Earlier this year Oxfam-India convened a two day workshop in Kathmandu to reflect on the status of maternal healthcare in the South Asia region as the UN’s Millennium Development Goals (MDGs) wind down at the end of 2015. Participants included representatives from government agencies, NGOs, medical professions and universities. I joined as a member of the India delegation to converse with groups representing Afghanistan, Bangladesh, Nepal, Pakistan, and Sri Lanka. I carried away four major impressions.
First, as a region, South Asia’s performance in meeting the MDGs for maternal health has varied significantly. Sri Lanka had achieved its MDGs even before they went into effect, and Nepal and Bangladesh are on track to achieve their goals by the end of the year. India, Pakistan, and Afghanistan will not meet their goals and face substantial gaps and challenges, but are nevertheless making considerable progress to improve maternal healthcare.
Second, India remains of acute importance if only because it historically—and to this day—accounts for the lion’s share of the global burden of maternal mortalities. The Government of India (GOI) reported dramatic declines from 27% of the global maternal mortalities in 1990 to 16% in 2011 with continued declines since. While the accuracy of maternal mortality reporting in India is contested and thought to under-estimate maternal deaths in childbirth due to problems with data collection and recording, the overall reduction is remarkable. The GOI attributes much of this success to the maternal health schemes which it launched in 2005 as part of its National Rural Health Mission (NRHM) program. The main thrust of these schemes has been to increase the number of hospital deliveries managed by licensed obstetricians by providing monetary incentives both to women who deliver at a public maternal health facility and to Accredited Social Health Activists (ASHAs) who refer women to such facilities. Improvements in ambulance transportation have also increased access to public maternity hospitals. In the 1990s approximately 20% of all deliveries in India occurred in hospitals whereas today hospitalized births account for close to 50% of all deliveries.
Problems, however, endure, rooted in India’s deep poverty and inequity. India’s Maternal Mortality Ratio (MMR) remains high at 190 in 2013, and is extremely uneven with some states reporting MMRs above 300 while others are below 100. The government acknowledges that much remains to be done with too many maternal deaths caused by hemorrhage, sepsis, unsafe abortions, hypertension disorders, and obstructed labor, as well as by the intractable problem of anemia (half of all pregnant women in India suffer from anemia caused by poverty-induced malnutrition). While increasing hospital deliveries with obstetricians and emergency obstetric interventions can clearly help address some of these problems, such as hemorrhage and obstructed labor, these interventions alone are not sufficient.
Third, concerns persist that the GOI has turned away from the integrated, life-cycle Reproductive Health Care program emphasized in the late 1990s, to a more narrow focus on obstetrician-managed institutional deliveries in response to the MDGs. That has meant a lowering of commitment to improve midwifery training through enhanced skills to manage low-risk pregnancies and identify early signs of high risk pregnancies in need of emergency care. By contrast, in Sri Lanka, as well as Afghanistan and Bangladesh, the sustained strong emphasis on midwifery training is fundamental to continued progress in lowering maternal mortality. Meanwhile, India’s public maternity hospitals, constrained by too few obstetricians and inadequate budgets, are often overwhelmed by the sudden influx of patients. Many states continue to struggle to attract competent physicians (particularly female) to work in rural areas. Unfulfilled promises and corruption arising from the monetary incentives to encourage institutional deliveries also lower women’s confidence and trust.
Fourth, there needs to be priority and attention to the endemic problem in India – and elsewhere in South Asia – of disrespect and abuse by medical professionals in hospitals of patients who are predominantly from lower class, lower caste, and tribal communities. Delegates from all other countries except Sri Lanka echoed this concern. Complaints range from condescending and derogatory comments about the so-called ignorance and “backward” nature of patients’ practices, to verbal and physical abuse in the form of yelling and hitting. While the GOI typically attributes patients’ resistance to hospital delivery to uneducated cultural preferences for home delivery, health professionals’ disdain towards their patients in public hospitals should be acknowledged as a factor. This issue can be addressed head on by highlighting the value of respectful patient care in medical education curricula; putting in place accountability mechanisms such as “Women Friendly” accreditation for maternity hospitals; building into advocacy campaigns to stop violence against women an explicit emphasis on hospital care of pregnant women; and improving the work conditions of healthcare practitioners in public maternity hospitals.
As the Sustainable Development Goals (SDGs) now under final deliberation come into force in 2016, it will be crucial for countries in South Asia to keep front and center the region’s unfinished maternal health agenda. India’s burden remains formidable; midwifery training remains fundamental to continued progress; and far more needs to be done to overcome pervasive disrespect and abuse of poor, marginalized pregnant women.
Cecilia Van Hollen, Associate Professor
Dept. of Anthropology, Maxwell School of Citizenship & Public Affairs, Syracuse University; author of Birth in the Age of AIDS: Women, Reproduction and HIV/AIDS in India