In Visakhapatnam's remote tribal village, Bhagya (23) just lost her eighth child during delivery after a three-hour struggle by her relatives to save the baby. Married at 13 and having delivered her first child at 14, Bhagya lost three babies within 20 hours of their birth. Fatigued with failure and wasted effort, Bhagya's relatives cut the umbilical cord but left the placenta intact, leaving her to the risk of post-partum haemorrhage.
This risk is not unique to Bhagya or because she lives in a tribal village, but common to deliveries that happen at home, which accounts for three-fourths of all child birth in India. Thus, both this year's World Health Day (April 7) and the World Health Report, "Every Woman and Child Counts", focus on maternal and child health. In this era of high technology and medical advances, the death every year of 11 million children and over half a million mothers around the world seems senseless. Ironically, most of these deaths are preventable and caused mainly by malnutrition, infections and lack of access to even basic healthcare and transportation. Almost all the deaths happen among the poor of the developing countries primarily because, as U.N. experts say: "This is not a high enough priority for many governments or the international community."
In 1990, leaders from 189 countries pledged to achieve by 2015 the Millennium Development Goal of reducing child mortality by two-thirds and maternal mortality by three-fourths. But can this happen?
The statistics are hardly encouraging: Every minute, across the world, 380 women become pregnant; 190 face unplanned or unwanted pregnancy; 110 experience a pregnancy-related complication; 40 have an unsafe abortion; and one woman dies of a pregnancy-related cause. Globally, some 550,000 pregnancy-related deaths are reported every year and 90 per cent of these deaths happen among the poor in the developing countries. Rightly, the World Health Organisation (WHO) calls maternal mortality "scandalous" and an "invisible emergency".
Social and cultural practices, which are largely responsible for the poor health conditions of most women, are also among the important causes of maternal mortality. Early marriage and pregnancy, when the reproductive organs are not yet properly developed; high fertility rate leading to recurrent pregnancies; and unwanted pregnancies, when the foetus is aborted crudely most often at home, all leave most women vulnerable. Only one out of six women aged between 17 and 35 receives prenatal care while more than half of them are anaemic. Hardly 20 per cent of mothers receive complete prenatal care.
WHO defines maternal mortality as the death of a woman while "pregnant or within 42 days of termination (by delivery, miscarriage or abortion) of pregnancy."
More than 80 per cent of maternal deaths worldwide have five direct causes: haemorrhage (34 per cent), unsafe abortion (18 per cent), obstructed labour (11 per cent), hypertensive disorders (16 per cent) and infections (21 per cent). All, easily preventable.
Of all the social indicators, maternal mortality accounts for the largest gap between rich and poor nations. Over 90 per cent of maternal deaths occur in Asia and Sub-Saharan Africa, with the latter accounting for 50 per cent of the fatalities.
The maternal mortality ratio or MMR (the number of deaths per 100,000 live births) is a measure of the risk of death once a woman becomes pregnant. In India it is 407, it is 95 in Vietnam, 60 in China and Sri Lanka, 15 in New Zealand, 12 in Japan, nine in Singapore and six in Australia.
There is, however, a wide regional difference in MMR within India. In Kerala and Punjab it is very low, while in 10 of the 15 major States (Assam, Bihar, Gujarat, Haryana, Karnataka, Madhya Pradesh, Orissa, Rajasthan, Uttar Pradesh and West Bengal) it is over 400; and in three States (Assam, Madhya Pradesh and Uttar Pradesh) it is over 700.
In India, over two-thirds of women give birth at home - close to 85 per cent in the rural areas, and 95 per cent in the remote areas. Every five minutes a woman dies from complications related to pregnancy and childbirth, adding up to around 136,000 fatalities a year, one of the highest in the world. For every woman who dies, at least 30 suffer injuries and often, permanent disability. Maternal mortality is the main factor that considerably lowers the life expectancy of women. Twenty-five per cent of maternal deaths occur during pregnancy; 50 per cent within 24 hours of childbirth; 20 per cent within seven days of delivery; and 5 per cent from two to six weeks of childbirth.
Says Joy Phumaphi, Assistant Director-General, Family and Community Health, WHO: "Pregnancy is a normal, life-affirming state. Women should not die giving birth. Their deaths are preventable even in the poorest countries." But many women have no role in decision-making even when it comes to their own health.
In India, only 9.7 per cent of married rural women (15-49) have a hospital within the village and 40 per cent live more than 10 km from a hospital. In such cases a skilled health worker is a boon. Thus, Unicef has taken up "ensuring skilled birth attendance for every birth" as a rallying point for this year's Safe Motherhood Day on April 11.
One of the biggest health concerns in India is the issue of young mothers. More than 10 per cent of girls below 20 are already mothers. According to the National Family Health Survey, 6.4 million women under 18 are married; 11 per cent of all under-20 women are mothers. According to the survey, the average age of marriage for women was 16 and the first baby was born at the age of 19.
Says Dr. Ardi Kaptiningsih of the WHO: "Many women die not only because they are too young but also because of repeated pregnancies for the sake of a son."
Three important ways by which maternal deaths can be controlled are: (a) family planning - that is, every pregnancy should be a wanted one; (b) skilled attendance at child birth - all pregnant women must have access to skilled medical care; and (c) essential obstetric care - all pregnant women must be able to reach a manned and equipped healthcare facility if complications arise.
Mandatory antenatal investigations for all pregnant women will dramatically lower pregnancy-related risks. They help in detecting and treating existing problems and complications and providing counselling thereafter to help the women prepare for birth and advise them where to seek care if complications arise. It was found that in the three years preceding India's National Family Health Survey 1998-99 (NFHS-2), 35 per cent of pregnant women received no antenatal care. Only 15 per cent of pregnant women receive complete antenatal care and only 58 per cent receive iron and folate tablets or syrup. Hardly two-thirds of deliveries are attended by skilled birth attendants and only a-third receive some postnatal care.
Maternal mortality and morbidity are more likely in nations and cultures that give little priority to the needs, status and situation of girls. In many of these cultures, maternal illness and suffering are viewed as natural, inevitable, and part of what it means to be a woman.
Girls routinely face discrimination in many cultures. In South Asia, the cycle of discrimination starts at birth because of a preference for sons and the perception of girls as an unwanted financial burden. Parents are reluctant to invest in girls' health and education because they will get married young. Studies have shown that female babies in South Asia are breastfed less frequently than male babies, and are often not treated for illnesses. In most households women eat last and the least, their growth is stunted by nutritional deficits. They marry early, do not use contraceptives, become under-weight and anaemic mothers; they are further weakened by frequent childbearing. Malnourished mothers have low-weight babies, who have few chances for survival.
One of the key words in the World Health Report (WHR) is `exclusion'. "Women," it says, "are being excluded from essential services, and governments have a responsibility to do something about it." U.N. Population Fund Executive Director Thoraya Ahmed Obaid says: "One sure way to make every mother and child count is to guarantee universal access to reproductive health, as was agreed at the International Conference on Population and Development [which was held in Cairo in 1994]."
Noting that pregnancy would be a death sentence for half a million women this year, Obaid stressed that more than 200 million others have an unmet need for safe contraception. "This is a public health crisis and a moral outrage as it can be easily dealt with," she says.
The WHR notes that every year, 68,000 women die from botched abortions. Dr. Ian Smith, adviser to WHO Director-General Dr. Lee Jong Wook, argues that family planning should be an integral part of women's overall health and each pregnancy should be made safe and desired.
The WHR puts India on the list of 51 "slow progressing'' countries with respect to infant, child and maternal mortality. The decline in the infant mortality rate is slow; the fall is lesser for neonatal mortality (NMR) and there is almost no change in the rate of stillbirths. Every year, as many as 10 per cent of all new-borns do not live to see their fifth birthday. In absolute terms, India accounts for 25 per cent of the over 10 million under-five deaths worldwide every year. Nearly half of these deaths occur in the neonatal period.
Vaccine-preventable diseases such as measles - the biggest killer- continue to claim children in thousands. Non-administration of Tetanus in newborns remains a major problem in at least five States - Uttar Pradesh, Madhya Pradesh, Rajasthan, West Bengal and Assam.
Says Vinod Paul of the All India Institute of Medical Sciences' paediatrics department: "A majority of infant deaths can be averted through affordable interventions such as breast-feeding, clean delivery, maintaining warm temperature for the baby and antibiotics."
As there is a clear correlation between the health of the new-borns and their mother's risk during and after delivery, the WHR points out that maternal and child deaths can be reduced through a "continuum care'' approach - from pregnancy to a safe delivery, followed by adequate post-natal care for the mother and the infant. This means a massive investment in health systems, particularly the deployment of more doctors, midwives and nurses, since millions of women are giving birth at home without professional medical care.
According to the WHR, the availability of resources for the health sector is a major challenge. Says Dr. Ian Smith of the WHO: "Most problems need simple cost-effective solutions." There is, however, a need for about $90 billion every year over the next 10 years in 75 developing countries. He says: "It is simply a question of what the Governments priorities are?"
Not that the government is not aware of all this. In fact, the latest National Population Policy of India focuses on the government's commitment to safe motherhood. Among the goals identified for 2010 are: reducing MMR to below 100, IMR to below 30; NMR to below 20; achieving 80 per cent deliveries within health institutions; addressing the unmet needs for basic reproductive and child health services, supplies, and infrastructure; and the presence of trained personnel in the community at all births.
To make childbirth safer, the Health Ministry last year decided to pay midwives to bring pregnant women to hospitals for check-up and delivery, and the latter for having their babies there. The idea, according to an official in the Health Ministry, is to raise the number of women delivering in medical institutions from 33 per cent to 80 per cent.
For the pregnant women who are caught between a poor and inadequate government health system and an unaffordable private one, midwives are godsend. But most important is that the midwives are trained to perform clean deliveries, recognise danger signs in the mother and the new-born, and be able to make appropriate referrals. Moreover, training can be beneficial only if the midwives are part of the larger health system and are provided the basic necessary equipment such as a disposable delivery kit.
According to a WHO study, a safe motherhood programme using existing resources would cost developing countries less than $3 per person a year. The study concludes: "Ultimately, the critical need may be one of generating sufficient political and social will at international and national levels to overcome this avoidable tragedy."
Dr. Ann Tinker of the international NGO, Save the Children, says: "Simple delivery kits that provide a clean blade to cut the umbilical cord, soap for hand washing and a plastic sheet to place the baby can go a long way in saving the mother and the child during delivery." According to her, the child's survival is closely linked to the mother's.
