A battle half won

In the post-delivery ward of a community health centre in Chharchh village of Madhya Pradesh, a February 2012 photograph. The State has launched a free maternity ambulance service to take pregnant women to health clinics in rural areas. The main reason why women in some other parts of the country opt for delivery at home is the lack of transport.-VIVEK PRAKASH /REUTERS

A study finds that institutional support alone cannot help reduce maternal mortality in India.

THE high rate of maternal mortality in India has been a cause for national concern, especially on account of the focus on reaching the United Nations Millennium Development Goals by 2015. Although there is a growing realisation that it will be difficult to meet the MDG targets by that deadline, there is a renewed interest in the government schemes that attempt to arrest maternal mortality.

According to the U.N., India accounted for 19 per cent of all maternal deaths worldwide in 2010. The prevalence of anaemia, as per the National Family Health Survey of 2005-06, was 55.3 per cent for all women in the country in the 15-49 age group; among pregnant women, this figure was 58.7 per cent.

A study conducted jointly by the Public Health Foundation of India (PHFI), the London School of Hygiene and Tropical Medicine, and the University of Aberdeen among 500 women who had recently delivered children in Jamtara district of Jharkhand sought to explore a different dimension altogether womens perceptions of quality and satisfaction with maternal care. Jamtara is one of the 264 high-focus districts under the National Rural Health Mission (NRHM). Of the women interviewed for the study, 210 had delivered at a primary-level institution and 290 at home. Interviews with service providers such as auxiliary nurse midwives (ANMs), accredited social health activists (ASHAs) and traditional birth attendants (TBAs) were also conducted.

In particular, the implementation and levels of satisfaction with the Janani Suraksha Yojana (JSY), one of the flagship maternal health programmes of the government, were studied. The JSY, a conditional cash-transfer programme, has been in operation since 2005. According to recent studies, institutional deliveries under the JSY went up from 53 per cent of all deliveries in 2005 to 73 per cent in 2009. In Jharkhand, the increase was from 19 per cent in 2005 to 40 per cent in 2009-10.

The women surveyed (95 per cent) belonged to the Scheduled Caste, Scheduled Tribe and Other Backward Class categories. The majority, 85 per cent, were from households with monthly incomes less than Rs.5,000. More than half (53 per cent) of them were illiterate.

The study focussed on the basic determinants of maternal satisfaction. The determinant that emerged as the most important was the interpersonal behaviour of the service provider. Abusive behaviour was clearly a disincentive. The study says the behaviour of the provider, in terms of respect, politeness, friendliness and encouragement emerged as a predictor of maternal satisfaction.

The study listed seven determinants of maternal satisfaction interpersonal behaviour of the providers, influence of community health workers in deciding the place of delivery, accessibility of the health institution, emotional support during delivery, faith in the clinical care provided in terms of the presence of skilled staff, availability of medicine and the cost of services.

The study included a literature review of the experiences of other developing countries with schemes like the JSY. Access to health centres in terms of distance and transport connectivity was found to be a leading determinant of maternal satisfaction in all of them. The perception of what constituted good care in other countries differed from what it was in India. Good care in the literature review revealed a range of determinants such as preference for female providers, emotional support (companion of choice at childbirth), cognitive support (prenatal counselling), length of consultation, completeness of procedures, and perceived provider competence, among others. But in India, the survey identified very basic determinants such as accessibility to institutions, cleanliness of the place of delivery, availability of trained medical personnel, availability of medicine in case of complication and for pain management, interpersonal behaviour of providers, better comfort and privacy, and presence of family members during delivery. These demands apply to any community or region.

In fact, accessibility to an institution that will ensure optimal transport costs and relative comfort of the transport used have for long been known to be considerations for maternal satisfaction. The problem in India is that women seldom get to decide when they want to get pregnant or where they would like to deliver.

In the Jharkhand survey, 22 per cent of the respondents said that institutional delivery was the decision of the husband or of their family; 69 per cent preferred institutional delivery as they perceived that the outcome would be better compared with home delivery, while one-third seemed to be attracted by the cash benefit.

Nearly two-fifths said they preferred home delivery on account of better comfort and privacy. One in three women reported they chose home delivery because there was no one to look after the other children at home. The absence of crche and Anganwadi services did not give them a choice in the matter.

Clearly, the women chose to deliver at home so as not to disrupt chores at home. Unlike their well-to-do counterparts who can afford a complete network of services, including the services of a nurse or a domestic help at home, the majority of women in India suffer the double burden of work during pregnancy and after delivery. It means that their rest period in the pre- and post-natal period is limited to a few days.

The study could have looked deeper into the socio-economic determinants of home versus institutional delivery and also presented the economic profile of the respondents to give a better understanding of why the women responded the way they did.

However, one thing is clear. The government cannot hope to arrest maternal mortality through conditional cash-transfer arrangements. If that was the case, the JSY would have been a resounding success. There are problems in the conceptualisation and implementation of the scheme, linked as it gets sometimes to the population stabilisation programmes of the government. Twenty-seven per cent of women preferred giving birth at home owing to the services of the TBA, or dai. Health activists and practitioners have argued for long that given the failure of the system to provide for a smooth transition from home delivery to institutional delivery, the TBAs should be trained to deliver a baby and to identify complications. It is only in the event of unexpected complications that women opt for institutional delivery.

Current statistics of the health infrastructure in the country show that it has a long way to go to provide health-care services at accessible levels. The current doctor-patient ratio is 1:2,000, as per the High Level Expert Group on health constituted by the Planning Commission. According to a Planning Commission draft on health for the Twelfth Plan period, there is a massive shortage of doctors (76 per cent), nurses (53 per cent) and laboratory technicians (80 per cent) in the public health-care sector. Creation of infrastructure has been slower in the high-burden States, called EAG (Empowered Action Group) States, than in other parts of the country, says the draft, while reviewing the performance in the Eleventh Plan. The shortfall in terms of total number of required facilities as of March 2011 was 17 per cent for sub-centres, 18 per cent for primary health centres (PHCs) and as much as 34 per cent for community health centres (CHCs). An important fact, says the draft, is that very few of these facilities meet the Indian Public Health Standards (IPHS).

The NRHM, aimed at strengthening health infrastructure with special focus on reproductive and child health services (RCHS), includes disease control programmes too.

Though largely restricted to rural areas, many of its services, such as RCHS, JSY and malaria control were extended to urban areas. The strategy consisted of strengthening sub-centres, PHCs and CHCs and providing a 30-50-bed CHC per lakh population for improved curative care meeting normative Indian Public Health Standards. Strengthening these institutions involved the creation and improvement of physical infrastructure as well as the recruitment of personnel, the draft chapter says.

A key element of the NRHM is putting in place a trained female health activist called ASHA for every 1,000 persons to facilitate community access to public health services. She is also expected to aid in bottom-up planning and provide community-level health education and care.

None of these targets has been met with satisfaction despite the NRHM accounting for nearly 73 per cent of the total budget of the Ministry of Health and Family Welfare. The maternal mortality rate (MMR) in India was targeted to come down to 100 deaths per 100,000 live births at the end of the Eleventh Plan. It had declined from 254 per 100,000 in 2004-2006 to 212 in 2007-2009. The largest decline is in the eight EAG States and Assam (from 375 to 308), followed by the southern States (149 to 127) and other States (174 to 149). The data for 2011-12 are not available.

The draft opines that the target for the Eleventh Plan will not be achieved even though the MMR has declined. If the current rate of decline continues, it is unlikely that the MDG goal of a three-quarters reduction in maternal deaths over the 1990 level will be reached by 2015, it says.

Therefore, there are other structural determinants that influence a decline or an increase in morbidity and mortality rates. The PHFI study found that one in four women reported that institutional delivery was too expensive.

Of the 225 women who indicated in the survey that they intended to deliver in an institution, 70 per cent delivered in an institution and the rest at home. Of the 275 respondents who said they intended to deliver at home, 81 per cent did just that, while the rest opted for institutional delivery when complications arose.

The study has underscored what several others have been saying for long that the ability to access the institution in time is one of the major factors deciding the venue for delivery. Women who preferred institutional delivery ended up delivering at home. The most common reason for this was that there was not enough time to reach the institution after labour pains started: transport was not available or there were no male or other family members available to arrange transport, accompany the pregnant woman or look after the household in her absence; or the woman felt too weak physically to go to the facility.

More than one-third delivered at home because they could not reach the facility in time as comfortable transport was just beyond their reach. More than 80 per cent, the study found, could not arrange transport. Bad roads, poor connectivity and unavailability of transport at night were some of the hurdles experienced by the respondents.

Notwithstanding the chest-thumping on the success of the JSY, some 40 per cent of women spent more than Rs.1,400 (the amount provided through the JSY) for institutional delivery alone. The money received was spent on buying drugs including injections, which often have to be procured from outside the facility. Informal payments to the facility staff raised the overall costs. The average expenditure on institutional delivery was Rs.1,050, compared with Rs.700 for delivery at home. Sheer poverty and high collateral costs of health care (bribes to hospital staff, transport expenditure, and so on) made women opt for home delivery, despite the risks.

While ASHAs had a role in convincing women to opt for institutional delivery, several studies show that they were treated like second-class citizens when they accompanied the pregnant women to hospitals. Earlier this year, ASHAs who were protesting in New Delhi against their working conditions told Frontline that they were not given a place to sit and eat their food at these institutions. They also said that pregnant women were routinely humiliated and shouted at by the staff at the health centres.

Apparently, the Ministry of Health is in the process of formulating guidelines for supportive supervision for quality monitoring of health services in facilities. But supportive supervision is right now confined to monitoring of the supply of services in individual facilities.

The joint study is unique in that it talks for the first time about the need for client feedback. Maternal mortality cannot be arrested by providing institutional care alone, limited as it is in the present form. There are nutritional requirements of the mother during pregnancy and after delivery, which are seldom met for want of money, that need to be taken care of. Client feedback should help find out what kind of nutritional support the women got throughout their pregnancy. Institutional support can at best be an enabling factor, not the real determinant of the reduction or elimination of maternal mortality.