Wednesday, May 1, 2013

Maternal Health in India

'God could not be everywhere and therefore he made mothers' - A Jewish proverb summarizes 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 which should be joyous - just when they are bringing life into the world. A further 300 million suffer from avoidable illness 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 for the Millennium Development Goals (MDG) 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 by two-thirds, between 1990 and 2015,the maternal mortality ratio

1. Maternal mortality ratio
2. Proportion of birth attended by skilled Health personnel

Target5B:Achieve, by 2015, universal access to reproductive health

1. Contraceptive prevalence rate
2. Adolescent birth rate
3. Antenatal care coverage
4. Unmet need of family Planning

Maternal mortality is an important indicator of the status of women in a society - a maternal death often represents the endpoint of a life of gender discrimination and deprivation 'inside' the household, and failure of the 'outside' (e.g., health system) to provide timely and effective care. Chronic conditions such as under nutrition, anaemia, 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 use of good health care can make maternal death a rarity, as it has in the developed world. Indeed, a striking feature of maternal health in the world today is the vast difference in maternal mortality in developed and developing countries, the latter still alarmingly high. In 2000, 13 developing countries accounted for 70 percent of maternal deaths worldwide and South Asia for one-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 death during pregnancy and delivery. 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 worse-off, and those with little or no education. Women who have received no antenatal care appear to be at greater risk of death (a cause or correlate), and those with unmet need for contraception are clearly at higher 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 its first two years without its mother. The health of women is critical to a country's social, economic and political development. The survival of women in childbirth reflects the overall development of a country and whether or not the health services are functioning. In reality, the survival of women reflects whether or not women matter.

As per NFHS-3 and SRS 2001-2003, various health indicators reflective of the current situation of Woman's health in India are

o Women in the reproductive age group constitute nearly 19% of the total population with 16% of women in the age group of 15-19 yrs. are already child bearing.The median age of child bearing in India is 19.8 years. (Urban area -20.9 yrs., Rural area - 19.3 yrs).

o 77% of the total pregnant mother received some form of Antenatal Care.( Urban area 91% , rural area 72%)

o Among women who received ANC, less than two-thirds had weight, blood, or urine taken or blood pressure measured, Three-fourths had their abdomen examined and 36% were told about pregnancy complications. 56% of married and 59% of pregnant women are anemic. 65% of the pregnant mother received or purchased Iron and folic Acid but only 23% consumed IFA for 90 days. In urban Area the 76% pregnant women received or purchased IFA and only 35% consumed IFA for 90 days and in the 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 are assisted by a skilled provider.(urban-68%,rural-29%)

o 13% of the lowest indexed women delivered in an institution in contrast to 84% of women in highest indexed group.33% of pregnancies belonging to SC caste delivered in the institution against 18% among Scheduled tribe.

o Only 42% of the postnatal mothers are receiving any forms of postnatal care. Maternal Mortality Rate has been gradually improving from 437 in 1992-1993 to 301/100000 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 & Orissa.

The overall average rate of MMR decline during the period 1997-2003 has been, of 16 points per year. At this rate of decline, MDG of 109 by 2015 may be difficult to achieve Under the prevailing conditions, the MMR would be around 231 by 2012.

They give us the impression that though we are moving in the right direction, the progress is slow and to prevent mothers from dying and living with problems related to child birth, a lot still needs to be done and at a much faster pace

The major causes of maternal mortality are excessive bleeding during childbirth (generally among home deliveries),(38%) obstructed and prolonged labour,(5%) infection/ sepsis (11%), unsafe abortion,(8%) disorders related to high blood pressure(5%) and other condition including anaemia.(34%).Forty seven per cent of maternal deaths in rural India are attributed to excessive bleeding and anaemia resulting from poor nutritional practices. Intermediate causes, which are the first and second delays in care-seeking, include the low social status of women, lack of awareness and knowledge at the household level, inadequate resources to seek care, and poor access to quality health care. Causes of third delay are untimely diagnosis and treatment, poor skills and training of care providers, and prolonged waiting time at the facility due to lack of trained personnel, equipment and blood. There are insufficient facilities for antenatal care and more than half of all deliveries are still conducted at home, very often by untrained helpers. The link between pregnancy-related care and maternal mortality is well established.

National programmes and plans have stressed the need for universal screening of pregnant women and operationalising essential and emergency obstetric care. Focused antenatal care, birth preparedness and complication readiness, 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 major goals of 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 to the reproductive health care, which includes skilled attendance at birth, operationalising Referral Units and 24 hours delivery services at Primary Health Centres. and initiation of Janani Suraksha Yojna (National Maternity Benefit Scheme). The program to attend the same is Rural Health Mission in EAG states and RCH II in the other states.

If India is to achieve the Millennium Development Goal 5 (MDG 5) by 2015, besides providing universal emergency obstetrical care to each of the pregnant mother in need it will have to tackle critical social and economic factors, such as the low status of women, the poor understanding of many families about health care, the cost of such care, and also the low standard

Strategies which need to be adopted are

o Enhance inclusion. Two important groups - poor women and adolescents -need to be brought squarely into the fold of reproductive health services through geographic and household targeting and clearly-directed outreach. Social and gender sensitivity among providers, managers and policymakers is essential to achieve this inclusion, as well as the supply and demand improvements noted below.

o Improve supply. Enhancing the supply of services for all stages of the reproductive life cycle, for which integrating the essential package and providing a client-centred continuum of care are good approaches. Four services have been particularly neglected and require additional attention in this context: combating unsafe abortion, nutrition counselling 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 in, training, field support and performance-based incentives would help to fulfil many needs, while contracting out of services and other client/provider payment systems could increase the availability of care for poor women.

o Increase demand. Increase demand for several services that are provided but underutilized, 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-side financing 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 merit special attention. Reforms are especially necessary in three areas to support the above 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 client focus, demand creation, and effective outreach.

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