:: OP-ED

250 mothers will die of childbirth in India today

Patralekha Chatterjee

Oct.23 : Shashi Kapoor stole the thunder from screen baddie and wealth-flaunting older brother Amitabh Bachchan in the 1975 blockbuster Deewar with just four words: "Mere paas maa hai". Being a mother is good, great and glorious in mythology, cinema and in the popular psyche in India. Sadly, in real life, motherhood is a hazardous experience in many parts of the country.

"No Tally of the Anguish: Accountability in maternal healthcare in India", a recent report by Human Rights Watch (HRW), the New York-based international NGO, is the latest reminder of the paradox of being a mother in India. We deify motherhood but do not do enough to save mothers.

"For an emerging global economic power famous for its medical prowess, India continues to have unacceptably high maternal mortality levels. In 2005, the last year for which international data is available, India’s maternal mortality ratio (MMR) was 16 times that of Russia, 10 times that of China, and four times higher than in Brazil," the 150-page report observes.

Some more damning figures: Of every 70 Indian girls who reach reproductive age, one will eventually die because of pregnancy, childbirth or unsafe abortion, compared to one in 7,300 in the developed world. More will suffer from preventable injuries, infections and disabilities, often serious and lasting a lifetime, due to failures in maternal care. Indeed, India contributes a little under a fourth of the world’s maternal mortality.

Given all these disturbing numbers, why do not we hear more about maternal deaths? The short answer: because the magnitude of the problem is not recognised and the life stories of the dead women remain untold. Deaths due to conflicts, disasters or terrorism instantly grab public attention, become talking points, pressuring politicians and policymakers towards action. Most maternal deaths, in contrast, are deaths due to neglect, and remain ill-monitored. Medical records typically capture the immediate, biological causes of maternal deaths. What gets left out are the personal, familial, socio-cultural and environmental factors contributing to these deaths. The key underlying reason behind a maternal death in India is not always lack of money. The brutal truth, as the HRW report notes, is that generally speaking, maternal mortality is high where women’s overall status is low, and public health systems are poor. It is the low status of women which leads to the low priority accorded to her health. Early marriage, women’s neglect of their reproductive health, inability to decide when and where to seek medical help, widespread malnutrition, lack of education, awareness, domestic violence and poor access to quality healthcare, including emergency obstetric services are some of the all too familiar factors which contribute to tens of thousands of maternal deaths.

A telling indicator: In rural India, even the desperately poor spend months planning every detail of a family wedding. The birth of a child, in stark contrast, is considered a routine affair, requiring minimal preparation and expenditure. Neglect during pregnancy and childbirth claims the lives of around 100,000 women across the country every year. Most such deaths can be averted but for the "three delays" — delay in decision to seek care, delay in reaching the appropriate health facility and delay in receiving care once inside a hospital.

Within India, there are also huge disparities. National averages camouflage sharp in-country variations in maternal mortality and morbidity. Northern India, made up of the so-called eight "Empowered Action Group" states, along with Assam, have the highest maternal mortality rates in the country. At 440 maternal deaths per 1,00,000 live births, Uttar Pradesh reports the second highest MMR (maternal mortality ratio) in the country. This is about 1.7 times the estimated national MMR and more than three times that of states like Tamil Nadu in south India.

Many of the insights in the HRW report are familiar to Indians working in public health. India’s flagship National Rural Health Mission (NRHM) seeks to address the twin challenges of maternal and child survival. Since its launch in 2005, the NRHM has pumped in huge sums of money to improve public health systems and reduce maternal and infant mortality. Recent data suggests that it has made some difference in parts of the country. All-India figures show a decline in maternal deaths between 2003 to 2006.

However, the initiatives will not produce the intended outcomes unless there is strict monitoring and healthcare system accountability, as the HRW report correctly stresses. We also need timely investigations into maternal deaths.

Unicef, for example, has piloted a verbal autopsy tool called Maternal and Perinatal Death Inquiry and Response, which involves communities.

Two years ago, while visiting districts across the country where this was being implemented, I saw promising signs. Trained health and community workers and NGO field staff visited families where a maternal death has taken place with a structured questionnaire. The questionnaire is a tool to facilitate a process of raising awareness, of getting people concerned and involved about issues impacting a mother’s health and make them more knowledgeable about how they can do something about them. In several instances, communities had come forward with local solutions to critical issues like referral transport during obstetric emergencies. Saving mothers is not rocket science, and certainly within the capacity of a country whose lunar programme just celebrated its triumphant discovery of water at the moon. What is needed is a determined focus on the specific cracks through which so many women fall. In the Indian context, this means paying attention to not only the disparities between different states and regions but also the significant differences in utilisation of maternal health care within states, districts and cities.

Rural women, the urban poor, and women in geographically-remote areas report poorer utilisation of maternal healthcare services than the middle class in urban areas. Pregnant women belonging to dalit and tribal communities use maternal health services less than women belonging to upper castes.

Maternal deaths continue in India because the women who die are not those we socialise with and their rights are not given the same value as our rights. India has the resources, tools and technical expertise to save its mothers and its children. It should do so not only because of what Human Rights Watch or any other organisation says, but because it is the right thing to do. It will be a critical step in making the idea of India more attractive.

Patralekha Chatterjee writes on contemporary development issues, and can be contacted at patralekha.chatterjee@

gmail.com