Building Community Based Mechanisms Workable Solutions to reduce Maternal Mortality in India Presentation at the Civil Society Window on Maternal Mortality Planning Commission of India November 21st by Vd. Smita Bajpai Programme Officer- CHETNA Founder and board member-Dai Association-Gujarat

2 The concern.. Every 5 minutes, one woman in India dies due to pregnancy and childbirth related causes. They die because they are not able to access quality, affordable and skilled care.

3 The concern A woman was brought to a rural nursing home. Hemoglobin 3gms%. System knew she was not going to survive. Paper work done. She collapsed during the second blood transfusion. (January’06) Reported by the doctor at a meeting with CBOs of Sabarkantha District Gujarat- November 2006 The manifestation of ill health is much beyond the institutional arena

4 The concern A woman in labour started to bleed. The Dai was called. Realizing the emergency, she called for a vehicle. The woman`s husband walked for several miles to the ANM, brought her back but the woman did not survive. CBO representative; Barmer 2003 Physical access to emergency obstetric services is a challenge for many women in rural areas

5 Realities in India.. Most maternal deaths occur in women from tribal/dalit communities, poor socio–economic status, living in rural, remote regions. Women do not have access to complete, continued care from the public health system Physical, socio- cultural and economic barriers affect access to institutional health services

6 Realities in India.. More than 65 % of births occur at home. State variations –95% home births Women prefer home births and it is a cultural reality Most castes / families have a culture of home delivery by the traditional/customary Dai At least 1 Dai is available in every village of India to assist during births Dais are available, accessible, affordable and accepted for their midwifery role in communities.

7 Some facts 85 % women will deliver normally % women will develop complications that will need medical interventions 3-5 % women will need surgical interventions (blood/Cesarean etc.) More chances of women having a normal delivery However delivery complications can occur suddenly, without any warning signals

8 Some facts 20-25% deaths occur during pregnancy % deaths occur during labour and delivery 25-40% deaths occur after childbirth ( More during the first seven days) It is important to focus attention during pregnancy and also after childbirth

9 Successful Models of Safe Motherhood service delivery MODEL 1  Home deliveries by trained community member Functional affordable referral transport system  Affordable emergency obstetric services MODEL 3 Professional provision of Basic Emergency Obstetric Care Functional affordable referral transport system  Affordable emergency obstetric services MODEL 2 Home deliveries by professionals Functional affordable referral transport system Affordable emergency obstetric services MODEL 4 Professional provision of Basic and Comprehensive Emergency Obstetric Care

10 Maternal Mortality Reduction in Sweden.. Sweden’s maternal mortality declined from 567 to 227/100,000 live births over three decades (1861 to 1894). Two interventions are credited nearly equally with this decline : Midwifery-assisted home births, which increased from 30% to 70% over this period the promotion of aseptic technique in both hospital and midwife-assisted home births. The percentage of women birthing in a hospital increased only slightly over this same period, from 1% to 3%. Home births by skilled assistants lead to reduced maternal mortality.

11 MM in Malaysia declined from 630 in 1947 to 148 in 1970 and 43 in 1990 A Government priority at Independence in 1957 was equity of care, meaning free and accessible health services. Midwives were placed at the village level to provide such care, including antenatal care, home-based delivery, and postpartum care. By partnering with the traditional birth attendants, midwives became the primary assistants for delivery, covering about 51% of deliveries in 1980 and 95% in 1996 Equity in health care and partnership with TBAs is essential Maternal Mortality Reduction in Malaysia

12 Maternal Mortality Reduction contd.. Country Year MMR PMR China (rural) Fortaleza, Brazil Gudhchiroli, India (1999) Jhagadia, India (2006) MMR /PMR was achieved through Model 1

13 With 75% home delivery, SEWA Rural could reduce MMR by 40% and NMR by 45% in three years with specific interventions at community level backed up by a functional FRU. Empowering TBAs/ Local women volunteers ensuring satisfactory Birth Preparedness / Complication readiness Clean & safe normal delivery ensuring critical new born care & postnatal follow up Timely identification of any complications during delivery and ensuring prompt referral to SEWA Rural’s functional FRU Professional provision of basic and comprehensive emergency obstetric care by SEWA Rural FRU (Combination of Model1 and 4) Maternal Mortality Reduction in Tribal Area -India

14 Present Policy trends Focus on labour and delivery with some attention on ante natal care Focus on institutional delivery -public and private Based on demography/population only Lack considerations for infrastructure, physical access, socio-cultural and Geographical factors.

15 Recommendations for MMR reduction in India Mapping of difficult, rural,tribal areas having no or minimal access and devising realistic location specific strategies. Ensuring access to emergency obstetric services to those women who need it. (15%) Implementing community based models relevant to the culture and geographical realities of India. ( A combination of Model 1 and 2 )

16 Success contd.. Supporting TBA_ANM partnerships and integrating TBAs in the public health system (Evidence of success from Guatemala, Bolivia, Indonesia) Providing affordable referral transport

17 Successful evidences for rural / tribal areas of India Building capacities and skills of TBAs to expand her role as a link with the public health services: Technical skills on her core role during labour and childbirth, identification of complications and referrals, Primary Health Care, Reproductive health issues, communicable diseases etc. Leadership/coordination skills to establish linkages between community and public health systems Attitudinal aspects to deal with class, caste, gender issues Social aspects to act as a social change facilitator We do not want to be frogs in the well but want to be fish swimming in fresh waters President of Dai Association- Gujarat

18 The story of a Dai from Gujarat “ It was night when a neighbor called me for help. On reaching her house, I realised that the woman needs hospital care. I took her to the civil hospital which is the nearest. The staff asked me to take the woman to the city civil hospital. I knew that she can deliver here. I woke up the medical officer and shared my concern. He asked the staff to admit the woman. She delivered a baby safely.” A Dai from rural Mehsana at a Dai Association Board meeting

19 Pioneering Effort in Gujarat Launch of Dai Association –Gujarat Dai-NGO-GO-INGO partnership 5000 dais-15 NGOs in 18 districts Standardization of Traditional Midwifery- curriculum developed by NGOs- publishing support by DHFW Government recognition of Dais` role through a GR DHFW partially funding capacity building of Dais under RCH-2 DHFW provided financial support to organize Dai`s in 15 districts

20 Cost The Dai Association Gujarat has developed a comprehensive capacity building curriculum for dais to be implemented over a period of three years. The training cost comes to Rs.5000/- per dai in an established training center The GOI has a 10 day programme for Dais focusing on clean Dai

21 Cost The Government of Andhra Pradesh through Academy of Nursing Studies has implemented a 90 day intensive training programme for TBAs at a cost of Rs.10,000/- per Dai including training centre cost The working group on Local Health Traditions has worked out a 15 crore plan to organise and strengthen dai associations in 15 states. A Rs. 5 lakh seed money to dai association has been recommended The struggle for recognition, value and empowerment of Dais continues …

22 Thank you Let us join hands to save women from dying needless maternal deaths by using our resources optimally and make a significant contribution to nations’ economy and development.