shiva is coordinator of the All India Drug Action Network (AIDAN) and one of the founding members of the People’s Health Movement (PHM). Striking out at a more endemic problem, she says, "The real problem is food. It is all about food, the cost of food and the nutrition content therein. These pregnant women have to fetch the water, make fuel, work the buffaloes, etc., all on the measly amount of food they can afford. How can the nutritive intake be enough? It becomes a negative calorie balance. In short, what is needed goes beyond a medical solution."
Sudarshan echoes Shiva's sentiment, "We need to move from a medical model to a social model. Nutrition for pregnant mothers is very important and the ICDS Anganwadi scheme has clearly not achieved the hoped results." Where antenatal care is good, the results are good as well. Kerala and Tamilnadu have good antenatal care and correspondingly have two of the lowest MMRs in India. In Assam and Bihar where antenatal care is almost zero, the MMRs are among the highest. India has the lowest percentage of antenatal coverage (60%) among countries like China, Brazil, Mexico, Thailand and Sri Lanka which are all in the high 86-95% range.
While antenatal care is paramount in the prevention of pregnancy-related deaths, septic abortions are more insidious. What is worse, the latter tends to go unreported due to the nature and circumstances surrounding it. In many rural areas couples do not use any spacing methods and women conceive within 7 months of having given birth. Dr Leena Joshi of Family Planning Association of India (FPAI) is familiar with this scenario. Her voice drops with concern when she mentions abortion rates in the remote reaches of Maharashtra. "The abortion rate in these areas is just so high. With it comes hidden mortality from septic abortion deaths. Since the PHCs do not have MTP methods, the abortions are performed by quacks. And even if the PHCs or district hospitals have MTP methods, the people opt for local help." Why? "It saves them money. These are very poor people and transport costs and medical costs can be saved by walking to a local quack." As a result there are a high number of abortion-related deaths which do not get reported under maternal mortality. Dr. Joshi laments that everybody only talks about deaths during the childbirth process. "But since there are so many septic abortion cases it all goes unreported."
The problem of unsafe abortion is something that Shiva worries about as well. "Abortion (MTP) being legal in India, no one is turned away. Second trimester abortion is a big reason for rising MMRs." People come late for the abortions and complications ensue. And apparently these are not only driven by spacing problems. "Contraceptives are used only by women and failure of these is common," says Joshi. Of course, abortion of female fetuses is routine and it goes on until the woman conceives a male child. The whole scenario makes one shudder.
But all this seems to be not even half the story.
Take malaria, for example. Orissa has a high incidence and accounted for 28.6% of detected cases of malaria -- 41% of falciparum -- and 62.8% of all material deaths in India (1998). Malaria and pregnancy form a sinister synergistic pair. Falciparum malaria leads to abortion and still births in the gravid woman and can severely compound anaemia. Coincidentally, Orissa has a high incidence of sickle cell anaemia. The combination is lethal. The haemoglobin in pregnant women could drop to 1gm/dL (healthy levels are between 12-16gms/dL). While drugs are available to treat the malaria, the treatment requires a high degree of awareness and care in administration. For example, the common primaquine and tetracycline are absolute no-nos during any stage of pregnancy. But chloroquine and quinine are allowed. "But mistakes occur and are lethal," says Shiva. Acting fast and carefully is paramount and any deaths due to these infections are primarily due to gross neglect or ignorance. Orissa has one of the highest rates of MMR in India at 738.
Another key reason for deaths during pregnancy is post-partum bleeding or haemorrhage. The need for blood in such cases is imperative and access is less than ideal. Both Sudarshan and Shiva worry about the blood bank policy in India. Heavily driven by the HIV/AIDS lobby, they feel that somewhere the important issue of access to blood has been sacrificed for quality and safety since the policy makers are looking at it all from the AIDS perspective. Says Sudarshan,"The policy says you have to keep the blood in an air-conditioned room. But in Coorg, for example, you don't need it. HIV awareness is good, but blood banks need to be demystified and access and availability improved." Shiva adds, "It is imperative in case of complications during pregnancy to have blood available. But no. NACO only sees blood banks from their perspective and only in an emergency are you allowed to take blood from the banks. It is a major concern." When it comes to donation, Shiva points to an endemic problem. The strange connection between men, caring for women, and giving blood. "If the men have to pay a lot of money and go far to get blood for their wives, they just won't. And men will never give blood. They think a 100 drops of blood equals one drop of semen and thus, giving blood is related to potency. And so many times, when women need blood, it is not available."
Organisational reasons
Early diagnosis of high-risk pregnancies and complications and quick referrals are of paramount importance. But is institutionalising deliveries the answer? By requiring 100% institutional deliveries, the World Bank supported vertical program Reproductive Child Health 1 (RCH1) resulted in the abolishing of the dais (Traditional Birth Attendants), and Sudarshan believes, probably increased MMR. Subsequently, following a public uproar, the program was amended to advocate "training" TBAs into Skilled Birth Attendants. "Institutional support will bring down MMR, yes, but what type of institution is important," says Sudarshan. "The so called Primary Health Care units are so dirty that infection will probably increase because of them." "In Bihar, for example," explains Sudarshan, "80% of the deliveries happen at home. In Karnataka it is 70%." Joshi concurs with this high degree of preference. "In the Bhandara area almost 100% prefer home deliveries. And if there are complications, it means there are inevitable delays in getting more sophisticated care."
Now, if there were a skilled birth attendant (SBA) at the time of each delivery or for antenatal checkups for each pregnancy, he or she can recognize a high-risk pregnancy or a potential complication and refer the mother to a district hospital or closest emergency care unit. The incidence of death from complications would be reduced. Countries like Malaysia have employed this strategy to bring down MMR to less than 100. In India only 43% of deliveries are attended by an SBA compared to between 86% and 99% in Mexico, China, Sri Lanka, Brazil and Thailand.
Sudarshan himself is involved in training tribal girls in the Soliga communities of Karnataka to be auxiliary nurse midwives (ANMs). For a population of 3000, there is a sub-centre and for every 5 or 6 sub-centres, there is a primary health care unit. Sudarshan's team trains the tribal girls in each village so that the few ANMs posted do not have to walk the 20 kms between the 4-5 villages this program covers. Joshi's team in Bhandara also trained 25 local dais or Traditional Birth Attendants (TBAs) to recognize complications and give basic medicines and obstetric care in the villages, one to each village. They also conduct antenatal checkups every month in about 10 villages. But funds for such programs are scant primarily because maternal health is not recognized as a priority issue in India. "The awareness that a pregnant woman should be taken care of is just not there," says Joshi. "If a woman is not delivering, the attitude used to be, let's wait and see, maybe tomorrow morning she will deliver. Now with our training, the dais can recognize complications but the money to shift the patient to a hospital is still not there."
This brings us to the next obstacle. So say the SBA refers to patient to an emergency obstetric care unit (EOC) and let's assume that we have one of those for every few villages. How would the patient reach the EOC? "Transport is a big issue. It is appalling that we do not have EMS (emergency medical services) that is efficient and well staffed," Sudarshan states categorically. He is working on building one for Karnataka with a coordinating body at district level which has jeeps, ambulances, even tractors available for responding to emergency calls. "We have to strengthen the PHC and an EMS is an integral part of that," he says. Bhandara is not so lucky. "Vehicles are available in 50% of the cases. But they are expensive. In the day, people can use buses, but not at nights. There are several rivers in this area and the buses are not allowed to travel over these at night," says Joshi.
Suppose the patient does reach the first referral unit (FRU) with complications that say, require a C-section. Is that a guarantee for a safe delivery? Sadly, no. Few FRUs run 24 hours. Joshi's hospital has 2-3 gynaecologists where the recommended number for the population of that area is 5-6. "All the C-sections and hysterectomies are carried out by these 2-3 gynaecologists. In the PHC in the villages, there is one doctor and 2-3 sisters (nurses), but they are only graduates, not post graduates or MBBS. So they cannot even do a complicated normal delivery, let alone C-sections."
Even in Karnataka, the FRUs are woefully understaffed and in some cases dangerously mismatched. "In one case," says Sudarshan with an ironic smile, "an orthopedist was posted where an obstetrician was required. With bribes, these so-called doctors can get posted to any area they want regardless of what is actually required there." And then there is the big problem of anaesthetists. At the Taluka level there is an acute shortage of them. Anaesthetists are required during complications and surgeries. When Sudarshan's team proposed that nurse obstetricians and other doctors also get trained in anaesthetics, the proposal was shot down by the medical lobby. Human resource management in the health sector seems to be a big issue. Shiva echoed the sentiment saying, "We need trained people in PHCs. And people with the right training. There is no point sending patients who require C-sections to where there is no anaesthetist or ob-gyn."
Government
Now, if we had fully staffed and functioning FRUs, would that bring down the mortality rate? Unfortunately, there is still one more layer that mothers have to contend with.
Shanta lives in a slum in Bangalore. When she was expecting her second child, she had the good fortune of being close to a government hospital where care would be free. Or so she thought. When she reached there, she realized that she had to 'buy' a bed or sleep on the floor. She also had to 'buy' food. So much so that she even had to 'buy' washing services or wear soiled clothes. And when it was time to "push" during delivery, she was just too weak, and the nurses slapped her. Left and right, again and again. They abused and cursed. "Is that the way to treat a patient?" Shanta queries in puzzlement. "My mother's house where I had my first born was better," she declared. Her sister-in-law Prema now laughs as she describes her own run-in with a local PHC outside Mysore. "They wouldn't give me my child until I paid up. Luckily I had saved all year, knowing this would be the case. The nurse was actually someone I grew up with. I thought she would be fair, but no. Everyone wants money." As soon as they got their money, she was sent home -– the same day -- with no medicines or follow-up monitoring either for her or her baby.
Corruption is not a new problem. "Even if the most sophisticated PHC is right across the road the ward boy needs to be bribed with Rs 150 to wheel the mother into the operation theatre and another Rs 300 to wheel her to the ward and most cannot afford that," declares a grave Sudarshan. In his opinion this final layer is the most important and toughest one to correct. "Bad governance. The real problem is not technological care but simply what I call the epidemic of corruption in the health services. And this is not just in the public healthcare sector, the private is just as bad," he says. "Doctors in Arunachal Pradesh take their pay checks but never show up. There is rampant corruption in procurement where, in one case, 123 spurious drugs were identified but bribes were taken and they were not reported. Dialysis machines which cost 5 lakhs are bought at 12.5 lakhs. Poor people end up spending huge amounts due to over-prescription of medicines that should be free to them. This is the real problem and no amount of infrastructure improvement will bring down MMR if governance is not improved," warns Sudarshan.
Shiva adds, "The private hospitals are mercenaries too. They perform unwanted C-sections and hysterectomies where none is required simply because there is big money in these procedures." Sudarshan, who sits in the anti-corruption cell of the Karnataka Government has presented strong recommendations to the Karnataka government regarding this issue. He stresses that good accreditation, accountability, good monitoring, and honest reporting are the only things that will actually bring down MMR, given the other necessities are taken care of.
And where will the money for the necessary infrastructure come from? Prime Minister Manmohan Singh has promised that the government spending on public healthcare -- which currently stands at an abysmal 0.9% of GDP (one of the five lowest in the world) -- will be increased to 2-3% of GDP which Sudarshan finds heartening, but tempers his optimism with caution. "It is great that there will be three times the amount available today for a sector that needs it badly, but one must plug the holes first. No point pouring all that money into a leaky vessel," he quips.
So, can it be done? Can MMR be brought down under 100 by 2015?
Sudarshan thinks so, but he will give it not 10, but 15 years. "It all comes down to political will. Sri Lanka, in spite of the civil war showed tremendous political will in tackling IMR and MMR and setting goals for themselves. Tamilnadu has a Deputy Commissioner (DC) monitor maternal mortality himself." This has increased the accountability and responsibility of the people in charge and has achieved good results. In Kerala, awareness about maternal health issues is high and the citizens demand more. Literacy plays a key role in keeping the MMR low. Kerala leads the way in successfully reducing MMR and Tamilnadu is close behind. While people like Sudarshan are doing everything to make sure it happens in Karnataka, the awareness and more importantly, recognition of this as an issue is lacking in other parts of India. In Uttar Pradesh, Madhya Pradesh, Bihar, Rajasthan, Assam and Orissa where the MMRs are well above the national average, it will require serious political will and accountability to change status quo.
The Ministry of Health and Family Welfare puts plans in place with the best of intentions (see here), but until governance and administration is addressed, people like Prema will still have no guarantees of care without paying beyond their means to like other pockets. But whether we will make progress will also be determined by when the Ministry recognizes MMR itself one of the key "Health and Population Indicators." Today, they do not. (See here.)
Both Shiva and Sudarshan agree that what India does not require is yet another vertical program to tackle maternal mortality. Verticals tend to be donor driven and cost intensive. MMR is not a disease unto itself. Clearly, high MMR is a symptom of a larger and wider problem in healthcare, namely the overall health of the woman, and should be treated as such and across verticals. Tackling a lot of the broader issues of governance and infrastructure should bring down the MMR. The National Rural Health Mission aims to reach across verticals to integrate services and by appointing an Accredited Social Health Activist (ASHA) at the community level provides decentralized first contact care. Shiva was part of one of the Task Forces of the NRHM and lauds its efforts as broadening the RCH program. But in order that the NRHM succeed, we come back to the need for evaluation methods and strong accountability.
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 ignoring an important determinant of the health of our nation. In doing so, we may be running the risk of damaging our chances for all-encompassing prosperity.
Ways to tackle maternal mortality
To check the maternal mortality rate in India, health experts have stressed on changing the traditional treatment and delivery system being practised in most villages.
At the 52th All-India Congress of Obstetrics & Gynaecology, the annual meeting of The Federation of Obstetric & Gynaecological Societies of India (FOGSI), gynaecologists from across the globe advocated the need to adopt advanced strategies practised in some of the countries in Africa.
“Lack of access and inadequate utilisation of healthcare facilities are responsible for maternal deaths in India. Countries like Mozambique have made good progress in reducing maternal mortality ratio (MMR),” explained Staffan Bergstrom, from Sweden.
Bergstrom added that the healthcare facilities in remote areas of countries like India are virtually absent, with no specialist doctors and advanced treatment facilities.
“In a number of countries with low per capita income, there is a scarcity of specialist doctors. Non-specialist doctors do major surgeries and fail to diagnose complications. Besides, many medical and clinical officers are being trained to perform surgeries in remote places, where specialists are not available. This is very risky,” Bergstrom explained.
“We should remember that children’s health is directly related to mother’s health. The MMR reflect the health of our nation. So, we should introduce advanced facilities in our villages,” said Gita Ganguly Mukherjee, former head of obstetrics and gynaecology, RG Kar Medical College and Hospital.
In India, one of 48 expecting mothers is at risk of dying during childbirth. According to the data of National Health Policy 2002, the MMR in India is as high as 407 per 100,000 live births. Other sources have put the MMR as high as 540 (NHFS and Unicef data, 2000).
“The chances of death of an Indian mother during childbirth is roughly 10 times more than that of her Chinese counterpart,” said Bergstrom.
India and other Third World countries have set a goal to reduce the MMR by three-quarters by 2015.
Also Read:
Motherhood Cursed Bliss in India
Obstetrical Interventions and Maternal Mortality
Death in Birth
The Heartbrake
Taj Mahal- One of the seven wonders of the world, One of the Greatest monuments, dedicated to the memory of the Queen Mumtaz , by her husband Emperor Sahajahan, is a testimony and a grim reminder of the tragedy of maternal mortality, that can befall any women in childbirth. The probability of an Indian mother dying during childbirth is roughly 10 times that of her Chinese counterpart. Reducing the Maternal Mortality Ratio (MMR) by three-quarters in 10 years is now a Millennium Development Goal. Why is MMR in India so high and how far are we from the goal? HNN unravels the many challenges to saving mothers' lives.
Maternal Death - A Tragic Reality
Women, undoubtedly is the most beautiful piece of creation. She is not just a female, she is more than it. She is definitely a special handiwork of God. That is why she is wanted, she is loved. Men love women. Isn’t so and why not they are always surrounded by women. First it is a woman, to whom they are born. Then they grow with women as sisters. They are married to women. And also women are the one who reproduces the generations. Yes, because women are the reason for the offspring and growth of society.
But the same women are put to menace for procreation of mankind. They are often treated as reproducing machines. Not cared, left as scraps or doormats at homes women die anonymously especially the poor. For women it is a joyful start to a life as the mother and for a child a whole new life. It is really indecent that there is no man or women who take care of them or good medical facilities when the women are in need of special care and attention during and after pregnancy. Hence they either develop complications in the womb or die soon after child birth. Lack of education and short of medical facilities would be the cause. Many stories of women dying with maternal deaths are largely untold and unheard.
This is a social issue and heeds attention. Thanks to the television channels for wonderfully presenting the shows on social problems. Balika Vadhu, is such a social serial on Colors, which had so far portrayed the maternal deaths of young women. It is a mirror of Indian Society. The Indian Government estimates that 301 women die annually for every 100,000 live births. In some states the maternal mortality ratio is even higher -- 358 in Orissa, 371 in Bihar, and 379 in Madhya Pradesh. It is also estimated that few rural women chooses to remain passive. Laajwanti (name changed) a rural girl barely 16 has no complaints; however, she says “It’s a woman’s duty to produce as many children she can. They are God’s gift.” It is been observed that the maternal mortality rate has risen faster as there is pressure on girls to produce as soon they reach puberty. It is a shame to our country which is developing but not the people. We’re still backward. Right!
As the new data analysis tool reveals an estimated 80,000 pregnant women or new mothers die each year in India often from preventable causes including hemorrhage, eclampsia, sepsis and anemia. Since many deaths happen in the anonymity of women's homes or on the way to seek help at a medical facility, they often go unrecorded. It is absurd because we know about such practices, we have heard it, we have also listen to the news channels and read in several newspapers but still there is no official complaint.
Over 67% of maternal deaths in eight districts in Orissa were among SC/ST groups. Illiteracy is as much a factor as lack of primary health care. After achieving so many laurels in academics, still we’re not fully educated. Though the enrolment in schools has risen from past, our country yet suffers from problems due to lack of information and knowledge. Also in Purulia, West Bengal, 48% of the women who had died had no formal schooling. That’s a real embarrassment. In Bihar’s Vaishali, we can see 42% of the deaths occurred due to Haemorrhage, the most common cause of delivery-related deaths, with almost all hemorrhages occurring after delivery. Many women who delivered at home also died from postpartum hemorrhage. Eclampsia, a serious complication during pregnancy that is attributed to under-developed arteries in the placenta, was the second most common cause of death (17% in Dholpur, 19% in Purulia, and 27% in Guna/Shivpuri). However, the standard treatment for eclampsia, magnesium sulfate, was often not available in these places. These are the shocking findings of an ongoing survey across six states being conducted in co-ordination with the United Nations Childrens’ Fund (Unicef). India is still quite far from achieving the Millennium Development Goal of reducing maternal mortality rate (MMR) by three quarters by 2015. On an average, there are at least 301 women dying annually for every 100,000 live births. In some states the MMR is even higher—358 in Orissa, 371 in Bihar and 379 in Madhya Pradesh.
Causes may be:
- Early marriage,Hidden pregnancy, history of abortion, etc
- Financial disasters, No medical facilities
- Smoking, drinking and drugs (urban women)
- Lack of knowledge (like the example I gave about Laajwanti above)
Maternal death is a sensitive issue of human race. We need to curb the social ailments from the society. It is like terrorism killing the number of innocent lives in the dark of ignorance. Though it is hard to eliminate fully from the society we can generate proper awareness about the loss of humanity with every mother dying during and post pregnancy.
Maternal mortality: This India story is a shame!
Over 67% of maternal deaths in eight districts in Orissa were among SC/ST groups. Illiteracy is as much a factor as lack of primary health care. In Purulia, West Bengal , 48% of the women who had died had no formal schooling.
Haemorrhage is the most common cause of delivery-related deaths, with almost all haemorrhages occurring after delivery. In Bihar’s Vaishali, 42% of the deaths occurred due to this. Many women who delivered at home also died from postpartum haemorrhage.
Eclampsia, a serious complication during pregnancy that is attributed to under-developed arteries in the placenta, was the second most common cause of death (17% in Dholpur, 19% in Purulia, and 27% in Guna/Shivpuri). However, the standard treatment for eclampsia, magnesium sulfate, was often not available in these places.
These are the shocking findings of an ongoing survey across six states being conducted in co-ordination with the United Nations Childrens’ Fund (Unicef). India is still quite far from achieving the Millennium Development Goal of reducing maternal mortality rate (MMR) by three quarters by 2015. On an average, there are at least 301 women dying annually for every 100,000 live births. In some states the MMR is even higher—358 in Orissa, 371 in Bihar and 379 in Madhya Pradesh.
A new tool, Maternal and Perinatal Death Inquiry and Response (MAPEDIR), has been developed to analyse the underlying medical and social reasons behind maternal death and is being used across 16 districts in Rajasthan, Madhya Pradesh, West Bengal, Jharkhand, Orissa and Bihar providing an ongoing, systematic collection of data to reconstruct and analyse the cases of 1,600 women—the highest number of audited maternal deaths in the world. MAPEDIR also informs health officials about the challenges local women face in accessing reproductive health care.
“The tragic reality is that too often maternal deaths are not visible. They don’t leave any trace behind, and their deaths are not accounted for. Unicef is committed to continue working with the National Rural Health Mission to promote surveillance as a key strategy to lower maternal and child mortality,” Chris Hirabayashi, Unicef India deputy director of programmes, said at a meeting with health officials from the six states who are using MAPEDIR.
“Unless we know the main reasons for maternal deaths we cannot take effective measures to tackle them. The traditional system did not deal with the issues adequately. Now using MAPEDIR, we can know if the death are due to delays in decision making at household level or lack of transport or delay at the facility or a cumulative of all three,” S P Yadav, director of medical and health services in Rajasthan said.
A team made up of state government health and nutriti on officials and NGO members, headed by a member of the local village council or Panchayati Raj Institution, conducts interviews with surviving family members at community-level with technical support from Unicef and funds from the United Kingdom’s department of international development (DFID) work under MAPEDIR.
Social and economic factors like the low status of women in communities, the poor understanding of families on when to seek care, lack of transport, poor roads, the cost of seeking care, multiple referrals to different health facilities and a delay in life-saving measures in rural areas have been listed out by Unicef as the reasons behind the high MMR.
Many of these deaths happen in the anonymity of women’s homes or on the way to a medical facility and so they often go unrecorded. An estimated 80,000 pregnant women or new mothers die each year in India often from preventable causes including hemorrhage, eclampsia, sepsis and anemia.
Who cries when mothers die?
Munna was nine months pregnant. She did experience pains few days back, when her husband and mother-in-law rushed her to the nearest primary health centre in Kushwai of the District Shahdol in the State of Madhya Pradesh in India. They had to make her travel by bus from their village, and then in pain Munna had to walk, which she could barely to reach the health centre.
But unfortunately the kushwai health centre, where they had come with lot of hopes, did not had a medical doctor for last one and half years. One male health worker mans the centre. Though, he puts in his best but that may not be enough for women like Munna and others who need medical support.
Inspite of reaching the primary health centre, she did not get any help. She has to travel another eight kilometers to Burhar, the place where there is a community health centre. The centre is fortunately newly built and has facilities for delivery. Munna did develop some complications during the delivery but fortunately survived to see her new born.
She was lucky but thousands of women which die in the state are not. App 10,000 women die every year in Madhya Pradesh during pregnancy or within 42 days after pregnancy. Majority of these could be prevented. Medically these deaths may be due to hemorrhage, infection, eclampsia or unsafe abortion or any of three delays. But fact is there exists a yawning gap in our health system which stands in between life and death of women in the state. This gap has linkage to availability and access to health services, infrastructure, awareness among communities of not only the services but even recognizing danger signs, issue of how where they can access the services etc. Studies also tells us that for every maternal death in India, 20 more women suffer from the impaired health.
But if the situation at ground is like this, and has been there. What is the state’s response to an issue like this? Does it impact the political leaders, their discourse? Does issue of women dying in the state is debated in discussions where funds are allocated or decisions are made? Does state’s machinery care for it? Does civil society raise its concern?
To answer some of these questions a dip stick assessment was done in year 2004 at various levels within civil society, debates in the state assembly, media analysis. Outcomes were revealing. First of all the issue concerned only few in health department. There were only handful of civil society partners, and their major role was to support service delivery system. As such there was no push or urgency to bring change. Interestingly, the issue had never being debated on the floor of the state assembly, a place where elected representatives ‘of the people, for the people and by the people’ decide. It did not impact them, many of them were not even aware of the fact that state has this high number of maternal deaths? An issue like this was never raised by the political leaders in the debates which happen there – an issue of total neglect at the highest political body. Media covered ‘event news’ around the safe motherhood day, probably they never got the right information too.
That was a starting point, but nevertheless situation has changed today. Today state recognizes it as a major issue when it comes to women and children. State calls for an action. It is on high priority list of the political head of the state, state party is being questioned on the number of deaths, gaps on the infrastructure and many related points. Today more than 150 civil society organizations are raising concern on the issue and demanding urgency and urgency of action in the state.
How it happened and what does it impact and what strengths does it generate? Movements don't just happen; the energy that underlies them must be marshaled, channeled, and focused. The principal means by which this is achieved in our society, and within our political tradition, is through advocacy networks and coalitions.
Networks like Madhya Pradesh Voluntary Health Association, Madhya Pradesh Jan Adhikar Manch and Collective for advocacy, resource and training, Madhya Pradesh Samaj Sewa Sanstha, Mahila Chetna Manch, and many others have not only contributed to help bring the issue at an individual level but as a part of informal collation added to that force which helped bringing the agenda on political normative framework. Some of the strengths which this informal network helped bring were the numbers of civil society partners raising concern on the issue spread across different regions of the state. From a handful few now it is more than 150 civil society partners in the state working in all divisions to bring the issue to forefront. The turn around is also in their way of working from being a service delivery partners or a social mobilization partners in supportive and submissive role in a new avatar of advocacy partner. In this new role civil society speaks on the issue of right to health, its violation, demands state’s accountability to provide for safemotherhood. In this new business influencing people who make decisions which impact human lives is the key.
The primary target of the civil society was to bring the issues which impact lives of women at the villages, blocks and districts to the agenda of the people who make or influence decisions, i.e. state assembly debates, political leaders, members of legislative assembly, ministers, media, rights commission etc. They had been to some part successful. ex-pression of this concern was undertaken by directly meeting and sensitizing political leaders. The evidences highlighting gap were shared with political leaders, urging them to rise above politics and give a strong call for action. These non governmental organizations wrote memorandums, shared information and collected evidences for the same purpose. Media engagement also supported by providing an enabling environment for change. Strong evidences i.e. case of maternal deaths which can be presented, health system gaps were highlighted which added pressure on the state and the leaders to react. Resultant of this solid gains achieved. Today questions on maternal mortality are being raised in the state assembly, the highest policy making body of the state. It is not just few many voices are being publicly heard on the issue. There is a increased concern within media.
From nowhere it came to a point where state publicly acknowledge the problem, and its commitment to act. Many new polices and schemes have been announced and that too in the rapid succession. This amount of concern and even expressed publicly by leaders had never been seen earlier in the state on the issue of maternal mortality. But that is not enough today empowered civil society and media is always looking with eagle’s eye on the new measures of the state and vocally points out the gaps This is a positive sign, where people are voicing their opinion. But it is not easy as said. Political leaders have started picking up real cases of deaths, gaps in infrastructure in the state, violation of rights, gaps in policies and seeking answers to what is being done by the state to response to the situation.
Advocacy experts tell us that ‘people centered advocacy’ is the best, i.e. position when people who suffer can speak for themselves. A step has been taken in the same direction by the engaged networks. Madhya Pradesh Jan Adhikar Manch in their work with communities helped to bring the issue to debate in various gram sabhas which were held by panchayats in Gwalior – Chambal division. Similarly women who had participated in various women conventions hosted by Madhya Pradesh Samaj Sewa Sanstha came forward and wrote about the problems women face in rural areas when it comes to issue of safemotherhood and why do women die in their villages while giving birth. As per sources of Madhya Pradesh Samaj Sewa Sanstha more than 200 women have written to the Chief Minister. On a simple fifty paise post card, they wrote by theselves and it was send to the Chief Minister. It looks simple but powerful, if it gets to his eyes. Recently a large number of women from villages across Madhya Pradesh have joined a signature (or thumb-impression) campaign to press for their right to health and to call upon the Government to ensure that the dream of safe motherhood becomes a reality. As a part of a special drive to raise concern on this crucial issue, more than 20,000 women from different villages of the State are now in the process of signing (or placing their thumb impression) on a various banners demanding the right to health and calling upon the State to ensure that the dream of safe motherhood becomes a reality. Madhya Pradesh Voluntary Health Association, Madhya Pradesh Samaj Sewa Sanstha are the civil society partners who are collecting these signatures/thumb impressions of women. They say that they do so after they are adequately sensitizing them on the issue of maternal mortality. Then if they feel that some concrete action is needed to improve the situation, they come and sign. Plan is to present the banners with their signatures to policy makers.
One might say that this is good effort, which indeed it is to bring the agenda of maternal mortality on to the political and action framework but it is still a long way to go. This is true. But if one looks back one and half years where there was hardly any concern, hardly anyone called for action, except few that too ‘within the box’. The focus was limited. From nowhere it has come somewhere, which is an important achievement by any means. Need of the day is to provide possible answers to the state, which is willing to listen. Answers which can help deliver results, within the context of the field realties and socio – cultural aspects – a new call to many!
Lhamu, a mother of twelve, lives in a remote village in Western Tibet. Three of her children died within a month of birth and the four year old strapped to her back looked as small as a one year old. She gave birth all alone, at home, all twelve times. But Lhamu was lucky. She didn't die. One in 33 women dies during childbirth in Tibet. Malnutrition, abject poverty and lack of any health care – however basic—plagues Lhamu's family, as it does much of Tibet. Tibet – vast lonely stretches of dead habit with nary a creature on its harsh plains and no economy to speak of. It can't be as bad here in new economy India, right?
Think again.
One in 48 women in India is at risk of dying during childbirth. The Maternal Mortality Ratio (MMR) in India is a high 407 per 100,000 live births, according to the National Health Policy 2002. Other sources put the MMR at a higher 540 (NHFS and UNICEF data, 2000). Reducing the Maternal Mortality Ratio (MMR) by three-quarters by 2015 is a Millennium Development Goal (MDG) for all countries including India. Achieving this means reducing the MMR to 100 by 2015. Part of the problem is this measurement – MMR data is just not there and if it is, it varies widely depending on what method was used to get it.
Studies show MMR among scheduled tribes (652) and scheduled castes (584) is higher than in women of other castes (516, according to one study). It is higher among illiterate women (574) than those having completed middle school (484). The key determinant seems to be access to healthcare. Less-developed villages had a significantly higher MMR (646) than moderately or well-developed villages (501 and 488 deaths, respectively).
"It is very sad that the numbers are so high even 57 years after independence," avers Dr H Sudarshan who is Vigilance Director (Health) of the anti-corruption body Karnataka Lokayukta. "Not only are the numbers from the Sample Registration System (SRS) high, they are also incomplete. We do not know how many mothers actually died during childbirth and why. Underreporting is rampant and people hide MMR numbers in fear of repercussions. We need state-wise and within states, district-wise data," says Sudarshan who was also Chairman of the Karnataka Health Task Force which made wide-ranging recommendations based on a 2-3 year detailed study conducted in the state. Regardless, the UN MMR numbers for India (540) are several times higher than those for other developing countries like China (56), Brazil (260), Thailand (44), Mexico (83) or even Sri Lanka (92).
Medical reasons
So what exactly leads to such a high MMR? The main reasons for maternal deaths related to pregnancy are anaemia, post-partum bleeding and septic abortions with anaemia being the most rampant. "Antenatal care is most important," declares Sudarshan, "and that is just not being done. This kind of care checks for high risk pregnancies."
Public health advocate Dr Mira Shiva agrees, "Hypertension and the toxemias of pregnancy can only be detected with antenatal care. There is a total neglect of a mother's health in India. [The situation] is disgusting because a big chunk of all this is preventable. The medical establishment is busy with micronutrients but that is not the answer. Giving one iron tablet to a woman during her pregnancy is too late." Shiva is coordinator of the All India Drug Action Network (AIDAN) and one of the founding members of the People’s Health Movement (PHM). Striking out at a more endemic problem, she says, "The real problem is food. It is all about food, the cost of food and the nutrition content therein. These pregnant women have to fetch the water, make fuel, work the buffaloes, etc., all on the measly amount of food they can afford. How can the nutritive intake be enough? It becomes a negative calorie balance. In short, what is needed goes beyond a medical solution."
Sudarshan echoes Shiva's sentiment, "We need to move from a medical model to a social model. Nutrition for pregnant mothers is very important and the ICDS Anganwadi scheme has clearly not achieved the hoped results." Where antenatal care is good, the results are good as well. Kerala and Tamilnadu have good antenatal care and correspondingly have two of the lowest MMRs in India. In Assam and Bihar where antenatal care is almost zero, the MMRs are among the highest. India has the lowest percentage of antenatal coverage (60%) among countries like China, Brazil, Mexico, Thailand and Sri Lanka which are all in the high 86-95% range.
While antenatal care is paramount in the prevention of pregnancy-related deaths, septic abortions are more insidious. What is worse, the latter tends to go unreported due to the nature and circumstances surrounding it. In many rural areas couples do not use any spacing methods and women conceive within 7 months of having given birth. Dr Leena Joshi of Family Planning Association of India (FPAI) is familiar with this scenario. Her voice drops with concern when she mentions abortion rates in the remote reaches of Maharashtra. "The abortion rate in these areas is just so high. With it comes hidden mortality from septic abortion deaths. Since the PHCs do not have MTP methods, the abortions are performed by quacks. And even if the PHCs or district hospitals have MTP methods, the people opt for local help." Why? "It saves them money. These are very poor people and transport costs and medical costs can be saved by walking to a local quack." As a result there are a high number of abortion-related deaths which do not get reported under maternal mortality. Dr. Joshi laments that everybody only talks about deaths during the childbirth process. "But since there are so many septic abortion cases it all goes unreported."
The problem of unsafe abortion is something that Shiva worries about as well. "Abortion (MTP) being legal in India, no one is turned away. Second trimester abortion is a big reason for rising MMRs." People come late for the abortions and complications ensue. And apparently these are not only driven by spacing problems. "Contraceptives are used only by women and failure of these is common," says Joshi. Of course, abortion of female fetuses is routine and it goes on until the woman conceives a male child. The whole scenario makes one shudder.
But all this seems to be not even half the story.
Take malaria, for example. Orissa has a high incidence and accounted for 28.6% of detected cases of malaria -- 41% of falciparum -- and 62.8% of all material deaths in India (1998). Malaria and pregnancy form a sinister synergistic pair. Falciparum malaria leads to abortion and still births in the gravid woman and can severely compound anaemia. Coincidentally, Orissa has a high incidence of sickle cell anaemia. The combination is lethal. The haemoglobin in pregnant women could drop to 1gm/dL (healthy levels are between 12-16gms/dL). While drugs are available to treat the malaria, the treatment requires a high degree of awareness and care in administration. For example, the common primaquine and tetracycline are absolute no-nos during any stage of pregnancy. But chloroquine and quinine are allowed. "But mistakes occur and are lethal," says Shiva. Acting fast and carefully is paramount and any deaths due to these infections are primarily due to gross neglect or ignorance. Orissa has one of the highest rates of MMR in India at 738.
Another key reason for deaths during pregnancy is post-partum bleeding or haemorrhage. The need for blood in such cases is imperative and access is less than ideal. Both Sudarshan and Shiva worry about the blood bank policy in India. Heavily driven by the HIV/AIDS lobby, they feel that somewhere the important issue of access to blood has been sacrificed for quality and safety since the policy makers are looking at it all from the AIDS perspective. Says Sudarshan,"The policy says you have to keep the blood in an air-conditioned room. But in Coorg, for example, you don't need it. HIV awareness is good, but blood banks need to be demystified and access and availability improved." Shiva adds, "It is imperative in case of complications during pregnancy to have blood available. But no. NACO only sees blood banks from their perspective and only in an emergency are you allowed to take blood from the banks. It is a major concern." When it comes to donation, Shiva points to an endemic problem. The strange connection between men, caring for women, and giving blood. "If the men have to pay a lot of money and go far to get blood for their wives, they just won't. And men will never give blood. They think a 100 drops of blood equals one drop of semen and thus, giving blood is related to potency. And so many times, when women need blood, it is not available."
Organisational reasons
Early diagnosis of high-risk pregnancies and complications and quick referrals are of paramount importance. But is institutionalising deliveries the answer? By requiring 100% institutional deliveries, the World Bank supported vertical program Reproductive Child Health 1 (RCH1) resulted in the abolishing of the dais (Traditional Birth Attendants), and Sudarshan believes, probably increased MMR. Subsequently, following a public uproar, the program was amended to advocate "training" TBAs into Skilled Birth Attendants. "Institutional support will bring down MMR, yes, but what type of institution is important," says Sudarshan. "The so called Primary Health Care units are so dirty that infection will probably increase because of them." "In Bihar, for example," explains Sudarshan, "80% of the deliveries happen at home. In Karnataka it is 70%." Joshi concurs with this high degree of preference. "In the Bhandara area almost 100% prefer home deliveries. And if there are complications, it means there are inevitable delays in getting more sophisticated care."
Now, if there were a skilled birth attendant (SBA) at the time of each delivery or for antenatal checkups for each pregnancy, he or she can recognize a high-risk pregnancy or a potential complication and refer the mother to a district hospital or closest emergency care unit. The incidence of death from complications would be reduced. Countries like Malaysia have employed this strategy to bring down MMR to less than 100. In India only 43% of deliveries are attended by an SBA compared to between 86% and 99% in Mexico, China, Sri Lanka, Brazil and Thailand.
Sudarshan himself is involved in training tribal girls in the Soliga communities of Karnataka to be auxiliary nurse midwives (ANMs). For a population of 3000, there is a sub-centre and for every 5 or 6 sub-centres, there is a primary health care unit. Sudarshan's team trains the tribal girls in each village so that the few ANMs posted do not have to walk the 20 kms between the 4-5 villages this program covers. Joshi's team in Bhandara also trained 25 local dais or Traditional Birth Attendants (TBAs) to recognize complications and give basic medicines and obstetric care in the villages, one to each village. They also conduct antenatal checkups every month in about 10 villages. But funds for such programs are scant primarily because maternal health is not recognized as a priority issue in India. "The awareness that a pregnant woman should be taken care of is just not there," says Joshi. "If a woman is not delivering, the attitude used to be, let's wait and see, maybe tomorrow morning she will deliver. Now with our training, the dais can recognize complications but the money to shift the patient to a hospital is still not there."
This brings us to the next obstacle. So say the SBA refers to patient to an emergency obstetric care unit (EOC) and let's assume that we have one of those for every few villages. How would the patient reach the EOC? "Transport is a big issue. It is appalling that we do not have EMS (emergency medical services) that is efficient and well staffed," Sudarshan states categorically. He is working on building one for Karnataka with a coordinating body at district level which has jeeps, ambulances, even tractors available for responding to emergency calls. "We have to strengthen the PHC and an EMS is an integral part of that," he says. Bhandara is not so lucky. "Vehicles are available in 50% of the cases. But they are expensive. In the day, people can use buses, but not at nights. There are several rivers in this area and the buses are not allowed to travel over these at night," says Joshi.
Suppose the patient does reach the first referral unit (FRU) with complications that say, require a C-section. Is that a guarantee for a safe delivery? Sadly, no. Few FRUs run 24 hours. Joshi's hospital has 2-3 gynaecologists where the recommended number for the population of that area is 5-6. "All the C-sections and hysterectomies are carried out by these 2-3 gynaecologists. In the PHC in the villages, there is one doctor and 2-3 sisters (nurses), but they are only graduates, not post graduates or MBBS. So they cannot even do a complicated normal delivery, let alone C-sections."
Even in Karnataka, the FRUs are woefully understaffed and in some cases dangerously mismatched. "In one case," says Sudarshan with an ironic smile, "an orthopedist was posted where an obstetrician was required. With bribes, these so-called doctors can get posted to any area they want regardless of what is actually required there." And then there is the big problem of anaesthetists. At the Taluka level there is an acute shortage of them. Anaesthetists are required during complications and surgeries. When Sudarshan's team proposed that nurse obstetricians and other doctors also get trained in anaesthetics, the proposal was shot down by the medical lobby. Human resource management in the health sector seems to be a big issue. Shiva echoed the sentiment saying, "We need trained people in PHCs. And people with the right training. There is no point sending patients who require C-sections to where there is no anaesthetist or ob-gyn."
Government
Now, if we had fully staffed and functioning FRUs, would that bring down the mortality rate? Unfortunately, there is still one more layer that mothers have to contend with.
Shanta lives in a slum in Bangalore. When she was expecting her second child, she had the good fortune of being close to a government hospital where care would be free. Or so she thought. When she reached there, she realized that she had to 'buy' a bed or sleep on the floor. She also had to 'buy' food. So much so that she even had to 'buy' washing services or wear soiled clothes. And when it was time to "push" during delivery, she was just too weak, and the nurses slapped her. Left and right, again and again. They abused and cursed. "Is that the way to treat a patient?" Shanta queries in puzzlement. "My mother's house where I had my first born was better," she declared. Her sister-in-law Prema now laughs as she describes her own run-in with a local PHC outside Mysore. "They wouldn't give me my child until I paid up. Luckily I had saved all year, knowing this would be the case. The nurse was actually someone I grew up with. I thought she would be fair, but no. Everyone wants money." As soon as they got their money, she was sent home -– the same day -- with no medicines or follow-up monitoring either for her or her baby.
Corruption is not a new problem. "Even if the most sophisticated PHC is right across the road the ward boy needs to be bribed with Rs 150 to wheel the mother into the operation theatre and another Rs 300 to wheel her to the ward and most cannot afford that," declares a grave Sudarshan. In his opinion this final layer is the most important and toughest one to correct. "Bad governance. The real problem is not technological care but simply what I call the epidemic of corruption in the health services. And this is not just in the public healthcare sector, the private is just as bad," he says. "Doctors in Arunachal Pradesh take their pay checks but never show up. There is rampant corruption in procurement where, in one case, 123 spurious drugs were identified but bribes were taken and they were not reported. Dialysis machines which cost 5 lakhs are bought at 12.5 lakhs. Poor people end up spending huge amounts due to over-prescription of medicines that should be free to them. This is the real problem and no amount of infrastructure improvement will bring down MMR if governance is not improved," warns Sudarshan.
Shiva adds, "The private hospitals are mercenaries too. They perform unwanted C-sections and hysterectomies where none is required simply because there is big money in these procedures." Sudarshan, who sits in the anti-corruption cell of the Karnataka Government has presented strong recommendations to the Karnataka government regarding this issue. He stresses that good accreditation, accountability, good monitoring, and honest reporting are the only things that will actually bring down MMR, given the other necessities are taken care of.
And where will the money for the necessary infrastructure come from? Prime Minister Manmohan Singh has promised that the government spending on public healthcare -- which currently stands at an abysmal 0.9% of GDP (one of the five lowest in the world) -- will be increased to 2-3% of GDP which Sudarshan finds heartening, but tempers his optimism with caution. "It is great that there will be three times the amount available today for a sector that needs it badly, but one must plug the holes first. No point pouring all that money into a leaky vessel," he quips.
So, can it be done? Can MMR be brought down under 100 by 2015?
Sudarshan thinks so, but he will give it not 10, but 15 years. "It all comes down to political will. Sri Lanka, in spite of the civil war showed tremendous political will in tackling IMR and MMR and setting goals for themselves. Tamilnadu has a Deputy Commissioner (DC) monitor maternal mortality himself." This has increased the accountability and responsibility of the people in charge and has achieved good results. In Kerala, awareness about maternal health issues is high and the citizens demand more. Literacy plays a key role in keeping the MMR low. Kerala leads the way in successfully reducing MMR and Tamilnadu is close behind. While people like Sudarshan are doing everything to make sure it happens in Karnataka, the awareness and more importantly, recognition of this as an issue is lacking in other parts of India. In Uttar Pradesh, Madhya Pradesh, Bihar, Rajasthan, Assam and Orissa where the MMRs are well above the national average, it will require serious political will and accountability to change status quo.
The Ministry of Health and Family Welfare puts plans in place with the best of intentions (see here), but until governance and administration is addressed, people like Prema will still have no guarantees of care without paying beyond their means to like other pockets. But whether we will make progress will also be determined by when the Ministry recognizes MMR itself one of the key "Health and Population Indicators." Today, they do not. (See here.)
Both Shiva and Sudarshan agree that what India does not require is yet another vertical program to tackle maternal mortality. Verticals tend to be donor driven and cost intensive. MMR is not a disease unto itself. Clearly, high MMR is a symptom of a larger and wider problem in healthcare, namely the overall health of the woman, and should be treated as such and across verticals. Tackling a lot of the broader issues of governance and infrastructure should bring down the MMR. The National Rural Health Mission aims to reach across verticals to integrate services and by appointing an Accredited Social Health Activist (ASHA) at the community level provides decentralized first contact care. Shiva was part of one of the Task Forces of the NRHM and lauds its efforts as broadening the RCH program. But in order that the NRHM succeed, we come back to the need for evaluation methods and strong accountability.
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 ignoring an important determinant of the health of our nation. In doing so, we may be running the risk of damaging our chances for all-encompassing prosperity.
Ways to tackle maternal mortality
To check the maternal mortality rate in India, health experts have stressed on changing the traditional treatment and delivery system being practised in most villages.
At the 52th All-India Congress of Obstetrics & Gynaecology, the annual meeting of The Federation of Obstetric & Gynaecological Societies of India (FOGSI), gynaecologists from across the globe advocated the need to adopt advanced strategies practised in some of the countries in Africa.
“Lack of access and inadequate utilisation of healthcare facilities are responsible for maternal deaths in India. Countries like Mozambique have made good progress in reducing maternal mortality ratio (MMR),” explained Staffan Bergstrom, from Sweden.
Bergstrom added that the healthcare facilities in remote areas of countries like India are virtually absent, with no specialist doctors and advanced treatment facilities.
“In a number of countries with low per capita income, there is a scarcity of specialist doctors. Non-specialist doctors do major surgeries and fail to diagnose complications. Besides, many medical and clinical officers are being trained to perform surgeries in remote places, where specialists are not available. This is very risky,” Bergstrom explained.
“We should remember that children’s health is directly related to mother’s health. The MMR reflect the health of our nation. So, we should introduce advanced facilities in our villages,” said Gita Ganguly Mukherjee, former head of obstetrics and gynaecology, RG Kar Medical College and Hospital.
In India, one of 48 expecting mothers is at risk of dying during childbirth. According to the data of National Health Policy 2002, the MMR in India is as high as 407 per 100,000 live births. Other sources have put the MMR as high as 540 (NHFS and Unicef data, 2000).
“The chances of death of an Indian mother during childbirth is roughly 10 times more than that of her Chinese counterpart,” said Bergstrom.
India and other Third World countries have set a goal to reduce the MMR by three-quarters by 2015.
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