October 7, 2009

No Tally of the Anguish

Accountability in Maternal Health Care in India

Abbreviations
Glossary
Summary
Disparities: From Global to Local
Recurrent Healthcare System Failures
Improving Accountability: The Critical Need for Need for Better Monitoring and Timely Investigations
Improving Accountability: Reforming Grievance and Redress Mechanisms and Creating Emergency Response Systems
Seven Concrete Recommendations
Methodology
Scope and Limitations
Note on Estimates
Note on Terminology
I. Preventable Maternal Mortality and Morbidity: A Global Public Health Emergency
Causes and the Three Delays
Reduction Strategies
International Commitments and Progress on Maternal Mortality Reduction
II. Maternal Mortality and Morbidity in India
Estimates and Causes
Delivery of Basic and Comprehensive Emergency Obstetric Services
The Janani Suraksha Yojana
Critiques of the Government's Approach to Maternal Health
The Importance of Accountability
III. Recurrent Health System Gaps Reflect Accountability Deficits
Poor Access to Emergency Obstetric Care
Poor Referral Systems
Gaps in Continuity of Care
Financial Barriers to Care
IV. Improving Accountability: The Critical Need for Better Monitoring and Timely Investigations
Poor District-level Monitoring
Barriers to Accurate Reporting of Maternal Deaths
The Tamil Nadu System of Investigating Maternal Deaths
Failure to Use Appropriate Indicators
Institutional Deliveries as an Inadequate Indicator of Progress
Poor Long-term Monitoring
V. Improving Accountability:  Reforming Grievance and Redress Mechanisms and Creating Emergency Response Systems
Establishing an Emergency Helpline
Role for an Ombudsman's Office
Problems with Existing Complaints Mechanisms
Women's Poor Awareness of Entitlements
Poor Access to Grievance Redressal Procedures
The Need to Follow-Through in Response to Grievances
VI. International Human Rights and the Indian Legal Framework
International Human Rights Law
International Commitments to Reduce Maternal Mortality
In-country Obligations of States
International Assistance and Cooperation for Maternal Mortality Reduction
Indian Legal and Policy Framework
Constitutional Law and Supreme Court Decisions
The Need for a Policy Requiring Health Officials to Report Maternal Deaths
VII. Recommendations
To the Indian Central Government and Uttar Pradesh State Government
To Donor Countries and International Agencies
Acknowledgments
Appendix I
Appendix II
Appendix III
Appendix IV
Appendix V