More than a personal tragedy

SHEELA RANI CHUNKATH and VENKATESH ATHREYA make a fervent plea to view maternal deaths not as a personal tragedy, but as a major health policy issue. The high level of maternal mortality is a cause for concern. So too the way in which maternal anaemia is tackled.

IT has rightly been said that unacceptably high levels of maternal mortality through most of the developing world - honourable exceptions like Cuba, Sri Lanka, China and the south Indian state of Kerala notwithstanding - constitute 'the scandal of our times.' Unfortunately, in patriarchal societies like ours, maternal death is treated only as a private, personal tragedy. It is not seen as a major health policy issue, so much so that reliable estimates of maternal mortality ratio (MMR) (defined as the number of maternal deaths per 100,000 live berths) are often not available even for large populations.

This state of affairs cannot be dismissed as merely a consequence of a very large sample size being required for estimation of MMR with any reasonable degree of precision. A sufficient degree of social concern for maternal survival should entail comprehensive registration and monitoring of all pregnancies, from registration of conception to final outcomes. After all, the attention we pay to comprehensive immunisation or to tracking down every instance of polio is enormous, but is rightly considered worthwhile. Maternal survival merits the same degree of attention and similarly adequate allocation of resources.

A United Nations Fund for Population Activities (UNFPA) report of 1997 provides the following MMR estimates for the year 1992: India - 453, Kerala - 87, Maharashtra - 336, Punjab - 369, Tamil Nadu - 376, Gujarat - 389 and West Bengal - 389. The 1997 Economic Review of Kerala's State Planning Board puts Kerala's MMR at 30. This figure is likely to be an underestimate but would not be very far off the actual situation on the ground.

Recent evidence for Tamil Nadu from successive massive vital events surveys covering each of the years 1995, 1996, 1997 and 1998, suggest a fairly stable MMR for the state between 160 and 180, much lower than the UNFPA estimate for 1992.

The reporting of maternal deaths has also improved significantly in Tamil Nadu over the last few years. The number of maternal deaths reported has risen from 640 in 1994 to 1297 in 1998 bringing down the proportion of underreporting to about 5 per cent. A number of policy initiatives taken in the last four years have contributed to the improvement in reporting. Large scale vital events surveys, workshops on IMR and MMR to sensitise public health personnel at various levels, creation of a commissionerate to coordinate the work of the various directorates in respect of MCH activities, and the declaration of 1998-99 as the year of Maternal and Child Health, signaled the State government's policy priorities in this regard.

Deliveries

In 1998-99, a total of 11.1 lakh deliveries were recorded as having occurred in Tamil Nadu. This figure is very close to the estimated number of 11.4 lakh births in the State, implying near total coverage of all deliveries in the State. Of these, 82.1 per cent took place in medical institutions. While private nursing homes accounted for 37.2 per cent of all deliveries in the state, the government sector accounted for 44.9 per cent. But primary health centres (PHCs) and health subcentre (HSCs) together accounted for only 8.3 per cent of all deliveries.

The proportion of institutional deliveries rose from just 20.3 per cent in 1971 to 82.1 per cent in 1998-99, while the share of deliveries conducted by untrained personnel declined from 61.7 per cent in 1971 to just 2.5 per cent in 1998-99.

An important feature of the situation in Tamil Nadu is that secondary and tertiary hospitals get overloaded with normal deliveries, which could in principle be handled easily in PHCs/ HSCs/ Urban Health Post (UHPs). The fact that 75 per cent of all deliveries in teaching hospitals and 79 per cent of those in district headquarters hospitals are normal shows how high this overload is. Ensuring that PHCs, HSCs, UHPs, and taluk and non- taluk hospitals are more fully utilised to conduct a far greater proportion of all normal deliveries than they presently do will free the human and physical resources of district and teaching hospitals to deal with high risk deliveries.

From an equity point of view, it is very important that the public sector health system responds to the need of the poor for quality services in the case of high risk pregnancies and caesarian deliveries.

In view of the high proportion of institutional deliveries in Tamil Nadu further reduction in MMR will depend crucially on provision of emergency obstetric care. In other words, Tamilnadu has entered a phase where quality of natal and postnatal care in medical institutions is crucial to maternal survival.

Around 40 per cent of maternal deaths in the State have been ascribed to haemorrhage, both postpartum and antepartum. A key to reduction of MMR therefore lies in reducing maternal deaths due to haemorrhage. Availability of adequate quantities of blood in time therefore becomes crucial. All the designated first referral units (FRUs) in the state need to be equipped with blood banks. Similarly, all FRUs need to have obstetric and gyneacology specialists, anaesthetists and paediatricians, preferably with a special 24 hour emergency obstetric unit.

An important component of any multi-pronged strategy for reduction of MMR is the provision of safe abortion services. Provision of abortion services must be given greater attention, and must not be made conditional on or linked to permanent sterilisation. The reduction of MMR also requires tackling maternal anaemia on a priority basis since anaemia accounts directly and indirectly for about 12 per cent of all maternal deaths.

Over the years, the state of Tamil Nadu has made good progress in bringing down MMR and improving the chances of maternal survival. Its current MMR of 160 compares favourably with most Indian states. However, it is well behind Kerala. Moreover, a substantial proportion of currently occurring maternal deaths can be prevented by focussing on provision of blood, ensuring presence of specialists in government hospitals, minimising inter - hospital referral, improving maternal (and adolescent girls') nutrition and provision of safe abortion services. The recent effort to incorporate non-medical causes of maternal death, such as delays in accessing care, delays in transport, delays in treatment on arrival at a medical institution, social factors pertaining to patriarchy and gender inequality, and communication problems, in the protocols for investigation of maternal death, is also a step in the right direction. The issue of referral also needs to be addressed seriously, both in the sense of ensuring early referral in case of risk and due follow up and feedback thereon, and in the sense of avoiding as far as possible re- referral which carries risks of death in transit.

Policy makers need also to explore the role of traditional and indigenous systems of medicine in preventive, promotive and curative health care during pregnancy and in the postnatal period.

A trend that should be of concern to policy makers is what may be loosely called 'over-medicalisation'. A particular form of this trend is that of resorting to caesarian deliveries when they are not warranted especially in some private hospitals. While government hospitals - especially district hospitals and teaching institutions - need to respond to the requirement of the poorer sections for caesarian delivery care, one needs also to be vigilant against the trend of unnecessary recourse to caesarian deliveries and other forms of 'over-medicalisation.'

Government policy interventions alone will not suffice to bring about significant improvements in maternal survival and health. We need an empowered community, and one which squarely tackles the issues of gender as well as social and economic inequality. Specifically, maternal death must cease to be seen as only a personal tragedy in the private domain, and must begin to be seen as a public scandal, unacceptable in the new millennium.

Send this article to Friends by E-Mail

Section  : Features
Previous : Opening borders, welcoming peace
Next     : In the light of reality