India: including women's voices when crafting maternal health policies.

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Maternal health is almost always seen as a technical and health issue which means that the medical establishment is regarded as best qualified to speak on it. Policy making on maternal health has therefore never consulted those who are directly affected, that is the women who undergo pregnancy. Policies and Five Year Plans set ambitious targets to reduce maternal mortality, but programmes continue to look away from women. Women have never been consulted on where they prefer to give birth, what support they need for their choices, what happens when they seek help, and what their experience have been in seeking abortions. Neither have women been asked whether all their pregnancies are of choice, whether they need more support in making reproductive decisions and whether they can actually exercise sexual choices and sexual health protection.

Today, policy making is also largely dictated by concerns of cost, since health care is rapidly becoming a lucrative industry rather than a right. In the name of being 'cost effective', however, often highly technical, unrealistic and cost-intensive solutions may be promoted. One classic example is the promotion of compulsory 'institutional delivery' for every birth as the only solution for averting maternal deaths. (1) Despite the fact that women may see birth as a private activity to be carried out in the comfort of home or that there are birth attendants in most communities who can be given more training, policy makers insist that all women should deliver in hospitals. This is despite the knowledge that only 15% of all births lead to complications and the rest are normal deliveries and that complications can happen in the ninth month of pregnancy or up to six weeks after delivery. Policy makers set aside the evident fact that large numbers of women cannot afford the travel costs and informal payments for undergoing birth in state-run institutions: more importantly, that in large parts of India there are no institutions or referral systems to handle the complicated cases! (2) Knowing all this, policy makers have preferred to promote institutional delivery through incentive payments and other means. (3)

A group of Indian NGOs working with directly affected women decided that they would take women to directly voice their concerns and their experiences regarding their right to maternal health to address the policy makers in the country's capital. A three-day policy dialogue took place in New Delhi on 27-29 December 2005, called "VOICES FROM THE GROUND: Policy Dialogues on Women's Right to Maternal Health," organised by SAHAYOG (Lucknow), CHETNA (Ahmedabad) and the Centre for Health and Social Justice (New Delhi), which was attended by 100 participants from eight states of India (apart from local media persons).

These dialogues enabled rural and urban low-income women to directly address the media, Ministry and Planning Commission officials and donors regarding their demands for the improvement of maternal health services in India. The rural women presented testimonies of their experience of seeking maternal health care, denial of health services and described maternal deaths in their families Supporting the women were a number of NGOs who had jointly drafted a set of concrete recommendations for the government. The NGOs supporting the women gave evidence from various parts of the country to indicate that maternal health services were highly inequitable, with a 'clustering of deaths' in certain states, among poor rural women and among Dalit and tribal women.

The meeting also saw a debate on skilled attendance at childbirth between rural traditional birth attendants who had organised themselves into a "Dai Sangathan" and representatives of UN agencies. The Ministry of Health and Family Welfare (Government of India) responded to the women by asking for detailed descriptions of the maternal death cases so that some action could be taken, and this was followed up by a series of faxes from the participating NGOs to the Ministry. Fortunately, the officials have taken action and enquiry letters were issued in 2006. The Ministry also invited the organisers to present these testimonies at three state-level meetings on maternal health (in states with high maternal mortality), so as to bring home the immediacy of the problem to officials at the state level.

However, the rural women and NGOs from Uttar Pradesh wanted to create more pressure from the 'demand side', as they had been documenting denial of maternal health services, doing case work and carrying on the dialogue with state officials for two years already. They felt there was need for a more concerted state-level campaign to raise awareness within the community and the government regarding women's right to maternal health. Rural women decided to call the campaign Complete Citizens Total Rights Campaign (Puri Nagrik, Pura Haq) and this was carried out over several districts of Uttar Pradesh from 6th March to 28th May 2006.

The rural women and NGOs collected around 35,000 signatures supporting their demands and took them to the Minister of Family Welfare on the eve of 28 May 2006 (International Day of Action for Women's Health). They met the local health officials in their districts and presented their problems, indicating their demands for maternal health rights through a poster. Women also monitored the implementation of the government's Rural Health Mission and gave feedback to the state's Director General of Family Welfare at a meeting to celebrate the first anniversary of the Mission launch. The rural women also met members of the State Commission for Women and made presentations inside the State Legislative Assembly. They marched in colourful processions, carrying a 'woman's corpse' to symbolise maternal death, and they stood dressed in shrouds with candles to protest against the forty thousand maternal deaths in the Uttar Pradesh state each year.

The outcome was that the Minister of Family Welfare began to make announcements in the media regarding the importance of maternal health. In some districts, the local health officials developed improved relations with NGOs and enlisted their support in implementing the National Rural Health Mission. The rural women themselves declared the launch of a state-level organisation to continue working on the issue of women's right to maternal health.

These two efforts indicate that women are able to clearly articulate their needs and preferences on maternal health services despite being non-literate, rural and from low-income families. Women are directly affected by health policies, and their experiences and their choices should form the content of policy deliberations, rather than only the technical medical point of view, which often overlooks the social and economic context within which maternity occurs. As we move towards a rights-based approach in maternal health, women's voices need to be given more space, and women's choices need to be considered in decision making.

Endnotes

(1) The report of the Registrar General (2005) called Maternal Mortality in India 1997-2003 says that institutional delivery in India has risen from 24.3% in 1991 to 28.3% in 2003.

(2) The data from reproductive and child health (RCH) Facility Survey mentioned in the RCH 2 document (2003) indicates that the government institutions equipped to provide essential and emergency obstetric care are rare since they either lack personnel, essential supplies or equipment. According to the RCH 2 document, the RCH Facility Survey revealed that first referral unit (FRU)/community health centre (CHC) and district hospitals attended only about 10 referred cases of delivery in a month.

* Only 36% of primary health centres (PHCs) had adequate physical infrastructure

* 31% PHCs had adequate supplies

* Out of every 10 PHCs, 8 have no Essential Obstetric Care Drug kit

* 34% PHCs offer delivery services, 3% offer abortions

* Only 10% of the CHCs and FRUs had adequate supplies

* Only 56 % PHCs, 49% CHCs and 89% District hospitals have all critical supplies (defined as 60% of critical inputs)

* 38% PHCs had adequate staff in position

* Out of 10 CHCs, 7 have no obstetrician, 8 have no pediatrician

* 25% of CHCs and 46% FRUs had adequate staff Details available at http://www.sahayogindia.org/what's%20new/main_complete_citizens.htm

(3) The current health mission National Rural Health Mission (NRHM) will pay ASHA community animators to motivate women to have delivery in hospitals and pay for costs. The NRHM is a large scale effort by the current government to improve the basic healthcare delivery system in India, especially to improve the availability of and access to quality healthcare by the rural poor, women and children. Details are available at http://www.mohfw.nic.in/NRHM%20Mission%20Document.pdf

By Jashodhara Dasgupta, Coordinator, SAHAYOG, A-240 Indira Nagar, Lucknow 226 016, India, P hone [phone] Fax [phone] E-mail: [e-mail]. Website: www.sahayogindia.org