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Unless all concerned – policy makers, civil society, communities and
families and all of us – contribute in our own different ways maternal health
would continue to be compromised and the human rights of women would continue
to be a casualty
By the time one finishes
reading this article, several women would have died of pregnancy related preventable
causes in India! Official figures suggest one unfortunate Indian woman loses her life every eight minutes,
which adds up to a loss of more than 63,000 young and productive lives every year.
All of us would agree that there can be no improvement in maternal health
without eradicating extreme poverty and hunger to which women, in general, and pregnant
mothers, in particular, are most vulnerable. Improved maternal health will, on
its own, bring about a visible improvement in child survival and child health also.
I use the term “maternal health”
in its broadest sense asthe culmination
of all that goes wrong with women generally and those from the poorer sections,
in particular – beginning with the discrimination from the embryonic stage when
detection of a female foetus leads to its elimination or termination; and if it
survives, the tragedy of the infant girl whose mortality rate is higher than
that of infant boys; and growing up to face the neglect as a girl child who has
to shoulder adult like responsibilities at the cost of her schooling and foregoing
exposure to her there entitlements in comparison to male siblings; and then is
confronted with the travails of vulnerable adolescence as she has no access to
basic sanitation facilities or even a sanitary napkin or its crude substitutes
become a luxury; and then she grows to assume young adulthood when sexual
health is not considered a priority for her in the reproductive age, deprived
as she is of sufficient nutrition, preventive health care, and denied the right to choose the timing of
conception or the power to decide on which method of contraceptive to use; and
then she is forced to double up as a provider of livelihood for the family; and finally, in her old age she is discarded and thrown out to beg and survive.
While approximately 10 to
15 percent of all pregnancies reportedly result in an emergency and obstetric emergencies
cannot be predicted and can happen to any pregnancy, whether the woman is rich
or poor, rural or urban; a woman’s social and paying status can make all the
difference and a rich woman living in Delhi will, for example, have access to a
hospital. Women may need caesarean
sections and/or blood transfusions, which
require the complex skills, facilities and logistical support only found in a
hospital. Yet for many women in our country, these services are simply not
One of the reason for inaccessibility
to such facilities to be the already overburdened Out Patient (OPD) load which leaves
the medical staff at Primary Health Centres with little time for postpartum
care. The lack of service from the public system leaves women to the care of
informal and private providers, and the poorest to the care of the family
itself which is ill equipped to handle complications or even basic issues like
blood pressure, haemorrhage, and obstructions during labour. Studies have found
that women from vulnerable sections are often not aware of many auxiliary services
they are entitled to apart from the cash benefits
under the Janani Suraksha Yojana, during ante-natal
care. User fee for either transportation or investigations further minimises
the communities’ access to maternal health services. The problem is worsened
when communities need to pay money for services like getting vaccinations or
cutting of umbilical cord of the newly born child.
Poor functioning, poor
hygiene and sanitation and unfriendly attitude on the part of the staff also render
government health facilities ineffective. Will the numerous initiatives taken
by the Centre and State governments to encourage institutional deliveries
including the special focus on the National Rural Health Mission, and
the just launched Janani-Shishu Suraksha Karyakram, make any difference?
Can the already overburdened district hospitals, Community Health Centres (CHC)
and Primary Health Centres (PHC) be counted upon to deliver? My visit to Bolangir
– one of the most back ward regions
of Orissa in the Kalahandi- Bolangir- Koraput (KBK) region – and to its
District Hospital, found that against a capacity of only 25 beds, on an
average 75 women are admitted and have to wait for hours before delivery
because the labour room can accommodate only three patients at a timeand
once out of the labour room, women are kept in the leaking and damp corridors
with newborns because of non-availability of bed. Women are not surprised
when they are discharged from hospital within hours of delivering to
accommodate new delivery cases and neither do the family members mind because they
would get the money under the Janani Suraksha Yojana as would the Accredited
Social Health Activist for bringing the women to the hospital. The lactating
mother may die even before reaching home due to post-natal complications but it
would be counted as an institutional delivery. On arrival at a health
facility they are allotted a bed, without bed-sheets, and the poor families are
expected to buy everything else needed for the delivery and aftercare. Sometimes,
the inability to arrange vital requirements such as that of units of blood due
to poverty proves fatal for the woman.
This grim scenario notwithstanding,
the Centre has made some genuine efforts to improve maternal and child health in
the country. Some of these measures have already started showing results with
an appreciable decline in the maternal mortality ratio and infant mortality
rate, while the impact of some other schemes should be visible in the coming years.
The Ministry of Health
and Family Welfare has issued operational guidelines for Home Based Newborn
Care. To be implemented by Accredited Social Health Activists (ASHAs),
HBNC will go a long way in ensure the safety of young mothers and infants who
cannot access health facility for various reasons. For this Training of
Trainers has been undertaken and translation of ASHA module in respective
Regional languages and would include post partum care also. Provision of
ante-natal and post natal care services for pregnant and lactating women
which includes iron and folic acid supplementation for prevention and treatment
of anaemia can go a long way in saving precious lives provided these are
consumed regularly. Women often take the tablets but do not consume defeating
the entire purpose of the scheme.
The Village Health and
Sanitation Committees, set up under the NRHM, now include Nutrition in its
mandate and have been renamed as Village Health, Sanitation and Nutrition
committee (VHSNC). Malnutrition and anaemia are important factors for high
maternal and infant mortality in India and 500,000 committees should make a
difference in the health status of expecting and lactating mothers.
The NRHM seeks to bring down
IMR to under 30 per 1,000 live births, MMR to 100 per 10,000 live births and total
fertility rate to 2.1. To achieve this, PHCs have been strengthened to
act as First Referral Units (FRUs) with capacity to provide comprehensive
obstetric emergency care. As many as 8,250 PHCs have been upgraded as 24X7
units. or the infants, 374 Special
Newborn Care Units, 1638 Newborn Stabilisation Units, and 1,1432 Newborn Care
Corners have already been established in addition to renovations taken up in
the already existing facilities and 1,951 Mobile Medical Units provided in 442
districts for delivery of health care
in difficult areas. Free transportation for shifting
pregnant women to health facilities and mother and child tracking system has
been set up to ensure and monitor timely health interventions.
The name based Mother
and Child Tracking System established to record every pregnant woman and child
and to follow up to ensure full ante natal check-ups and immunisation of
children has picked up in most States. A database of more than 3.25 crore pregnant
women and children has already been created. At the root of the problem of 42
percent children in India being malnourished and a substantial percent
suffering from stunted growth and wastage is under-nourished and anaemic mothers.
government has taken a policy decision to review every maternal death both at
the health facilities and in the communities, for which guidelines have been
provided to the States. The purpose of the review is to find gaps in service delivery which lead to maternal deaths and take corrective action to improve
the quality of service, and not for taking punitive action against service
providers. All States have institutionalised the MDR process and a preliminary
study reveals what has already been in the public domain. Lack of
transportation, infrastructure, privacy and behaviour of the staff are the main
issues that need to be addressed urgently.
A review of the NRHM, government’s flagship programme by
the former Union Health Secretary Javid Chowdhury suggested that it was
not a grand success after all with only one third of the PHCs functioning round
the- clock. While Mr Chowdhury’s report was based on
official data, my field visits to remote areas also present a not so happy picture. The structures created under the
NRHM are not of much use because of lack of trained human resource and supply of medicine. In a far flung village of Orissa, a PHC had not seen even a single delivery
from 2007. All patients were referred to the District Hospital at Bolangir which
was unable to take the burden.
A new initiative namely Janani
Shishu Suraksha Karyakaram (JSSK), launched in June 2011 which
guarantees free entitlementsto pregnant
women and sick new born till 30 days after birth, including C-Section, drugs
and consumables, diagnostics, diet during stay in the health institutions,
provision of blood, exemption from user charges, transport from home to health
institutions, including transport between facilities in case of referral and
free drop back home after 48 hrs stay, has failed to show tangible results
because of lack of awareness. The benefits of the scheme are not known even at the hospitals. Expecting people
to benefit from
it would be rather far-fetched.
Similarly, the results of
Adolescent Sexual Reproductive Health (ARSH) strategy for the promotion
of menstrual hygiene among adolescent girls in the age group of 10-19
years in rural areas, is far from satisfactory. This programme is aimed at
ensuring that adolescent girls (10- 19 years) in rural areas have adequate knowledge
and information about menstrual hygiene and the use of sanitary napkins. Under
this scheme, 1.5 crore girls across these districts will be reached with
the behaviour change communication campaign and provided access to an NRHM
brand of sanitary napkins that will be sold to the girls by the ASHA at
subsidised costs. This is expected to prevent reproductive tract infections
(RTI) and sexually transmitted infections (STIs).
Official statistics also
show that 46.8 percent women in India have low body mass index and over 55
percent are anaemic. The government’s initiative to provide iron and folic
tablets to adolescent girls and pregnant women will need to be better monitored
and implemented because women, often, chose to ignore their health. Maternal
death audits have shown that women did collect the tablets but never consumed
these to overcome anaemia. Strips of tablets were recovered from a young woman’s
house in a tribal district of Gujarat who died of excessive bleeding because
the hospital asked the family to arrange for blood which it was unable to do.
Child Health and Immunisation
Over the past several
years, the focus of the government has also been on child health and immunisation that has helped in bringing down the child mortality and
achieving polio free India.
Pulse Polio Immunisation
Seven million children
die globally before their reach their fifth birthday. Of these,
1.7 million are in India—highest anywhere in the world.
Half of these deaths occur within a month of the child being born. While India
has made some progress with the under-five mortality falling from 116 per 1000 live births in 1990 to 59
per 1000 live births in 2010, this is still inadequate.
These figures also mask the gross inequalities
between the States and between different social, cultural, gender and economic groups
India’s major achievement
of the recent past has been the eradication of polio. With only 42 polio cases detected
in 2010 compared to 741 cases detected during 2009, the most significant progress was seen
in the endemic States with no type 1 case detected in UP since November 2009
and only one type 1 case detected in 2010 in Bihar with onset of July 2010.
During 2011, only a single case of wild polio virus was detected in Howrah district
in West Bengal.
Earlier this year, the
World Health Organisation officially removed India from the list of polio-endemic
countries, as India has not had a case of polio since January 13, 2011.
Universal Immunisation Programme
Immunisation programme is
one of the key interventions for protection of children from life threatening
conditions, which are preventable. In India, full immunisation coverage is
increasing but continues to be just about 60 percent and lesser in rural
settings and other deprived sections not having access to pure drinking water and
sanitation. Under the Universal Immunisation Programme (UIP) vaccination
is carried out to prevent seven vaccine preventable diseases i.e. Diphtheria,
Pertussis, Tetanus, Polio, Measles, severe form of Childhood Tuberculosis and Hepatitis
B. Since 2006, single dose of Japanese encephalitis vaccine has been
introduced under routine immunisation in the high burden districts in phased
Pentavalent vaccine which consists of vaccines
against five diseases (Diphtheria, Pertussis Tetanus,
Hepatitis Bandand Haemophilus influenzae B) has also been
introduced in some States. Vaccine against Hib disease (Haemophilus
influenza B) is a new addition to the immunisation programme. Pentavalent
vaccine is administered to children at 6, 10 and 14 weeks of age and will
replace the existing DPT and Hepatitis B vaccine primary dose of which is given
at the same age.
The Government claims
that Pentavalent vaccine will ensure complete immunisation against 5 diseases
three injections to children and also reduces the chances of an Adverse Event
Following Immunisation due to less injection load, but the claim is contested by
rights-based health activists. It is estimated that 40 percent of all
under-5 mortality in India is attributed to Pneumonia, Meningitis and
Diarrhoea. Hib disease is estimated to cause 2.6 lakh cases of pneumonia
and 52 thousand cases of meningitis every year.
In India, as in other
parts of the world, the cost of healthcare is often prohibitive for the poor
and discourages the use of the services that exist. Also many States with high
levels of child mortality do not spend all the resources that have been
allocated. It is always the poorest and the most marginalised Indian
children who are at the greatest risk.
Under the Family Planning
programme, eligible couples are now being counseled to delay their first child and then better space their children for which contraceptives like condoms are provided by ASHAs
at the doorsteps. The ASHA charges a nominal amount from beneficiaries for her effort to deliver contraceptives at doorstep.
However, there can be no improvement
in maternal health, unless women are enlightened through education at least
till the primary level and we cannot imagine improved maternal health in any
society that does not promote gender equality or in one which does not empower
its women; or in one which does not reduce child mortality rates.
It goes without saying
that unless all concerned – policy makers, civil society, communities and
families and all of us – contribute in our own different ways to eliminate the
social, economic, cultural and political factors which reinforce discrimination,
denial, deprivation and disempowerment of women in every stage of their life
from the womb to the tomb, maternal health would continue to be compromised and
the human rights of women would continue to be a casualty.
Aarti Dhar The author is Special Correspondent, the Hindu, New Delhi.