Maternal tragedies

A scene inside the Government Maternity Hospital in Kothi, Andhra Pradesh. In this file photograph, two lactating mothers, with their babies, are seen sharing the same bed. The lack of proper post-natal care often proves fatal.-P.V. SIVAKUMAR

THE maternal mortality ratio (MMR) is calculated by the number of maternal deaths for every 100,000 births. Consider this: In 2005, Indias MMR was 16 times that of Russia, 10 times that of China and four times higher than that in Brazil.

Why should there be such high maternal mortality rates in a country that claims to have almost reached superpower status? A report titled No Tally of the Anguish, published by Human Rights Watch, points out that there is just no uniform mechanism or system in place to detect the large number of maternal deaths that occur each year. The report, based on research conducted between November 2008 and August 2009 with field investigations in Uttar Pradesh, argues that if only government officials across the country ensure that policies make a difference in the lives of all women and girls, regardless of their backgrounds, incomes and caste, the goal of reducing maternal mortality by 75 per cent, as part of the countrys commitment to the Millennium Development Goals, can be achieved.

The author of the report is Aruna Kashyap, a researcher with the Womens Rights Division of Human Rights Watch. It focusses on Uttar Pradesh because the State has a high MMR and is one of the States where the government has introduced an executive order requiring that all maternal deaths be investigated.

The report says that of every 70 Indian girls who reach reproductive age, one will eventually die because of unsafe pregnancy, childbirth or unsafe abortion, compared with one in 7,300 in the developed world. Quoting a 2005 study by the World Health Organisation (WHO) on maternal mortality estimates drawn by several other United Nations agencies, the report says India alone contributes to a little under a fourth of the worlds maternal mortality, with 450 maternal deaths for every 100,000 births.

Some records of maternal deaths are maintained, but the report argues that these camouflage the disparities within communities and within States. For instance, there must be an explanation for the increase in maternal mortality in Haryana and Punjab though both States have high per capita incomes. In addition, poor maternal health care continues to be pervasive among the poorer sections, in particular the marginalised Dalit communities. So, on the one hand there are already sections with poor maternal health; on the other, there have been increases in maternal mortality in areas that did not report high death rates earlier.

There are disparities between States, too. The MMR in Uttar Pradesh is three times higher than that of Tamil Nadu. Within States, too, there are differential levels of access to health care, depending on economic factors and, to some extent, social and cultural ones, the report says. It is apparent that it is mainly easy and cheap access to health care that determines how frequently people are inclined to visit health care providers. This access is still missing in most places. A humane approach to the very basic health needs of a population is also lacking.

The research conducted in Uttar Pradesh shows that a health worker trained in midwifery is often constrained to deal with an inadequate supply of drugs for obstetric first aid and the absence of emergency obstetric care and referral systems to deal with complications such as haemorrhage, obstructed labour and hypertensive disorder. Often referrals are made without the provision of emergency transport. Uttar Pradesh alone faces a shortage of 583 community health centres; fewer than a third of the existing ones have a full-time obstetrician or a gynaecologist, and 45 per cent do not have the funds to operate even one ambulance. Most of the staff at the community health centres told the researchers that they conducted only what was called normal deliveries, implying that they were not equipped to deal with complications. When they have to refer pregnant women for specialised care, the referral centres with blood transfusion facilities and Caesarian sections are often located more than 100 kilometres away. The want of timely attention often proves fatal, the report says.

The best institutional delivery cannot save a pregnant woman or a new mother unless she is cared for in the immediate post-natal period, that is, between 24-72 hours, with a follow-up care in case of complications, states the report. A 2008 government survey reveals that in Uttar Pradesh there was a drop in care even within the immediate post-natal period of 48 hours of delivery.

The governments health care systems promise a range of free services, but there is discrimination built into the system. The Janani Suraksha Yojana, meant to encourage institutional deliveries with the larger objective of controlling maternal deaths and improving maternal health, is in many States not open to pregnant girls under 19 and women who already have two children. The report argues that if there is a proper system to monitor maternal deaths, corrective measures can follow. Among the problems in Uttar Pradesh is the failure of information from the district level onwards on where, when and why deaths and injuries occur. There are also no grievance and redress mechanisms, not even emergency response systems. Even after institutional deliveries, there is no follow-up effort to record whether the mother survived the post-natal period without injuries, disabilities or infections.

There is no information about the type of care that women get. There is also no exhaustive documentation of maternal deaths in the State. Health workers are told to record deaths directly related to pregnancy or delivery and the ones that occur within six to eight hours of delivery. Beyond that there is no information.

In contrast, the report says that in Tamil Nadu there are awareness campaigns around maternal deaths, and that the authorities encourage the reporting from multiple sources, including family members and health workers, of deaths of all pregnant women irrespective of the cause of death, and educate health workers on why such reporting is important. The report argues for a robust civil registration system that can record all births and deaths, including the cause of death. Uttar Pradesh, it says, has the worst civil registration systems in the country.

Though the government, through the National Rural Health Mission, is trying to encourage institutional deliveries in an effort to check maternal mortality, health activists are sceptical. In addition to the architectural correction of the health system, they would like the mission to institutionalise a system of investigations into maternal deaths. A sensitive approach to dealing with pregnancy and pregnancy-related complications is also needed.

The impoverished women who avail themselves of the government health facilities often do not complain against health providers for fear of reprisals from doctors and health workers. Most maternal deaths are preventable. What is required is a comprehensive approach to health care, not only in purely medical terms but in addressing the nutritional needs of women.

Nearly 65 per cent of maternal deaths are caused by direct obstetric causes such as haemorrhage followed by sepsis and unsafe abortions. Maternal deaths are also caused by such indirect causes as tuberculosis, viral hepatitis, anaemia and malaria; the rate of such deaths in India is much higher than the global average.

These problems get more complicated for women from the poorer sections, who have inadequate access to healthy food and low-cost health care. The investigation of systemic causes can help establish systemic responses. A numerical target of reducing maternal mortality by itself means little in the context of the absence of health services and nutrition.