Despite the government’s efforts to reduce maternal deaths by encouraging deliveries at health centres, the system continues to fail poor women.

I gave birth in the developing world, in South Africa, to be precise. South Africa was in the spotlight recently when a government-commissioned report showed a 20 per cent increase in the number of deaths from pregnancy-related causes between 2005 and 2007 over the previous three-year period. The report said that nearly 40 per cent of these deaths were avoidable.

I was lucky, and privileged enough, to be able to pay for private healthcare, which in South Africa is world-class. I saw my obstetrician every month during the first eight months of my pregnancies, and then every week. He did an ultrasound during each visit, and I was able to watch the healthy development of my children. I even had a 3-D scan, which showed my son sucking his fingers. When I went into labour, my husband drove me to the hospital.

I gave birth in a private delivery room in a hospital, with my obstetrician and two nurses in attendance. I had access to excellent pain relief and post-natal care. I may have given a fleeting thought to the risks of pregnancy and birth, but it never seriously occurred to me that I could die, that over half a million women do die every year worldwide from pregnancy-related causes.

India is a lot like South Africa — it has exceptional healthcare, if you can afford it, but an alarmingly high rate of maternal deaths. The Indian government, to its credit, has recognised this as a national crisis and has developed programmes designed to end preventable maternal deaths.

A cornerstone of the government’s response has been to encourage women to give birth in health facilities, rather than at home. The Janani Suraksha Yojana, or literally Mother Protection Scheme, provides cash incentives equivalent to $28 to women who give birth in health facilities. In a country with a third of the world’s poor, and where 42 per cent of the population lives on $1.25 a day, this is a significant amount of money. The programme appears to have had some success, with 20 million deliveries taking place in health facilities between 2005 and March 2009. The government uses this number as a measure of overall progress in maternal health.

There is no doubt that giving birth in a health facility is important. Research suggests that access to emergency obstetric care is one of the most important factors in reducing maternal deaths. The Indian government’s efforts have no doubt brought some pregnant women with complications, to health facilities that could help them.

But these numbers do not begin to tell the story. The government does not collect sufficient information about the outcomes of deliveries in these health facilities. In fact, as Human Rights Watch recently conducted research on the high rate of maternal deaths in Uttar Pradesh for a new report that we issued on October 7, we found that this State does not even collect the numbers of pregnancy-related deaths.

We found many examples of how the system continues to fail women: K. Kavita, for example, delivered her baby in a community health centre under the Janani Suraksha Yojana programme. But when she developed complications after being discharged, she went from one hospital to another for five days trying to get treatment, and eventually died.

Our research showed serious gaps in services: Uttar Pradesh has fewer than half of the 1,097 community health centres the government says it should have. Less than a third of these have an obstetrician or a gynaecologist on the staff. Only one in 20 of these referral units offers caesarean sections, and one in a hundred has a blood storage facility. Given these shortcomings, it is unclear whether women actually receive better care than they would giving birth at home.

The fact that 20 million women give birth in these facilities also tells us little about their struggles to reach a facility that would provide them with an adequate standard of care. Human Rights Watch research documented cases of women who, in an emergency situation, were unable to pay for transportation to a hospital, who were turned away from several facilities that said they could not provide the required assistance and who died outside clinics that were not prepared to admit them.

If India’s plans to reduce maternal deaths are to work, the government needs to make sure that all public health facilities are staffed and equipped so that they meet public health standards. It should monitor actual pregnancy outcomes, including by investigating maternal deaths, to identify and fix health system gaps and barriers to getting care so that in the future deaths can be prevented. The government also needs to improve the overall health of women, with attention to nutrition, access to contraceptives, and participation in health-related decision-making. And it should keep track of whether women with pregnancy-related complications can actually access the help they need.

At the end of the day, the Indian government should recognise that good healthcare, including maternal healthcare, is a basic right. It should pay attention to the painful cry of the families which witness such preventable deaths and their members who say, “Let this not happen to anyone else.”

(Liesl Gerntholtz is the Director of the Women’s Rights Division at Human Rights Watch.)

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