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By Rashme Sehgal

Approximately 80% of maternal and infant deaths could be averted if pregnant women and newborns had access to basic healthcare services, says Unicef's State of the World's Children Report 2009. This has been proved in Guna district of Madhya Pradesh, where Unicef and the government have set up 24-hour transportation and care services

The state of the world's children 2009In September 2007, UNICEF and the Madhya Pradesh government set up a call centre in the Guna district hospital to provide round-the-clock emergency transportation for pregnant women. Pregnant women in far-flung districts of the state, who had to travel in overcrowded public buses or by tractor to reach the nearest hospital, can now call on the Janani Express Yojana ambulance service to get there safely and quickly.

This is not the only intervention that has changed the lives of women and children in Guna district.

UNICEF also launched a Sick New Born Care Unit (SNCU) manned by Dr Prakash Verma and three colleagues. The district has a high infant mortality rate so providing specialised care for neonates and skilled neonatal care and support has reduced infant mortality. Dr Verma estimates that he and his colleagues have saved the lives of 1,500 children in the last two years.

The success of this intervention has ensured that more and more pregnant women can opt for institutional deliveries in Guna and their infants can also receive specialised care.

The success of this initiative has prompted the Madhya Pradesh government to start similar schemes in Shivpuri and Mansaur districts. The state of Uttar Pradesh has also started an SNCU in Lalitpur district which is providing neonatal care to sick newborns.

Regional rates of neonatal mortality

The emphasis on the health of infants and mothers is a result of several reports and surveys that have shown India's maternal and infant mortality figures to be among the worst in the world. UNICEF's State of the World's Children Report 2009, released in New Delhi on January 15, 2009, focuses on the maternal and newborn health of Indian mothers.

"Millions of women who survive childbirth suffer from pregnancy-related injuries, infections, diseases and disabilities, often with lifelong consequences. The truth is that most of these deaths are preventable -- research has shown that approximately 80% of maternal deaths could be averted if women had access to essential maternity and basic healthcare services," the report says.

Speaking at the launch of the report, Dr Karin Hulshof, the UNICEF India representative, added that, "Of every 100 children who die, 22 deaths are from India, with the majority dying during the first month of birth."

While India has succeeded in reducing its under-five mortality rate from 117 to 72 between 1990 and 2007, its neonatal deaths remain among the highest in the world.

Statistics revealed by the report show that 40% of deaths of under-five children occur in the first 28 days of life with the majority occurring during the first week.

Efforts to reduce deaths among women from complications related to pregnancy and childbirth have been less successful, with the result that childbirth continues to remain a serious health risk. On an average, every day, 1500 women die from pregnancy-related complications and childbirth mainly in sub-Saharan Africa and South Asia.

A child born in a developing country is almost 14 times more likely to die during the first 28 days of life than one from an industrialised country. The report highlighted that 80% of these deaths could have been averted if women had access to essential health-care services.

Direct causes of maternal deaths, 1997-2002

Children's lives, Hulshof pointed out, are intrinsically linked with the health of the mother.

The Indian government has been striving to improve these dismal figures. To assist pregnant mothers, the Planning Commission has come up with the Conditional Cash Transfer (CCT) scheme under which every pregnant mother will receive Rs 2,000 in two instalments, both prior and after her delivery.

At present, only a woman who undergoes an institutional delivery receives a cash incentive under the Janani Suraksha Yojana scheme of the Ministry of Women and Children. Dr Syeda Hameed, member of the Planning Commission said at the release of the UNICEF report that "mothers and infants are most vulnerable in the days and weeks preceding and following delivery and so this is the time to make critical life-saving interventions. The CCT will help her through this period of crisis".

"Funds for the implementation of this scheme have been set aside by the Planning Commission but the scheme will have to be implemented fast (as the term of the government will soon be ending)," Hameed revealed. "Infant and maternal mortality rates can only be lowered if essential services are provided at key points in the life of a mother and her newborn," she insisted.

The government is also keen to spread the Janani Express Yojana across hundreds of districts in the country. This would be co-ordinated under the National Rural Health Mission.

According to the UNICEF report, two-thirds of all maternal deaths occur in Uttar Pradesh, Uttarakhand, Bihar, Jharkhand, Madhya Pradesh, Orissa, Chhattisgarh, Rajasthan and Assam. In Uttar Pradesh, one out of 42 women will die during delivery in comparison to Kerala where it is 1 out of 500.

Africa and Asia in the global challenges for children and women

The problem is that while deaths of under-fives are reducing, the figures for maternal health remain intractable. This could be because of the woman's disadvantaged position in society, the report says.

The report recommends enhancing maternal nutrition to improve a woman's health and productivity and also to lower a mother's risk of mortality. Research has shown that in India, babies whose mothers die during the first six weeks of their lives are far more likely to die in the first two years of their lives than children whose mothers survive. In Afghanistan, 74% of infants born alive to mothers who died of maternal causes also subsequently died.

Iodine deficiency during pregnancy and malaria are responsible for a higher incidence of stillbirths and miscarriage. Malaria also contributes to low birth weight and neonatal deaths. Prevention of malaria through the use of insecticide-treated mosquito nets is therefore vital to reduce its impact on pregnant women and newborns.

The report cites the example of Farida Begum, who delivered her first child at Lahorighat Primary Health Centre (PHC) in the Morigaon district of Assam. She received a cheque for having an institutional delivery, and was also given an insecticide-treated mosquito net which was big enough for her three daughters and son to sleep under.

"What matters the most is that the net protects my children from nasty mosquito bites and the dreadful fever they cause. What more can a woman want?" Farida Begum was quoted as saying

UNICEF is supporting the National Rural Health Mission and the Directorate of Health Services, Assam, to provide nets in eight blocks of four districts of Morigaon, Sibsagar, Golaghat and Goalpara.

"Between May-November 2008, 8,438 mothers came for institutional deliveries at our PHCs," Dr Atul Pator, the health officer at Lahorighat has revealed in the report, adding, "Each of these mothers received a cheque and a bednet."

The report also revealed that while 46% of children born in India are underweight, another 43% are not fully immunised.

Lack of spacing between children has remained stagnant in India during the last 30 years, at 31 months. Even Bangladesh has better figures -- 39 months -- and in Indonesia it is 54 months.

Globally, one million neonatal deaths take place every year and 1,500 women die every day due to complications during delivery. Many of these deaths can be averted if the number of healthcare professionals increases. The world is facing a shortage of 4.3 million skilled delivery personnel. The greatest shortage is in India and Bangladesh where vacancies persist in rural areas.

The government must ensure an integrated approach to resolve the crisis of maternal and newborn health.

Download the full report PDF click here

InfoChange News & Features, January 2009