Making India a safer country for child birth – What will it take?

With maternity care services divided almost equally between government and private facilities, it is essential that they collaborate in strengthening quality and equity in the delivery of healthcare services.

Making India a safer country for child birth – What will it take?
While intrapartum care is crucial to bring down maternal mortality, a more holistic approach towards quality care can not only avert maternal and neonatal deaths, but also significantly improve the quality of their lives.

By Pompy Sridhar

Every year, 32,000 women in India die from preventable causes during childbirth. At 122 deaths per 100,000 live births, India has registered a close to 80 percent drop in maternal mortality over a 25-year span, much above the global average of 44%. However, we still have a challenging journey to traverse in order to meet the SDG 3 target of less than 70 deaths per 100,000 live births by 2030. Given that the private sector accounts for nearly half of the institutional deliveries in India, it has a critical role to play in addressing ways to reduce preventable maternal mortality in India. Recognizing this associations like the Federation of Obstetric and Gynecological Societies of India (FOGSI) have initiated several interventions to – ensure that evidence-based protocols are followed during childbirth.

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As a part of their overarching commitment to improve health in India, FOGSI recently organized a summit in New Delhi, to discuss the complex challenges and brainstorm solutions for improving access, equity and quality for women’s health in India. The summit witnessed representation from stakeholders across the healthcare ecosystem, including the Government of India, international organizations, and the private sector. Amongst the many topics that were unpacked, in focus were the reproductive rights of women, family planning programs, and the rising burden of non-communicable diseases. Particular emphasis was laid on the challenges that India grapples with in providing quality maternity and child care in public and private facilities. At the summit, I had the pleasure to moderate a panel session along with Dr Hema Divakar, titled, ‘The Journey to Quality Care’.
Bringing together diverse experts from the healthcare community, the session was extremely insightful. I share here some of the key lessons that emerged from the dialogue. These, I believe, have the potential to chart the future course of maternity care services in India.

The percentage of institutional deliveries in India has more than doubled in a decade, from 38.7% to 78.9%, according to the National Family Health Survey-4. Despite this achievement, we continue to lose thousands of mothers every year due to avoidable complications owing largely to India’s fragmented healthcare system, which lacks standardization of quality care within and across private and public providers. The unregulated nature of private maternity facilities commonly results in their non-adherence to evidence-based quality care standards during childbirth – risking the lives of mothers and newborns. It is therefore crucial that we address the quality vacuum in maternal care by developing mechanisms to standardize quality, building the capacities of healthcare providers, and strengthening our health ecosystems.

This need has been recognized by the international community, and concrete steps have been taken towards institutionalizing quality care mechanisms. The World Health Organization has developed a Quality of Care framework comprising eight domains of care with an accompanying standard for every domain that should be evaluated. On the panel, Dr Ram Chahar, representing WHO, stressed the importance of measuring the journey, monitoring progress, and sharing results in the QoC context. He also pointed out that ten years ago, the focus was only on improving healthcare infrastructure for service delivery. At present, however, quality care has been recognized as a universal human right – not a luxury – and is crucial for bringing down MMR.

Dr Nandita Palshetkar, President, FOGSI, further elucidated that infusing quality is an exercise in capacity building and skilling of the healthcare team as a whole. Every individual who directly provides care to a mother or her child – whether its nurses, midwifes, or paramedics – needs to be trained in quality and respectful care, as well as basic emergency obstetric protocols to save a mother’s life in the absence of the doctor.

In this context, programs that improve and enhance access to quality care are essential. They focus on imparting critical lifesaving skills and best practices for safe and respectful care to various health professionals who cater to mothers. The importance of skilling for enhancing access was emphasized by Dr Alka Kriplani, renowned gynaecologist. She also highlighted the contribution of healthcare providers other than doctors in ensuring quality care. She pushed for the strengthening of midwifery culture as a method to reduce maternal mortality and bring down C-section rates.

Globally, there’s growing recognition of the fact that data sharing – can be a cornerstone solution for enhancing quality of care and service delivery, reduce costs, and improve health outcomes. In India, however, we’re still grappling with the problem of reconciling data sharing with patient privacy. Dr Jaideep Malhotra, Former FOGSI President, spoke about the issues of trust and privacy that hinder the ability of physicians to freely share data. She pointed out that without data sharing, strategies for epidemiology or improving healthcare services would remain incomplete and ineffective. However, there is no legislation or policy to protect patient data. With government guidelines for the private sector that can ensure privacy and security of shared data, healthcare providers will be able to reach that last mile in service delivery and care quality.

Dr Ameya Purandare reaffirmed his faith in technology as a tool to facilitate quality, equity, and last-mile service delivery in healthcare. He cited the example of Project ECHO, a videoconferencing-based knowledge-sharing network, and its ability to provide medical education in remote parts of the country, as a major success story for tech in healthcare. Dr Sachin Gupta (USAID) spoke about ASMAN – Alliance for Savings Mothers and Newborns – a technology-enabled quality care initiative for public health facilities, stating that the future lies in improving quality care standards through technology.

While intrapartum care is crucial to bring down maternal mortality, a more holistic approach towards quality care can not only avert maternal and neonatal deaths, but also significantly improve the quality of their lives. As Dr Malhotra pointed out, the foundation of many non-communicable diseases is laid in-utero. This is why antenatal care, including pre-conception care, is as important as intrapartum care – not only medically, but also emotionally and spiritually.

Holistic care also includes access to family planning services. Dr Gupta spoke about the 3-fold challenge in reducing maternal mortality: too close, too early, too many. Anaemia and post-partum hemorrhage (the leading cause of maternal deaths globally) are caused primarily because of inadequate spacing between births. Access to contraception and safe abortion are therefore critical in saving lives and ensuring holistic care for mother and child.

With maternity care services divided almost equally between government and private facilities, it is essential that they collaborate in strengthening quality and equity in the delivery of healthcare services. Experts reiterated that the conversation around quality care cannot move forward without fully engaging the private sector. Dr. Dinesh Baswal, Deputy Commissioner (Maternal Health) at the Ministry of Health and Family Welfare, also emphasized the need for private facilities to have standardized care practices for quality antenatal, intrapartum, and postnatal care.

In this context, the panelists highlighted the approach followed by Manyata, a FOGSI-led quality certification program. Manyata aims to standardize quality maternity care in private facilities by facilitating the adoption and practice of 16 clinical – and 10 facility standards. The program complements the government’s flagship labour room quality improvement initiative (LaQshya) for public healthcare facilities. Dr Baswal spoke about the Ministry’s commitment to reducing maternal mortality through LaQshya, which aims at improving intrapartum and postpartum care. Recently, these two programs joined hands in Maharashtra to launch LaQshya-Manyata, in a synthesis of efforts to improve maternal health outcomes in the state.

This partnership is significant because it promotes an intrinsic value of quality care — equal access. Without reducing the inequities in access to safe and consistent maternal care, the quality conversation is incomplete. Reiterating this on the panel, Dr Palshetkar emphasized that quality cannot be disengaged from equity – they go hand-in-hand. It is the duty of healthcare providers to provide quality and respectful maternity care to all women regardless of their socio-economic background.

In order to make equal access a reality, two factors are indispensable. One, providing quality and respectful care to all mothers at an affordable cost. And two, ensuring seamless and efficient mechanisms for quicker referrals and better access to transportation, so that women are able to get the care they need, when they need it. This is no mean task; achieving equity will necessitate the integration of maternity care into the Universal Health Coverage agenda. This means that in order to improve maternal outcomes in -India, cross-sectoral collaboration is paramount.

Lastly, one of the key concerns that emerged out of the session was the dire need to equip healthcare facilities – in rural areas with the arsenal to manage obstetric complications and emergencies, essential to avert deaths every year. Everyone echoed the sentiment to join hands as a collective force -to ensure safer outcomes for every mother and child in India.

(The author is Director – India, MSD for Mothers. Views expressed are personal.)

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