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Health campaigners question whether fall in maternal mortality in India is a result of more hospital deliveries

BMJ 2012; 345 doi: https://doi.org/10.1136/bmj.e7337 (Published 31 October 2012) Cite this as: BMJ 2012;345:e7337
  1. Ganapati Mudur
  1. 1New Delhi

An Indian government programme to reduce the number of home births by giving expectant mothers cash grants has increased the number of hospital deliveries, but gaps in healthcare services are still causing avoidable maternal deaths, an alliance of health organisations has said.

The National Alliance for Maternal Health and Human Rights, a non-governmental coalition, has said that India’s health ministry has stirred demand and increased the number of hospital deliveries without paying enough attention to factors that determine maternal safety.

The health ministry’s Janani Suraksha Yojana (Mothers Protection Programme) provides a cash incentive of 1400 rupees (£16; €20; $25) mainly to poor and underprivileged pregnant women to give birth in hospital. The ministry said that the programme had helped increase the proportion of hospital deliveries in India from less than 49% when it was launched in 2005 to more than 72%.

But the maternal health alliance has cautioned that surveys across several states had shown that public health centres lacked the infrastructure to support women with high risk pregnancies and that doctors and nurses were often unable to manage obstetric complications.

Jashodhara Dasgupta, a coordinator at Sahayog, one of the member organisations in the alliance, told the BMJ, “A cash incentive to encourage deliveries in hospitals is no solution to maternal mortality. India’s maternal mortality isn’t the result of a lack of demand for institutional deliveries; it is the result of the lack of supply of safe and reliable maternal healthcare services.”

Earlier this month the alliance called on the health ministry to provide better training for health staff in emergency obstetric care, rigorous reviews of maternal mortality, and enforced public health standards in maternal health services.

Priya John, a gender studies specialist who has been tracking maternal deaths in the eastern state of Jharkhand, said, “We’re not asking for anything extraordinary. What we’re seeking from the public health system should have been in place many years ago.”

Members of the alliance said that their surveys in six states—Chhattisgarh, Gujarat, Jharkhand, Karnataka, Madhya Pradesh, and Uttar Pradesh—indicated that auxiliary nurse midwives in health centres were not trained to spot high risk factors in pregnancy such as severe anaemia, infections, or pre-eclampsia. They said that doctors often had no access to the infrastructure needed to manage postpartum haemorrhage and other obstetric emergencies.

Soumik Banerjee, an independent health activist in Godda district in the eastern state of Jhakhand, said, “Public hospitals face shortages of specialists, but even when specialists are present they’re handicapped by lack of equipment or infrastructure and thus reluctant to take on the risks of handling emergencies.”

Banerjee, who has documented 35 maternal deaths in a cluster of villages around Godda over the past 18 months, said, “Time is lost when patients are referred from one health centre to another. Some women have died on the way and others just after reaching the next hospital.”

In a statement earlier this year on the achievements of the Janani Suraksha Yojana, the health ministry said that the programme had made “impressive gains,” with the annual number of women benefiting from it rising from 700 000 in 2005-6 to 10 million in 2011-12.

The ministry has suggested that the rise in hospital deliveries has led to a “resultant decline” in India’s maternal mortality, from about 254 per 100 000 live births in 2004-6 to 212 per 100 000 by 2007-9.

But health policy analysts say that fewer children and marriage at an older age have also helped to reduce maternal mortality.

Aditi Iyer, a research coordinator at the Centre for Public Policy at the Indian Institute of Management, Bangalore, said, “We need strong evidence to establish that the Janani Suraksha Yojana has helped pull down maternal mortality.

“The question is: has this programme substantially helped avert deaths in life threatening situations? We don’t see convincing evidence yet.”

Iyer and others pointed out that the health ministry’s own scrutiny of the programme had conceded last year that the increase in hospital deliveries had not necessarily meant more access to skilled birth attendants.

Most nurses and auxiliary midwives who were providing birth services in public health centres were not trained in the management of third stage labour, the use of magnesium sulphate to manage hypertension, or neonatal resuscitation, a report from the National Health Systems Resource Centre pointed out.1 The report said that training in basic emergency obstetric and newborn care in some locations was “almost completely absent.”

Notes

Cite this as: BMJ 2012;345:e7337

References

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