As we approach the 2015 deadline for the Millennium Development Goals, what does the future hold for international maternal mortality targets? The MHTF is pleased to be hosting a blog series on post-2015 maternal mortality goal setting. Over the next several weeks, we will be featuring responses and reactions to proposed targets from around the world. Please share your thoughts with us!
In India, there has been considerable economic progress, but the country is still grappling with inequities and the basic right to safe childbirth. There are about 30 million pregnancies; 27 million deliveries and about 56,000 women are lost in childbirth each year. This accounts for 19 percent of maternal deaths around the world. Most of these can be prevented. India still has a way to go to reach MDG 5, which would require reducing the maternal mortality ratio (MMR) to 109 deaths per 100,000 births by 2015. There has been some progress in the country in the last decade. The MMR has fallen from about 390 to 212 deaths per 100,000 live births in about 10 years, approximately 67 percent decrease. There are some areas in the country, such as states of Assam, Rajasthan, Uttar Pradesh/Uttarakhand that still have MMRs greater than 300 deaths per 100,000 live births. Social determinants such as early age of marriage and early and repeated childbearing are also contributing factors. 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 main causes of death in India have been found to be heavy bleeding (hemorrhage) and eclampsia (high blood pressure).
The Government of India has policies and programs to improve outcomes for maternal health. 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 over 75 percent in the last 5 years; however the maternal mortality ratios have only declined by approximately 25 percent. But the question arises: Are the health facilities equipped with the desired quality to handle the onset of numbers? Is there adequate inter-partum care and emergency care for complicated deliveries? Is the poorest woman being able to reach services? Is it inclusive and equitable?
To address quality of care issues, quality protocols are being developed — for the labor room, antenatal care and postnatal care by the government and there is an effort to standardize. There is an attempt to strengthen supportive supervision, task shifting (reduce dependence on doctors and train a cadre of health workers for providing services), strategic skilling, respectful maternal care and maternal death reviews. However, challenges still remain: India is a vast country, and problems of supplies of essential drugs, medicines, inadequate human resources, inaccessible terrain, socio-cultural factors, and translating policies/programs into action persist. The government of India is grappling with all these issues and is focusing on improving quality of services. There is a realization that only looking at numbers is not enough. Improving quality of services is critical. As Anuradha Gupta, Additional Secretary, Ministry of Health and Family Welfare (MOHFW), Government of India and Mission Director, National Rural Health Mission has said in a recent meeting, “We need a shift in the focus on achieving numbers to achieving quality of care”.
The global targets for preventing maternal deaths are useful in providing goals to aspire for a country. They have acted as a catalyst to accelerate progress. However, the targets currently only reflect maternal mortality. They do not reflect maternal morbidities or the fact that for every woman dying in childbirth, many more women suffer long-lasting and debilitating illnesses, which are now being neglected. For countries, a relative or percentage target may be more useful; and those countries that are on track should also examine the reaching of targets sub-nationally. However, within countries, focusing only on numbers is not enough. Efforts need to go beyond numbers to reflect on enhancing the quality of services, and, in turn, improving the lives of women and children.
If you would like to submit a guest post for to our ongoing series exploring potential goals for maternal health in the post-MDG development agenda, please contact Andrea Goetschius: goetschi@hsph.harvard.edu