Maternal mortality and role played by midwives

Any health or health related problem which affects a vast majority of people and hampers the progress of an area or nation or which damages normal lifestyle of people and moreover which is preventable at least to a certain extent, can be called a public health problem. In India, Maternal Mortality Rate has become a major public health problem. MMR is defined as death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of pregnancy, from any cause related to or aggravated by pregnancy or its management but not from accidental or incidental causes.

Present situation:

The right to survive pregnancy and childbirth is a basic human right. Under international law, the government of India bears a legal obligation to ensure that women do not die or suffer complications as a result of preventable pregnancy-related causes. The staggering scale and continuing occurrence of maternal deaths and morbidity in India reveals the government’s failure to protect women’s reproductive rights, and comply with international law.

But the present situation of India has been described as below:

• India has recorded a decline in maternal mortality rates between 1990 and 2013 but along with Nigeria it accounted for one third of the global maternal deaths.
• According to World Health Organization's Trends in maternal mortality estimates 1990 to 2013, an estimated 289,000 women died in 2013 from complications in pregnancy and childbirth, down from 523,000 in 1990.
• Although the MMR dropped but, India is far behind the target of 103 deaths per live births to be achieved by 2015 under the United Nations-mandated Millennium Development Goals (MDGs).
• The MMR in southern states fell 17% from 127 to 105, closer to the MDGs. Assam and Uttar Pradesh/Uttarakhand were the worst performing states, with an MMR of 328 and 292, respectively. Kerala and Tamil Nadu have surpassed the MDG with an MMR of 66 and 90, respectively.
• According to the Annual Health Survey (AHS), which covers nine states, India has made headway in institutionalizing child deliveries, i.e. taking place in hospitals. More than 40% of child deliveries in Chhattisgarh and 79% in Madhya Pradesh were institutional in 2012, compared with 34.9% in Chhattisgarh and 76.1% in Madhya Pradesh in 2011.
• The states covered by the AHS are Rajasthan, Uttarakhand, Uttar Pradesh, Madhya Pradesh, Bihar, Jharkhand, Chhattisgarh, Odisha and Assam.
• More than 85% of the total births took place in government institutions in Madhya Pradesh and Odisha in 2011, and this was more than 60% in the other states surveyed, except Jharkhand, according to the latest AHS data.
• Total fertility ratio (TFR), or the average number of children given birth by a woman, reach a preferred level of 2.1 in only 29 out of 284 AHS districts, whereas in 2011 it was 20 districts, according to the AHS data.

Steps taken by Government:

The government has launched the reproductive and Child Health Programme Phase II (RCH-II) under the umbrella of the National Rural Health Mission (NRHM), aims to improve access for rural people, especially poor women and children to equitable, affordable accountable and effective primary health care, with a special focus on 18 States, with the ultimate objective of reducing Infant Mortality , Maternal Mortality and Total Fertility Rates.

The key strategies and interventions under the NRHM for reduction of Maternal Mortality Ratio are:

• Janani Suraksha Yojana (JSY), a cash benefit scheme to promote Institutional Delivery with a special focus on Below Poverty Line (BPL) and SC/ST pregnant women;
• Operationalizing round the clock facilities for delivery services in the 24X7 Primary Health Centres (PHCs) and First Referral Units (FRUs) including District Hospitals, Sub-district Hospitals, Community Health Centres and other institutions
• Augmenting the availability of skilled manpower thorough various skill- based trainings of Skilled Birth Attendants; training of MBBS Doctors in Life Saving Anesthetic Skills and Emergency Obstetric Care including Caesarean Section
• Provision of Ante-natal and Post Natal Care services including prevention and treatment of Anaemia by supplementation with Iron and Folic Acid tablets during pregnancy and lactation
• Organizing Village Health and Nutrition Days (VHNDs) at anganwadi Centres to impart health and nutrition education to pregnant and lactating mothers.
• Systems strengthening of health facilities through flexible funds at Sub Centres (PHCs) and Community Health Centres (CHCs) and District Hospitals.
• Provision of early detection of pregnancy, regular check-up of blood pressure, hemoglobin, fetal growth free of cost.
• Regular home visit by Accredited Social Health Activist (ASHA) and sensitizing mothers about the need of taking one extra meal, eight hours sleep at night and two hours rest at daytime, early detection of complication of pregnancy etc. ASHAs educate the mothers about the need of institutional delivery and delivery by skilled birth attendant.
• Provision of arrangement of mothers' meeting every month at Anganwadi center.
• Establishment of First Referral Units (FRUs) at block level having provision of normal delivery, caesarian section and assisted vaginal delivery. FRUs are equipped with gynecologists, pediatricians, anesthetists and blood transfusion facility.
• Under VandeMataram scheme gynecologists who are not in Governmental service, if treat pregnant ladies atGovernment facilities free of cost, then they receive a particular amount of incentive from the Government and also get Vande Mataram certificate.
• Some NGOs are working for pregnant ladies in hard to reach area like hilly areas and delta islands like Sundarban.
• Government of India has launched Janani Shishu Suraksha Karyakaram (JSSK). The initiative entitles all pregnant women delivering in public health institutions to absolutely free and no expense delivery, including caesarean section. The entitlements include free drugs and consumables, free diet up to 3 days during normal delivery and up to 7 days for C-section, free diagnostics, and free blood wherever required. This initiative also provides for free transport from home to institution, between facilities in case of a referral and drop back home. Similar entitlements have been put in place for all sick newborns accessing public health institutions for treatment till 30 days after birth. This has now been expanded to cover sick infants.

Role of Midwives in reducing maternal mortality

One of the key components of the National Rural Health Mission is to provide every village in the country with a trained female community health activist ASHA, midwives. Selected from the village itself and accountable to it, the ASHA will be trained to work as an interface between the community and the public health system. Following are the key components of ASHA :

• They are empowered with knowledge and a drug-kit to deliver first-contact healthcare, thus every ASHA is expected to be a fountainhead of community participation in public health programmes in her village.
• ASHA is the first port of call for any health related demands of deprived sections of the population, especially women and children, who find it difficult to access health services.
• ASHA is a health activist in the community who create awareness on health and its social determinants and mobilise the community towards local health planning and increased utilisation and accountability of the existing health services.
• She is a promoter of good health practices and will also provide a minimum package of curative care as appropriate and feasible for that level and make timely referrals.
• ASHA provide information to the community on determinants of health such as nutrition, basic sanitation & hygienic practices, healthy living and working conditions, information on existing health services and the need for timely utilisation of health & family welfare services.
• She counsel women on birth preparedness, importance of safe delivery, breast-feeding and complementary feeding, immunization, contraception and prevention of common infections including Reproductive Tract Infection/Sexually Transmitted Infections (RTIs/STIs) and care of the young child.
• ASHA mobilise the community and facilitate them in accessing health and health related services available at the Anganwadi/sub-centre/primary health centers, such as immunisation, Ante Natal Check-up (ANC), Post Natal Check-up supplementary nutrition, sanitation and other services being provided by the government.
• She act as a depot older for essential provisions being made available to all habitations like Oral Rehydration Therapy (ORS), Iron Folic Acid Tablet(IFA), chloroquine, Disposable Delivery Kits (DDK), Oral Pills & Condoms, etc.
Activities performed by ASHAs
• Mobilizing pregnant mothers for ANC and escorting them for Institutional delivery.
• Mobilizing Children & mothers for immunization.
• Conducting home visits & surveys.
• DOTS Provider
• Collecting blood slides.
• Salt testing & water testing.
• Conducting VHSC meetings.
• Organizing VHND & other health activities in the village.
• Motivator of family planning.
• Depot holder of basic drugs.
• Promoter of healthy lifestyle.
• Assisting ANM in Home Deliveries.

Issues in implementation

• Corruption is widespread is providing health care facilities. The inability of pregnant woman to pay the informal demands for money in exchange for services has been identified as a leading cause of maternal mortality. It appears that JSY is wrongly being seen as a scheme to cover out-of-pocket costs for institutional delivery, which is supposed to be free, rather than as a cash assistance program for nutritional and other support. There also have been reports of ANMs selling state-provided medicines illegally and pocketing the earnings.
• Many institutions are increasing promotion of institutional delivery without first addressing or improving the quality of care, which has led to poor services and medical care. Often institutions are not fully staffed or do not offer services for evening births, leading to women being turned away or being sent to private hospitals where they may incur huge medical costs. Health centers also have a lack of workable toilets and basic sanitation facilities. Further, referral systems are weak or nonexistent, leading women to be shuttled back and forth between providers with no continuity of care.
• Health workers are not adequately trained, which leads to mismanagement of delivery cases, such as the widespread, unsupervised use of oxytocin injections before delivery.
• Certain provisions of the NRHM are problematic insofar as they fail to take into account circumstances that deny women the ability to control when, under what circumstances and how often they become pregnant. For instance, in JSY making cash incentives conditional on consent for sterilization is a form of coerced sterilization, as women who belong to BPL households are not likely to have the financial ability to reject the cash payment, even if they prefer a nonpermanent method of birth control. The implications of these provisions for women’s well-being and basic human rights have been overlooked by policymakers and need to be addressed.

New Initiatives

• Maternal Death Review
The process of maternal death review (MDR) has been implemented & institutionalized by all the States as a policy since 2010. Guidelines and tools for conducting community based MDR and Facility based MDR have been provided to the States. The States are reporting deaths along with its analysis for causes of death.
• Delivery Points (DPs)
All the States & Union Territories have identified DPs above a certain minimum benchmark of performance to prioritize and direct resources in a focused manner to these facilities for filling the gaps like trained and skilled human resources, infrastructure, equipments , drugs and supplies, referral transport etc. for providing quality & comprehensive RMNCH (Reproductive, Maternal, Neonatal & Child Health) services.
• Web Enabled Mother and Child Tracking System
Name Based Tracking of Pregnant Women and Children has been initiated by Government of India as a policy decision to track every pregnant woman , infant & child upto 3 yrs, by name for provision of timely ANC, Institutional Delivery, and PNC along-with immunization & other related services.
• A Joint MCP Card
Ministry of Health & Family Welfare and Ministry of Women and Child Development (MOWCD) has been launched as a tool for documenting and monitoring services for antenatal, intranatal and postnatal care to pregnant women, immunization and growth monitoring of infants.
• Tracking of severe Anaemia during pregnancy & child birth by SCs and PHCs:
Severe anemia is a major cause for pregnancy related complications that may lead to maternal deaths. Effective monitoring of these cases by the ANM as well as the Medical Officer in charge of PHC has been started to line list these cases and provide necessary treatment.