PRB

(July 2003) Hena is four months pregnant and her expression tells it all: Her eyes are dull and her face is pale as she waits to be examined by the doctors at Calcutta Rescue, a nongovernmental organization that works with poor people. Her husband is a rickshaw puller, and she can neither afford to see a paid doctor nor buy medicines. Like many women from poor areas, she trudges to the center in the early morning to get free medical treatment.

In West Bengal state (Calcutta is the capital), it is common to see women in labor traveling on the backs of open, three-wheel “cycle vans” over pot-holed roads to distant rural health centers. Many other women opt for home delivery, often under dangerously unhygienic conditions.

By contrast, upper- and middle-class women in metropolitan areas spend thousands of rupees for delivery at private nursing homes. These women would not venture to the government hospitals in the city, where, at times, two mothers with newborns must share a single bed.

These and other scenarios illustrate the lopsided nature of maternal care in India, where maternity-related complications are leading causes of death and disability among women of reproductive age.

In this country of roughly 1 billion people, where women have, on average, about three children, some 440 women die of maternity-related complications for every 100,000 live births. The United Nations estimates that at current levels of fertility and mortality, one out of every 55 women in India faces the risk of maternal death, compared with one in 80 in Pakistan and one in 610 in Sri Lanka.¹

A Cluster of Causes

The direct causes of maternal deaths in India are similar to those of other developing countries. They include excessive bleeding, infections, pregnancy-induced hypertension, obstructed labor, and unsafe abortions. (Abortion in India is permitted on medical, socioeconomic, and health grounds, with gestational limits.)

As with other countries, most of the maternal deaths in India can be prevented. Many are due to a lack of appropriate care during pregnancy and childbirth and to inadequate services for identifying and managing complications, according to the World Bank.²

The government took such issues into account as it shifted focus during the 1990s from contraceptive and fertility reduction targets and incentives for population control toward a broader system of performance goals and measures designed to encourage a wider range of reproductive and child health services. This approach seeks to address issues such as safe motherhood, unsafe abortion, and the quality of health services.

Under this broader approach, the government initiated the Child Survival and Safe Motherhood Programme in 1992 in partnership with the World Bank and the United Nations Children’s Fund (UNICEF). The safe motherhood component of the program focuses on maternal health, detection and treatment of complications, teaching traditional birth attendants clean delivery practices, and strengthening referral facilities for obstetric emergencies. Later in the 1990s, a new Reproductive and Child Health Programme incorporated the safe motherhood and child health services as the government sought to improve the survival of mothers and their children.

Care Before and After Birth

A major thrust of the Reproductive and Child Health Programme is the provision of care for pregnant women. However, a large proportion of women still do not receive antenatal checkups, even though such care can detect and treat existing problems and complications, provide counseling on symptoms of problems, help the woman prepare for birth, and advise her on where to seek care if complications arise. In the three years preceding India’s National Family Health Survey 1998-99 (NFHS-2), 35 percent of pregnant women received no antenatal care: only marginally better than the 36 percent in the 1992-93 NFHS.³

The situation is worse in rural areas. A 2001 Population Council study in Uttar Pradesh, India’s most populous state, showed that fewer than half of pregnant women had sought any care.⁴ The study painted an even gloomier picture in two of the rural state’s districts, Sitapur and Agra. More than three-fourths of women in Sitapur and three-fifths of women in Agra reported having no antenatal care. Women who did seek care tended to do so only in the second trimester of their pregnancy mainly to confirm that they were indeed pregnant.

The national survey showed that the women who failed to seek care tended to be older (ages 35 to 49), with a high number of previous pregnancies, and to be illiterate and socioeconomically disadvantaged.

Reasons given in NFHS-2 for not seeking care included not thinking that the checkups were necessary (60 percent) or customary (4 percent). Inability to meet the costs related to visiting a health facility was another reason (15 percent); some were not allowed to have these checkups by their families (9 percent). Lack of knowledge of antenatal care as well as long distances to health centers and lack of transportation were additional reasons given for not seeking care during pregnancy.

Checkups for mother and child in the two months after birth are also seen as important by health care professionals, particularly when deliveries do not take place in a health facility. The majority of maternal deaths take place after delivery, most of them within 24 hours after childbirth. Postpartum care allows health workers to detect and manage problems and to make sure mother and child are doing well. Yet, India’s national survey found that just 17 percent of the deliveries that took place outside of a health institution were followed by postpartum checkups within two months. And only 14 percent of these checkups took place within the critical two-day period following delivery.

Professional Help During Delivery

Since many complications cannot be predicted, professional care during delivery is key. The Reproductive and Child Health Programme emphasizes the need for mothers to deliver babies in hygienic conditions under the supervision of skilled health professionals, but most women in India deliver their babies at home without professional help. NFHS-2 estimated that 65 percent of births, particularly those in rural areas, took place at the women’s or parents’ homes. Among these deliveries, fewer than one in seven were attended by a health professional. These professionals, including doctors, nurses, and midwives, can usually manage normal deliveries, treat complications, or refer patients for appropriate care.

Again, the situation is worse in rural areas. The Population Council study in Uttar Pradesh found that most deliveries took place in situations in which it would be difficult to identify or respond to obstetric complications. Close to 90 percent of deliveries took place at home, and in nearly half these cases family members or kin delivered the babies. On the other hand, a skilled health professional can ensure hygienic conditions during delivery, recognize complications, and either provide safe care or stabilize and refer the woman for appropriate care. In the districts of Sitapur and Agra, unskilled birth attendants oversaw 90 percent and 60 percent of deliveries, respectively.

The Population Council study also examined the readiness of public health centers to handle some of the direct causes of maternal death. In particular, the study examined the capacity of primary health care facilities and the knowledge of auxiliary nurse midwives at these facilities to detect and manage complications, including excessive bleeding, infections, pregnancy-induced hypertension, and obstructed labor. According to the survey, “rudimentary capacity in terms of equipment and supplies and staff competence to handle some complications exist, but there is considerable scope for improving the readiness of services to detect and manage obstetric emergencies.”

The national survey found that the roughly one-third of births that took place in health facilities were equally divided between private facilities and public institutions, including government-operated district, town, or municipal hospitals, and primary health centers.

A Way Forward

In its Annual Report 2001-2002, the government of India’s Planning Commission notes that both the lack of universal screening of pregnant women for risk factors and the lack of appropriate referral are the major reasons that maternal and child morbidity and mortality have not declined substantially in the past four decades.⁵ The goals of the National Population Policy 2000 for 2010 include

• Reducing the maternal mortality ratio below 100 per 100,000 live births;
• Achieving 80 percent deliveries within health institutions;
• Delivery of all births by trained personnel; and
• Addressing the unmet needs for basic reproductive and child health services, supplies, and infrastructure.

However, the Population Council researchers found that much needs to be done in efforts to achieve the goal of reducing maternal deaths. They found that while getting more women to facilities with skilled health workers was important, resources within public sector facilities — including equipment and technical competence — must be strengthened to better handle obstetric emergencies. The researchers proposed a three-pronged strategy to strengthen the government’s initiative in providing essential and emergency maternity-related care:

• First, auxiliary nurse midwives should be taught routine care as well as life-saving skills that emphasize detection of complications and referrals for hospital deliveries for women with high risk of complications. Also, hospitals should acquire the necessary emergency obstetric care equipment.
• Second, work should be done intensively with communities to encourage women and their families to enlist the aid of trained attendants at deliveries and to increase the number of women who seek antenatal care. Communities also need to be educated to identify problem situations that arise when trained attendants are not available. These efforts should target pregnant women, postpartum women, key community decisionmakers, traditional birth attendants and other local health practitioners, and staff at primary health care facilities.
• Finally, health care workers should take advantage of women’s antenatal visits as a crucial point of contact between health services and pregnant women. These visits can be used to teach women about danger signs and hygienic practices.

Reaching Out to the Community

In the meantime, a number of programs work at the community level to spread awareness about care during pregnancy and after birth and considerations during birth, including the following:

• UNICEF collaborates with state governments to produce simple communication material in local languages so that health workers can explain to families in the villages the requirements for pregnant mothers. The material includes sections on how to recognize danger signals, preparing for birth, the wisdom of having money for transportation and health care expenses, and finding a means of transport so that women in labor can be taken to the nearest health center.
• Dais or traditional birth attendants are persuaded to encourage pregnant women to seek care at health institutions. Since dais make their living from home deliveries, they are offered monetary incentives to take pregnant women to adequately equipped health centers. UNICEF recently started its Border District Cluster Strategy in West Bengal’s Purulia district. The strategy concentrates on disseminating information in border areas that have a lot of interstate labor migration. These are areas far from the center of power, and they are served by rudimentary sub-health centers.
• The Suraksha Aaichi (“safety of the mother”) program, run by the Department of Community Medicine at the Mahatma Gandhi Institute of Medical Science in Maharashtra state, counsels adolescent girls, men, newly married couples, health workers, and village leaders in safe motherhood practices and maternal nutrition. The campaign emphasizes reproductive health, male participation in women’s health, and community participation. The program encourages women to deliver their babies at health institutions and makes arrangements for transportation so that pregnant women, particularly those in rural areas, may visit a health center before childbirth. The campaign involves cooperation and coordination between community leaders, health workers, medical students, nongovernmental organizations, and the women in the community, among others.

Ranjita Biswas is a freelance writer based in Calcutta, India.

References

1. World Health Organization (WHO), United Nations Children’s Fund (UNICEF), and United Nations Population Fund (UNFPA), Maternal Mortality Database (1995), accessed online at www.childinfo.org/
   eddb/mat_mortal/database.htm, on May 7, 2003.
2. World Bank, “Improving Women’s Health in India,” accessed online at www.worldbank.org/html/extdr/hnp/population/iwhindia.htm, on June 20, 2003.
3. International Institute for Population Sciences (IIPS) and ORC Macro, National Family Health Survey (NFHS-2) 1998-99 (Mumbai, India: IIPS, 2000).
4. Saumya RamaRao, Leila Caleb, M.E. Khan, and John W. Townsend, “Safer Maternity in Rural Uttar Pradesh: Do Primary Health Services Contribute?” Health Policy and Planning 16, no. 3 (2001): 256-63.
5. Planning Commission, Government of India, Annual Report 2001-2002, accessed online at http://planningcommission.nic.in/sitemap/
   search.htm, on June 20, 2003.