Safe Births, Stronger Futures: Rethinking Maternal Care in India

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"Women are not dying because of a disease we cannot treat. They are dying because societies have yet to make the decision that their lives are worth saving."

This bold statement by Mahmoud Fathallah, President of International Federation of Gynaecology and Obstetrics (FIGO) at the World Congress, Copenhagen 1997 still holds true in our present scenario related to maternal deaths, after nearly two decades.

Pregnant women form a priority group in public health as maternal mortality is a sensitive indicator that helps to understand the health care system as well as the prevailing socio-economic scenario.^[1] Preventive healthcare at its best, can reduce the maternal mortality through several innovations and ideas catering to maternal healthcare in India.

Since times immemorial, the key public health issues in developing countries including India have been maternal and child health (MCH) outcomes. Although there have been concerted global efforts to improve MCH in low-and-middle-income countries (LMICs), much more progress is needed to meet the targets laid out in the Sustainable Development Goals (SDGs).^[2] The Sustainable Development Goal 3 is to ensure healthy lives and promoting well-being for all at all ages and associated targets aim to reduce the maternal mortality ratio (MMR).

Multi-pronged strategies have been adopted to improve maternal health and pregnancy related services. For further progress to be made, the focus must shift to identifying populations and geographical areas where mortality is higher/concentrated and assessing the medical and systemic causes leading to mortality among them.^[3]

The Reproductive, Maternal, New-born, Child and Adolescent Health (RMNCH+A) framework has been adopted by the Government of India in 2013, to address causes of mortality and morbidity among women and children, and it also establishes guidelines to understand delays to access and utilization of health care services. The basic strategies are guided by equity, universal care, accountability in order to provide a ‘continuum of care’ at all stages of life.^[4,5]

Complete maternal healthcare coverage comprises of availability of health services, appropriate utilization of these services, and includes the complete gamut of antenatal care (ANC), care during delivery, and postnatal care. Pregnancy and childbirth should be looked forward to as joyful endeavours, however, safe motherhood and childbirth depend majorly on the care and attention provided to pregnant women and newborns.^[6]

A newer concept of respectful maternity care has also been established to further the RMNCH+A model. A new initiative “Surakshit Matritva Ashwasan” has been launched by the Ministry of Health and Family Welfare (MoHFW), Government of India which aims to provide assured, dignified, respectful and quality healthcare. Further, it is to be given at no cost and with zero tolerance for denial of services for every woman and newborn visiting the public health facility. The goal is to provide a positive birthing experience and to end all preventable maternal and newborn deaths and morbidities. The expected outcome of this new initiative is "Zero Preventable Maternal and Newborn Deaths and high quality of maternity care delivered with dignity and respect".^[4]

To reach these goals, under the National Health Mission, the Maternal Health Division is striving to improve the quality of services to pregnant women and their newborns. This is being envisaged through various interventions, programmes, local information, education and communication activities, capacity building and health system strengthening.^[4]

The current key MCH indicators as per the National Family Health Survey-5 (NFHS-5), indicate worsening of maternal and child nutrition indicators across several states of India.^[7]

Thus, there is a pressing need to implement strategies to improve these indicators as well as roll out targeted approaches for the same.

Till now the focus has been on addressing the direct causes of maternal deaths, which are often quite apparent. It is necessary to identify the indirect causes of poor maternal outcomes in order to further reduce the MMR. Most of these indirect causes can be addressed by assessing the 3 delays, as done by Thaddeus and Maine in their study.^[8]
1. Delay in deciding to seek care on the part of the individual, the family, or both;
2. Delay in reaching health care facility;
3. Delay in receiving adequate care at the health facility.

Maternal health – morbidity and mortality continue to remain a challenge though services critical to its prevention viz. availability, accessibility and quality of care during pregnancy and childbirth is ever expanding in India.^[5]

There can be several factors viz. access to emergency obstetric care, antenatal care, anaemia rates among women, education levels of women, and other factors which may lead to the varying levels of maternal morbidity and mortality. Review articles have shown about twenty determinants identified under four themes such as socio-cultural factors, perceived benefit/need for skilled attendance, economic and physical accessibility and some contextual factors which may help define a model to help meet health policy objectives for increase uptake of maternal health services.^[9,10] One of the studies has tried to find out reasons of maternal deaths based on the three delay model.^[11]

Trying to find out these factors requires extensive studies into the cause of maternal health issues and deaths. Thus, Maternal Death Review (MDR) should be routinely undertaken. The primary goal of these reviews is to eliminate preventable mortality by obtaining and strategically using information to guide public health actions and monitoring their impact.^[10,12]

Quantitative studies into the cause of death may help ascertain some of the direct causes of maternal deaths. However, to know the indirect causes and the delays at different levels, Community based MDR using a verbal autopsy format is a method of finding out the medical causes of death and ascertaining the personal, family or community factors that may have contributed to the deaths. Thus studies essentially looking into “why a mother dies”- going under the surface and looking for a variety of contributing factors at her home, referral centres and the care centres where the final untoward outcome occurred are an urgent need.^[12]

Independent research has highlighted rural communities of India having their own issues like deep rooted traditional beliefs and practices, lack of awareness about danger signs of pregnancy and childbirth, when and where to seek care, lack of decision-making power to the woman and financial factors. Even when decision is made to seek care with arrangement of transport and payment, journey on the bumpy roads is not an easy task. Several issues related to Early reporting and registration of pregnancy, ante-natal care, pregnancy risk assessment and management, associated co-morbid conditions, issues arising during Labour and delivery, terminal events and perception of family to the adverse events, caregivers and facilities need to be undertaken in detail.