What does it mean to be poor, pregnant and powerless in India?

Aggregate reports of maternal death reviews need to be put in the public domain for a better understanding of the direct and indirect causes, and a better response

In a country that deifies motherhood, and where a Bollywood blockbuster famously memorialised the line – 'mere paas maa hai', what does it mean to be poor, pregnant and powerless?

The answer is embedded in the many inconvenient truths tucked away in the landscape of deprivation across India. Whether a woman lives or dies in childbirth, or immediately after, depends a lot on who she is and where she is. That is the stark reality on the 75th year of independence from British colonial rule.

Consider the latest maternal mortality statistics. The most recent maternal mortality ratio or MMR (defined as the number of maternal deaths during a given time per 1,00,000 live births during the same time) indicates progress. According to the SRS bulletin of March 2022, which relates to the period 2017-19, India's MMR stands at 103, down from 113 in 2016-18 and 407 in 2000.

This is good news, and we must credit the various government interventions over the years. But it is too early for a full-throated celebration.

Here is why: as in everything else in India, the national figure masks huge disparities between districts, states and regions.

Seven states have already reached the UN Sustainable Development Goal (SDG) target of 70 maternal deaths per 1,00,000 live births by 2030, according to the latest data. These are Kerala (30), Maharashtra (38), Telangana (56), Tamil Nadu (58), Andhra Pradesh (58), Jharkhand (61), and Gujarat (70).

But many large states in India are still far from achieving the global goal. One needs to look at the good news against the backdrop of the MMR data from large states like Assam (205), Madhya Pradesh (163), Chhattisgarh (160), Uttar Pradesh (167), and Bihar (130). Interestingly, a state like Punjab, by no means among the poorest, has a disturbingly high MMR at 114, confirming once again that rich states are not necessarily the best or the safest for giving birth. The variations are not just between states but also between districts in the same state and between population groups.

Mapping maternal deaths and the underlying reasons is critical because maternal mortality is a telling marker of the outreach and quality of a country's health services and its socio-cultural ethos. The glaring differences in MMR between different parts of India reflect the glaring disparities in access to skilled birth attendants, emergency obstetric care, prenatal care, levels of anaemia, and the status of women.

A recent academic paper points out that in 448 districts out of the total 640, maternal mortality is still way above the SDG target of 70 maternal deaths per 100,000 live births. Estimates and correlates of district-level maternal mortality ratio in India by Srinivas Goli, Parul Puri, Pradeep S. Salve, Saseendran Pallikadavath, K S James, published in July this year, is the first-ever district-level study and reminds us that despite the progress over the past decade, India accounts for 12 per cent of global maternal deaths, next only to Nigeria (23 per cent).

The study has key messages.

First, "despite decent progress in reducing maternal mortality, several districts in India need to initiate immediate action to meet the ambitious SDG-3 target of MMR and ultimately eliminate preventable maternal mortality. The states that made a concerted effort to reduce maternal mortality, especially post-2005, provide pathways to accomplish the acceleration necessary to reduce preventable maternal deaths substantially. In particular, post-2005 MMR reduction in Maharashtra, Telangana and Andhra Pradesh is very impressive."

Second, it is vital to recognise that safe motherhood does not begin and end with institutional delivery. The study highlights "that maternal health care, especially postnatal care, and maternal nutrition are key for reducing maternal mortality."

The study goes on to flag another important factor - despite several government initiatives like Janani Suraksha Yojana, which links cash assistance to institutional deliveries, out-of-pocket expenditure on maternal health care in several states of India is way higher than Janani Suraksha Yojana incentives.

This, it points out, maybe "impacting accessing quality antenatal and institutional delivery care and, as a result, this is impacting on reducing maternal mortality."

The authors say that the ongoing Pradhan Mantri Matritva Vandana Yojana (a maternity benefit scheme implemented in all districts of the country in accordance with the provision of the National Food Security Act, 2013) must consider raising Janani Suraksha Yojana incentives to ensure affordable and quality maternal health care for all.

The study also notes that "a significant association between sex ratio at birth and MMR suggests that maternal deaths are also happening due to unsafe abortions and thus need policy attention."

Which brings us to the most critical issue – how do we pinpoint the specific reasons leading up to maternal death?

Statistics on maternal deaths tell us only part of the story. For the rest of the story, we need to know not only where women are dying but why and in granular detail.

This means not only the immediate medical cause but also the social, cultural, and biological factors contributing to a maternal death.

This necessarily brings to the fore what experts call the 'three delays' that put pregnant women at great risk and can be fatal.

The first delay is the delay in the family taking a decision to seek care for an obstetric complication. This can happen due to many reasons – including late recognition that there is a problem, fear of the costs that may be incurred, or even a lack of an
available decision maker.

The second delay relates to the hurdles after a decision has been taken. This includes a lack of appropriate transport. Many villages in India are still handicapped by limited transport options for such emergencies. Add to that the poor condition of roads linking remote villages to hospitals that can deal with obstetric complications.

The third delay relates to the delay that many pregnant women without resources and connections face in accessing the necessary care at the hospital. Often, they have to wait for hours at the referral centre because of a host of reasons, including lack of staff, equipment, operating theatre and blood supply.

India has a system of maternal death reviews; if properly done, they can greatly help in pinpointing the causes and in formulating the specific steps that need to be taken to make motherhood safe for the poorest and most vulnerable.

The Government of India acknowledges the need for such reviews. The Guidelines for Maternal Death Surveillance & Response, put out by the Ministry of Health and Family Welfare, says the importance of The Maternal Death Review (MDR) process, initiated by the Government of India in 2010, lies in the fact "that it provides detailed analysis on various factors at community, facility, district, a regional and national level that are required to be addressed to reduce maternal deaths. Analysis of these deaths can identify the delays that contribute to maternal deaths at various levels and the information used to adopt measures to fill the gaps in service delivery."

What is happening on the ground, often, is another story.

"All maternal deaths are not reported even though they are mandated to be. The ones which are reported are meant to be reviewed. We have had national guidelines on maternal death reviews since 2010, but there is no information in the public domain on whether every state and every district are conducting these reviews or what they have found," says Dr Subha Sri, an obstetrician and health activist who works with CommonHealth, India (Coalition for Reproductive Health and Safe Abortion).

In southern India, Tamil Nadu has been regularly doing these reviews, but no information is in the public domain, she points out. Kerala FOG (Kerala Federation of Obstetrics and Gynaecology) has done confidential reviews of maternal deaths for close to two decades now and has published aggregate reports. As for the rest of India, she says, "We simply don't know what proportion of deaths are reported or reviewed. This is not the case with many other developing countries. Sri Lanka has regularly conducted maternal death reviews, which go into medicine as well as other factors before the recent troubles. Bangladesh has been doing it. Also, Nepal. Several African countries do maternal death reviews regularly."

Health activists like Dr Subha Sri have been demanding that aggregate reports of maternal death reviews be put in the public domain for many years. "If we had these, we would be better positioned to know the direct and indirect causes, and the response would be better."

Reducing maternal mortality is not rocket science. Most of these deaths are preventable. And India can draw inspiration from within as well as beyond its shores.

Many years ago, I researched and co-authored a monograph which documented an initiative that sought to empower communities to avert maternal deaths in India and was being piloted in several districts in the country with the support of UNICEF. The initiative was called Maternal and Perinatal Death Inquiry and Response (MAPEDIR). It offered a tool – a detailed verbal autopsy questionnaire, which sought to capture missing links in officially recorded data to help reconstruct the chain of events and pinpoint the causes of a maternal death.

My research took me to remote villages, many without electricity or telephone connectivity, to places like Gurpana in Purulia district, West Bengal, and to villages like Muradpur in Guna district, Madhya Pradesh, down bumpy roads through parched, dusty land dotted with mud huts and thatched roofs.

I saw first-hand the challenges on the ground. As maternal death reviews potentially strengthened the death reporting systems, many within the establishment were scared of reprisals in case instances of neglect came to light.

But there were encouraging signs too. One example - is the MAPEDIR process had led to the initiation of health audits in all the Gram Panchayats in Guna in 2007. It had also led to collateral benefits like the arrangement of referral transport vehicles round the clock within the government system.

As a country with one of the highest numbers of maternal deaths, India's success in reducing maternal mortality is central to the global battle for safe motherhood. Today, it is the poor, pregnant and powerless who are most at risk of maternal death in this country.

This must change.

(Patralekha Chatterjee is an independent journalist and columnist)

Disclaimer: The views expressed above are the author's own. They do not necessarily reflect the views of DH.