Wider choices vital for safe motherhood

India has made commendable progress towards ensuring safe motherhood for women in recent years. However, any satisfaction one may derive from the steep decline in maternal mortality ratio (MMR) from 398 per 1,00,000 live births in 1998 to 167 in 2013 is tempered by the fact that the country still accounts for 17 per cent of all global maternal deaths.

Safe motherhood has three significant components that need to be addressed equally: mortality, morbidity and social determinants of fertility. Unsafe delivery and pregnancy related complications are major factors why women die before, during or after child birth. While the direct medical causes of mortality – haemorrhage, sepsis, unsafe abortions, hypertensive disorders and obstructed labour – are largely preventable through provision of better quality healthcare services, a significant proportion of maternal deaths are also attributed to indirect causes like anaemia and malaria.

One aspect of safe motherhood that is often overlooked in India is unwanted or early-age pregnancies and high unmet need for contraception. In India, according to National Family Health Survey, adolescents (15-19 years) contribute about 16 per cent of total fertility in the country and 15-25 years age group contributes 45 per cent of total maternal mortality. Nearly 21 per cent of all pregnancies are either unwanted or mistimed. This not only exposes women to avoidable maternal health complications, it also affects their overall well-being.

A more accessible and equitable family planning programme that offers a wider choice of contraceptive methods to couples constitutes a simple, low-cost investment which can reduce maternal and child mortality by preventing early age pregnancies and unwanted pregnancies at a later age.

The present day discourse on maternal health pays insufficient attention to the issue of morbidity. For every woman who dies in childbirth in India, about 20 more suffer from long-lasting illnesses with physical, psychological, social and economic consequences. Severe and continuing ill-health among women affects their children’s health too, in terms of nutrition and nurture, thereby having inter-generational consequences.

To be sure, family planning has had many successes over the last two decades. An analysis of the SRS 2011 report reveals that 800,000 births a year are being averted through the provision of family planning. Births among 15-19 year olds have come down by 350,000. Additionally, 1,700 maternal deaths are now being prevented each year and three out of four births are taking place in institutions.

Despite this, significant disparities and inequities in women’s access to healthcare continue to persist and the country remains far away from achieving the Millennium Development Goal of an MMR of 109 by 2015. The decreasing maternal mortality figures as a whole mask wide variations between different communities, states and even districts in the same state. Assam’s MMR of 390 compares poorly with 81 for Kerala. Many poor women from marginalised communities continue to exist outside the ambit of the healthcare system.

Safe abortions

It is estimated that if the current unmet need could be fulfilled within the next five years, India can avert 35,000 maternal deaths and 12 lakh infant deaths, while saving more than Rs 4,450 crore in the process. If safe abortion services are coupled with an increase in family planning services, the savings made to the country could be to the tune of Rs 6,500 crore.

To ensure proper health and avert maternal deaths, it is important to widen the basket of choice with the addition of more methods, address issues of accessibility and quality of family planning services, and allay myths and misplaced health concerns that prevent women from using modern contraceptives. Excessive focus on sterilisation as the primary contraception tool and a target-driven approach are ironically adding to maternal morbidity and mortality. Sterilisation is also not an optimal family planning choice for young women, whose primary need is birth spacing.

Of equal significance for safe motherhood are social determinants of fertility. Women’s low status in the family and in society means they eat last and the least, resulting in low body mass index. About 33 per cent of all women in India are malnourished, and 52 per cent are anaemic. This, along with marriages at an age not ideal for conception, makes women vulnerable to maternal morbidity and mortality, with long-term negative impact on the entire family.

The issue of safe motherhood in India is much wider in scope than providing healthcare and family planning services for women. It involves a wider debate about their education, dignity, and reproductive rights and denying them the choices which they should be making on their own.

(The writer is Executive Director, Population Foundation of India)