The second birth

India accounts for 20 per cent of the world's maternal mortality rate. Experts suggest that registering maternal deaths can help analyse the causes and solve the problem. But data can only be a means to an end, writes D. J. RAVINDRAN.

THE much-venerated motherhood has its risks and sacrifices, at least for those women living in developing countries. Every year in developing countries nearly 6,00,000 women disappear due to maternal deaths. The statistics can be numbing - more than one death a minute. The maternal mortality rate for India is very high which is estimated as 420 maternal deaths per 1,00,000 live births. In Sri Lanka, it is only 30 maternal deaths per 1,00,000 live births while in Madhya Pradesh it is 498, Bihar 451, Rajasthan 607, Uttar Pradesh 707 and Orissa 739 respectively. India reportedly accounts for over 20 per cent of the world's maternal deaths.

The maternal mortality numbers also reveal the deep divide between the developed and developing countries. In Bangladesh, maternal deaths are estimated to be nearly 33,000 each year, while it is less than 500 in the United States, although the U.S. population is twice as large as that of Bangladesh. An estimated one in 12 women die of maternal causes in West Africa compared to one in 4,000 in Northern Europe.

The fact that it is scarce in some countries shows that maternal deaths can be prevented. Maternal deaths are of concern, "not simply because these are women in the prime of their lives; not simply because a maternal death is one of the most terrible ways to die. But above all because almost every maternal death is an event that could have been avoided, and should never have been allowed to happen." The above quote is taken from the book Safe Motherhood Initiatives: Critical Issues which was published last year by the journal Reproductive Health Matters. The book contains well-researched papers by different authors providing an overview of the problems and challenges in tackling maternal mortality. It has articles on values and limitations of different forms of measurement of maternal mortality and morbidity; reviews different national policies and programmes including their achievements and what needs to be done; contains case studies of the causes of maternal deaths and morbidity; and how deaths can be prevented through effective, evidence-based policies and programmes. The book takes both a public health and a social justice perspective on these issues.

First and foremost, it advocates the need for making every maternal death count. Measurement of levels and trends in maternal mortality is vital. However, experts agree that measuring adequately is a challenge since accurate registration of deaths coupled with medical certification of cause of death is not feasible in most developing countries.

However, in the last decade there is a move away from accurately measuring maternal mortality ratios to more diagnostic action oriented gathering of information on where, how and why deaths are occurring. The book contains an article on the question of measurement with an interesting example from Nepal where the approach for collecting information was redirected towards answering "why" questions rather than mere collection of data. Two direct studies in Nepal found levels of maternal mortality ratios as 500 - 600 per 1,00,000 live births but these studies did not provide information on the underlying reasons for these deaths. The Ministry of Health conducted a detailed investigative study regarding the medical and non-medical causes of death by using both quantitative and qualitative methods with information from the community and facility sources. The study has provided evidence for developing interventions by the Government of Nepal and other agencies. The article rightly says that "there is much to be learned from examining individual maternal deaths and not just the aggregated statistics".

It is evident that data is only a means to an end. More importantly, it is not the question of data but of imagining what it is to suffer a maternal death. As Deborah Maine, who has written a piece in the book, states, "But how many people have imagined what it means to be in labour for five days, in pain, exhausted, knowing that your baby is already dead and you will die soon because the hospital where the caesarean section could be done is out of reach, either physically, financially or socially?" The same author argues that it is important to change the strategy from a focus on risk screening to accepting that every pregnancy faces risks. In this context it becomes important to take into account the chronic maternal morbidity since maternal mortality is just the tip of the iceberg. The book contains some insightful articles on various aspects of maternal morbidity.

The book, based on studies on different countries, shows that community involvement is essential for reducing maternal mortality. The Bangladesh Association of Voluntary Sterilisation (BAVS) initiated a programme for training village nurses known as "palli" nurses who perform normal deliveries and recognise and refer complications. These women, with eight years of schooling, are selected by their communities and receive six months of training to become community nurses. The training includes clinical hands-on training at a government maternity hospital in Dhaka.

The Bangladesh Rural Advancement Committee (BRAC) has established numerous mini-health centres in remote areas, which are staffed by a doctor and a nurse. These centres have links with communities by placing traditional birth attendants (TBAs) who also get on-the-job clinical training from the nurse and the doctor. The International Centre for Diarrhoeal Disease Research, Bangladesh, has placed trained midwives in villages. An important aspect of this programme is the availability of a boatman in the project area for referral services, which has contributed to reducing maternal mortality in the project area.

Preventing maternal mortality requires a range of interventions that are, according to the editors of the book, highly medical, highly technical, and highly social and political. The most difficult issues are probably not the technical ones, but the political and economic ones. In the last decade, both the governments and women's organisations turned their attention to the issue of maternal mortality. Governments have committed to reduce maternal mortality by one half of the 1990 levels by the year 2000, and by a further half by 2015. However, their policies do not reflect their commitment to reduce maternal mortality. The cuts in welfare spending, introduction of user's fees for accessing health care and privatisation of health care are likely to have a negative impact on the access to and utilisation of services by most in need.

The South African government is an exception and it has boldly introduced free maternal and child health care, which was one of the first policies adopted by it in 1994. An article in the book reviews the South African experience of providing free maternal health care and its possible impact on maternal health. The book also discusses the efforts to reduce abortion-related mortality in South Africa. The South African government not only passed a liberal abortion law but also has launched the National Abortion Care Programme, which aims at providing safe, efficient and accessible abortion services. Estimates of maternal mortality in South Africa reveal the deep divide between the whites and the rest of the population. For African women, the estimate ranges between 156 to 250 deaths per 1,00,000 births as compared to 3-8 deaths per 1,00,000 births for white women. It is a clear indication that health status is linked to social and economic status.

Similarly, a paper by Dr. Vinaya Pendse from Udaipur, which is based on her personal experience, shows that merely improving the health infrastructure cannot reduce maternal mortality, but it is also important to reduce social and economic inequalities. In 1980, Dr. Pendse was appointed as Professor and Head of the Department of Obstetrics and Gynaecology at the RNT Medical College and Zanana Hospital attached to it. The hospital that had been set up in 1959 had not seen any major improvements though the number of deliveries conducted had increased manifold. Witnessing a large number of maternal deaths, Dr. Pendse in 1983 - 1985 decided to document the maternal deaths occurring in the hospital. She prepared a report on 100 women who had died in the hospital. Dr. Pendse mailed the report to the Central and State Ministers and the World Health Organisation. As a result of her initiative, in 1991, the Government allocated funds for improving the hospital facilities. In 1994 - 1996, she collected information on a further 100 women who died from maternal causes at the hospital. The 1994 - 1996 study showed significant increase in the percentage of death from those belonging to the Dalits and Adivasis. The deaths among "higher" caste groups declined from 35 in 1983 - 1985 to eight in 1994 - 1996. However, within the "higher" caste groups, the number of maternal deaths among the "Rajput" women remained almost unchanged. The inference made from the Rajput women's plight is that it linked to the high level of gender discrimination prevalent within the community. The 1994 - 1996 study also showed that compared to the previous decade, more women died from clearly preventable causes, i.e. complications arising from illegal abortions and severe anaemia and malaria. The only change has been the improvements in the network of roads and access to public transport, which meant more women reached the hospital, but many arrived in such bad condition that nothing could be done to save them. Dr. Pendse rightly concludes that, "To the extent that more women are now coming to the hospital from farther away and from poorer and lower caste groups, the changes in the profile of women dying over the past decade may be viewed as positive. However, unless and until all the factors contributing to the continuing high numbers of maternal deaths are put right, starting from the social and economic inequalities which place women at a disadvantage even before they become pregnant, women will continue to die needlessly in childbirth, both within and outside hospitals."

The maternal mortality is linked to discrimination faced by women and it cannot be ignored while developing programmes for preventing maternal mortality. The link between disempowerment of women and maternal deaths is most visible in the issue of access to family planning methods and safe abortion. Women who do not wish to become pregnant should have the freedom to use family planning methods including safe abortion. This would reduce the number of women with unwanted pregnancies and the deaths that might result from these. However, these are contentious issues in most societies and reflect women's lack of power to develop policies that will benefit them. Susanna Rance's article in the book challenges the use of the term "Safe Motherhood" for tackling the problem of maternal deaths. According to her, "the naming of a programme such as Safe Motherhood is more than a matter of political convenience. Rather, it is an ideological statement which constructs women as mothers, who deserve protection and safety only as such?

In the words of T. K. Sundari and Marge Berer, who edited the book, "Working to prevent maternal deaths is not an act of benevolence towards women because they are mothers, but the duty of all who respect human rights which includes the right of women to life."

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