Maternal mortality in India

Maternal mortality in India is presented with current numbers varying from 254 to 301.(1;2;15) With a high percentage of the women delivering at home and not receiving any ante natal care, a correct number of complications or mortality is difficult to measure.

Irrespective of confusing numbers and differences in the baseline, the sources agree that progress has been made; MMR in India is declining. Maternal morbidity and mortality also differs from state to state. In the state of U.P. MMR has declined from 517 to 440 in the period 2003- 2006, still leaving the state with a MMR higher than the national average. (15)

5 Causes of death

The most frequent causes of maternal deaths are severe bleeding (25%), infections (15%), eclampsia and hypertension-related diseases (12%), obstructed labour (8%) and unsafe abortions (13%). In addition come other direct causes (8%) and indirect causes (20%). (1) The registered mortality is suggested to be only a “tip of the iceberg”, with 20-30 women suffering severe morbidity for every death. (1) Difficult labour is also recognized as a major cause of infant mortality. Like the maternal mortality, India’s infant mortality is declining. In 2006 the measured number was 57, a reduction from 80 in 1991. (17)

Maternal care: A brief history

The organized work for mother and child health in India dates back to the beginning of the previous century, where rural midwives or Traditional Birth Attendants (TBAs) were trained to conduct safe deliveries. From 1918, Midwifery Supervisors were trained at the Lady Reading Health School in Delhi, and from 1931, the expanding work for mother and child health was coordinated under the Indian Red Cross Society. By this time some of the states also established agencies for maternal welfare, but the work progressed at a slow pace. From 1955 the government started to integrate the mother and child health in the general health services, and international agents, such as WHO and UNICEF, increased assistance to the country. (18)

The first Indian National Health Policy was framed in 1983. The target of this policy was to achieve “health for all” by the year 2000, where a central component in this work was the arrangement of primary health care services and the provision of primary health centers. (17) Home deliveries and Traditional Birth Attendants (TBAs)

Until recent times, the traditional way of giving child birth in the rural parts of India has been to deliver at home. Here the women have been assisted by female relatives, by a TBA or by an Auxiliary Nurse Midwife (ANM). (5)

A TBA, also called dai²

2 Dai is the Hindi expression for birth attendant, and also the expression used by the informants when talking about a TBA.

, is a person who assists a mother during childbirth and who acquires her skills by delivering babies herself or through apprenticeship to other TBAs. (4) The expression TBA is an umbrella term including women with varying practices, according to local and personal differences. They are often respected in their community for their skills and knowledge, and they tend to be older, non-literate women. (19;20) Because such a high

6

number of women traditionally have been assisted by TBAs at delivery, large efforts has been made to improve their skills by organized training. From the 70’s WHO and the international society recommended and funded training programs, in India as well as in other low income countries. The target was to train the TBAs in basic skills for child delivery. From the beginning of the 90’s persistently high

MMR and poor documentation on the efficacy of the training led to an end to the programs. (19) In current plans and strategies TBAs are no longer considered effective resources in combating maternal mortality. Nevertheless, in some rural areas the major percentage of women still delivers at home without a skilled attendant. (5)

Institutional deliveries and Skilled Birth Attendants (SBAs)

Current strategies for reducing MMR in low income settings are now based on encouraging institutional deliveries with attendance of a Skilled Birth Attendant (SBA) and availability of Emergency Obstetric Care (EmOC). The term EmOC refers to the services of treatment for complications during pregnancy and child birth. (21) An SBA is defined by the WHO as a person with midwifery skills (for example doctor, midwife or nurse) who has been trained to proficiency in the skills necessary to manage normal deliveries and diagnose, manage or refer obstetric complications. (22) Thus, aiming at improving safe deliveries with these two

components, the new focus is now to encourage women to come to an institution for child delivery.

In India, governmental services for providing delivery care have gone through an extensive change after the implementation of the National Rural Health Mission program started in 2005. Significant initiatives under this program include upgrading of facilities, incentives for institutional births and introduction of the new worker Accredited Social Health Activist (ASHA). Guidelines for the program are given from the central government, but implementation is delegated to the government of states. This causes services and standards of care to differ to some extent, depending on the situation in the individual state.

Re-training of TBAs in Hathras District

7 Coverage and training of midwives

Like most of India’s rural areas, the rural parts of Uttar Pradesh have a vast unmet need for health personnel. Health indicators calculate a need for 7295 nurse/midwifes in the state, and the number of positions currently occupied is less than half, 3340. (15) With the clear exception of male doctors at the PHCs, shortage of all types of health personnel is reported.

Both health infrastructure and utilization of the services are connected with other types of demographic factors, as availability and possibilities are highly dependent on local context.

Today there are two types of midwife education in India. (23) The trained nurse midwife has a three-year nursing program containing six months of midwifery. This gives a degree and registration as both a nurse and a midwife. The Auxiliary Nurse Midwife (ANM) is a multipurpose female health worker with 18 months training, six of them in midwifery. Both groups are educated to manage normal deliveries, but responsibilities and tasks vary a lot depending on geography. The distribution between the two groups is also geographically skewed, with 90% of the trained nurse midwives working in urban areas, and 90% of the AMNs working in the rural areas. (23) The ANM has also traditionally attended home deliveries in rural areas. (19)

The organization Society of Midwives, India (SOMI) was launched and registered in 2000.

This union for midwives works tightly with the nursing academies to improve midwifery services and professional integrity. Headquarter for SOMI is located in Hyderabad, and national conferences are arranged annually. (23)