Worldfocus spoke with Aruna Kashyap, the lead researcher of the in-depth study, “No Tally of the Anguish.”
Is the rate of maternal mortality still exceptionally high in India?
Kashyap: Yes. India is an emerging economic superpower known for its medical prowess. There are also large portions of money allocated for healthcare programs – including maternal healthcare programs – that go unspent annually. This context is very important when analyzing data on maternal mortality. If we look at the “BRIC” countries – India’s maternal mortality level is 16 times that of Russia, 10 times that of China, and 4 times that of Brazil. Also, about 1 in 70 girls who reach reproductive age in India will eventually die because of a pregnancy-related cause, compared to 1 in 7,300 in the developed world.
The latest all-India estimates show that there has been a small decline in maternal mortality since 1997. But maternal mortality measures are mere estimates. They are also presented as averages, and averages do not tell the actual story. For example, while all-India figures show a decline, Haryana and Punjab show an increase in maternal mortality. Critically, these estimates camouflage the huge disparities in access to healthcare, including maternal healthcare, between the rich and the poor. The question is whether the little progress that health authorities are making in reducing maternal mortality is percolating down to the marginalized and the poor. Many populations in India endure poor maternal health because of many levers of inequality, including those based on caste, residence, education and awareness, age, and number of children. For example, a 2007 UNICEF study showed that 60 percent of the maternal deaths documented in six northern Indian states occurred in Dalit and tribal communities.
Moreover, for every maternal death, around 20-30 women are left with injuries, diseases or infections after childbirth or unsafe abortions, many lasting a lifetime. A woman may survive childbirth but suffer obstetric fistula and ensure life-long humiliation and even abandonment if not treated. There is very little data on this, but health experts believe that maternal morbidity levels are also very high in India, which is a cause for concern.
What are the most successful government policies in reducing maternal mortality?
Kashyap: Globally, about 80 percent of all maternal deaths are said to be caused by direct obstetric causes—hemorrhage, obstructed labor, eclampsia, and unsafe abortions. Many years of research and evaluations of different health interventions have led public health experts to conclude that there are four key maternal mortality reducing strategies that address these direct obstetric causes–access to emergency obstetric care, good referral systems, skilled birth attendance, and reducing the number of unwanted pregnancies. Health authorities should also strengthen women’s access to safe abortions. The indirect causes of maternal mortality and morbidity are malaria, hepatitis, tuberculosis, and HIV. There have to be interventions to ensure that these indirect causes are also addressed.
In India, about 65 percent of all maternal deaths are caused by direct obstetric causes and 35 percent are caused by indirect causes. So for maximum impact, healthcare interventions have to address both.
To what extent do you blame village-level government officials for not doing enough?
Kashyap: It depends on what aspect we are looking at. For example, if we look at civil registration, there are village level officers who are supposed to register deaths which they are not doing. Where this is because the state has not appointed such officers the state is to blame, but otherwise, a part of the blame also lies with the village level authorities.
In the case of delivery of maternal healthcare services, at the village level, female health workers implement the maternal healthcare programs. Most of them have very little say in how programs are designed and implemented because the healthcare system is top-heavy. These workers should also be equipped with essential drugs, blood pressure measuring machines, weighing machines, gloves, and so on that they can use to check the health of pregnant women and conduct deliveries. If they are not equipped, then there is very little they can do. For example, we interacted with health workers who are charged with providing antenatal care but had not been given a blood pressure gadget for several years even though they had put in repeated requests to get such gadgets.
The decisions are made at the national, state, and district levels. So unless decision-makers at these different levels do not change policies and programs, health workers at the field level cannot be blamed. Be it caste-based discrimination or corruption at any level, the power to monitor and undertake corrective action largely lies with district and state health authorities.
There have been attempts to change this. The Indian government has tried to decentralize decision making under its flagship rural healthcare program, the National Rural Health Mission, 2005. Under this, the Indian government has provided for “untied funds” that can be managed by health workers along with local elected village council heads. But this has not been very effective for several reasons. Poor awareness regarding these provisions, a lack of initiative by elected village council heads, corruption, are some of the reasons. The Indian government has also created Patient Welfare Committees (Rogi Kalyan Samiti) to decentralize decision-making and management of the hospital. These committees also have grievance and redress powers. But once again, these are yet to be effectively utilized.
What is your outlook for realistic improvements in maternal mortality over the next two decades?
Kashyap: There has been little progress in the last decade not only in India but in many other countries. But since 2005, at least on paper, the Indian government guarantees a host of maternal healthcare services free of cost. In order to ensure that these are effectively implemented, the Indian government should monitor the implementation of these programs. This can be done in several ways: recording and investigating all maternal deaths to identify and rectify health system failures; monitoring whether women with pregnancy-related complications are actually getting access to maternal healthcare; setting up a grievance and redress protocol including emergency response systems like a telephone hotline that can be used by pregnant women in distress; paying attention to strengthening the public health system, including training health workers in midwifery.
If all of this is done, then perhaps India will be able to show more results not only in averages but also for the poor and the marginalized.
How has your experience with maternal mortality issues affected you personally?
Kashyap: I feel outraged by the injustice of these preventable deaths. There are some women’s faces and stories that come back to me often. For example, the mother-in-law who cried while describing how her pregnant daughter-in-law died in a community health center because she could not afford to take her a better health facility. She had just one lingering plea that it should not happen to anyone else. Then another woman who asked me why she would take 1400 rupees (the cash assistance given to rural women to deliver in health facilities) and go to a health facility to kill herself –- referring to the fact that many women are often turned away from such facilities without medical assistance because they are ill-equipped to handle pregnancy complications. I hope the government will read some of these stories and make their health system more accountable to these women.
– Ben Piven