India: Malnourishment & early marriage major factors in shameful/avoidable maternal mortality rate
Chandigarh, India ~ Friday September 16 2011
Tragedy of childbirthby Shree Venkatram
It is ironic that India, which is aiming to become a hub of medical tourism and boasts of world class medical facilties, cannot provide even basic midwifery services and primary health care to thousands of pregnant women. Not only is the country’s maternal mortality rate high, in some districts like Purulia nearly half the women die during pregnancy and child birth
IN the 15 minutes you might take to read this article, three Indian women in the prime of their life would have succumbed to complications arising from pregnancy and childbirth. In all probability they would have left behind newborn babies or toddlers, many of whom would die or be consigned to a life of undernourishment, neglect and a compromised future.
It is very risky becoming a mother in India. According to a Unicef estimate, India sees 78,000 maternal deaths. Other agencies have pegged the figure to be higher. There are districts in the country, Purulia for example, where nearly half the women die during pregnancy and child birth. For each one of these deaths, scores of others suffer acute maternal morbidity that leaves them permanently disabled and confined to a lifetime of pain and misery. The irony is that most of these women could have been easily saved.
Over the decades there has been some progress in bringing down maternal deaths. But the decline has not been fast enough. For a country which has become the preferred medical destination for people from around the world for complicated surgeries, to have women die from childbirth related causes is a real shame. According to the State of the World's Children, 2009 there are 450 maternal deaths per 100,000 live births, the figure having fallen from 540 ten years earlier. The latest Sample Registration System (SRS) survey puts the figure at 212 while the World Health Organisation and some other international agencies peg it at 231 and some others at 250. Whatever be the figure, one thing is clear: India is nowhere near reducing the number to 109, the target set for 2015 under the Millennium Development Goals.
CAUSES BEHIND HIGH MMR
A slew of social, economic and administrative factors contribute to the making of this monumental tragedy, which gets compounded as it impacts another generation. The poor diet of the women, the lack of importance attached to their lives, low level of education, early marriage, the woefully inadequate medical services, the corruption that exists in the system are some prime factors responsible for the high Maternal Mortality Ratio(MMR) in India. Among the major causes of maternal death are excessive bleeding during childbirth, prolonged and obstructed labour, infection, unsafe abortion, disorders related to high blood pressure and anaemia. Forty-seven percent of maternal deaths in rural India are attributed to excessive bleeding, obstructed labour and anaemia resulting from poor diet.
The National Family Health Survey-3 (NFHS-3) shows that 36 per cent of Indian women are chronically undernourished and 55 per cent are anaemic. In a recent study in Rajasthan, 70 per cent of adolescent girls were found to be suffering from moderate to severe anaemia. The Harvard School of Public Health found a link between a mother's height and the health of her children using Indian data. Children with mothers shorter than 4 feet 9 inches were 70 per cent more likely to die than those whose mothers were at least 5 feet 3 inches tall. Maternal height indicated a mother's own childhood health and has a direct bearing on the next generation. An anaemic mother's children are more likely to be underweight, have anaemia and face the risk of death. Over 2 million children less than five years old die every year.
Half of India's girls are married off before their eighteenth birthday. A teenage pregnant girl faces a greater risk to her life and that of her unborn child, more so if she is anaemic. The NFHS-3 reports that 28 per cent of women had become mothers by 18 years of age. Younger women are also more likely to experience domestic violence. In many Indian homes this continues during pregnancy and compromises the well being of the mother-to-be and the unborn child. So ingrained in us is the fact that women are some lowly creatures who need to be beaten by men that a national survey has noted that 57 per cent young men and 53 per cent young women think it is okay for men to beat their wives! Changing such an attitude is a monumental task.
Chinks in schemes
It has been six years since the launch of the National Rural Health Mission (NRHM) which aims at strengthening the health system and the Janani Suraksha Yojana (JSY), where cash assistance is given to poor women to deliver in an institution. The figure varies from Rs 700 to Rs 1400 depending on the category the state has been put under. Data shows that women are going into the institutions as the number of 'beneficiaries' have been rising every year reaching 90 lakh beneficiaries now. India sees about 27 million births every year, pointing to the fact that a large percentage of women still deliver without medical supervision, especially in rural areas and much work still needs to be done to cover them.
There has been criticism against cash transfer schemes. The astronomical amount could be used for enhancing the health infrastructure which is woefully inadequate. Initial studies reveal that women are staying for a couple of hours only in the institution so as to collect the incentive amount. The stipulation is that the woman stays for at least 48 hours so that she and the newborn can be under medical supervision and any complication can be met. But now, while delivery is taking place under trained hands, the mother and child are not under observation and in case of any complication cannot get the attention needed. Most often, the referral system is poor and the health centres and hospitals do not have the required staff or even lab facilities.
Ailing health system
The availability of nurses and doctors remains a big issue. Posts of gynaecologists, paediatricians and technical laboratory staff are lying vacant even in better run states like Punjab. The nurses who man government hospitals are overworked affecting service. There is a crying need for more health centres and hospitals. Unless the capacity and infrastructure is enhanced, India will not be in a position to offer institutional delivery to all its women. And that does not look like happening soon.
Last year, there was a huge public outcry against the callousness of the public health system in the Barwani district of Madhya Pradesh which saw 26 maternal deaths from April to November. Civil society teams visited the district on a fact finding mission as did NRHM's Advisory Group on Community Action. They found a complete mismanagement and lack of basic infrastructure: A Primary Health Centre functioning from a very dilapidated building, an ANM who could not check blood pressure, no Haemoglobinometers to conduct the very essential haemoglobin test on pregnant women, the absence of ante-natal check up, only a nurse and a dai to manage the labour room and 60 beds for 16 hours at the district hospital where 300 deliveries take place in a month. There had been no augmentation of staff after the start of the NRHM and JSY, and there were no review, monitoring or redressal mechanisms in place.
Apart from addressing such mismanagement and proper deployment of resources, much more needs to be done. Poonam Muttreja who heads the Population Foundation of India, says all out efforts need to be made to keep girls in school and postpone marriage. This way early marriage which poses a risk to their lives could be avoided. She advocates cash and food incentives for antenatal care so that the pregnant woman can be monitored for anaemia and blood pressure. And lastly she calls for a bigger investment in family planning. When babies are not wanted, they are neglected, she says. People should know about and be able to easily access spacing methods. The states with the lowest Contraceptive Prevalence Rate also have the worst MMR. Uttar Pradesh, Madhya Pradesh, Uttarakhand and Chhattisgarh report very high unmet needs for family planning and also have a high MMR.
The task ahead is indeed monumental. But it must be taken up as top priority for at stake is the health of India's women and future generations.
The writer works in the development sector