The many challenges of ensuring maternal and child health in India

Though India has notched up substantial improvements in reducing maternal and child mortality over the decades, much more remains to be done in terms of bringing more people into institutional systems, reducing anaemia and inequity in healthcare 

August 03, 2023 03:39 pm | Updated August 07, 2023 09:38 am IST - CHENNAI

A loving mother holding sleeping baby boy in her arms. Image used for representational purposes only.

A loving mother holding sleeping baby boy in her arms. Image used for representational purposes only. | Photo Credit: Getty Images

As yet another World Breastfeeding Week commences, with hectic educational activity around the mother and her newborn, it would seem the best time to bring attention to what needs to be done in the field of maternal and child healthcare.

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A recent perception poll called the 2021 Hologic Global Women’s Health Index, in its second year and in a tie up with Gallup, says the gap in index scores between women in high-income and low-income economies nearly doubled between 2020 and 2021. In 2021, 22 points separated women in high-income economies — whose score remained unchanged at 61 — and women in low-income economies, whose score dropped from 49 to 39.

In India, a total of 1,382 women were polled on the question: “Do you think most pregnant women in the city or area you live [in] receive high-quality healthcare during their pregnancies, or not?” in 2021. In 2020, the same question had been asked to 917 women in India. In the first year, 76.3% of Indian women in the poll had answered ‘yes’ (76.3%) and 15.7% answered ‘no’ (15.7%). In 2021, the perception seemed to have changed slightly, with only 67.1% women saying ‘yes’, and nearly 30% of the women surveyed saying they thought most pregnant women in their city or area did not receive high-quality care during pregnancy.

In urban areas too in particular, a lower percentage of urban women said that high-quality care was available for pregnant women in 2021 than in 2020. 81.2% individuals in urban areas answered ‘yes’, while 10.9% answered ‘no’ in 2020. In 2021, the first figure dropped to 71.3% while nearly 30% said no in urban areas. In rural areas, the percentage who said they did not think good care was available, went up from 18.7% in 2020 to 31% in the next year. The perceived quality drop was therefore in both rural and urban groups. 

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Released earlier this year, a WHO, UNICEF, UNFPA document titled ‘Improving maternal and newborn health and survival and reducing stillbirth progress report 2023’, observed that India’s share of the total maternal and newborn deaths and stillbirths was about 17%.

Both newborns and women are extremely vulnerable in the hours and days after birth and therefore routine early post-natal care and hospital services for small and sick newborns are crucial, according to the report. Of the regions with sufficient population coverage data, only Latin America and the Caribbean reached the goal of 80% of mothers receiving PNC.

The Indian government recognises Maternal Mortality Ratio (MMR) as an important indicator of the quality of health services in the country. No doubt, India’s progress in reducing MMR has been commendable in the last two decades. In 1990, the MMR in India was very high with 600 women dying during childbirth per hundred thousand live births, which equated to approximately one-and-a-half lakh women dying every year. Globally, MMR at that time was 400, India at that time contributing to 27% of the global maternal deaths, according to data from a 2013 Union government report. As per a statement in Parliament in March 2023, in 2018-2020, India had dropped its MMR to 97 per 1,00,000 live births.

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No mean achievement this. And it could not have been done without significant efforts taken to reach maternal and child healthcare to the corners of the country. Schemes such as the Janani Suraksha Yojana (JSY), launched in April 2005, which allowed a conditional cash transfer for women coming to institutions for delivery, have helped to a great extent to reduce infant and maternal mortality. The initiative of other State governments, particularly in the south, has also demonstrated progress in terms of bringing down pregnancy-related mortality and morbidity.

And yet the sheer numbers are still high. The UN report puts total maternal deaths, stillbirths and neonatal deaths at 788,000. Of these, maternal deaths amounted to 24,000, stillbirths totalled 297,000 and neonatal deaths stood at 468,000, as per the report. These numbers are evidence of far too many avoidable deaths.

“Doubtless, the Indian MMR scenario has really made huge strides. But we have to stay on our toes, given our numbers,” says Hrishikesh Pai, president, Federation of Obstetric and Gynaecological Society of India (FOGSI). While the net reproductive rate has stabilised, it is still going to be a while before it comes to a halt, he says.

“We cannot afford to be complacent about our achievements, we have a lot of way to cover,” he adds. From curative healthcare, he says, the time has come to move to preventive healthcare. “In a recent [series of] nationwide health camps conducted by FOGSI branches in various States, we discovered that only 5-10% of the women that came had ever had a gynaecologist check-up ever. There is a tendency among our women to tolerate — be it sickness, poverty, ill-health — and not seek care for it. This is what we should go after, we should go after our people, door to door maybe, and shake them out of the inertia that comes with acceptance.”

One way of doing this, he suggests, in addition to national outreach programmes supporting pregnant women, is to conduct camps, particularly to serve the rural populace and middle-class women. “There are about 400 million women who are caught in a storm by the very act of continuing to support the family, they have very little time, money or inclination to go to a health centre, public or private, and do not go unless they cannot function anymore,” Dr. Pai says. There are studies on, he explains, to check if a lower dosage of iron tablets might be more acceptable in terms of patient tolerance and fewer side effects to the intake. There are also proposals to consider providing iron injections to women who are severely anaemic.

At the end of the day, he says, equity is very important. Every woman in the country has to be able to access quality healthcare at low or no cost, at every juncture, and be confident that the medical treatment can not only ameliorate her quality of life, but also that of her progeny, if she should choose to have them.

Besides, unless pressure is stepped up, it would be impossible to catch up with and achieve the Sustainable Development Goal targets of reducing global MMR by 2030, to less than 70 per 100,000 live births; by the same year, end preventable deaths of newborns and children under five years of age; reduce neonatal mortality to 25 per 1,000 live births, and reach 12 or fewer stillbirths per 1,000 total births.

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