Ahmedabad: Maternal health has rarely got the attention of the
government, but, fortunately since 1990, government has come up with different
programmes such as Child Survival and Safe Motherhood programme (additional
budget $300 million) in 1992; and Reproductive and Child Health-I (additional
budget $250 million) in 1997. However, these programmes also lacked strategic
focus on critical interventions to reduce maternal mortality. The much talked
National Rural Health Mission (NRHM), launched in 2005, has focused on producing
health volunteers at village level, fancily called, Accredited Social Health
Activities (ASHA).
The health ministry believes that the neglect of the maternal health and
non-development of fully qualified well-trained midwives will be compensated by
minimally trained village women called ASHA. On the other hand, to improve
services for women in delivery, government has been promoting deliveries in
hospitals and health centres by paying money to women who deliver in government
institutions.
The old wine of 'incentives' which were used in family planning programme is in
the new bottle of Janani Suraksha Yojana. The development partners have invented
a new name for these payments -- they are now called 'demand side financing' or
'conditional cash transfers'. Unfortunately, not adequate and effective steps
are taken to improve the public health institutions where women are coming for
deliveries. Kanti is just one example of how poor quality care can not help
prevent deaths of mothers.
Even today the government does not systematically monitor how many PHCs and
community health centres are providing good quality delivery services and
emergency obstetric care (EmOC) on 24 hours seven days in a week. One of the
reasons for this lack of monitoring is that our public health departments are
ridiculously thin at the top.
We have only three technical officers for maternal health at the national level
and almost no state in India has a director at state level only focusing on
maternal health. Such thinly staffed health departments can not plan, implement
and monitor maternal health program in a country of 1 billion with 26 million
births per year.
According to National Family Health Survey (2006), only 52% of women receive
three antenatal contacts and 42% receive any postnatal care in India. With more
than 60% of births as domiciliary deliveries, India needs skilled birth
attendance by well-trained and accountable midwives at community level to reduce
maternal mortality rate.
Relying on traditional birth attendants (TBAs), which India has done for years,
will not work to save mothers. Sweden stared to train midwives 300 years ago and
it passed a law not to employ TBAs about 150 years ago. Sri Lanka made policy to
ensure deliveries by public health midwives about 50 years go and hence both
these countries have very low maternal mortality rate. In India, on the other
hand, we de-facto abolish the whole cadre of midwives which existed before
independence and till 1960s. And that is why we still have a high maternal
mortality rate.
Therefore, to reduce maternal mortality rapidly, we need skilled birth
attendance by midwives back up by emergency care by obstetricians and referral
services. To convert the goals of maternal health into reality in India, we
require a comprehensive maternal health services within efficient public health
systems. Maternal health should be seen in the framework of women's health and
welfare. The increased political priority, managerial capacity, and resource
allocation will determine seriousness of our efforts and future of maternal
health in India.
Source : Centre for Management of Health Services, Indian Institute of
Management, Ahmedabad.
