By Samiya Anwar &
M H AhssanTaj 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 RealityWomen, 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
