Twenty-two-year-old Kousalya (name changed), a Scheduled Caste woman in a remote village in Karnataka, was in an abusive marriage. She had suffered a late miscarriage in her first pregnancy and had been very careful with seeking antenatal care early in this pregnancy. She had moderate anaemia which was not identified or treated at the taluka hospital.
She completed three antenatal visits and also came to the community health centre for delivery. There were three other women in labour at the time. The staff present included an MBBS doctor, a staff nurse, a dai (midwife) and a lab technician, none of whom were trained in conducting deliveries.
The doctor went home to rest at one point and delegated the management of the delivery to the other staff. They tried to hasten the ‘job’ at hand by giving fundal pressure and shouting and beating Kousalya and also abused her. The doctor was called back and he complained to the family that she was not cooperating. She finally delivered a still-birth and then started bleeding profusely. The doctor gave her injections to contract the uterus but did not diagnose the cervical tear.
Since she continued to bleed, she was then transferred to another health facility where she died on arrival.
In the past few years, civil society groups from different parts of the country (Madhya Pradesh, Bihar, Jharkhand, Uttar Pradesh, Chhattisgarh, Rajasthan and Odisha), including from the so-called `developed’ States like Gujarat, West Bengal, Tamil Nadu, Karnataka and Kerala, have been documenting maternal deaths. All of these reports bring out very clearly the need for a more comprehensive approach which goes beyond technical and narrow indicator-oriented approaches and must address the social determinants such as nutrition, violence, poverty as well as healthy systems.
“Maternal death reviews (MDR) are mandated and are being done in several States but many maternal deaths still fail to get reported and there is no public disclosure of the analysis of maternal deaths, or of the measures planned to address the causes of maternal deaths,” says Jasodhara Dasgupta of National Alliance for Maternal Health and Human Rights.
Activists engaged in monitoring the state of health services pointed out that women still continue to die during pregnancy and labour because health facilities in many parts of the country are not equipped to provide Emergency Obstetric Care, the screening during antenatal care provided is inadequate, and safe abortion services are inaccessible for the majority of women in rural areas. “The current approach to addressing maternal health in India is fragmented and focussed on promoting institutional deliveries alone, while overlooking the need for a continuum of quality care, including reproductive rights,” they point out.
A review of institutional delivery data of the district level Health Survey-3 from six States with bad human development indicators suggests that the adverse outcomes after institutional delivery were significantly higher after the Janani Suraksha Yojana came into vogue, particularly with respect to perinatal mortality, and increased rates of vaginal bleeding.
Institutional delivery cannot be a uniform or mandatory solution for all Indian women who have a child. “We have to make provisions for some kind of skilled support at home for women who have their delivery at home with provision for emergency transport to adequately equipped Emergency and Obstetric Care facilities,” says B. Subha Sri of CommonHealth.
Calling for training of Skilled Birth Attendants (SBAs), local birth attendants and Auxiliary Nurse Midwives (ANMs) in remote areas without all-weather roads for normal deliveries at home and basic management of complications, the activists also want that all maternal deaths must be notified through positive incentives to frontline workers and Panchayati Raj Institutions.
“All maternal deaths – whether en route, or at the gate of institutions, or at home, or during referral, or in private institutions or of migrating women, must be notified and recorded. There must be a rapid response to verify the maternal death and check if there was any rights violation involved. A maternal health ombudsman should ensure that a proper MDR is carried out and report sent,” N.B. Sarojini of Sama says. Abusive and unethical behaviour towards poor and socially marginalised women and their harassment for informal payments must be made punishable, she added.
The MDR teams must be objective – not comprise local doctors to avoid conflict of interest and the team should not only have teaching hospital staff (over-focus on bio-medical aspects) and must include the community to ensure socio-economic factors are recognised. The reports must be reviewed confidentially and the government must bring civil society/women’s organisations on board in district and State review committees, the activists have suggested.
Demanding that MDR findings must be made public through an annual report in each State and specify learnings in terms of gaps in health system that contributed to the deaths, the activists say the MDR report must announce the remedial action taken to prevent similar deaths in future and grievance redressal mechanism must be made simple and accessible for the poor and less literate.
The panchayats and local communities (through village health and sanitation committees and rogi kalyan samitis) must be enabled to carry out social audit of health facilities by Indian Public Health Standards guidelines and community-based monitoring of maternal health services.
