Sunita, a young woman in her fourth month of pregnancy in rural Odisha, suddenly discovered that she was bleeding profusely. It took her a while to understand that the situation was serious and called her husband Ramesh. He rushed home from work. They realized they needed to go to a hospital, but discovered they did not have enough money. After spending precious time trying to borrow money, they managed to hire an auto-rickshaw and reached the hospital. But it was too late. There were no doctors or nurses available and Sunita died.
Sunita's death could have been prevented. If she and her husband had understood the danger signs on time, had money to reach the hospital on time and been able to access timely quality health services, she could have been saved.
In India, about 56,000 women each year are lost in childbirth, that's one every eight minutes. This accounts for 19 percent of maternal deaths around the world. Seventy percent of these can be prevented. The main causes of death are heavy bleeding (hemorrhage) and eclampsia (high blood pressure). On the one hand, there has been economic progress in India but on the other, the country is still grappling with inequities and the basic right to safe childbirth.
A large number of global maternal and neonatal deaths are from India. According to the recent State of World's mothers report released in May 2013, by Save the Children, India ranked 142 out of 176 countries. The index for this ranking was developed on the basis of five indicators -- maternal health, children's well-being, educational status, economic and political status of women in the country.
In India, there has been some progress. The maternal death rate has fallen from about 390 to 212 deaths per 100,000 live births in about 10 years, a 67 percent decrease. However, for every woman dying in childbirth there are about 20 women who suffer long-lasting and debilitating illnesses which is completely neglected. The states of Assam, Rajasthan, Uttar Pradesh/Uttarakhand still have a high maternal death rate above 300 per 100,000 live births.
The north-eastern state of Assam with the highest maternal deaths in the country has managed to drop its number of maternal deaths in the last few years. However, they continue to be the highest in the country. Assam is grappling with challenges such as difficult terrain and inaccessibility to health services as a percentage of the population live on islands along the Brahmaputra, a majestic river, which can be aggressive and harsh in the rainy season. Earlier there were no health services available in these areas. For the last eight years, a Public Private Partnership between the Government of Assam and civil society has been running boat clinics to reach the remote, under served, unreached areas and saving lives.
Social determinants such as early age of marriage, early and repeated childbearing where 47 per cent of girls marry before the age of 18 are also contributing factors. Early marriage traditions have serious repercussions as girls are more likely to become pregnant at younger and riskier ages. Thirty-six percent of Indian women are malnourished and about 55 percent are anemic. Bodies are ill prepared to handle childbirth with poor nutrition, stunting with negative outcomes for maternal health.
The Government of India has policies and programs to address delays of decision making, transport and access to services. Janani Suraksha Yojana, a safe motherhood cash assistance scheme, and now the Janani Shishu Suraksha Karyakarm (JSSK) have facilitated the shift of births from homes to health facilities. Births in clinics and hospitals have increased 10 times in the last 7 years. But the question arises: Are the health facilities equipped with the desired quality to handle the onset of numbers? Is the poorest woman being able to reach services? Is it inclusive and equitable? We shouldn't bring deaths from the home to the health facilities.
The government started ambulance services like the Janani Express and 1098 services to address the challenges of transportation and reaching health facilities on time, but the implementation varies across the country. To address quality of care issues, quality protocols are being developed -- for the labor room, ANC and PNC by the government and there is an attempt to standardize.
But challenges remain -- vast country, diversity, problems of supplies (drugs, medicines), malfunctioning of equipment, inadequate human resources, inaccessible terrain, religious and socio-cultural factors. There is a need to do some task shifting, reduce dependence on doctors and train a cadre of health workers for providing services where none exists. India still has a way to go to reach the Millennium development Goal 5 for India of reducing maternal deaths to 109 by 2015.
Communities including women need to become more aware of their rights and available services. There is a need to focus more on issues such as girls' education, violence against women, family planning, nutrition, mental health and sensitizing men which all impacts maternal health.
White Ribbon Alliance India (WRAI) is an alliance of maternal health advocates. One-thousand-eight-hundred organizations are members and many hundreds are individuals. Also, there are alliances in five states. WRAI has been trying to raise the volume of discourse, working with government to make things better for women, working with the media and committed individuals. WRAI also mobilizes communities, and has initiated the use of innovative solutions like technology and mobile phones for accountability and enhancing quality. For example, an intensive advocacy initiative by volunteer members of White Ribbon Alliance in two eastern Indian states, used social accountability tools such as checklists, community score cards and 'verbal autopsies' (face to face questioning) to collect evidence, create awareness, mobilize people, build their skills and increase accountability. In recent years WRAI has organized over one hundred public hearings to promote the process of airing people's concerns, making women's voices heard, working with health staff and officials to improve services
We believe that every woman counts and where every woman despite her class, caste has the right to have a safe childbirth. Maternal health is a sound investment strategy and we believe that it is important to speak collectively, act quickly and bring about long-lasting change.