No Tally of the Anguish
October 7, 2009

VII. Recommendations

The Indian central government and states with high maternal mortality rates have six years until 2015 to meet global goals on maternal mortality reduction. Countries such as Sri Lanka and Malaysia have shown that maternal mortality can be halved within a period of five or six years. Indian central and state governments, particularly Uttar Pradesh and similarly situated governments have an obligation to take positive measures to ensure the progressive realization of women's right to maternal health-care, and they have very strong local expertise to rely on. 

The Indian central and many state governments have taken several positive measures to strengthen accountability, including measures towards institutionalizing a system of maternal death investigations, upgrading health facilities, and improving monitoring by introducing the HMIS. But implementation has lagged due to inadequate political will and failure to apply available resources to strengthen monitoring mechanisms.

To the Indian Central Government and Uttar Pradesh State Government

On Investigating Maternal Deaths

Human Rights Watch recommends that both governments should:

  • Require that healthcare providers, public and private, report all pregnancy-related deaths. 
  • Make maternal death investigation a mandatory component of the NRHM (as has been done with the ASHA scheme, Village Health and Sanitation Committees, and Patient Welfare Committees). To this end:
    • Allocate available resources for maternal death investigations.
    • Constitute a team to develop and issue guidelines through a participatory and transparent process, preferably before the start of financial year 2010-11.
    • Ensure that any procedure for investigating maternal deaths has the following essential minimum features:
      • Identifies health system shortcomings in addressing the socio-economic and medical causes of maternal deaths.
      • Takes into account the underlying determinants of health such as nutrition.
      • Develops remedial measures that should be implemented in a time-bound manner.
      • Includes periodic reports of progress made and remedial corrective measures taken after such investigations, respecting patient privacy and confidentiality.
  • Ensure that unsafe abortions are reduced by effectively implementing the Medical Termination of Pregnancy Act, 1971.

In the states that have already begun institutionalizing maternal death investigations, Human Rights Watch urges the Indian central government to assess whether the relevant policies and procedures:

  • Incorporate the essential features of investigation outlined above.
  • Include maternal death investigations in NRHM state annual project implementation plans.
  • Integrate findings from maternal death investigations into state policy and planning under the NRHM. 
  • Call for periodic release of data informing the public of the findings and any remedial actions taken.

On Access to and Utilization of "Skilled Birth Attendance" and Emergency Obstetric Care

Human Rights Watch recommends that the Indian central government invite a group comprising technical experts including representatives from local nongovernmental organizations and international agencies:

  • To determine whether health facilities are providing services in accordance with the NRHM concrete service guarantees and are equipped with "skilled birth attendants" as defined by international organizations such as the WHO, ICM, and FIGO. Those that pass should receive certification.
  • To revise its monitoring protocols for the JSY through a participatory consultative process in accordance with the 1997 United Nations Process Indicators to Monitor the Availability, Utilization, and Quality of Emergency Obstetric Care (UN process indicators), and the United Nations Guidelines for Monitoring the Availability and Utilization of Obstetric Services (UN guidelines).

In the interim, the Indian central government, the Uttar Pradesh state government and similarly situated state governments should:

  • Issue directions to identify, upgrade, and certify on priority basis a minimum number of geographically well-distributed basic and comprehensive obstetric care facilities in every district in accordance with international and national standards.
  • Implement the JSY in a manner that all pregnant women, particularly women from marginalized communities and remote areas have access on an equal basis to facilities that are certified as providing "skilled care." Alternative interim arrangements for skilled birth attendance should be made in remote and underserved areas.

On Complaints Mechanisms

Human Rights Watch urges the Indian central government to constitute a high-level body consisting of governmental, nongovernmental, and intergovernmental organizations to:

  • Develop, through a participatory and consultative process, guidelines for the creation of an emergency helpline. Such a helpline should include the following essential features:
    • Be accessible to vulnerable communities, especially rural women with little or no formal education.
    • Have the power to take complaints around the clock and provide immediate interventions to avert preventable maternal deaths.
  • Develop, through a participatory and consultative process, guidelines for the creation of grievance redressal mechanism through independent facility or regional-level ombudsman's office with the following essential features:
    • Be accessible to vulnerable communities, especially rural women with little or no formal education.
    • Conduct inquiries in an impartial, transparent, and time-bound manner.
    • Assess complaints in keeping with the principle of non-discrimination and equality, by examining the effect of a particular action on vulnerable communities rather than the intent of the actor.
    • Examine not only the conduct of frontline health workers but also district and sub-district health officials' failure or negligence in planning or oversight.
    • Ensure that remedies are not restricted to taking action against individual healthcare providers in deserving cases, but also include systemic corrective actions to ensure non-recurrence of the same problem.

On the Civil Registration System

The Indian central and Uttar Pradesh state governments should appoint a full-time special officer at the national and state levels to oversee the implementation of the civil registration system, and create a special plan of action allocating funds for its implementation.

On Maternal Morbidities

Acknowledging that existing government surveys and norms address maternal morbidities to some extent, Human Rights Watch calls upon the Indian central government to: 

  • Ensure continuity of care to reduce not only preventable maternal mortality but also preventable maternal morbidity.
  • Develop and design in consultation with governmental, nongovernmental, and intergovernmental organizations a periodic survey to monitor sexual and reproductive morbidity, including severe health conditions such as fistula, uterine prolapse, eclampsia, infertility, and so on.

To Donor Countries and International Agencies

Donor countries and international agencies have a crucial role to play in strengthening international and national accountability in reducing maternal mortality. At the international level, countries should ensure that a system for monitoring progress is put in place. Donor countries and international agencies should also be held accountable for the interventions that they promote in countries such as India.

To this end, donors and international agencies should provide technical and financial assistance for implementation of the recommendations outlined to the Indian central government and Uttar Pradesh state government above, and in particular:

  • Provide technical and financial assistance to promote notification and investigation of maternal deaths.
  • Provide technical and financial assistance to ensure that all government health interventions, particularly interventions funded by them, are monitored and evaluated in accordance with the UN process indicators and periodically release the results of such monitoring and evaluation to the public.