Friday, 26 June 2015: Despite the launch of National Rural Health Mission, Janini Suraksha Yojana and many other schemes targeting maternal, new born and child heath, India still continues to struggle with the global burden of infant, child and maternal deaths1 reflecting poor status of some of the basic RMNCH services in India. To address the issue of quality of care and accountability in the Reproductive, Maternal, Neonatal and Child Health (RMNCH), Public Health Foundation of India in association with CAMTech (Boston based Consortium for Affordable Medical Technologies) organised a focussed session on “Family Planning & Reproductive Health: Addressing Quality of Care and Accountability in RMNCH”.

Every year more than half a million women die of causes related to pregnancy and childbirth, and almost 4 million new-borns die within 28 days of birth. There are millions more who suffer from disease, infection, injury and disability.[i] In 2010 India accounted for 19% of all global maternal deaths despite an annual decline of 5.7% in maternal mortality between the years 2005 and 2010. Moreover, in terms of numbers India has largest number of child deaths (approximately 15.8 lakh) under the age of five years than any other country.[ii]

Quality of care is a significant predictor of service utilization in maternal health, even more than access. Despite the improvement in quality of maternal health services in the last 10 years, India still fairs poorly in comparison to most emerging economies.3 Standards in maternal health care cannot be raised unless the health system guarantees good quality care that follows a consistent and continuous uptake of maternal health services across the country.[iii] In order to achieve this, policy and programmes that help implement interventions based on evidence, and support micro-level programme planning are a must. Consistent monitoring and progress evaluation are however critical for its success.[iv] An environment that efficiently facilitates and supports safe motherhood and childbirth is substantially dependent on the care and attention delivered to women and new-borns by their: families and communities, the expertise of skilled health workers, the availability of adequate health care facilities, medicines and emergency care when required.

Yet, 2014 ended with the tragedy of sterilization deaths of women in the state of Chhattisgarh (15 women died and 70 were hospitalized in critical condition after undergoing poor and substandard sterilization operations) as a result of poor infection control followed by inflicted blindness on patients in Punjab through botched cataract operations . A bleak reminder that India’s maternal and child health sector in continues to be infiltrated by issues related to lack of accountability, poor infrastructure, and low quality health services.[v]

The panel was Chaired and Moderated by Dr. Priya Balasubramaniam-Kakkar from PHFI and had discussions on questions such as -- Are targeted approaches to family planning still relevant in the Indian context, Quality of care in issues RMNCH –What are some of the gaps in access and efficiency in the delivery of RMNCH care today, and who should be accountable? (Pre Natal/Post Natal Care), and finally what are some of the solutions and where can technology play a role in addressing administrative inefficiencies?

In her address Dr Priya Balasubramaniam Kakkar, Senior Public Health Specialist – M&E, Public Health Foundation of India and Director: Universal Health Coverage for India Initiative, PHFI said, “Despite India making significant progress on Maternal and Child Health Indicators as part of the MDGS’s, it continues to contribute to one-fourth of the global burden of infant, child and maternal deaths. This reflects continuing challenges in some of the basic RMNCH services directed at preventing deaths of women and newborns from complications during birth-control, pregnancy, childbirth, and the postnatal care. Provision of good quality of care has emerged as a significant predictor of service utilization in maternal health, even more than access. Standards of maternal health care quality will be consistently compromised unless we have a health system that is accountable for and guarantees good quality care that follows a consistent and continuous uptake of maternal health services across the country. The need to address quality of care issues in RMNCH is especially urgent in the wake of the sterilization deaths tragedy in Chhattisgarh where 15 women died and 70 were hospitalized in critical condition after undergoing poor and substandard sterilization procedures.”

Dr Balasubramaniam further said “responsible health system that facilitates and supports safe maternal health, motherhood and childbirth is equally dependent on the care and attention delivered by families and communities, the expertise of skilled health workers, availability of adequate health care facilities, equipment, medicines and emergency care when required. It is time that India’s health policies and programmes that help implement a host of targeted interventions are based on accountable decision making, good evidence and supported by consistent monitoring and evaluation.”

About 140,000 to 150,000 maternal deaths can be prevented worldwide through efficient family planning (FP) measures. [vi],[vii] Evidence shows that FP is a cost effective intervention with immediate impact on maternal mortality.[viii] FP through sterilization is the most common method of contraception in India. The current provision of incentives for accepting sterilization has further lead to poor practice of spacing and other contraception methods.9 Emphasis of the Janini Suraksha Yojana on institutional deliveries (driven by compensation package for the delivering woman and ASHA worker) has led to side-lining of other important aspects like immediate post-partum contraception that ensure good maternal health. Moreover most women who deliver in public health facilities are discharged within 4-6 hours of delivery due to high work load or lack of space.[ix]

Postnatal care is a critical component of maternal and new-born health. Immediately after birth, bleeding and infection pose grave risk to the mother’s life, while preterm birth, asphyxia and severe infections threaten the life of a new-born contributing to two-thirds of the neonatal deaths.[x],[xi],[xii] Appropriate postnatal care critical to reducing maternal and neonatal problems is unfortunately s one of the most neglected components of maternal care in India. Data from NFHS-3 shows that only 42% of women surveyed received postnatal care after their most recent delivery.[xiii] Urban areas too face health care issues due to lack of knowledge and awareness about health facilities among the urban poor, weak linkages between service providers and communities, and the limited role of communities negotiating capacities.