Lhamu, a mother of twelve, lives in a remote village in Western Tibet. Three of her children died within a month of birth and the four year old strapped to her back looked as small as a one year old. She gave birth all alone, at home, all twelve times. But Lhamu was lucky. She didn't die. One in 33 women dies during childbirth in Tibet. Malnutrition, abject poverty and lack of any health care – however basic—plagues Lhamu's family, as it does much of Tibet. Tibet – vast lonely stretches of dead habit with nary a creature on its harsh plains and no economy to speak of. It can't be as bad here in new economy India, right?

Think again.

One in 48 women in India is at risk of dying during childbirth. The Maternal Mortality Ratio (MMR) in India is a high 407 per 100,000 live births, according to the National Health Policy 2002. Other sources put the MMR at a higher 540 (NHFS and UNICEF data, 2000). Reducing the Maternal Mortality Ratio (MMR) by three-quarters by 2015 is a Millennium Development Goal (MDG) for all countries including India. Achieving this means reducing the MMR to 100 by 2015. Part of the problem is this measurement – MMR data is just not there and if it is, it varies widely depending on what method was used to get it.

Studies show MMR among scheduled tribes (652) and scheduled castes (584) is higher than in women of other castes (516, according to one study). It is higher among illiterate women (574) than those having completed middle school (484). The key determinant seems to be access to healthcare. Less-developed villages had a significantly higher MMR (646) than moderately or well-developed villages (501 and 488 deaths, respectively).

"It is very sad that the numbers are so high even 57 years after independence," avers Dr H Sudarshan who is Vigilance Director (Health) of the anti-corruption body Karnataka Lokayukta. "Not only are the numbers from the Sample Registration System (SRS) high, they are also incomplete. We do not know how many mothers actually died during childbirth and why. Underreporting is rampant and people hide MMR numbers in fear of repercussions. We need state-wise and within states, district-wise data," says Sudarshan who was also Chairman of the Karnataka Health Task Force which made wide-ranging recommendations based on a 2-3 year detailed study conducted in the state. Regardless, the UN MMR numbers for India (540) are several times higher than those for other developing countries like China (56), Brazil (260), Thailand (44), Mexico (83) or even Sri Lanka (92).

Medical reasons

So what exactly leads to such a high MMR? The main reasons for maternal deaths related to pregnancy are anaemia, post-partum bleeding and septic abortions with anaemia being the most rampant. "Antenatal care is most important," declares Sudarshan, "and that is just not being done. This kind of care checks for high risk pregnancies."

Public health advocate Dr Mira Shiva agrees, "Hypertension and the toxemias of pregnancy can only be detected with antenatal care. There is a total neglect of a mother's health in India. [The situation] is disgusting because a big chunk of all this is preventable. The medical establishment is busy with micronutrients but that is not the answer. Giving one iron tablet to a woman during her pregnancy is too late." Shiva is coordinator of the All India Drug Action Network (AIDAN) and one of the founding members of the People’s Health Movement (PHM). Striking out at a more endemic problem, she says, "The real problem is food. It is all about food, the cost of food and the nutrition content therein. These pregnant women have to fetch the water, make fuel, work the buffaloes, etc., all on the measly amount of food they can afford. How can the nutritive intake be enough? It becomes a negative calorie balance. In short, what is needed goes beyond a medical solution."

"It is all about food, the cost of food and the nutrition content therein. These pregnant women have to fetch the water, make fuel, work the buffaloes, etc. all on the measly amount of food they can afford. How can the nutritive intake be enough?"
-- Dr Mira Shiva

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Sudarshan echoes Shiva's sentiment, "We need to move from a medical model to a social model. Nutrition for pregnant mothers is very important and the ICDS Anganwadi scheme has clearly not achieved the hoped results." Where antenatal care is good, the results are good as well. Kerala and Tamilnadu have good antenatal care and correspondingly have two of the lowest MMRs in India. In Assam and Bihar where antenatal care is almost zero, the MMRs are among the highest. India has the lowest percentage of antenatal coverage (60%) among countries like China, Brazil, Mexico, Thailand and Sri Lanka which are all in the high 86-95% range.

While antenatal care is paramount in the prevention of pregnancy-related deaths, septic abortions are more insidious. What is worse, the latter tends to go unreported due to the nature and circumstances surrounding it. In many rural areas couples do not use any spacing methods and women conceive within 7 months of having given birth. Dr Leena Joshi of Family Planning Association of India (FPAI) is familiar with this scenario. Her voice drops with concern when she mentions abortion rates in the remote reaches of Maharashtra. "The abortion rate in these areas is just so high. With it comes hidden mortality from septic abortion deaths. Since the PHCs do not have MTP methods, the abortions are performed by quacks. And even if the PHCs or district hospitals have MTP methods, the people opt for local help." Why? "It saves them money. These are very poor people and transport costs and medical costs can be saved by walking to a local quack." As a result there are a high number of abortion-related deaths which do not get reported under maternal mortality. Dr. Joshi laments that everybody only talks about deaths during the childbirth process. "But since there are so many septic abortion cases it all goes unreported."

The problem of unsafe abortion is something that Shiva worries about as well. "Abortion (MTP) being legal in India, no one is turned away. Second trimester abortion is a big reason for rising MMRs." People come late for the abortions and complications ensue. And apparently these are not only driven by spacing problems. "Contraceptives are used only by women and failure of these is common," says Joshi. Of course, abortion of female fetuses is routine and it goes on until the woman conceives a male child. The whole scenario makes one shudder.

But all this seems to be not even half the story.

Take malaria, for example. Orissa has a high incidence and accounted for 28.6% of detected cases of malaria -- 41% of falciparum -- and 62.8% of all material deaths in India (1998). Malaria and pregnancy form a sinister synergistic pair. Falciparum malaria leads to abortion and still births in the gravid woman and can severely compound anaemia. Coincidentally, Orissa has a high incidence of sickle cell anaemia. The combination is lethal. The haemoglobin in pregnant women could drop to 1gm/dL (healthy levels are between 12-16gms/dL). While drugs are available to treat the malaria, the treatment requires a high degree of awareness and care in administration. For example, the common primaquine and tetracycline are absolute no-nos during any stage of pregnancy. But chloroquine and quinine are allowed. "But mistakes occur and are lethal," says Shiva. Acting fast and carefully is paramount and any deaths due to these infections are primarily due to gross neglect or ignorance. Orissa has one of the highest rates of MMR in India at 738.

Another key reason for deaths during pregnancy is post-partum bleeding or haemorrhage. The need for blood in such cases is imperative and access is less than ideal. Both Sudarshan and Shiva worry about the blood bank policy in India. Heavily driven by the HIV/AIDS lobby, they feel that somewhere the important issue of access to blood has been sacrificed for quality and safety since the policy makers are looking at it all from the AIDS perspective. Says Sudarshan,"The policy says you have to keep the blood in an air-conditioned room. But in Coorg, for example, you don't need it. HIV awareness is good, but blood banks need to be demystified and access and availability improved." Shiva adds, "It is imperative in case of complications during pregnancy to have blood available. But no. NACO only sees blood banks from their perspective and only in an emergency are you allowed to take blood from the banks. It is a major concern." When it comes to donation, Shiva points to an endemic problem. The strange connection between men, caring for women, and giving blood. "If the men have to pay a lot of money and go far to get blood for their wives, they just won't. And men will never give blood. They think a 100 drops of blood equals one drop of semen and thus, giving blood is related to potency. And so many times, when women need blood, it is not available."

Organisational reasons

Early diagnosis of high-risk pregnancies and complications and quick referrals are of paramount importance. But is institutionalising deliveries the answer? By requiring 100% institutional deliveries, the World Bank supported vertical program Reproductive Child Health 1 (RCH1) resulted in the abolishing of the dais (Traditional Birth Attendants), and Sudarshan believes, probably increased MMR. Subsequently, following a public uproar, the program was amended to advocate "training" TBAs into Skilled Birth Attendants. "Institutional support will bring down MMR, yes, but what type of institution is important," says Sudarshan. "The so called Primary Health Care units are so dirty that infection will probably increase because of them." "In Bihar, for example," explains Sudarshan, "80% of the deliveries happen at home. In Karnataka it is 70%." Joshi concurs with this high degree of preference. "In the Bhandara area almost 100% prefer home deliveries. And if there are complications, it means there are inevitable delays in getting more sophisticated care."

In India only 43% of deliveries involve a skilled birth attendant compared to between 86% and 99% in Mexico, China, Sri Lanka, Brazil and Thailand.