‘Jab khush khabri ka pata chale tab, paanch gaantt bhandh lo….’.
This catchy slogan is a television commercial promoted by the Ministry of Health and Welfare and has a special social message to give away. In line with the Millennium Development Goals (MDGs)-5A set by World Health Organisation (WHO); this ad is initiated to improve maternal health and reduce maternal mortality rate (MMR) in India. Interestingly, the ad these days is being flashed every half an hour on India’s popular television channels, leaving a powerful impact in the minds of lakhs of Indians across the country.
Kudos to the government for using television, the fastest and most preferred means of mass communication in India, as a medium to create awareness on maternal mortality and educate every expectant parent of his/her responsibilities during the crucial nine months. Perhaps, this technique of reaching out to people would help in augmenting the initiatives taken to bring down the toll of MMR across the country, which despite the various health programmes made available by the government continues to be a major cause of concern for India.
The MDG-5A, in the year 1990, prescribed a level of 109 maternal deaths/100,000 live births by 2015, in order to curb the growing incidence of MMR across the globe, especially in developing countries including India. Sadly, the MDG Report issued by the UN Secretary General last year reported that every 10 minutes an Indian woman dies from complications related to pregnancy and childbirth and meeting the MDG seems to be a pipe dream.
The problem
The reasons behind the disturbing number of maternal deaths in India are mainly anaemia caused by malnutrition, lack of family planning, unsafe abortions, ante and post-partum haemorrhage, obstructed labour, hypertensive disorders,post-partum sepsis and lack of healthcare facilities in reproductive health in the hinterlands. As per the Planning Commission of India the percentage attributable to the causes are stated below:
The Government of India, for this reason, has created a Maternal Health division under the Department of Health and Family Welfare which has introduced safe motherhood programme in the year 2005 which is also called the Janani Suraksha Yojana (JSY). This scheme was launched under the umbrella of National Rural Health Mission (NRHM) and proposed by way of modifying the National Maternity Benefit Scheme (NMBS). While NMBS is linked to the provision of better diet for pregnant women from below poverty line (BPL) families, JSY integrates the cash assistance with antenatal care during the pregnancy period, institutional care during delivery and immediate post-partum period in a health centre by establishing a system of coordinated care by field level health worker.
With the help of this initiative the MMR toll in India has been reduced a bit. As per the Registrar General’s Govt of India report, MMR in the country was 327 per 100,000 live births in 1999 but it has come down to 212 per 100,000 live births in 2007-09 i.e. a decline by 115 points in the last 10 years. Thus, the country has reduced MMR by an average of 11 points per year. In view of this there is likely to be a decline of another 50 to 60 points by 2015 i.e. country may attain MMR of 162. However, this is just a small drop in the ocean. There is still a very long way to go. Statistics from the National Population Policy of India reveal that India still accounts for over 20 per cent of the world’s maternal deaths. According to the National Health Profile report, states such as Kerala, West Bengal, Tamil Nadu and Maharashtra, have succeeded in bringing down the numbers; however, Assam, UP/Uttarakhand, Rajasthan, MP/Chhattisgarh, Bihar/Jharkhand and Orissa lag behind, which adversely affects the average rate of MMR of the country.
| Causes for maternal mortality | Percentage |
| Haemorrhage | 30 |
| Anaemia | 19 |
| Sepsis | 16 |
| Obstructed labour | 10 |
| Abortion | 10 |
| Toxemia | 10 |
| Others | 8 |
Deterrents to progress
The current state of MMR in India raises numerous questions. Regardless of continuous efforts and rapid economic progress, India still falls short of meeting the set MMR target, so what has actually gone wrong? Were the efforts taken under the JSY not up to the mark? Were these efforts taken up too late in the day? Or is India expecting the “revised” MDG? And why is it that only few states in India have been able to succeed in undermining MMR?
Addressing these questions, Dr Ranjit Chakraborti, Obstetrician, Gynaecologist and Laparoscopic Surgeon, Fortis Hospital, Kolkata says, “Geographical vastness and socio-cultural diversity in India indicates that maternal mortality varies across the states, and therefore uniform implementation of health-sector reforms is a tall task.” Pointing out the other factors that have been detrimental to the progress of these initiatives, he goes on to say, “Maintaining healthcare standards at the grassroots level requires interdisciplinary cooperation and collaboration among doctors, midwives, auxiliary nurses and other paramedical staff. The provision of healthcare at the terminal end of healthcare system in the rural areas urgently requires a well intended political drive to improve the present scenario. The high MMR is due to large number of deliveries conducted at home by unskilled persons with zero compliance to basic hygiene standards. Added to this, lack of adequate referral facilities to provide emergency obstetric care for complicated cases also contribute to high MMR. Other prominent concern areas are the age of marriage and child bearing, child spacing, family size and fertility patterns, literacy, socio-economic status and the age-old customs and beliefs.”
Dr Sujata Datta, Consultant Obstetrician and Gynaecologist, Fortis Hospital -Anandapur, Kolkata also blames it on the poor healthcare system in our country. She opines, “Lack of transport and infrastructure that would ensure delivery of service at grassroot level, lack of trained manpower, socio- cultural and political factors which together determine the status of the woman, her health, fertility and access to healthcare, unmet need for contraception of women resulting in unplanned pregnancies, unsafe terminations causing sepsis and maternal deaths, as well as lack of emergency care facilities at the rural level causing deaths from eclampsia are some of contributors to the slow progress in achieving the goal against MMR in India.”
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On the same lines, Dr Neena Bahl, Sr Consultant, Obstetrics and Gynaecology, Max Hospital feels that the increase in rate in maternal mortality is a reflection of poor health facilities in rural areas. Lack of knowledge, prevalence of home delivery by dai maas, low preference to female health in rural setting leads to increase in MMR.
Taking umbrage at the absence of ambulance services in the rural areas, Dr Asha Singhal, Consultant Obstetrician & Gynaecologist, Bombay Hospital Institute of Medical Sciences, Mumbai states, “We need better roads and transport facilities for quick transportation to provide urgent medical attention. It is not uncommon to see pregnant women in rural areas being transported on bicycles, motorcycles, handcarts, bullock carts, auto rickshaws, and tractors to the medical centres which are not within easy reach. Quick ambulance services should be available in all regions. With the use of cell phones it should be possible, in today’s day and era, to call the ambulance (equipped with trained paramedical staff) to transport the patients,” she points out.
Apart from lack of organised healthcare systems and infrastructure at the primary level, marriage and childbirth at an early age has also been one of the leading reasons for the problem in India. About 50 per cent of the women in India marry before they are 18 and by 19 years of age half of them have their first child, states the millennium goal report of last year. Dr Vivek Padgoankar, Director, Organization of Pharmaceutical Producers of India (OPPI), flagged another important issue. He draws attention towards the mindset that people living in the rural areas have. “Women here, go by the beliefs of their mothers and grandmothers who delivered babies at home. This mindset becomes the biggest challenge that healthcare workers working in these areas face. The other challenge related to the mindset of people, is that the preference for a male child in comparison to a girl child. People in rural India keep having babies till they have a male child. This, again, is one of the major causes for maternal deaths in India. I personally feel that if we can change this mind set we will be able to overcome many women related issues in India,” he alludes.
However, if there are so many road blocks in the path to achieve the set targets for MMR, how have the states of Maharashtra, Tamil Nadu, West Bengal, and Kerala scored well in curtailing the growing incidence?
| Case study: MMR in Maharashtra |
| According to Suresh Shetty, Minister of Health, Maharashtra, the state has already achieved the set target of 109/100000 before time. He lists down various programmes introduced by the Public Health Department of Maharashtra to reduce MMR. Some of them are as follows:
Strengthened ante-natal care (ANC): This was done by conducting maternal medical campaign that included early registration of ante-natal case (i.e. pregnant mother) before 12 weeks, conducting baseline investigations – haemoglobin, blood pressure, weight, height, body-mass index, urine-albumin/sugar, HIV testing, sonography. These investigations are done for identifying high risk factors such as high BP, protienuria, anaemia, twins, hydramnios, IUGR etc. Distributing free medicines, conducting screening programmes for high risk pregnancies such as short stature, multipara, elderly primigravida, through clinical examination of ANC is done during these ANC visits and by creating a mother & child tracking system (MCTS) wherein all mothers and children are tracked and provided services from time to time, resulting in increasing ANC coverage. Strengthen intra-natal care and post natal care (PNC): This was done by ensuring 100 per cent deliveries at institutions by micro – birth planning by way of keeping a track of the mother throughout the pregnancy term and well up following up with the delivered mother on 2nd, 7th, 10th Day and for baby on Day – 7, 14, 21, 28 and 42 day Infrastructure strengthening: The government has mapped all health facilities available in the state. The government has also strengthenied sub centres, primary health centres (658) as per Indian Public Health Standard (IPHS) norms, strengthening of first referral units (220). In addition, the government has also provided for blood transfusion facilities at most of these centres, free referral transport services for these women, free diagnostics and medicines, free diet during stay, and adequate PNC care is being implemented across the state. Strengthening of manpower: The government of Maharashtra provides forvarious trainings are being taken such as,skilled attendant at birth – (ANM/LHV/Staff Nurse): 7038 trained Basic emergency obstetric care training: 4372 trained Comprehensive emergency obstetric care training:133 trained Life saving anaesthesia skill training of MOs:173 trained Janani Suraksha Yojana (JSY): Under the JSY, the state provides for conditional cash transfer scheme. The beneficiaries must be BPL. In case of SC and ST, benefit should be given to all pregnant women (including non BPL). The age of pregnant mother should not be less than 19 years. The benefit should be given to the beneficiaries up to two living children. For home delivery, Rs 500 is to be given to the BPL beneficiary only. The beneficiary from urban area, if she delivered in a health institution gets an amount of Rs 600 within seven days and those from rural areas get Rs 700 within seven days. In case of Lower Segment Cesarean Section (LSC S), Rs 1500 is to be given to the beneficiary if she has undergone caesarean section delivery in private accredited hospital. There are 5370 private accredited hospitals in the state. Human Development Programme: Human Development Mission was established in 2006 and initially the Human Development Programme was launched in 25 talukas of 12 districts. With success and improvement in the Human Development Index (HDI) the programme was extended to 125 blocks in 22 districts in the year 2011. Through this programme, various schemes for pregnant and delivered mothers such as specialist camps are implemented. Through these schemes BPL and SC/ST mothers are paid Rs 800 as loss of wages, at the end of eighth month of pregnancy so that she can take rest during ninth month of pregnancy and to encourage them for institutional delivery. Indira Gandhi Matrutva Sahayog Yojana (IGMSY): It is being implemented on pilot basis in the districts of Amravati and Bhadara. This is also a conditional cash transfer scheme under which Rs 4000 are given to pregnant mothers for antenatal checkup, institutional delivery, and post natal follow up including immunisation of new born and follow up for six months. This will help in reducing maternal mortality as well as neonatal and early infant mortality. Maternal death review is a tool used to review all facility-based and community-based maternal death. Started in the state since 2010 as per government regulation dated May 28, 2010. This process has helped the state in identifying the type of delays, reasons for delay and the system gaps which are responsible for maternal death. State has been identifying gaps and implementing the corrective measures. |
Tightening loose ends…
Like every dark cloud has a silver lining, the declining numbers of MMR within the states of Maharashtra, West Bengal, Tamil Nadu, and Kerala, indeed brings some respite. These states have really done well on reducing MMR. After all, health is the matter of the each state and it is the primary responsibility of the state government to build the necessary infrastructure and manpower to meet the needs of its people. Some learning lessons from these states include:excellent implementation of the JSY by way of strengthening the ante-natal care (ANC) and intra-natal care provided under this scheme as well as creating partnerships with various private players and NGOs to create infrastructure for the same and provide manpower.
A case study of how the state of Maharashtra was able to achieve the MDG-5A is quite revealing. (See box: Case study: MMR in Maharashtra). Citing an example of a successful PPP in this sphere, Dr Padgoankar informs that the Government of Maharashtra has partnered with the OPPI, the Rotary Club of Mumbai, the Indian Medical Association (IMA) and a NGO Pragati Pratishthan to initiate a pilot project for reducing MMR in the rural areas of the state. This campaign aims to reduce maternal and new born child mortality through collaborative action and training at all levels, from basic emergency obstetrics and new born care (BemONC), following the World Health Organisation (WHO) standards. So far, 10 medical camps have been organised in the areas of Jawhar, Mokhada, Vikramgarh and some more- the result of which are really gratifying in certain parts of the state,.
A noteworthy effort indeed. If these efforts can be duplicated within the states with high MMR rate, we can certainly move faster towards meeting the goal. Nevertheless, each state has a different set of problems and on a larger scale; a cumulative effort by all stakeholders is the need of the hour.
Suggesting strategies that need to be adopted to improve the present scenario within states with high MMR, Dr Chakraborti prescribes forging partnerships between the public and private sector. He says, “PPP in this sphere is the way forward for the healthcare sector in India. There is also an urgent need to improve the transparency and accountability on the cost of delivery of healthcare services.” Agreeing to the same, Dr Padgoankar also feels that if all healthcare stakeholders work together in partnership , this concerted effort will get a pushover.
Dr Singhal, says, “Government should allocate adequate funds especially to primary health centres (PHC). All PHCs should have periodic supervision from more advanced centres.” Further on, the Health Minister of Maharashtra advices other states to promote institutional delivery and conduction of delivery by skilled birth attendants who may be a nurse or a doctor and for this, training of Auxiliary Nurse Midwife (ANMs)/NMs/ lady Health Visitor (LHVs)/staff nurses in skilled birth attendant training and medical officers in basic emergency obstetric care training is essential. Accredited Social Health Activist (ASHAs) must be actively involved in promotion of institutional delivery. States also should have schemes from their own budget such as Human Development Programme in addition to central assistance. Also, the central government should give more and more emphasis on the underveloped states with regard to their development in different socio-economic-health and infrastructural aspects in order to achieve the revised goals.
Over and above, educating each and every woman of India will help in curbing a lot of women related health issues. Education women will not only bring about the necessary change in the outlook and encourage women to take every possible step in safeguarding herself during childbirths, but will also help in resolving the current state of MMR in India. Let’s not forget that a healthy woman builds a healthy family and this in turn builds a healthy community.
Lastly…
With just three years in hand, there is a lot more to do. If all of the above mentioned strategies are put in perspective, India can certainly cut the red tape and further its efforts in meeting the MDG on maternal health.
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