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Maternal Health in India
‘God could not be everywhere, so he created mothers’ – A Jewish proverb sums up the relevance of a mother. That should place mothers in a highly privileged position. But the irony is that every minute a woman dies in childbirth. 536,000 women continue to die needlessly each year at a time that should be joyful – precisely when they are bringing life into the world. Another 300 million suffer from preventable disease and disability.
About 14 years have passed since the International Conference on Population and Development (ICPD) formulated a reproductive health agenda for the world, and about seven years remain before the Millennium Development Goals (MDGs) are to be achieved
The fifth Millennium Development Goal (MDG) (Table 1), which aims to ‘improve maternal health’ – is desperately off track.
Table 1 MDG 5 – Improve maternal health
Target 5A: reduce maternal mortality by two-thirds between 1990 and 2015
1. Maternal mortality ratio
2. Proportion of births attended by skilled health personnel
Goal 5B: Achieve, by 2015, universal access to reproductive health
1. Prevalence rate of contraception
2. Teenage birth rate
3. Pregnancy care coverage
4. Unmet need for family planning
Maternal mortality is an important indicator of women’s status in a society – a maternal death often represents the end point of a life of gender discrimination and deprivation ‘inside’ the household and failure of the ‘outside’ (eg the health system) to provide timely and effective care. Chronic conditions such as malnutrition, anemia, diabetes and hypertension make women more susceptible to maternal death, but even healthy women can succumb to an unexpected complication during pregnancy or childbirth.
Only the use of good health care can make maternal death as rare as it has been in the developed world. In fact, a striking feature of maternal health in the world today is the huge disparity in maternal mortality in developed and developing countries, with the latter still alarmingly high. In 2000, 13 developing countries accounted for 70 percent of maternal deaths worldwide and South Asia for a third. The country with the single largest number of deaths was India, where an estimated 136,000 women died.
A number of individual and household factors put women at high risk of dying during pregnancy and childbirth. These include age (too young or too old), high parity, poor nutritional status, low access to health services, low social status, illiteracy and poverty. As with other indicators of reproductive health, maternal mortality is higher in rural areas, among the economically disadvantaged and those with little or no education. Women who received no antenatal care appear to be at greater risk of death (a cause or association), and those with unmet need for contraception are clearly at greater risk than they would be if they could avoid pregnancy.
A maternal death is a death like no other. The impact of a maternal death on families and communities is devastating – but is especially so for surviving children. A newborn baby is three to ten times more likely to die within the first two years without its mother. Women’s health is crucial for a country’s social, economic and political development. Women’s survival during childbirth reflects a country’s overall development and whether or not the healthcare system is functioning. In reality, women’s survival reflects whether women matter or not.
As per NFHS-3 and SRS 2001-2003 are various health indicators that reflect the current situation of women’s health in India.
o Women in the reproductive age group constitute almost 19% of the total population with 16% of women in the 15-19 age group. are already fertile. The median age of childbearing in India is 19.8 years. (Urban area -20.9 years., Rural district – 19.3 years).
o 77% of all pregnant mothers received some form of antenatal care (urban area 91%, rural area 72%).
o Among women receiving ANC, less than two-thirds had weight, blood or urine taken, or blood pressure taken, three-quarters had their abdomen examined, and 36% were told about pregnancy complications. 56% of married people and 59% of pregnant women are anemic. 65% of pregnant women received or purchased iron and folic acid, but only 23% consumed IFA for 90 days. In urban area, 76% pregnant women received or purchased IFA and only 35% consumed IFA for 90 days and in rural area 61% received or purchased IFA and 19% consumed the same for 90 days.
o 49% of all deliveries are institutional. Only about 1 in 7 home deliveries is assisted by a skilled supplier. (city-68%, rural district-29%).
o 13% of the lowest indexed women gave birth in an institution, in contrast to 84% of women in the highest indexed group. 33% of pregnancies belonging to SC caste born in the institution against 18% among Scheduled Tribes.
o Only 42% of postnatal mothers receive any form of postnatal care. Maternal mortality has gradually improved from 437 in 1992-1993 to 301/100,000 live births. Maternal mortality in India is not uniform. High maternal mortality is clustered among the EAG states of Bihar, Jharkhand, Madhya Pradesh, Chhattisgarh, Rajasthan, UP, Uttaranchal, Assam and Orissa.
The overall average decline in MFR in the period 1997-2003 has been 16 points per year. At this rate of decline, the MDG of 109 in 2015 may be difficult to achieve. Under the prevailing conditions, the MMR will be around 231 in 2012.
They give us the impression that although we are moving in the right direction, progress is slow and to prevent mothers from dying and living with problems related to childbirth, there is still much to be done and in a very faster pace.
The main causes of maternal mortality are excessive bleeding during childbirth (generally in home births), (38%) obstructed and prolonged labor, (5%) infection/sepsis (11%), unsafe abortion, (8%) disorders related to high blood pressure ( 5%) and other conditions including anemia. (34%). Forty-seven percent of maternal deaths in rural India are attributed to excessive bleeding and anemia resulting from poor nutritional practices. Intermediate causes, which are the first and second delays in seeking care, include women’s low social status, lack of awareness and knowledge at the household level, insufficient resources to seek care, and poor access to quality health care. Reasons for third delay are untimely diagnosis and treatment, poor skills and training of nursing staff, and prolonged waiting time at the facility due to lack of trained staff, equipment and blood. There are inadequate facilities for antenatal care and more than half of all births still take place at home, very often by untrained assistants. The link between pregnancy-related care and maternal mortality is well established.
National programs and plans have emphasized the need for universal screening of pregnant women and operationalization of essential and emergency obstetric care. Focused obstetric care, birth preparedness and complication preparedness, skilled attendance at birth, care within the first seven days and access to emergency obstetric care are factors that can help reduce maternal mortality. One of the main objectives of the Government of India’s Department of Health and Family Welfare is to reduce maternal mortality and morbidity. The focus has shifted from individualized interventions to attention on reproductive healthcare, which includes skilled attendance at birth, operationalization of referral units and 24-hour delivery services at primary health centres. and initiation of Janani Suraksha Yojna (National Maternity Benefit Scheme). The program to participate in the same is Rural Health Mission in EAG states and RCH II in the other states.
If India is to achieve Millennium Development Goal 5 (MDG 5) by 2015, in addition to providing universal emergency obstetric care to every pregnant woman who needs it, it will have to tackle critical social and economic factors such as the low status of women, the poor status of many families understanding of health care, the cost of such care and also the low standard
Strategies to be adopted are
o Improve inclusion. Two important groups – poor women and youth – need to be brought directly into the fold of reproductive health services through geographic and household targeting and clearly targeted outreach. Social and gender sensitivity among providers, managers and policy makers is critical to achieving this inclusion, as well as the supply and demand improvements noted below.
o Improve supply. Improving the provision of services for all stages of the reproductive life cycle, where integration of the essential package and provision of a client-centred continuum of care are good approaches. Four services have been particularly neglected and require further attention in this context: combating unsafe abortion, nutrition counseling and care, postnatal care and RTI/STI diagnosis and treatment. Improving the availability and quality of frontline female health workers through recruitment and/or contracting, training, field support, and performance-based incentives will help meet many needs, while outsourcing services and other payment systems to clients/providers can increase the availability of care for the poor women.
o Increase demand. Increase demand for more services offered but underutilised, such as ANC, IFA, institutional deliveries and family planning (although supply may be a constraint in some areas). In addition to ‘behaviour change communication’, demand funding is important to achieve this.
o Reform the health sector for reproductive health. As reforms take place in the health sector, the delivery and financing of reproductive health services deserve special attention. Reforms are particularly needed in three areas to support the above-mentioned approaches to improving reproductive health. Decentralized planning and resource allocations, human resource development and financing improvements are important to implement targeting, integration of services, supply improvements, a customer focus, demand generation and effective dissemination.
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