Emergency Maternal Care: The Missing Piece of the Puzzle
India, home to 17% of the world's population, accounts for an unflattering 12% of all maternal deaths. The maternal mortality ratio (MMR), a metric used to study maternal deaths, is defined as the number of maternal deaths per 100,000 live births due to pregnancy-related complications. In India, maternal deaths have reduced from 113 per 100,000 live births during 2016-18 to 97 during 2018-20. However, we still have a long way to go as India aims to reduce MMR to <70 by 2030.
The leading causes of maternal deaths in India are excessive bleeding after delivery, infections, high blood pressure, delivery-related complications, and unsafe abortions. Various factors like home deliveries, a lack of skilled birth attendance (SBA), and poor access to emergency obstetric care only compound the situation.
The Janani Suraksha Yojana (JSY), a scheme sponsored by the central government is one of the several governmental initiatives working towards reducing maternal mortality. It aims at promoting institutional deliveries and reducing maternal deaths through cash transfers (INR 1400 and INR 1000 respectively in rural and urban areas of low-performing states). This serves a dual purpose of motivating a woman to deliver at a health facility and reducing pregnancy-related expenses. Between 2010 to September 2015, the scheme benefitted 57.9 million women.
Evaluation of the JSY by the National Health Systems Resource Centre (NHSRC) in 2011 found that among those who had previously delivered at home, over 50% opted for institutional deliveries since. Representation of marginalized sections had improved, indicating better equity in access to institutional deliveries. The program also brought about additional benefits in the form of increased contraceptive use, early initiation of breastfeeding, and compliance with postnatal checkups.
Despite JSY, home deliveries continued. Lack of ambulance services was identified as the most crucial barrier to institutional deliveries by a study done in rural Haryana from 2010-13. Over a third of home deliveries were due to an inability to pay for transport, half of which were avoidable. To tackle this issue, in 2011, the Janani Shishu Suraksha Karyakram (JSSK) was launched. The programme entitled pregnant women to free-of-cost ambulance and delivery services, including a cesarean section at public health facilities. An increase in institutional deliveries to the tune of 2.7 times was seen following the implementation of the JSSK. Various other programs like the Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA) and The ‘LaQshya - Labour room Quality improvement Initiative’ were launched in 2016 and 2017, respectively to improve maternal care and thus reduce maternal mortality.
Thanks to these initiatives, the proportion of institutional deliveries, a lowly 40.8% in the National Family Health Survey - 3 (NFHS-3, 2005-06) improved to 88.6% in the NFHS-5 (2019-21). Although these initiatives have yielded positive change, much remains to be done.
About 15% of pregnancies develop complications and 10% require cesarean sections. The range of services required to handle them is what constitutes Emergency Obstetric Care (EmOC). Nine clearly defined signal functions are used to classify EmOC facilities. Basic Emergency Obstetric Care (BEmOC) facilities deliver seven basic services whereas Comprehensive Emergency Obstetric Care (CEmOC) facilities deliver all nine.
BEmOC facilities can administer IV antibiotics, IV oxytocin, and anticonvulsants, manually remove the placenta, remove retained products of conception, perform assisted vaginal delivery, and perform basic neonatal resuscitation. Comprehensive Emergency Obstetric Care (CEmOC) facilities can handle cesarean sections and blood transfusions in addition to the basic services. A recommendation of at least five facilities per 5,00,000 population has been set, one of them being a CEmOC.
However, the distribution of these facilities in India is not uniform. Despite meeting the benchmark at 5.9 facilities per 500,000 population in northern Karnataka, most of the facilities in this region were in the private sector and congregated in a select few towns. Similarly, in Madhya Pradesh, EmOC facilities were mainly located in the larger districts. Disparities in the quality of services exist too; the JSY programme facilities lacked the full range of EmOC services whereas the non-programme (private) facilities fared better.
Program evaluation of JSY highlighted that training on Basic Emergency Obstetric Care (BEmOC) and facility-based newborn care was inadequate for healthcare workers. Simple equipment for neonatal resuscitation was missing in about half the public facilities. Private facilities oversaw only 12.5% of deliveries but rendered care in over half (60%) of the cases developing complications and requiring emergency care.
A study done in six Indian states in 2013-14 reported that only a small proportion of pregnant women used the free-of-cost ‘108’ ambulance service, possibly a result of a lack of knowledge. For those who used the service, the transport time exceeded the targeted 20 minutes. The travel times and distances were longer in women with obstetric emergencies, probably due to a lack of EmOC facilities in the vicinity.
Various solutions have been suggested to the above-mentioned problems of incompetent healthcare workers, poor infrastructure, and transport services - developing checklists to ensure the quality of care provided, engaging general surgeons to perform cesarean sections, and managing its complications, and establishing public-private partnerships (PPPs).
One such PPP model is the Chiranjeevi Yojana (CY) in Gujarat. Private medical practitioners, mainly obstetricians, were impaneled to provide perinatal and emergency care to below-poverty-line women. A study from three districts of Gujarat found that the CY increased the availability of free CEmOC facilities, however, the facilities were mostly private (80%) and concentrated in 30% of the towns. The availability of BEmOC facilities was below the recommended standards.
EmOC is of the essence if the gains in maternal mortality reduction are to be preserved and enhanced. Regional disparities in facilities along with the training of healthcare workers need to be addressed urgently. Efforts need to be directed toward upgrading the competencies of the birth attendants, especially in the facilities below the block level. Free service doesn’t always make it accessible and therefore increasing ambulance services needs to be prioritized to promote better utilization of the public healthcare system.
Besides making healthcare more accessible, it is also important to work on quality improvement of the services delivered. Public facilities need to be equipped with proper infrastructure and competent human resources. Privatization of healthcare needs to be monitored as it only makes healthcare more inaccessible, especially for people from poor socioeconomic backgrounds. Public-private partnerships like the Chiranjeevi Yojana have shown that collaboration can improve the EmOC scenario, but they aren’t without limitations. Lastly, community-based efforts addressing the lack of awareness regarding maternal health schemes and services would improve healthcare utilization and eventually help India in achieving its target maternal mortality rate by 2030.
About the Authors:
Sharvari Mande is a Final Year MBBS Student at Rajarshi Chhatrapati Shahu Maharaj Government Medical College, Kolhapur, Maharashtra, and a researcher at ASAR.
Shreyas Patil is a Junior Resident in the Department of Community and Family Medicine at AIIMS Patna