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Non-governmental organizations, working in the field of reproductive health, have asked the government to reconsider their approach towards maternal and child health for the vulnerable sections by putting in a multi-pronged effort that includes research and more context-situated interventions, even if these challenge the ‘template approach’ currently adopted.

In a report, “”CHRONICLES OF DEATHS FORETOLD,””– A civil society analysis of maternal deaths In seven districts from the states of Odisha, West Bengal, Jharkhand and Uttar PradeshâÂÂthe groups have drawn the attention of the government towards the fact that millions of children continue to be born at home, leaving these women at greater risk and the presence of informal providers and community birth companions and the existing health care practices which may not be really healthy.

The study was done by SAHAYOG and the National Alliance for Maternal Health and Human Rights (NAMHHR) and it documents the stories of about 140 women who did not survive pregnancy and childbirth, and it calls for a more pragmatic approach about the socio-cultural situation in these villages. It asks the government to move away from ‘hospital delivery equals safe delivery’ assumption to building skill in continuum of care for prevention and management of adverse outcomes.

“”Can we stop imagining that only IFA tablets with reduce severe anaemia? Anemia must be treated with something more effective than IFA tablets which are not helping women who are already severely anaemic. Can we continue our focus on terminal contraception and ignore informed contraceptive choice for all women? The lack of acceptable and appropriate family planning counseling and services is life-threatening for many women. Can we acknowledge that one-third of deaths in India are due to “”other causes”” that include domestic violence and non-obstetric causes of death, such as malaria, kalazar and falciparum malaria, and other local health problems. Can we make safe abortion services available at sub-district level?  Can we realize that the lowest functionary ASHA alone cannot easily negotiate the complex chain of referrals and the health system for the family? Can we move away from this ‘input-focused’ high priority area approach given the interconnecting webs of risks and vulnerabilities for specific populations at risk,âÂÂâ the report has sought answers for these questions.

The report points out that the current approach of Priority Actions in high-focus districts and vulnerable populations has two major limitations. The first is that it primarily includes more ‘inputs’. It also has a very limited definition and understanding of ‘vulnerable populations’. The primary measure of vulnerability that is used is ‘reaching the unreached’ and clubs a diverse range: from the poor, urban slum dwellers to tribals, and even adolescents. There is no analysis of why the system fails these people and there is an assumption that “”implementing and monitoring high impact interventions”” will be sufficient to address equity. “If we are serious in wanting to address disparities it is necessary to move from this ‘input-focused’ high priority area approach to a ‘highly vulnerable population’ approach which integrates inputs with processes and is informed by existing health care practices and socio cultural understanding of health determinants among the vulnerable communities,âÂÂâ it says.

To achieve this, the government should develop  a Highly Vulnerable Populations Approach  Mapping of Vulnerabilities and Risks and the existing health care practices in areas where  maternal health outcomes are poor, not showing the anticipated improvements and where the proportion of marginalised communities is higher. It has called for developing an appropriate cadre of providers – new personnel like emergency patient facilitators at secondary and tertiary care hospitals as well additional training to improve quality of care through improved interpersonal interactions, and adverse management outcomes skills.  Identifying niches within existing practices and practitioners for building an alternative safety plan (including the support of Dais and Informal providers where appropriate) and focussed on saving lives, and developing context specific plans from home to institution and from ante natal to postpartum period, are some other suggestions.

Developing Appropriate Protocols and Procedures for managing adverse outcomes using a team approach as well as ICT to support decision making is another suggestion made in the report. The team would include public and private providers located in different spaces from village to the tertiary care facilities. These protocols and procedures would need to be done for Management of Risks and Complications during Pregnancy, strengthening the Referral Chain, providing effective Comprehensive Obstetric Care Services to the marginalized, and monitoring ‘performance’ of the ‘adverse outcome management’ system, it says.  

We need MDRs to be done systematically in the community, and the health system to publicly share the findings or Action Taken from MDR. The community-perspective needs to be strongly incorporated in all MDR by having PRI members accompany the women’s family even for facility-based MDR, and promote reporting and review of all the maternal death cases with the health officials. The role of adequately trained civil society organizations (CSOs) is important when we see the extreme disempowerment of marginalized communities. CSOs can play a role in non-partisan, non-adversarial CB-MDR work in selected districts, according to the report.

The Janani-Shishu Suraksha Karyakram entitlements also means that supply of medicines should be ensured in all health facilities and the private sector needs more monitoring and better regulation: the quality and rationality of treatment is doubtful in the private hospitals, but huge sums of money are taken. There is serious need for regulation of the costs of services provided by the private sector. Families are paying any amount for unskilled and poor quality care of women in critical condition, and getting into debt. In addition the public sector doctors examining/treating patients who come to public hospital privately and public providers are also referring women into the private sector, which needs to be checked, the report says.”