II. Maternal Mortality and Morbidity in India

Estimates and Causes

For an emerging global economic power reputed for its medical prowess, India continues to have unacceptably high maternal mortality levels. In 2005, the last year for which international data is available, India's maternal mortality ratios were 16 times that of Russia, 10 times that of China, and 4 times higher than in Brazil.[38] Of every 70 Indian girls who reach reproductive age, one will eventually die because of pregnancy, childbirth, or unsafe abortion, higher than 120 other countries including India's neighbors such as Pakistan, Sri Lanka, the Maldives, and China. More will suffer preventable injuries, infections, and disabilities, often serious and lasting a lifetime, due to failures in maternal care.

While country data on maternal mortality is poor, there is far less government data on maternal morbidity (injuries, infections, and disabilities associated with pregnancy, childbirth, and unsafe abortions). There is some state-wide data on obstetric fistula and infertility. For instance, the District level Facility and Household Survey (DLHS) shows that nearly 1.6 percent of married women in Uttar Pradesh reported obstetric fistula, and 10 percent experienced primary or secondary infertility.[39] The latest nation-wide government-funded survey, the National Family and Health Survey (NFHS), shows that rural women experience many health problems during pregnancy including difficulty with vision during daytime, night blindness, convulsions not from fever, swelling of the legs, body, and face, excessive fatigue, and vaginal bleeding.[40]

National averages camouflage in-country variations in maternal mortality and morbidity, which indicate poor health equity and a lack of equality in access to and utilization of maternal health care. The northern belt in India, comprising the eight Empowered Action Group (EAG) states and Assam, has the highest maternal mortality rates nationally.[41] At 440 maternal deaths per 100,000 live births, Uttar Pradesh reports the second highest maternal mortality in the country, about 1.7 times the estimated national MMR and more than three times that of states like Tamil Nadu in south India.[42]

There are disparities in utilization of maternal health care even within states, districts, and cities. Rural women, the urban poor, and women in geographically remote areas report poorer utilization of maternal healthcare services than those in urban areas.[43] The incidence of morbidity is significantly higher in rural than in urban areas, with rates often two or three times as high.[44] Pregnant women belonging to marginalized communities such as Dalits (so-called untouchables), other backward classes (the so-called lowest caste just above Dalits in the hierarchy), and tribal communities utilize maternal health services far less than women belonging to the uppercastes.[45]A 2007 UNICEF study in six northern states showed that 61 percent of the women who died during pregnancy and childbirth belonged to Dalit or tribal communities.[46]

Roughly 65 percent of all maternal deaths are caused by direct obstetric causes. Hemorrhage is the main cause of death in India, followed by sepsis, and unsafe abortions.[47] At 35 percent, the proportion of maternal deaths due to indirect causes such as tuberculosis, viral hepatitis, malaria, and anemia is also much higher in India than the estimated global average of 20 percent.[48] Poor overall health and nutrition, poor education, women's lack of decision-making power within families, domestic violence, and son-preference coupled with women's poor autonomy in using contraceptives of their choice adversely influence their maternal health.[49]

Maternal mortality remains high in many parts of India despite decades-long initiatives aimed at reducing it.[50] Acknowledging that the number of maternal deaths is "unacceptably high,"[51] the Indian central government itself has identified maternal mortality reduction as a national priority,[52] aiming to bring the MMR below 100 by 2012.[53] The Indian Planning Commission has stated that it will be difficult for India to meet this goal at the present rates at which maternal mortality is declining.[54] Latest all-India estimates show a small decline in maternal mortality from 301 to 254 between 2003 and 2006.[55]

Delivery of Basic and Comprehensive Emergency Obstetric Services

The tiered public health system (see Table 1 on next page) coupled with the services of field-based female health workers including auxiliary nurse-midwives (ANMs) forms the backbone for delivering free basic and comprehensive emergency obstetric care to the rural poor. Norms for providing maternal health care at each of these tiers were recently revised through the Indian government's flagship seven-year rural healthcare program, the National Rural Health Mission (NRHM), read in conjunction with the 2006 Indian Public Health Standards (IPHS).[56] 

Table 1: Tiered Public Health System in India[57]

Health facility	Level	Population Norm
Health sub-center (HSC)	Primary	Plains: One for every 5,000 Hilly or tribal areas: One for every 3,000
Primary health center (PHC)	Primary	Plains: One for every 30,000
Community health center (CHC)	Secondary	Plains: One for every 1,20,000
First Referral Unit (FRU)	Secondary	One in every 300,000-500,000 (Community health centers are also being upgraded as first referral units)
District hospital	Tertiary	One for every 2-3 million (In some areas district hospitals function as the first referral unit)
Medical college hospital	Tertiary	One for every 5-8 million

Introduced in mid-2005, the NRHM seeks to "improve access to rural people, especially poor women and children to equitable, affordable, accountable and effective primary health care" with a special focus on maternal mortality reduction.[58] Seeking to achieve goals set under the 2000 National Health Policy and the Millennium Development Goals, it aims to reduce maternal mortality ratios to below-100 levels by 2012,[59] and commits to "report publicly on progress."[60]

The NRHM subsumed the former Reproductive and Child Health Program (RCH-II) program,[61] developing new strategies for maternal mortality reduction. Amongst other things, it seeks to upgrade primary health centers into around-the-clock facilities for basic emergency obstetric care and emergency obstetric first aid.[62] In remote areas where primary healthcare centers are unavailable, the state can accredit sub-centers to conduct normal deliveries. Where sub-centers are also unavailable, the state can accredit private health facilities to provide such care.[63]  The NRHM also requires states to upgrade community health centers as "first referral units" equipped to provide comprehensive emergency obstetric care.[64] 

The NRHM provides "concrete service guarantees" for many health needs (see Table 2 on next page). These include health education, skilled attendance at all births, free antenatal care, postnatal care, and in-patient facility-based care for delivery and other maternal health conditions at primary and secondary sub-district and district public health facilities, for women below the poverty line.[65] Private healthcare facilities, which are poorly regulated, conduct about 20 percent of the deliveries and also play a significant role in providing abortion services, but these are not governed by the NRHM service guarantees or the IPHS.[66]

Table 2: Service Guarantees under the NRHM

Health sub-center (HSC)	Primary health center (PHC)	Community health center (CHC)
Antenatal care · An ANM with the help of an ASHA should conduct three antenatal check-ups and a fourth visit around 36 weeks. · Each antenatal check includes examination of weight, blood pressure, anemia, abdominal examination, height and breast examination, minimum laboratory investigations including hemoglobin, urine albumin, and sugar. · The health staff should identify and promptly refer high-risk pregnancies to the appropriate health facility. Intranatal care · Sub-centers in remote areas to conduct normal deliveries. · They should promptly refer cases to an appropriate health facility. Postnatal care · ANMs with the assistance of ASHAs should conduct a minimum of two home visits (irrespective of place of delivery), the first within 48 hours of delivery and the second within seven or ten days of delivery.	All norms for antenatal and postnatal care in sub-centers apply to PHCs. They should provide the following services: · Free out-patient services. ·  24-hour delivery services for normal and assisted deliveries (vacuum and forceps delivery) and manual removal of placenta. · Safe abortions. · 24-hour emergency pre-referral first aid, management of pregnancy induced hypertension. · Prompt referral of complicated cases to the appropriate health facility. · All referral services guaranteed free.	CHCs should provide the following facilities: · All facilities present in PHCs. · Surgical and other medical interventions including cesarean sections and safe abortions. · Blood storage. · Referral services including transport.

The NRHM is applicable to all states, but 18 focus states, including Uttar Pradesh, receive additional funding for the stated goal of regional equity.[67]

The Janani Suraksha Yojana

Reforms introduced through the NRHM are coupled with the Janani Suraksha Yojana (JSY, literally, Mother Protection Scheme)-an NRHM scheme replacing the earlier National Maternity Benefit Scheme-that promotes facility-based deliveries through cash incentives for pregnant women and ASHAs.[68] The Indian government promotes facility-based deliveries with the stated objective of improving access to skilled birth attendants for pregnant women, especially those below the poverty line and members of Dalit and tribal communities.[69] Women who deliver in health facilities are given greater cash assistance than women who deliver in their homes. Theoretically, the scheme integrates cash assistance with delivery and post delivery care.[70]

The success of the JSY depends on the ASHAs-rural women appointed as community health aides who are given many tasks including tracking pregnancies, assisting with polio drives, and sharing information about family planning. Under the JSY, ASHAs are tasked with developing a micro birth plan to track the progress of every pregnancy within her area of work.[71] They should identify and register all pregnant women and provide services described as the "four Is." These include "informing" dates for antenatal check-ups, "identifying" a health center for referral, "identifying" the place of delivery, and "informing" pregnant women the expected date of delivery.[72]

ASHAs should facilitate both antenatal and postnatal care, assisting women in getting at least three antenatal check-ups during their pregnancy, and visiting them "within seven or ten days of delivery." During the postnatal care visit, they are responsible for facilitating further access to medical assistance if needed. ASHAs are primarily responsible for arranging transport and escorting the pregnant woman to a pre-identified health facility for delivery.

The cost of the scheme is entirely covered by the Indian central government. The government gives women who choose to deliver in government health facilities or accredited private health facilities 1,400 rupees (US$28) in rural areas.[73] In focus states, such as Uttar Pradesh, the cash assistance to women delivering in public health facilities is not limited by age or number of children.[74] Women who choose to deliver in their homes are given 500 rupees (US$10). But such cash assistance for home deliveries is limited to women above age 18 and with up to two live children.

Critiques of the Government's Approach to Maternal Health

NRHM has resulted in greater attention to maternal health but many government officials and civil society groups have concerns about the government's approach. They argue that poor accountability adversely affects not only planning based on women's health needs but also the implementation of existing maternal healthcare interventions. These gaps in accountability manifest themselves in many ways, notably recurrent health system or programmatic gaps and a lack of government action to ensure that health programs are actually reaching pregnant women from marginalized communities including the poor, Dalit, other  backward classes, religious minorities and tribal communities, or women in geographically remote areas. Furthermore, activists say that poor monitoring and attention to the supply-side coupled with the spurt in demand for institutional deliveries has resulted in substandard maternal health care at these facilities.[75]

Moreover, state governments' pattern of unspent NRHM funds buttresses calls for better accountability by activists and doctors.For instance, millions of dollars in government funds for health care in Uttar Pradesh go unspent each year. A study for the Indian Planning Commission shows that roughly 40, 40, and 30 percent of the amount allocated under the NRHM to the Uttar Pradesh government went unspent in fiscal years 2005-06, 2006-07, 2007-08[76]. In February-March 2009, activists in Uttar Pradesh claimed that nearly "700 crore rupees [US$140 million]" remained unspent even though it was almost the end of fiscal year 2008-2009.[77]In a January 2009 letter to 71 district chief medical officers, the Uttar Pradesh NRHM Mission Director urged each of them to spend "30 lakh rupees [US$60,000]" within two months, that is, by the end of March 2009.[78]

Health experts and activists have also expressed concerns about the effectiveness of existing government strategies to improve maternal health. While the JSY has improved access to health care during deliveries, many groups argued that the Indian central and state governments are not taking adequate measures to address unsafe abortions-a significant cause of maternal mortality in India. Even though the NRHM guarantees safe abortion services in public health facilities, and abortions are allowed in accordance with the Medical Termination of Pregnancy Act, in practice, little is being done to promote awareness and access to these services. Furthermore, health care to address maternal morbidities, which affect thousands more women leaving many disabled for life, is not given the attention it requires. What was intended to be a cash assistance integrated with antenatal and postnatal care, in practice, operates as a cash incentive to increase women's demand for facility-based deliveries without information on birth preparedness.[79]  

Women's rights and public health experts caution that the government's interventions to improve maternal health are too vertical, ignoring concerns about the overall health of women during their life-cycle, including the underlying determinants of girls' and women's health and their other rights including food, potable water, employment, and access to contraceptives of their choice.[80] The underlying determinants of health influence maternal health care. Dr. Sundari Ravindran, a leading public health expert on the reproductive and sexual health of women, said that in many areas of India, women are likely to experience a far higher rate of pregnancy-related complications requiring emergency obstetric care than the global average of 15 percent.[81] This is because of their overall poor health resulting from poor nutrition and anemia and has implications for the number of facilities that need to be equipped with comprehensive emergency obstetric facilities.

Further, activists repeatedly emphasize that vertically run programs, notably polio eradication, have had negative outcomes, which should not be replicated in maternal healthcare programming.[82] One of the main adverse outcomes of the polio eradication campaign is that field-based health workers spend a large part of their time on it, forcing other health concerns into the backseat. For instance, senior officials from the Uttar Pradesh Directorate of Family Welfare concede that "[p]ulse polio-all focus is on this project and other programs are neglected."[83] A study commissioned by the Uttar Pradesh Health Systems Development Project quotes a USAID study in Uttar Pradesh saying that one of the many challenges to maternal health care is that "National programmes such as Polio eradication [are] consuming half of health functionaries time."[84]

Moreover, many feel that the government mistakenly continues to approach the reproductive and sexual health of women within an overarching framework of "population control or stabilization." The government has not taken measures empowering women to make informed, autonomous, health-related decisions, especially about use of contraceptives or facilitated use of contraceptives that encourage male participation.[85] They point to the government's sterilization program, noting that field-based health workers spend a considerable amount of their time on sterilization without providing information about non-terminal contraceptive methods.[86]  

Several women and men from rural Uttar Pradesh reported seeing ASHAs or nurse-midwives only during polio drives or complained that they received prompt assistance only when they wanted to get themselves sterilized.[87] For instance, Vimala V. died after delivering at home and Revati R., a relative who was present at the time of delivery, said she had died without assistance from any health worker. Revati R. explained: "If you tell her [health worker] that it is for sterilization, then they will go to any length to help you-will arrange their own vehicle and take you to the hospital. But if you say that it is for something else, they will not even turn around and look at you."[88]

The "population control" approach has found its way into the JSY as well. In the non-Empowered Action Group states, JSY benefits are restricted to women above age 19 for up to two live births.[89] Likewise, cash assistance for home-based deliveries is restricted to women above age 19 and up to two live births. This shortchanges the medical needs of young mothers and pregnant women with multiple pregnancies.

Finally, the private sector continues to play a significant role in providing healthcare services, including obstetric services. About 64 percent of women go to private healthcare providers for complete antenatal care and about 20 percent of all deliveries occur in private health facilities.[90] Many activists said that the absence of regulation of the private sector posed a significant challenge to ensuring affordable quality maternal health care to all women.[91]

The Importance of Accountability

Accountability is the "raison d'être of a rights-based approach" to health care.[92] Often it is mistakenly equated with blame and punishment of individual medical staff and frontline health workers. While individual responsibility is important in appropriate cases, accountability also includes assessing the performance of district-level planning and decision-making and identifying systemic flaws that need to be rectified. This requires effective monitoring and tracking of progress and obstacles, followed by action holding planners and decision-makers accountable so that policies, programs, and practices are improved.   

Several processes enhance health system accountability. First the state should ensure that systemic problems with the provision of health care are identified and fixed instead of being repeated. If despite decades of programming for maternal health, women continue to die because of poor access to emergency obstetric care, inadequate referral systems, or lack of continuity in antenatal and postnatal care, this indicates a failure in planning and implementing maternal healthcare programs. Constructive changes should be made to break the cycle of health system shortcomings by monitoring implementation, replicating successful health interventions, and identifying and rectifying those interventions that do not work.[93] This will enable states to make the most effective use of their resources.

Another thread of accountability is grievance redressal. Ensuring women have access to effective mechanisms to address complaints and concerns about treatment that they have experienced whilst accessing healthcare services improves implementation as well as public trust in health facilities. Such grievance mechanisms should be capable of identifying through a fair and transparent process whether there is culpable behavior on the part of particular individuals, but the mechanisms should also contribute to identifying the full extent of the state's liability for any harm sustained by women when they seek to access maternal health care. This means that the mechanisms must examine not only the decisions of individual front line actors, but also whether the authorities have put into place appropriate systemic measures to minimize, to the greatest extent possible, any risks to life or health of pregnant women. If authorities are found negligent in failing to take such measures, there should be consequences.

Accountability also necessitates that states make progressive improvements in delivery of maternal healthcare services over time in accordance with their international human rights obligations. Governments should monitor progress in maternal health care by gathering data based on appropriate indicators, including pregnancy-related deaths. And such monitoring should occur at all levels-international, national, state, and particularly at the district level where there is power to plan, review, change, and implement schemes within the public health system. Tracking progress in maternal health care over time requires both short-term and long-term monitoring, and should apply to public and private healthcare sectors.