Innovative Measures to Curb Maternal Mortality in India Raina Chawla “Advance means progress to something better, not progress

to something new” - Ogilvy The need for concern Maternal mortality has become a decisive issue in healthcare circles the world over, more so in the developing and the under developed world. A look at the shocking statistics makes us realize how far behind we are in resolving this matter even though the vast majority of these are preventable.
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Over half a million women die each year worldwide due to complications during pregnancy and delivery.1 In the year 2000, the estimated number of maternal deaths worldwide was 529,000.3 95% of these deaths occurred in Africa and Asia.1 While women in developed countries have only a 1 in 2800 chance of dying in childbirth, and a 1 in 8700 chance in some countries, women in Africa have a 1 in 20 chance. In several countries the lifetime risk is greater than 1 in 10. In India this risk is 1 in 70.2 In India, every year, a mindboggling 78000 mothers die in childbirth. According to estimates for the year 2003 - 2008, the adjusted maternal mortality rate for India was 450 (UNICEF statistics) per 100,000 live births. The trend has not changed significantly in the last 5 years.2

In order to comprehend this vast array of statistics in simpler terms (mentioning too many of which dilutes the importance) these translate to one woman dying every single minute of the day as a result of pregnancy or childbirth!! In fact, there is no single cause of death or disability for men, between the ages of 15 and 44 that is close to the magnitude of maternal death and disability. These figures would overwhelm anyone but the poignant issue is that in spite of efforts put into curbing this alarming trend, a significant change is yet to be observed. As was once put: “Whose faces are behind the numbers? What were their stories? What were their dreams? They left behind children and families. They also left behind clues as to why their lives ended so early”3 Avoiding maternal deaths is possible even in resource poor settings. What is required is the right knowledge on which to base our programs. The statistics point to the immensity of the problem but more importantly as the above citation states, to know the cause of the mortality in each individual case and to take steps from further mortality occurring is what is essential to each individual mother and family.

Where are we going wrong? When I researched this topic for the purpose of this essay what surprised me was the amount of literature on this particular issue, i.e. measures to reduce maternal mortality. There are pages and pages, hundreds of websites devoted to this concern and a considerable amount of time and effort has gone into this matter – both in India as well as in other countries So why then are we not seeing the results in terms of numbers? The basic questions that kept coming to my mind is what are we doing wrong and where does the solution lie? Maintaining health care standards which are being provided to our population requires interdisciplinary collaboration amongst doctors, midwives, auxiliary nurses and other paramedical staff and health care workers. The provision of essential obstetric care at the terminal rural level also requires a determined political drive to improve the current scenario. The high maternal mortality rate can be attributed to the high number of home deliveries which are performed by untrained persons. To motivate and encourage them to deliver in a hospital or health care facility requires motivation of a large number of people right from the politicians who make decisions to the society as a whole who accepts these decisions. There are several gray areas in society – illiteracy, child marriage, gender inequality and various customs and beliefs all of which hinder our progress towards building a better future for our women. Measures to curb maternal mortality: those taken and those that can be done: The majority of maternal mortality is due to obstetric hemorrhage, sepsis, pre eclampsia, eclampsia and unsafe abortions, accounting for 80% of all mortality, almost all of which are preventable. Almost three quarters of these deaths can be averted if women had access to emergency obstetric care. The problem therefore lies in reaching out to women or bringing them closer to obstetric care. To delve further into this multifaceted problem we need to focus on a few basic issues, without solving which, it becomes impossible to attain our goals. These few but indispensible concerns are as follows: •

Gender equality and education and empowerment to women Provision of water and improving sanitation Cessation of harmful practices like child marriage

Dealing with these basic issues and entitling women to these basic rights should be the first step in improving maternal health. Educating girls and women, removing inequality between men and women and providing basic necessities goes a long way in achieving simple goals. In a country like India, however these fundamental rights are largely denied to women due to gender inequality and the relegation of women to a lower status in society. Overcoming this inequality lies at the crux of solving maternal health issues particularly reducing maternal mortality rates.

Changing the status of women in society cannot be done in a defined time period as it involves changing the views of society as a whole. The passing of the Right of Children to Free and Compulsory Education Act 2009 was indeed a historic moment in Indian history but has the true meaning of this act percolated down to those living in the rural areas, where after a year of this act being passed, girls are still prohibited from going to school? To increase awareness of this act especially in the rural and less developed areas of India, the local political bodies, i.e. the panchayat level should be responsible for dispersing this information. Apart from political motivation, organizations especially non governmental organizations can increase knowledge and promote awareness say for example by organizing street plays and door to door census of girl’s education status. In today’s world where the media has such a stronghold on people, where the television and radio are reachable now to even far flung areas, they should be used to promote social messages about gender equality and education of girls. Initiatives such as the FOGSI Astra Bharat Jagruti Yatra (2008) should be promoted. The vision of this was to take this message to every FOGSI society and influence and awaken each member towards their contribution to women’s health and well-being and unite the people of India towards one goal - a healthier, happier mother as well as educating the girl child. The overall impact of this program was very positive as it increased awareness amongst women regarding safe motherhood and delivery services. This initiative should set an example and many more should follow. The other crucial concern is how to bring essential and emergency obstetric care closer to where it is needed most – the rural and the lesser developed areas. One basic system I have seen work is at Manipal, Karnataka. There are seven satellite primary health centers located in rural areas around Manipal within a 45 Km radius. All essential obstetric care facilities are provided at the center which is looked after by Kasturba Medical College. Deliveries are conducted by post graduates in the department of Obstetrics and Gynecology who are provided with an ambulance service from the college and the same ambulance is used to transfer high risk patients (Antepartum and intrapartum) to the hospital which is a tertiary care center. The maternal mortality rate in the district (Udupi) is low (35 per 100000 live births) which is much lower than the national average and comparable to many developed countries! The system works quite well as trained post graduates are in primary contact with the patient and there is a working transport system. Similar set ups wherein several primary centers should be affiliated to tertiary care referral centers or where villages can be adopted by a tertiary care center. Existing primary centers can be affiliated to different hospitals. Incentives in the form of monetary concessions for delivery should be made for women having regular antenatal visits with the primary center to increase the rate of hospital deliveries thereby minimizing complications. Another innovative measure to reduce maternal complications is to provide cell phones to the expecting mother or her family. If any problem develops in the antenatal period or whenever she goes into labor, the family can contact the nearest trained health worker or primary health center to avail better care and transport facility. This would lead to better connectivity directly between the patient and her primary health care provider. This is a

feasible project where a mobile handset company in association with the government can work out an agreement. Several other ways of reaching out to women in the less accessible areas would be to give incentives – monetary and otherwise, to deliver in a hospital as against a home delivery. For example, providing blankets, clothes and other neonatal necessities following delivery or promoting birth of a girl child by ensuring her education and other costs of living for her. Several such initiatives are ongoing in several states but these have to be introduced to a wider area and cover a larger population. Incentives for undergoing tubectomy and vasectomy procedures (which already exist) should be revised by the government. Other family planning methods should be promoted in a larger way. Skilled health workers should be involved in propagation of this information to ensure its reach to the grass root levels. In the day and age of the internet and where social networking sites are thriving, they can be used as a medium to spread awareness among people. Though this would probably cater to a middle and upper class society, it can be used as a medium for the younger generation to be actively involved in spreading awareness in the less well off societies especially in an urban population. Websites like facebook and twitter can be used to spread awareness among society to problems. It can encourage philanthropists and other concerned people to contribute to society. An example of this is Similarly, awareness can be brought about through theatre, magazines, messages can be printed on t-shirts, mugs etc.. Celebrities can be roped in to spread awareness as the common man looks up to them. Similarly local religious leaders can be used as a crucial resource in the fight against maternal mortality. In certain communities, especially those where religion plays an important role, the word of a cleric carries more power than anyone else. Their influence can be used for a healthy cause Another important initiative is implementing ‘evidence based medicine’ to everyday practice in health care. Evidence Based Medicine (since its introduction by Sir Archie Cochrane in the 1970’s) has received great enthusiasm in academic centers the world over, more so in developed countries. It involves integration of best research evidence with clinical expertise and patient values. This concept has been described as a paradigm shift in medicine and its application to practice has grown steadily over the past decade. Its application in the developing world however still faces challenges though integrating this into our health care system has its benefits even in reducing maternal mortality as shown by the following example. In 1995, a large trial showed that magnesium sulfate was the most effective treatment for eclampsia, a major cause of maternal mortality. At that time, one third of the world’s obstetric practices were using less effective therapies. Integration of this treatment begins at the international level with the WHO ensuring that magnesium sulfate is included in the essential drugs list. At the national level, the government should ensure the drug is available and that medical curriculums and clinical guidelines are consistent with best treatment practices. At the local level, doctors and midwives need to be aware of the treatment protocols. However, we still see eclamptic patients who receive outdated drugs instead of magnesium sulfate. The information needs

to reach the grass root level. There are several ways of promoting the dissemination of information. Workshops oriented towards practicing evidence based medicine need to be conducted. Pharmaceutical companies can help in organizing workshops. Disseminating the findings of systematic reviews to policymakers, health professionals and health care workers is an essential prerequisite to changing practices. Accountability can to a great extent help in reducing maternal mortality. Holding enquiries into why maternal deaths have occurred, say in a district setting or even in FOGSI societies. These can be held every 6 monthly or yearly and each case of maternal mortality can be discussed and evaluated. Participating in reviews, whether by describing one’s contribution to the care of a particular woman, to how the death could have been prevented, to what were the risk factors involved and how similar cases should be managed in the future is, in itself a health care intervention. Often those participating in the review are motivated to change or review their existing practices. But perhaps, one of the most powerful reasons for such reviews is the personal and long lasting impact that the death of a woman known to them has had on their own clinical practice. Having to seriously evaluate the care given to a particular woman, whose face they can still see and whose grieving family they can still remember will change their clinical practice and subsequently save many lives. Persons involved in the care of women right from the primary center to the referral center should attend and contribute to such meetings. A striking documented working example is as described: In the UK, the most dramatic decline in a local maternal mortality rate was achieved in Rochdale, an industrial town in the poorest of England, which in 1928, had a maternal mortality rate of 900 per 100,000 live births, more than double the national average of the time. Following local concern, the local public health department undertook a confidential enquiry into maternal deaths in the community and associated hospitals, action on the results of which reduced the maternal mortality rate to 280 by 1934, the lowest in the country. This decline took just 6 years and this achievement was all the more remarkable as it took place in a time of severe economic depression3. As the report itself states ‘it is important to note that the results were obtained by a change in spirit and method and without any alteration in the personnel or any substantial increase in public expenditure’4. Last but not least essay competitions like this itself are a brilliant idea in itself in promoting awareness! It made me ponder on the deaths that I have encountered till now and how and what went wrong in those cases Conclusion Apart from portraying a few ideas as mentioned above, plenty has already been written by several people on improving health funds, increasing initiatives on behalf of the government, improving the availability and training of local health care workers, construction of better roads and transport facilities, health education, emphasizing the need for proper aseptic conditions at delivery, ensuring antenatal booking and adequate antenatal care and I’m sure there are a dozen more issues that have been addressed time and again. The question that needs to be asked now is how can all this be accomplished. What new, novel ideas can we conjure to make all of this happen? As students we read how India’s maternal mortality has hardly changed but isn’t it now time to actually do something? Aren’t we as obstetricians responsible and answerable to society? Writing this essay has inspired me and I hope many others in this endeavor to do what we can in

impeding something which can definitely be stopped - maternal mortality. Pregnancy is not a disease… no woman should have to die giving birth! I am only one, But still I am one. I cannot do everything, But still I can do something; And because I cannot do everything I will not refuse to do the something that I can do.5

References: 1. UNFPA website, www. 2. Who’s got the power? Transforming Health Systems for Women and Children, Millennium Project, Task Force on Child Health and Maternal Health, 2005. 3. Gwyneth Lewis. Beyond the Numbers: reviewing maternal deaths and complications to make pregnancy safer. British Medical Bulletin 2003; 67: 27 – 37 4. Oxley W, Phillips M, Young J. Maternal Mortality in Rochdale. BM 1935; 193: 304-7 5. Edward Everett Hale

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