When 20-year-old Hukam Kawar was brought for delivery to a primary health centre in Bhilwara District of Rajasthan, her husband Chan Singh was not sure whether his wife and child would survive. Though he kept praying to return home with a healthy baby and wife, he was haunted by the memory of his sister dying while waiting outside the delivery room waiting for help. When the staff nurse informed him that both mother and baby were well, he sighed with relief. “If only maternal health services had been available near our village ten years back, my sister would have been alive today,” lamented Chan Singh.
Indeed, for millions of poor villagers, pregnancy and childbirth have long been associated with unexpected tragic end of the mother or child or both. In fact, when the Child Survival and Safe Motherhood Programme was implemented in India after the 1987 Safe Motherhood Conference, at Nairobi, public health experts were pessimistic. Even in the 90s, many believed that significantly reducing maternal mortality was a distant dream for India. The vast country accounted for highest maternal death burden in the global maternal mortality figures, and faced significant barriers to changing the situation.
But the latest maternal mortality estimates show excellent progress: India’s maternal mortality rate has declined from 570 deaths per 100,000 live births in 1990 to 230 in 2008, which means that the country could come very close to, or even reach, the Millennium Development Goal 5 indicator, which calls for declines of 75 per cent (from 1990 to 2015).
MDGs galvanized support
When world leaders committed to the MDGs in 2000, the eight interconnected goals galvanized support and commitment at the highest levels. In India, this meant that more resources were pledged to the health sector, and maternal health in particular was prioritized. From 2000-2005, the government’s approach was to scale up successful evidence-based policies and programmes, including those supported by UNFPA, the United Nations Population Fund, along with its partner, the Averting Maternal Death and Disability initiative of Columbia University's Mailman School of Public Health. For instance, a $1.4 million health systems strengthening project that reached 80 facilities in seven health districts was used as a model by Rajasthan throughout the huge state, with the help of $100 million from the World Bank. Elements of the model then played a catalytic role in shaping India's national Reproductive and Child Health programme, which reaches millions more mothers.
Civil society also played an important role
In addition, development partners began drawing the attention of policy makers to the growing public concern about maternal mortality being voiced by civil society organizations. The advocacy led to renewed commitment by the public health communities. Maternal mortality reduction emerged as a clear priority and was endorsed in the National Population and Health Policies and was reiterated in the National Development Goals Since then, India has been witnessing a ‘silent revolution’ in making motherhood safer.
According to Dr. B. C. Behera, Additional Chief Medical Officer of Mayurbhanj District, in the eastern state of Orissa, “In the past, we neither had sufficient resources, nor appropriate programmatic interventions, to address avoidable maternal deaths. Now, the onus lies on the public health care system to utilize resources and improve services to ensure a positive pregnancy outcomes.”
India’s income inequalities, lack of skilled health workers, and large rural population, many of whom live in vast hard-to-reach areas, all present challenges that result in wide disparities within and among different states and populations. For instance, the maternal mortality ratio in the northeastern state of Assam is about five times as high as that of the southern state of Kerala.
Key drivers for improved pregnancy outcomes
In spite of these challenges, the increase in service coverage is better than ever before. The National Rural Health Mission, launched in 2005 provides accessible, affordable, accountable, effective and reliable health care, especially to the poor and the vulnerable sections of the population in rural areas. Under this overarching health programme, the “Janani Suraksha Yojana” (conditional cash transfer scheme for institutional deliveries) has further reduced maternal mortality – especially amongst the socially marginalized sections of the society. In addition, a wide range of evidence-based interventions have been implemented, including family planning services, skilled birth attendance, emergency obstetric care, and community mobilization and information dissemination by community health workers.
India is showing promising progress on all key drivers of maternal mortality reduction. The first driver is reduction in fertility, from 3.4 (1992-1993) to 2.7 (2005-2006), according to National Family Health Surveys. A second key driver is the overall economic growth and increased financial commitment to the health sector, which has translated to greater access to maternal healthcare. The third is a steady increase in institutional deliveries, especially in states that have high rates of maternal death. The fourth is a rapid increase in births attended by skilled providers in recent years. Other factors that are improving the situation include an increase in female literacy, enhanced community links with the health care delivery system, and improved transportation and communication.
However, it is necessary to speed up the pace of development further in order to accomplish the Millennium Development Goal 5. Healthcare systems need to be strengthened more rapidly, powered by interventions that help reach the unreached and prevent the deaths of some 60,000 women each year.
— Hemant Dwivedi