EDITORIALS
Achieving Millennium Development Goal 5: is India serious?
Dileep MavalankarI; Kranti VoraI,1; M PrakasammaII
ICenter for Management of Health System, Indian Institute of Management, Vastrapur, Ahmedabad 380015, India
IIAcademy for Nursing Studies, Hyderabad, India
India has the largest number of births per year (27 million) in the world.1 With its high maternal mortality of about 300500 per 100 000 births, about 75 000 to 150 000 maternal deaths occur every year in India.2,3 This is about 20% of the global burden hence India's progress in reducing maternal deaths is crucial to the global achievement of Millennium Development Goal 5 (MDG 5). Why is India's maternal mortality high in spite of rapid economic growth? We believe the key reasons are political, administrative and managerial rather than a lack of technical knowledge.
Absence of focus on emergency obstetric care
Since the 1990s, it has been recognized that emergency obstetric care (EmOC) is one of the cost-effective strategies for reduction of maternal deaths.4 In 1992, India launched its Child Survival and Safe Motherhood programme (at a cost of approximately US$ 300 million) followed by a five-year programme (approximately US$ 250 million) called Reproductive and Child Health-I in 1997. Although EmOC was one of the strategies, it was not implemented due to lack of focus and limited management capacity. Even today the government does not systematically monitor how many EmOC facilities are fully functional.5 The National Rural Health Mission, a major new reform initiative launched in 2005, has been promoting training of village health volunteers and institutional deliveries. Again, improving EmOC is one of the many activities of the National Rural Health Mission lacking clear strategy or focus.6
Missing midwives
In the 1960s, India created a cadre of two-year trained rural midwives called "auxiliary nurse midwives" (ANMs) to provide maternal and child health services. They substantially fitted the definition of skilled birth attendant. Unfortunately, their designation as "auxiliary" undermined their status and function as midwives. Sri Lanka had a similar cadre of workers called "public health midwives" with a focus on delivery care, which contributed significantly to reducing maternal mortality. After 1966, under pressure from international agencies, the role of ANMs in India changed from midwifery to family planning and immunization.7
India also abolished the posts of institution-based midwives, replacing them with general nurse midwives. Nurses were rotated in all the departments of the hospital, thus they did not develop any expertise in midwifery, and the training programmes exclusively for midwifery were stopped.As a consequence, although female nurses and ANMs are automatically registered as midwives, there are no professional/skilled midwives in India.
As more than 60% of births are domiciliary deliveries, India needs to come up with an option to provide skilled birth attendance at community level. Lack of qualified midwives is a major human resource constraint for providing locally accessible skilled delivery care for rural women. Any country with a political commitment to reducing maternal mortality has to concentrate on well-trained midwives in the hospital and the community. Conversely, India ignored the development of a midwifery cadre, which has led to persistent dependence on traditional birth attendants for deliveries and a high maternal mortality rate.
Lack of management capacity in the health system
India has only three technical officers for maternal health at the national level! Almost no state in India has a maternal health director. This explains why maternal health strategies are not implemented effectively, and maternal deaths and pregnancy outcomes are not monitored. Lack of management capacity in the health system has led to poor quality services and slow progress.8
No political will
For politicians, health is a low priority. Government expenditure on health has been a mere 0.9% of GDP,6 while a large percentage of the budget is spent on defence, un-targeted subsidies and non-vital infrastructure. No political party has maternal health on its priority agenda. Hardly any questions are asked about maternal deaths in the parliament or state legislatures. Mass media has also ignored maternal health.
Absence of comprehensive maternal care services
With the change in the role of ANMs and programme priorities, comprehensive services have been neglected. Not only delivery care but antenatal and postnatal care are also neglected. The National Family Health Survey (2006) shows that only 52% of women receive three antenatal contacts and 42% receive any postnatal care.9 Abortion and birth-spacing services are receiving less attention lately. All of this has a major impact on maternal health indicators.
In spite of rhetoric from the National Rural Health Mission, changes on the ground to improve maternal health care are slow and lack focus. We feel strongly that without a clear strategic focus on skilled birth attendance, EmOC and referral services, India will not be able to reduce maternal mortality rapidly. There is a need to provide comprehensive maternal health services, including antenatal care, delivery care, EmOC and postnatal care, within an efficient health system. The extent of the increase in political priority, managerial capacity and resource allocation will determine, if and when, India will be able to meet MDG 5. 
Competing interests: None declared.
References
Available at: http://www.who.int/bulletin/volumes/86/4/07-048454/en/index.html
References
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3. National Family Health Survey (NFHS-2) Key Findings. International Institute for Population Sciences; 1998-99. p.12.
4. Maine D. Safe motherhood programs: options and issues. Columbia University; 1993.
5. Ved RR, Dua AS. Review of women and children's health in India: focus on safe motherhood [Background paper for "Burden of Disease in India"]. National Commission on Macroeconomics and Health Publication, India; 2005.
6. National Rural Health Mission [Mission Document]. Available from: http://mohfw.nic.in/NRHM/Documents/Mission_Document.pdf [accessed on 12 February 2008].
7. Mavalankar D, Vora K. Changing role of auxiliary nurse midwife in India. Ahmedabad: Indian Institute of Management; 2007.
8. Mavalankar D, Raman P, Shankar M. Top management capacity: key constraints in Safe Motherhood Program in India. Ahmedabad: Indian Institute of Management; 2006.
9. Maternal Health, National Family Health Survey, NFHS-3. India: International Institute for Population Sciences; 2006. Chapter 8.
1 Correspondence to Kranti Vora (e-mail: kranti_vora@rediffmail.com).
doi:10.2471/BLT.07.048454