India: Too Many Women Dying in Childbirth - Human Rights Watch

Despite National Commitment, Many Unable to Access Services

October 7, 2009

Relatives mourn the loss of Kiran Yadav, who died after giving birth. Gopalpur, Uttar Pradesh.

© 2009 Susan Meiselas/Magnum

Related Materials:

No Tally of the Anguish

Other Material:

Magnum In Motion

Related videos:

• In Silence: Maternal Mortality in India

Unless India actually counts all the women who die because of childbirth, it won’t be able to prevent those thousands of unnecessary deaths. Accountability might seem like an abstract concept, but for Indian women it’s a matter of life and death.

Aruna Kashyap, South Asia Researcher in the Women's Rights Division

(Lucknow, India) - Tens of thousands of Indian women and girls are dying during pregnancy, in childbirth, and in the weeks after giving birth, despite government programs guaranteeing free obstetric health care, Human Rights Watch said in a report released today.

The 150-page report "No Tally of the Anguish: Accountability in Maternal Health Care in India" documents repeated failures both in providing health care to pregnant women in Uttar Pradesh state in northern India and in taking steps to identify and address gaps in care. Uttar Pradesh has one of the highest maternal mortality ratios in India, but government surveys show it is not alone in struggling with these problems, including a failure even to record how many women are dying.

"Unless India actually counts all the women who die because of childbirth, it won't be able to prevent those thousands of unnecessary deaths," said Aruna Kashyap. "Accountability might seem like an abstract concept, but for Indian women it's a matter of life and death."

The report cites numerous examples of cases in which breakdowns in the system ended tragically. Kavita K., for example, developed post-partum complications, but the local community health center was unable to treat her, according to her father, Suraj S., who said the family then tried to take her to government hospitals in three different towns.

"From Wednesday to Sunday - for five days - we took her from one hospital to another," he told Human Rights Watch. "No one wanted to admit her. In Lucknow, they admitted her and started treatment. They treated her for about an hour, and then she died."

India created a flagship program, the National Rural Health Mission, in 2005 to improve rural health, with a specific focus on maternal health. The program promises "concrete service guarantees," including free care before and during childbirth, in-patient hospital services, comprehensive emergency obstetric care, referral in case of complications, and postnatal care. But the system is not working as it should in many cases, Human Rights Watch research showed.

The report identified critical shortcomings in the tools used to monitor the health care system and identify recurring flaws in programs and practice. While accountability measures, such as monitoring how and why women die or are injured, or how many pregnant women with complications can use the government's emergency obstetric facilities, may seem dry or abstract, they are critical to intervening in time to make a difference and to saving the lives of women.

The major gaps in the system identified by Human Rights Watch are:

• The failure to gather the necessary information at the district level about where, when, and why deaths and injuries are occurring and whether women with pregnancy complications in practice get access to emergency obstetric care; and
• The absence of accessible grievance and redress mechanisms, including emergency response systems.

"India has recognized that thousands and thousands of its women are dying unnecessarily, and it could be leading the world in reversing that deadly pattern," said Kashyap. "But for all India's good intentions, the system still leaves many women at risk of death or injury."

The research for the report was conducted between November 2008 and August 2009, and included field research and interviews with victims, families, medical experts, officials and human rights activists in Uttar Pradesh and elsewhere in India. Researchers reviewed government surveys and reports by local and international nongovernmental organizations.

The investigations in Uttar Pradesh also show that while health authorities are upgrading public health facilities, they still have a long way to go. The majority of public health facilities have yet to provide basic and comprehensive emergency obstetric care. Many have a health worker trained in midwifery but who can do little to save the life of a pregnant woman unless supported by a functioning health system, including an adequate supply of drugs, emergency care, and referral systems for complications.

The reality is far different from what is guaranteed to women on paper. Niraja N., a health worker who routinely accompanies pregnant women to health facilities so they can give birth told Human Rights Watch:

"Nothing is free for anyone. What happens when we take a woman for delivery to the hospital is that she will have to pay for her cord to be cut ... for medicines, some more money for the cleaning. The staff nurse will also ask for money. They do not ask the family directly ... We have to take it from the family and give it to them [staff nurses] ... And those of us [ASHAs] who don't listen to the staff nurse or if we threaten to complain, they make a note of us. They remember our faces and then the next time we go they don't treat our [delivery] cases well. They will look at us and say ‘referral' even if it is a normal case."

In part, this happens because many women are unaware of their entitlements under health care programs and have no way to make sure that their complaints and concerns about the treatment meted out to them at health facilities or by health workers are heard and addressed.

Also available in:

• Español
• Deutsch
• 日本語

In War and Isolation, a Fighter for Afghan Women

By DENISE GRADY

Everybody wants Pashtoon Azfar. Her government, American aid groups and her own colleagues, the midwives of Afghanistan, all want her to work for them, lead them, help them rebuild a health system from the rubble of war.

Ms. Azfar, 51, is trying to oblige. By day she directs Afghanistan’s Institute of Health Sciences, by night she works for a nonprofit group from Johns Hopkins University that focuses on women and children’s health, and somehow she also manages to serve as president of the Afghan Midwives Association.

Visiting from Kabul recently, she was the star at a Capitol Hill briefing titled “Maternal Health in Afghanistan: How Can We Save Women’s Lives?” Her audience included members of the Congressional caucus for women’s issues.

Afghanistan has the world’s second-highest death rate in women during pregnancy and childbirth (only Sierra Leone’s is worse). For every 100,000 births, 1,600 mothers die; in wealthy countries the rates range from 1 to 12. In one remote northeastern province, Badakhshan, 6,507 mothers die for every 100,000 births, according to a 2005 report in the medical journal Lancet. In all, 26,000 Afghan women a year die while pregnant or giving birth.

The main causes of these deaths are hemorrhage and obstructed labor, which can be fatal if a woman cannot obtain a Caesarean section. Even if the mother survives, obstructed labor without a Caesarean usually kills the baby. Most of the maternal deaths — 78 percent, according to the Lancet report — could be prevented. Against this bleak history, Ms. Azfar told her Washington audience, “I would like to share some successes with you.”

An intense woman with short, graying hair, Ms. Azfar rarely smiles. She ran through statistics showing notable increases recently in the country’s number of midwives, their education and the percentage of women who give birth with the help of a “skilled attendant,” usually a midwife. The United States, the World Bank, the European Commission, Unicef, the Hopkins group (known as Jhpiego) and other donors have all helped Afghanistan’s Ministry of Public Health to make improvements.

But there is a long way to go. Most women in Afghanistan, as many as 80 percent, still give birth without skilled help, and only a third receive any medical care at all during pregnancy.

Afghanistan’s problems mirror those of many other poor countries: shortages of personnel, supplies and transportation to clinics or hospitals, especially in remote regions and mountainous areas that are snowbound half the year. The deeper problems are cultural, rooted in the low status of women and the misperception that deaths in childbirth are inevitable — part of the natural order, women’s lot in life.

During her talk in Washington Ms. Azfar quoted Dr. Mahmoud Fathalla, an Egyptian physician and advocate for women’s health: “Women are not dying of diseases we can’t treat. ...They are dying because societies have yet to make the decision that their lives are worth saving.”

Ms. Azfar works 12 hours a day, seven days a week. She has irked relatives by missing weddings and other family events because of work.

“My children are not happy,” she said in an interview after her speech.

Ms. Azfar grew up in a village about an hour from Kabul.

“Everywhere then, girls went to school,” she said. “Women’s rights before the Taliban were the same as in Western countries. Women had the right to vote.”

Her mother had 10 children, 2 of whom died. She always gave birth alone, behind a closed door. When Ms. Azfar was 9, she began to help, by waiting outside the door to receive the newborn baby and wash and swaddle it, while her mother then delivered her own placenta.

Ms. Azfar never actually saw a birth until she began studying midwifery at age 16, and only then, she said, did she realize how brave her mother had been. She finished the rigorous three-year program at the top of her class in 1976.

“It was a very well-respected profession in my country,” she said.

But decades of war destroyed midwifery and much of health care, she said. Professionals fled the country, and many never went back.

“One day, 100 rockets came into Kabul,” she said. She and her husband, a physician, took their four children and moved to Pakistan, living there from 1992 to 2003. She had a fifth child there.

By the time she returned to Afghanistan, she said, midwifery was in a shambles. Spots in professional schools of all kinds were being filled by people with political connections instead of those with good grades. The midwives who had stayed behind had not received any continuing education. Their skills were outdated, and their attitudes were even worse.

“A culture of war was going on,” Ms. Azfar said. “If a mother came for delivery they didn’t treat her as she deserved or needed to be treated. There was no emotional support.”

Attitude counts in midwifery: if midwives and other health workers seem indifferent or disrespectful, women start to avoid the clinics, and they miss out on the help they urgently need.

Ms. Azfar acknowledged that it was hard to change attitudes, but she insisted that it could be done, by making “interpersonal skills” part of the training and the tests that students must pass to be allowed to practice. In Afghanistan, these things became part of the midwifery curriculum in 2004.

“Does she greet the mother properly?” she asked. “Offer her a chair? A drink of water? Introduce herself? Let the mother ask questions? They are trained. They have to do it.”

She has seen signs of progress, of hope.

“Just five years ago we started the reconstruction of this profession,” Ms. Azfar said. “These midwives, they are champions. Oh, I love them. They are my heart.”

Maternal Mortality, Unplanned Pregnancy and Unsafe Abortion in Timor-Leste

Dili, 09 June, 2009-- The improvement in the quality of life of Timorese women and their families is the objective that Alola Foundation, supported by UNFPA, expects after launching the report, "Maternal Mortality, Unplanned Pregnancy and Unsafe Abortion in Timor-Leste: A Situation Analysis." The launch of this publication took place on Tuesday 3 June at the Alola Foundation installation, and was attended by Kirsty Gusmao, Chairwoman of Fundasaun Alola, Dr. Hernando Agudelo, UNFPA Country Representative and Eng. Idelta Maria Rodrigues, Secretary of State for the Promotion of Equality (SEPI).

This research, carried out by the Charles Darwin University with the endorsement of the Ministries of Justice and Health, will offer to the Government and to the people in Timor-Leste tangible facts regarding the occurrence and practice of unsafe abortion in the country.

"With this study in Timor-Leste, we wanted to show this reality -women may die because of unsafe abortion- within the Timorese society and give to the society a tool for reflection, for taking informed decisions at this point time of its history where the parliament and the government were taking the decision on how to deal with this controversial issue, this study shows that there are unwanted pregnancies and therefore a necessity to ensure country wide access to Family Planning services" added Dr. Agudelo.

Due to their continuous work debating on the issues of abortion and the reproductive health of mothers, Alola and other women’s organizations have been branded as pro-abortion by certain institutions in the country. Ms. Kirsty Gusmao, in her speech referring to this regard, specifically after the publication of this report, appoints: "Such public defamation is inappropriate and offensive to our organizations which have worked tirelessly to free the women of Timor-Leste from a life of violence, ignorance, poor health and poverty… We must not turn a blind eye to the reality of women's lives, to their sexuality, to their experiences of violence in their homes and communities, just because the reality does not sit nicely with the image of Timorese culture we would like portray to the world."

This publication will be used as an advocacy tool in lobbying for women's full access to quality medical care and family planning services and the full realization of their reproductive rights.

For more information, contact Mariano Redondo, UNFPA, Tel: +67..., Email: redondo@unfpa.org

Alita Verdial – Alola Foundation, Tel: +670 7..., Email: alita.adv@alolafoundation.org

Source - http://easttimorlegal.blogspot.com/2009/06/alola-foundation-and-unfpa-launch.html