MDG 5 Improving Maternal Health A Critique Renu Khanna Jan Swasthya Abhiyan, CommonHealth Sept. 15 2010

A historical perspective Women’s and Health movements’ struggles Health needs beyond MCH Against family planning targets International acceptance of Reproductive Rights - ICPD (Cairo 1994) Acceptance of Sexual Rights - Beijing Women’s Conference (1995)

Feminist critique of MDGs MDGs - going back to narrow Maternal Health agenda Backtracking on Reproductive and Sexual Health and Rights promises of ICPD and Beijing

MDG 5 Improving Maternal Health Initial Goal 5 – Improve Maternal Health Targets Reduce maternal mortality by ¾ between 1990 and 2015 Increase proportion of births attended by skilled birth attendants Revised Goal 5 (2005) – Improve Maternal Health and Achieve by 2015 universal access to Reproductive Health

MDG 5 Improving Maternal Health Targets Target 5.1 Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio Target 5.2 Proportion of births attended by skilled health personnel Target 5.3 Contraceptive Prevalence Rates Target 5.4 Adolescent birth rate Target 5.5 Ante natal coverage (at least one visit and at least four visits) Target 5.6 Unmet need for family planning

GOI Mid Term Review GOI decision – we will monitor only 5.1 and 5.2 ‘A revised UN framework of MDG indicators has been introduced ……. which India has not adopted for strategic and technical reasons.’ ?????? Contraceptive Prevalence Rates Adolescent birth rate Ante natal coverage (at least one visit and at least four visits) Unmet need for family planning

GOI Mid Term Review The MDG target for India is from 447 in 1990-91 to 109 by 2015. MDG 5 MMR has taken a quick down turn during 2003-2006, from 301 per 100,000 live births in 2001-03 to 254 per 100,000 live births in 2004-06 according to SRS estimates. In 2000 to 2002, the MMR declined by 26 points and in 2002-2005 by 47 points. At the historical pace of decrease, India will reach 135 by 2015.

GOI Mid Term Review The rate of increase in institutional deliveries is slow from 26% in 1992-93 to 47% in 2007-08. Skilled birth attendance at deliveries has increased from 33% to 52% in the same period. The rural urban gap in coverage by skilled birth attendants in 2005-06 was 36 % points By 2015, India can expect only 62% deliveries to be attended by skilled personnel.

GOI Mid Term Review Two-thirds of maternal deaths in India in Assam, Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Orissa, Rajasthan, Uttaranchal and Uttar Pradesh (RGI Report 2006). Kerala and West Bengal set to achieve their targets of reducing MMR by 3/4th before 2015 Bihar/Jharkhand starting from high MMR of 531 have also achieved a rapid rate of reduction of Maternal Deaths. increase in Maternal Deaths in Haryana and Punjab -developed, well performing states Assam, UP/Uttranchal and Rajasthan’s MMRs in 2004-06 also worrisome

Our critique Who dies? How and why she dies?

Who dies? Analysis of inequities NFHS 3 indicators for tribal women and scheduled caste women worse than those of ‘Other Women’ 23.7 % tribal women and 19% Schedule Caste women moderate to severely anaemic compared to 14% ‘Other’ women 21.2% tribal women and 18.% Schedule Caste women moderately/severely thin compared to 13.1% ‘Other’ women Women not receiving any ante natal care tend disproportionately to be women with no education, women in households with low wealth index and Schedule Tribe women.

How and why she dies? Analysis of Causes of death

Analysis of Maternal Deaths No accurate system of collecting data on maternal deaths public declaration of annual maternal death reports with causes of deaths, profiles of women who died, and followup action initiated by the state health systems not yet done.

Skilled Birth Attendance, Institutional Deliveries, or Safe Deliveries? NFHS 3 - 47% of births in five years preceding survey assisted by health personnel, 37 % by a TBA and 16 % by friends/relatives/other persons ‘Unless institutional delivery in the States, particularly in those which are lagging way behind the national coverage, is widely accessible and becomes a way of life, the ultimate objective of reducing maternal deaths to the level that should be reached by 2015, will continue to remain distant.’ GOI Mid Term Report

Skilled Birth Attendance, Institutional Deliveries, or Safe Deliveries? NFHS 3 Reasons for preferring home deliveries 72 % of women who did not deliver their last birth in a health facility - did not feel it necessary to deliver in a health facility 26 % - it costs too much to deliver in a health facility 11 % - health facility too far away or transport not available Government still continues to pursue the strategy exclusively of institutional deliveries. Denial that trained traditional birth attendants may be able to play a positive role in difficult to reach areas.

Skilled Birth Attendance, Institutional Deliveries, or Safe Deliveries? Janani Suraksha Yojana – skilled birth attendance? Safe deliveries? Who is a Skilled Birth Attendant? ANM? Paul Hunt’s report Inequities in health work force resulting in PPPs like Chiranjeevi, franchised private hospitals

Access to universal reproductive health Critique of the four indicators, Why is GOI not looking at adolescent birth rates? Quality of ANC? Redefining ‘unmet needs’? What about other indicators? Post natal care? Access to safe abortions? anaemia in women and girls? Maternal and RH morbidities – vesicovaginal fistulas, uterine prolapses, infertility, cancers?

Determinants of women’s health Poverty – increasing feminisation Hunger - nutritional status Gender equity – work, control over resources (own income, family resources) Gender norms and values – violence against women, reproductive rights Verticalisation of MDGs – MDG 1 and MDG 3 are intrinsic to MDG 5! Let us not look at each separately……

Reproductive and Sexual Health and Rights The kamaal of our vertical programmes Only reproductive health (and rights ?) for ‘normal’/general women? (RCH Programme) Only sexual health (and rights ?) for ‘target’/ ‘hi risk women’/ ‘population’ ? (NACP 3)

Recommendations for reducing Maternal Mortality (NAMHHR) Policy and budget level Programme implementation Regulating private sector

Recommendations for improving RSHR including maternal health Convergence on MDGs – maternal health cannot be looked at without looking at poverty and gender. How does poverty affect maternal health? How do TB and Malaria affect pregnant women? Convergence of programmes – NACP and RCH. Women in marriages have sexual health needs and sexual rights. ‘High risk’ groups have reproductive health needs and reproductive rights.

Acknowledgements Contents of this presentation draw upon COHERENCE OR DISJUNCTION? MDGS, SRHR, GENDER EQUITY AND POVERTY IN INDIA (A draft report dated June 18, 2010) by Ranjani K.Murthy, Renu Khanna with Anagha Pradhan and Lakshmi Priya. This study is part of a three country assessment of the MDGs on Poverty, Gender and Maternal Health from the perspective of Sexual and Reproductive Health and Rights, initiated by DAWN in 2008. Inputs from Dr. Abhay Shukla (JSA) and Dr. TK Sundari Ravindran (CommonHealth) A summary report of ‘A Public Dialogue to discuss the Report on Maternal Mortality in India by the UN Special Rapporteur on the Right to Health, 2007-2010, 13 August 2010, New Delhi’, organized by the National Alliance on Maternal Health and Human Rights