Maternal mortality: A silent killer that claims a life every five minutes in India

The soldier is dying. The farmer is dying. The mother, just a 20-something-year-old girl stretching her pelvis to bring a new life into the world, is also dying. According to Lancet, an independent medical journal, the global maternal mortality rate has come down by nearly half (44 percent) since 1990. In 2015, a total of 45,000 maternal deaths in India along with 58,000 in Nigeria accounted for one-third of the global total.

“It’s like a plane crashing every day. These girls are also martyrs, the system is failing them. A majority of the deaths are avoidable if a set of minimum standards for childbirth, that are practical, effective and universally applicable, are implemented,” said Hema Divakar, former president of FOGSI (The Federation of Obstetric and Gynaecological Societies of India).

According to the Ministry of Health and Family Welfare, out of the total 5.29 lakh pregnancy-related deaths recorded world over, 1.36 lakh occur in India; a woman dies every five minutes in child birth or during pregnancy in India. This grim state-of-affairs exists despite the fact that India has come a long way in reducing maternal mortality due to a range of government-led efforts.

Various schemes like the Janani Suraksha Yojana (JSY) and Rashtriya Swasthya Bima Yojana (RSBY) have contributed to a large upsurge in institutional deliveries, which stand at more than 80 percent as of today. But despite this phenomenal rise in deliveries at healthcare facilities, it does not reflect in the rate of reduction in maternal and especially neonatal mortality.

The missing link in this anomaly is quality. According to the study conducted to understand the impact of JSY on maternal mortality in Madhya Pradesh (MP), one of India’s largest provinces, the proportion of JSY-supported institutional deliveries rose from 14 percent (2005) to 80 percent (2010). A community-based survey in Delhi revealed a poor quality of a range of maternity care practices across the healthcare spectrum in Delhi and points to a systemic absence of quality of care.

The survey highlighted the overuse of ultrasound, caesarean section, induction, and episiotomy, especially in private facilities, and a deficiency of patient-centred practices (such as counselling and labour support) particularly in public hospitals. For example, while a significantly higher proportion of the deliveries at private facilities were attended by a child specialist, non-ideal norms such as routine shifting of the baby to the nursery and delayed initiation of breastfeeding continued to be widely prevalent. A minority of the babies stayed with the mother in the first hour after birth across the health care spectrum.

To address this issue of lagging quality care in the private healthcare sector, especially during the critical periods of just before, during and immediately after childbirth, in 2012, Jhpiego (a non-profit health organisation affiliated with The Johns Hopkins University) with support from MSD for Mothers (a 10-year $500 million initiative focused on well-being of mothers during pregnancy and childbirth by MSD, a global healthcare company with a history of 125 years) and in partnership with FOGSI developed a quality assurance model for maternity institutions in the country. The pilot project that recently concluded has started a revolution in the sector.

Here’s why the move was necessary: The nursing staff at Zanana Hospital in Alwar, Rajasthan has recently been oriented on the use of the Safe Childbirth Checklist (SCC). Here, a 20-year-old Mamta arrived at the facility with strong labour pains and a pounding headache. Babita Sen, who was then the nurse on duty, looked for danger signs. Babita checked her urine for protein, which was one of the several steps on the checklist attached to her chart. As Babita suspected, Mamta had an elevated protein level, a symptom of pre-eclampsia that can be fatal for the mother and the child. In the process, two lives were saved.

Similarly, in Bikaner district, Kiran Khatri is known as a one-woman army. She was the only nurse on duty at the Community Health Centre in Bajju when Geeta Sumersingh, from the neighbouring village of Gandhi, came in with labour pains, in the wee hours of the morning. The moment the membrane ruptured, Khatri noticed that there was meconium-stained liquor. She describes how she was listening to the baby’s FHR and found it to be low.

“The moment the baby was delivered, with the help of a mucus extractor the mouth and nose were cleaned. The baby was starting to turn blue and its heart rate was slowing down. We quickly clamped the baby’s cord and put her in the baby warmer. We then used the ambu bag to help the baby breathe,” she recounts, adding that timely orientation helps medical staff tackle with not just new-born resuscitation or pre-eclampsia, but also postpartum haemorrhage.

“Testing the skills of the providers before and after the training showed a remarkable improvement in their knowledge and skills. As a follow up to the training, regular supportive supervision visits have been carried out to assist in institutionalisation of services,” said Bulbul Sood, country director, Jhpiego.

The task at hand is huge, because nearly 26 million deliveries happen each year. India need to build at least 50,000 centres and a healthcare workforce of one million to match up to developed countries. So, collaboration of public and private forces is key. Under this pilot-project, a quality of care framework has been implemented at 146 select private sector facilities spread over 11 cities in Jharkhand and Uttar Pradesh.

The problem will offer customised, on-site support by FOGSI or FOGSI-recommended centres or organisations for improving the quality of care for maternity services, and improving general hospital practices and protocols in line with the NABH (National Accreditation Board for Hospitals & Healthcare) recommendations.

It will also provide certification of quality of services by NABH after assessing adherence of the facilities to its entry level pre-accreditation standards and FOGSI-recommended clinical standards of maternity care.

Up until 2013, a NABH certification was only limited to larger structures like trust-run bodies, multi-specialities and large corporate hospitals that fulfilled its 64 requirements. “By way of accreditation, we want to minimise medical errors and bring about standardisation in a sector that is poorly regulated,” said KK Kalra, who has recently retired as the CEO of NABH.

“Our definition of small healthcare facilities is anything less than 50 beds. By starting an entry-level standardisation, we are looking to bring into the umbrella of quality a majority of the nearly 80,000 medical facilities in the country,” said Kalra, who spearheaded the movement.

Earlier, NABH was focussed on systems and infrastructure, such as whether delivery rooms are fire-safe, or if there’s a new born baby corner or if birth certificates are being issued on time. With the more functional entry-level certification, clinical procedures like the right dosage, monitoring of labour and after care are also stressed upon.

Experts feel that this is a historic and much-needed shift in approach and it’s high time that patients start recognising a seal of quality in healthcare, just like they do while buying gold or consumer durables. Only once that happens will small nursing homes strive harder to earn the prestigious badge of quality, because then it will also affect business.

“It’s more profitable to work hard and acquire a certification because effectiveness of the staff improves,” said Neelima Yadav, who works at the recently-certified Galaxy Hospital in Lucknow. There is an effective distribution of roles especially between nurses, ward aayas and attendants.

While central India lags behind, Divakar reveals that areas like Rajasthan, Maharashtra and Assam also require a lot of attention. FOGSI, a 32,000-strong medical fraternity is tying up with local NGOs to facilitate the shift toward quality across the country.

Parallely, there is the Hindustan Latex Family Planning Promotion Trust that runs the Merrygold Health Network in Uttar Pradesh, Rajasthan, Chhattisgarh and Bihar and has a total of 1,500 facilities. In Kerala, their mobile medical units had reached out to 8,194 mothers during 2013-2014. They have tied up with Asian Research & Training Institute for Skill Transfer (ARTIST) and taken up capacity and quality building in 70 facilities in Rajasthan, in the first phase that started in 2015.

Once these centres attain a degree of quality, in about a year, they will apply for the NABH-FOGSI accreditation.

“It’s high time that basic practices like giving drugs to contract the uterus, a uterine massage and controlled cord-traction become common knowledge because these will minimise the bleeding by 60 to 70 percent,” she explains. The incidents of pregnancy anaemia is over 50 percent and this itself pushes them in a risk category, so they just cannot afford to lose a little bit of extra blood, warn the doctors.

The gap that needs plugging is checking if the drugs are given at the right time and that people are trained in actionable skills. The experts say that the Clinical Establishments Act 2010 cannot be limited to statutes and must be enforced in all states, and must go beyond drug stocks and expiry dates of medicines.

It’s not a question of private vis-à-vis government healthcare anymore, it’s about a basic degree of uniformity; the ‘McDonaldisation’ of healthcare in India is the clarion call of those dedicating their lives toward this cause. Why should any life be lost? To war, to demonetisation, or to the natural desire to create life?

Three decades ago, this exact week, stage and cinema prodigy Smita Patil died of childbirth complications. Whether it’s Smita Patil’s or someone else’s, why should any life be lost to reasons painlessly avoidable?