"We never had anything like the Republic we are going to have now..." - That was Dr Rajendra Prasad, as he put the motion for the adoption of India's new Constitution to vote in the Constituent Assembly two months before India became a republic in November 1949.
Imagine for a minute that shambolic entity called the Republic of India at that moment, with its 361 million people and innumerable needs, demands and expectations. Not all of these people received the Republic's attention.
As fresh evidence emerges of India's unconscionably high rates of maternal mortality (MMR) and infant mortality (IMR) - UNICEF's 'State of the World's Children 2009' has just put India's MMR at 450 per 100,000 live births and its IMR at 57 per 1,000 live births - it points to the lack of support accorded to the nation's young mothers.
Who were these women anyway? According to Census data, women numbered around 175 million in 1951. They had a life expectancy below the national average of 40 years. By age 16, they were more likely than not to have been married, and they would have given birth, on an average, to six children in the course of their lifetimes. The poet A.K. Ramanujam may well have been describing one of them when he once wrote, "I see my mother run back/from the rain to the crying cradles..."
It is not as if the leaders and planners of the Republic did not have the right perspectives or the necessary empathy. As early as 1946, the Health Survey and Development Committee of the Government of India had noted that morbidity in Indian women was the result of malnutrition, frequent pregnancies and anemia. In 1955, Prime Minister Jawaharlal Nehru, in his foreword to 'Social Welfare in India - The Planning Commission', observed: "...Welfare must be the common property of everyone in India and not the monopoly of the privileged groups as it is today. If I may be allowed to lay greater stress on some, they would be the welfare of children, the status of women and the welfare of the tribal and hilly people in our country." The Planning Commission's 'Plans and Prospects for Social Welfare in India, 1951-1961' laid down in the narrative for the First Five Year Plan that "Women are considered to be handicapped by social customs and social values and therefore social welfare services have specially endeavored to rehabilitate them."
With such telling observations and with such excellent intentions, why did the country lose the plot on maternal mortality? How did things go so wrong that, today, India does worse than the much-poorer Bangladesh in terms of its under-five mortality rate? That one in 71 of India's women die of maternity related factors, compared to China's one in 1,300?
The feisty, clear-sighted women, who wrote the Report of the Status of Women Committee in 1974, had sounded the alarm bells loud enough. They had warned of the consequences of the steadily declining share of investment in the social services and the easy assumption that all welfare programmes will benefit women indirectly, if not directly. The Committee had pointed to the inadequate number of maternity beds which, in 1968, constituted less than 17 per cent of total hospital facilities and to the fact that only about nine per cent of births in rural areas were attended by trained personnel. It had expressed concern that the numbers of auxiliary nurse midwives were clearly inadequate and that the masses of Indian women were consigned to the status of "expendable assets".
The Committee had also tracked the health budget and flagged the fact that by the Third Five Year Plan (1961-1966), India was allocating more to Family Planning (Rs 269.70 crore) than to health programmes (Rs 226 crore). It observed: "From the Third Plan ... restraint of population growth received a much greater emphasis and priority, with time-bound targets for reducing the birth rate and heavy investment in the administrative network to mount the programmes on the lines of a military operation... Some state governments even adopted measures to deny maternity benefits to women government servants after the third child. We feel strong about this measure, for the denial of maternity benefits to a working woman is likely to affect both the health of the mother as well as that of the child." This, incidentally, was stated years before the political backlash to forced sterilizations during the emergency manifested itself.
While the Fifth Plan tried to correct this trend somewhat, health continued to figure low in national priorities, with expenditure on public health declining from 1.3 per cent of the GDP in 1990 to 0.9 per cent in 1999. There is, then, a history to the stark figures that stare out of UNICEF's 'State of the World's Children 2009 Report', a history of callous administration and deliberate neglect. The UNICEF report underlines that "Growing inequities, combined with shortages in the provision of primary health care and the rising cost of care are complicating the country's efforts to meet the health-related Millennium Development Goals."
The high maternal mortality levels in India are the direct consequence of four factors. One, the lack of agency of the expectant mother - National Family Health Survey-3 (NFHS-3) estimates that 45 per cent of Indian women are married before they reach the age of 18 and that 37 per cent of married women face domestic violence. Two, the poor general health of the mothers: here again the NFHS-3 reveals that 56.2 per cent of "ever-married women aged 15-49" were anemic. Three, serious infrastructural lacunae, ranging from poor quality village roads to badly equipped primary health centers and district hospitals. Four, direct causes such as hemorrhage, sepsis, eclampsia, obstructed labor and complications of abortion, which may or may not be linked with the other three factors.
Maternal health is the fountainhead of social well-being including, most crucially, infant health. The National Rural Health Mission (NRHM) has the potential to be a catalyst for such well-being, with its strategy to train at the household level Accredited Social Health Activists (ASHAs), expand the agency of Panchayati Raj institutions in health delivery, and strengthen the existing three-tiered system - of sub-centers to cover 3,000-5,000 people; primary health centers to cater to 20,000 to 30,000 people, and community health centers, with at least 30 beds, covering a population of 80,000 to 1,20,000.
The point is that you don't need high technology to bring down maternal mortality rates. Dr Abhay and Dr Rani Bhang's interventions in Gadchiroli, Maharashtra - providing home-based health care delivered through trained female community health workers - brought down the neonatal mortality rate in the region by 70 per cent.
What the Republic needs to do today is to make up for lost time and keep both Mother India and the Other India at the centre of its health delivery.