The Prime Minister's recent observation that maternal mortality in India is higher than in neighbouring Bangladesh has suddenly made this a matter of concern for the mandarins in Nirman Bhawan. It is unfortunate that it has needed a comparison with Bangladesh, which is perceived to be a poor cousin in the South Asian region, for this delayed wake-up call. The National Rural Health Mission, which was launched in April last year, and the Reproductive and Child Health (RCH 2) programme are now expected to help India achieve a reduction in Maternal Mortality in the next seven years to less than a fifth of the estimated 500 maternal deaths for every one lakh live births that occur now. It is a very necessary target, and there are a few states where the maternal mortality rates are already as low. But it is going to be a major challenge elsewhere - in Uttar Pradesh, Bihar, Rajasthan and Orissa where maternal mortality rates are comparable with those in sub-Saharan Africa.

The current strategy for reducing maternal deaths hinges on three simultaneous efforts, namely:

  • ASHA - Janani Suraksha Yojna - Skilled Birth Attendant: A village level health worker (ASHA- Accredited Social Health Activist), will identify pregnant women, and motivate them to avail services. The Janani Suraksha Yojna will provide financial support to poor women, above the age of 19 years, for their first two deliveries, and a third only if she undergoes sterilization at the time of delivery. The skilled birth attendant will be a person with the ability to not only delivery babies, but to handle life-threatening risks immediately.

  • Universal institutional delivery: Birth should occur only in government health centres and hospitals, or in private nursing homes where the doctors will be provided with a fixed fee for normal delivery or for caesarian operations.

  • Increasing Emergency Obstetric Care: Providing a basic package of services at Primary Health Centres and at Rural Hospitals.

On the face of it, these three together appear to form a very reasonable strategy; nonetheless, there are significant challenges in implementing such a strategy successfully.

The most important challenge lies in the place of delivery. In states like Uttar Pradesh and Orissa, over two-thirds of deliveries take place at home, and through the support of family members or traditional birth attendants. Until about two generations ago, even in urban India many deliveries took place at home, but today in middle class households, hospital delivery has become the rule. It is widely assumed that hospital delivery is safer for mothers and infants, and this middle class urban norm is sought to be applied to rural UP, Rajasthan or Orissa, with immediate effect. This assumption needs to be examined carefully for theoretical as well as operational validity.

There is literature now available from different parts of the world showing that for low-risk cases, home-based deliveries are comparable if not safer than hospital deliveries. Additionally in home-based deliveries babies can be breast-fed earlier, and women complain of fewer back-aches, and are physically more comfortable and free of stress. Compared to women who intended home delivery, women with hospital-based deliveries also showed higher rates of medical interventions - like Caesarian sections as well as other interventions like induction, rupture of membranes, and use of pain-killers. These studies, conducted in the West, have shown that babies were better off in home deliveries.

It can be validly argued that these conditions may not be true in India, but there are other realities to consider too. Facilities for conducting institutional deliveries in rural India are more or less non-existent. A study conducted by the Government of India (RCH Facility survey, GoI 2003) showed that in UP, Rajasthan and Orissa a labour room was available in less than half the Primary Health Centres surveyed, and emergency drugs (that should be available) for managing labour were available in less than 5% of the PHCs. At the level of Community Health Centres (where emergency services should be available) the situation was not any better. Over the whole country only a quarter (26.9%) of the CHCs had a labour room, and less than half (48%) had a labour room kit! While nearly 30 percent had an obstetrician/gynaecologist, less than 10% had an anaesthetist. Thus, even if women from the rural communities were to come to the CHC, the chances of receiving full emergency obstetric care from qualified specialists would be quite low. At the district level too, the availability of staff trained in emergency obstetric care was found to be very low. It is not surprising, therefore, that women continue to die despite reaching hospitals on time.

An about-turn in policy

Today most deliveries in these high-risk states are conducted by traditional birth attendants (TBA), and the government has spent crores of rupees training lakhs of women. Now, with one stroke of the pen the government has not only overturned this earlier approach - without assigning any reason, moreover - but also disempowered lakhs of rural women. I mention disempower, because many of these women were fulfilling important community leadership roles as well. One alternative suggested by the authorities is these women could themselves become ASHAs, but in recommending this they seem to be forgetting that ASHAs are expected to have passed at least the eighth standard, an impossible criterion for the majority of TBAs.

Similarly, one might ask: isn't becoming a skilled birth attendant (SBA) an alternative for trained TBAs as well? After all the training that they received was to make them skilled in attending births. This is easier said than done, however, because SBAs must not only be able to manage normal deliveries and recognize complications, but be competent to manage some complications and be able to supervise referral to a higher centre. Unfortunately even Auxiliary Nurse Widmives, who are the frontline female health workers, do not possess such competencies, and some doctors too may actually be found wanting. It is certainly desirable to have skilled birth attendants conducting the millions of deliveries in rural India, but where are the skilled attendants going to emerge form at such short notice, when already there is a huge shortage of trained personnel? This larger question that seems to have somehow escaped our planners.

One alternative that is being discussed is to try to enlist doctors running private nursing homes, hoping they would pitch in for this national effort. These doctors will be paid a fixed fee by the government for conducting normal deliveries and Caesarian sections, but would not charge the patients. If there are adequate numbers of doctors at the sub-district level, who agree to abide by the conditions in word and in spirit without adding charges or increasing un-necessary procedures and medications, this may turn out to be a valuable strategy. However it may also run the risk of ending the way of the Vande Mataram scheme of the earlier government, which simply died an unsung death.

Although deliveries in hospital and clinics are preferred, the facilities for conducting institutional deliveries in rural India are more or less non-existent.

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The government has to spend huge sums of money in adding infrastructure and facilities at the rural level. However already there are a large number of vacancies of medical officers, nurses and specialists for the positions already created. It is not uncommon to find that those who are posted to rural areas choose to stay away, using various means from arranging deputations to falsifying attendance records. Many also use political and financial influence to get away with these transgressions, and these tendencies cannot be addressed by the mere infusion of funds. 'Contract employment' is being suggested as an alternative, but with insecure service tenures doctors, especially women doctors, may not be tempted into reverse migration back to the countryside.

The Janani Suraksha Yojna has been rolled out with good intentions, but there are some provisions which make it discriminatory and may reduce its effectiveness in serving some of those who need it the most. In a bid to promote delaying of first child birth and to dissuade large families, the JSY uses a 'minimum age' criterion and a 'two child' cut-off. However it is well known - from both large-scale surveys and smaller in-depth studies - that women do not fully have control over their ages of marriage and childbirth, and that risks are higher at younger ages. This knowledge makes the minimum age cutoff seem patently discriminatory towards young women, and may also be counter-productive. Similarly women do not usually have the right to decide the number of children they will have, and the phenomenon of sex pre-selection is increasing. The two-child cut-off will thus exclude women have their third - or more - deliveries, who may also be at higher risk, and families may also be tempted to opt for sex-selection to reduce family sizes. This has been shown true in Haryana and Himachal Pradesh, where such the two-child norm has been accompanied by rapid declines in the child-sex-ratio.

More assertive demands

There are a few promising signs, which may serve to shake up the health departments at the State, district and sub-district levels. This includes the growing sense of unease within communities at the lack of proper health care services in rural areas. Today, as a result of various economic and women's development programmes, there are millions of women at the community level who are increasingly becoming assertive. In Rajasthan and in Uttar Pradesh there have been a number of occasions when such women have come together to demand better services from the district and State officials. In late December last year a group of women from different states came to Delhi and met with the officials of the Health Department and with the officials of the Planning Commission. The health department on its part is now inviting women's voices at State level meetings on maternal health. Such meetings have already been held or being held in UP, MP and Orissa.

The National Rural Health Mission includes provisions for giving voice to communities through village- and district-level planning, Citizen's Charters, public hearings and social audits. If citizens, especially women whose lives are most at risk without proper care, are given the opportunity to directly place their concerns before decision-makers and planners, the chances of success of many of the provisions in the Mission will increase. But the signs of positive change in this direction are too few; there are only a handful of examples of the bureaucracy providing opportunities to citizens to take charge of their own lives. It is certainly a welcome change that unsafe motherhood has finally been acknowledged as a major health and development issue, and the promise of additional funds to tackle this is positive too. It remains to be seen whether the usual bureaucratic lethargy and cussedness, or citizens' assertions, will finally claim the day.