The Fourth Common Review Mission evaluating the progress of the National Rural Health Mission has recently submitted its report and noted considerable improvement in the development of health systems in various States. However, a civil society report states that mothers continue to die in remote corners of the country due to lack of governance and accountability in the health care system.

Recently, a fact finding team of medical doctors and women's health activists undertook a visit to Barwani district, Madhya Pradesh, in January 2011 to investigate into reports of a large number of women dying during pregnancy and delivery in recent months in the district with many of the deaths taking place in the District Hospital (DH), Barwani. The team conducted the investigation on behalf of Jan Swasthya Abhiyan, CommonHealth and Sama and the team members were Dr. Subha Sri (Obstetrician Gynaecologist), Sarojini N (Health Activist and Nutritionist) and Renu Khanna (Health Systems Analyst).

Most of the 26 deceased women belonged to Scheduled Tribes which points towards severe caste/class based inequities in access to health care. The Janani Suraksha Yojana had increased the load of institutional deliveries tremendously and the facilities were ill equipped to handle this. There were also inordinate delays in providing Emergency Obstetric Care once women reached appropriate facilities; multiple referrals back and forth without initiation of any emergency treatment was contributing to significant delays. The quality of recording in the case sheets in general was found to be very poor.

Quality of care in healthcare facilities was found to be very poor -there was no skilled birth attendance at delivery, no standard management protocols like use of partographs were followed, infection prevention measures were found inadequate, cleanliness was unsatisfactory. None of the women who had a maternal death within the District Hospital had any operative intervention on them; although the operation theatre at the District Hospital was well equipped to perform all types of obstetric and gynaecological surgeries. Many of the referrals were inappropriate and of women in critical condition, raising issues about accountability during referral. Families had to pay for various services including drugs, laboratory services and blood transfusions, even when certified to be Below Poverty Line.

While anaemia was widely prevalent in the area, lab tests had not been conducted, ante-natal screening and treatment of anaemia was inadequate, and anganwadi centres were non-functional. The team met several pregnant women with severe anaemia, some with haemoglobin at dangerously low levels of 2gms/dl. It also found that anaemia contributed directly to seven of the 26 maternal deaths investigated and Sickle cell anaemia and malaria seemed to aggravate nutritional anaemia further.

The investigation team has spelt out several recommendations for the district, State and at the national level to remedy the situation. These include specific actions to improve governance and accountability in health systems, setting up grievance redressal mechanisms, effecting change in organizational culture of health systems, rebuilding public confidence in them and improving transparency. There are also several recommendations on strengthening health systems including equipping health care facilities, strengthening human resource, improving quality of care and setting up of monitoring mechanisms. The report also recommends actions to improve social determinants of maternal health.

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