More than half a million women and girls die every year globally because of pregnancy, childbirth, and unsafe abortions. Most of these deaths are preventable. Over 99 percent of maternal deaths take place in developing countries which account for 86 percent of world’s births. Well over three-quarters of these deaths occur in South Asia: in India, Bangladesh and Pakistan. There are more maternal deaths in India in one day than are in all the developed countries in one month combined. The country has seen a fall in maternal mortality rate (MMR) by 59 percent between 1990 and 2008, but the huge rural urban divide in these rates are overlooked making it home to the highest number of women dying during childbirth across the world. Though blueprints for safe motherhood programs, National Rural Health Mission (NRHM) to improve public health systems and reduce maternal mortality in particular exists, the equipment and technical competence to provide services is weak at the present moment. The decline, however, is small in relation to the scope of the problem, and camouflages disparities.
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India has an average maternal mortality ratio of 407 per 100, 000 live births at the national level. At the state-level these rates are under-estimated; in fact there are certain states that reach up to 745 maternal deaths per 100,000 live births. The discrepancies not just end here, in a majority of northern states the rural and urban rates differ significantly. One such state is Uttar-Pradesh, a highly populous state with more than170 million people which continues to have highest reported maternal mortality ratio at 440 per 100, 000 live births and which still remains above the national average. Even within a state, the access to and utilization of maternal health care varies based on region rural or urban, caste, religion, income, and education. Research has identified four important reasons for the continuing high maternal mortality rate in Uttar-Pradesh: barriers to emergency care, poor referral practices, gaps in continuity of care, and improper demands for payment as a condition for delivery of healthcare services. While accountability in such a context is already a dry or abstract, the issue literally can be a matter of someone’s life and death.
Factors contributing to maternal deaths in Uttar-Pradesh were not much different than any other state but the prolonged neglect and irrevocable beliefs, behaviors and attitudes of the people here have made maternal mortality invincible. Beliefs such as early marriage, illiteracy, women’s poor control over access to and use of contraceptives, husbands or mothers-in-law dictating women’s care-seeking behavior, overall poor health including poor nutrition, poverty, lack of health education and awareness, domestic violence, and poor access to quality health care, including obstetric services are deeply embedded in this community. Less than half of the pregnant women in Uttar-Pradesh seek any antenatal care, even where the care is sought, it usually tends to be in the second trimester with the sole purpose to confirm pregnancy. These observations are not a surprise in the context where women’s health care utilization is in general low and pregnancy is not considered an event requiring any special medical attention.
When the reasons are further explored, many factors that perpetuate the condition become exposed. There is no record system in place, the system fails to gather the necessary information at the district level on where, when, and why deaths and injuries are occurring. More than 90percent of pregnant women deliver at home attended by Dai’s or untrained professionals. In cases of emergency, a mid-wife is approached but health worker trained in midwifery can do very little to save the life of a pregnant woman unless she is supported by a functioning health system including an adequate supply of drugs for obstetric first aid, emergency obstetric care. The case is referred to an obstetrician and gynecologist in events of complications such as hemorrhage, obstructed labor, and hypertensive disorders. Unfortunately there are no referral systems, transportation, blood storage or support in place. Uttar-Pradesh has 583 fewer community health centers than Indian public health standards require. Less than a third of existing community health centers have an obstetrician or gynecologist and about 45 percent do not have funds to operate even the one ambulance they have. The issue of maternal mortality has many facets here and needs a multipronged approach.
The available information on maternal mortality in rural India is inadequate and scanty. In order to improve the maternal health outcomes in states such as Uttar-Pradesh the policy makers need to leverage a wide spectrum of resources, both public and private to address the health needs of the population in need with appropriate means to deliver them. Reductions in maternal mortalitywould require interventions to improve service delivery, as well as community mobilzation.Time is the key, the availability of the emergency facilities and most important, human resource when required can prevent needless anguish. A strategic plan that considers identifying the roots of the problem, counting true numbers, improved technical skills and equipment, increase utilization of health care, provision of emergency health care resources and all the aspects of health system offers a best opportunity for achieving improved health outcomes for women and children in resource-constrained settings in rural areas. The government should collaborate and co-operate and make efficient use of the opportunities available. The need of the time is weigh the available options and stabilize up a weak health infrastructure to minimize a disaster, as the road ahead is uncertain, but definitely not short.
Maternal and Child Health Department,
School of Public Health and Health Sciences,
George Washington University.