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Achieving Millennium Development Goal 5: Is India Serious? Dileep Mavalankar,A Kranti Vora a & M Prakasamma B

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Achieving Millennium Development Goal 5: Is India Serious? Dileep Mavalankar,A Kranti Vora a & M Prakasamma B Editorials Achieving Millennium Development Goal 5: is India serious? Dileep Mavalankar,a Kranti Vora a & M Prakasamma b India has the largest number of births “auxiliary” undermined their status and No political will 1 per year (27 million) in the world. With function as midwives. Sri Lanka had a For politicians, health is a low priority. its high maternal mortality of about similar cadre of workers called “public Government expenditure on health has 300–500 per 100 000 births, about 75 health midwives” with a focus on deliv- been a mere 0.9% of GDP,6 while a 000 to 150 000 maternal deaths occur ery care, which contributed significantly 2,3 large percentage of the budget is spent every year in India. This is about 20% to reducing maternal mortality. After on defence, un-targeted subsidies and of the global burden hence India’s prog- 1966, under pressure from international non-vital infrastructure. No political agencies, the role of ANMs in India ress in reducing maternal deaths is cru- party has maternal health on its priority changed from midwifery to family plan- cial to the global achievement of Millen- agenda. Hardly any questions are asked ning and immunization.7 nium Development Goal 5 (MDG 5). about maternal deaths in the parlia- India also abolished the posts of Why is India’s maternal mortality high ment or state legislatures. Mass media institution-based midwives, replacing in spite of rapid economic growth? We has also ignored maternal health. believe the key reasons are political, ad- them with general nurse midwives. Nurses were rotated in all the depart- ministrative and managerial rather than a Absence of comprehensive lack of technical knowledge. ments of the hospital, thus they did not develop any expertise in midwifery, maternal care services Absence of focus on emergency and the training programmes exclu- With the change in the role of ANMs obstetric care sively for midwifery were stopped. As and programme priorities, comprehen- a consequence, although female nurses sive services have been neglected. Not Since the 1990s, it has been recognized and ANMs are automatically registered only delivery care but antenatal and that emergency obstetric care (EmOC) as midwives, there are no professional/ postnatal care are also neglected. The is one of the cost-effective strategies for skilled midwives in India. National Family Health Survey (2006) reduction of maternal deaths.4 In 1992, As more than 60% of births are shows that only 52% of women receive India launched its Child Survival and domiciliary deliveries, India needs to three antenatal contacts and 42% re- Safe Motherhood programme (at a cost come up with an option to provide ceive any postnatal care.9 Abortion and of approximately US$ 300 million) skilled birth attendance at community birth-spacing services are receiving less followed by a five-year programme level. Lack of qualified midwives is attention lately. All of this has a major (approximately US$ 250 million) called a major human resource constraint impact on maternal health indicators. Reproductive and Child Health-I in for providing locally accessible skilled 1997. Although EmOC was one of the delivery care for rural women. Any In spite of rhetoric from the National strategies, it was not implemented due country with a political commitment Rural Health Mission, changes on the to lack of focus and limited manage- to reducing maternal mortality has to ground to improve maternal health care ment capacity. Even today the govern- concentrate on well-trained midwives are slow and lack focus. We feel strongly ment does not systematically monitor in the hospital and the community. that without a clear strategic focus on how many EmOC facilities are fully Conversely, India ignored the develop- skilled birth attendance, EmOC and functional.5 The National Rural Health ment of a midwifery cadre, which has referral services, India will not be able Mission, a major new reform initiative led to persistent dependence on tra- to reduce maternal mortality rapidly. launched in 2005, has been promoting ditional birth attendants for deliveries There is a need to provide comprehen- training of village health volunteers and and a high maternal mortality rate. institutional deliveries. Again, improv- sive maternal health services, including ing EmOC is one of the many activities Lack of management capacity in antenatal care, delivery care, EmOC and postnatal care, within an efficient of the National Rural Health Mission the health system lacking clear strategy or focus.6 health system. The extent of the in- India has only three technical officers crease in political priority, managerial Missing midwives for maternal health at the national capacity and resource allocation will level! Almost no state in India has a determine, if and when, India will be In the 1960s, India created a cadre of maternal health director. This explains able to meet MDG 5. ■ two-year trained rural midwives called why maternal health strategies are not “auxiliary nurse midwives” (ANMs) implemented effectively, and maternal Competing interests: None declared. to provide maternal and child health deaths and pregnancy outcomes are not services. They substantially fitted the monitored. Lack of management capac- References definition of skilled birth attendant. ity in the health system has led to poor Available at: http://www.who.int/bulletin/ Unfortunately, their designation as quality services and slow progress.8 volumes/86/4/07-048454/en/index.html a Center for Management of Health System, Indian Institute of Management, Vastrapur, Ahmedabad 380015, India. b Academy for Nursing Studies, Hyderabad, India. Correspondence to Kranti Vora (e-mail: [email protected]). doi:10.2471/BLT.07.048454 Bulletin of the World Health Organization | April 2008, 86 (4) 243 Editorials References 1. Ronsmans C, Graham WJ. Maternal mortality: who, when, where, and 6. National Rural Health Mission [Mission Document]. Available from: http:// why. Lancet 2006;368:1189-200. PMID:17011946 doi:10.1016/S0140- mohfw.nic.in/NRHM/Documents/Mission_Document.pdf [accessed on 12 6736(06)69380-X February 2008]. 2. Maternal mortality in India: 1997-2003. Trends, causes and risk factors. New 7. Mavalankar D, Vora K. Changing role of auxiliary nurse midwife in India. Delhi: Registrar General; 2006. Ahmedabad: Indian Institute of Management; 2007. 3. National Family Health Survey (NFHS-2) Key Findings. International Institute 8. Mavalankar D, Raman P, Shankar M. Top management capacity: key for Population Sciences; 1998-99. p.12. constraints in Safe Motherhood Program in India. Ahmedabad: Indian Institute 4. Maine D. Safe motherhood programs: options and issues. Columbia of Management; 2006. University; 1993. 9. Maternal Health, National Family Health Survey, NFHS-3. India: International 5. Ved RR, Dua AS. Review of women and children’s health in India: focus Institute for Population Sciences; 2006. Chapter 8. on safe motherhood [Background paper for “Burden of Disease in India”]. National Commission on Macroeconomics and Health Publication, India; 2005. Bulletin of the World Health Organization | April 2008, 86 (4) A.
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