Towards Equity and Rights: South Asian Partnerships for Reducing Maternal Mortality

Maternal mortality in south Asia South Asia has the highest concentration of maternal mortality after sub-Saharan Africa South Asia has the highest concentration of maternal mortality after sub-Saharan Africa It is said to be responsible for almost half of the estimated half a million maternal deaths worldwide (Bhutta et al BMJ 2004) It is said to be responsible for almost half of the estimated half a million maternal deaths worldwide (Bhutta et al BMJ 2004) MMR ranges from 23 per 100,000 live births in Sri Lanka to 539 in Nepal MMR ranges from 23 per 100,000 live births in Sri Lanka to 539 in Nepal

India’s unique position Considered a world-class health care provider, but women are unable to access the basic health care needed to avoid maternal deaths and illnesses Considered a world-class health care provider, but women are unable to access the basic health care needed to avoid maternal deaths and illnesses Has the highest number of maternal deaths globally (WHO estimates 140,000) Has the highest number of maternal deaths globally (WHO estimates 140,000) Strong political will required to ensure that the 25 odd million births (and abortions wherever needed) that take place each year are safe Strong political will required to ensure that the 25 odd million births (and abortions wherever needed) that take place each year are safe

Political will for maternal health “Maternal and Child Health is matter of highest priority for our government …we need a comprehensive approach to deal with the painfully high levels of maternal and child mortality … We have the knowledge, we have the resources; what is needed is a collective will …” – Speech by Sonia Gandhi, Chairperson UPA at the WHO meeting in Delhi 7 April 2005

Comparative data (Bhutta et al, BMJ 2004) Est births MMR % Skilled birth attendance % TT coverage India Bangladesh Pakistan Nepal Sri Lanka

Health and related expenditure HDI Gross National Inc/ capita Per capita exp health 2001 % govt exp health ‘ % govt exp on defence ODA in mill.$ 2001 Banglad esh $5$5%10%1024 India127480$4$2%16%1705 Nepal143230$3$5%5%388 Pakista n $4$1%18%1938 Sri Lanka 99840$15$6%18%330

What does the data indicate? The fundamental obstacle remains the willingness of the governments and policy makers to give due importance to and apportion resources for human development and public health The fundamental obstacle remains the willingness of the governments and policy makers to give due importance to and apportion resources for human development and public health Investment in maternal and child health as a central focus of public health policy is critical Investment in maternal and child health as a central focus of public health policy is critical Lessons may be learnt from better performance in other countries such as Sri Lanka Lessons may be learnt from better performance in other countries such as Sri Lanka

Strategies in Sri Lanka (Senanayake, 2005) Maternity Care including surgery and blood transfusion is available free of cost to every woman in Sri Lanka Maternity Care including surgery and blood transfusion is available free of cost to every woman in Sri Lanka During their ‘high MMR’ stage, Sri Lanka managed with a strategy of low level skilled attendance During their ‘high MMR’ stage, Sri Lanka managed with a strategy of low level skilled attendance Established foundations for Established foundations for Professionalized midwifery Professionalized midwifery Monitoring systems Monitoring systems Advocacy Advocacy

Strategies in Sri Lanka Gave priority to improving access to rural & marginalized groups Gave priority to improving access to rural & marginalized groups Improvement of utilization of available services by improved quality of care Improvement of utilization of available services by improved quality of care Focus on Client Empowerment (Demand side) Focus on Client Empowerment (Demand side)

Maternal death Audit in Sri Lanka Maternal mortality reviews from 1970: Visits to home and hospital for each maternal death Visits to home and hospital for each maternal death Detailed report and fact-finding enquiry (not fault finding) Detailed report and fact-finding enquiry (not fault finding) Regional and national meetings to plan remedial measures Regional and national meetings to plan remedial measures

Recommendations for 11 th Plan Empowerment of users through massive public education on entitlements Empowerment of users through massive public education on entitlements Training of all community birth attendants (low to medium skilled) for ensuring that all deliveries are covered Training of all community birth attendants (low to medium skilled) for ensuring that all deliveries are covered Offer completely free comprehensive maternal care including post-partum and post-abortion care, to women, in accessible institutions, Offer completely free comprehensive maternal care including post-partum and post-abortion care, to women, in accessible institutions, User groups and Panchayats to monitor the quality of care through Social Audit of facilities and services in both public and private hospitals in rural areas User groups and Panchayats to monitor the quality of care through Social Audit of facilities and services in both public and private hospitals in rural areas

Recommendations for 11 th Plan Use of IT (all ‘dais’ with special mobile phones) for monitoring all births and for improved referral to institutions during complications Use of IT (all ‘dais’ with special mobile phones) for monitoring all births and for improved referral to institutions during complications Strengthen the system of auditing maternal deaths (based on Sri Lanka model) Strengthen the system of auditing maternal deaths (based on Sri Lanka model) Examine evidence from different parts of the country to understand what works best where – especially in rural, hilly, tribal, conflict-ridden /disturbed, remote, poor or urban slum areas Examine evidence from different parts of the country to understand what works best where – especially in rural, hilly, tribal, conflict-ridden /disturbed, remote, poor or urban slum areas

Recommendations for 11 th Plan Provide for learning opportunities and exchanges/study visits for policy makers, managers and providers to learn how to address Maternal Mortality Provide for learning opportunities and exchanges/study visits for policy makers, managers and providers to learn how to address Maternal Mortality (Especially from states with greater need to improve maternal health services - EAG states and Assam) Strengthen the Civil Society – Government interface on this crucial issue by constituting a National Maternal Health Task Force Strengthen the Civil Society – Government interface on this crucial issue by constituting a National Maternal Health Task Force

WHRAP Policy Dialogues Recognizing that the region has many similarities in terms of problems as well as situation on the ground - Policy makers, technical experts and officials from Pakistan, Nepal, Bangladesh and India have been meeting at Regional Policy Dialogues Policy makers, technical experts and officials from Pakistan, Nepal, Bangladesh and India have been meeting at Regional Policy Dialogues These are organized by WHRAP, a civil society network in South Asia These are organized by WHRAP, a civil society network in South Asia A Sub-regional Task Force is being formed to take up the issue of maternal health and young people’s access to SRH rights. A Sub-regional Task Force is being formed to take up the issue of maternal health and young people’s access to SRH rights.

Thank you! Jashodhara Dasgupta SAHAYOG Lucknow, UP