Maternal Mortality: Who Killed My Mummy?
When doctors at the local primary health centre in Banda, Uttar Pradesh, were unable to stop her bleeding, Phuli, 28, was moved to the Banda district hospital and then to the hospital in Kanpur. But here she was denied life-saving care and gave birth outside the hospital gates. While the baby died within an hour, Phuli died later that night.
Did Phuli need to die? Could she have been saved if she had not been the wife of a daily wage laborer belonging to a marginalized community? Would she have survived if she knew that the symptoms of blood loss were not normal or that she was seriously sick? Why is it that over 75,000 women continue to die from pregnancy-related causes in India each year? Can the health system be made legally accountable? These were some of the concerns raised at a recent meeting in New Delhi to discuss Maternal Health, Human Rights and Law, as a part of the nationwide ICPD +15 (International Conference on Population and Development) Gains and Gaps review process.
"In India, there is one maternal death every five minutes. These are preventable deaths. There is no justification for maternal mortality. India has more than 300 maternal deaths for every 100,000 live births. In Sri Lanka, the corresponding figure is 56, in China it is 45, in Namibia, 210 and in Egypt, 130. The biggest cause is discrimination and the lack of equality that prevents women from accessing information and services. However, women should not remain objects of interventions but also be empowered," contends Anand Gover, UN Special Rapporteur on Right to Health.
Litigation can become a tool to empower women by making maternal health a right says Jasodhara Dasgupta, member of the steering group for ICPD+15 review. "Equity has to become a marker for measuring maternal mortality. Less than 50 per cent of women give birth with the assistance of a skilled attendant and only 40 per cent of deliveries occur in an institutional setting. Even access to maternal health varies by state. So while in West Bengal over 90 per cent receive antenatal care, only 34 per cent receive it in Bihar," she informs.
But maternal health is not only about numbers. It is about a woman's dignity and her right to health - two reasons why accountability is needed. Maternal mortality is symptomatic of a deeply ingrained gender inequality, feels Melissa Upreti, senior legal advisor of the Centre for Reproductive Rights, an international NGO. "India has taken many steps to reduce maternal mortality including the National Rural Health Mission (NRHM), but it lacks effective monitoring and enforcement. This has undermined the country's efforts. Human rights law and the Constitution provide a strong basis for lawyers to demand change and hold the government accountable for maternal deaths," she says.
CRR (Center for Reproductive Rights), which uses the law to underline reproductive freedom as a fundamental right to all governments, launched a global initiative in 2004 to promote the use of strategic litigation for achieving women's reproductive rights worldwide. In 2006, it organized the first ever training on reproductive rights for lawyers in India in collaboration with the Human Rights Law Network (HRLN). It was at this meeting that the potential for developing constitutional litigation to address maternal mortality through the use of international norms and comparative law was discussed for the first time. It also inspired the just-published report, 'Maternal Mortality in India: Using International and Constitutional Law to Promote Accountability and Change'.
The report, which assesses the situation in India and recommends strategies and laws that can be used to tackle the problem, was shared at the recent meeting, where it was released. "It (the report) is a tool to establish a protective legal environment to enable women to exercise their right to survive pregnancy and childbirth and lead healthy and productive lives. The absence of legal accountability for maternal deaths and morbidity caused by the health system failures, socio-economic disparities and discriminatory social practices is a major impediment to successfully reducing maternal mortality. Law can help fight maternal mortality," points out Upreti.
This was seen in Madhya Pradesh (MP) last year. A public interest litigation (PIL) was filed against the state by Jan Adhikar Manch, a network of local NGOs and the HRLN. The PIL exposed the failure of the state to implement official policies on maternal health as a result of which women in the state were not receiving adequate antenatal and postnatal care. It used data from the National Family Health Survey (NFHS) to show that less than half of all pregnant women in MP receive antenatal care and 20 per cent do not receive any care at all. This gap has contributed to the large number of high-risk pregnancies that go undetected and lead to a high incidence of maternal mortality and morbidity. MP has the third highest Maternal Mortality Rate (MMR) in the country (379 per 100,000 live births).
"Since the filing of the PIL, a blood bank - one of the demands made - was set up at Bhind Hospital. The case is still being heard. This shows that courts can be proactive and restore rights of women," contends Jameen Kaur, HRLN. "It takes courage on the part of the victims to approach the court and seek redressal and hope. They have a voice in the form of PILs but it is the government, the upholder of these rights, which does not have ears."
Disparities in maternal health between north and south India are striking. According to the CRR report, analysis of government data reveals that 93 per cent women in south India receive some form of antenatal care than do a dismal 43 per cent of women in the north. Even the quality of care received by women in the north is poorer. Only 23 per cent received information of danger signs during pregnancy and delivery care compared to 44 per cent in south; 60 per cent women were given iron and folic acid tablets compared to 91 per cent in south. Despite the fact that eclampsia is the second most common cause of maternal death, health facilities in many parts do not stock magnesium sulfate, its standard treatment (NFHS - 1998-99).
Women's groups have begun campaigning for state accountability to ensure equal rights for women. In Uttar Pradesh, the state with the highest MMR, 'Complete Citizen, Total Rights', a campaign to demand accountability on the basis of constitutional obligations to protect, promote and fulfill women's rights has been started by HealthWatch, an NGO working for women's right to health. HRLN has also filed several PILs seeking implementation of service guarantees under NRHM.
Three delays that cause women to die - the delay in deciding to seek care, the delay in reaching the appropriate health facility and the delay in receiving quality care once inside an institution. It is evident that these deaths are not random occurrences, but the foreseeable result of a failure of the health system. Dismissive attitudes and a lack of basic health facilities in hospitals have exacerbated the fragile situation. Hopefully, now the courts will step in to lead the way in upholding a woman's right to health.
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