Maternal mortality causes 56,000 deaths every year in India, accounting for 20 percent of maternal deaths around the world, said John Townsend, vice president and director of the Population Council’s reproductive health program. It is a key battleground for maternal health advocates. But maternal health is sometimes eclipsed by other major health and development issues on the sub-continent. For example, nearly five times as many people suffer from HIV/AIDS and more than 400 million people live on less than $1.25 a day.

Townsend was joined at the Wilson Center on April 4 via videoconference by participants in New Delhi and from Harvard University’s School of Public Health to discuss key challenges to improving maternal health in India as part of the Global Health Initiative’s Advancing Dialogue on Maternal Health series. The public event was preceded by a day-long workshop in New Delhi with 70 leading development practitioners, senior government officials, and a wide range of donors and media representatives who came together to participate in roundtable discussions identifying future priorities.

A Holistic Approach

Poonam Muttreja, executive director of the Population Foundation of India, which co-convened the India workshop, said that one of the key points participants in New Delhi agreed on was the need for increased attention on maternal morbidity in addition to maternal mortality.

While maternal deaths fell from 390 to 200 deaths per 100,000 live births in just 10 years (though still well above the developed-country average of 9 per 100,000), Muttreja said that “for every woman dying in childbirth about 20 suffer long-lasting and debilitating illnesses.” For many of these women, “life is a living death.”

One way to address this gap is to “promote a life cycle approach” to care instead of addressing specific components, like family planning, maternal health, and reproductive and sexual health, separately.

Leela Visaria, honorary professor at the Gujarat Institute of Development Research, agreed: “In practice, what it means is offering women a broad set of family planning and reproductive health services and maternal health services at the same delivery site and by the same provider,” she said. “I think we all know this, and yet we have not been able to achieve this.”

One gap that needs to be addressed is sexual health and health education, she said. Sexual health programs, especially ones targeting adolescents, are “almost nonexistent.”

Visaria also emphasized the importance of family planning as part of maternal health. Contraception can help women space births further apart, leading to healthier pregnancies, healthier mothers, and healthier children, she said.

Addressing the gaps in care after childbirth could also significantly reduce morbidity. Few women have access to postpartum care, especially in the north of the country, said Visaria. Abhay Bang, director of the Society for Education, Action, and Research in Community Health, noted that 43 percent of rural women suffer from some kind of postpartum morbidity and that home-based care through accredited social health activists could significantly reduce these numbers.

The Indian government has recognized the need for integrated healthcare throughout women’s lives, and has set up a coalition to deal with reproductive, maternal, newborn, child and adolescent health in a more holistic manner, said Muttreja.

Social Determinants of Care

“Maternal health will not be improved to its full potential by focusing on maternal health alone,” Bang said, quoting the manifesto for maternal health produced at January’s Global Maternal Health Conference in Arusha, Tanzania. “That is precisely where social determinants come in.”

In India, he said, early marriage traditions have serious negative impacts on maternal health as girls are more likely to become pregnant at younger – and riskier – ages. He also noted that women have generally low status in traditional Indian families, leading to poor nutrition: 36 percent of Indian women are malnourished and 55 percent are anemic.

Women who are born into the lower castes or tribal women are especially likely to lack access to healthcare. “These are the last people that are served, these are the last people who have access to care,” said Townsend, “and this inequity will be a problem…for every element of society.”

Joining the event from Boston, Mary Nell Wegner of the Maternal Health Task Force, focused on ways to “change the odds” for these underserved women. An integrated approach could help address their multiple needs by reducing the number of points of contact they have to make in order to receive care, she suggested. The complexity of social determinants of health can make reaching these women difficult, but organizations should figure out how to build trust and interact with those who generally spend little time in health-care institutions.

Dr. H Sudarshan, of the Karuna Trust, pointed to another social factor. The “greatest problem today in the health care service is the corruption in the system,” he said from New Delhi. For example, although anemia is a major problem throughout India, during one two-year period some states didn’t have any iron tablets to distribute to women. Transparency within hospital administrations and community monitoring schemes could help curb this graft, he said, mentioning that there are pilot programs in nine states that have helped.

As evidenced by the great progress made in the last decade, the government has taken community monitoring seriously, said Muttreja. She pointed out that the National Rural Health Mission has made this a particular focus, but noted that equally important as improving oversight is making communities more aware of the rights and the services to which they’re entitled.

The Post-2015 Development Agenda

Bang pointed out that there is great potential in home-based care, including prenatal, delivery, postpartum, and newborn care. Reaching out to women at home – provided the quality of service remains acceptable – can improve access to care, especially for women who tend to fall through the cracks. He also said that India needs to focus on gender issues outside maternal health, like girl’s education, violence against women, mental health, and sensitizing men.

From New Delhi to Boston and Washington, DC, all the panelists emphasized the need to continue to focus on maternal health in the post-2015 development framework (when the Millennium Development Goals are set to expire), especially within the greater framework of integrated health care. They also said that quality of care is an important priority: a system of accreditation for facilities and services should be introduced alongside guidelines, protocols, and checklists to promote best practices.

Maternal health is a “sound investment strategy” for development, Townsend said, but part of the challenge is communicating the benefits. “I don’t think we should be timid,” he said. “If we want women and maternal health to be central on the development agenda, we have to speak with a strong and vibrant voice.”

Drafted by Carolyn Lamere, edited by Schuyler Null and Sandeep Bathala