 |
PFI Report on Maternal Health Consultation April 3-4 2013 |
|
|
1 Pages 1-10 |
▲back to top |
|
|
1.1 Page 1 |
▲back to top |
Consultation on Maternal Health:
Emerging Priorities
Population Foundation of India, Woodrow Wilson International Center for
Scholars, Maternal Health Task Force, United Nations Population Fund
April 3-4, 2013, Delhi
Maternal Health: Emerging Priorities
1
|
|
1.2 Page 2 |
▲back to top |
Contents
Acronyms ................................................................................................................................................ 4
Executive Summary................................................................................................................................. 5
India has witnessed a marked decline in maternal mortality over the last ten years (from 301
per 100,000 births in 2003 to 212 in 2009) as a result of advocacy and interventions on
Millennium Development Goal (MDG) 5. ....................................................................................... 8
Day 1: Wednesday, 3 April 2013 ............................................................................................................. 8
The Plenary session: Maternal Health in India ................................................................................... 8
Key points from Neglected Areas in Maternal Health by Dr Srinath Reddy, President, Public
Health Foundation of India ............................................................................................................. 8
Maternal Health: Making Strategies more Effective, Dr. A K Shiva Kumar, Member, National
Advisory Council (NAC) ................................................................................................................. 10
Discussant: Dr SK Sikdar, Deputy Commissioner, Family Planning Division, Ministry of Health and
Family Welfare (MoHFW) ............................................................................................................. 11
Discussant: Dr. Gita Sen, Professor, Indian Institute of Management (IIM), Bangalore .............. 12
Open Floor Discussion...................................................................................................................14
Group 1: Quality of Care - Moderator: Dr Sharad Iyengar, Action Research and Training for Health
(ARTH) ............................................................................................................................................... 14
Group 2: Connecting Maternal Health, Family Planning and Reproductive Health - Moderator: Dr
Leela Visaria, Gujarat Institute of Development Research (GIDR).................................................... 16
Group 3: Social Determinants and Maternal Health - Moderator: Dr Abhay Bang, Society for
Education, Action and Research in Community Health (SEARCH)....................................................17
Open Floor Discussion...................................................................................................................18
Group 4: Accountability of the Public Health System on Maternal Health - Moderator: Dr H.
Sudarshan, Karuna Trust (presentation by Dr Jashodhara Dasgupta, SAHAYOG) ............................ 19
Group 5: Knowledge Gaps and Research Needs- Moderator: Dr Priya Nanda, International Centre
for Research on Women (ICRW) ....................................................................................................... 20
Open Floor Discussion...................................................................................................................20
Respondent: Ms Sujatha Rao, Former Secretary Health, Government of India ............................... 21
Summing up: Ms Dipa Nag Chowdhury, Deputy Director, India, MacArthur Foundation ............... 21
Closing Remarks, Mr Anders Thomsen, Deputy Representative India/ Bhutan, United Nations
Population Fund................................................................................................................................21
Day 2: Thursday, 4 April 2013 ............................................................................................................... 22
Welcome Remarks, Mr Michael Kugelman, WWICS & Dr Mary Nell Wagner, Maternal Health Task
Force (MHTF) .................................................................................................................................... 22
Background on Maternal Health in India, Ms Poonam Muttreja, Population Foundation of India
(PFI) ................................................................................................................................................... 22
Maternal Health: Emerging Priorities
2
|
|
1.3 Page 3 |
▲back to top |
Connecting Maternal Health, Reproductive Health and Family Planning, Dr Leela Visaria ............. 23
Social Determinants and Knowledge Gaps, Dr Abhay Bang ............................................................. 24
Quality of Care and Accountability Mechanisms, Dr Sudarshan ...................................................... 25
Discussant: Dr John Townsend, Population Council ..................................................................... 26
Discussant: Dr Mary Nell Wegner, Maternity Health Task Force ................................................. 27
Open Floor Discussion...................................................................................................................27
Press coverage ...................................................................................................................................... 30
2. The Hindu, April 9, 2013 - Woman at risk, Aarti Dhar .................................................................. 32
3. Down to Earth, April 10, 2013- Experts call for holistic approach to reproductive healthcare,
Jyotsna Singh.....................................................................................................................................33
5.Deccan Herald, April 3, 2013 - Maternal morbidity, a new problem in rural India,Kalyan Ray, New
Delhi .................................................................................................................................................. 39
8. Maternal Health in India: Making Progress in a Key Battleground, Carolyn Lamere, Thursday,
April 18, 2013 .................................................................................................................................... 41
Participants List ..................................................................................................................................... 45
Maternal Health: Emerging Priorities
3
|
|
1.4 Page 4 |
▲back to top |
Acronyms
ANC
ANM
ARSH
ARTH
ASHA
AYUSH
DFID
DLHS
GIDR
GPS
HIV
ICDS
ICPD
HMIS
ICRW
IFA
IIM
IUD / IUCD
JSSK
JSY
MDG
MDR
MHTF
MMR
MNREGA
MoHFW
MTP
NAC
NBSU
NFHS
NRHM
OB/GYN
PFI
PHC
PHFI
PIP
RMNCH+A
RTI
SEARCH
SNCU
SRHR
SRS
STI
UNFPA
VHSC
WHO
WWICS
Antenatal Care
Auxiliary Nurse Midwife
Adolescent Reproductive and Sexual Health
Action Research and Training for Health
Accredited Social Health Activist
Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy
UK Department for International Development
District Level Household Survey
Gujarat Institute of Development Research
Global Positioning System
Human Immunodeficiency Virus
Integrated Child Development Scheme
International Conference in Population and Development, Cairo
Health Management Information System
International Center for Research on Women
Iron and Folic Acid
Indian Institute of Management
Intrauterine Device / Intrauterine Contraceptive Device
Janani Shishu Suraksha Karyakram
Janani Suraksha Yojana
Millennium Development Goal
Maternal Death Review
Maternal Health Task Force
Maternal Mortality Ratio
Mahatma Gandhi National Rural Employment Guarantee Act
Ministry of Health and Family Welfare
Medical Termination of Pregnancy
National Advisory Council
New Born Stabilization Unit
National Family Health Survey
National Rural Health Mission
Obstetrician and Gynaecologist
Population Foundation of India
Primary Health Centre
Public Health Foundation of India
Programme Implementation Plan
Reproductive, Maternal, Newborn, Child and Adolescent Health
Reproductive Tract Infection
Society for Education, Action and Research in Community Health
Special New Born Care Unit
Sexual and Reproductive Health and Rights
Sample Registration System
Sexually Transmitted Infection
United Nations Population Fund
Village Health and Sanitation Committee
World Health Organisation
Woodrow Wilson International Center for Scholars
Maternal Health: Emerging Priorities
4
|
|
1.5 Page 5 |
▲back to top |
Executive Summary
The report captures key discussions held and recommendations made during the Consultation on
Maternal Health: Emerging Priorities co-hosted by Population Foundation of India, the Woodrow
Wilson International Center for Scholars (WWICS), the Maternal Health Task Force (MHTF) and the
United Nations Population Fund (UNFPA) on April 3-4, 2013 in Delhi. The consultation was a part of
the Wilson Center's Global Health Initiative's Advancing Dialogue on Maternal Health Series, which
works to address many critical and neglected maternal health issues. The series convenes experts
from the maternal health, health systems, donor and policymaking communities. The consultation
was aimed at identifying best practices, gaps and areas requiring focused interventions in maternal
health in India.
The discussions focused on the following key points:
India has witnessed a marked decline in maternal mortality over the last ten years; however,
the poorest communities in the country, including scheduled castes, tribes and other
marginalized groups continue to lack access to maternal health services.
Though the Government of India’s new Reproductive, Maternal, Newborn, Child and
Adolescent Health (RMNCH+A) strategy is comprehensive and well-articulated, in order to
operationalize it, six deficits need to be addressed:
o Accountability deficit at the top levels of decision making
o Ownership deficit at the federal structure of governance, especially on the concept
of universal health coverage
o Knowledge deficit in terms of benchmarks and monitoring
o Competency deficit in evaluation and cost effectiveness studies
o Trust deficit in the government as well as the private sector
o Financial deficit in health expenditure, both at central and state level
Despite attention to maternal mortality, the issue of maternal morbidity is often neglected.
It has not even been listed in the Millennium Development Goals (MDGs). Maternal
morbidity is an important dimension of maternal health, which continues to be
underestimated.
Quality of care in the Indian public health system remains a low priority issue and needs to
be viewed in conjunction with accountability, especially that of the lowest level of health
service providers.
There should be a movement from a mortality perspective to a health and wellbeing
perspective. This would entail adopting:
o a life cycle approach (need to address widespread anaemia among girls to improve
maternal health)
o a rights-based approach (e.g. despite the government focus on institutional
deliveries, home deliveries constitute up to 50 percent of deliveries in some
districts)
o the integration of maternal health, reproductive health, sexual health, family
planning and adolescent health
o the linking of maternal health with larger issues of women's empowerment and
gender justice.
Maternal Health: Emerging Priorities
5
|
|
1.6 Page 6 |
▲back to top |
In addition, an analysis of the politics of policy making and its implementation is essential.
imperative.
Key recommendations from the consultation:
1. Connecting Maternal Health, Reproductive Health, and Family Planning: The current
implementation of the family planning programme is vertical. While there are efforts to
reposition family planning within the maternal health construct, sexual and reproductive health
remain a neglected agenda. There is need to integrate these in the broader perspective of
women’s health.
There is a need to undertake a systematic analysis to remove the conceptual separation
between these areas as well as consider the costs and policy risks related to integration.
Though India adopted a target-free approach to family planning in 1996, the ‘target mind-
set’ has remained and continues to lead to direct and indirect coercion. It has been observed
that what is incentivised is what is ‘done’ and measured, e.g. sterilisation. Thus, it is
important to evaluate and analyse the incentives for health functionaries.
Post-partum care, including insertion of post-partum IUD, needs to be improved.
There is a need to focus on adolescent health, including the provision of comprehensive
sexuality education.
Male responsibility in family planning must be enhanced.
Access to, and quality of abortion services, must be improved, and medical abortion must be
included in the public health system.
2. Social Determinants: There are several social determinants of maternal health. Key among them
are violence against girls and women; political disempowerment of women; social customs,
beliefs and practices (e.g. child marriage and early pregnancy); nutrition; and protection from
three major risk factors (indoor air pollution from cooking stoves, alcohol and tobacco).
Socio-anthropological studies around gender, rights, and equity in access (e.g. home
delivery) must be conducted to inform policies and programmes.
To aid decision making, there is a need for gender disaggregated data on health at various
levels.
Girls’ education should be guaranteed till Class X (age 15-16). Under the Right to Education
Act, it is currently till Class VIII (age 13-14).
Health awareness programme for both women and men need to be undertaken. Men must
be sensitised on maternal and gender issues.
The health care delivery system should connect with women’s micro-credit groups and
elected female representatives.
A rapid health care response has to be operationalized for women affected by violence.
Mental health services are required for women.
There should be universal cashless services under the RMNCH+A.
3. Knowledge Gaps
Systematic reviews, including on perinatal mortality and maternal morbidity are crucial.
A robust methodology is needed to measure maternal morbidity.
There is a need for national level studies on maternal mortality and morbidity.
Maternal Health: Emerging Priorities
6
|
|
1.7 Page 7 |
▲back to top |
The quality of data collected and generated through Health Management Information
System should be improved.
Real time data must be used for planning.
4. Quality of Care: The government has made major investments by way of facilities, equipment,
supplies, central guidelines and accreditation norms through the National Rural Health Mission
(NRHM). This has led to a large increase in service utilisation. However, quality has not improved.
Quality needs to be prioritised and a system of accreditation of facilities and services must be
introduced.
There should be a development of guidelines, protocols and checklists for both the public
and private sector. These protocols need to be disseminated after building consensus. The
community’s perspectives on quality should be included.
Indicators for issues directly linked to quality of care such as perinatal deaths and morbidity
also need to be included in the HMIS and measured in order to receive adequate attention.
The quality assurance mechanism needs to be established. This would include periodic
assessments by external teams, and in-facility quality assurance committees.
Conduct modelling exercises to assess staff capacity and allocation to workload (e.g. number
of deliveries per 24 hours / bed occupancy), pre- and in-service training and follow up.
5. Accountability: There is a greater awareness of corruption and a clamour for change in the
country. Mechanisms like e-procurement and e-governance are bringing more transparency and
accountability. However, bad management and corruption mainly affect the poor and women.
This is exemplified in the procurement of equipment, drugs (e.g. lack of Iron Folic Acid for
anaemia) and human resources. While national policy encourages institutional deliveries, there is
no plan to manage the transition from home delivery to institutional delivery.
Community monitoring was started under the National Rural Health Mission (NRHM), but
needs to be scaled up with adequate budget allocation, as well as a grievance redressal
mechanism with an ombudsperson at the district level.
The health system requires administrative reforms for transparency and accountability in
procurement, and use of transparency mechanisms like Transparency International’s
integrity pact tool.
Introduction
The Consultation on Maternal Health: Emerging Priorities was co-hosted by the Population
Foundation of India, the Woodrow Wilson International Center for Scholars (WWICS), the Maternal
Health Task Force (MHTF) and the United Nations Population Fund (UNFPA). It was a part of the
Wilson Center's Global Health Initiative's Advancing Dialogue on Maternal Health Series, which
works to address many critical and neglected maternal health topics. It convenes experts from the
maternal health, health systems, donor, and policymaking communities.
The consultation in India was aimed at identifying best practices, gaps, and areas requiring focused
interventions in maternal health.
Maternal Health: Emerging Priorities
7
|
|
1.8 Page 8 |
▲back to top |
India has witnessed a marked decline in maternal mortality over the last ten years (from 301 per
100,000 births in 2003 to 212 in 2009) as a result of advocacy and interventions on Millennium
Development Goal (MDG) 51.
Despite this, the poorest communities in the country, including scheduled castes, tribes, and other
marginalized groups, continue to lack access to maternal health services. An example of this are 26
maternal deaths in Barwani District Hospital in Madhya Pradesh over eight months in 2010. Twenty
one of them were of women from scheduled tribes. It is clear that in spite of an overall improvement
in human development, the poorest quintile has yet to see a significant reduction in maternal
mortality. India has to focus on migrant populations and women who temporarily migrate to their
birthplace for delivery and do not get public health services. There is a need to link the maternal
health with the larger issues of women's empowerment and gender justice.
Day 1: Wednesday, 3 April 2013
The Plenary session: Maternal Health in India
(From left to right) Dr AK Shiva Kumar, Dr Srinath Reddy, Ms Poonam Muttreja, Dr SK Sikdar and Dr Gita Sen
Key points from Neglected Areas in Maternal Health by Dr Srinath Reddy, President,
Public Health Foundation of India
Despite attention to maternal mortality, the issue of maternal morbidity is often neglected.
It has not even been listed in the Millennium Development Goals (MDGs). Maternal
morbidity is an important dimension of maternal health, which continues to be
underestimated both globally and nationally, due to inadequate methods of measurement
and the poor capacity of health systems to apply the existing methods.
For every woman who dies in childbirth, approximately 20 more have long lasting illnesses
with physical, psychological, social, and economic consequences. Severe and continuing ill-
1 The goal calls for reduction by three quarters, between 1990 and 2015, of the maternal mortality ratio and
universal access to reproductive health.
Maternal Health: Emerging Priorities
8
|
|
1.9 Page 9 |
▲back to top |
health among women affects their children’s health as well, in terms of nutrition and
nurture, thereby having inter-generational consequences.
Acute or ‘near-miss’ cases are defined by the World Health Organisation (WHO) as those
women who have nearly died but survived a complication during pregnancy, childbirth, or
after the termination of pregnancy. Illnesses under this ambit would include cardio-vascular,
respiratory, renal, coagulation disorder, liver failure, neurological failure and uterine
dysfunction. Current methods of measurement are varied and make international
comparisons difficult. However, WHO’s method of the near-miss index, embedded with a
maternal severity index (MSI), provides for better estimates and can be used for
benchmarking, better planning, assessment and evaluation of programmes. Other acute
morbidities that are not near-misses include severe ante-partum haemorrhage, placenta
praevia, severe post-partum haemorrhage, feto-pelvic disproportion and ruptures. These
need to be estimated too.
There is a huge spectrum of chronic morbidities -- from physical to mental. While violence is
not listed as a maternal morbidity, women face it during and after pregnancy, especially
when they are blamed for the birth of a female child. Thus, violence against women is a
substantial component of maternal morbidity.
Globally, of the 136 million births that take place annually, about 1.4 million women
experience a near-miss, 9.5 million suffer other complications, and 20 million have long-term
disabilities. Globally, 42 percent of pregnant women suffer anaemia. The estimated rate of
mental ill-health is 20-30 percent, ranging from transient mood changes to severe
depression or psychotic illness. The global estimate of vesicovaginal fistula is 2 million
women and for uterine prolapse cases it ranges from between 1 per 10,000 to 1 per 1,000.
However, these problems are more commonly found in developing countries and remain
challenges that need to be addressed. In addition, malaria and the concurrent problems of
tuberculosis and HIV can endanger pregnancy. A host of non-communicable diseases,
including pregnancy-induced and pregnancy-associated hypertension (i.e. preceding
pregnancy), and gestational diabetes, which affects up to 15 percent of pregnant women
worldwide, including an estimated 4 million women in India also endanger pregnancy.
However, there is a lack of incidence data or a standardised national study. About 50
percent of women with gestational diabetes tend to develop diabetes in the next 5-10 years.
The following surveys provide a profile of the dimensions of maternal morbidity in India:
Dr. Rani Bang’s study in Gadchiroli suggested an incidence of 53 percent maternal morbidity
in rural India - 18 percent during labour and 43 per cent during peurperium.2
Dr Iyengar’s study in Rajasthan reported that 7.6 percent of postpartum women had life
threatening morbidities.3
2 Maternal morbidity during labour and the puerperium in rural homes and the need for medical attention: A
prospective observational study in Gadchiroli, India; Bang RA, Bang AT, Reddy MH, Deshmukh MD, Baitule SB,
Filippi V. British J. OB-GY 2004, 111:231-238.
http://www.searchgadchiroli.org/Research%20Paper/bjog%20bang%27s%20paper.pdf
Maternal morbidity during labour and the puerperium in rural homes and the need for medical attention: A
prospective observational study in Gadchiroli, India.
Maternal Health: Emerging Priorities
9
|
|
1.10 Page 10 |
▲back to top |
While incidence varies, there is a huge problem of maternal morbidity that needs a comprehensive
response. This includes antenatal care, nutrition, vaccination, screening, detection of postnatal
sequelae, contraception, facility and community based services. Also required is a standardised
quality of care, audits of maternal morbidity, and better attention to determinants of outcomes, and
linking of outcomes to programme evaluations.
At a high-level consultation in Botswana on health goals in the post-2015 agenda, there was a
widespread commitment to the continuation and acceleration of the MDGs. Participants recognised
that morbidity and equity were missing and needed to be included. The broader life course
perspective of improved health across all stages of life was also deemed important.
The maternal health discourse has to bring in maternal morbidity. However the new global
development goals are reframed, maternal morbidity needs to be clearly defined, measured, and
included.
Maternal Health: Making Strategies more Effective, Dr. A K Shiva Kumar, Member,
National Advisory Council (NAC)
The Government of India recently launched a comprehensive and well-articulated document, A
Strategic Approach to Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCH+A)4
in India. The strategy has two distinct features:
1. It adopts a life-cycle approach, recognising that reproductive, maternal, and child health
cannot be addressed in isolation, as the health of adolescent girls impacts women's health at
different life stages, including pregnancy.
2. Much depends on the places where care is provided.Just as different stages of the life cycle
are interdependent, all levels of the health care system, from home to community, require
focus.
The ‘plus’ refers to three aspects:
1. The inclusion of adolescence as a distinct life stage.
2. The linking of maternal and child health to reproductive health and components like family
planning, adolescent health, gender, pre-natal sex determination, thus giving maternal
health a much broader interpretation.
3. The linking of facility and community-based care to create a continuous care pathway.
These three aspects emphasise the need to look at health in a much more integrated manner and to
make linkages between health and investments in non-health sectors. The document lays out two
reasons for the approach to succeed:
3 Early Postpartum Maternal Morbidity among Rural Women of Rajasthan, India: A Community-based Study
Kirti Iyengar http://www.arth.in/wp-content/uploads/2012/08/Early-postparum-maternal-morbidity-among-
rural-women-of-Rajasthan-India-a-community-based-study.pdf
4 Copies of the document, A Strategic Approach to Reproductive, Maternal, Newborn, Child and Adolescent
Health(RMNCH+A) in India were distributed to the participants.
http://www.unicef.org/india/1._RMNCHAStrategy.pdf
Maternal Health: Emerging Priorities
10
|
|
2 Pages 11-20 |
▲back to top |
|
|
2.1 Page 11 |
▲back to top |
1. India already has a community-based programme given a huge fillip by the Accredited Social
Health Activist (ASHA) workers.
2. India has a three-tiered health system in place.
In order to operationalize the strategy, six deficits would need to be addressed:
1. Accountability deficit – Much of the focus on accountability so far has been located in the
slogan, “People’s health in people’s hands.” However, this seems to infer that people should
be held fully responsible for their own health.
Following from this slogan is the community monitoring mechanism which focuses on the
community level health system. But, in fact, the real challenge is accountability at the top
levels of decision-making. There is a need to tackle the lack of accountability at the top,
rather than simply holding frontline health workers or ASHAs responsible.
2. Ownership deficit – The lack of ownership, coordination, or convergence emerging from the
federal structure of governance generates a lack of collective ownership. A case in point
being the concept of universal health coverage, which had a weak mention in the 12th Five-
Year Plan and has not been embraced.
3. Knowledge deficit – There is a lack of benchmarks. For example, while there were targets of
reducing maternal anaemia by 20 percent, there was no benchmark to measure the 20
percent reduction. Having goals without monitoring, commitment, or interest in tracking
progress, makes the goals pointless. The document mentions the development over time of
an approach to tribal health (not a strategy).
4. Competency deficit – There is a need to strengthen the training of doctors and frontline
health workers, and also to develop competencies in evaluation and cost effectiveness
studies.
5. Trust deficit – This has two dimensions:
a. There is no trust in the government, evidenced by the increasing clamour that the
government is unable to deliver on the health of the country. However, basic
economics states that the private sector cannot deliver on public health. Therefore,
there is a need to come up with good evaluations that demonstrate what works,
lessons learnt, and reinforce some confidence in the government.
b. There is a lack of faith in the private sector, which includes NGOs. Elements in the
private sector need to be examined, though not just through regulatory frameworks.
6. Financial deficit –The Finance Minister did his best to provide a 2.5 - 3 percent commitment
to health in this year’s budget despite the economic slowdown. However, even when the
country was experiencing high growth rates, investment in health was low. Therefore, India
experiences a lack of commitment to health. There is a need for the equalisation of public
expenditure on health among the states, i.e. the example of Bihar’s low spending versus
Kerala’s higher spending. There is also the need for incentives for better performance.
Discussant: Dr SK Sikdar, Deputy Commissioner, Family Planning Division, Ministry of
Health and Family Welfare (MoHFW)
Several schemes of the MoHFW have been targeted towards achieving the RMNCH+A goals and
objectives.
Maternal Health: Emerging Priorities
11
|
|
2.2 Page 12 |
▲back to top |
Janani Shishu Suraksha Karyakram (JSSK)5is the best example of scale up, with widespread
awareness. Though the facility for dropping clients back home has not been established due
to lack of adequate ambulances, beneficiaries in Rajasthan reported not having spent any
money at health institutions.
Community distribution of contraceptives was scaled up in six months and evaluated by
three organisations, Population Foundation of India (PFI), Family Health International (FHI),
and Pathfinder, with positive reports.
Referral transport is an area where there is a great push. Ambulances will soon be fitted with
GPS to ensure pick up of patients within 30 minutes of the call and drop to the facility within
30 minutes of pick-up.
Dedicated and complete maternal and child health wings were added to 100 hospitals last
year. This was done through the Programme Implementation Plan (PIP) funds. Rs 20 billion
have been invested.
As the delivery points have been formalised using the concept of functional, rather than
structural places, benchmarks are being used to determine number of deliveries being
conducted. A total of 16,000 functional places are being strengthened with a full
complement of services.
Every mother is being tracked for anaemia as this is mandated under the state PIPs.
Monthly reports from the states are sought on the maternal death reviews.
Facility-based care, including Special New Born Care Unit (SNCU) and New Born Stabilization
Unit (NBSU), as well as equipment in the labour rooms, are now available even in remote
areas. However, the training of staff remains to be done at scale.
Family planning is now not positioned as population stabilisation, but instead as an
intervention for improving maternal and child health. An analysis of the SRS 2011 report
reveals that 800,000 births a year are being averted through the provision of family
planning, of which 500,000 are high risk births (i.e. among women aged 15-19 years and
those over 35 years). Additionally, births among 15-19 year olds have come down by
350,000. Maternal deaths averted are 1,700 a year, of which 500 would be high risk.
There is a focus on community monitoring.
Discussant: Dr. Gita Sen, Professor, Indian Institute of Management (IIM), Bangalore
Two important lessons from the plenary:
1. It is important to address maternal morbidity in the same manner that mortality is
addressed. This means addressing prevention, identification, and manifestations as well as
doing maternal morbidity audits to obtain the burden of disease estimates.
2. The RMNCH+A’s six deficits are a reminder of the central need to locate maternal health in
the context of the larger health system. In India the range of deficits and problems are
largely linked to systemic issues. The solutions, however, tend to disregard the larger issues
and focus on smaller actions that are manageable and do-able. The result is that system
linked problems remain unsolved.
5The Janani Shishu Suraksha Karyakram provides completely free and cashless services to pregnant women,
including normal deliveries, caesarean operations and sick newborn (up to 30 days after birth) in government
health institutions in both rural and urban areas
Maternal Health: Emerging Priorities
12
|
|
2.3 Page 13 |
▲back to top |
Positive aspects of maternal health policy in the country since 2005:
1. Maternal health has received more attention and resources (human, financial, and
institutional) than it received since Independence.
2. Despite the controversies around it, the rate of increase and extent of institutionalisation
under Janani Suraksha Yojana (JSY)6 shows a positive direction.
3. There are now over 800,000 ASHAs, or village level health workers.
Major steps are needed in three areas:
1. Supply side – The quality of services needs to improve considerably to deal with morbidity.
While equipment is being provided, and labour rooms tiled, the question of whether women
are actually receiving quality services remains. Accountability remains a key issue. There are
major human resource gaps and weaknesses, especially at the first point of contact where
there is an inability to recognise the problem. There are Ayurvedic, Yoga and Naturopathy,
Unani, Siddha and Homoeopathy (AYUSH) practitioners at Primary Health Centres (PHC) with
little ability to recognise and handle emergencies. While there is a provision for transport,
what happens with women at these institutions is a question. AYUSH doctors need training.
Blood supplies are not available, especially in remote and difficult to reach areas. Post-
partum care is still weak and inadequate and, in fact, post-partum intrauterine devices
(IUDs) need to be examined for quality of care. There is need to ensure that rights are not
violated, coercion doesn’t occur, and IUDs are not being pushed into semi-comatose women
coming out of labour.
2. Pre and early pregnancy stage – Even a healthy pregnant woman can have an emergency
during delivery; thus the National Rural Health Mission (NRHM) is focusing on institutional
delivery. However, when most of the population is anaemic, and almost 50 percent of Indian
girls face child marriage and early pregnancy, there is the need to address the three delays in
maternal health – in seeking care, identifying and reaching the health care facility and
receiving adequate care. Anaemia among girls needs to be addressed as a priority;
otherwise, the problem is addressed too late. There is also a need to review what works and
what doesn’t work through systematic reviews on reduction of anaemia among adolescent
girls.
3. What does a rights-based approach mean in this regard? The fulfilment of the right to
services, while critical, is not enough and lets us get away with providing any kind of service,
ignoring other crucial elements of rights. Issues like menstrual hygiene, nutrition, violence
against women, early marriage and pregnancy, unsafe abortion, which still makes a
significant contribution to maternal mortality and morbidity, need to be addressed through
a rights-based approach. The problem of an adverse sex ratio has made Medical Termination
of Pregnancy (MTP) fall by the wayside. This too, is a rights question that has to be
addressed. Though family planning is not being positioned as population stabilisation, it is
being positioned as maternal health, which harks back to the discussions (just before ICPD
1994) 20 years ago.
6Janani Suraksha Yojana is a safe motherhood intervention under the National Rural Health Mission with the
objective of reducing maternal and neo-natal mortality by promoting institutional delivery among poor
pregnant women
Maternal Health: Emerging Priorities
13
|
|
2.4 Page 14 |
▲back to top |
Open Floor Discussion
The comments from the participants focused on the issue of home deliveries, which were over 50
percent in some districts, despite 7-8 years of the NRHM. In addition, they pointed out that the
rapid acceleration of institutional delivery, in the absence of quality of care, has led to higher rates
of maternal morbidity. They gave examples of poorly equipped Primary Health Centres from the
areas they worked in and pointed out that it was the poor, the Dalit, and the tribal people who were
facing the brunt of a poorly prepared system.
The issue of converging maternal and reproductive health was also raised along with the possibility
of talking about women’s health in a more cohesive and integrated paradigm which fits with rights
and ensures that morbidities were covered.
The need for mid-level health professionals was highlighted; especially for providers to be located
closer to homes. The lack of an increase in number of staff vis-à-vis the increase in number of
women accessing institutional deliveries was identified as contributing to the low quality of care.
This was also related to the loss of skill among field functionaries as the Auxiliary Nurse Midwives
(ANMs) are instructed not to do any deliveries. This is resulting in pregnant women not getting any
help during an emergency.
As there is a top-down approach to quality improvement, there were recommendations to enable
the lowest level of service providers to become accountable for quality improvement. This would
need to be done through the use of data at the health facility as well as inclusion of the community’s
perception of quality of care. Another recommendation was to standardise the framework for
quality of care across the health system. The need to look at administrative reforms, and the
incentivisation of good performance were recommended as measures for better accountability.
The article on the global burden of disease with maternal morbidity constituting a large part,
published in the Lancet, was discussed. Home-based maternal care was quoted as resulting in a
reduction of maternal morbidities from 43 percent to 2 percent.
Group 1: Quality of Care - Moderator: Dr Sharad Iyengar, Action Research
and Training for Health (ARTH)
Discussion Points
1. Need for guidelines, protocols, and checklists to be adapted to the private and public sectors
and level of institution
There is a lack of clarity among those involved in providing services about what quality
means to them. While there have been heavy investments by the NRHM on equipment,
supplies, hiring a second ANM, and in providing incentives for various achievements,
there is inadequate investment in the processes.
There is the need to include the private sector. The protocols and guidelines they
follow vary. It is important to build consensus on the use of protocols and guidelines,
since forcing a checklist on a doctor will result in it getting filled out without an
improvement in quality. There was some debate in the group on having a
Maternal Health: Emerging Priorities
14
|
|
2.5 Page 15 |
▲back to top |
comprehensive list versus a simple list. The members gravitated towards having a
simple list which could later be expanded.
2. Need to look at process and outcome indicators, not just input indicators
Quality shouldn’t be a technical / technocratic indicator. It should be based on how
people provide services, human rights and dignity of clients. There is a need to look at
services and related patient care processes and strengthen them through supervision.
The supervision protocol or checklist is not used, and often there is inspection rather
than constructive supervision.
There is a need to monitor ‘adherence to quality’ and look at outcome as a quality
indicator though outcomes are not influenced merely by quality. Quality is a necessary
indicator with respect to morbidity, as poor healthcare leads to stillbirths, near-miss,
etc. In addition, perinatal outcomes emerge from poor quality maternal health and the
cause of perinatal death is often difficult to determine.
There was a consensus on the need for simple lists of indicators that could be used at
the community level.
3. Human resource issues, especially midwifery
The group discussed the merits and demerits of having contract employees versus regular
employees. Staff shortages exist and need to be mapped and monitored. There is a ‘real’
shortage as well as a virtual staff shortage, with staff not working or having made a transition
from being clinical workers to clerical workers, i.e. doing paperwork and pushing files rather
than attending to their clinical duties. There is a need to monitor staff numbers vis-à-vis the
number of deliveries per month. The group was in agreement that rather than focus on training
and creating midwifery cadres, there is a need to create staff posts, so that those from the
nursing and midwifery cadre would stay in the labour room and not be rotated out. The quality
of pre-service midwifery training was considered to be too large a problem to be handled in the
short-term. The need to recognise their position as health providers was emphasised.
4. Quality assurance
The group debated on whether the Rogi Kalyan Samitis7 should be watching over quality as they
are headed by doctors who have not taken an interest in quality issues. It was pointed out that
these samitis also include community members. The recommendation was to have external
quality assurance cells at the district and state levels, with a super-coordinating authority and
instruments, periodic assessments and feedback.
The group emphasised the need for transparency, and that the results obtained from
monitoring quality should be widely shared.
5. Community perspective
The group recommended that –
The patients’ charter on health be disseminated across the community
7Rogi Kalyan Samiti or Patient Welfare Committee is a management structure under the NRHM intended to
monitor quality of care and standards in local government health institutions. The Samitis can be composed of
local people’s representatives, district and health officials, community leaders, among others.
Maternal Health: Emerging Priorities
15
|
|
2.6 Page 16 |
▲back to top |
Work with self-help groups and local elected representatives to add their perspectives
on quality
Regular feedback got from consumers through surveys
The discussion acknowledged that patients may not complain about the quality of a facility that
they have to return to. Therefore, grievance redressal was needed, so that people were not
scared to address major lapses.
Group 2: Connecting Maternal Health, Family Planning and Reproductive
Health - Moderator: Dr Leela Visaria, Gujarat Institute of Development
Research (GIDR)
Discussion Points
1. Need for a systematic analysis to build the case for removing the conceptual separation
between maternal health, family planning and reproductive health. These are not
separate entities as women go to health facilities to receive these services.
2. Requirement for analysing incentivisation and how it affects health functionaries, including
ASHAs. The group emphasised that what is incentivised is what gets done in the field and
what is done is what is measured. Thus, there is no real information on what women need
as this is not necessarily being measured. The ASHAs have an incentive for all the tasks that
they do and some tasks have a higher monetary value than others.
3. Overt and covert coercions in family planning due to targets given to health workers are a
matter of concern.
4. Sexual health has been forgotten with respect to reproductive health. While the discourse
after the International Conference in Population and Development (ICPD) was around
sexual and reproductive health, sexual health appears to have been dropped. It was
highlighted that one cannot talk about reproductive health without sexual health.
5. Gender and comprehensive sexuality education for adolescents is the basis for the future
integration of these issues.
6. Medication abortion should be part of the public health system.
7. Need to include pharmacists among para-health care providers as pharmacists are the first
point of contact for anyone needing healthcare, including medical abortion.
8. Need to improve post-partum care including the Intrauterine Contraceptive Device (IUCD)
programme being rolled out in Bihar and Uttar Pradesh (UP). The providers should be
familiarised with the guidelines, the training given, the monitoring mechanism, and the
global standards of post-partum IUCD.
9. Reproductive Tract Infections (RTI) and Sexually Transmitted Infections (STI) needed to be
integrated into ANC provided to women. Currently, pregnant women are given IFA tablets
but not tested for RTIs and STIs.
10. Newborn care needs to be added to maternal health.
Maternal Health: Emerging Priorities
16
|
|
2.7 Page 17 |
▲back to top |
Group 3: Social Determinants and Maternal Health - Moderator: Dr Abhay
Bang, Society for Education, Action and Research in Community Health
(SEARCH)
Discussion Points
Key social determinants for Reproductive, Maternal, (Sexual), Newborn, Child and Adolescent Health
were identified as:
1. The status of girls and women in society and the value society places on women, examples -
survival of a female foetus and value of a girl in a family.
2. Nutrition, especially proteins, which determine the body mass index of a girl and micro-
nutrients for anaemia.
3. Traditions and customs, for instance cases where women are encouraged to decrease their
calorie intake during pregnancy so that the foetus doesn’t grow too large and delivery is
easy.
4. Migration, where a new environment means a lack of a social network for women. Women
migrate due to marriage and delivery. At each time of migration, the woman is
disempowered.
5. The age at marriage of girls which determines how soon the girl becomes sexually active and
pregnant.
6. The political disempowerment of women in the family, community, and at the national level.
7. Alcohol and tobacco consumption by men affects the women’s well-being. Tobacco
consumption among women has been shown as the number two risk factor in India in the
global burden of disease list. An example from a district sample survey in Gadchiroli revealed that
the total money spent under various government schemes totalled Rs 560 million (Rs 220 million
under NRHM; Rs 140 million under the Integrated Child Development Scheme (ICDS), and Rs 200
million under the Mahatma Gandhi National Rural Employment Guarantee Act(MNREGA). At the
same time, the women had spent Rs 730 million. This was more money than they contributed in their
self-help groups.
The group recommended
1. The need to generate women specific health information, at various levels of decision
making. Up-to-date and comprehensive data needs to be generated.
2. Health literacy of men and women should be carried out, providing them with information,
knowledge and skills to prevent illnesses by avoiding risks, seeking care and entitlements.
3. Universal health care must be adopted as it has been in various countries around the world.
The Planning Commission has accepted universal health care only partly, due to a lack of
resources. Therefore, universal health care should prioritise RMNCH+A, with cashless
services. There should be a universal health care card that is portable so that regardless of
location in the country, access to healthcare is provided.
4. Sensitisation of men on maternal health and gender.
5. Health care must mobilise emergency response to victims of violence against women.
Maternal Health: Emerging Priorities
17
|
|
2.8 Page 18 |
▲back to top |
6. The goal for girls’ education should be at least till 10thstandard and should be monitored, as
this will lead to delay in marriages.
7. Women should be protected from the ill-effects of domestic smoke, alcohol and tobacco.
8. Health services should be connected with women in self-help groups and those who are
elected to the Panchayat. This would involve women in planning, decision making and
accountability.
Open Floor Discussion
The issue of home deliveries was brought up again as an important focus point, despite the
increased number of institutional deliveries. An estimate given was that 25-27 million births were
taking place in homes every year.
The issue of referrals was also mentioned with regard to quality of care. Reviews have shown that
multiple referrals are given to women. While transport is provided to them, there is no
accountability in the referral system once the woman is referred out of the system. It was
acknowledged that referral was a stressful event and it was worth tracking indicators on it.
Contraception is important and needs to be placed within a rights discourse. An anecdote shared of
rights violations related to the insertion of post-partum IUDs from Tamil Nadu. The IUDs were being
placed during women’s caesarean sections, and they were later told that their husbands had been
informed.
Wage losses during maternity should be included in the social determinants as the poorest wealth
quintile was dependent on the daily wage earnings of both husband and wife. During pregnancy,
families see a dip in income, exacerbated with the steep rise in family expenditure (nutrition and
celebration). They managed these by taking loans and cutting food consumption. Thus, advising
women on exclusive breastfeeding for six months, without a budget allocation, was futile as these
women needed to get back to work as soon as possible.
The group focused on the continuing lack of access to maternal health services and special
schemes for Dalits, scheduled castes, migrants, and people living in unreached and/or tribal areas.
In some areas it takes two hours for a woman to reach a motorable road for an ambulance. There is
a need for specifically reaching out to these disadvantaged women.
The members emphasised on moving from a morbidity perspective to a health and wellbeing
perspective for integrating maternal health, family planning, reproductive health as well as
adolescent health. This would enable the focus of action to move from the facility to include the
community and lead to a continuum of services. An example was provided of UNFPA's work in 100
villages in Maharashtra where a male health worker was working with the ASHA, Anganwadi
Worker, and ANM to ensure that this continuum is carried forward.
A suggestion made was to analyse the politics of policy making and its implementation and
evaluate questions such as: What effect ‘population stabilisation’ has on maternal health?; What
activities are incentivised?; What are the issues around gender, rights, and power?; and the fact that
parliamentarians do not prioritise women’s rights and health (e.g. only 170 parliamentarians were
present when the bill on rape and violence against women was passed, versus the larger number
present when foreign direct investment was being discussed).
Maternal Health: Emerging Priorities
18
|
|
2.9 Page 19 |
▲back to top |
This issue is exemplified with technical issues like providing oxytocin for faster delivery. This was
being done because service providers were given cash for delivery only if the delivery took place
during their shift. Thus, there were vested interests in hastening women’s deliveries. Similarly,
ASHA’s incentives are withheld she brings in two to three sterilisation cases. Thus, politics is an
important factor to consider when examining quality of care.
Group 4: Accountability of the Public Health System on Maternal Health -
Moderator: Dr H. Sudarshan, Karuna Trust (presentation by Dr Jashodhara
Dasgupta, SAHAYOG)
Discussion points
1. Community monitoring
India has several examples of community monitoring. Scale up after studies and support for the
civil society organisations that are trying out different models is needed.
Budget allocation to the Village Health and Sanitation Committees is coming down. Therefore
there is a need to ring-fence funds on monitoring and accountability. Community monitoring
involves a lot of capacity building and investment and has to be long-term (at least a five-year
commitment). Learning from these processes should systematically feed in to planning at the
district and state levels.
2. Maternal Death Review (MDR)
These were mandated for a while, but were not done universally. What was done, was not
shared. The review must be carried out in an accountability framework, and not just from a
biomedical perspective. The review should be so designed as to pick up other situations like
morbidities and near-miss. Social workers should be part of the team to make the exercise less
intimidating for villagers.
Publication of findings from MDR is required to ensure that the public is aware of them. It is not
enough for government functionaries to know about MDR. In this exercise, the health system
lapses needed to be identified, as they often highlight community failure, along with remedial
action within a timeframe. These should be published as well. Care should be taken to see that
these do not violate privacy.
3. Grievance redressal
The first step would be to make the Rogi Kalyan Samitis aware that grievance redressal is also
their function. Learning from experiences in Karnataka, an ombudsperson be appointed if the
Rogi Kalyan Samitis don’t work. There is also a need to link up with the justice system as there
may be criminal issues. In addition, witness protection is required as there is often a backlash
on whistle blowers. The group expressed concern about punishing the lowest functionaries like
ANMs, emphasising that the purpose was not to have a scapegoat but to ensure that larger
issues were addressed.
Maternal Health: Emerging Priorities
19
|
|
2.10 Page 20 |
▲back to top |
4. Governance of the health system
All societies at the district and state levels need to be made accountable to the missions at the
national level. The ‘culture of impunity’ has been in place for far too long in the health sector.
Penalties and answerability should be required for policy makers and planners, and not just for
implementers. Transparency must become overarching, with disclosure not just of budgets, but
also expenditures and entitlements. Skill building is needed in impact assessments and policy
evaluations and in using the learning for change. There need to be administrative reforms and
penalties in place for poor performance, along with incentives for good performance.
5. Research
There was not enough known on accountability for maternal health. Government data needs to
be examined for accountability and there is a need to improve and disaggregate the data. Policy
research also needs to be funded. The institutes of management could be called upon to help
the health system. Good practices need to be understood to provide models.
The group acknowledged that they had not considered the accountability of the private sector, e.g.
through consumer forums.
Group 5: Knowledge Gaps and Research Needs- Moderator: Dr Priya Nanda,
International Centre for Research on Women (ICRW)
Discussion Points
Data gaps identified by the group include:
1. Most data is focused on mortality and not on morbidity and near-misses. There is an
underutilisation of data from National Family Health Survey (NFHS), Sample Registration
System (SRS) and District Level Health Survey (DLHS).
2. Lack of data on problems around maternal mortality, where resources need to be allocated
to reduce MMR, etc.
3. Lack of inclusion of community workers (e.g. ASHAs) and community based solutions on data
collection.
4. Maternal Death Reviews are numbers alone.
5. Poor quality of data in the Health Management Information System (HMIS). Available data
from HMIS not effectively used for PIPs.
6. Lack of links between policy makers, health care providers, and researchers leading to no
use of the evidence.
7. Research underway is not focused on national health outcomes.
8. Standardisation of approaches for research is needed to improve the quality of studies.
9. Lack of data on non-institutional deliveries and factors contributing to reduction in maternal
morbidity.
Open Floor Discussion
Participants endorsed the views on expanding the ambit of maternal death audits / reviews to
include community members’ views. The difficulty of tracking data on maternal morbidities was
Maternal Health: Emerging Priorities
20
|
|
3 Pages 21-30 |
▲back to top |
|
|
3.1 Page 21 |
▲back to top |
acknowledged, though it was mentioned that symptom-based and complaint-based morbidities
could be monitored.
Respondent: Ms Sujatha Rao, Former Secretary Health, Government of India
It is important to consider who would be responsible for taking on all these recommendations. There
are challenges faced by the Ministry of Health and Family Welfare. It is understaffed along with low
financial absorption, has low institutional capacity to translate any of these ideas to action.
As far as the community is concerned, would bureaucratically engineered community accountability
be successful? There is a need for civil society organisations to engage in this. Communities need to
take on direct responsibilities for the functioning of sub-centres and PHCs.
Summing up: Ms Dipa Nag Chowdhury, Deputy Director, India, MacArthur
Foundation
The consultation reached a consensus on:
- the need to go beyond maternal mortality
- the need to link maternal health, sexual and reproductive health, family planning and
adolescent health
- moving from the mortality paradigm to the health and wellbeing paradigm
- defining and measuring morbidity
- the need for better quality information and data on a range of issues, as well as its use
- the need to strengthen community accountability to improve the health system.
While it is not clear where the funds could come from, better utilisation of existing budgets is
needed, as well as a movement from outcomes to results.
Closing Remarks, Mr Anders Thomsen, Deputy Representative India/
Bhutan, United Nations Population Fund
- Health systems all over the world are extremely complex and in India this complexity has
multiplied manifold.
- UNFPA has focussed on adolescent health, especially of girls and young women, looking at
improved nutrition and life skills education for negotiating later marriage. This speaks of the need
for using a larger continuum approach, moving from mortality to morbidity to wellbeing. Twenty
years from now, mortality would have dropped and wellbeing and preventive measures and
knowledge would be the focus. Therefore, adolescent health is important for adopting a holistic
approach to health.
- Administrative reform has to take centre stage to make a big impact on the health system.
- Investment in human resources is necessary, and investments should include training,
motivation and competency building.
Maternal Health: Emerging Priorities
21
|
|
3.2 Page 22 |
▲back to top |
Day 2: Thursday, 4 April 2013
Tri-partite video-conference between audiences in India, Washington
(WWICS) and Boston (MHTF)
Welcome Remarks, Mr Michael Kugelman, WWICS & Dr Mary Nell Wagner,
Maternal Health Task Force (MHTF)
He welcomed the audiences at all three sites. and gave a brief introduction to WWICS and the
collaboration to bring about the consultation. The partnership with PFI was aimed at bringing the
policy dialogue to a high level group of policy makers in India and to discuss with American
audiences India's current maternal health scenario, including successes, as well as provide
recommendations for addressing emerging priorities in maternal health.
Background on Maternal Health in India, Ms Poonam Muttreja, Population
Foundation of India (PFI)
Around 70 leading development practitioners had met in Delhi the previous day to look at future
priorities in maternal health in India. The three linkages between the current maternal health
scenario and key priorities that emerged from the discussions were:
Reductions in MMR are impressive and should continue, but we have yet to cover the last mile
and reach those most deprived. According to the NFHS 2005-6, mothers from scheduled castes
and scheduled tribes were least likely to receive ANC.
We are currently neglecting maternal morbidities.
Although the government has endorsed Universal Health Coverage in the 12th five-year plan,
the slowing down of economic growth and fiscal deficit has meant a reduced spending on
health, therefore no budget allocations have been made for Universal Health Coverage.
While there have been significant reductions in maternal deaths, services have still not reached the
most marginalised and disadvantaged communities including Scheduled Tribes. According to the
NFHS 2005-6, pregnant women from Scheduled Castes / Scheduled Tribes were least likely to receive
ante-natal care. The example of Barwani (quoted earlier) was used to exemplify this, with PFI’s
finding (as the secretariat for community monitoring) that each of the 26 deaths were avoidable.
Points made in plenary session the day before included:
Dr Sikdar drew attention to three key achievements of the NRHM. Data of 2011 estimated
that the provision of family planning has averted 800,000 births a year, of which 500,000
were high risk (adolescent) births. Additionally, 1700 deaths have been averted, which is
almost halfway to the required number for achieving the desired MMR. The Janani Suraksha
Yojana was launched in 2005. It is reaching a large number of women, but challenges
remain. The Government of India launched the RMNCH+A, which aims to develop a cohesive
approach to women’s health, on a life-cycle basis.
Dr Srinath Reddy emphasised the need to focus on maternal morbidity – for every woman
dying in childbirth, 20 suffer long-lasting and debilitating illnesses and undergo psychological
Maternal Health: Emerging Priorities
22
|
|
3.3 Page 23 |
▲back to top |
stress. There is a need for morbidity and equity to be included in the post-2015 goals by
using the life cycle approach.
Dr Gita Sen reiterated the importance of social determinants like violence against women,
child marriage, early pregnancy, unsafe abortion, sex selection and emphasised rights and
informed choice.
Dr Shiva Kumar situated maternal health and maternal morbidity within the overall health
care programme in the country, highlighting six deficits that must be addressed.
The collective vision emerging from the dialogue is to expand existing frameworks and paradigms –
include morbidities and women’s empowerment.
Connecting Maternal Health, Reproductive Health and Family Planning, Dr
Leela Visaria
The first concern was that the current implementation of various programmes on maternal health,
reproductive health, and family planning in India has become vertical and there is a great need to
integrate them. This integration provides opportunities to streamline and improve the reproductive
health of women and the care given to them. Giving women a broad set of services at the same
delivery site, and by the same provider, improves women’s health to a considerable extent.
The second issue was the repositioning of family planning, which not only helps in spacing births,
meeting unmet need, and helps towards population stabilisation, but also improving the health of
women and, in turn, of their children. There is evidence from states that women in India do not want
too many children (those in the age group 20-29 years do not want more than two children).
The third concern was that sexual health has been dropped. Though some efforts are made to
provide information on HIV and safe sex to adolescents and young people, services for them are
almost non-existent. Those that exist are rarely responsive to their needs or youth-friendly.
In the context of this background, the following recommendations were made:
There is a need to undertake a systematic analysis to remove the conceptual separation
between maternal health, sexual and reproductive health, and family planning as well as
understand the related costs.
Incentives, especially for sterilisation, which were introduced in the Sixties to reduce the birth
rate, continue even today. The total fertility rate has come down to 2.4 and in more than 50
percent of the population it has reached replacement levels. In such a situation, the question
remains on whether we still need incentives. What is incentivised is what gets done, and what
gets done is what gets measured.
Although India has adopted a target-free approach since 1996 (post-ICPD), the target mind-set
remains. Several arguments have been made, including the Malthusian argument, fears that
India would overtake China in population, the population will take longer to stabilise if there are
no incentives and targets. There is a need to examine this issue more closely for evidence.
Post-partum care is practically non-existent.To discuss and promote post-partum IUD, requires
further reflection and research.
Maternal Health: Emerging Priorities
23
|
|
3.4 Page 24 |
▲back to top |
There is a need to focus on adolescent health, enhance male responsibility in family planning
and reproductive health, and increase access and quality of abortion services, including
medication abortion, in the public health system.
Social Determinants and Knowledge Gaps, Dr Abhay Bang
There was near consensus that the agenda needs to be broadened and expanded from only
maternal mortality and family planning, to morbidity, maternal health, child health, etc. In other
words, what was called the reproductive health agenda in Cairo, the Government of India has called
RMNCH+A.
The recent Global Maternal Health Conference in Arusha, Tanzania, made an important statement
that maternal health cannot be improved by focusing on maternal health alone. It is important to
analyse the social determinants. Some of the social determinants of maternal and women’s health
in India are:
Social customs, beliefs and practices: For example − in most of north India, girls are married
early, and the earlier the marriage, the earlier the pregnancy; women cut down food intake
during pregnancy to avoid a large foetus and difficulty in delivery; male child preference; and
sex selection.
Nutrition: Apart from poverty and availability of food, women’s low status in the family means
that they eat last and the least, resulting in low body mass index (36 percent women in India are
malnourished, 55 percent women in India are anaemic).
Violence against women: This includes domestic violence and intimate partner violence.
Political disempowerment of women in India. Even though women occupy the highest positions
in national leadership (past President, Speaker of the Parliament, Leader of the ruling party,
etc.) there are, in fact, very few female Members of Parliament or Ministers. At the grassroots,
however, a large number of micro-credit and savings groups have emerged to become a voice,
and 33-52 percent of elected representatives at the village level are women.
Indoor air pollution, alcohol and tobacco are ranked as the top three factors for disease burden
on women. Alcohol results in violence against women, and the women’s movement has
mobilised against it. While women in India do not smoke much, 60 percent use oral / chewing
tobacco. Families spend more money on tobacco than the government spends on healthcare.
Successful efforts at addressing many social determinants included Dr Bang’s own work in Gadchiroli
where his organisation, SEARCH, had initiated community-based post-partum care. Briefly, this is a
method where:
village health workers are trained to collect maternal histories and observe post-partum
women in their homes
these health workers work in cooperation with (trained) traditional birth attendants, and
the health workers advise referrals to the women in case of problems during peurperium.
Recommendations include:
Need for socio-anthropological studies on gender, rights, and power, i.e. who makes the
decisions for home delivery, newborn care, etc.
Maternal Health: Emerging Priorities
24
|
|
3.5 Page 25 |
▲back to top |
Need for sex-specific information on various aspects of health, which is important for planning,
monitoring and prioritising.
Girls’ education, currently mandatory till Class 8, should be mandatory till Class 10. This would
advance age at marriage.
Community level health care should be connected with women’s groups at the grassroots, i.e.
self-help groups and elected women representatives.
Need to operationalize rapid health care response for women affected by violence.
Men’s involvement and sensitisation.
Mental health services for women.
Adoption of Universal Health Care for the most vulnerable and in the implementation of the
RMNCH+A strategy.
Knowledge gaps identified:
Systematic reviews including on perinatal mortality and maternal morbidity.
More robust methodology to measure morbidity.
National-level studies on maternal mortality and morbidity.
Quality of data collected and generated through the Health Management Information
System.
Use of real time data for planning. Currently seven to eight year old data is used for national
planning.
Research funds for RMNCH+A should focus on common problems faced by women like
depression, addiction, RTIs and violence.
Quality of Care and Accountability Mechanisms, Dr Sudarshan
Though the NRHM has achieved a lot, quality of care still has a long way to go. The focus on
institutional deliveries has resulted in large numbers seeking facility-based services, but there has
been no improvement in quality. Recommendations include:
Need to develop guidelines, protocols and checklists that are adapted to the sector (both public
and private) and to the level of institution. Existing guidelines are currently reaching only a few
states.
Need for Quality Assurance mechanisms, including periodic assessments by an external team
and an in-facility quality assurance committee.
Need for empowering the nurse and midwifery cadre, and establish staff positions for the
labour room, and stop their rotation; examine workloads and training requirements.
The greatest problem in the health care system is corruption. There have been a few efforts to bring
in e-procurement and e-governance for more transparency and accountability. Bad management
affects mainly poor women. For example, the procurement of (IFA) tablets was not done by the
central government for two years, despite anaemia being a major problem. National policy making
is also problematic and removed from ground realities. For example, the NRHM decided to move
towards institutional deliveries but did not address the transition from home deliveries to
institutional deliveries. As a result, despite 7-8 years of NRHM, there are pockets in India where 50
percent of the deliveries are taking place at home. Therefore, there is a need to make policy makers
accountable.
Maternal Health: Emerging Priorities
25
|
|
3.6 Page 26 |
▲back to top |
Recommendations include:
The need for health system accountability, especially health system reforms, as has been done
in Karnataka with a progressive transfer policy for staff to reduce corruption related to
transfers; the Integrity Pact of Transparency International has also been tried out in Karnataka,
to bring down the cost of procurement.
The need for scaling up, prioritisation and budget allocation for community monitoring
mechanisms, along with grievance redressal, and a district level ombudsperson. Community
planning and monitoring is also intended to minimise corruption at the grassroots.
Mere technological packages can result in small health outcomes, but good governance can lead to
greater outcomes.
Discussant: Dr John Townsend, Population Council
1. Scale – there are 27 million births annually in India; 42 percent of the population lives on less
than a dollar a day; there are 2.5 million people living with HIV, many undiagnosed; and, all
these factors have health consequences at a later stage. While the total number of births has
come down, there is still a 1 in 140 risk of dying during childbirth. Health is a state issue, not a
central issue, so the trickle down of policies is difficult. Diversity and equity are also problems
for scale as the legacy of caste and class survives, with Dalits and scheduled tribes and castes
being the last to receive care. Despite this, there have been dramatic improvements in reducing
poverty and increasing economic growth.
2. Though there is a 3 percent increase in income, large income distribution inequity remains.
India is 76th in the world on the GINI index8, so this inequity does not seem to be related to
income.
3. A weak health infrastructure, typically in poorer states, is exacerbated by health being a state
issue. Investment in health is a small percentage of the GDP, and state spending may not
necessarily prioritise health. Traditionally, the district hospitals are the lowest on the
investment chain. The rapid increase in service uptake with the JSY has overwhelmed many
hospitals, but whether this translates to better quality of the health facility is questionable.
Quality is an issue that has always come second in Indian policy. Coverage and finances have
been the top concerns.
4. Morbidity is the biggest issue now because it is a 20-fold problem and is the leading
determinant of movement into poverty. In addition, deaths of women who die after they leave
the hospital due to morbidities are not recorded.
5. The biggest corruption is around purchases and staff not coming to work.
6. Though unsafe abortion was not mentioned in detail, most abortions in India occur with
unskilled providers and unsafe locations and this has to be addressed.
7. While the rate of maternal deaths associated with HIV may be low in India, the numbers need
to be examined.
8. The gender inequality index is relatively high for India. Women’s labour force participation is
16 percent lower than those in Indonesia and Japan; 40 percent of women are still married
8 According to the World Bank, the GINI index measures the extent to which the distribution of income or
consumption expenditure among individuals or households within an economy deviates from a perfectly equal
distribution
Maternal Health: Emerging Priorities
26
|
|
3.7 Page 27 |
▲back to top |
under the age of 18, which has implications on issues on informed consent, preparation for
pregnancy and childbirth.
9. Weak information systems and the ability to use data –Communities must use information for
accountability and policy makers must use information to plan and decide on budget
allocations. There is a need to refine and simplify measurement systems.
Discussant: Dr Mary Nell Wegner, Maternity Health Task Force
Even if Universal Health Care seems beyond reach this year, a lot can still be done in India. The
broader spectrum of care and evolution to RMNCH+A is heartening, especially the inclusion of
adolescents, and it is important to understand how to broaden access.
The Barwani example of a tribal woman highlights the differences in rural and urban healthcare, and
the complexity of social determinants; the multiplicity of (her) needs, including of economic and
educational opportunities; the lack of measurement, community involvement and trust in the health
system and the continuum of care.
Wegner asked how discrepancies in care were being addressed in Karnataka through the community
monitoring mechanisms, and whether there were any local technologies applicable and relevant to
the situation of all women.
Open Floor Discussion
In response to the issue of the urban-rural divide, the panel said that the focus of NRHM had been
on rural health, while a separate urban health mission was to be developed. However, more
recently, a decision has been taken to create a National Health Mission that combines the two. The
status of the health of the urban poor is worse than that of the rural poor as there are no Primary
Health Centres in urban areas.
Questions from the audience in Washington, and responses:
Are women in India aware of the legality of abortion and where to access it?
Awareness on this is low not only among women but also among health workers. The
problem has been compounded by the community level information on sex selection, which
was not nuanced, leading to the impression that all abortion is illegal. While many women
access illegal service providers, medical abortion is available, but many gynaecologists still
use obsolete methods like dilation and curettage. Though trained providers are available,
there is not enough equipment; therefore, there is a need to expand the availability of
medical abortion in the health system. Abortion is not well documented, so there is a dearth
of data. Women will always put greater value on confidentiality over safety and distance.
Is a scale up of Dr Bang’s model of community based post-partum care possible?
The home-based newborn care model, developed in Gadchiroli, has become part of the
national programme and ASHAs are being trained on this to reach nearly 20 million neonates
in India. This is also accompanied by incentives, so a rapid scale up is taking place. However,
operational issues of quality and supervisionamong others still exist and need to be
addressed. The other part of this model is the possibility of home-based post-partum care,
Maternal Health: Emerging Priorities
27
|
|
3.8 Page 28 |
▲back to top |
which has been developed, and has demonstrated a steep reduction in maternal morbidity
in a controlled field trial.
If the government fails to provide IFA, has there been any work with nutritionists to prevent
anaemia?
The IFA tablets cost less than a cent and are the cheapest way to prevent anaemia. However,
the lack of procurement implies bad management, which needs to be addressed. In India,
nutritionists are not considered part of the mainstream in health. In addition, counselling
alone on nutrition is inadequate because people are very poor and cannot afford what is
being advised. Therefore, the IFA tablet is a better short-term solution.
The example of the Centre for North East Studies’ innovative programme in Assam, for reaching the
unreachable through boat clinics, was cited as one that attempts to address the needs of varied
communities. Assam has the worst MMR in the country and despite a dramatic improvement,
remains at the bottom. One of the reasons is that these are areas of conflict - this issue did not come
up during the discussions of the previous day. Conflict implies a lack of service delivery. The role of
the media in dissemination is critical. There is also a need for counselling in areas of conflict due to
trauma.
Questions from the audience in Boston and responses:
How are the community monitoring groups functioning and what are the mechanisms to link
them with the state and central level?
One of the five pillars on which the NRHM stands is community monitoring. The government
has taken it seriously, forming an advisory group on community action of which PFI is the
Secretariat. There is work at different levels with the communities, and the health system with
the objective of strengthening the Village Health and Sanitation Committees (VHSC). The VHSC
includes local frontline health workers, Integrated Child Development Scheme (ICDS) workers
and panchayat representatives. Accountability ultimately comes with the village being more
aware of its entitlements, grievance redressal and feedback from the community in the form of
report cards. The idea is to take the public back to public health. All states in India have
allocated funds in their PIPs for community monitoring in recent years.
Is the ratio between trained health care workers and the population what leads to lack of
quality health care?
There is a skewed distribution of healthcare providers in India, with most specialist doctors like
obstetrician and gynaecologists located in urban areas. The NRHM had earmarked funds to hire
doctors from the private sector, but these were inadequate. There are some task shifting efforts
underway, from doctors to paramedics, and training is planned, though the quality of the
training needs to be examined.
The panel asked the moderators in Washington and Boston on how the dialogue would be used, and
what was proposed in working towards a common agenda. The response was that with national
ownership and the strong skills of both providers and analysts, maternal health in India would get on
to the global development agenda. Universal Health Care should focus on women’s health, maternal
Maternal Health: Emerging Priorities
28
|
|
3.9 Page 29 |
▲back to top |
health, and morbidity, and there is a need to continue to look at this as an investment decision.
There is evidence that this is a sound investment strategy for development, and this needs to be
shared with finance ministers. More innovations are required as well as ideas on financing these
issues, contributing to the cost of care and reaping the benefits of the investment.
Ms Poonam Muttreja stated that PFI and the moderators are planning to present these
recommendations to national and international policy makers and donors, and put them out in the
media.
Maternal Health: Emerging Priorities
29
|
|
3.10 Page 30 |
▲back to top |
Press coverage
1. Saving our mothers
http://www.hindustantimes.com/News-Feed/Columns/Saving-our-mothers/Article1-1063962.aspx
Poonam Muttreja, Hindustan Times
May 22, 2013
India has taken several big strides over the past decade to reduce maternal mortality. The results
are beginning to show. A decade ago, close to 75,000 women died every year during child birth or
due to pregnancy-related causes. By 2010, this number had fallen to 50,000. The country’s
maternal mortality ratio fell from 301 per 100,000 live births in 2003 to 212 in 2009. The pace is
gaining momentum, but is it enough to reach the United Nations Millennium Development Goal of
109 by 2015? The chances are good, provided the State makes a special effort to reach
disadvantaged communities.
The National Rural Health Mission (NRHM) and the Janani Suraksha Yojana (JSY) have contributed
positively in improving the reach of healthcare to women. According to the 2009 Coverage
Evaluation Survey, nearly three out of four births were taking place in institutions — up from less
than 40% in 2005-06. More than two-thirds (69%) of pregnant women received at least three
antenatal checkups, and around 90% received more than two tetanus toxoid injections.
Despite the overall progress, wide disparities and inequities in women’s access to healthcare
continue to persist. Sadly, access to health services still depends upon where one lives, how
educated one is, how rich one is, and to which community one belongs. For instance, as against the
national average of 73% of women who gave birth in institutions, the proportion was 54% among
women who had no education, 55% among women belonging to the lowest wealth quintile, 57%
among Scheduled Tribes, and 68% among rural women.
Those of us working in the field know that the poorest among women, those belonging to
Scheduled Castes and Scheduled Tribes in many parts of the country have still to be brought into
the fold of an inclusive healthcare system. For example, 26 maternal deaths took place in the
Barwani district hospital in Madhya Pradesh over a period of eight months in 2010. Tragically, 21 of
these 26 women belonged to Scheduled Tribes. Even more alarming is that an enquiry
commissioned by the government found all the 26 maternal deaths to be avoidable.
The Population Foundation of India, supported by the United Nations Population Fund (UNFPA), the
Woodrow Wilson International Center for Scholars and the Maternal Health Task Force, recently
convened around 70 leading development practitioners and public health experts for a consultation
on maternal health. Participants included SK Sikdar, Abhay Bang, Sharad Iyengar, K Srinath Reddy,
AK Shiva Kumar, Gita Sen, H Sudershan and Leela Visaria.
Seven strong conclusions emerged from the deliberations. One, we must recognise maternal
morbidity as a serious health issue. For each woman who dies, an estimated 20 more suffer from
infection, injury and disability during pregnancy and childbirth. Some women die, while for others,
life is a living death experience. These complications range from fistula, uterine prolapse, painful
sexual intercourse, reproductive tract damage and infections, anaemia and even infertility.
Maternal morbidity, like maternal mortality, can be easily prevented.
Two, we must integrate maternal health, reproductive health and family planning — now delivered
as vertical programmes — into a universal health coverage plan that recognises woman’s health as
Maternal Health: Emerging Priorities
30
|
|
4 Pages 31-40 |
▲back to top |
|
|
4.1 Page 31 |
▲back to top |
a basic right. For example, anaemia among girls needs to be addressed at a younger age. Waiting till
they are pregnant and then treating them for the condition may be too late. Similarly, a substantial
number of maternal deaths can be prevented by merely meeting the unmet need for family
planning and providing access to safe abortion services. The government of India has taken a right
step by announcing a comprehensive strategy on reproductive, newborn, child and adolescent
health (RMNCH+A).
Three, we must focus on the marginalised. Within an overall framework of universal health
coverage, the State needs to adopt special and differentiated strategies to reach women in remote
rural areas, those belonging to tribal communities, and the more disadvantaged groups in society.
Four, we must improve the quality of care by putting in place adequate guidelines, protocols,
checklists and introducing a system of accreditation for facilities and services for both the public
and private sector. Five, address the shortage of human resources. Despite the more than 10-fold
increase in institutional births over the past five years, there has not been a matching increase in
staff strength. Skills of field functionaries such as auxiliary nurse and midwives (ANMs) have been
lost as they have been instructed not to conduct deliveries. Many healthcare providers trained in
the Indian systems of medicine fail to recognise clinical symptoms of an obstetric emergency.
Six, ensure greater accountability from the highest level instead of holding the frontline health
worker or the Accredited Social Health Activist (ASHA) responsible. A greater involvement of the
communities in monitoring the health services, which has begun under the NRHM, needs scaling up
with adequate budget allocation. Seven, gaps in knowledge must be addressed. Better monitoring
and evaluation systems need to be introduced. A community perspective should be brought into
the assessment of service delivery. A robust methodology should be developed for measuring
morbidity and collecting real time data. More regular studies on maternal mortality and morbidity
should be planned.
The last mile is always the most exhausting, exasperating and difficult to cover. The State needs to
give a big push to maternal health.
Poonam Muttreja is Executive Director, Population Foundation of India
Maternal Health: Emerging Priorities
31
|
|
4.2 Page 32 |
▲back to top |
2. The Hindu, April 9, 2013 - Woman at risk, Aarti Dhar
http://www.thehindu.com/news/cities/Delhi/woman-at-risk/article4595109.ece
Photo: Satish H.
While institutional deliveries have increased in rural India, maternal morbidity is still an issue.
For every one woman who dies due to pregnancy-related complications, there are 20 others who
suffer from acute and chronic morbidity which could even be life-threatening.
But these morbidities go unnoticed and unaccounted for since there is no formal documentation.
While maternal mortality audit has been made mandatory by the government, there is no such
provision for auditing maternal morbidities.
Making a strong pitch for auditing pregnancy-related morbidities for a better roll-out of healthcare
for reproductive and child care, Dr. Srinath Reddy, president of the Public Health Foundation of India
said while institutional deliveries in the last five years had increased over the years, there was not
adequate availability of trained manpower in rural India that had resulted in high incidence of
“maternal morbidity.”
The maternal morbidities can be obstetric fistula, uterine prolapse — a condition followed by a
traumatic childbirth -- high diabetes, damage of the reproductive tract, loss of child-bearing ability.
In addition to a high burden of diabetes, mental ailments during and after pregnancy are also serious
issues. Incidence of violence against women, too, is a major concern.
According to Dr. Reddy, the women are suffering because of inability of people attending the
primary health care centres to recognise the clinical symptoms, failure in referring to a bigger
hospital in time, poor quality medical intervention and absence of even basic facilities in the labour
room.
Speaking at a national consultation on “Maternal Health: Emerging Patterns” organised by the
Population Foundation of India, Gita Sen, professor at the Indian Institute of Management,
Bangalore, said earlier pregnant women died at home or in between home and a health care centre.
Now they die between a primary health care centre and referral institution because the persons
attending a PHC – many of them are Indian system of medicine doctors – have little training to
recognise clinical symptoms.
“Without quality manpower, hurried roll out of the policy has backfired. Children are being delivered
in PHC labour rooms without electricity connection,” said Abhijit Das, assistant professor at the
University of Washington.
Globally, 20 per cent women suffer from mental health issues during and after pregnancies while
this percentage goes up to 30 per cent in the developing countries. The mental health issue can
range from baby blues, depression and psychotic illnesses.
Maternal Health: Emerging Priorities
32
|
|
4.3 Page 33 |
▲back to top |
Two million women suffer from fistula across the world and one in every 1,000 woman suffers
uterine prolapse. Then there is high incidence of TB, HIV infection and other non-communicable
diseases. Women who have diabetes during pregnancy have 50 per cent higher chance of getting
diabetes within 5 to 10 years of delivery.
While cities have an average of 9-13 doctors per 10,000 population, the number is just about 2-3
doctors in the rural area. The number of nurses comes down by one-third in villages compared to
cities, according to the statistic of the Union Health and Family Welfare Ministry released in
December 2012.
While the maternal mortality ratio improved from 254 in 2004-06 to 212 in 2007-09 per 100,000 live
births, it is still a long way from the Millennium Development Goal of 150 for India.
Institutional delivery and improved family planning have helped reduce an annual estimated 8 lakh
maternal deaths in the last three years. Out of the estimated 24 lakh death averted in the last three
years, more than 10 lakh deaths were in the age group of 15-19 years while the remaining were
mothers above 35 years.
3. Down to Earth, April 10, 2013- Experts call for holistic approach to reproductive
healthcare, Jyotsna Singh
http://www.downtoearth.org.in/content/experts-call-holistic-approach-reproductive-healthcare
Maternal Health: Emerging Priorities
33
|
|
4.4 Page 34 |
▲back to top |
In a recently held consultation in Delhi on maternal and reproductive health, experts called for key
shift in policy for healthcare of women. They said policy planners should look at women's health
with a wide angle lens, include sexual health within the ambit of reproductive health, and make
access to reproductive health services universal and free. They also stressed on the need for a
holistic approach on women's health.
The consultation was organised by the non-profit, Population Foundation of India (PFI), in
collaboration with the Woodrow Wilson International Center for Scholars, the United Nations
Population Fund and the Maternal Health Task Force of Harvard University. It had civil society
representatives, field researchers, public health experts and policy makers.
At the end of the meeting, the group drafted a set of recommendations. The recommendations will
influence global agenda and sustainable development goals (SDGs), which will replace the
millennium development goals (MDGs) in 2015. The recommendations will become part of
suggestions extended by the Harvard University and Woodrow Wilson International Center to
agencies in the United States and global bodies working for SDGs. In India, they will be shared and
pursued with the Union government.
Srinath Reddy, president of Public Health Foundation of India, while delivering the keynote lecture,
said international discourse on maternal health must include maternal morbidity as a key issue in
SDGs for action, measurement and evaluation. For each
woman who dies in child birth, an estimated 20 more suffer
from infection, injury and disability connected to pregnancy
India battles high maternal
mortality
and childbirth. Experts said India's policies are too limited to
include them and extend treatment.
Maternal mortality rate (MMR) in
India remains high, with 212
Another key recommendation that emerged was to bring
scattered programmes under one umbrella. "The "S" (sexual
women dying per 100,000 live
births every year.
health) is handled by agencies like National AIDS Control States like Assam, Rajasthan and
Organisation while reproductive health has a separate Uttar Pradesh have MMR of over
department. It seems as if RH is not related to S. They, along
with maternal health, should be brought under one
300. India’s target for 2015 is an
MMR of 109.
programme," said Gita Sen, professor of public policy at
Indian Institute of Management in Bengaluru.
In the same vein, Malalay Ahmadzai, health specialist, UNICEF, said that paediatrics and gynaecology
are treated as separate disciplines in India. "The gynae ward is far from the children's ward, making
it difficult to give proper care to the new born. They should be closely located. This shows the
approach towards reproductive health, too,” she said.
The experts also noted that obstetricians and gynaecologists are not trained to conduct vasectomies.
Recommendations noted that basic integration of family planning with maternal health would be
needed for this training.
Maternal Health: Emerging Priorities
34
|
|
4.5 Page 35 |
▲back to top |
Poonam Muttreja, executive director of PFI, said, "Although the government has endorsed universal
health coverage (UHC) in the 12th Five Year Plan document, the slowing down of economic growth
and the high fiscal deficit have meant insufficient financial allocations during the coming year. As a
result, plans for UHC is not likely to be rolled out this year." A member of UNICEF said that this will
affect efforts towards reducing maternal mortality rate (MMR) in India and meeting the millennium
development goal.
Despite declines over the past decade, MMR in India remains high, with 212 women dying per
100,000 live births every year. States like Assam, Rajasthan and Uttar Pradesh have MMR of over
300. India’s target for 2015 is MMR of 109.
Expressed in sheer numbers, between 78,000-100,000 women die annually in India as a result of
childbirth and pregnancy, the main causes of these deaths are haemorrhage, eclampsia,
hypertension, sepsis, obstructed labour, anaemia and unsafe abortions. These numbers underscore
the need for skilled attendants at birth, and better nutrition and safe abortion facilities.
4. OneWorld, April 4, 2013 - Make maternal morbidity a priority: health
experts, Ashok Kumar
http://southasia.oneworld.net/news/make-maternal-morbidity-a-priority-health-experts
Maternal Health: Emerging Priorities
35
|
|
4.6 Page 36 |
▲back to top |
Maternal morbidity is far more difficult to handle than maternal mortality and it is high time that the
Indian government addresses health concerns related to it, said speakers at a consultation on
maternal health in New Delhi.
The consultation held by the Population Foundation for India (PFI) in collaboration with the
Woodrow Wilson International Center for Scholars, the Maternal Health Taskforce of the Harvard
School of Public Health, and the United Nations Population Fund, critiqued the government for not
having a proper mechanism to assess the impact of interventions for improving maternal healthcare
in the country.
Poonam Muttreja, Executive Director, Population Foundation of India (PFI), lamented that the
Millennium Development Goal 5 (MDG 5) which focuses on improving maternal health has failed to
address the health issues of the poorest of the poor including the Dalits and tribals. “In spite of
increased skilled attendance at the time of birth and access to institutional deliveries, pregnancy
continues to be a major health risk for women in many parts of the country. Only half of all women
in India receive three or more antenatal checkups. The situation is much worse when we look at data
for scheduled caste, scheduled tribes and minorities,” she said.
Muttreja said that MDG 5 has only benefitted women from the relatively well-off families in the rural
parts of India. She also stressed that the post-MDG agenda for maternal health should be country
specific for better delivery. “The likelihood of having received antenatal care from a doctor is lowest
for scheduled tribe mothers and highest for mothers who do not belong to a schedule caste,
scheduled tribe or backward class,” she said.
Talking about the role of consultation in influencing policy makers, Muttreja said, “Medical
practitioners and researchers from India and around the globe will deliberate on what needs to be
done, and frame a road map, including a list of key policy priorities and recommendations which will
help the government in reframing policies, which have neglected maternal morbidity so far,” she
said.
Dr Srinath Reddy, President, Public Health Foundation of India (PHFI), highlighted the role of gender
preference in perpetuating violence against women and said it was unfortunate that the MDGs have
talked about mortality but not morbidity. He said 42 per cent of pregnant women worldwide suffer
from anemia while around 15 per cent live with gestational diabetes.
Reddy pointed out that that not less than 53 per cent of pregnant women face maternal morbidity in
rural India.
Dr AK Shiva Kumar, Advisor, UNICEF and Member of the National Advisory Council of India, said that
six deficits - knowledge deficit, proper evaluation system, competency, trust deficit, financial deficit
and the ownership issue - need immediate attention for improving maternal health in India.
Defending the Government, Dr SK Sikdar, Deputy Commissioner of Family Planning Division, India’s
Ministry of Health and Family Welfare (MoHFW), said that the health ministry is asking for monthly
reports from the states about maternal health care.
Maternal Health: Emerging Priorities
36
|
|
4.7 Page 37 |
▲back to top |
Sikdar highlighted how community health workers can be roped in for furthering the cause of
improving maternal health care. “In family planning, the distribution of contraceptives is being
efficiently carried by the ASHA health workers,” he noted.
Dr Gita Sen, professor of Public Policy at the Indian Institute of Management Bangalore (IIM-B), and
adjunct professor of Global Health and Population, Harvard School of Public Health, said that
morbidity is far more difficult to handle than mortality and hence it needs the same kind of attention
which is given to maternal mortality.
Maternal Health: Emerging Priorities
37
|
|
4.8 Page 38 |
▲back to top |
Maternal Health: Emerging Priorities
38
|
|
4.9 Page 39 |
▲back to top |
5.Deccan Herald, April 3, 2013 - Maternal morbidity, a new problem in rural
India,Kalyan Ray, New Delhi
http://www.deccanherald.com/content/323723/maternal-morbidity-problem-rural-india.html
Rapid rollout of institutional child delivery in the last five years without adequate trained
manpower in rural India has spawned a new problem of “maternal morbidity” in which women
suffer from serious health consequences, claim public health specialists who alerted the
government on the emerging crisis.
Women in rural India are suffering primarily because of the inability of people managing PHC centres
to recognise clinical symptoms resulting in their failure in timely referral to a bigger hospital. Poor
quality medical intervention and absence of even basic facilities like electricity in labour rooms
further compound the problem.
Health ministry officials, however, argued that institutional delivery and improved family planning
helped reduce an annual estimated 8 lakh maternal deaths in the last three years. “Out of the
estimated 24 lakh death averted in the last 3 years, more than 10 lakh deaths were in the age group
of 15-19 years while the remaining were mothers above 35 years,” said S K Sikdar, deputy
commissioner (family planning) in the health ministry.
“For every woman who die due to pregnancy related complications, there are 20 who suffer from
acute and chronic morbidity, some of them are life-threatening,” K Srinath Reddy, president of
Public Health Foundation of India told Deccan Herald.
Maternal morbidity includes obstetrics fistula, damage of the reproductive tract, loss of child-
bearing ability after the first birth and uterine prolapse, a genital problem that comes from
traumatic childbirth.
Risk factor
In addition, high diabetes, which often leads to bigger babies, and mental suffering also come under
maternal morbidity. “Earlier the would be mother died at home or in between home and a health
care centre. Now they die between a primary health centre and referral institution because the
persons attending a PHC – many of them are Indian system of medicine doctors – have little training
to recognise clinical symptoms,” Gita Sen, a professor at the IIM-Bangalore, and an adjunct professor
at Harvard School of Public Health, said at a national consultation meeting on maternal health here
on Wednesday.
While cities have on an average 9-13 doctors per 10,000 population, the number dips to 2-3 doctors
in the countryside. Nurse density is down by one-third in villages compared to cities, according to
Union health ministry December 2012 data.
Absence of easy access to blood banks in remote areas was yet another contributing factor behind
maternal morbidity, the public health experts said, while stressing on the need to launch an audit to
find out the extent of maternal morbidity. “Without quality manpower, hurried roll out of
institutional delivery policy has backfired. Babies are being delivered in PHC labour room without
electricity connection,” said Abhijit Das, assistant professor at the University of Washington.
While the maternal mortality ratio improved from 254 in 2004-06 to 212 in 2007-09 per 100,000 live
births, it’s still way above India’s target of 150 as per the Millennium Development Goals.
Maternal Health: Emerging Priorities
39
|
|
4.10 Page 40 |
▲back to top |
6.In the Op-ed piece titled, Sign of the times
….AND THESE REALITIES …
By Humra Quraishi
Kashmir Times, April 25, 2013
Earlier this month, the Population Foundation of India, an NGO working in the field of heath
and population, organized a consultation on Maternal Health on April 3 and 4, 2013 with
support from the United Nations Population Fund, the Woodrow Wilson International Center
for Scholars, and the Maternal Health Taskforce of the Harvard School of Public Health.
Let me quote Poonam Mutterja, the executive director of the Population Foundation of India
on the current scenario - "We all know that maternal mortality has declined significantly over
the last decade. In India, the figures dropped from 301 per 100,000 births in 2003 to 212 in
2009. Yet, these reductions have not reached the most marginalized and disadvantaged
communities and groups in society; tribal communities, schedule castes, and those belonging
to the poorest quintile… According to the National Family Health Survey - 2005-06, scheduled
tribe mothers are least likely to have received any antenatal care or care from a doctor.
Moreover, only 23% of mothers in the lowest wealth quintile received antenatal care from a
doctor as against 86% of mothers in the highest wealth quintile. I refer to the case of the 26
maternal deaths that took place at Barwani district hospital in Madhya Pradesh over a period
of 8 months in 2010. 21 of these 26 women belonged to Scheduled Tribes. Population
Foundation of India which is the secretariat for community monitoring conducted an enquiry
at the government's request and found that each of the 26 maternal deaths was avoidable…"
And this Foundation has also released some more of their findings on the 'maternal health' in
the country -I quote -
"India's current MMR levels still remain unacceptably high and by many estimates account for
nearly one-quarter of all such deaths worldwide. Expressed in sheer numbers between 78,000-
100,000 women die annually in India as a result of childbirth and pregnancy. Moreover, for
each woman who dies another estimated 20 more suffer from infection, injury and disability
connected to pregnancy and childbirth. The toll that unsafe motherhood takes on the lives and
health of Indian women, and their families and communities, is even more tragic because it is
mostly avoidable…
“In other words despite increasing skilled attendance at birth and more pregnant women
being offered at least minimal care, pregnancy continues to be a major health risk for women
in many parts of the country. Only 50% of the women in India receive three or more antenatal
check-ups, leaving the other half deprived of adequate care (DLHS-3, 2007-08). The situation is
worse when we look at data by caste/tribe. The likelihood of having received any antenatal
care and care from a doctor is lowest for scheduled tribe mothers (25%) and highest for
mothers who do not belong to a scheduled caste, scheduled tribe, or other backward class.
Among mothers in households with the lowest wealth quintile, 59 percent received antenatal
care and only 23 percent received antenatal care from a doctor. By contrast, among mothers
Maternal Health: Emerging Priorities
40
|
|
5 Pages 41-50 |
▲back to top |
|
|
5.1 Page 41 |
▲back to top |
in households in the highest wealth quintile, 97 percent received antenatal care and 86
percent received antenatal care from doctors. … in India the unmet need for contraceptives
remains high, it is over 30% in Bihar (36%), Jharkhand (34%) and Uttar Pradesh (33%) and over
20% in Orissa (23%) and Uttarakhand (20%). This unmet need reflects the gap between a
woman's desired fertility and her access to family planning services."
*(Humra Quraishi is a freelance columnist based in Delhi and is currently a visiting Professor in
the Academy of Third World Studies in Jamia Milia University).
7. The article also appeared online edition of the Metrognome , titled No nation for poor
mothers
http://www.themetrognome.in/columns/enough-said/no-nation-for-poor-mothers
8. Maternal Health in India: Making Progress in a Key Battleground, Carolyn
Lamere, Thursday, April 18, 2013
http://www.newsecuritybeat.org/2013/04/maternal-health-india-making-progress-key-
battleground/#.UXA_EbXCbTo
Maternal Health: Emerging Priorities
41
|
|
5.2 Page 42 |
▲back to top |
Maternal mortality causes 56,000 deaths every year in India, accounting for 20 percent of maternal
deaths around the world, said John Townsend, vice president and director of the Population
Council’s reproductive health program. It is a key battleground for maternal health advocates. But
maternal health is sometimes eclipsed by other major health and development issues on the sub-
continent. For example, nearly five times as many people suffer from HIV/AIDS and more than 400
million people live on less than $1.25 a day.
Townsend was joined at the Wilson Center on April 4 via videoconference by participants in New
Delhi and from Harvard University’s School of Public Health to discuss key challenges to improving
maternal health in India as part of the Global Health Initiative’s Advancing Dialogue on Maternal
Health series. The public event was preceded by a day-long workshop in New Delhi with 70 leading
development practitioners, senior government officials, and a wide range of donors and media
representatives who came together to participate in roundtable discussions identifying future
priorities.
A Holistic Approach
Poonam Muttreja, executive director of the Population Foundation of India, which co-convened the
India workshop, said that one of the key points participants in New Delhi agreed on was the need for
increased attention on maternal morbidity in addition to maternal mortality.
While maternal deaths fell from 390 to 200 deaths per 100,000 live births in just 10 years (though
still well above the developed-country average of 9 per 100,000), Muttreja said that “for every
woman dying in childbirth about 20 suffer long-lasting and debilitating illnesses.” For many of these
women, “life is a living death.”
One way to address this gap is to “promote a life cycle approach” to care instead of addressing
specific components, like family planning, maternal health, and reproductive and sexual health,
separately.
Leela Visaria, honorary professor at the Gujarat Institute of Development Research, agreed: “In
practice, what it means is offering women a broad set of family planning and reproductive health
services and maternal health services at the same delivery site and by the same provider,” she said.
“I think we all know this, and yet we have not been able to achieve this.”
One gap that needs to be addressed is sexual health and health education, she said. Sexual health
programs, especially ones targeting adolescents, are “almost nonexistent.”
Maternal Health: Emerging Priorities
42
|
|
5.3 Page 43 |
▲back to top |
Visaria also emphasized the importance of family planning as part of maternal health. Contraception
can help women space births further apart, leading to healthier pregnancies, healthier mothers, and
healthier children, she said.
Addressing the gaps in care after childbirth could also significantly reduce morbidity. Few women
have access to postpartum care, especially in the north of the country, said Visaria. Abhay Bang,
director of the Society for Education, Action, and Research in Community Health, noted that 43
percent of rural women suffer from some kind of postpartum morbidity and that home-based care
through accredited social health activists could significantly reduce these numbers.
The Indian government has recognized the need for integrated healthcare throughout women’s
lives, and has set up a coalition to deal with reproductive, maternal, newborn, child and adolescent
health in a more holistic manner, said Muttreja.
Social Determinants of Care
“Maternal health will not be improved to its full potential by focusing on maternal health alone,”
Bang said, quoting the manifesto for maternal health produced at January’s Global Maternal Health
Conference in Arusha, Tanzania. “That is precisely where social determinants come in.”
In India, he said, early marriage traditions have serious negative impacts on maternal health as girls
are more likely to become pregnant at younger – and riskier – ages. He also noted that women have
generally low status in traditional Indian families, leading to poor nutrition: 36 percent of Indian
women are malnourished and 55 percent are anemic.
Women who are born into the lower castes or tribal women are especially likely to lack access to
healthcare. “These are the last people that are served, these are the last people who have access to
care,” said Townsend, “and this inequity will be a problem…for every element of society.”
Joining the event from Boston, Mary Nell Wegner of the Maternal Health Task Force, focused on
ways to “change the odds” for these underserved women. An integrated approach could help
address their multiple needs by reducing the number of points of contact they have to make in order
to receive care, she suggested. The complexity of social determinants of health can make reaching
these women difficult, but organizations should figure out how to build trust and interact with those
who generally spend little time in health-care institutions.
Dr. H Sudarshan, of the Karuna Trust, pointed to another social factor. The “greatest problem today
in the health care service is the corruption in the system,” he said from New Delhi. For example,
although anemia is a major problem throughout India, during one two-year period some states
didn’t have any iron tablets to distribute to women. Transparency within hospital administrations
and community monitoring schemes could help curb this graft, he said, mentioning that there are
pilot programs in nine states that have helped.
As evidenced by the great progress made in the last decade, the government has taken community
monitoring seriously, said Muttreja. She pointed out that the National Rural Health Mission has
made this a particular focus, but noted that equally important as improving oversight is making
communities more aware of the rights and the services to which they’re entitled.
The Post-2015 Development Agenda
Bang pointed out that there is great potential in home-based care, including prenatal, delivery,
postpartum, and newborn care. Reaching out to women at home – provided the quality of service
remains acceptable – can improve access to care, especially for women who tend to fall through the
Maternal Health: Emerging Priorities
43
|
|
5.4 Page 44 |
▲back to top |
cracks. He also said that India needs to focus on gender issues outside maternal health, like girl’s
education, violence against women, mental health, and sensitizing men.
From New Delhi to Boston and Washington, DC, all the panelists emphasized the need to continue to
focus on maternal health in the post-2015 development framework (when the Millennium
Development Goals are set to expire), especially within the greater framework of integrated health
care. They also said that quality of care is an important priority: a system of accreditation for
facilities and services should be introduced alongside guidelines, protocols, and checklists to
promote best practices.
Maternal health is a “sound investment strategy” for development, Townsend said, but part of the
challenge is communicating the benefits. “I don’t think we should be timid,” he said. “If we want
women and maternal health to be central on the development agenda, we have to speak with a
strong and vibrant voice.”
Maternal Health: Emerging Priorities
44
|
|
5.5 Page 45 |
▲back to top |
Participants List
Consultation on ‘Maternal Health: Emerging Priorities’ April 3-4th, 2013 , New Delhi
Name
Designation
Abhay Bang
Abhijit Das
Aditi Bishnoi
Director, Society for Education, Action and Research in Community Health
(SEARCH)
Director, Centre for Health and Social Justice (CHSJ)
Editor, Women Feature Service
A K Shiva Kumar
Member, National Advisory Council and Advisor, UNICEF
Alison Morse
Pathfinder International
Alok Vajpeyi
Amit Kumar Ghosh
Anand Bang
Anders Thomsen
Acting Director, Programme, Population Foundation of India (PFI)
Mission Director, National Rural Health Mission (NRHM)& Executive
Director, State Innovations in Family Planning Services Project Agency
(SIFPSA), Government of Uttar Pradesh
Senior Consultant, National Health Systems Resource Centre
Deputy Representative, India/Bhutan UNFPA
Anjali Sen
Aparajita Gogoi
Avina Sarna
Regional Director, International Planned Parenthood Federation (IPPF),
South Asia Region
Executive Director, Centre for Development and Population Activities
(CEDPA) India
Country Director, Population Council
Bijit Roy
Programme Coordinator, Population Foundation of India (PFI)
Bobby John
President, Global Health Advocates
B Subha Sri
Steering Committee Member, CommonHealth Coalition
Briana Olson
Human Rights Law Network
Bulbul Sood
Country Director India, Jhpiego
Chandni Tandon
Programme Officer, Population Foundation of India (PFI)
DevendraKhandait
Dipa Nag Chowdhury
Programme Officer State Programs, Bill and Melinda Gates Foundation
(BMGF)
Deputy Director - India, MacArthur Foundation
Ena Singh
Assistant Representative, UNFPA India
Francesca Barolo Shergill
Frederika Meijer
Gautam Chakraborty
Manager, Innovation and New Partnerships, Population Foundation of
India (PFI)
Country Representative India / Bhutan, UNFPA
Public Health Economist, Population Foundation of India (PFI)
Genevieve Begkoyian
Chief of Health, UNICEF
Gita Pillai
Gita Sen
H Sudarshan
Director / Chief of Party, Urban Health Initiative, India
Professor, Centre for Public Policy, Indian Institute of Management and
Adjunct Professor, Global Health and Population, Harvard School of Public
Health
Secretary, Karuna Trust
Indu Capoor
Director, Centre for Health Education, Training, Nutrition and Awareness
(CHETNA)
Maternal Health: Emerging Priorities
45
|
|
5.6 Page 46 |
▲back to top |
Ishita Chaudhry
Jagdeep Singh Gambhir
JashodharaDasgupta
Jayati Sethi
Kranti Suresh Vora
LalithaIyer
Lauren Herzer
Leela Visaria
Loveleen Johri
M. Prakasamma
Malalay Ahmadzai
Mandira Kalra Kalaan
Manmohan Sharma
Medha Gandhi
Monique Kamat
Neera Jain
Neeru Bhatia
Nihar Ranjan Mishra
Nozer Sheriar
Poonam Muttreja
Pradeep Panda
Pritha Biswas
Priya Anant
Priya Nanda
Rajni Wadhwa
Chief Executive Officer , The YP Foundation
Senior Programme Manager, Population Foundation of India (PFI)
Coordinator, SAHAYOG
Programme Officer, Population Foundation of India (PFI)
Associate Professor, Indian Institute of Public Health, Gandhinagar
Advisor Gender and Social Development, Futures Group
Program Associate, WWICS
Honorary Professor, Gujarat Institute of Development Research and
Independent Researcher
Sr. Scientific Affairs Specialist, U. S. Department of Health and Human
Services-South Asia Office
Director, Academy Of Nursing Studies And Women Empowerment
Research Studies
Health Specialist, UNICEF
Manager, Advocacy and Communication, Population Foundation of India
(PFI)
Executive Secretary, Indian Association of Parliamentarians on Population
& Development (IAPPD)
Advisor Policy, Ipas India
Medical Director, Family Planning Association of India (FPAI)
General Manager - Maternal Health, State Programme Management Unit
(SPMU), NRHM, Government of Uttar Pradesh
Executive Director, Astron Hospital & Healthcare Consultants
Manager, Population Foundation of India (PFI)
Secretary General, Federation of Obstetric and Gynaecological Societies of
India (FOGSI)
Executive Director, Population Foundation of India (PFI)
Micro Insurance Academy (MIA)
Medical Advisor, Marie Stopes International (MSI)
Associate Director, Access Health International, India
Director - Social & Economic Development Group, International Center for
Research on Women (ICRW), Asia Regional Office
Technical Specialist, Urban Health Initiative, India
Rajiv Saurastri
Rashmi Mohanty
Renuka Motihar
Rupsa Mallik
Sainath Bannerjee
Sandeep Bathala
Project Director, Population Foundation of India (PFI)
Program Manager, Urban Health Initiative (UHI)
Independent Consultant
Director, Programs and Innovation, CREA
Chief of Party, Health of the Urban Poor Program, Population Foundation
of India (PFI)
Senior Programme Associate, WWICS
Maternal Health: Emerging Priorities
46
|
|
5.7 Page 47 |
▲back to top |
Sanjai Sharma
SanjoyHazarika
Saurabh Raj
Shalini Singh
Sharad Iyengar
ShibanGanju
S.K Sikdar
Sona Sharma
Srinath Reddy
Subhadra Menon
Suchitra Dalvie
Sudhir Maknikar
Sujatha Rao
Suneeta Dhar
Suneeta Mittal
Sutapa B. Neogi
Vanita Mukherjee
Venkatesh Srinivasan
Vinod Paul
Vishwajeet Kumar
V S Chandrashekar
Sita Shankar Wunnava
Director Health Rights, Socio Legal Information Center
Managing Trustee, C-NES
Programme Officer, Population Foundation of India (PFI)
All India Institute of Medical Sciences (AIIMS)
Chief Executive, Action Research & Training for Health (ARTH)
Save a Mother (SAM)
Deputy Commissioner, Family Planning Division, Ministry of Health and
Family Welfare
Joint Director, Advocacy and Communication, Population Foundation of
India (PFI)
Head , Public Health Foundation of India (PHFI)
Director, Health Communication, Public Health Foundation of India (PHFI)
Coordinator, Asia Safe Abortion Partnership
Senior Technical Advisor, Pathfinder International, India
Former Secretary Health, Ministry of Health and Family Welfare,
Government of India
Secretary & Director, Jagori
Director and Head, Dept. of Obstetrics &Gynaecology, Fortis Memorial
Research Institute
Researcher, Indian Institute of Public Health, Delhi
Program Officer, Youth Sexuality, Reproductive Health and Rights Initiative,
Ford Foundation
Assistant Representative, UNFPA
Professor and Chair of the Department of Paediatrics at the All India
Institute of Medical Sciences (AIIMS)
Director and Principal Scientist, Community Empowerment Lab, Johns
Hopkins-KGMU Collaborative Project
India Country Advisor, The David and Lucile Packard Foundation
Director, Maternal and Child Health/Nutrition, PATH India
Maternal Health: Emerging Priorities
47