Dr Amrit Patel is a Consultant based in Ahmedabad/India.

International Women’s Day – keeping an eye on women’s health

Despite much progress in maternal health, especially in the course of the Millennium Development Goals, a large number of mothers still die each year in the context of pregnancy, child birth and post-partum period in India. The Indian Government ought to take advantage of International Women’s Day to review the policy and programmes on women’s health in order to reduce the maternal mortality rate with an emphasis on rural areas, where the prevalence of deaths is the highest, our author maintains.

The health and education of all human beings living in a country are its most precious assets. In India, education has been a fundamental right of human beings, and with the adoption of the National Health Policy Statement, the 1978 “Health for All Declaration” became the guiding concept for Government of India’s policy. The survival and well-being of mothers are most important for the country’s future generations.

The Maternal Mortality Rate (MMR) is one of the important indicators of quality of health services provided to pregnant women (see Box). Despite good progress especially since 2005, still estimated 47,000 mothers continue to die annually due to causes related to pregnancy, child birth and post-partum period. The major medical causes of these deaths are haemorrhage, sepsis, abortion, hypertensive disorders, obstructed labour and anaemia. Besides, a number of determinants like illiteracy, low socio-economic status, early age of marriage, low empowerment of women and traditional preference for home delivery are responsible for maternal deaths. A recent review of maternal deaths suggests that about 26 per cent of maternal deaths occurred at home, 25 per cent in transit, and 48 per cent at the health facilities.

The Maternal Mortality Rate
The number of women who die from any cause related to pregnancy (excluding accidental or incidental causes), during pregnancy and child birth or within 42 days of treatment of pregnancy, irrespective of the duration and site of pregnancy, per 100,000 live births is called the Maternal Mortality Rate (MMR). The causes attributed for such deaths include general health status, educational level and physical movement during pregnancy and child birth. Most maternal deaths are avoidable and can be prevented through appropriate health care, managing complications during pregnancy and deliveries. Improved access to antenatal care during pregnancy, skilled care during child birth and in the weeks after child birth reduces maternal deaths. As the reduction in MMR is highly influenced by various healthcare factors, it is also used as the measure of the quality of a health care system.

India on an international scale

In 1990, MMR in India was very high, at 600, which meant approximately 150,000 women dying each year as compared to 400 MMR globally, indicating 540,000 women dying each year.  At that time, India contributed 27.77 per cent of the global maternal deaths. In 2010, global MMR was 210, against 178 in India in 2011. India is now contributing only 16 per cent of global maternal deaths. Globally, there was a decline of 47 per cent between 1990 and 2010, as against a decline of 70 per cent between 1990 and 2011 in India, which showed an annual rate of decline of 5.6 per cent as compared to 2.4 per cent at global level.

Programmes and policies to strengthen women’s health

Today, the maternal mortality rate in India is at 178. The highest rates of decline are evident from the years 2004-06 on. The following programmes and measures were above all responsible for this improvement:

  • Janani Suraksha Yojana (JSY) (“Mother security scheme”): The programme, launched in April 2005, aims at reducing maternal mortality among pregnant women by encouraging them to deliver in Government health facilities. Currently, as many as 16.6 million women are reported to have delivered in public health institutions.

  • National Rural Health Mission (NRHM): The Government of India launched the NRHM (now part of the National Health Mission) during 2005–12 to carry out necessary architectural corrections in the basic healthcare delivery system, with a special focus on 18 States which have weak public health indicators and / or weak infrastructure. The emphasis had not been on health services per se but also on adopting a synergistic approach by relating health to determinants of good health such as segments of nutrition, sanitation, hygiene and safe drinking water.

  • Janani Shishu Suraksha Karyakram: The Mother&Child Security Program launched in 2011, provides service guarantee in the form of entitlements to pregnant women, sick new-borns and infants for free delivery including Caesarean section and free treatment in public health institutions. This includes free to and fro transport between home and institution, diet, diagnostics, drugs, other consumables and blood transfusion if required.

Maternal Mortality Rate during 1990-01 to 2010-12

    Year         MMR    
    1990-01         327 (100.000)    
    2001-03     301 (80,000)
    2004-06     254 (67,000)
    2007-09     212 (56,000)
    2010-12     178 (47,000)

Figures in parentheses indicate the total number of deaths (MMR is estimated periodically by pooling three years of data to yield reliable results).

Rural areas need special attention

According to the scientific journal The Lancet, a quarter of all maternal deaths in India are caused by anaemia, and nearly a fifth by calcium deficiency, both of which lead to frequently fatal complications at childbirth. The problem is especially acute in rural areas (see Box at end of article). Therefore, intervention programmes to provide iron supplements to women should be scaled up in rural areas and effectively implemented.

In addition, the awareness campaign for supplemental nutrition among rural women has to be intensified to remove superstition and rumour about its effects on unborn children. The chief task would be to improve universal access to nutrients through a basket of commodities (including pulses, fruits and vegetables) that can be supplied through a variety of channels. Clearly, the Public Distribution System and community-run not-for-profit institutions would form the backbone of such an effort. What is often grossly neglected in practice is the importance of early childhood nutrition (crucially, the first 1,000 days) for life-long health. The Government should amend its National Food Security Act appropriately to provide universal access to nutritious food.

Measures to be implemented

The NRHM – now being a part of the National Health Mission – should not dilute the focused attention in rural areas to provide equitable, affordable and quality health care to the rural population, especially the vulnerable groups, among them women. The following measures should be implemented to strengthen maternal health in rural areas:

  • Agencies implementing health programmes must involve Gram Panchayats (local governments) in planning and monitoring the implementation of all health-related programmes such that each village not only achieves the mandated MMR targets on time but also surpasses the urban areas within the respective Block and district. For this purpose, the Gram Panchayats have to be trained, and their respective capacity building needs improvement.

  • Millions of women self-help groups SHGs that have been formed, nurtured and linked to banks must be involved to create awareness among all rural women in the respective village and motivate them to demand health services under the respective programmes as a matter of right.

  • Optimum utilisation should be made of the rural health infrastructure already created, including human resources to yield expected results.

  • Print and electronic media have a responsibility to identify the gaps in the successful implantation of the programmes in specific locations in rural areas and follow up to enable it to achieve the intended objectives.

  • Particularly in rural areas, elected State Legislators and Parliamentarians must be involved in the half-yearly review of the progress of each health programme in their constituencies and identify specific deficiencies inhibiting progress and find solutions at local level as also take up the matter with the State and central Government.

  • Continuous studies should be carried out by independent accredited institutions to identify the factors inhibiting the progress in rural areas as compared to urban areas within the Block, District and State. This can help improve the performance of remedial measures. 

  • The budgetary resources [State and Union] need to be raised to five per cent of GDP by 2019-20 and allocated in proportion to the rural and urban populations.

 

The rural-urban divide
The under 5 mortality rate [U5MR] is the number of children dying before reaching the age of five years per 1,000 live births in a specified year. Rural areas have registered high rates compared to urban areas. In 2013, the U5MR in rural areas was 55 against 29 in urban areas. During 2009–13,  the urban U5MR declined from 41 to 29 as compared to from 71 to 55 in rural areas. U5MR in rural areas continued to increase from 73.2 per cent in 2009 to 89.6 per cent in 2013 over that in urban areas.

IMR is the number of deaths in children under one year of age per 1,000 live births. The causes attributed to IMR include the health of mothers and the extent of pre/postnatal care, general living conditions, rates of illness, quality of the environment, among others. Thus, IMR is a very important  indicator of health for children as well as for the population as a whole. Rural and urban areas have witnessed significant decline in IMR for several years. However, IMR in rural areas continues to be at a much higher level than urban IMR, exhibiting a rural-urban gap (44-27) in 2013. IMR in rural areas marginally declined by 63 per cent in 2013 from 70 per cent in 1990 over that in urban areas.

The Coverage Evaluation Survey of the UNICEF and the Government of India shows that India achieved 74 per cent of one-year-old children immunised against measles in 2009. Although there has been substantial improvement in the coverage since 1992/93, when it was 42 per cent, at this rate of coverage, India was likely to achieve 89 per cent coverage by 2015, falling short of universal coverage. There is a rural-urban gap in the coverage of immunisation against measles as in rural areas coverage, was 72 per cent against 78 per cent in urban areas. The extent of coverage is highly correlated to mother’s level of education.

For reducing MMR and IMR, it is necessary that all births are attended by skilled health personnel as timely treatment by professional can make the difference between life and death. Skilled health personnel include only those who are properly trained and who have proper equipment and drugs but not traditional birth attendants, even if they have received a short training course. Skilled and trained health personnel provide care and counsel women during pregnancies and the labour and postpartum periods. They facilitate safe deliveries and care for newborns. The goal is 100 per cent coverage of live births by skilled health personnel. In 2013, at national level, skilled health personnel attended 84.1 per cent live births in rural areas and 98.2 per cent urban areas. There are States which are far behind 100 per cent coverage and exhibit a significant rural-urban gap in coverage.

Source : Annual Reports (2010-15) of Ministry of Women & Child Development, Government of India

Dr Amrit Patel,
 Consultant, Ahmedabad/India 

Email: dramritpatel(at)yahoo.com