By Patralekha Chatterjee
In rural India, even the poorest spend months planning every detail of a family wedding. The birth of a child, in stark contrast, is considered a routine affair, requiring minimal preparation and expenditure. Death by neglect during pregnancy and childbirth claims over 100,000 women across the country.
Most such deaths can be averted but for the ‘three delays’ - delay in decision to seek care, delay in reaching the appropriate health facility and delay in receiving care once inside a hospital. If the silent tragedy persists, it is because the magnitude of the problem is often not recognized. In India, as in many other developing countries, many maternal deaths are unrecorded. The stories of the dead women remain untold.
The good news: there are small stirrings of change. In parts of India, where women have been traditionally at high risk during pregnancy, childbirth and immediately after, there are signs of hope.
Medical records typically capture the immediate, biological causes of maternal deaths. What gets left out are the personal, familial, socio-cultural and environmental factors contributing to these deaths.
Today, this crucial gap is being bridged by a verbal autopsy tool called Maternal and Perinatal Death Inquiry & Response (MAPEDIR). Piloted in Purulia, one of the poorest districts in West Bengal, in June 2005, it is currently being implemented in 15 districts in 5 Indian states with high maternal mortality. These are West Bengal (Purulia), Rajasthan (Dholpur, Tonk, Udaipur); Jharkhand (Ranchi); Madhya Pradesh (Guna, Shivpuri); Orissa( 8 Navjyoti districts – Nuapada, Nabarangpur, Koraput, Malkangiri, Rayagada, Gajapati, Kandhamai, Keonjar).
In the frontline are trained health and community workers and NGO field staff who visit families where a maternal death has taken place with a structured questionnaire. The questionnaire is a tool to facilitate a process of raising awareness, of getting people concerned and involved about issues impacting on maternal deaths and make them more knowledgeable about how they can do something about them.
Despite remarkable economic progress in the past decade, India remains a maternal mortality hot spot. India’s MMR has declined from 407 in 1998 to 301 in 2001-2003 according to the latest Sample Registration System (SRS) data from the Registrar General. But the deaths are still too many and needless. Two-thirds of maternal deaths in India occur in a handful of states --- Bihar, Jharkhand, Orissa, Madhya Pradesh, Chhattisgarh, Rajasthan, Uttar Pradesh, Uttaranchal and Assam.
MAPEDIR is an exciting collaborative effort involving several institutions and groups with different strengths: the Health Ministry, State Governments, District Administrations, Panchayati Raj (village-level institutions), women’s self-help groups, local NGOs, medical faculties of Indian universities, Johns Hopkins Bloomberg School of Public Health (USA) and UNICEF.
MAPEDIR’s roots lie in UNICEF’s Maternal Mortality Reduction Advocacy Project, supported by the United Kingdom’s Department for International Development (DFID).
The Project underscored the need for information about the underlying causes of maternal deaths in villages. Such data, it was felt, could identify shortfalls within the health system as well as gaps at the community and family level.
It grew out of UNICEF’s decision to support maternal death inquiry as one component of a strategy to reduce maternal mortality within the context of the ongoing second phase of the Reproductive and Child Health Programme (RCH II).
In RCH II, the emphasis is on increasing the demand for quality health care and for greater community participation in the planning of public health interventions
In 2004, UNICEF developed a structured questionnaire to unearth information not readily available in the routine records of maternal deaths in the country in consultation with Dr. Henry Kalter, a globally renowned scientist specializing in standardized verbal autopsy instruments, and affiliated to Johns Hopkins. Dr. Kalter continues to provide technical support to the MAPEDIR process in India.
“MAPEDIR was conceptualized to cover perinatal deaths as well. But it was decided to start small and prioritize. In the first stage, only maternal deaths were covered. The questionnaires were pre-tested in the field and shortened and simplified along the way.
Investigation of perinatal deaths may be introduced at a later stage - when the methodology stabilizes and is adopted institutionally by state governments. Secondly, it was originally a scientific investigation tool meant for research. We adapted it, transforming it also into a tool for action,” says Dr Marzio Babille, UNICEF’s Chief of Health in India.
Signs of Progress
Nearly two years down the line, this verbal autopsy tool has generated significant village and district specific evidence and deepened understanding of the environmental and socio-cultural factors contributing to maternal deaths.
The insights shared with communities and with local health authorities have begun to spur local action. Part of the process is the birth of new, strategic partnerships between government agencies, NGOs and the UN system. These linkages are now being leveraged in several districts to promote greater awareness about existing government facilities and schemes for safe motherhood such as Janani Suraksha Yojana (JSY) among rural communities.
“If I tell villagers in Dholpur that thousands of women are dying across India while giving birth, it does not make an impact. But if I describe the chain of events that led to a death in some place nearby, people instantly listen. If you want to influence the local situation, motivate communities and authorities to take action at the local level, you have to use local evidence,” says Ashok Tiwari, president of the Mangalam Seva Samiti, a NGO based in Rajasthan’s Dholpur district. A Mangalam runs a 24-hour helpline for referral transport for obstetric emergency cases in Dholpur with support from UNICEF and the district administration.
The idea of the Helpline came out of the process of maternal death reviews. As they went on their rounds, MAPEDIR interviewers realized that lack of transport facilities and consequent delays in reaching health facilities were responsible for several maternal deaths in the area.
MAPEDIR in Emergency Situations
In May-June 2007, when Dholpur and neighbouring areas in Rajasthan were engulfed in sectarian tension and violence, the Helpline kept working. “For six days during the strife, around 30 deliveries benefited from the Helpline’s services. Involvement of local community members as field supervisors helped to run the Helpline during such difficult times …” says Om Prakash Singh, UNICEF’s field consultant in Rajasthan.
Today, in remote villages in the district, households deprived of education and other basic amenities are beginning to realize that delays at critical junctures can cause deaths. In many cases, the arrival of MAPEDIR interviewers in a village has sparked a sense of urgency among local authorities to modernize maternal care facilities. The tool has also underscored the need for better reporting of maternal deaths in states with weak health systems and infrastructure.
Despite signs of progress in MAPEDIR pilot districts, hurdles remain. Two critical issues that would eventually determine the success or otherwise of the initiative are monitoring and supervision of the whole process. Teething problems include the reluctance of health workers to report maternal deaths for fear of repercussions, reluctance of families to discuss details of women’s care, and the varying quality of training and supervision of interviewers.
MAPEDIR is not the magic bullet that can resolve all the systemic ills that contribute to maternal deaths in the country. But it is powerful ammunition in the movement to save mothers and their children, and can help India achieve the Millenium Development Goal of 109 maternal deaths per 100,000 live births by 2015.