Mother and child: The foundation of a healthy nation

Each year, an estimated 358,000 women die from complications during pregnancy or childbirth and more than seven million children die before their fifth birthdays. Most of these deaths occur in developing countries and are preventable. Many mothers lose their lives during or immediately after childbirth due to excessive bleeding, high blood pressure, prolonged and obstructed labour, or infections. Many more infants and children die from preterm birth, severe infections, asphyxia, pneumonia, diarrhoea, malaria and malnutrition.

India is a signatory to the Millennium Development Goals (MDGs). The fourth MDG is the reducing of child mortality and the fifth MDG is aimed towards improving maternal health. Reducing maternal, neo-natal, infant and child mortality is not just an issue of development, but also an issue of human rights. Preventable maternal and child mortality also represents a violation of the right to life. At present, the health indicators of our country mirror poor maternal and child health conditions, along with practices of early marriage and childbirth during adolescence in the country.

According to Sample Registration System (SRS) Report by the Census office, the maternal mortality ratio (MMR) has come down to 178 (2010-12) from 212 in (2007-09). Similarly, the Infant Mortality Rate (IMR) has also registered two points decline to 42 in 2012 from 44 in 2011, though every sixth death in the country pertains to an infant. The MDG target for India is to bring down maternal deaths to 109 and to reduce IMR to 28 by 2015. At the current rate of decline, India will miss the MDG-4 & 5.

Differences/ disparities

Maternal, neonatal, and under-five mortality rates are the highest in sub-Saharan Africa and Southern Asia. Children born in low-income countries are nearly 18 times more likely to die before age five than children born in high-income countries.

The maternal mortality ratio in developing countries is 240 per 100000 births vs 16 per 100000 in developed countries. There are also large disparities within countries, between people with high and low income and between people living in rural and urban areas. A deep divide exists in access to quality healthcare among various socio-economic classes of rural and urban areas.

Disparities exist even across the states in India. The MMR ranges from 81 in Kerala to 390 in Assam, while Rajasthan, Uttar Pradesh (UP) and Uttarakhand have recorded MMR’s of more than 300. The IMR ranges from 67 in Madhya Pradesh to 12 in Kerala. Eight states contribute to 75 per cent of infant mortality: UP, Bihar, Madhya Pradesh (MP), Rajasthan, Andhra Pradesh, Orissa, Gujarat and Assam. 56 per cent of all new-born deaths occur in five states: UP, Rajasthan, Orissa, MP and Andhra Pradesh. With a view to improving IMR and MMR in the country, the government has identified high-priority districts (HPDs) where the MMR and IMR is significantly high and more focus is required to achieve the MDG’s. National Rural Health Mission (NRHM) is running special programmes in these HPDs for vaccination, nutritional needs and to provide more health facilities to mothers and children, which could improve their health. Jharkhand faces higher maternal and new-born mortality ratios than India as a whole and the villages of the Seraikela block, a region of Jharkhand with difficult geographic terrain and low levels of literacy, experience even higher ratios than the state. 11 districts in Jharkhand have been identified as HPDs, one of which is Saraikela Kharsawan.

Improving the way forward through PPPs

Public health has made breath-taking strides globally, but those benefits have not been equally shared, either among countries or the various social groups within them. Maternal and child mortality ratios strongly reflect the ineffectiveness of India’s health system which can be strengthened by combining the potential of technology and knowledge management. Most of the causes of deaths can be prevented or managed by households, communities and health facilities. However, they often are unable to provide the required care that involves a chain of interventions beginning with complete antenatal care, skilled attendance at birth, equipping first referral units to deal with emergency obstetric care and ensuring that both the mother and new-born are followed up postpartum. These interventions could sharply reduce both maternal and neonatal deaths.

The Indian government has the reach and the resources to make a difference but by partnering with a private player it could spread the knowhow to the remotest of areas. Such initiatives, therefore, require public private partnership (PPP) models to be successful in the long term.

The Maternal and New-born Survival Initiative (MANSI) programme by American India Foundation is one such program that is committed to saving lives by establishing a community-focused health intervention by partnering with, the Government of Jharkhand, the widely recognised technical partner- Society for Education, Action, and Research in Community Health (SEARCH) and Tata Steel’s Rural Development Society (TSRDS). Jharkhand’s many rural and tribal areas make it consistently one of the highest risk states in terms of maternal and child mortality in India. MANSI’s public-private partnership improves the existing health system and health status on a concentrated population of nearly 83,000 residents in 167 villages with an approach that focuses on training the local female community health workers, identified by the National Rural Health Mission as Sahiyya. The rationale behind this programme is Home Based New-born Care (HBCN), which has been acknowledged and recommended by WHO.

In rural areas, the problem is of access to emergency care as most Community Health Centres (CHCs) and Primary Health centres run short of Medical officers and trained ANM’s, gynaecologists, obstetricians, as well as anaesthetists (In India, neither a nurse nor a doctor with post graduate degree can administer anaesthesia or perform emergency care services). The only option left is to travel to the closest district hospital which in some cases is several kilometres away. Many districts will not even have that facility as it is in the case of Jharkhand’s Saraikela Kharsawan district. It is in this context that efforts were initiated to upgrade the existing community health centres and sub-district hospitals into First Referral Units (FRUs), to be equipped for providing delivery of emergency obstetric care to pregnant women with complications.

Greater emphasis should be put on building health infrastructure. This would include revitalising existing facilities, constructing clinics and hospitals, and creating incentives that will help retain skilled health professionals.

Building a strong pool of health personnel is equally important. In addition to the shortage of human resources discussed earlier, the distribution of health workers is uneven with greater concentration in urban areas as compared to the rural areas. With three quarters of all maternal deaths occurring during childbirth or the immediate post-partum period, having skilled health personnel attend deliveries is crucial to reduce maternal mortality.

The MANSI programme is being implemented in Jharkhand and follows the model of primary intervention by training Sahiyyas to provide home-based pre and post pregnancy care to women and infants. AIF supports the government healthcare system to improve mechanisms in maternal and new-born and child healthcare by increasing the capacity of Sahiyyas to provide life-saving healthcare. Sahiyyas are trained in identifying and managing the new-borns with asphyxia, hypothermia, sepsis, pneumonia and low birth weight.

Another example is the state of Gujarat where the shortage of skilled healthcare providers has prompted the state government to join with private hospitals to provide free obstetric care for pregnant women living below the poverty line.

But building infrastructure and expanding medical interventions is just one part of improving maternal and new-born health. We need to boost women’s empowerment by ensuring that girls as well as boys are educated and are provided basic public health awareness. Till the time a mother is not educated and empowered, achieving MDG 4 and 5 would remain just an aspiration!