It’s funny when you bump into your neighbors on the other side of the world. Today I spoke about the Global Health Initiative’s recent collaboration with the Population Foundation of India at a regional briefing on health in South and Southeast Asia before the 2013 Women Deliver conference in Kuala Lumpur, Malaysia. The special roundtable was part of a week-long study tour for a group of U.S. Congressional staffers that work on foreign affairs.

Management Sciences for Health, CARE, the Center for Health and Gender Equity (CHANGE), the Global Health Council, PATH, Population Services International (PSI), and Women Deliver all partnered to bring this study tour to Kuala Lumpur during the Women Deliver conference for briefings and site visits that demonstrate the importance of investing in global health. I participated in a briefing that provided the staffers with important insight on the diversity of the health needs of countries in South and Southeast Asia.

Progress and Challenges in India

Drawing on our dialogue in New Delhi last month and a forthcoming report summarizing its recommendations, I discussed the recent progress and remaining challenges in maternal health care in India.

India has made big strides over the past decade to reduce maternal mortality. A decade ago, close to 75,000 women died every year during childbirth or due to pregnancy-related causes. By 2010, this number had fallen to 50,000. The country’s maternal mortality ratio fell from 301 maternal deaths per 100,000 live births in 2003 to 212 in 2009.

But despite this, India is not on pace to reach the maternal mortality Millennium Development Goal of 109 or fewer maternal deaths per 100,000 live births by 2015. Twenty percent of all maternal deaths worldwide still occur in India. To close this final gap, special effort needs to be made to reach disadvantaged communities.

The National Rural Health Mission (NRHM), its rural health care workers, and the Janani Suraksha Yojana (a conditional cash transfer program for institutional births) have contributed positively to improving the Indian women’s access to health care. According to the 2009 Coverage Evaluation Survey, nearly three out of four births took place in institutions – up from less than 40 percent in 2005-06. More than two-thirds (69 percent) of pregnant women received at least three antenatal checkups, and around 90 percent received more than two tetanus toxoid injections.

Wide disparities and inequities in women’s access to healthcare continue to persist, despite the overall progress. Sadly, access to health services still depends on a woman’s education, wealth, the community she belongs to, and where she lives. For instance, although in total 73 percent of Indian women give birth in institutions, the number is much lower (54 percent) among women who have no education, who belong to the lowest wealth quintile (55 percent), are a member of the Scheduled Tribes (57 percent), or live in rural areas (68 percent).

The poorest women–those belonging to Scheduled Castes and Scheduled Tribes–have yet to be brought into the fold of an inclusive healthcare system in many parts of the country. For example, over a period of eight months in 2010, 26 maternal deaths took place in the Barwani district hospital in Madhya Pradesh. Tragically, 21 of these 26 women belonged to Scheduled Tribes. Even more alarming is that an inquiry commissioned by the government found all 26 deaths were avoidable.

Regional differences are also important. States like Assam, Rajasthan, and Uttar Pradesh have maternal mortality rates over 300 maternal deaths per 100,000 live births. Attention also needs to be paid to transient populations, including women who temporarily migrate to their birthplace for delivery.

Expert Recommendations

As summarized by Executive Director of the Population Foundation of India Poonam Muttreja in a column for the Hindustan Times, seven strong conclusions emerged from the deliberations we helped organize in New Dehli:

One, we must recognize maternal morbidity as a serious health issue. For each woman who dies, an estimated 20 more suffer from infection, injury and disability during pregnancy and childbirth. Some women die, while for others, life is a living death experience. These complications range from fistula, uterine prolapse, painful sexual intercourse, reproductive tract damage and infections, anemia and even infertility. Maternal morbidity, like maternal mortality, can be easily prevented.

Two, we must integrate maternal health, reproductive health and family planning – now delivered as vertical programs – into a universal health coverage plan that recognizes woman’s health as a basic right. For example, anemia among girls needs to be addressed at a younger age. Waiting till they are pregnant and then treating them for the condition may be too late. Similarly, a substantial number of maternal deaths can be prevented by merely meeting the unmet need for family planning and providing access to safe abortion services. The government of India has taken a right step by announcing a comprehensive strategy on reproductive, newborn, child and adolescent health (RMNCH+A).

Three, we must focus on the marginalized. Within an overall framework of universal health coverage, India needs to adopt special and differentiated strategies to reach women in remote rural areas, those belonging to tribal communities, and the more disadvantaged groups in society.

Four, we must improve the quality of care by putting in place adequate guidelines, protocols, checklists and introducing a system of accreditation for facilities and services for both the public and private sector.

Five, address the shortage of human resources. Despite the more than 10-fold increase in institutional births over the past five years, there has not been a matching increase in staff strength. Skills of field functionaries such as auxiliary nurse and midwives (ANMs) have been lost as they have been instructed not to conduct deliveries. Many healthcare providers trained in the Indian systems of medicine fail to recognize clinical symptoms of an obstetric emergency.

Six, ensure greater accountability from the highest level instead of holding the frontline health worker or the Accredited Social Health Activist (ASHA) responsible. A greater involvement of the communities in monitoring the health services, which has begun under the NRHM, needs scaling up with adequate budget allocation.

Seven, gaps in knowledge must be addressed. Better monitoring and evaluation systems need to be introduced. A community perspective should be brought into the assessment of service delivery. A robust methodology should be developed for measuring morbidity and collecting real time data. More regular studies on maternal mortality and morbidity should be planned.

I also emphasized an eighth recommendation to the staffers: Social determinants to maternal health need to be addressed. Key among those are social customs, beliefs, and practices that occur across much of the world that contribute to poor health and inequity for women, including child marriage and early pregnancy, violence against women, and the political and economic disempowerment of women.

As Muttreja so eloquently says, “the last mile is always the most exhausting, exasperating and difficult to cover.” Collectively, we can do it. Whether here at global gatherings like Women Deliver or in New Delhi and Washington, DC, we need to continue to spread the message about the importance of investing in maternal health.

Read the Global Health Initiative’s full coverage from Women Deliver, part of our Advancing Dialogue on Maternal Health series with the Maternal Health Task Force and UNFPA.

Sources: Hindustan Times, UN.

Photo Credit: Schuyler Null/Wilson Center.