|Photo Credit: UNICEF|
The report by the Registrar General of India on maternal mortality which was released in December 2013 came as a respite in the face of India’s failure to achieve the targets under the Millennium Development Goals. Maternal mortality has significantly decreased in India over the past few years. India’s maternal mortality rate (MMR), or the rate of deaths among women during or after pregnancy, declined by 16 percent in 2011-12 from 2007-09, according to the Census data.
Although, the MMR dropped from 212 deaths per 100,000 live births in 2007-09 to 178 in 2010-12, India is lagging behind the target of 103 deaths per 100,000live births to be achieved by 2015 under the United Nations-mandated Millennium Development Goals (MDGs).
Moreover, international comparisons reveal a grim picture. According to the 2010 figures from the "World Development Indicators", South Korea has a maternal mortality count of 16, followed by Sri Lanka (35) and China (37). India is way below at 200, lagging behind even Nepal (170). The three regional countries that are behind India are Indonesia (220), Bangladesh (240) and Pakistan (260).
So what is preventing India from not even matching countries like Nepal in ensuring better health care facilities to expecting and new mothers? Lack of institutional delivery or delivery by skilled professionals, poor health budgetary allocation to health, discrimination against women and cultural attitudes that do not consider professional prenatal and delivery care are the major contributors to this sorry picture.
The NFHS data released by the Ministry of Health and Family Welfare in 2012 also revealed that with the existing rate of increase in deliveries by skilled personnel, the achievement for 2015 is likely to be only 62 percent which is still considerably short of the targeted universal coverage. High out of pocket expenses by pregnant women and their families on institutional deliveries like drugs, user charges, diagnostic tests, diet and C –sections prevented the poor from accessing health care centres leading to high mortality rates.
Janani Suraksha Yojana by the National Rural Health Mission was launched in 2005 as a response to this poor health infrastructure. It provides for graded scale of cash assistance based on the categorisation of States as well as whether beneficiary was from rural/urban area. However, is merely doling out money to BPL families enough to reduce maternal deaths? Is this an effective policy approach to a complex issue like maternal mortality?
In the “high focus” states (Bihar, Madhya Pradesh, Rajasthan, Uttar Pradesh), according to the NRHM document, the MMR is high because there are not enough rural hospitals and road connectivity is poor. If the objective is to reduce MMR in these states, an all-out effort has to be made in both these fronts: creating the health infrastructure in rural areas which is truly functional and ensuring road connectivity. There is a lack of a policy framework which can move beyond the idea of financial incentive and respond to the underlying hindrances to improved maternal health. There is a need to pilot solutions which address the intertwined factors which lead to high number of deaths among pregnant women or new mothers. It is the need of the hour that we have policies which are born from a better understanding of the ground reality rather than mere financial assistance.
There are quite a few successful approaches we can learn from. Unicef’s work in Madhya Pradesh is worth a mention. Along with the State Government, Unicef has upgraded maternal and neonatal health centres in several remote districts of MP. A call centre was also established in the district hospital two hours away to make sure that the ambulance reaches women on time and takes them home again, once they’ve given birth. If there are problems with a birth, the ambulance can take the mother to a newborn care unit in the district hospital. The unit is equipped with incubators and can accommodate children born underweight and unwell.
Maternal and Prenatal Death Inquiry and Response (MAPEDIR) is yet another innovative tool which is being used by health experts, policy makers and communities. This innovation extends across select districts in Rajasthan, Madhya Pradesh (MP), West Bengal, Jharkhand, Orissa and Bihar. It seeks to kindle the community’s participation in probing why women died in pregnancy, delivery or soon after, with an emphasis on developing feasible solutions to the identified problems. The entire process includes identifying and investigating maternal deaths, sensitising the community, galvanising communities and health systems into action, and monitoring and adjusting interventions through continuing inquiries. The accumulated evidence can help communities understand the root causes behind these deaths so they can take effective local action and advocate for improved services to prevent future deaths.
The role of private sector and public-private partnerships in increasing availability and physical access to services for women in rural areas is another solution which can be considered.
Whatever be the approach, reproductive freedom lies at the heart of the promise of human dignity, self-determination, and equality. Every woman in India should have the right to access to best reproductive health care available. Only then can they participate with full dignity as equal members of the society.