 |
Policy Recommendations for Materanl Health in India Briefer |
|
|
1 Page 1 |
▲back to top |
Policy Recommendations
For Maternal Health In India
Background
Maternal mortality in India has reduced substantially
over the last decade because of policy and
programmatic interventions for improving maternal
health in the country. However, the rate of decline is
far short of that necessary to achieve the Millennium
Development Goal target of reducing the maternal
mortality ratio' (MMR) by three quarters by 2015. For
India, this figure stands at 109 by 2015.
A consultation was 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 3rd
and 4th April, 2013 in New Delhi, India, to identify
best practices, gaps, and areas requiring focused
interventions in maternal health.
The consultation brought together experts from
maternal health, health systems, donor, and policy
making communities and highlighted that policies
and programmes on maternal health in India have
been limited to reducing maternal deaths through
promoting institutional deliveries and increasing
access to Emergency Obstetric Care. While these
policies have increased the demand for institutional
deliveries, quality of maternal health care has
emerged as a major issue.
These and other areas of concern and
recommendations emerging from the consultation
form the basis of this policy brief.
Reaching the Unreached -
Addressmg Inequities
The decreasing maternal mortality ratio for India as a
whole hides wide discrepancies between states and
different communities in the area of maternal health.
A small number of states contribute to about 2/3rds
of all maternal deaths in the country - while Assam
has an MMR of 390, Kerala has already achieved the
MDG target with an MMR of 81 (1).
Several reports and studies point out that women
from poor and marginalized communities continue
to lack access to maternal health services. For
example, in a series of maternal deaths in the district
hospital in Barwani, Madhya Pradesh in 2010, 81
per cent of the women who died belonged to the
scheduled tribes (3). Similarly, 17 out of 23 maternal
deaths documented in a one year period in Godda
district, Jharkhand occurred among women from
indigenous tribal groups (4). Data from the National
Family Health Survey III shows that women from
poorer wealth quintiles and scheduled castes and
tribes have poorer health indicators including in
receiving antenatal care and skilled birth attendance,
having an institutional delivery, and in levels of
anaemia (see Figure 1) (2).
Rgure 1: Maternal health care indicators las percentagel by wealth and caste status INFHS11I1121
120
100
00
60
40
20
o
_ Wealth Quintile Highest
_ Wealth Quintile Lowest
_ Other Caste
Scheduled Caste
Scheduled Tribe
It is thus evident that special efforts need to be
made to reach the women who are being left out of
programmes presently and ensure equity in access
to maternal health and health care.
Policy Recommendations
• The recently launched Reproductive, Maternal,
Newborn, Child and Adolescent Health strategy
(RMNCH+A strategy) (5) has broadened the set of
services provided for maternal and reproductive
health. However, good maternal health care is
not possible without functioning primary health
systems. Thus, to ensure that the most vulnerable
are included, Universal Access to Health Care must
be ensured.
• A single one-size-fits-all policy does not address
specific problems of different situations. Area
specific contextual analysis and planning is
required to address determinants of maternal
health. For example, malaria prevention and
treatment interventions are necessary for malaria
endemic areas. Provision for safe home deliveries
is required where access to institutional deliveries
is difficult. Portable maternal health entitlements
and services are required for migrant women.
,
Maternal
mortality ratio-
maternal deaths
per 100,000 live
births, women
aged 15-49
|
|
2 Page 2 |
▲back to top |
~i ~ fOUND.q~
O~
10
:J
~
~ .1f.1'.1 ~ POLICY RECOMMENDATIONS
FOR MATERNAL HEALTH IN INDIA
":'/1W
Wilson
Center
• Investment in health infrastructure, health
personnel and in other social (education) and
infrastructure (roads and transport facilities)
domains need to be increased in areas that have
historically been under served, for example, in
tribal areas, hill and desert regions.
• A Health Human Resource policy, which ensures
that competent and dedicated health officers and
managers are placed in these challenging contexts,
needs to be implemented in order to effect change.
Maternal Morbidity - A Neglected
Area
While maternal mortality has received policy attention,
maternal morbidity continues to be a neglected area.
It has long been estimated that for every woman who
dies in childbirth, 20 suffer long term negative health
consequences. Maternal morbidity spans a huge
spectrum from physical to mental illnesses and has
. intergenerational consequences because of its effect
on the children of these women. A recent community
based study on early post partum morbidity from
Rajasthan has shown that nearly three fourths of all
women in the study had some morbidity including 7.6%
with life threatening morbidity post partum. Very high
levels of anaemia were detected in the post partum
period in this study with 7.4% women having severe
anaemia and 46% having moderate anaemia (6).
Long term morbidity in the form of prolapse,
incontinence, fistulas has also been documented
in small studies (7). Mental ill health ranging from
mood swings and depression to psychotic illness
is another form of long term morbidity (8). Anxiety
and depression due to daughter aversion and son
preference are also being recognized as mental
health issues related to maternal health (9). It is
also well known that women face increased risk
of violence during pregnancy thus making it an
important component of maternal morbidity (10).
I come from a big joint family. I had to do all the
work myself - grind Ragi and paddy manually soon
after delivery. One day, after lifting a pot of water
to my head (within two weeks of delivery) I felt
something give way. Since then my uterus slips
down when I squat.
My husband gets angry because I find sex
uncomfortable and am reluctant. These days I am
not even able to go for work regularly. I often get
(urinary) infection and white discharge, I can't do
much about it in my situation.
Testimony of a woman with uterine prolapse, Tamil Nadu (7)
In addition, communicable diseases like malaria,
tuberculosis and HIV and non communicable
diseases like hypertensive disorders of pregnancy
and gestational diabetes are increasingly becoming
significant causes of maternal mortality and morbidity
(11,12).
Policy Recommendations
• Present day maternal health discourse does not
address maternal morbidity. The focus of safe
motherhood needs to be expanded to include
maternal morbidity.
• Measurement of maternal morbidity is problematic
because of lack of standard definitions and
mechanisms of reporting. Data on incidence
and prevalence of maternal morbidities needs
to be improved. Maternal morbidity should be
measured in large surveys like NFHS, DLHS, AHS.
Maternal morbidity audits should be initiated to
obtain stronger burden of disease estimates .
• Maternal morbidity needs a comprehensive
response - increased access to Reproductive
Health care, both facility based and community
based, as well as addressing antecedents to poor
maternal health through a life cycle approach need
to be ensured.
Integrating Maternal Health within the
Reproductive Health Continuum
Women's health care needs go beyond care during
pregnancy and delivery. Contraception, safe abortion
services, healthcare for other reproductive health
issues and access to information are important
aspects of services when a life cycle approach to
women's health is applied. The ICPD in 1994 changed
the discourse to include sexual and reproductive
health based on a rights perspective. It is well
recognized that continuum of care across life stages
and from home to hospital is essential for complete
physical, mental and social well being.
Data from NFHS III (2) shows that 47 per cent of
Indian women are married by the age of 18 and that
56 percent of women in this age group are anaemic.
This places them at risk of early pregnancy and
also at higher risk of complications in pregnancy.
Unmet need for contraception continues to remain
high and contributes to mortality and morbidity
due to unsafe abortion. A large study among youth
in India shows that one in seven young men and
a smaller proportion of young women reported
having sex before marriage and many of them had
engaged in sexual activities uninformed or in an
unsafe manner (13). Other studies show that about
one third of young, married women suffer from
reproductive tract infections (14). Such sexual
and reproductive health problems compromise
maternal health and pregnancy outcome, and
these in turn may further compromise sexual and
reproductive health.
|
|
3 Page 3 |
▲back to top |
Rights violations related to contraceptive services
continue to occur. 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 incentivized is what is 'done' and measured,
e.g. sterilization (9).Thus, it is important to evaluate
and analyse the effects of incentivization on health
functionaries. There are also serious concerns about
issues of informed consent around post partum
IUCD insertion (9).
Policy Recommendations
• Maternal Health, Reproductive Health, and Family
Planning need to be integrated. There is a need
to undertake a systematic analysis to remove the
conceptual separation between these areas as well
as to work out the operational aspects of integration.
• Post-partum care needs to be improved including
provision' of contraceptive services in a rights
respecting manner.
• Male responsibility in contraceptive use must
be enhanced such that there is consistent and
correct use of condoms and increased acceptance
of vasectomies. Male Multipurpose Workers and/
or male ASHA workers have a significant role in
this area.
• There is a need to focus on adolescent health,
including the provision of comprehensive sexuality
education. Providing access to family planning
information and counselling to adolescents and
youths on their fertility and reproductive health
and rights is critical.
• The access to basket of choices in contraceptive
methods, particularly spacing methods should be
increased
• Access to and quality of abortion services must be
increased, and medical abortion services must be
included in the public health system.
Maternal Health and Gender Equity
Women's low status in society is intimately linked
with their health. Studies in the past have shown
that women's restricted mobility, lack of decision
making power, lack of control over economic
resources and socialization leading to silence
around their health problems, all affect women's
access to health care (15). Low age at marriage
deprives young girls of opportunities to develop
themselves through education and puts young girls
at risk of poor maternal health outcomes. Unequal
household distribution of food is known to be a
contributor to women's poor nutritional indicators
as compared to men. In addition, women continue
to work long hours during pregnancy at home and
outside and this could impact both maternal and
child health outcomes. Importance of other social
determinants like violence against women, unsafe
abortion, sex selection needs to be recognized and
addressed.
Thus, while improving the availability of services
is necessary, it may not be sufficient in itself
to improve women's access to these services.
Addressing gender inequality and improving
women's status is necessary to ensure that these
services reach the poor and marginalized women
that they are intended for.
Policy Recommendations
• Girls' education, currently mandatory through
class 8, should be mandatory through class 10 to
increase the age at marriage.
• Linkages should be forged between community
level health care provision and women's groups
at the grassroots, for example, self-help groups
and elected women representatives, with an
aim of increasing health literacy, organising
for prevention of violence against women, and
increasing awareness of health entitlements.
• A rapid health care response for women survivors
of violence should be operationalized.
• Men's involvement and sensitisation needs to
be promoted in order to promote gender equity.
Boys and young men should be exposed to
discourse around transformatory masculinities
that uphold respect for women and girls and
encourage men to be caring and equal partners
of women.
Improving Quality of Maternal Health
services and Accountability
Quality of maternal health services and weak
accountability and governance in health systems
are major concerns that need an urgent response.
Although institutional deliveries have increased
and investments have been made in strengthening
Emergency Obstetric Care, readiness of institutions
to manage the increased numbers of women
approaching them has been cause for concern.
For example, the fact finding in Barwani district
found that community level services for problems
like anaemia were non existent, peripheral
facilities were poorly equipped to provide even
basic tests like haemoglobin and antenatal care,
and women were forced to travel long distances
to higher facilities for institutional deliveries.
Even in higher facilities, cleanliness and hygiene
were of poor quality, standard protocols were
not being followed, irrational practices like use
of oxytocin for augmenting labour were rampant
and human resource was inadequate and without
appropriate skills. (3) In addition, referrals are
inappropriate and indiscriminately done, bordering
on denial of services and a lack of accountability
(3, 4). Women complain of disrespectful treatment
and abuse in labour rooms (3, 4). Lack of quality
control and grievance redressal mechanisms, large
scale corruption in health systems, and lack of
attention to context specific issues all point to poor
governance and accountability.
|
|
4 Page 4 |
▲back to top |
~ifOUND4r,
O~
'0
s
~o~
~ I.f1.'1. ~ POLICY RECOMMENDATIONS
FOR MATERNAL HEALTH IN INDIA
":'/1W
Wilson
Center
Policy Recommendations
In order to improve quality of care:
• Comprehensive guidelines, protocols and checklists
for both public and private health care institutions
and the institutional infrastructure need to be
developed. Existing guidelines, which currently
reach only a few states, must be disseminated to
all states.
• Quality assurance mechanisms, including
periodic assessments by an external team and
in-facility quality assurance committees, need
to be instituted. District level quality assurance
committees for reproductive, maternal and child
health need to be mandated in all districts and
strengthened, supported and made functional.
• Human resources need to be reformed, including
training nurses and midwives, and recruiting new
staff for labour room instead of rotating existing
staff. The workload and capacity of all staff
needs to be critically examined and accordingly
necessary recruitment and training needs to be
carried out. In order to improve governance and
accountability.
• Health system accountability needs to be ensured.
This should include a progressive transfer
policy for staff to reduce corruption related to
transfers, supportive supervision measures, and
inclusion of measures like the Integrity Pack of
Transparency International to bring down the cost
of procurement.
• Community monitoring mechanisms need to
be prioritized and scaled up including ensuring
budgetary allocations. This would also help
minimise corruption at the grassroots levels.
• Grievance redressal mechanisms need to be
put in place including appointing a district level
ombudsperson.
• Regulation of the private sector both in terms of
costs of maternal health care as well as quality of
services provided needs to be instituted.
1. RGI. SPECIAL BULLETIN ON MATERNAL
MORTALITY IN INDIA 2007-09. New Delhi:
Registrar General, India; 2011.
2. International Institute for Population Sciences
(liPS) and Macro International. National Family
Health Survey (NFHS-3), 2005-06, India: Key
Findings. Mumbai: liPS; 2007.
3. B, Sarojini N, Khanna R. An investigation of
maternal deaths following public protests in a
tribal district of Madhya Pradesh, central India.
Reproductive Health Matters. 2012; 39 (12):11-20.
4. Banerjee S, John P,Singh S. Stairway to Death.
Economic and Political Weekly. 2013; XLVIII
(31):123-30.
5. A Strategic Approach to Reproductive, Maternal,
Newborn, Child and Adolescent Health
(RMNCH+A) in India. MoHFW, New Delhi; 2013.
6. Iyengar K. Early postpartum maternal morbidity
among rural women of Rajasthan, India: a
community-based study. Journal of health,
population, and nutrition. 2012 Jun;30 (2):213-25.
7. Ravindran 1, Savitri R, Bhavani A. Women's
Experiences of Utero-Vaginal Prolapse: A
Qualitative Study from Tamil Nadu, India. In:
Berer M, RavindranT, editors. Safe Motherhood
Initiatives: Critical Issues. London: Reproductive
Health Matters; 2000. p. 166-72.
8. Patel V, Prince M. Maternal psychological
morbidity and low birth weight in India. The British
journal of psychiatry. 2006 Mar;188:284-5.
9. Consultation on maternal health: Emerging
priorities. Population Foundation of India,
New Delhi; 2013
10. WHO multi-country study on women's health
and domestic violence against women: summary
report of initial results on prevalence, health
outcomes and women's responses. WHO,
Geneva; 2005.
11. Iyengar K, Iyengar SD, Suhalka V, Dashora K.
Pregnancy-related Deaths in Rural Rajasthan,
India: Exploring Causes, Context, and Care-
seeking Through Verbal Autopsy. J HEALTH
POPUL NUTR. 2009;27 (2):293-302.
12. Iyengar K,Yadav R, Sen S. Consequences of
Maternal Complications in Women's Lives in
the First Postpartum Year: A Prospective Cohort
Study. J HEALTH POPUL NUTR. 2012;30 (2):226-
40.
13.Youth in India: Situation and Needs. Population
Council, New Delhi, 2007.
14. Prasad JH, Abraham S, Kurz KM, George V,
Lalitha MK, John R, et al. Reproductive tract
infections among young married women in
Tamil Nadu, India. International family planning
perspectives. 2005 Jun;31 (2):73-82.
15. Ramasubban R, Jejeebhoy S, editors. Women's
Reproductive Health in India. Rawat Publications;
2000.
POPULATION FOUNDATION OF INDIA
B-28, Qutab Institutional Area, Tara Crescent, New Delhi- 110016, INDIA
Telephone: + 91-11-43894100; Fax: +91-11-43894199
E-mail: info@populationfoundation.in;
Website: www.populationfoundation.in