Maternal Mortality in India: Dying to Give Birth

Background Overview paper for the 10th IWHM, 2005

By

Jashodhara Dasgupta

In collaboration with TATHAPI (Pune)

CHETNA (Ahmedabad) WOHTRAC (Vadodara) and

ANS-WERS (Hyderabad) Advisory inputs – Dr. Abhijit Das, New Delhi

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Maternal Mortality in India: Dying to Give Birth

Background Overview paper for the 10 IWHM

Abstract

The paper explores the seriousness of the problem of maternal mortality in India and indicates that maternal mortality is not decreasing despite India’s remarkable progress in medical technology and other economic indicators. The historical development of the issue is traced from British times to the present and the current policies and laws are analyzed. The paper traces the key perspectives and debates surrounding maternal mortality and argues that we need to go beyond technical solutions towards a rights based approach. The paper highlights the current state of services and finances for maternal mortality and strategies in use by key civil society groups. The paper concludes by suggesting that maternal mortality can be tackled by adopting a rights based approach that empowers women for their entitlements and reinforces state accountability to fulfil, protect and promote women’s rights.

Jashodhara Dasgupta

Coordinator, SAHAYOG

A-240 Indira Nagar, Lucknow 226016 India

Phone-++91-522-2716453

Email jashodhara@sahayogindia.org

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Maternal Mortality in India: Dying to Give Birth

Background Overview paper for the 10th IWHM Jashodharai

Context As the world moves ahead in the 21st century, large sections of the Indian population have experienced relative prosperity and economic development. Information technology has created revolutionary changes in communication systems all across the country. Indian doctors, computer experts and scientists are in worldwide demand. Despite this, close to 140,000 Indian women lose their lives every single year for reasons that are almost medieval: they die in pregnancy, during childbirth or even after, or are killed by unsafe abortions. In numbers, this translates to one woman dying every five minutes. The risk of maternal death is one in 37 in India while it is one in 230 in neighboring Sri Lanka compared to one in 5000 in Singapore and one in 7300 in Norway. While India has 16% of the world’s population, one fifth of the world’s maternal deaths occur in India, the highest figures for a single country. According to the National Commission for Women 2002 Report maternal mortality in India is high enough that it has an effect on the overall female mortality of India. This is a grave violation of women’s human rights because the burden of ill health is being disproportionately borne by women solely due to their biological role in reproduction. As this burden of morbidity and mortality is borne by women in their most productive years (age-group of 15-45), it is also a major development concern. In fact, maternal morbidity and mortality rates are higher in young women (age 15-19) or those above the age of 35. Jejeebhoyii states “the majority of maternal deaths and episodes of ill-health in India are preventable given that both the knowledge and means of prevention are available”. The state has clearly failed to provide women with the system of health protection that enables them to go through pregnancy and childbirth with safe and healthy outcomes. Yet the actual number of deaths appear to have actually increased over the last few years: the National Family Health Survey (NFHS) II brought out the surprising fact that the maternal mortality ratio (MMR) in India has not significantly changed from 424 deaths per 100,000 live births in 1991 to 540 in 1997-98. There is a disagreement about the figures for maternal mortality between surveys, national registration systems and individual researchers. There are also wide differences in estimates by the Sample Registration System (SRS 1998) and the studies done by FOGSIiii as shown below:

Table One – Estimates of maternal mortality ratio by FOGSI and SRSiv State Estimated MMR

(FOGSI – 1994) Estimated MMR –SRS 1998

Bihar 1668 452 Madhya Pradesh (Incl Chattisgarh)

1038 498

Orissa 1292 367

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Table Two: Maternal Health care in some of the EAG states

UP MP Bihar Orissa MMR 707 498 452 367 Complete ANC

4.4 10.9 6.4 21.4

Institutional delivery

15.5 20.1 14.6 22.6

Births w/out health professional

77.6 70.3 76.6 66.6

Post natal care in home delivery

7.2 10 10 19.2

From NFHS 2 1998 -99 and SRS 98

Rajasthan 634 670 Uttar Pradesh 1359 707 Punjab 992 199 West Bengal 1034 266 Even though there is inconsistency in the MMR, everyone agrees to the fact that the MMR in India is high. Secondly, there is agreement that there has been no decline in the last decadev. Within India however, wide disparities exist and the situation in some states is not so dismal. Antenatal care and institutional deliveries are increasingly becoming common in states of the south. According to 1998 data for Maternal Mortality Ratio (MMR), Tamil Nadu in the south gives a figure of 79, Andhra Pradesh 159, Kerala 198, Karnataka 195, Maharashtra 135, while in the north, the relatively prosperous states of Haryana and Punjab have MMR of 103 and 199 respectively.

In a stark contrast, the “EAG states” (states with the poorest indicators) such as Uttar Pradesh (UP), Bihar, Madhya Pradesh (MP) and Orissa (see Table Two) have MMR ranging from 707 to 367. Rajasthan is a close second to UP with an MMR of 670. Reviewing the quality of care it is evident that while there have been some provisions made within the framework of policies and programs there has a huge failure in large tracts of the country in providing infrastructure, maintaining supplies and providing competent personnelvi. The mortality figures speak volumes about the

very poor outcomes of the maternal health services. There is no major change in the causes of maternal deaths in the last decade, except that toxemia related causes have reducedvii. Deliveries attended by health professionals and those conducted in institutions rose only marginally between 1992-93 and 1998-99. While health professionals attended 34.2% of births in 1992-93, there was a slight increase to 42.3% in 1998-99. Deliveries in institutions were only 25.5% in 1992-93 and rose to 33.6% in 1998-99 (GOI, Planning Commission, 2002). Surveys show that the percent of women receiving antenatal care went up from 49.2% in 1992-93 to 65.4% in 1998-99. But only 43.8% of women received three or more antenatal checkups in 1998-99 (NFHS I and II) and only 20.0% of pregnant women received all recommended types of antenatal care in 1998-99. In 1992-93 the leading causes of death were anemia (19%) and bleeding during pregnancy (22%) (NCW 2002:82-83, Jejeeboy 2000:141-142). Jejeebhoy also attributed sepsis infections accounting for 13% of deaths in 1993 (Jejeeboy 2000:140). Gopalan and Shiva state: “The incidence of anaemia during pregnancy increases with 50% of Indian women being anaemic. 85% of pregnant women have been found anaemic.150 ml of blood loss due to haemorrhage of pregnancy and labour can be fatal in these conditions” (Gopalan and Shiva 2000:193). In the

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year 1998-99, 13.2% women were below 145 cms and classified as nutritionally at risk. NFHS data show that in 1998-99, 51.8% have any anemia, 35.0% have mild anemia, 14.8% have moderate anemia and 1.9% suffer due to severe anemia (NFHS 2, 1998-99). Unsafe abortion is also one of the most important reasons for maternal deaths. Jejeebhoy cites that in 1993, 12% of maternal deaths in India were due to unsafe abortion in which sepsis accounts for the majority of the deaths (Jejeebhoy 2000:141, NCW 2002:83). This is despite the fact that abortion has been legal in India for over two decades (Jejeebhoy 2000:158).

Table Three – Abortion trends Trends regarding Abortion 1991 1997

Estimated number of abortions 10.1 million 8.5 million The number of spontaneous abortions 3.4 million 3.2 million The total number of illegal abortions 4.5 million 4.3 million The total number of induced abortions 5.1 million 4.8 million Total number of legal abortions (CEHAT, 2002) 5,81,215 5,38,075

According to estimates, ill health related to pregnancy, abortion and childbirth (maternal morbidity) is also unacceptably high in India. It is estimated that between 4 and 5 million women suffer ill health due to childbearing complications (Jejeebhoy 2000:134). However, research on maternal morbidities is far less than research on maternal mortality. Maternal morbidity and mortality rates are higher in young women (age 15-19) or those above the age of 35, which becomes a vital factor when nearly 17% of girls between the ages of 13 and19 have commenced childbearing (Jejeebhoy 2000:150, IIP 155). The historical development of the issue The British colonial government in nineteenth century India condemned the natives for the extremely high maternal mortality of their women folk. Qadeer (2005) describesviii how the British government in India set up the Lady Dufferin Fund in 1885 to provide maternity care, which also attracted British women doctors into the colony. These women doctors persuaded traditional dais1 to bring cases to their private clinics and hospitals, but did not recognise their good practice or teach them better practices. In 1914 the earlier reliance on volunteerism of women doctors was changed by setting up the Women Medical Service, whereby the state accepted its responsibility for providing maternity services. The Bhore committee (GOI, 1946) laid the foundation for public health in India with an emphasis on health services being as close to people as possible. After Independence, the WHO stressed the contribution of basic public health programmes to improving maternal health, advocating an integrated approach to Maternal and Child Health (MCH). But by the late sixties and early seventies, population control became an overriding concern. The focus shifted from comprehensive maternal health to an instrumental approach, whereby the mother could become an easy ‘target’ for contraceptive acceptance. Throughout the seventies, health department workers were under pressure to bring in ‘cases’ for 1 Community birth attendant with varying roles

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sterilisation to meet their allotted targets, on pain of disincentives and punishment. In 1971, an act for Medical Termination of Pregnancy made abortion legal, perhaps in order to avoid unwanted births. A cadre of village health guides was started in 1977 but the scheme could not continue due to programmatic problems and withdrawal of professional and political support. However, the peripheral health infrastructure was strengthened considerably between 1971-1991ix, with PHCs increasing from 5131 to 22,243 and Sub-centres for the community Auxiliary Nurse Midwife increasing from 27,929 to 131,098. Additionally, the seventies saw the emergence of several development NGOsx that worked on community based primary health care including maternal health. Many of these NGOs trained village health workers as part of their extension programme, and demonstrated the feasibility and effectiveness of alternative health care models that were successful in reaching the unreached and serving the unserved (Pachauri, 1994). After the Alma Ata Declaration in the late seventies, a joint high-level committee of the ICMR-ICSSR tried to bring public health and primary health care back into focus specially (ICMR-ICSSR, 1980). They recommended formation of village health units at 1000 population and the increase of health budget. Following on this the National Health Policy (GOI, 1983) stressed on the provision of universal comprehensive primary health services in the spirit of the Alma Ata Declaration and to transfer health knowledge to village based health workers. But these principles did not get translated into programmes. In 1992 the Child Survival and Safe Motherhood (CSSM) programme was launched for early detection and treatment of complications as well as referrals for hospital deliveries for women with a high risk for complications. There was also an Intensified Dai Training Programme started by the government to have at least one trained TBA in each village. It was also planned to make emergency care more accessible by establishing First Referral Units (FRUs) at sub-district level. The aim was to reduce maternal mortality to 200 per 100,000 live births by the year 2000. However, an assessmentxi in two rural districts of Uttar Pradesh in 1997 showed that women had not sought ante-natal care, and barely half received tetanus toxoid injections, and between 75-90 % of deliveries were attended by family members or other untrained attendants. Primary health centres and sub-centres were found to be incapable of dealing with any of the major complications that led to maternal death. In the early nineties, the World Bank was recommending that India take up a ‘comprehensive reproductive health approach’ as opposed to the ‘target-oriented approach’ in the family welfare programme. In 1994 India signed on the Programme of Action of the International Conference on Population and Development (ICPD PoA), promising to promote ‘reproductive rights’ that included the right to reproductive health, of which one aspect was the right to go safely through pregnancy and childbirth. Subsequently the government launched the RCH Programme in October 1997 offering client-centred, demand-driven, quality service approach as opposed to the previous provider-centric target-based approach.

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The GOI document on the RCH programme (1997) tried to follow the reproductive health concepts and definition stated in the ICPD document. The RCH goals were defined as, “People have the ability to reproduce and regulate their fertility, women are able to go through pregnancy and childbirth safely, the outcome of pregnancies is successful in terms of maternal and infant survival and well being and couples are able to have sexual relations free of fear of pregnancy and of contracting diseases” (GOI, 1997 p.3). RCH ‘Camps’ were introduced in 2001 in 102 districts in seven states with poor performance in maternal health care to improve maternal and child health services to people living in remote areas. In practice, however, the major service provided to women was sterilization operations. The RCH programme also involved large numbers of NGOs through the ‘Mother NGO Scheme’. For the first time in an official health document, the rhetoric of rights was brought in with RCH, referring to the rightsxii of the ‘client’ who used state services. This shift to market terminology that seems ironic considering the impoverished beneficiaries of the welfare state. Meanwhile, health sector reform programmes were started off in various states of India from the late nineties, pushing for reduced public spending on health and promotion of the private healthcare sector. It led to significant promotion of institutional deliveries for all childbirths. Collapsing public health services, rising costs of drugs and investigations, and imposition of user fees led to increased indebtedness in seeking healthcare. The early 21st century also saw a slew of policies in India that set the ambitious goal of reducing maternal mortality to 100 per 100,000 live births by 2010, including the National Population Policy 2000, the National Policy for Empowerment of Women 2001 and the National Health Policy 2002. The new UPA government in 2004 set forth a Common Minimum Programme, within which a National Rural Health Mission was launched in April 2005. At present the second phase of the RCH programme is also being set up with Plans for Implementation of Programmes (PIP) being made at every level. Analysis of law and policy around maternal health Constitutional provisions There is a recognition of the role of the state regarding people’s health in the Constitutional guarantee: “The State shall regard the raising of the level of nutrition and the standard of living of its people and the improvement of public health as among its primary duties…” (Article 47, Constitution of India). It has also been articulated by Supreme Court case law that reads the right to health into the right to life under Article 21 of the Constitutionxiii. Additionally, according to the Constitution, Article 14 grants Equality before law, Article 15 encourages the State to make special provisions for women and Article 38 declares that the State has to secure a social order for the promotion of welfare of the people. Women’s entitlement to sexual and reproductive rights and health is affirmed through Constitutional guarantees and court rulings in India, which provides an opportunity for rights claiming through this normative framework. Further, the Reproductive and Child Health (RCH) programme of the government has declaredxiv ‘it is the legitimate right of the citizens to be able to experience sound

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Reproductive and Child Health and therefore the RCH programme will seek to provide relevant services for assuring RCH to all citizens’. The right to abortion is currently not recognised under law. However, the state permits abortion through its Medical Termination of Pregnancy –MTP Act (1971, amended 2003). The MTP Act has considerable freedoms for women choosing to undergo an abortion in that a woman is not required to get any other person’s consent for MTP if she is an adult. The MTP Act permits abortion if “the continuance of the pregnancy would involve a risk to the life of the pregnant woman or of grave injury to her physical or mental health” and any woman above 18 years can freely seek abortion services without any other person’s consent. The state also promotes safe abortion through the same Act, which specifies that abortion may only be performed at government or ‘approved’ hospitals. However, there continues to be a contradiction in that ‘forced miscarriages’ are considered criminal according to the Indian Penal Code and this has not been changed yet. Forced “miscarriages” are criminal (Indian Penal Code, Art. 313). The Indian Penal Code (Art. 314) specifies punishment for “miscarriage” that leads to a woman’s death. Further, forced sex-selective abortions are declared illegal in the Pre-Natal Diagnostic Techniques Act (1994). Apart from that there is also a National Maternity Benefit Act of 1961, which provides for 12 weeks’ maternity leave for working women, and recognizes that women are entitled to leave with pay when they go through childbirth. The Child Marriage Restraint Act (1929 amended 1978) was meant to prevent early marriages and consequently protect girls from early pregnancy. The Indian Penal Code also has a provision (304 –A) for punishing medical negligence. Similarly under the Consumer Protection Act, patients may seek compensation for suffering injury or loss due to medical negligence. The implementation of law However, a major challenge is that the laws that exist to protect maternal health are violated with impunity. For example, the law to provide abortion on request and ensure safe abortions is also violated: about 10% are performed with the supervision of a health care services (Jejeebhoy 2000:158). Only one-quarter of PHCs in Uttar Pradesh and Maharashtra provide abortion services, in Gujarat and Tamil Nadu, it is one-third and two-third. Where CHCs are concerned, about 59% in Uttar Pradesh, 78% in Gujarat, 89% in Maharashtra and 95% (CHCs and Sub district hospitals together) in Tamil Nadu provide abortion care services. In Maharashtra and Tamil Nadu less than one-fifth abortions take place in government health center.xv Moreover, where women are able to access legal abortion, they are compelled to provide their husband’s consent and have to bear heavy costs.

In a study done by Cehat2 (136 cases reported) private health providers provide eighty-two percent of all abortion services.

The average cost per abortion was Rs. 1415.36, being Rs. 1746.52 for induced abortions and Rs. 113.71 for spontaneous abortions.

2 Draft report of RAI Study, CEHAT 2004

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In another collation of information (by Cehat) from 36 PHCs through a structured questionnaire, it was found that only two PHCs offered MTP services. Abortion services are available at the PHC when sterilisation operations take place only; and these are charged for illegally depending on how many months the pregnancy has advanced.

Husbands’ consent was required in 87% of all instances of abortion, across the private and public sectors, as well as urban-rural settings.

Source: Tathapi, 2004 Similarly the law on minimum age at marriage is not enforced although it puts millions of young women at risk of early pregnancy with a high possibility of complications. The prevention of under-age marriage is complicated by the inability of state machinery to register all marriages. Overall age at marriage for females marginally increased from 17.2 years in 1971 to 18.4 in 1981, and 19.3 in 1991. According to NFHS II the female age at marriage was 19.7 in 1998-99. However, there are wide differences across the country. In some states (AP, Katnataka, Tamilnadu) there is no difference in the nearly ten years between 1991 and 1998. The lowest mean age at marriage is in AP and Rajasthan (18.3 years). Manipur and Goa have the highest mean age at marriage of about 25 years. In Maharashtra, which has 4.41 million adolescent girls, nearly 2 million become mothers before reaching 20 years of age. More than 50% of girls within the age group of 15-19 have anaemia. Of the girls married at this age, the rate of pregnancy is higher among those who are illiterate. Fertility at age 15-19 accounts for 26 %, indicating that there is a substantial amount of teenage fertility in both urban and rural areas of Maharastra (NHFS-2).xvi The National Maternity Benefit Act, 1961, protects the rights of women workers. However, male partners are not granted paternity leave to support the women in child rearing. Moreover the Act specifies that only working women with a continuous employment record qualify for this paid leave, which does not recognize that most women are compelled for gendered reasons to work in the unorganized sector where they do not get continuous employment. Under the National Maternity Benefit Scheme, maternity benefit in the form of one-time cash assistance is provided to women of households below the poverty line. Only pregnant women for up to the first two live births provided they are of 19 years of age and above are eligible. Thus, young married girls who have to prove their fertility and become mothers at an early age are excluded. Policies around maternal health India has recently formulated a number of policies that mention maternal health including the National Population Policy (NPP, 2000), the National Health Policy (NHP, 2002) and the National Policy for Empowerment of Women (2001). The policy prescriptions of the National Health Policy are largely reflected in the Tenth Five Year Plan. A National Nutrition Policy has been formulated in 1993. Some of the states have also formulated their state level Population Policies. The Reproductive and Child Health (RCH) programme of the government is the key implementation mechanism for sexual and reproductive health and rights (SRHR) interventions. It is now entering its second phase as RCH II. A National Rural Health Mission (NRHM) has also been recently announced (April 2005) to make primary health care delivery more effective.

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The National Population Policy (NPP) 2000 lays out its long term, medium term and immediate objectives as stabilizing population by 2045, bringing the Total Fertility Rate (TFR) to replacement levels for contraception, while providing integrated services for basic reproductive and child health care, respectively. The Policy states fourteen National Socio Demographic goals to be achieved by 2010, among which it has set the goal of reducing Maternal Mortality to below 100 per 100,000 live births by 20103. The Traditional Birth Attendants (TBAs) have found their place in the NPP 2000 while they were ‘missing’ in the 1997 RCH Document. The policy highlights the increasing role of the private health sector in secondary and tertiary level care and speaks of the need for statutory licensing, regulation and monitoring to ensure minimum but adequate standards of diagnostic centers. The National Population Policy 2000 appears to recognize the serious nature of the problem (para 16) and considers maternal mortality a social justice issue. Despite this concern for maternal health, the NPP continues to be primarily concerned with population projections. Another challenge is that the interpretation of the National Population Policy has been different in different states, with a strong emphasis on reducing fertility rather than ensuring health. For example, in the population policies of Gujarat and Uttar Pradesh states, the paragraph on Objectives reveals a domination of demographic objectives like Unmet Need for Contraception, reducing the Total Fertility Rate (TFR) and increasing Contraceptive Prevalence Rate (CPR). With special reference to maternal health, one objective of the Gujarat Policy is to reduce MMR to 100 per 100,000 live births by 2010. However, a reading of the policy does not clarify how this would be done. This anomaly is also present in the State Population Policy of Uttar Pradesh, which aims to reduce maternal mortality from 707 in 1997 to 394 by 2010. The National Health Policy (NHP) 2002 sets a goal of bringing down the Maternal Mortality Ratio to 100 by 2010. The NHP analyses that “Social, cultural and economic factors continue to inhibit women from gaining adequate access even to the existing public health facilities,” but it goes on to take an instrumentalist approach to women. Rather than recognizing women’s right to health care on its own merit, it addresses women only as catalysts for improving the health standards of the community. There is neither a gendered analysis of women’s different needs nor recognition of disadvantages women face in seeking healthcare. On the other hand, the National Youth Policy (2003) has an acknowledgement that (para 5.2) “prevailing gender bias (is) the main factor responsible for the poor status of health … of women in our society.” In terms of promises, the National Youth Policy (2003) (para 5.2) enunciates that: (b) Women will have access to adequate health services (including reproductive health programmes) and will have full say in defining the size of the family. (e) Young men, particularly the male adolescents shall be properly oriented, through education and counseling to respect the status and rights of women. Some key objectives of the Tenth Five Year Plan included reduction in IMR to 45 per 1000 live births by 2007; and reduction in maternal mortality ratio to 2 per 1000 3 Other goals include the promotion of marriage at a lower age for girls, and compulsory and free education for all up to age 14; complete registration of all births, deaths, marriages, and pregnancies; and prevention of communicable diseases (NPP 2000:3)

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live births by 2007 and to 1 by 2012. The Tenth Five Year Plan puts forth a commitment to providing essential primary health care, emergency life-saving services and family welfare free of cost to all. It also commits to introducing “quality control concepts and tools … into every aspect of health care …to ensure … defined and institutionalized norms, accountability and responsibility.” The Plan gives emphasis to maternal health services including essential and referral care. It also lays emphasis on improving and expanding women’s access to early and safe abortion. Some major debates and perspectives on the issue Some major debates emerge from the history and policy positions above, such as the debate around causes of maternal ill-health and death, debates between technical solutions as opposed to a broader consideration of socio-economic determinants, the homebirths versus institutional delivery debate, around abortion, integrated public health approach versus MCH as a vertical programme and so forth. Some of these are elaborated below. Causes of maternal ill health and death Research over the last several decades has investigated the causes of maternal ill health and death towards identifying solutions. One approach sees maternal death as caused by anaemia, bleeding, sepsis, obstructed labour, eclampsia and abortion complications. Other factors that heavily influence maternal well-being but are outside the direct ambit of pregnancy are ignored, such as nutritional status of girl children, early child-bearing or long-standing infectious diseases that may be exacerbated during pregnancy. Additionally the cultural meanings of health and illness within a particular community impact greatly upon women’s access to timely and appropriate care. The bio-medical analysis often leads to techno-centric programme solutions, such as ‘screening of high risk cases’ and ‘emergency obstetric care’. It could minimize interventions to just preventing anaemia and unwanted pregnancies. The vertical approach has the risk of working with reductionist formulae such as “MH = ANC+ INC+ PNC4” or “ANC= 2 TT + 100 FFA + 3 check ups5” in which the complex negotiations of pregnancy and childbirth are reduced to a set of easily recorded services. This approach bypasses the political process of decision making regarding seeking healthcare, and erroneously presumes that once services and infrastructure are in place, they will by default function optimally to ensure healthcare to poor women. Against this, Trollope-Kumar (1995) argues, “the socio-cultural context is the matrix within which the problem of maternal mortality is negotiated and experienced…an analysis of problem recognition within the socio-cultural context needs to begin at the household level where illness perception, illness meanings, behaviours and strategies are first negotiated….” Jeffery, Jeffery and Lyon (1989) in their study of two villages in western Uttar Pradesh point out that ‘women’s medical services have a lower priority within the structure of health service provision than those for children or men, and their quality is poorer; … Maternal and child health services 4 Maternal health = Antenatal care + intra-natal care + postnatal care 5 Antenatal care = Two tetanus toxoid injections + 100 tablets of Iron Folic Acid + three check ups

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are approached cautiously (by rural women), because the women want to avoid putting themselves in debt to the health staff.’ Regarding hospital-based care, they observe that ‘medical treatment may be provided in a very demeaning and threatening manner. …Often treatment appears conditional on agreeing to contraception (which would be a further deterrent if the family feels the woman has not attained her desired family size).’6 Homebirths versus institutional delivery Another long-standing debate is around the role of traditional birth attendants or TBA, dais and home births. Global and national policy has swung between skilled facility-based care and community-based care, detracting from steady progress in both, for community and clinical care are both important components of a functional health systemxvii. The current insistence on institutional delivery as the only way of ensuring maternal health can compel the poor to lose what home-based care they have now. In states with low institutional delivery, the existing state services for safe motherhood are often culturally unacceptable and therefore poorly utilized. Here the trained TBA is uniquely positioned to prevent maternal mortality and morbidity since she is easily available, women already see her as an essential part of the birth process, and women themselves can make the decision to use her services. While the range and quality of the TBA’s services can be upgraded and she can facilitate access to referral services, thereby bridging the cultural divide, yet it would be fallacious to equate TBA training with ensuring safe motherhood. This is becasue the position and influence of the TBA varies from one community to another. In some places the birth attendant is simply an older woman in the family or neighborhood who comes for support during labour. The cord and placenta may not be touched by anyone other than those ritually polluted such as the ‘lower caste’ sweeper or masseur or the birthing mother herself. The trained TBA’s status and identity may profoundly affect her ability to negotiate safe childbirth for the mother, as might the current beliefs about ritual pollution in childbirth. The TBA’s retention of the new learning is also influenced by the extent of supervised practice and the reinforcement from successful deliveries or referrals. Yet in many areas, doctors in referral hospitals regard TBAs with contempt (Trollope-Kumar, 1995). It emerges that capacity building for TBAs must be implemented simultaneously with extensive community education about maternal health, and with supplemented with transport and referral linkages. It is also imperative to improve the quality of institutional care for pregnant women in (including reorientation of the providers’ perception of TBAs). In practice however, the training of TBAs has often been limited to making them learn the ‘five cleans7’ without addressing important issues such as the status of the TBA in the family of the childbearing woman, and the recognition of the TBA’s role by health providers in referral hospitals. The RCH programme has had since October 2000 a scheme of training of traditional birth attendants (TBAs) or dais in 142 districts of India. An evaluation of the programme in the Dangs district (Gujarat) however showed that none received a certificate and identification card after being evaluated, and neither did they receive any follow up 6 Jeffery et al 1989, pg. 202-217 7 These include - clean place, clean hands, clean thread, clean blade and clean cord

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support by the ANM or doctor. (Das, Dey, Bhatt and Patel, no date). An NGO in Gujarat describes a seven year struggle to get the local TBAs trained (ANANDI, Gujarat)xviii. In the earlier Ninth Plan, a training programme for Traditional Birth Attendants (TBAs) was started in 15 states. However the current policy position in the Ministry of Health and Family Welfare with reference to the RCH II, is emphasizing the ‘Skilled Birth Attendant’ in place of the TBA. The SBA is a literate woman who will be provided training by the government but expected to provide services in the community for payment that she negotiates on her own. In fact the current policy and donor discourse across the country heavily favours institutional delivery, although five-sixths of deliveries are usually normal and can be done at home. Studies have shown that roughly one-sixth of all deliveries can develop complications and need expert supervision and care. This means that all deliveries do not need to come to institutions but there needs to be a very effective system of screening before the onset or during labour and a efficient means of referral. Today if in fact all women from the villages of the EAG states started approaching their local PHC for delivery services they would most probably be faced with absent doctors, unavailable beds, dysfunctional labour-rooms, no ambulance facility for referral to the Emergency Obstetric Care if necessaryxix. There would be no guarantee that the designated EmOC would be functional Technical solutions or socio-economic determinants There are also debates about whether maternal health can be ensured through technological and medical interventions, or whether maternal health is a function of a wide range of socio-economic determinants. For example, in order to achieve safe motherhood, Maine (1991)xx suggests the following priorities: Priority One: Ensure access to medical treatment for obstetric emergencies

(including improving existing referral facilities to handle obstetric complications, upgrading the ability of peripheral facilities to provide obstetric first aid, informing the community about danger signs during pregnancy and delivery and working with the community to improve access to emergency care)

Priority Two: Reduce exposure to the risks of unwanted pregnancies (including providing accessible and acceptable family planning services and safe abortion services)

Priority Three: Establish and improve other maternal health services (including training of TBAs to refer and treat women with complications, improving prenatal care services and establishing maternity waiting homes)

This is largely affirmed by RamaRao et al (2001). Jejeebhoy (2000) additionally suggests addressing adolescent child-bearing, empowering women to take charge of their pregnancy related needs and addressing health system inadequacies for making motherhood safe. The “Four Delays Modelxxi” argues that women who experience life-threatening complications often never receive the required life-saving emergency services because of what are now called the “four delays”. These delays can result in

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maternal mortality or increase the severity of morbidity, and so interventions should attempt to minimize these delays in order to save lives: Delay 1: Delay in recognizing the problem (lack of awareness of danger signs) Delay 2: Delay in deciding to seek care (inaccessible health facility, fear of costs, lack of resources to pay for services, supplies and medicines) Delay 3: Delay in reaching the health facility (no transport available, unaware of appropriate referral facility) Delay 4: Delay in receiving adequate treatment once a woman has arrived at the health facility (health facility not adequately equipped, lack of trained personnel, emergency medicines, blood), Qadeerxxii on the other hand identifies inequitable social and economic structures, poverty, gender discrimination in health services, low welfare inputs by the state and poorly developed health services as the reasons behind high maternal mortality. The socio-economic analysis recognises that long term change can only be brought about by challenging the status quo: by implementing equitable development policies, by ensuring women’s social and economic empowerment, by improving comprehensive public health services and making them accountable to their users, and by ensuring equitable access to emergency care. Apart from the medico-technical or socio-economic analyses, development theorists and practitioners, using the different perspectives of ‘rights holders’ and ‘duty-bearers’, are also exploring models of agency and rights. These include, on the one hand, the inability of ‘rights holders’- girls and women to negotiate all the entitlements8 that promote safe motherhood, as a result of which their vulnerability to maternal mortality and morbidity is increased. On the part of the ‘duty-bearers’- the state actors, this would include lack of accountability for poor and inadequate services, poor enforcement of laws that promote maternal health, poor regulation of the private sector and absence of effective grievance redressal forums in cases of rights violations. Debates around abortion There is a polarization of viewpoints regarding ensuring access to safe abortion. At one level, there is a reluctance to include abortion services as a part of ‘safe motherhood’ since it implies ‘choosing not to be a mother’ which is conflicts with the cultural image of ‘motherhood’. The preferred approach is to link it with failed contraception and family planning services. In actual terms this means women who come in for the service providers who are anxious to ‘control population’ may coerce women seeking induced abortion to accept a terminal method of contraception. This however does not address the fact that roughly 10% of all pregnancies result in spontaneous abortions that also require treatment. In 1971, an act for Medical Termination of Pregnancy made abortion legal in India, although it is debatable whether it gave women rights to abortion. The regulations within the Act made it difficult for rural women to access abortion, since the certification of clinics has become a bottleneck. There were over 22,010 PHCs; 2,662 CHCs and 13,692 Hospitals in India in 1997, all of which were eligible under the MTP Act to offer MTP facilities. Of these only 8,891 (23.2%) have been 8 Nutrition, choices regarding marriage, safe sex, quality information and services, and influence over political processes that decide policy and resource priorities

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approved MTP institutions in 1996-97. These institutions conduct, on an average, 61 legal induced abortions every year, which falls far short of the actual abortion figures (see Table Three above). While the medical and legal fraternity consider ‘safe’ to be the operative word, and would rather place restrictions on when abortions can be performed and by whom, women and health researchers and NGOs have been urging that ‘access’ is more crucial and therefore abortion should optimally be provided by the ‘least technically trained provider available.’ As such capacity building of community level providers to perform first trimester Manual Vacuum Aspiration has been permitted but on a restricted scale in the new RCH II programmexxiii. Another threat to abortion access has come from the findings of the recent Census. An alarming rise in sex pre-selection of children has become evident from the steady drop in under-five sex ratioxxiv in a number of affluent states such as Gujarat, Haryana, Himachal Pradesh and Punjab. This has occurred despite the existence of a law to prevent pre-natal diagnostic testing (PNDT Act, 1996). The suspected use of pre-birth elimination methods has led to a call to revise the act and concurrently revise the MTP Act to reduce abortion access and thereby prevent its ‘misuse’. The use of words like ‘female foeticide’ has become popular in the movement to combat the declining adverse sex ratio and religious groups have become active in building public opinion against the pre-birth elimination of the girl child. Unfortunately, women’s organisations have also accepted the pro-life and anti-choice rhetoric being used by such bodies, thus contributing to the anti-abortion discourse.

• The current status Services The goals set out in the various polices are extremely ambitious, yet the situation of maternal health in India does not seem to be improving. Policy and programme indicators in India have always stressed family planning and immunization indicators to the detriment of quality and efficacy of maternal health services. This insistence on family planning coverage also de-skilled the 150,000 Auxiliary Nurse-Midwives (ANMs) who were originally meant to provide maternal health services at the community level. The combined effect of dilution of ANMs’ skills and withdrawal of support to TBAs has created a void in safe childbirth services in at the community levelxxv. The nature of vertical programmes is to oversimplify the issue: thus safe motherhood was limited to selected targeted interventions such as antenatal registration, administration of Tetanus Toxoid injection and distribution of iron and folic acid tablets that are equated with ‘antenatal coverage’; promotion of institutional deliveries is assumed to lead to low maternal deaths. Short-term populist schemes like the Vande Mataram Scheme9 or organizing camps and ‘melas’ (health fairs) that have no follow up support to those availing treatment are used in place of serious long-term strategies to tackle the issue. Despite the very real threat of maternal death due to haemorrhage and severe anaemia, access to blood transfusion in rural areas is almost nil. For example, all the First Referral 9 A free ante-natal clinic once a month by private practitioners

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Units (FRUs) in Madhya Pradesh and 118 FRUs in Uttar Pradesh lacked blood transfusion facilitiesxxvi. The more substantive actions that the RCH I Document talked of in 1997 have not been done all these years later. For example, 24-hour delivery services were to be set up in CHCs/ PHCs, transport for referrals were to have been made available through Panchayatsxxvii. According to the RCH II documentxxviii, the RCH Facility Survey revealed that FRUs / CHC and district hospitals attended only about 10 referred cases of delivery in a month.

o Only 36% of PHCs had adequate physical infrastructure. o 31% PHCs had adequate supplies o Out of every 10 PHCs, 8 have no Essential Obstetric Care Drug kit o 34% PHCs offer delivery services, 3% offer abortions o Only 10% of the CHCs and FRUs had adequate supplies o Only 56 % PHCs, 49% CHCs and 89% District hospitals have all critical

supplies (defined as 60% of critical inputs) o 38% PHCs had adequate staff in position o Out of 10 CHCs, 7 have no obstetrician, 8 have no pediatrician o 25% of CHCs and 46% FRUs had adequate staff

The government is also unable to ensure that doctors and nurses reside in the Primary Health Centres or Sub-Centres or in the same village, and is unable to provide accommodation for all of them. The absentee rate of health care workers in Primary Health facilities (average for 17 states) is 40% in India, second only to Indonesia. Doctors have a higher rate of absenteeism than other health workers (World Development Report 2004). With these kinds of statistics it is difficult to expect 24-hour services for safe childbirth. As a result, emergency obstetric care continues to be inaccessible to many rural women. In Maharashtra, feedback from 36 PHC areasxxix shows that 17% of PHC had no public transport facility to reach the centre at night, while 8% reported no transport at all. One in three doctors do not stay at the PHC, while the number of PHCs that did not have adequate facilities – such as water (50%), Vehicle (39%) laboratory facilities (31%), no adequate medicines (86%). The number of PHCs reported, as not having any facilities even for deliveries was as high as 14%, while 36% reported no gynecological care given. The number of registered abortions in India was 5,80,744 in 1990-91. These increased to 7,23,142 in 2000-01 (GOI, 2001). But a large number of abortions are being provided without being recorded, some by private practitioners who are not registered under the MTP Act. The ratio of illegal to legal abortion ranges from 3:1 to 8:1. Between 12-20% of maternal deaths occur due to septic abortions performed under unsafe conditions. Around 15000 to 20,000 abortion related deaths are reported each year. The percentage of deaths due to abortion was 11.8% in 1990 and 17.6% in 1995 (GOI-RGI, 2001). UP has the highest estimated rate of abortion in the country. Over 20 lakh abortions take place in the state of Uttar Pradesh every year of which about 60% are induced. Complications from abortion are responsible for 15 – 30% of all maternal deaths in the state. Serious complications of unsafe abortion include infection, bleeding, and injuries to the reproductive tractxxx.

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Despite the promise of a comprehensive range of services within the Reproductive and Child Health Programme (GOI, 1997), the data collected from three states of Uttar Pradesh, Maharashtra and Gujarat indicates that although services are reaching some women for prophylactic ante-natal care, state services for delivery, post-partum care and safe abortion are poor. This is despite the fact that Gujarat and Maharashtra are two states with the highest development indicators - these have not yet translated into better health services for womenxxxi. Women’s Experience – Case studiesxxxii of Uttar Pradesh

A study of twelve case studies from Uttar Pradeshxxxiii brings out an aspect of women’s experiences of maternal health services in India. The cases show denial of services and information with an absence of accountability of the public healthcare system and unregulated private providers. There are cases of mortality due to complications in childbirth, post-abortion complication and post-partum complications or heavy bleeding. There are also cases of morbidity due to repeated miscarriages, complications in pregnancy, delivery or at the post-partum stage. At the outset it is clear that women or their families in Uttar Pradesh do not receive information about routine care, danger signs or where to seek services in pregnancy, abortion, childbirth and post-partum stages. This has led to as many as seven or eight pregnancies, several of them unwanted. Some repeated pregnancies are due to repeated miscarriage and infant mortality. This lack of information has had fatal consequences as women go through high-risk pregnancies and seek care from unqualified providers, leading to deaths. The lack of information to young and sexually active women has led to unwanted pregnancy and providers have actually misled them into seeking unsafe abortion services, leading to death. Lack of information about entitlements prevents women from negotiating affordable care at state-run facilities, or families from initiating legal action against those responsible for willful medical negligence. Apart from information, a large number of the cases had been deprived of routine service as well as emergency services for maternal health. Women have never been visited by the ANM and those who have been registered by their ANM have not been screened for obvious danger signs or referred to a hospital. In two cases the pregnant women who came to the PHC ended up with illegal abortions performed by the ANMs. In case of emergency, the ANM was unavailable and quacks provide the first level of services. In one case the PHC doctor turned away the patient without even opening his door to see her, in one case there was no woman doctor present in the entire district, in two others, women with complications were turned away because there was no doctor at the hospital. In two cases, doctors did not see women who came to the hospital in labour. Whatever services are provided are accompanied by extortion, whether by quacks or by state-run hospitals. Service costs are largely unaffordable for the poor families: in one case after the women died, the doctor had to contribute the money for the family to take the body back home. Poor women who cannot pay ‘enough’ are beaten and harassed, even thrown out while in the second stage of labour. Delivery in hospitals may lead to sepsis whereas services provided by quacks are of dubious quality and may lead to death.

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The health system has no feedback mechanism to detect all these errors of omission and commission, despite their fatal consequences. Women and their families are not compensated for the neglect of providers that causes them grave losses. In one case, the Enquiry Team sent by the department actually tried to injure the woman to the extent that she developed sepsis and was close to death. The untrained local providers enjoyed influence with the local police to the extent that the case for death by negligence could not be registered in one case without a struggle. When the families are too poor they are unable to take on the challenge of registering a case. The question of recording medical evidence is also difficult since providers are reluctant to implicate each other. Finances India has been spending under 0.93% of its Gross Domestic Product on healthcare, which is among the lowest in the world. It is even lower today than the 1.3% of the GDP that was achieved in 1985-86. Of all the health expenditure in the country, 17% is borne by the government (comparatively, in Sri Lanka 45.4% is borne by the government), the rest of the costs are borne by the people, making this the country with the most privatized healthcare in the world. In 2000, there were 18,218 hospitals in India of which 75% were private. National surveys show that the proportion of people who can no longer afford healthcare has doubled between 1986 to1995.xxxiv There are no separate budget lines for Maternal Health or for Sexual and Reproductive Health in India. Part of the services is provided within the Family Welfare Department (prophylactic services) and curative or hospital based care is provided by the Department of Health. Currently the two departments have been merged. In 2004-2005, the share of health in the overall Government of India budget was 2.1% at Rs. 10025 crores (the target is 25% of total government spending by 2010). Various UN agencies, multilaterals and bilaterals also contribute significant technical and material assistance to SRHR programmes in India. The World Bank and UNFPA contributed USD 348.3 million and the EU contributed 200 million Euros between1997-2002 for the first phase of the Reproductive and Child Health Programme. The central and state governments equally share spending on most national health programmes, with the central government spending on disease control and family planning programmes, while the states spend on the primary secondary and tertiary healthcare institutionsxxxv. The states, which bear between 75% to 90% of the burden of public health spendingxxxvi, have their funds largely tied up in “non-plan” salary expenditures, leaving little room for essential drugs, supplies, operations and maintenance. Curative services are highly pro-rich in distribution. Three times more money is spent on the richest 20 percent of the population compared to the poorest 20 percent. Government spending on health per capita is seven times lower in rural areas than urban areas. There were 12500,000 doctors and 800,000 nurses in India in 2000, but the ratio of doctors to population in rural areas is six times lower than that of urban areasxxxvii. More than 94% of doctors and 68.5% of hospitals are located in urban areas where 27.8% of the population residesxxxviii.

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Health sector reforms (HSR) have been started in several states of India with external support. The HSR in Tamil Nadu (2004-10), Uttar Pradesh (2000-05), Rajasthan (2004-09) and Maharashtra (1998-2005) have World Bank support, and are expanding the involvement of the private sector in service provision, including franchising, contracting and social marketing of services. However, there has been no increased coverage of rural or underserved areas or groups, and the weak accountability provides no guarantee for quality of services. HSRs in the three states have reduction of MMR as an indicator, with the surprising exception of UP; however, none have a focus on safe abortion or adolescentsxxxix. User charges for health care services apply at some public facilities including hospitals, in some cases with exemptions for the poor. Less than 10% of the population is covered by health insurancexl, and the insurance is often private. Abortion and childbirth are often not included within the insurance coverage. Overall, the efficiency and cost effectiveness arguments have weakened equity and rights in maternal health care. Costs in Maharashtra

In Mumbai, it is reported that women are charged Rs. 500/- (receipt is given) for a third or higher order of delivery. This amount is refunded if and when the woman returns for a sterilisation operation [Alert India].

At the Osmanabad district Hospital, the rate is displayed and delivery is free only if accompanied by a tubectomy operation. [TISS]

Five case studies of denial of services for childbirth show that women are not admitted or attended by PHC staff even when they are in labour. In case of complication, there are attempts at extortion.

[Source: Tathapi, 2004]

• Strategies that have been used or can be used to address the issue and for movement building around the issue

Strategies in use Currently there are several strategies that are being used for movement building around the issue. These include the Primary Health Care approach using grassroots health workers used by a large number of community health NGOs trained by the Voluntary Health Associations across the country, the Sexual and Reproductive Health and Rights (SRHR) movement post-Cairo (1995 onwards), the movement for promoting the traditional knowledge of TBAs led by the Women and Health WAH! Group, and the Right to Health strategy of the People’s Health Movement (PHM) that has been active since 2000. The community-based health care model used by a large number of NGOs has provided information and basic services for maternal health at the grassroots level, often at the very doorstep of the women through community health workers. The services have usually included antenatal registration, check-up and prophylactic care, screening for high-risk and referral advice, training of community birth attendants and distribution of safe delivery kits. These services have succeeded in reducing maternal deaths when the NGO itself provides strong linkages to referral obstetric services for the emergency cases. But in the absence of this crucial component, there are complex negotiations in accessing emergency care that lead

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to doubtful maternal health outcomes, especially for poor and marginal communities. The post-Cairo efforts around SRHR led to focus on neglected issues such as Reproductive Tract Infections, information and services for adolescents, safe and women- friendly contraceptives, mental health, abortion, violence against women and addressing men as responsible partners. Apart from strategies such as research and interventions, groups also advocated for policy change at the national level, and promoted policy participation through consultations and monitoring studies. Additionally public hearings and tribunals organised by NGOs focused media attention on rights violations within coercive population control programmes. Litigation was also used to challenge the quality of care provided within the government family planning programme. While not focusing exclusively on maternal health, the SRHR approach has broadened the understanding on reproductive health and the associated rights issues involved, both in the public and private realm. The TBAs were occasionally provided training by the government but overall the attitude of providers towards them is laced with contempt. This often affects the quality and promptness of emergency obstetric care for pregnant or post-partum women referred or brought in by a TBA. It also affects the future motivation of the TBA to accompany women to the hospital. In an effort to counter this, there has been a movement to provide TBAs with credibility and confidence by creating trade unions and federations of trained TBAs. These unions have been able to negotiate the accreditation of the TBAs with the local health providers and health administration, especially in Gujarat. However, the successful role of the TBA in averting maternal deaths often depends on whether the health facilities are able to provide the emergency services required in time. Unfortunately, this is not the case in several states of India (RCH II Plans of Implementation, Pg 17, 2003). The Right to Health movement has relied on economic data and hard evidence to make a claim and supplemented this with appeals to the National Human Rights Commission (NHRC). The NHRC has held a series of hearings across the country on the violations of the Right to Health; these however included all healthcare issues, not just the problems around maternal health. However, the PHM evidence highlighted the enormity of the problem of maternal health in India, and has resulted in acknowledgment by policy makers. Strategies that can be used A number of bio-medical and social interventions have already been suggested by researchers (Maine, Jejeebhoy, the Four Delays model etc) in which essential information for the pregnant woman, her family and the community and adolescents have been proposed, as well as an essential package of routine and emergency maternal health services within the framework of primary health care. Access to effective emergency obstetric care must be ensured for all women through strengthening First Referral Units (FRUs) with 24x7 services including critical infrastructure and supplies. Support and training of TBAs needs to be supplemented with strong linkages to FRUs, however, it is important that institutional delivery is not made obligatory. ‘Registered medical practitioners’ can

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be encouraged to save women’s lives through bridge courses in basic obstetric care. Agency and Rights In terms of future strategies, it may also be worthwhile to explore models of agency and rights, from the perspective of rights holders and duty-bearers. This would include, on the one hand, the ability of girls and women to negotiate all the entitlements that promote safe motherhood such as accessing nutrition, being supported in making choices regarding marriage, negotiating safe sex, increasing citizen voice to demand accessible high quality services and finally, increased influence over political processes that decide policy and resource priorities. On the part of the state actors this would include accountability for the accessibility, quality and range of services provided, strict enforcement of laws that promote maternal health, strong regulation of the private sector and effective grievance redressal forums in cases of rights violations that are accessible to the poor and marginalized. This would therefore require certain interventions at the community level that raise information and awareness about health entitlements, work with special groups such as adolescents, men and youth, building awareness on citizenship and gender, supporting movements that raise the demand for improved policy and resource allocation at every level. This would also imply building civil society capacities to engage in policy analysis, monitoring of policy and programme implementation and budget review. Skill building is also required for documentation of rights violation, and in various advocacy strategies. Advocacy is needed for example to press for the enactment of laws and rules to enforce minimum medical standards to ensure quality of care in maternal health services, to review discriminatory laws and put in place a more transparent system of grievance redressal. Donor policies also need to be monitored to guard against vertical programmes as against a more broad-based primary health approach. On the side of the ‘duty bearers,’ technical skill building and re-orientation of health providers would be required to provide the services required, apart from strengthening of regulatory, monitoring and grievance redressal systems, and provisions for horizontal and vertical oversight of policy and programmes with strong civil society participation. Transparency and accountability could be promoted, for example, with strict monitoring of absenteeism and illegal private practice through committees with citizen involvement. State systems of vertical oversight such as audits need to also incorporate impact and performance criteria. Moreover, reviews or social audits of maternal deaths could be conducted to identify malpractice or system failures, and accessible forums constituted for grievance redressal of women or their families.

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Endnotes i With inputs from Dr. Abhijit Das, TATHAPI Pune, WOHTRAC Vadodara, CHETNA Ahmedabad and ANS-WERS Hyderabad ii Jejeebhoy, Shireen in Ramasubban, Radhika. Jejeebhoy, Shireen (editors). Women’s Reproductive Health In India. Rawat Publications, Jaipur and New Delhi, 2000. Pg.134 iii Federation of Obstetricians and Gynecologists Society of India iv Rawal, Asha, ‘Trends in Maternal Mortality and Some Policy Concerns’ in Indian Journal of Community Medicine Vol. XXVIII, No.1, Jan-Mar 2003 v Prakasamma, Dr. M., et al, Ten Years After ICPD - India Country Monitoring Report, ARROW, 2004 vi Das, A. (2004) Improving Quality of Care of Reproductive Health Services in India: An Advocacy Handbook, Population Foundation of India vii Dr. M. Prakasamma ibid viii Qadeer, Imrana (2005), Paper presented at the SID-SAN and Shirkat Gah Regional Conference on ‘Maternal health in South Asia: Strategies for meeting the MDGs ix Dr. M. Prakasmamma (pg 2) x Pachauri, Saroj: NGO Efforts to Prevent Maternal and Infant Mortality in India, Social Change, Sept-Dec 1996, 26(3-4) xi RamaRao, Saumya, Leila Caleb, M.E. Khan and J.W. Townsend, 2001. “Safer maternity in rural Uttar Pradesh: do primary health services contribute?” Health Policy and Planning 16 (3): 256 -263 xii The RCH Programmes for Implementation says ‘it is the legitimate right of the citizens to be able to experience sound Reproductive and Child Health ...’ (RCH, Pg 3, GOI, 1997).

xiii In Bandhuva Mukti Morcha v. Union of India (1984) 2 SCR 67: (AIR 1984 Supreme Court 802) Bhagwati, J. while affirming the proposition that Article 21 must be construed in the light of the Directive Principles of State Policy observed thus (at pp.811 and 812 of AIR): "This right to live with human dignity enshrined in article 21 derives its life breath from the directive Principles State Policy and particularly clauses (e) and (f) of Article 39 and Article 41 and 42 and at least therefore, it must include protection of the health…

xiv RCH Programme, Schemes for Implementation (Pg.3) GOI, October 1997 xv Abortion Assessment Project India report 2004 (CEHAT and Healthwatch Trust) xvi Women’s Access to Health Care in Maharashtra (Tathapi Report on Monitoring CEDAW Implementation, 2004) xvii DFID Health Resource Centre: ‘Clinical versus community-based care: a conflict? Quick guide through the key issues’ by Joy Lawn with Zulfiqar Bhutta xviii “Maternal Mortality in Gujarat: CEDAW monitoring report” WOHTRAC with inputs from ANANDI, DCT and others (2004) xix Case studies from ‘Women’s Voices’ the CEDAW Monitoring Report for Uttar Pradesh (KRITI, 2004) amply demonstrate this xx As quoted in Bullough, 2000, pg 16 xxi Ransom, Elizabeth I. and Nancy V. Yinger, Making Motherhood Safer – Overcoming Obstacles on the Pathway to Care, Population Reference Bureau, Feb 2003 (pg 4) xxii Qadeeer, ibid xxiii GOI Website – Maternal Health Programme GoI.htm (Visited 2 August 2005) xxiv Census 2001 xxv Dr. M. Prakasamma et al 2004 xxvi Report of the Comptroller and Auditor General, Govt. of India, 2001 xxvii Local elected councils xxviii RCH II Plans of Implementation, (Pg. 17) 2003 xxix Collation of information on 36 PHCs, Mukta Project, CEHAT, 2004 xxx Study report of Johns Hopkins University – www.jhpiego.org/pubs/TR/tr516sum.htm xxxi Tathapi 2004

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xxxii Uttar Pradesh cases:

1 Ramadevi, 35 Hardoi dist. Complications in delivery-Death 2 Bhori, 35 Chitrakoot dist. Repeated miscarriages-Morbidity 3. Somari, 26 Mirzapur dist. Postpartum complication -Death 4. Besania, 26 Chitrakoot dist. Postpartum haemorrahge-Death 5. Radha, 18 Sitapur dist. Post-abortion complication-Death 6. Santoshia, 25 Chitrakoot dist. Complication in pregnancy-Morbidity 7. Meena, 25 Sitapur dist. Complications in delivery-Morbidity 8. Munni, 35 Kanpur dist. Post-abortion complication-Death 9. Suman, 30 Sitapur dist. Complication in delivery-Morbidity 10. Nirmala, 25 Chitrakoot dist. Post-abortion complication-Death 11. Nankai, 20 Lucknow dist. Post-partum morbidity 12. Fulmati, 26 Lucknow dist. Complications in delivery xxxiii Collected by KRITI, Lucknow, Healthwatch UP and partners for the report ‘Women’s Voices’ xxxiv CEHAT, Policy Brief, undated xxxv Women of the World: Laws and Policies Affecting their Reproductive Lives, Center For Reproductive Rights, 2004 xxxvi The states of Kerala, Punjab, and Tamil Nadu have double the per capita public health spending of Bihar and Madhya Pradesh. xxxvii CEHAT Policy Brief, undated xxxviii Varatharajan et al, EPW August 2004 xxxix Murthy, Ranjani K. “Health sector reforms and Safe Motherhood and ARH services in South Asia: Lessons and Advocacy Issues emerging from the former Rand R Initiative and ICPD+10 Alternative Country Reports”, a presentation prepared for the Regional NGO Seminar at Dhaka, ARROW. xl Center for Reproductive Rights, ibid Other References National Commission For Women. Towards Equality, The Unfinished Agenda,

Status of Women in India-2001. Published in 2002 Khanna, Renu. Shiva, Mira. Gopalan, Sarala. Towards Comprehensive Women’s

Health Programmes and Policy. Published by: Society for Health Alternative (SAHAJ) for WAH!, 2002.

International Institute of Population Sciences (IIPS). National Family Health Survey (MCH and Family Planning), India (1992-1993). Mumbai, 1995

Ramasubban, Radhika. Jejeebhoy, Shireen (editors). Women’s Reproductive Health In India. Rawat Publications, Jaipur and New Delhi, 2000. ----Jejeebhoy, Shireen. “Safe Motherhood in India: Priorities for Social Science Research”.